Background: Ventilator-associated pneumonia (VAP) primarily occurs due to the aspiration of secretions containing microorganisms from the oropharynx or stomach into the lungs. Preventing aspiration is a critical strategy for reducing VAP incidence. This study analyzed the impact of aspiration prevention measures—head-of-bed elevation (HOBE) and enhanced oral care—on VAP rates in adult intensive care units (ICUs). Method: This interventional study was conducted in the adult ICU of a 2,734-bed tertiary care hospital. A total of 8 ICUs (medical, surgical, cardiology, cardiovascular, neurology and neurosurgery) with 112 beds observed an increase in VAP incidence from January to April 2023, prompting enhanced measures in May 2023. The first intervention involved revising and reinforcing indications for head-of-bed elevation (HOBE) while strengthening monitoring and on-site feedback. During clinical procedures such as positional changes requiring a supine position, oropharyngeal suctioning was performed before lowering the head of the bed, and staff were trained to ensure prompt restoration of the HOBE to the appropriate position afterward. The second intervention improved oral care by replacing chlorhexidine and gauze with tooth brushing. A protocol was developed requiring 2 minutes of brushing teeth, artificial airways, tongue, and palate using a silicone toothbrush moistened with saline or sterile water, excluding patients with contraindications such as bleeding risks. Monitoring revealed missed areas during brushing, necessitating additional simulation training using dental models and colored toothpaste to confirm plaque removal. The pre-intervention period was conducted over 9 months (August 2022 to April 2023), while the intervention period lasted 17 months (July 2023 to November 2024). VAP incidence rates were compared before and after the intervention. Additionally, the incidence of VAP associated with pathogens such as Klebsiella pneumoniae, Acinetobacter baumannii, or Pseudomonas aeruginosa, often isolated from dental plaques of ICU patients, were analyzed. Results: The incidence rate of VAP per 1,000 ventilator days among adult ICU patients decreased from 3.9 (66/16,849) before the intervention to 2.4 (78/32,185) after the intervention (IRR, 0.62, 95% CI, 0.45-0.86; P = 0.007). Similarly, the incidence rate of VAP associated with pathogens K. pneumoniae, A. baumannii, or P. aeruginosa were 1.6 (27/16,849) before the intervention, and 1.0 (31/32,185) after the intervention (IRR, 0.60, 95% CI, 0.36-1.01; P = 0.07). Conclusion: As a result of implementing enhanced head-of-bed elevation and oral care protocols for ventilated patients in the adult ICU, the incidence of VAP significantly decreased. Further multicenter studies are needed to validate our findings.

Background: Effective integration of antimicrobial resistant organism (ARO) admission screening into clinical information systems (CIS) can facilitate prompt identification of patients at risk of an ARO and interrupt transmission. However, ARO admission screening remains suboptimal in Alberta, Canada following implementation of the ARO admission screening tool in the provincial CIS. We sought to understand the determinants of adherence with the use of the ARO admission screening tool in the CIS. Methods: A mixed-methods study was conducted using a survey, human factors observations, and qualitative focus groups. Eligible participants included nursing staff and physicians from emergency departments and inpatient units in acute care and acute rehabilitation facilities where the ARO admission screening tool was utilized in the CIS in Alberta, Canada from September 6, 2023 to June 18, 2024 (n=100). A survey (REDCap) explored staff perceptions and experiences using the tool in the CIS. Observations and interviews of nursing staff completing the tool were guided by the Systems Engineering Initiative for Patient Safety model. Virtual (Zoom) semi-structured focus groups explored barriers and enablers of using the tool guided by the Theoretical Domains Framework. Descriptive analysis of survey responses was conducted using Microsoft Excel (Version 2409). Field notes and focus group transcripts were used for a rapid qualitative, thematic analysis. A weaving narrative by theme was used to integrate survey results with findings from the observations and focus groups. Results: There were 527 survey respondents representing all 5 health zones, 5 nurses observed and 20 interviews conducted by the human factors team, and 24 participants in 6 focus groups. Focus group participants represented different sized hospitals (12-1,099 beds) with varying ARO admission adherence rates (29-83%). Three emergent themes arose: context, the ARO admission screening tool, and the individual. Contextual factors included time constraints, increasing nursing workload, competing priorities, lack of patient cooperation, and a need to increase interactions with infection prevention and control programs. Attributes of the tool impacting completion included location of the tool within the CIS, lack of prompts, and multiple sources of information required to complete the tool. At an individual level, themes arose related to experience, perceptions of ARO screening, and lack of training that influenced completion of the tool. Conclusions: Among the emergent themes, multiple determinants were identified influencing the use of the ARO admission screening tool in the provincial CIS. These findings will help inform future strategies to improve ARO admission screening and reduce ARO transmission.

