Background: Carbapenem use is a primary target of antimicrobial stewardship programs with attempts made to limit usage to patients with suspected or documented multidrug resistant Gram-negative infections. Antimicrobial use (AU) data and the standardized antimicrobial administration ratio (SAAR) are metrics for comparing observed to predicted days of antimicrobial therapy and are increasingly used by stewardship programs to assess use within their institutions. However, the SAAR does not account for individual drug class or resistance rates within an institution, limiting the ability to assess appropriateness and whether a high or low SAAR requires action. To try to assess carbapenem use as a function of resistance within hospitals in Michigan, we developed a novel measure utilizing National Healthcare Safety Network (NHSN) AU and Antimicrobial Resistance (AR) data. Methods: Included hospitals had reported both AU and AR data for the calendar year of 2023. To assess the “resistance burden” requiring carbapenem use at an institution, three antimicrobial resistance phenotypes from the NHSN AR data were chosen as a surrogate; extended-spectrum cephalosporin resistant (ESC) E.coli, ESC Klebsiella spp., and resistant Pseudomonas aeruginosa, which was defined as any isolate intermediate or resistant to cefepime, ceftazidime, or piperacillin/tazobactam. The resistance rates for these three phenotypes were combined to create a weighted antibiogram for total resistance burden requiring carbapenem usage at an institution. AU data for carbapenem use per 1,000 days present for each institution was then employed to normalize carbapenem use (numerator) to resistance burden (denominator at each institution), measured as carbapenem use per unit of resistance. The median value for included hospitals was then calculated, and finally, institutional use relative to this median was reported. Results: Twenty-one hospitals, ranging from 6 to 1,011 beds, met inclusion criteria. There were 18 acute care and 3 critical access hospitals; 19 (90.4%) were part of a health system. When normalized to the median value, adjusted carbapenem use per unit of resistance within hospitals ranged from 0.214 to 4.155 (Figure 1). The highest value of adjusted carbapenem use per resistance was 19.4 times that of the lowest value. Conclusion: This novel measure of antimicrobial use attempts to correct for the burden of resistance in individual facilities. As such, when applied to hospital populations, this represents a step forward in assessing antimicrobial use appropriateness and would have public health impact related to antimicrobial stewardship efforts. Future objectives include application to additional hospitals, years of data, antimicrobial resistance phenotypes, and agents.

Background: Upper respiratory infections (URIs) are common causes of outpatient visits in children. While many URIs are viral, antimicrobial prescribing remains high. In preparation for action planning to address this issue within our multi-state health system, this study aimed to characterize current antimicrobial prescribing patterns for pediatric URIs in our outpatient setting. Methods: Retrospective analysis of pediatric (<18 years) antimicrobial prescribing for URI diagnosis codes in 639 outpatient sites (nine states), including clinics, urgent cares, and emergency departments (ED) between July 1, 2023 to June 30, 2024. Primary outcome was overall antimicrobial prescribing rates for URIs and by individual URI diagnosis (sinusitis, bronchitis, pharyngitis, otitis media). Logistic regression machine learning model was used with SHapley Additive exPlanations (SHAP) analysis to show feature contributions to antimicrobial prescribing. Results: A total of 125,590 patient visits by children with URI were included. Antimicrobial prescribing rates varied by diagnosis (sinusitis: 53%, bronchitis: 18%, pharyngitis: 45%, otitis media: 40%, p<0.001). Overall prescribing ranged from 18%-52% across states. Patients seen in the ED had the lowest use of antimicrobials (25%) while those seen in urgent care had the highest utilization (58%). Non-bronchitis diagnosis, non-ED encounters, ≤10 years of age, and specific states had the strongest positive associations with antimicrobial prescribing, while race and social vulnerability index (SVI) were not associated. Conclusions: Antimicrobials were most commonly prescribed for pediatric patients seen for sinusitis, pharyngitis, and otitis media. Factors most associated with increased prescribing included non-ED encounters, >10 years of age, and geography. These data support action to standardize practices and address clinical variation.

Specialty Infectious Disease physician.

Clinical Associate Professor University of South Dakota Medical School

Consultants for South Dakota Department of Health regarding antibiotic stewardship

Consultants West Virginia Hospital Association regarding antibiotic stewardship Background: An equitable distribution of antibiotic stewardship expertise is a challenge for rural communities across the United States. The advantage rural communities have is that there are fewer barriers for implementation of effective antibiotic stewardship strategies.

The authors worked with several rural communities in the United States over the paste several years implementing a proven antibiotic stewardship strategy that has been shown to decrease Clostridioides infection. Method: Strategy employed was avoidance of the more common microbiome damaging broad spectrum antibiotics in favor of more targeted narrow spectrum antibiotics based on local antibiogram data. Additionally, ongoing infectious disease and antibiotic stewardship access for questions as well as data review with feedback were provided.

