Background: Invasive fungal diseases (IFDs) are severe infections caused by fungi that can spread throughout the body, particularly in individuals with weakened immune systems. These infections are increasingly challenging, especially those that are resistant to antifungal treatments. IFDs represent an emerging global threat, highlighting the urgent need for increased attention and research. In 2022, the World Health Organization (WHO) released the WHO Fungal Priority Pathogen List (WHO-FPPL), ranking 19 fungal pathogens as critical, high, or medium based on criteria such as incidence, treatment options, and mortality rates. While Candida albicans and Candida auris are well-known and included on the list, it also features four other species of concern (C. glabrata, C. tropicalis, C. parapsilosis, C. krusei) that are not typically listed on disinfectant master labels. This study aims to evaluate the antimicrobial susceptibility differences between Candida species from commonly used healthcare disinfectant products. Method: Antimicrobial efficacy testing was conducted using common healthcare disinfectants against the WHO-FPPL listed Candida species, following standard operating procedures typically required for disinfectant product registration by the U.S. EPA. Each disinfectant formulation represented a common active ingredient, or active ingredient blend, used in healthcare settings for surface disinfection, ranging from ready-to-use sprays to wipes. Products were tested at approximately 75% of the manufacturer-defined contact time listed on the EPA master label to stress the chemistry and elucidate antimicrobial susceptibility differences between Candida species. Results: Antimicrobial efficacy varied across Candida species for the tested chemistries. Of the six Candida species tested, C. parapsilosis was the most difficult to eradicate. The remaining Candida species exhibited less variability with C.auris and C. krusei demonstrating slightly lower susceptibility across all of the disinfectant types than C.albicans, C. glabrata, and C. tropicalis. Conclusion: This study underscores the variability in efficacy between these emerging fungal pathogens and common healthcare disinfectants. While C. auris remains a primary concern in healthcare settings, these findings highlight the continued need for ongoing fungal surveillance, research of emerging fungi, and the potential impact on environmental hygiene practices.

Background: Candida auris, a multi-drug resistant fungal pathogen, was first detected in Tennessee healthcare facilities in 2022. C. auris can colonize a patient’s skin and cause clinical infection. Patients with clinical infections have high mortality, with a wide range of reported rates between 30 – 72%. Here we compare the risk factors associated with 30-day all-cause mortality among colonized and clinical cases in Tennessee. Method: Clinical and colonization C. auris case data was obtained from the Tennessee State Public Health Laboratory. Cases with only a skin specimen were classified as colonization, while patients with any other sterile or non-sterile collection site were classified as clinical. Mortality data was obtained through the Tennessee Office of Vital Records and matched with C. auris case information. Risk factors for multi-drug resistant organism acquisition were collected using a REDCap survey completed by facility staff. Chi-square tests were used to compare mortality and risk factor differences. All analyses were conducted in SAS Enterprise Guide v8.3. Result: Between 2022 and 2023, 130 out of 418 colonized patients (31.1%) and 33 out of 108 clinical cases (30.1%) died with no significant differences in age. Of the patients that died, 20 (60.6%) with clinical infection and 50 (38.5%) with colonization died within 30 days of specimen collection (p<.05). However, eight patients with clinical infection who died within 30 days of specimen collection were previously colonized. Risk factors associated with C. auris acquisition were available for 55 patients with clinical infection and 120 with colonization. Patients with clinical infection who died within 30 days of specimen collection were more likely to have incontinent urine (p<.05), a draining wound (p<.05), and have a gastric tube placed (p<.05) than those who survived. Patients with colonization who died within 30 days of specimen collection were more likely to have a previous stay in an inpatient rehabilitation facility (p<.01), an ambulatory surgery center (p<.01), and less likely to have a tracheostomy tube placed (p<.05) than those who survived. Conclusion: Patients with clinical C. auris infection are more likely to die within 30 days of specimen collection than patients with colonization in Tennessee. However, risk factors associated with C. auris acquisition varied between patients with clinical infection or colonization and are not consistently associated with higher mortality. Clinical teams should emphasize infection prevention and control practices that reduce the risk of invasive infection in colonized patients in all settings, regardless of perceived risk.