Background: Clostridioides difficile infections (CDI) are associated with patient morbidity and mortality and also may impact reputational and financial metrics. CDI was identified as a healthcare-associated infection of concern at several of the hospitals in our healthcare system and set as a target for improvement. We sought to create an easily interpretable tool to help select hospitals with the greatest opportunity to benefit from this work. Methods: The National Healthcare Safety Network’s (NHSN) data (infection counts and number of predicted infections) for LabID CDI from Oct 2023-Sept 2024 were exported for 3 academic and 8 community hospitals in our healthcare system in eastern Massachusetts and New Hampshire. Using published source code from the Centers for Disease Control and Prevention recreated in R software (v.4.3.3), we calculated the statistical significance of the Standardized Infection Ratio (SIR) relative to 1.0 using the p-value. We then performed the statistical test iteratively by adjusting the number of infections by one in each direction from the true observed number of infections, to establish thresholds for significantly improved or worsened performance. Data were displayed as gauge charts with indication of current SIR statistical significance defined by color (red, yellow and green) and distance to threshold that would alter that significance (See Figure). Viable opportunities for improvement were defined as being within 5 or fewer infections of calculated thresholds. Results: Review of CDI data across all 11 sites demonstrated more improvement opportunities at some sites than others. Four sites were in green ranges, seven in yellow and none in red. All opportunities for viable improvement were identified in the yellow range; 5 of 11 sites had potential for improvement in SIR (Hospitals C, D, E, I, K) and 2 for worsening of SIR (Hospitals G, J); see Figure. Conclusion: In our healthcare system, this model provided insight into site-specific opportunities for improvement in CDI by highlighting sites closest to achieving a statistically significant change in SIR. Although factors such as morbidity and cost may influence selection of targets for improvement, visual depiction of viable thresholds for change in SIR may provide an indicator of facilities likely to yield the most benefit relative to investment required for reduction efforts.

Background: Hospitals experienced increased demand for acute care and specialty services during recovery following COVID-19 epidemics. Internal analysis identified potential inaccuracies in NHSN location unit designations across a large healthcare system with 2,249 mapped NHSN locations. Findings revealed inconsistencies in how location change decisions were determined mainly from the type of data applied. Facilities utilized finance data to determine NHSN location mapping creating limitations. NHSN locations defined by patient populations, associated with baseline risk adjustments to provide comparison performance and impacts CMS metrics. Methods: Decision Support Tool (DST) based on NHSN to evaluate patient populations for acuity, service line data indicating specialty services, financial billing codes, DRG and surgical or non-surgical populations. The DST outlines data elements for review when validating mapped locations. Each tab represents a unique data element to analyze as part of the NHSN decision algorithm (Figure 1). Unit level data aggregates in DST tabs (Figure 2). Implementation consisted of a pilot followed by a regionally phased implementation via coaching calls and follow-up touchpoints. Although all units were reviewed, specific activities focused on non-CMS reportable units such as telemetry, step-down, mixed acuity. As a part of the defined change control process facilities followed an internal standardized workflow to document changes, dates and reasons for change for historical reference (Figure 3). NHSN facility population changes were applied to vendor surveillance software utilized for CDA direct reporting to NHSN. System and facility internal record keeping promotes a standardized process for data validity, associated software maintenance and CMS reporting compliance. Results: The majority of changes were made to units mapped as telemetry with a 62% reduction overall. Figure 4 illustrates the non-CMS reporting locations with notable location mapping changes. Patients in an ‘observation’ status were found to be housed within any inpatient unit and required another data tool for analysis. Overall, the number of mapped 24-hour observation units is low (1.7%) across the healthcare system. Conclusions: The initiative standardized objective data and competency which elevated the trained infection preventionists on this topic. Admission orders offer telemetry for evaluation and treatment requiring continuous cardiac monitoring. NHSN definition is specific requiring 80% of unit patients to have a cardiac centered DRG/care and cardiac specialty treatment to meet telemetry definition. NHSN recommends at minimum annual mapping evaluation. As a large healthcare system, the DST analysis is managed continuously due to growing service lines, acquisitions and construction projects.

Background: Surgical site infections (SSIs) are a serious complication following surgery. The emergence of multidrug-resistant pathogens has diminished the effectiveness of traditional antimicrobials necessitating a new approach to prevention and treatment. We are developing an innovative device (xIP) that uses UV-C to inactivate pathogens in surgical incision sites, mitigating the risk of developing an SSI.

Irradiation in the UV-C range (200-280 nm) is known to inactivate surface and airborne pathogens by damaging nucleic acids. However, there is a limited research on its effectiveness for surgical sites. Methods: A Krypton-Chloride Excimer (KrCl*) lamp (λpeak = 222 nm), a pulsed Xenon (PX) emitter (broad spectrum), and a UVC LED (λpeak = 282 nm) were evaluated. Inactivation of E. coli ATCC 29425 and MRSA USA300 was determined by in vitro exposure to UV-C at doses of 0 (control), 2, 5, 10, 15, and 20 mJ/cm2. Dosing was controlled by measuring irradiance (mW/cm2) from each lamp and calculating the time to reach desired exposure levels.

Microbial suspensions of log-phase cultures were pelletized and resuspended in phosphate buffered saline three times and diluted to 107 CFU/mL. After UV exposure, suspensions were plated on an agar substrate using a grid-based method. After incubating for 48 hours at 37°C, remaining viability was determined. Results: PX and KrCl* emitters exhibited 5+ log reduction for both microorganisms, while LED showed 4 and 4.5 log reduction against E. coli and MRSA, respectively. PX demonstrated the highest inactivation efficiency (log-reduction per unit dose), followed by KrCl* and LED. Conclusions: In-vitro data suggest that surgical sites could be effectively treated in less than a minute with a small hand-held device and in less than 10 seconds with a larger device. Inactivation of MRSA using a superficial wound model in hairless SHKI1-elite mice (Charles River strain code 477) is in progress. In-silico modelling using optical raytracing is in progress to understand the impact of wound and skin micro-environment on the performance of the device. These data will inform ex-vivo testing using porcine or cultured human skin (EpiDerm FT) models to evaluate the performance in different wound types including incisions, abrasions, and burns, as well as the impact of fluids like saline and blood. Development of the xIP device is underway in collaboration with healthcare professionals to produce a product that is effective, fits into current practice, and user friendly. Upon successful completion of a prototype device, clinical efficacy will be explored.