Findings: Clostrioides infection was eliminated in some communities and others markedly decreased as shown by a very low percentage of toxin positive, PCR positive to toxin negative PCR positive isolates expected for that region. Conclusion: This strategy is translatable to other communities accompanied by antibiotic stewardship expertise and support and can be a model for community wide antibiotic stewardship which further optimizes patient and resident safety from Clostidioides infection.

Background: Upper respiratory infections (URIs) are a common cause of outpatient visits in adults. While most URIs are viral, antimicrobial prescribing rates remain high. The COVID-19 pandemic disrupted usual practices, necessitating an evaluation of the post-pandemic landscape for antimicrobial prescribing for URIs. This study sought to characterize factors contributing to variability in utilization in a large multi-state health system. Methods: Retrospective analysis of antimicrobial prescribing in patients ≥18 years of age for URI diagnosis codes in 863 outpatient sites (eight states), including office visits, urgent care, and telemedicine between July 1, 2023 to June 30, 2024. Primary outcome was antimicrobial prescribing rates for URIs overall and by individual URI diagnosis (sinusitis, bronchitis, pharyngitis, otitis media). HEDIS definitions were applied where appropriate. Logistic regression machine learning models were used with SHapley Additive exPlanations (SHAP) analysis to show feature contributions to antimicrobial prescribing. Results: A total of 84,724 patient encounters were included with four URI diagnoses. Antimicrobial prescribing rates varied by diagnosis (sinusitis: 60%, bronchitis: 48%, pharyngitis: 33%, otitis media: 35%, p<0.001). Prescribing ranged from 37%-58% across states (p<0.001). Sinusitis diagnosis and specific states had the strongest positive associations with antimicrobial prescribing, while race and social vulnerability index (SVI) were not associated. Conclusions: In this study in a large multi-state US health system, antimicrobials were most commonly prescribed for patients with sinusitis. Regional variation was also associated with increased prescribing. These data support efforts to standardize practices and address clinical variation.

Background: Urinalysis with reflex culture order sets (reflex order set) require urinalyses to meet specific criteria before triggering a culture to reduce unnecessary urine cultures and inappropriate treatment of asymptomatic bacteriuria (ASB). A reflex order set was designed and implemented at a large academic medical center in 2016 and updated in June 2022 to require clinicians to select which pre-specified exemption the patient met to bypass the reflex order set and order a urine culture. We aimed to assess the association between reflex order set bypass and antibiotic prescribing for urinary tract infections (UTIs) in outpatient encounters. Methods: Patient demographics, co-morbidities, encounter diagnoses, and treatment data, including required antibiotic indications, were extracted from all outpatient healthcare system adult and pediatric patient encounters utilizing the reflex order set. Using multivariable logistic aggression, we assessed associated odds with 95% confidence intervals (95% CI) of bypassing the reflex order set and antibiotic prescribing for UTI. Results: From June 2022 to June 2024, 192,310 encounters met inclusion criteria. After adjusting for patient factors, bypassing the reflex order set was associated with higher odds (2.87 95% CI: 2.81 to 2.94) of antibiotic prescribing for UTI. Increasing age, female gender, indwelling catheter, history of urological surgery, UTI, and neurogenic bladder were associated with increased prescribing. Being on immunosuppression, pregnancy, pending urological surgery, renal transplant status and chronic kidney disease were associated with reduced odds of antibiotic prescribing (Table 1). Discussion: Urinalysis reflex order set implementation in a large ambulatory clinic system was associated with lower likelihood of antibiotic prescribing for UTI. Further analysis will evaluate accuracy of selected bypass indications and appropriateness of antibiotic prescriptions to identify opportunities for optimizing this intervention.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction(PCR) is a rapid screening test (turnaround time ~1-2 hours) used to evaluate nasal colonization with MRSA. For respiratory and bloodstream infections, MRSA nasal swab has a high negative predictive value >95% which could help de-escalation of MRSA directed therapy in the appropriate clinical setting. Tufts Medical Center recently implemented this test and requires an indication for ordering: pneumonia, sepsis or septic shock, bacteremia, or other (with free-text reason). Intervention/Aim: Evaluate clinician adherence to the recommended indications through reviewing of ordering indication and assess utilization of MRSA PCR as a tool for de-escalating MRSA directed antibiotics. Methods: Retrospective review of MRSA PCR orders between September 28, 2023, and March 28, 2024. Ordering data including indication selected and test result was extracted from the electronic medical records. Other variables were collected by chart review by two study members. Free-text reasons documented when selecting “other” were categorized by system (e.g genitouniary or skin and soft tissue). Free text reasons were evaluated based upon published negative predictive value (NPV). Indications with NPV lower than 95% were considered inappropriate. MRSA antibiotics were considered vancomycin, daptomycin, linezolid, or ceftaroline. Changes in MRSA antibiotics were determined by chart review of the antibiotics administered at least 24 hours prior to MRSA PCR administration and 24 hours after administration. Results: 113 of 1339 tests were ordered with “other” indication. Only 17 (15%) of these orders were considered appropriate. Among the appropriate tests were infections involving the head, eyes, ears, nose, and throat (HEENT). Of 441 tests reviewed, 411 were negative (93.2%). Of those with negative tests 324 (78.8%) were given MRSA antibiotics prior to the test. and only 92 (28.4%) remained on MRSA therapy after a negative test Conclusion: Reviewing “others” helped identify gaps in knowledge to target educational interventions and identify additional appropriate indications to include in the computerized order entryMRSA Nares is an effective tool to de-escalate MRSA antibiotics, but other interventions are needed to increase appropriate antibiotic de-escalation with a negative test.