Background: Candida auris is an emerging multidrug-resistant pathogen that presents significant infection control challenges due to its ability to cause invasive infections and outbreaks. Despite its increasing prevalence in healthcare settings, there is limited guidance or data related to perioperative infection prevention in patients colonized with C.auris.(1-4) CDC guidelines do not address perioperative screening or management of C.auris in surgical patients, including solid organ transplant recipients.(5)

This study examines the reported experiences and approaches infectious diseases professionals take in managing C.auris colonization perioperatively. Methods: An online “Quick Query” poll was distributed to members of the Emerging Infections Network (EIN). EIN Quick Queries are a unique tool that utilize focused rapidly-deployable polls to ascertain members’ opinions/approaches to emerging infectious diseases with limited data, allowing for hypothesis generation or identifying areas of need. Our poll included 6 questions assessing perioperative prevention of C.auris infection. Descriptive analysis was used to evaluate responses. Results: Eighty-four EIN members completed the poll, representing 29 U.S. states and three other countries/territories. California accounted for the largest share of responses (17%), followed by Massachusetts (7%), and Florida (6%). Institutional protocols for C.auris prevention/management in surgical patients existed in 17% (14/84) of facilities, with only one facility reporting transplant-specific guidelines (Figure 1). Preoperative screening for C. auris was reported by 8% (7/84) of respondents, predominantly from California (5/7). Among the 44 respondents who encountered colonized surgical patients, only four (9%) used perioperative antifungal prophylaxis, with micafungin as the preferred agent. Notably, none of the seven sites utilizing preoperative screening reported using perioperative anti-fungal prophylaxis for C. auris colonization. Three of the four respondents who used perioperative antifungal prophylaxis also reported encountering postoperative C.auris infections in colonized surgical patients, suggesting evolving practices influenced by clinical outcomes. C.auris colonization in transplant recipients prior to transplantation was reported by 11 respondents (13%), while only two (2%) reported encounters involving transplants from colonized donors. In total,19% of respondents (16/84) reported postoperative invasive C.auris infections in previously colonized patients, including 13 surgical patients and 3 transplant recipients. Three other cases were described among transplant recipients without known donor or recipient colonization pre-transplant. Conclusion: The survey highlights the lack of institutional guidelines for Candida auris prevention in perioperative settings, including among solid-organ transplant patients. Postoperative C.auris infections are being encountered, although uncommon, underscoring the need for further research and standardized guidelines to address perioperative prevention of this emerging pathogen.

Background: Hand hygiene is an important strategy for reducing healthcare-associated infections. While efforts to improve nursing home (NH) staff hand hygiene have been prioritized, there are few if any policies in-place to improve resident hand hygiene. Further, CMS guidance requires that residents be bathed “twice a week.” The objective of this study was to characterize resident hand hygiene knowledge and habits as well as bathing practices to identify barriers in a setting where new intervention strategies could be aimed. Methods: The survey was administered at 20 NHs across the United States between December 2023 and July 2024. Verbal consent was obtained from residents before survey administration. Survey questions explored residents’ hand hygiene knowledge and differences in hand hygiene habits and bathing practices since entering the NH from their last place of residence. Three knowledge-based questions assessed residents’ understanding of the recommended length of time to wash hands and use hand sanitizer in addition to when hand washing should be utilized instead of hand sanitizer. Frequency of hand washing, either through soap and water or hand sanitizer, instances of when and how residents wash and dry their hands, and whether resident’s faced challenges were assessed. Results:Of the 495 residents who completed the survey, only 142 (29%) residents answered all three knowledge-based questions correctly. Residents who answered two or three questions correctly reported washing their hands more frequently at their previous residence compared to residents who answered zero or one correct (Figure 1). Frequency of hand hygiene was lower at the NH compared to their previous residence across a variety of indications (Figure 2). More residents faced challenges with washing their hands at the NH compared to their previous residence (30% vs. 7%, P<.001). The most common challenges included: mobility limitations, medical issues, need for assistance, bathroom accessibility and inadequate bathroom supplies/equipment. About half the residents (53%) reported never being reminded to wash their hands; 60% reported that they would use hand sanitizer if it was easily accessible. 51% of residents reported bathing with soap and water less at the NH compared to their previous residence with reported causes being needing help and not receiving it, nursing home policy, medical issues, and mobility limitations. Conclusions: Survey results indicate opportunities for interventions aimed at reducing the barriers to hand hygiene practice and improving bathing practices in NHs. Policy changes and hand hygiene educational opportunities addressing these barriers could serve as potential strategies.