Background: Our Candida auris surveillance protocol dictates that all patients who have been admitted to a skilled nursing facility (SNF), long-term acute care hospital (LTACH), and/or acute inpatient rehab (AIR) in the prior six months be screened on hospital admission. When hospital-onset (HO) cases are identified, point prevalence surveys (PPS) are conducted. Despite this, we identified two units with high prevalence of C. auris and an increasing number of HO cases. To investigate, we initiated an expanded C. auris screening pilot. Methods: Infection prevention (IP) verified that two units, the medical intensive care unit (MICU) and the pulmonary medicine unit (PMU) had the highest C. auris prevalence and number of HO cases. We formed a multidisciplinary process improvement team (MPIT) to develop recommendations. A pilot was launched to implement universal admission and transfer screening by PCR and weekly screening by culture on MICU and PMU. Screening consisted of two swabs: bilateral nares and bilateral axilla/groin. For patients with a tracheostomy or endotracheal tube, an endotracheal aspirate was collected. Pilot data were analyzed and shared with executive leadership. Results: In the 15 months prior to the pilot, 24/47 (51%) of the hospital-wide HO C. auris cases occurred on the pilot units resulting in 17/40 (43%) of all PPS performed. The pilot, conducted between 5/7/24 – 8/24/24, screened 868 unique patients and detected 9 present-on-admission (POA) C. auris cases and 8 HO C. auris cases (Figure 1). This surveillance avoided a minimum of 7 PPS and identified a cluster of C. auris on MICU. Notably, 9/9 (100%) of the POA cases were exposed to a SNF, LTACH, and/or AIR within 6 months prior to admission. Of the HO cases, 7/8 (88%) were epidemiologically linked with another C. auris patient, and 4/8 (50%) were co-colonized with at least one other multidrug-resistant organism at the time of collection. The pilot was established as routine practice on the two units. Conclusion: Our screening pilot identified POA and HO C. auris cases and demonstrated that HO cases decreased over time. This suggests that active surveillance allows for rapid identification and isolation of patients, preventing transmissions and outbreaks. In our experience, IP education and hospital-wide admission screening did not stop cases on units with a high prevalence of patients with C. auris. The pilot confirmed that our current hospital-wide admission screening protocol identifies cases on admission but alone will not prevent nor capture HO cases.

Introduction: Within our healthcare system, hospitalists receive feedback on antibiotic prescribing via an observed-to-expected ratio (OER) calculated by days of therapy (DOT) for CDC defined broad-spectrum, hospital-onset (BSHO) antibiotics and adjusted for patient characteristics and billing. In this sub-analysis, we quantify the impact of infectious disease (ID) consultations on OER. Methods: For each two-month period in five hospitals, encounters were assigned to each hospitalist if they billed for ≥1 day of care. The encounter was considered to involve an ID consult if an ID provider billed during the encounter. Percent of encounters with ID consultation (density) was calculated and stratum defined by gross ratios (e.g., 1 in 3 or 1 in 4 patients). We assessed whether consult density varied overtime, by facility, or by DOT. We assessed the effect of consult density on antibiotic DOT using established linear mixed effects model with random intercepts for both provider and facility (nested) and adjusted for patient characteristics and billing. Distribution of OERs were compared among strata to evaluate how ID consult changes OERs. Results: Between January and June 2023, 154 unique providers collectively received 458 bi-monthly OERs reflecting their care for 53,815 unique patients. Overall, 21% of hospital medicine patients were evaluated by an ID consultant during inpatient stay; median consultation density varied among providers by facility (19%-26%, Figure 1). Multivariate models (accounting for sepsis, UTI, renal disease) estimated significantly increased DOT for hospitalists having ~1:3 (+3.4 DOT, 95% CI 0.9 – 5.9) or 1:4 (+2.7 DOT, 95% CI 0.4-5.0) patients with ID consults compared to hospitalists with fewer than ~1:7 with an ID consult; however the effect was not significant in other strata and not linear (Table 1). Calculating the distribution of OERs both before and after adjusting for consult density resulted in small changes in OERs (Figure 1b). Discussion: The frequency of ID consults affected hospitalists’ BSHO-DOT in a non-linear fashion. Impact of ID consultation on prescribing metrics should be considered in building credibility of stewardship prescribing performance metrics.