Background: Antimicrobial resistance (AMR) is one of the most pressing health challenges of our time, fueled by the widespread misuse and overuse of antibiotics. Tackling this issue requires accurate, real-world data on how antimicrobials are prescribed and used. Point Prevalence Surveys (PPS) have become invaluable in this effort, offering a clear picture of prescribing practices and guiding the development of effective stewardship programs. This study focuses on antimicrobial use in three healthcare facilities in Ekiti State, Nigeria, leveraging the Global-PPS methodology to uncover patterns, pinpoint gaps, and identify opportunities to improve prescribing practices and support the fight against AMR. Method: This study took a hands-on approach to understanding antimicrobial prescribing practices in Ekiti State by using the well-established Global-PPS protocol. Three healthcare facilities - one each from the tertiary, secondary, and primary levels-were carefully selected to provide a broad view of prescribing behaviors. Data were gathered using standardized tools to capture key details such as patient demographics, reasons for antimicrobial use, prescribing patterns, and adherence to clinical guidelines. Descriptive statistics were used to summarize the trends, while comparisons across the facilities highlighted important differences. To ensure the findings were practical and relevant, we worked closely with the relevant MDAs, fostering a collaborative effort that added depth and context to the study. Results: Preliminary findings revealed significant variations in antimicrobial prescribing patterns, with the tertiary facility showing 75% adherence to stewardship protocols, compared to 45% and 30% in secondary and primary centers, respectively. Factors contributing to inappropriate prescriptions included limited diagnostic access (tertiary - 85%, secondary - 50%, primary - 25%), inadequate guideline dissemination (tertiary - 90%, secondary - 40%, primary - 20%), and insufficient prescriber training. Empirical therapy without justification was common, accounting for 60% of cases in secondary and 75% in primary centers. These gaps underscore the need for targeted interventions to improve prescribing practices. Conclusion: This study highlights the pressing need for customized antimicrobial stewardship programs in Ekiti State, Nigeria. By shedding light on prescribing habits and identifying critical gaps, these findings pave the way for meaningful, locally relevant interventions that encourage responsible use of antibiotics. Strengthening healthcare capacity, expanding access to diagnostic tools, and fostering adherence to treatment guidelines are essential next steps. These efforts not only hold the promise of improving patient care in Ekiti State but also contribute to the broader fight against antimicrobial resistance.

Introduction: Pre-authorization and prospective audit and feedback, though effective interventions for reducing antibiotic use, require manpower, time and can impinge on prescriber autonomy. We describe a unique approach to optimizing antibiotic use. Methodology: The antimicrobial stewardship program at our hospital is physician-led and supported by clinical pharmacists. To reduce time and manpower, we adopted a collaborative approach of structured audits. A baseline phase measured antibiotic consumption, mapped antibiotics to clinical syndromes, and documented inappropriate antibiotic use about choice, dose and duration. We then went to an intervention phase where for a month, prospective audit and feedback was performed for all the patients in the department in real time, communicated and discussed with a liaison from the treating team. At the end of this period, we presented data regarding antibiotic consumption and the proportion of justified antibiotic use in terms of choice, dose, and duration compared to the baseline phase. Literature evidence of appropriate antibiotic use was presented along with actionable data where gaps had been identified. Results: Structured thematic audits were conducted across seven key departments, including Medicine, Surgery, Orthopedics, Obstetrics and Gynecology, Urology, Hematology, and Emergency Medicine. As an example, the data on Orthopedics is presented here. The audit was done over one month across three general wards, and 94 patients were recruited. The antibiotic consumption was DOT/100PD=78.2, and the average length of therapy was 6.2 days. The antibiotic utilization for the broad infectious specific syndrome is shown in Table 1. Non-infective elective surgery and closed fracture received 4.4 and 5.6 mean days of antibiotics, which was deemed unnecessary. However, no institutional antibiotic protocol for open fractures (considered contaminated) existed. On discussion with the entire orthopedics department, a consensus was reached on antibiotics for open fractures with or without contamination for a maximum of 72 hours or until wound closure. Other areas where antibiotics could be optimized according to standard guidelines were also agreed upon and reinforced. This meeting resulted in consensus building and collaborative clinical decision pathways adopted into our institutional antibiotic guidelines. Conclusion: This unique thematic structured audit approach enhanced judicious antimicrobial prescribing practices, leading to consensus building across the hospital. It also led to changes in policy, fostering ownership and breaking the hierarchical model of stewardship, shifting accountability to the primary departments. It also reduced the time and resources required for the AMS team.