Background: Hand hygiene is the most crucial practice for reducing the transmission of infections in healthcare settings. Despite substantial data highlighting its importance, healthcare institutions frequently struggle to maintain high hand hygiene compliance rates among healthcare workers (HCWs). Low HCW hand hygiene compliance can lead to an increase in healthcare-associated infections, longer hospital stays, antimicrobial resistance, and higher healthcare costs. Low compliance can also have regulatory and reimbursement implications for healthcare systems. This highlights the urgent need for innovative interventions focused on improving HCW hand hygiene compliance. Methods: We piloted a novel program at Brown University Health (BUH) that enabled patients and visitors to audit HCW hand hygiene using an online interface. This trial was implemented in an iterative fashion in 1 outpatient clinic and 5 inpatient units over 5 months (Figure 1). A poster with program information and a QR code linked to the audit form was placed in each room and/or handed to patients/visitors. Patients/visitors were instructed to scan the QR code with their phones to access the audit form, which included three questions about their location (inpatient/outpatient), if HCWs performed hand hygiene (yes/no), and if they would feel comfortable asking staff to perform hand hygiene (yes/no). The form was available in English, Spanish, and Portuguese. Responses were recorded securely and anonymously in the online platform and monitored by Infection Control. Additionally, HCWs on these units received a survey to provide feedback on this program. Results: Patients and visitors recorded 98 hand hygiene audits of staff during the program trial: 72 from the outpatient clinic and 26 from the inpatient units (Table 1). HCW hand hygiene compliance observed by patients/visitors was 92% in both inpatient and outpatient settings, resulting in an overall compliance rate of 92% during the pilot program. Figure 1 shows HCW hand hygiene compliance rates as measured by trained BUH staff in the pilot units and clinic during 2024 in relation to the implementation of this program. We found that after the start of education and implementation of the patient/visitor hand hygiene auditing program in these units, compliance generally increased and remained above pre-intervention levels. Conclusions: This pilot program demonstrates the feasibility and potential effectiveness of engaging patients and visitors in hand hygiene interventions. The results of this pilot suggest that this novel approach warrants further investigation and broader implementation as part of larger efforts improve HCW hand hygiene compliance and reduce healthcare-associated infections.

Introduction: Hand hygiene (HH) performance in our facility declined during the COVID-19 pandemic and failed to return to baseline despite a widespread education campaign and increased HH rounding. To better understand provider perceptions and inform future interventions, we conducted a survey examining self-perception of HH performance, factors determining HH practices, barriers to adherence, and burnout. Methods: The survey assessed self-perceived HH performance relative to peers, perceived opportunities for improvement, barriers to HH, factors causing variation in personal HH practice (workload/acuity, peers, time of day, patient characteristics), and self-reported burnout using a validated, single-item burnout scale. Surveys were conducted in-person with clinical providers on one high-performing and three lower-performing intensive care units. All available clinical team members were included; non-clinical staff were excluded. Self-perception of performance was compared by unit, role, years of experience, and burnout rating using the Kruskal-Wallis test. Analyses were completed in SAS 9.4, Cary, NC. Results: One hundred surveys were completed. One person declined. The majority of those surveyed believed themselves to be in the top quartile of HH performers (87%). The actual HH compliance measured on these 4 units for 1/2024-11/2024 was 65% based on 7726 total directly observed opportunities. No one selected bottom or bottom 3rd quartiles. Figure 1 shows responses by percentile self-ranking. There was no difference in perceived performance by unit (p=0.4006), years of experience (p=0.9679), or burnout (p=0.2621). Non-clinical “other” type providers perceived performance to be slightly higher than clinical provider types: mean 91st percentile versus 82nd for prescribing providers, 84th for students, and 81st for nurses/nurse assistants, p=0.0353. Empty HH dispensers was the most frequent barrier cited, by 77%. A point prevalence survey on these 4 units completed the week after the survey ended verified that 22% (25/113) of dispensers were empty, however, in all of the 25 except for 1, there was a filled dispenser within 8 feet of the empty one. Discussion: HH performance was perceived to be better than average by the majority of inpatient healthcare providers (HCP) surveyed, despite data from these units indicating opportunities. Empty dispensers were consistently cited as a barrier, but likely could have been surmounted by a few steps based on the locations of the next available filled dispensers. Further improvement in HH will be difficult without efforts to move perception closer to reality for individual HCPs. Video footage or re-enactments of an observed care episode may help identify opportunities for improvement.