Background: Hospital antibiotic stewardship programs (ASPs) are essential for reducing unnecessary antibiotic use and combating antimicrobial resistance. While many ASP interventions have been described, their feasibility and sustainability remain unclear, particularly for smaller hospitals with limited informatics resources. This study aimed to assess the feasibility and sustainability of common ASP interventions and examine the impact of hospital bed size on sustainability. Methods: A cross-sectional survey was conducted between April and May 2023 across 69 hospitals in Michigan participating in the Michigan Hospital Medicine Safety Consortium, representing both large (<200 beds) hospitals. Quality improvement or antimicrobial stewardship staff from each hospital ranked the feasibility of 7 common antibiotic stewardship interventions on a scale from 1 (easiest) to 7 (hardest). Respondents were then asked to report their status with 43 individual stewardship interventions as: a) implemented and sustained, b) implemented, but not sustained, c) tried but unable to implement, or d) never done. We used descriptive statistics and Fisher’s exact tests to compare reported intervention feasibility and implementation by hospital bed size (small vs. large). Results: All 69 hospitals responded to our survey (100% response rate). Across all hospitals, increasing audit and feedback by pharmacists was reported as the easiest new intervention to implement, whereas starting clinician peer comparison was reported as the hardest (Figure 1). Hospitals had implemented and sustained multiple stewardship interventions with substantial variation by intervention (Figure 2). Reported feasibility of the 7 common stewardship interventions did not significantly differ between large and small hospitals. However, small hospitals had significantly higher implementation of five antibiotic stewardship interventions: removal or change in order sets in urine culture testing (implemented by 73.1% of small hospitals vs. 46.3% of large hospitals; p=0.04), two-step urine culture initiative to reduce unnecessary testing (27% vs. 7%; p=0.04), Emergency Department order set with decision support de-emphasizing broad-spectrum antibiotics for CAP (77% vs. 48%; p = 0.02), daily pharmacy review of antibiotics for UTIs (58% vs. 30%; p=0.04), and daily pharmacy review of anti-pseudomonal antibiotics for CAP (73% vs. 46%; p=0.04). Conclusions: Feasibility and implementation of ASP interventions varied widely, with most interventions sustained once implemented. Technical solutions were 26.4% more likely to be sustained than adaptive ones. Small hospitals showed higher implementation rates for several interventions, potentially due to smaller patient populations and fewer administrative barriers. Hospitals should tailor ASP priorities to their local context, focusing on feasible and sustainable interventions.

Background: Calls within the clinical community for revising guidance on the appropriate durations of antibiotic therapy (i.e., shorter is better) and adherence (i.e., no longer advising to always finish a course), reflect important gains in evidence-based prescribing. However, changing medical guidance can have negative public effects (e.g., frustration, distrust, and disengagement) when not communicated in ways that resonate with patients. To inform efforts to effectively communicate evolving evidence on appropriate antibiotic use, we examined US adults’ perceptions and preferences regarding antibiotic durations and adherence. Methods: From March to April 2024, we invited US adults, aged ≥18 years, to an online survey about antibiotics. Question topics included durations of antibiotic therapy, adherence to a prescribed course of antibiotics, and demographic characteristics. Results: Table 1 shows the characteristics of the 1,476 respondents [completion=89%]. Most respondents reported they preferred to take a longer course of antibiotics (≥7 days) than a shorter one (3-5 days) for a bacterial respiratory infection (60.4% vs. 39.5%) and rated longer courses as both safer and more effective (Table 2). In open-text questions, respondents who preferred shorter courses described a general aversion to medication and concerns about side effects and resistance, whereas those who preferred longer courses saw them as familiar and a ‘better safe than sorry’ approach, associating longer durations with greater efficacy. In addition, 88.4% of respondents agreed that ‘it is important to always finish a prescribed course of antibiotics, even if you start to feel better’ and had either been told this by a medical professional (76.3%) or seen this guidance in a public health message (61.2%). Conversely, only 17.5% said they had ever been told they could stop taking antibiotics early. Preference for longer antibiotic courses was associated with older age, trusting their doctor’s advice about antibiotic therapy durations, having been told by their doctor to ‘always finish a course of antibiotics’, less worry about antibiotic side effects, discomfort about potentially being asked by a clinician to stop taking antibiotics when they start to feel better, and perceiving the clinician suggesting that as less competent. Conclusions: Many US adults prefer longer durations of antibiotic therapy for respiratory infections than are likely necessary. Almost all survey respondents believed it important to always finish a course and many were uncomfortable with advice to the contrary. These findings highlight the need for evidence-based communication strategies for aligning US adults’ antibiotic duration and adherence preferences with current guidance.

Introduction: Community-acquired pneumonia (CAP) is the leading infectious cause for hospitalization. Guidelines recommend use of a macrolide antibiotic with a beta-lactam for coverage of atypical organisms; however, data supporting macrolide coverage disproportionately include patients with severe CAP. Debate remains regarding the benefit of macrolide coverage among patients hospitalized with non-severe CAP. Methods: We emulated a target trial to evaluate outcomes associated with azithromycin use among patients hospitalized with non-severe CAP between 7/2017 and 8/2024 across 69 hospitals in Michigan. Included patients had an ICD-10 discharge diagnosis code of pneumonia, >2 signs or symptoms of CAP, and radiographic findings. Patients with severe CAP, risk factors for multi-drug-resistant organisms, those not started on standard CAP therapy with a narrow-spectrum beta-lactam with or without azithromycin, or those initially receiving doxycycline were excluded. Time zero was the time of first antibiotic administration on encounter day 1 or 2. Groups receiving and not-receiving azithromycin were balanced using inverse probability of treatment weighting (IPTW) assessed using standardized mean differences (SMD). The primary outcome was time to clinical stability. Secondary outcomes included intensive care unit (ICU) transfer, 30-day rehospitalization, 30-day mortality, and protocol deviation (i.e., azithromycin initiation after time zero [no-azithromycin group], patients receiving <5 days of azithromycin [azithromycin group]). We used the Cox model and multivariable Poisson regression for time-to-event and binary outcomes, respectively. Based on point prevalence of outcomes within our cohort, we were well powered to detect the demonstrated relative differences in all outcomes. Results: Of the 59,698 patients meeting criteria for pneumonia, 19,108 patients were included in the final post-exclusion cohort. Of these, 93.7% (17,904/19,108) received azithromycin on day 1 or 2 (median antibiotic duration 4.0 days [IQR 3,5]), while 6.3% (1,204/19,108) did not. After IPTW, groups receiving and not-receiving azithromycin were well balanced (SMDs <0.1). After adjustment, median time to clinical stability did not differ between the azithromycin and no-azithromycin groups (3 vs 3 days; HR 1.01 [95% confidence interval 0.97–1.14], p=0.74), nor did rate of ICU transfer (0.9% vs 1.3%; HR 0.90 [0.51–1.62], p=0.73). Patients receiving azithromycin had lower rates of 30-day rehospitalization (10.8% vs 15.3%, HR 0.69 [0.58–0.82], p<0.001) and 30-day mortality (2.3% vs. 4.0%; HR 0.70 [0.50–0.93), p=0.03). Protocol deviation occurred more commonly in those initially receiving azithromycin (56.5% vs 11.1%; HR 1.58 [1.32–1.82], p<0.001). Conclusions: Addition of azithromycin to beta-lactam therapy in patients hospitalized with CAP did not influence short-term outcomes but may reduce 30-day rehospitalization and mortality.