Background: Bacteremia is associated with significant morbidity and mortality. At least 14 days of antibiotic treatment has traditionally been the standard of care. However, shortening the duration of antibiotic therapy is a key strategy for improving antimicrobial stewardship. This meta-analysis of randomized controlled trials (RCTs), including the recently published BALANCE trial, seeks to identify the duration of antibiotics needed to optimize this mortality benefit by comparing seven versus 14 days of antibiotic duration. Hypothesis: The mortality risk ratio (RR) in the 7-day group is similar to 14-day group. Methods: Multiple electronic databases and trial registries were searched on December 29, 2024, for RCTs reporting mortality outcomes in patients with bacteremia treated for seven versus 14 days of antibiotics. We estimated the effect of these two-treatment durations using random-effects meta-analyses with the generic inverse variance method. Subgroup analyses were conducted to assess the impact of the source of bacteremia on mortality. Results: Four eligible RCTs consisting of 4,794 patients with bacteremia, were included. Median age was 71 years (interquartile range (IQR): 69-73), and 47% (IQR: 45%-49%) were male. Of the patients with bacteremia, 87% had gram-negative bacteria and 13% gram-positive bacteria. Patients with Staphylococcus aureus bacteremia, severe immune compromise, prosthetic heart valves, syndromes with well-defined requirement for prolonged treatment such as infective endocarditis or osteomyelitis, single positive blood culture with common contaminant, Candida or other fungi were excluded. Overall mortality rate was 8%. The RR for 90-day and 30-day mortality between 7 versus 14 days was 0.92 (95% CI: 0.79 – 1.06) and 0.92 (95% CI: 0.96-1.12), respectively. Median antibiotic-free days were higher in the 7-day group than 14- day group (19 days vs 14 days, p=0.03). The rates of Clostridioides difficile infection were similar in two groups (1.6% vs 1.5%, p=0.97). Subgroup analysis indicated no effect modification by the source of bacteremia. The risk of bias was assessed as low. Conclusions: This systematic review and meta-analysis of RCTs found no difference in mortality between 7- and 14-day treatment durations in low-risk patients with non-Staphylococcus aureus bacteremia. Reducing antibiotic treatment for uncomplicated gram-negative and gram-positive bacteremia to 7 days is a critical antibiotic stewardship intervention.

Background: Blood culture contamination is a large burden on the health system with significant excessive costs and antimicrobial use. In 2024, a national blood culture shortage required intensive conservation strategies regarding blood culture collection. We developed clinical guidance on blood culture utilization and embedded it in electronic health record (EHR). Our goal is to evaluate its impact on blood culture utilization and anti-MRSA agent usage at our institution. Methods: The antimicrobial stewardship team provided educational communication, and blood culture bottle conservation strategy (BCBCS) recommendations that were embedded into the EHR in July 2024 (Figure 1). Patient charts with a laboratory identified blood culture growing a contaminant in December 2023 (prior to BCBCS) and October 2024 (post-BCBCS) were reviewed. Patients were excluded if they had another clinically relevant pathogen in blood cultures, were discharged prior to blood culture result, or died within 48 hours of blood culture result. Information on anti-MRSA agent (vancomycin, linezolid, daptomycin, ceftaroline) days of therapy (DOT), total hospital blood culture volume, blood culture contamination rates, and ID consultation was collected. Results: 54 patients pre-BCBCS and 29 patients post-BCBCS were reviewed. Anti-MRSA DOT in patients reviewed with contaminated cultures was 161 pre-BCBS and 56 post-BCBCS (Table1). Overall blood culture volume and contamination rate were reduced post BCBCS implementation (Table 2). Total hospital anti-MRSA DOT was noted to be less post EHR guidance as well (1529 pre-BCBCS and 1279 post-BCBS). Conclusions: Reduction in both the volume of blood culture collection and overall contamination rate contributed to a reduction of anti-MRSA therapy at our institution. These results highlight the impact that diagnostic stewardship may have on antimicrobial stewardship metrics.