Background: A comprehensive understanding of antimicrobial prescribing practices, requires antimicrobial stewardship (AMS) clinicians to assess both the quantity and quality of antimicrobial prescribing. In Australia, two national programs collect and analyse such data in the hospital setting; the National Antimicrobial Utilisation Surveillance Program (NAUSP) a continuous, volume-based surveillance program that monitors antimicrobial usage trends; and the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) a standardised auditing program that assesses antimicrobial prescribing appropriateness. This study aims to analyse the 2023 NAUSP and Hospital NAPS data to compare the volume and appropriateness of inpatient antimicrobial use in Australian hospitals. Methods: Data were extracted from hospitals that participated in both programs in 2023, including systemically administered antimicrobials for adult patients. NAUSP data were aggregated and acute inpatient usage rates relative to patient activity were calculated as Defined Daily Doses (DDD) per 1,000 Occupied Bed Days (OBD) for individual antimicrobials.

Hospital NAPS data on appropriateness of prescribing, as assessed by local auditors as a point prevalence survey and using a standardised assessment matrix, were aggregated and calculated for each antimicrobial. Antimicrobials with high-volume use (NAUSP data), high rates of antimicrobial prescribing (NAPS data), or classified as medium to high risk for antimicrobial resistance potential according to the World Health Organization AWaRe classifications were further investigated. Results: There were 192 acute care hospitals that contributed in 2023 to both NAUSP (representing 12, 619, 253 OBDs) and Hospital NAPS (representing 21,017 antimicrobial prescriptions). Figure 1 summarizes the aggregate usage rates and appropriateness for antimicrobials of interest. Antimicrobials with the highest usage rates, including amoxicillin-clavulanic acid and cefazolin (92.2 and 78.8 DDD/1,000 OBD respectively), had moderate levels of appropriateness (67.8% and 69.9% respectively). Similar ‘Access‘ antimicrobials such as doxycycline, amoxicillin and metronidazole, which tend to be unrestricted in hospital formularies, had moderate levels of appropriateness. Cefalexin had the lowest rate of appropriateness (52.2%). In comparison, ‘Watch‘ antimicrobials, including meropenem and vancomycin, which tend to be restricted, had lower usage rates (14.3 and 19.8 DDDs/1,000 OBD respectively) but higher rates of appropriateness (83.5%, 82.8% respectively). Conclusion: This analysis highlights the importance of assessing and analyzing antimicrobial quantity and quality concurrently, providing a holistic view of prescribing practices. Furthermore, AMS efforts should include all antimicrobials, regardless of restriction category, as commonly used, unrestricted antimicrobials may have substantial rates of inappropriate prescribing.

Background: In summer 2024, our institution implemented enhanced blood culture (BCx) stewardship due to a global BCx shortage. Centers for Medicare and Medicaid Services’ (CMS) SEP-1 quality measure requires BCx. We evaluated whether the BCx shortage and stewardship impacted SEP-1 compliance. Methods: A retrospective review of SEP-1 data from an academic and a community hospital (1/1/2022-9/30/24) was performed and grouped by quarter. SEP-1 compliance was abstracted per CMS criteria. Failures due to BCx were categorized by timing of antibiotics prior to BCx: short delay (0-3 hours after antibiotics), long delay (>3 to 24 hours or no BCx). SEP-1 failures due to no BCx underwent manual chart review to determine infectious source, alternative culture obtainment, and adjudication if BCx would have changed clinical management. BCx failures were compared descriptively by quarter with emphasis on the BCx shortage (quarter 3 of 2024). Results: Over 11 quarters, 690 cases were abstracted for SEP-1 review (mean 62.7 cases/quarter). The mean SEP-1 success rate pre-shortage was 51.1%, while SEP-1 success rate during BCx shortage was 40.3%, the lowest rate since 2022. SEP-1 failures due to improper BCx obtainment were the cause of SEP-1 failure in a mean of 12.3% of cases reviewed pre-shortage, but this increased to 30.6% during the BCx shortage (Figure 1). Pre-shortage BCx failures were due to short delays (77.9%), long delays (15.6%), and no BCx (6.5%). During the shortage, BCx failures were more commonly due to long delays (31.6%) or no BCx obtained (31.6%) (Figure 2). The majority (7/12) of cases with no BCx obtained were during the shortage. Upon adjudication of no BCx cases, positive BCx would have significantly changed management in only 2/12 cases. Reasons BCx would not have changed management included urinary tract infection with positive urine culture (5/12), non-infectious/non-bacteremic diagnoses (3/12), and community-acquired peritonitis with surgery (2/12). Specifically during the shortage, 5 were UTIs (4 had positive cultures), 1 with peritonitis (positive intra-abdominal cultures), and 1 without bacterial infection. Conclusion: SEP-1 failures increased during the BCx shortage, possibly driven by efforts to reduce unnecessary BCx use. Use of alternative culture sites with higher yield than blood cultures resulted in SEP-1 failures that did not result in patient harm. SEP-1 should be re-evaluated, as BCx are not the only means of diagnosing the microbiologic etiology of infection and are often low yield in select patients with sepsis.

Introduction: The prevention of colonization of new inpatient room sinks with epidemiologically important pathogen (EIP) is poorly understood. Methods: We performed a randomized controlled trial and microbiological analysis to describe the timing and frequency of EIP contamination of in-room handwashing sinks in a renovated general medicine unit and to test the efficacy of a disinfectant on wastewater drains. Unit renovations included new distal plumbing for all unit sinks. Sinks were randomized 1:1 to intervention and control. 15 intervention sinks underwent the application of a foamed disinfectant into each study sink’s drain (Virasept [Ecolab]) every Monday, Wednesday, and Friday. 15 control sinks underwent standard disinfection. Microbiological samples were taken every week from 3 locations from each study sink: the top of the bowl, the tail pipe, and the p-trap. The primary outcome was sink conversion events (SCEs), defined as species-specific-EIP contamination of a sink in which that EIP had not previously been detected. EIPs were defined as Enterobacterales, Acinetobacter spp., Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Sink hygiene compliance was also measured. Results: Sink samples were obtained 11 times from July 2024 to October 2024 giving 990 total cultures, 495 in each study arm. The first sampling occurred after renovations were completed and one week before patients returned to the unit. In total, 314 patients were admitted to the study unit during the study period. We observed 15 SCEs (68%) overall; 3 sinks (20%) in the intervention and 12 (80%) in the control arms (p < 0 .01) (Figure 1). Overall, 135 EIPs were recovered: 27 from intervention and 108 from control sinks (p < 0 .01). On the first sampling, 6 intervention and 3 control sinks already harbored EIP. Of those, all 6 in the intervention arm were not detected in subsequent samplings whereas all 3 in the control arm were. The [DAM1] [A2] most common organisms recovered were Acinetobacter spp. (70 [52%]), Stenotrophomonas maltophilia (29 [21%]), and Enterobacter spp. (23 [17%]). Of the 300 opportunities to measure sink hygiene compliance, 229 (76%) did not meet compliance, most commonly containing absorbent pads. Discussion: In a renovated general medicine unit, the application of the intervention led to significantly lower SCEs (20% vs. 80%) and EIPs (27 vs. 108) recovered from study stinks compared to control. Sink hygiene compliance was suboptimal, with 76% of observed instances involving inappropriate sink use. These findings highlight the importance of effective sink disinfection and sink hygiene protocols in reducing the risk of pathogen transmission.

Background: Candida auris (C. auris) is an emerging multidrug-resistant fungus associated with high mortality from healthcare-associated infections (HAIs). Public health authorities have classified it as an urgent threat due to its persistence in healthcare environments and difficulty in identifying asymptomatic carriers. Active surveillance testing (AST) is recommended to detect multidrug-resistant organisms (MDROs) early and evaluate transmission control measures. Infection prevention and control (IPC) strategies, including hand hygiene, personal protective equipment (PPE), and equipment disinfection, are essential for improving healthcare safety and ensuring continued prioritization by executive leadership. Method: A sequential explanatory mixed methods study evaluated the impact of AST for C. auris in a large South Florida hospital system. Retrospective data identified patient risk factors and calculated incidence and prevalence density rates. Logistic regression analyzed the association of risk factors with healthcare-onset C. auris events. Focus groups at a high-prevalence hospital ward explored barriers and facilitators to infection prevention behaviors, such as hand hygiene, PPE compliance, and equipment disinfection. The study applied the CDC Framework for Program Evaluation to assess AST’s influence on IPC behaviors to reduce C. auris transmission. Results: A total of 3,688 unique patients were included across five study hospitals, of which 185 (5%) patients were new positive C. auris cases. The study found an adjusted odds ratio of 3.279 (CI: 1.785-6.024) for patients admitted with tracheostomies for testing positive for C. auris on AST. The incidence density and prevalence of positive C. auris from AST and clinical results increased from 2020 to 2022 and decreased slightly in 2023. Percent positivity decreased from 7.58% in 2020 to 2.47% in 2023 as AST increased from 66 total to 1619 total per year. 40 staff participated in 6 individual focus groups separated by caregiver type and themes on IPC behaviors for C. auris emerged related to accountability, communication, social influence, self-protection, fatigue, environment or resources, and knowledge. Key barriers identified opportunities related to observations and feedback, perception of lack of discipline, and safety culture. Facilitators identified social influence and modeling as well as organization and accessibility of preferred supplies. Conclusion: While AST usage increased during the study period, the number of clinical and AST positive results decreased indicating early identification of cases had a possible impact on overall C. auris prevalence. AST as an intervention cannot be used effectively without a combined focus on IPC behaviors that are essential to preventing transmission of C. auris in the healthcare setting.