Background: Presence and documentation of clinical symptoms of Clostridioides difficile infection (CDI) prior to diagnostic testing is not well-described. The Infectious Diseases Society of America (IDSA) guidelines recommend that patients have ≥3 episodes of unexplained loose stool in the previous 24 hours before testing. In populations predisposed to chronic non-infectious diarrhea, such as those undergoing chemotherapy or with chronic gastrointestinal (GI) illness, more explicit signs of infection may be needed. Our objective was to evaluate CDI symptoms that proceeded testing in a cohort of inpatient Veterans with chronic GI illness or undergoing chemotherapy. Methods: This retrospective cohort study included Veterans hospitalized at 8 VA facilities from January 1st, 2019-December 31st, 2022, who were tested for CDI, and were receiving chemotherapy or had chronic GI illness. Charts reviewed identified the following symptoms in the 24 hours prior to testing: greater than 3 loose stools in 24 hours, bloody stool, nausea, vomiting, abdominal pain, fever (temperature ≥100.4°F), and white blood cell count >10,000/mm3. The presence of 3 loose stools in 24 hours alone was deemed the minimal indication for CDI testing, while the presence of any additional symptoms was considered high indication for testing. CDI treatment was defined as at least one dose of metronidazole, oral vancomycin, or fidaxomicin ±7 days from testing. Chi-square tests assessed the association between indication for CDI testing and test positivity. Results: A total of 676 tests for 577 unique patients were reviewed (69.1% White, 94.5% male, mean age=68.3 years). Most had a chronic GI illness (90%); colitis, and presence of a gastrostomy were the most frequently reported. Only 14% of CDI tests were positive. The minimal indication for CDI testing was present for 243 tests (36%). 190 tests (28%) were ordered for patients with symptoms highly indicative of CDI. Of the negative tests, 55% were associated with at least one dose of CDI treatment. There was no association between test indication and test positivity (p-value=0.82). Conclusion: In a population predisposed to chronic non-infectious diarrhea, nearly two thirds (64%) of those tested did not meet the minimum requirement (3 documented loose stools in 24 hours). This may partly explain the low-test positivity rate of 14%. Over half of negative tests were associated with CDI treatment. Future work should focus on diagnostic stewardship to improve documentation of loose stool and other CDI symptoms prior to testing to reduce unnecessary testing and overtreatment.

Background: Clostridioides difficile infections (CDI) are a leading cause of health-care associated morbidity and costs. University Health Truman Medical Center is a longstanding 238-bed safety net hospital in Kansas City, MO, where there was an increase in hospital-onset (HO) CDIs in 2024. To improve our infection prevention and control measures, we sought to study these HO CDI cases. Methods: Using a retrospective cohort study design and electronic health records, we retrieved data for inpatients who were identified as having HO CDI by our department of infection prevention and control in 2024. HO CDI was defined as a positive test for toxigenic Clostridioides difficile (C. difficile) polymerase chain reaction (PCR) performed on unformed stool collected on hospital day > 3 (with preagreed intuitional criteria in place). Data included demographic and epidemiological variables, comorbidities, onset of diarrhea and timing of stool collection, length of stay (LOS) and exposures (within prior 6 months) to hospitalization, surgery, and/or medications including laxatives, proton-pump inhibitors, immunosuppressants and antimicrobials. Results: In 2024 there were 20 HO CDI cases (versus 9 in 2023) with consequent increase in the CDI rate per 10,000 patient days and the standardized infection ratio. The characteristics of the CDI cases (percentage; mean ± standard deviation) were as follows. Most cases were females 60%. The mean age was 61 ± 18 years and BMI 28 ± 11 kg/m2. Recent hospitalization was common; 50% of cases had been hospitalized within 28 days and 70% within 6 months of their positive C difficile test. All cases had one or more comorbid conditions while one patient (5%) had past history of CDI. The median LOS was 18 days with frequent room changes and 35% of cases had an intensive care unit exposure. All had received systemic antibiotics either singly or in combination and the most commonly used agents included cephalosporins (90%) and penicillins with beta-lactamase inhibitor (35%). Laxative use was common (65%) as were history of surgery (55%) and intravenous contrast exposure (50%). Most cases (70%) were treated with oral vancomycin with three cases receiving a taper/prophylaxis, while five cases received fidaxomicin; there was one case of recurrence. Conclusions: Recent hospitalization and laxative use were high among HO CDI cases in a safety net hospital, raising concern for potential over-diagnosis. Switching to a two-step C difficile stool testing algorithm (PCR+ toxin enzyme immunoassay), though more costly, would be a useful mitigation strategy.

Background: Approximately half of all fevers in intensive care units (ICUs) are attributed to noninfectious causes. Despite this, most providers routinely culture urine from patients with indwelling urinary catheters who develop a new fever, which can lead to overdiagnosis and unnecessary antibiotic use. This study evaluated the impact of transitioning from a urinalysis (UA) with reflex to culture order to a stand-alone UA with microscopy in the Surgical and Neurosciences Intensive Care Unit (SNICU) on the frequency of urine cultures ordered and Catheter-Associated Urinary Tract Infections (CAUTIs). Methods: This quasi-experimental before-and-after study was conducted at the University of Iowa between July 2022 and August 2024 and included all SNICU patients. In August 2023, SNICU staff were educated to send a UA with microscopy, review results with the care team, and then decide whether a reflex to culture was warranted. This initiative was collaboratively developed by SNICU leadership and the hospital epidemiology team. Data on the frequency of urine cultures and CAUTI rates per 1,000 catheter days were compared before and after implementation using a P chart in QI Macros. Results: During the pre-intervention period, SNICU ordered approximately 66 urine cultures per 1,000 patient days, with a CAUTI rate of 1.55 per 1,000 catheter days (Figure 1a and 1b). While all data points remained within control limits, red data points between November 2022 and January 2023 indicated possible special cause variation; after further investigation, the specific cause was not identified and data points returned to normal cause variation. Following implementation, the frequency of urine cultures decreased to approximately 32 per 1,000 patient days, and the CAUTI rate dropped to 0.47 per 1,000 catheter days. The intervention also resulted in greater process stability, as evidenced by a narrower range between the upper control limit (48.97) and lower control limit (15.36). These improvements demonstrated the effectiveness of transitioning to a deliberate, decision-making process based on UA with microscopy. Conclusion: Transitioning from reflex urine culture orders to a stand-alone UA with microscopy, combined with provider decision-making and leadership engagement, significantly reduced the frequency of urine cultures and CAUTI rates in the SNICU. By requiring a deliberate review of UA results before ordering cultures, this intervention successfully optimized diagnostic stewardship. The pilot program will be integrated into the electronic medical record and expanded to other units.