Background: Isolation and cohorting are essential components of an effective infection prevention and control (IPC) program within healthcare settings to prevent spreading infectious diseases. In Bangladesh, no related study has explored knowledge or practices of isolation and cohorting practice. This study aims to investigate the perception and practice of isolation and cohorting among healthcare workers (HCWs) at tertiary care hospitals in Bangladesh. Methods: From September 2020 to January 2021, this hospital-based, multi-center cross-sectional study was conducted in seven tertiary hospitals across Bangladesh. Participants were HCWs (physicians, nurses, cleaning staff) involved in direct patient care and agreed to participate. A pre-tested structured questionnaire was employed through face-to-face interviews for data collection. Descriptive and multivariate analyses were performed using STATA Version 15. Compliance with isolation precautions was categorized into “good” and “poor” groups based on the mean response score. Results: A total of 1511 HCWs were interviewed, in the study. Overall, 88.7% of HCWs were familiar with the terms ‘isolation’ and ‘cohorting’. Still, 40.5% of them did not have a thorough understanding of when to implement these strategies. Only 18.0% of the HCWs reported good compliance towards isolation and cohorting practice. Entry-level (under 31 years) HCWs exhibited better compliance to isolation and cohorting compared to mid-level (31 to 40 years) HCWs (59.6% vs 29.4%). The majority of HCWs (93.7%) who participated in infection control training demonstrated a high level of compliance with isolation. In terms of good compliance with isolation precautions, physicians and nurses had higher odds (OR: 11.0) than cleaning staff. Moreover, HCWs with < 5 years of experience were more likely to comply with good adherence (OR: 1.56, 95%CI: 1.09-2.21) than those with over 10 years of experience. Conclusions: The study revealed that HCWs have a limited understanding and implementation of isolation and cohorting practices. To address this issue, policymakers and hospital leadership should adopt strategies that promote these practices by providing regular training and awareness programs for healthcare workers. Such initiatives are essential to help limit the spread of infections in healthcare settings.

Background: The role of environmental sampling to monitor airborne fungal loads (AFL) in healthcare facilities is controversial due to a paucity of data to guide the interpretation of results. Systematic surveillance for infections that might result from exposure to airborne fungal spores is furthermore limited by the lack of standardized definitions for healthcare-associated invasive mold infections (IMI).

Setting: 490-bed tertiary-care pediatric hospital Methods: Retrospective ecological study of the relationship between AFL and IMI. Volumetric samples for fungal culture from 1000 L of air were obtained approximately monthly from November 2018 through October 2023 with a bioaerosol impactor on units caring for patients at risk for IMI. Fungi in environmental cultures were classified as opportunistic fungal pathogens versus those that are rarely pathogenic. Prospective surveillance was conducted using standard definitions for proven and probable IMI. Cases with symptom onset after one week of hospitalization or in patients with either a previous hospitalization or more than one ambulatory encounter at our facility during the month prior to admission were considered healthcare-associated events. Poisson regression was used to examine the association between AFL and monthly average IMI rates. AFL values were also categorized to analyze the association with IMI rates using the chi-square test for trend. Results: During the period of AFL surveillance, 51 healthcare-associated proven or probable IMI were identified of which 33 were in hematology/oncology patients (including stem-cell transplant recipients) and 7 were in cardiac patients. The median total AFL on occupied inpatient units was 2 CFU/m3, and the most frequent pathogens identified were Penicillium species, dematiaceous molds, and Aspergillus species. No significant association was found between IMI rates and the average house-wide AFL for opportunistic fungal pathogens. The hematology/oncology IMI rate, however, increased by 1.48-fold (95% CI 1.00-2.19, P = .05) in association with an increase of 1 CFU/m3 in the pathogen AFL on units caring for these patients. The local AFL of Aspergillus species demonstrated an even stronger association with the hematology/oncology IMI rate (15.9-fold increase for an increase of 1 CFU/m3 [95% CI 2.8-90.7, P = .002]). The figure summarizes trends in hematology/oncology IMI rates across different ranges of average monthly AFL values. Conclusions: Environmental surveillance for AFL on appropriate hospital units may identify periods of increased risk for IMI among hematology/oncology patients. Additional work is needed to define the role that routine AFL surveillance may serve in infection prevention activities for immunocompromised patients.

Background: Turnover within the field of Infection Prevention is high, and this can cause significant organizational disruption and associated costs. Career growth and professional development are important retention factors in the field of infection prevention, however many infection preventionists (IP) tend to find their roles become stagnant resulting in attrition. The objective of this study was to determine organizational and leadership factors that contribute to IPs staying with an organization while still growing their career and profession. Methods: A mixed-methods approach with focus groups and survey methodology was used to assess organizational and leadership factors. Focus group and survey participants were stratified by (1) IPs who had been with the same organization for >5 years (long-term IPs), (2) IPs who have changed from one IP role to another IP role within the last 3 years (short-term IPs) and (3) IP leaders. Survey responses were analyzed using a Cochran Mantel-Haenszel test for associations. Qualitative responses were analyzed using a thematic analysis to identify themes and subthemes. Results: There were 82 participants in the focus groups and 632 survey respondents. 37.5% (n=117) of long-term IPs responded that their organizations were effective at providing career advancement opportunities in infection prevention compared to only 16.1% (n=20) of short-term IPs (p) Conclusion: The findings suggest that healthcare organizations could reduce turnover amongst IPs by providing career advancement opportunities and supporting professional growth. Future studies should focus on identifying the most effective professional advancement pathways specific to the field of infection prevention and control.