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections (HAIs), often resulting in prolonged hospital stays, increased healthcare costs, and additional clinical interventions. The COVID-19 pandemic introduced new challenges to infection prevention, with global reports indicating increased rates of certain HAIs, such as ventilator-associated pneumonia and bloodstream infections, due to healthcare strain and the intensified use of invasive devices. However, trends in CAUTI rates during the pandemic varied across healthcare settings. Methods: This retrospective study was conducted at the University of Iowa Health Care Medical Center, an 866-bed academic hospital, from 2018 to 2023. Manual chart reviews of CAUTI cases reported to the National Healthcare Safety Network (NHSN) were performed to collect data on patient demographics, medical histories, catheter usage, and infection prevention practices. CAUTI incidence was analyzed over time and compared with monthly COVID-19 admission rates. Results: A total of 226 CAUTI cases were identified during the study period. The average CAUTI rate per 1,000 catheter line-days declined from 1.23 in 2019 to 0.85 in 2020, but increased to 1.28 in 2021, coinciding with COVID-19 surges (Figure 1). The median patient age was 61 years, with females accounting for 56% of cases. Foley catheters were already in place upon admission in 24% of cases. Non-intensive care unit (ICU) inpatient settings accounted for 24% of catheter placements, while ICUs accounted for 18%. Additionally, 16% of cases originated from the operating room, and 7% from the emergency department. Neurologic disease was the most common admission diagnosis (27%), followed by cardiovascular disease (13%) and Hematologic/Oncologic disease (13%). Twenty six percent of cases were incontinent of urine and 24% of stool. Comorbidities included immunocompromised status (20%) and diabetes (36%). The primary indication for Foley catheter use was monitoring intake and output (42%). Of the 226 cases, 61% of patients were clinically considered to have a UTI. In-hospital mortality was 22%. Conclusion: The findings from this study provide insights into factors contributing to CAUTI at our institution. Fluctuations in CAUTI incidence, particularly during the COVID-19 pandemic, underscore the need for robust infection prevention strategies. The finding that only 61% of cases required treatment suggests urine cultures were often obtained inappropriately or positive results were not used in selected situations. This highlights an opportunity for diagnostic stewardship to improve urine culture practices. Addressing identified risk factors and enhancing catheter management are critical to reducing CAUTI incidence and improving patient outcomes.

Introduction: Patients with mechanical circulatory support (MCS) devices, such as ventricular assist devices (VAD) and extracorporeal membrane oxygenation (ECMO), are excluded from the National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) criteria, whereas patients with intra-aortic balloon pumps (IABP) and Impella devices remain included. Since both MCS and Impella/IABP devices are associated with bloodstream infection risks, this study compares bacteremia rates among patients with VAD/ECMO, IABP/Impella, and central venous catheters (CVCs) to inform more accurate infection reporting. Methods: Using a surveillance database, we retrospectively reviewed bloodstream infections among patients with a CVC, ECMO/VAD, or IABP/Impella admitted to Duke University Hospital Cardiology units from January 2019 to July 2024. Bacteremia episodes were calculated per 1000 device days, with de-identified data pooled for final analysis. Results: A total of 849 bacteremia episodes were observed in patients with only a CVC (0.14 episodes/1000 device days), 98 in patients with ECMO/VAD (0.19/1000 device days), and 64 in patients with IABP/Impella (0.16/1000 device days). (Figure 1) Bacteremia incidence rate ratio (IRR) in patients with ECMO/VAD compared to patients with only a CVC was 1.30 (95% CI 1.05, 1.60, p-value 0.01). Bacteremia IRR in patients with Impella/IABP compared to patients with only a CVC was 1.12 (95% CI 0.87, 1.45, p-value 0.37). However, when we combined both ECMO/VAD and IABP/Impella bacteremia episodes and compared the bacteremia rate to patients with only a CVC, the incidence rate ratio was 1.22 (95% CI 1.03, 1.44, p-value 0.02). Discussion: The significantly different combined bacteremia rates among ECMO/VAD and IABP/Impella suggest that both device categories have significantly higher rates of bacteremia compared to CVC-only patients. Thus, NHSN should reconsider NHSN exclusion criteria for Impella/IABP patients similar to that for ECMO/VAD patients. Further collaboration with institutions, could strengthen findings and refine infection control protocols in high-risk, device-dependent patients.