Background: Gaps in knowledge and compliance regarding control of Candida auris contribute to ongoing spread in healthcare facilities, but few studies have evaluated barriers to effective prevention measures. Methods: We assessed the knowledge, attitudes, beliefs, and practices for control of C. auris among frontline healthcare workers at 2 long-term acute care hospitals (LTACH) with high admission prevalence of C. auris in the Chicago, Illinois region. Surveys included 92 questions including the following subjects: participant demographics; awareness of multidrug-resistant organisms [MDRO]; attitudes and beliefs regarding C. auris; motivation for using and compliance with personal protective equipment [PPE]; knowledge of C. auris prevention measures; perceived barriers and facilitators of C. auris prevention; sources of education and training; and preferred learning styles. Responses were measured on a 5-point Likert scale. Anonymous online surveys were administered during the one-month study period Recruitment efforts included posters, fliers, email, and in-person rounds with the LTACH infection preventionist. Participants were eligible to win a gift card upon survey completion. Only complete surveys were analyzed. Results: Fifty-three surveys were completed (estimated 12% response rate across all facility staff) with respondents identifying as 92% female, 43% nurses, and 60% with >10 years of experience in their current role. Participants were familiar with commonly identified MDROs (i.e., Clostridoides difficile [98%], methicillin-resistant Staphylococcus aureus [88%]) but were less aware of extended-spectrum β-lactam-resistant (68%) and carbapenem-resistant pathogens (56-79%) (Figure 1). Participants felt that their actions helped prevent C. auris spread (85%) but were less confident when asked whether C. auris is a problem at their own hospital (53%). Participants were able to successfully identify most prevention strategies for C. auris (≥72% correct for all measures). The highest ranked barriers to C. auris prevention were understaffing (63%) and inadequate training (51%) (Figure 2). Information regarding C. auris was most commonly obtained through training provided within their hospital (62%) and from coworkers (45%). Participants responded that they prefer to learn about infection prevention through in-person teaching by experts at their facility (83%) or from another institution (79%), although self-learning styles were also popular (67-73%) (Figure 3). Conclusion: We identified perceived barriers to effective C. auris prevention among frontline healthcare workers in 2 LTACHs. While staff members successfully identified most prevention strategies for C. auris, they may benefit from enhanced education and training programs that support multiple learning styles.

Background: Conferences play a crucial role in the early dissemination of significant research to peers and experts within the same field. They provide a platform for receiving feedback, fostering collaborations, and refining groundbreaking findings, which can eventually be developed into full articles for publication in peer-reviewed journals. The transition of presented abstracts to full research journal publications is a key metric for evaluating research productivity, quality, and dissemination. Despite this, there is limited data on the proportion of abstracts that are ultimately published as full articles in peer-reviewed journals. Method: All abstracts (351) presented at the SHEA Spring Conference in 2018 and 2021 were indexed and cataloged from the 2018 online archive and the 2021 Antimicrobial Stewardship & Healthcare Epidemiology journal supplement. We then manually searched the top 20 results of both Google Scholar and PubMed to determine the publication status of each abstract as of Jan 10, 2025. Publication status criteria included: matching at least three keywords between the abstract and any resulting manuscript, having at least one common author, and publication occurring after and inclusive of the year of abstract acceptance. Data was compiled into an Excel spreadsheet, categorizing abstracts as ‘yes’ or ‘no’ for publication. Publication rates were then calculated using Excel formulas based on these categorizations. Factors associated with publication were evaluated, and publication metrics were described. Result: All 351 abstracts were analyzed. Among these, 175 (49.9%) were published as full articles in peer-reviewed journals indexed in Google Scholar or PubMed. Abstracts presented in 2021 and those presented orally had higher publication rates, though the association was statistically nonsignificant (p = 0.06 and p = 0.66, respectively). Abstracts with authors from different institutions and those with more than six authors showed a statistically significant association with higher publication rates (p = 0.002 and p = 0.003, respectively). Infection Control & Hospital Epidemiology was the most common journal in which abstracts were ultimately published, accounting for 51 (29.1%) of the publications. The publication rates surpass those reported in most similar studies of other internal medicine and subspecialty conferences, including IDWeek. Conclusion: Approximately half of the abstracts presented were subsequently published as full articles. Collaborative research, involving more authors and authors from different institutions, was associated with a higher publication rate. These findings highlight the strong academic impact of SHEA-presented research. Further research into the barriers to publication is warranted to improve the dissemination of conference abstracts.

Genomic surveillance of Staphylococcus aureus in hospitals usually focuses on clinical infections, missing transmissions from asymptomatic carriers and delaying detection and timely intervention. To address the issue, we performed whole-genome sequencing (WGS) on over 5,000 S. aureus isolates obtained from colonization screens at admission, in addition to standard clinical cultures, at two interconnected urban hospitals. By integrating genomic data with timestamped location information, we identified hundreds of transmissions missed by standard methods. However, nearly 70% of transmissions were detected during readmission after the index case had been discharged. This finding indicates that even with dense genomic sampling, real-time detection remains challenging due to asymptomatic carriage. Therefore, effective monitoring of nosocomial S. aureus transmission will likely require WGS and colonization sampling at both admission and discharge. The data also highlight patient- and strain-specific factors, including methicillin resistance, as predictors of S. aureus spread, which may enable cost-effective, targeted sequencing surveillance strategies.