Background: Central Line-Associated Bloodstream Infections (CLABSI) are multifactorial, making trends difficult to identify. CLABSI can occur from the time of insertion to delayed removals beyond the time central access was indicated. The objective of creating a CLABSI Preventability Index tool was to enable strategic quality improvement work. Methods: A preventability index tool was created with stakeholder input and was categorized into four categories (see Table 1): Indication for Line, Care and Maintenance and Line Access, Diagnostic Stewardship, and Specimen Collection. Each category had one or more questions prompting users to assign points for each preventable action. Scores range from 0 through 15, with the higher score indicating more prevention opportunities. (See table 2). Results: During the 2024 calendar year, there were 25 Adult CMS CLABSIs. The preventability index was applied to each case. There was 1 ‘extremely preventable’ case, 2 ‘very preventable’ cases, 6 ‘preventable’ cases and 16 ‘not preventable’ cases. In the 3 cases scoring very preventable or extremely preventable, the category “indication for line” was consistently scored high. Two of the 3 cases had preventable actions from a care and maintenance standpoint, 2 cases scored for diagnostic stewardship category and all 3 cases scored in the specimen collection category. In the 22 cases scoring 6 or lower, 0 scored in the indication for line category, 16 scored in the care and maintenance category, 11 scored in diagnostic stewardship and 4 scored in specimen collection. Conclusion: The preventability index objectively identifies the highly preventable CLABSIs in order to target high-priority actions to prevent future cases. Based on this tool, the use of central lines when not indicated causes the highest preventability scores, but care and maintenance activities score the most frequently.

Background: We aimed to examine the impact of daily bathing with chlorhexidine gluconate (CHG) on central line associated bloodstream infections (CLABSIs), catheter associated urinary tract infections (CAUTIs), and bloodstream infections with methicillin-resistant Staphylococcus aureus (LabID MRSA) across a large, rural healthcare system. This healthcare system encompasses 8 large community hospitals, one academic hospital, and 11 hospitals with 50 or fewer beds. Starting in August 2023, all facilities were required to adopt daily CHG bathing for patients with central lines and/or in intensive care units. Some facilities also chose to adopt CHG daily bathing for patients with foley catheters. Methods: We analyzed the hospital-wide monthly incidence of select healthcare associated infections (HAIs) in the year before and after implementation of CHG bathing across a large, decentralized, rural healthcare system. We conducted negative binomial regressions to examine the difference in HAIs before/after implementation of CHG bathing, and we used the National Healthcare Safety Network’s (NHSN) predicted numbers of HAIs to adjust for confounding among hospitals. Results: After adjusting for each hospital’s predicted number of infections, we saw a 40.1% decrease in CLABSIs (p=0.008) and a 33.2% reduction in CAUTIs (p=0.018, Table 1); we also observed a 34.3% reduction in LabID MRSA, although this was not statistically significant (p=0.105). Conclusion: System-wide implementation of CHG daily bathing in a large, decentralized, rural healthcare system was associated with a significant reduction in CLABSIs and CAUTIs.

Background: Social vulnerability factors have been associated with negative health outcomes. However, it remains unclear how they affect device-related infections in different population groups. Methods: This retrospective observational cohort study included Central-Line Associated Bloodstream Infections (CLABSI) and Catheter Associated Urinary Tract Infections (CAUTI) in an 850-bed, academic tertiary care facility. Information was collected on patient demographics, the CDC Social Vulnerability Index (SVI), hospitalization, comorbidities, and COVID-19 status. SVI analysis included overall vulnerability comprised of the four themes: socioeconomic status, household characteristics, racial/ethnicity minority status, and housing type/transportation. Chi-square and Wilcoxon rank-sum tests were used for categorical and continuous variable comparisons. GEE models compared pre- and pandemic periods by interrupted time series analysis. Results: Between 1/1/2018 to 5/31/2022 98,791 patients were admitted 151,550 times. Of those, 17,796 patients received 29,483 central lines and 45,180 patients had 65,422 Foleys. 314 patients developed 338 CLABSI and 216 patients had 217 CAUTI. 1,552 patients tested positive for COVID-19 with 22 developing CLABSI and 14 CAUTI. The pre-pandemic downward trend in CLABSI and CAUTI was reversed during COVID-19 (p Throughout the study Black patients had higher device days (p In the SVI analysis the socioeconomic theme was associated with higher risk of device-related CLABSI across the entire study (p=0.03). During COVID-19 overall SVI and the household characteristics theme were associated with higher device-related CLABSI rates (p=0.03; p=0.03). Adjusting for race or ethnicity dissolved those associations. For CAUTI race/ethnicity minority status was linked to an event throughout the study (p=0.03). This held true after adjusting for individual race or ethnicity status. No associations were detected in the pre- and pandemic periods for CAUTI. Conclusions: Health outcome disparities affected Black (CLABSI and CAUTI) and Hispanic/Latino (CLABSI) patients. Of note, both groups had significantly higher device utilization rates. Per-patient infections increased during the pandemic without altering race/ethnicity differences. Higher race/ethnicity minority status SVI was linked to CAUTI. However, CLABSI were driven by the socioeconomic SVI. The findings can help clarify the relationships between race/ethnicity and other demographic and socioeconomic factors associated with device-related infections on the community and individual level.

Background: Catheter-related or central line-associated bloodstream infection (CRBSI/CLABSI) is a common and serious complication in patients undergoing hemodialysis (HD), often resulting in significant morbidity and mortality. Managing CRBSI/CLABSI often requires removing the central venous catheter (CVC) and placing a new one at a different vascular site. However, this approach is not always feasible for these patients that often have limited vascular access. No adjunct antimicrobial lock therapy has been FDA-approved for managing such infections and is urgently needed to salvage HD vascular access. Our study evaluated a novel triple combination antimicrobial catheter lock solution containing minocycline, EDTA, and ethanol (Mino Lok (MLT)). MLT has shown broad-spectrum in-vitro activity and positive results in a Phase 2 trial. Herein, we report the results of MLT CVC-salvage therapy in the subgroup of HD subjects from a phase 3 trial. Methods: This international, multicenter, superiority trial was conducted at 34 sites. HD, cancer, or other patients requiring a long-term CVC (LTCVC), aged ≥ 12 years, with CLABSI/CRBSI, were enrolled and randomized (1:1 ratio) to receive MLT or site-specific standard of care (SOC) antimicrobial lock therapy for 2 hours/day for 7 days. The primary endpoint was median time to catheter failure (i.e., mortality, catheter removal due to inability to administer lock or infectious-related reasons, worsening signs/symptoms, persistent or recurrent bloodstream infection, or deep-seated infection). Results: From February 2018 to February 2024, 54 HD patients were enrolled and randomized: 26 to MLT and 28 to SOC. Gram-negative bacteria accounted for 50% of CLABSI/CRBSIs, gram-positive bacteria 43%, and Candida species 7%. Highly virulent organisms (non-commensals) caused 69% of all cases. Patients in SOC had a significantly shorter time to catheter failure compared to MLT (p=0.03) with 25% of CVCs failing by day 6 and 50% by day 22 in SOC compared to 25% failing by day 37 in MLT (Figure 1). Similarly, 16 subjects (57%) in SOC had a CVC failure event compared to only 8 (31%) in MLT. Adverse events (AEs) and serious AEs (SAEs) were comparable between the two groups. There were no drug-related SAEs. Conclusion: This phase 3 pivotal study demonstrated MLT to be highly effective and superior to SOC antimicrobial lock therapy in salvaging LTCVCs associated with CRBSI/CLABSI in HD patients. MLT has broad-spectrum activity, was well-tolerated, and was not associated with drug-related SAEs. MLT may satisfy an urgent unmet need in salvaging HD catheters in patients with CRBSIs/CLABSIs.

Background: During the COVID-19 pandemic, the rate of central line-associated bloodstream infections (CLABSI) decreased at the Veteran Affairs North Texas Health Care System. From fiscal year (FY) 2022 Quarter (Q)4 to FY2023 Q2, the CLABSI rate increased from 0 to 0.79 per 1,000 device days. Breaches in evidence-based practices for the maintenance of vascular access devices (VAD) were hypothesized to have contributed to the increase in CLABSI rate. Methods: In March 2023, a multidisciplinary workgroup was created with the primary goal of improving compliance with VAD standards of care to ≥ 95% by FY2023 Q4 and a secondary goal of decreasing CLABSI rates. A baseline assessment of 12 VAD insertion and maintenance process measures was developed using an assessment tool to record nurses’ observations and review documentation in the computerized patient record system. In addition, the facility VAD policy was updated, and nurses received competency training on VAD management. Baseline compliance data for the 12 VAD process measures was compared to data during the intervention period for acute and critical care areas. CLABSI rates (classified using the National Healthcare Safety Network surveillance criteria) were compared to the period before the creation of the workgroup, policy updates, and training. Results: Nurse observations in acute and critical care units during FY2023 were 19 (Q2), 1,284 (Q3), and 718 (Q4). From FY2023 Q2 to Q4, three of the 12 process measures met the ≥ 95% compliance goal by FY2023 Q4. The process measures that met the goal from Q2 to Q4 were clean peripheral IV catheter hub: 100% to 95.0%, unused tubing Y-sites capped with swap cap: 0% to 96.0%, and documentation of the last dressing change in CPRS: 0% to 99.0%. Notable increases were also seen for three other measures: appropriately dating of peripheral IV tubing: 78.9% to 88.0%, presence of Coban or kerlix occluding site: 0% to 46.0%, and documentation of device insertion: 0% to 89.0%. Persistent deficits were noted in the documentation of peripheral intravenous dressing dates and initials (compliance Conclusions: Enlisting a multidisciplinary team approach, including training, and updating VAD policy/procedures, led to a moderate improvement in VAD management compliance and a decline in CLABSI rates.