Background: Uganda has a high prevalence of healthcare associated infections (HCAIs) with 28% often linked to inadequate hand hygiene practices among health workers. Hand hygiene is one of the most important measures in reducing the transmission of nosocomial infections. Implementing a world health organization (WHO) multimodal hand hygiene improvement strategy has shown influence on health workers’ behaviors, knowledge and practices. We aimed at evaluating hand hygiene compliance among health workers before and after implementation of the WHO multimodal improvement strategy at select health facilities(HF) in Uganda. Method: 27 health facilities were randomly selected from two regions in Uganda to implement the WHO multimodal hand hygiene improvement strategy over a period of 4 weeks. Before the interventions, healthcare worker’ (HCW) compliance with hand hygiene during routine patient care was directly observed using the WHO hand hygiene observation tool. Interventions included; weekly onsite mentorships focusing on Training and education, provision of locally produced alcohol-based hand rubs (ABHR), soap, and placement of reminders such as posters at point of care areas to emphasize the importance of hand hygiene. HCWs from different facility departments were designated to champion hand hygiene. We recorded and distributed hand hygiene promotional videos to the health facilities to reinforce key messages consistently. After the interventions, follow up observations were conducted and data was analyzed using SPSS 20. Results: A total of 156 health workers were observed at baseline and 151 at follow on. 1,205 hand hygiene opportunities were recorded at baseline and 1,369 at follow on. 454 actions were observed at baseline and 845 after. Healthcare worker hand hygiene compliance improved from 32.6% (SD=23) to 60.7% (SD=23; p=0.0083) after the intervention. The increase in compliance to hand hygiene was different across all professional categories with significant improvement among Lab technicians (72% Versus 35%). Compliance among students remained low at 36% versus 38% post intervention. 76% of the observed health workers preferred use of locally produced ABHR while 22% used water and soap. Conclusion: The improvement in hand hygiene compliance among health workers following short term interventions using the WHO multimodal improvement strategy shows potential effectiveness. This underscores the importance of prolonged commitment from hospitals in adopting and reinforcing this strategy for long-term improvements in hand hygiene practices among health workers.

Background: Appropriate hand hygiene is one of the most important ways to reduce the transmission of pathogens and prevent healthcare-associated infections (HCAIs), but the rate of compliance among doctors remains low. The purpose of this study is to evaluate the impact of the COVID-19 pandemic on the rate of hand hygiene compliance among doctors during outpatient consultations. Method: This study was conducted on doctors providing outpatient care at Mie University Hospital (Japan) from January 2019 to December 2023. The electronic counting device, Hand Hygiene Monitoring System Compleo-IO, was used, which automatically tallies the amount of alcohol-based hand sanitizer used by installing a wireless device under the hand sanitizer dispenser. The hand hygiene compliance rate was calculated by dividing the number of times hand disinfection was performed by the number of patients receiving outpatient care. We measured the hand hygiene compliance rate of each department and each doctor every month, and evaluated the changes in the impact of the pandemic on the hand hygiene compliance rate. In addition, we categorized the compliance rate into poor (0% to < 25%), average (25% to < 50%), and good (50% or more) categories, and visually evaluated the transition of the categories over the years. Result: The hand hygiene compliance rate in 27 departments was 24.8% on average before the pandemic (2019), but rose to 35.2-39.4% in the early stages of the pandemic (2021-2022). However, in the late stages of the pandemic (2022-2023), it had returned to baseline values of 25.4-27.2%(figure1, 2). The hand hygiene compliance rate among individual doctors (based on 97 doctors for whom data could be measured continuously over a five-year period) was similarly 26.9% on average before the pandemic, but rose to 32.1% - 37.7% in the early stages of the pandemic. However, in the late stages of the pandemic, it had returned to baseline values of 26.0-26.6%(figure 3,4). Conclusion: During the unprecedented COVID-19 pandemic, hand hygiene compliance rates increased in the early stages of the pandemic, but eventually returned to pre-pandemic levels. We hope to use this experience to help us improve compliance rates on an ongoing basis.

Background: Several studies have shown an association between deprivation and excessive antibiotic use in the US. However, these studies were limited by their geographic design, making them unable to assess a causative relationship. This study analyzed the impact of socioeconomic deprivation on antibiotic days supplied among older Medicare Part D beneficiaries in the US using an instrument variable (IV) approach. Method: This study utilized the Medicare Part D and the Social Deprivation Index (SDI) repositories. The maximum Earned Income Tax Credit was chosen as an IV to consider the reverse causality of the SDI values. Spatial dependence between predicted SDI and study outcome (log antibiotic days supplied per 100 beneficiaries) was evaluated by global Moran’s I analysis and cluster mapping. Linear regression models were performed to assess the impact of predicted SDI or its components (poverty, single parent, low education, no car, renter-occupied, crowding, and non-employment) on the study outcome. The study adjusted for the following confounders: prescriber gender, specialty, graduate school rank, teaching location, metropolitan area, US state, and beneficiary characteristics (demographics, risk scores, and dual public insurance). Results: A total of 438,431 providers were included. There was no spatial dependence between the predicted SDI and study outcome (I = 0.007, P = 0.0656, Figure). Higher predicted SDI values resulted in higher antibiotic days supplied (log) per 100 beneficiaries (estimate 0.58, SE 0.16, P) Conclusion: This study showed a causative relationship between SDI and antibiotic days supplied. It highlights opportunities for public health in the US to explore gaps in antimicrobial stewardship. More studies are needed to investigate the knowledge and attitudes of patients and providers and potential barriers to access that might impact antibiotic prescription in older patients.

Background: Pediatric patients with underlying malignancies and hematological disorders, especially those undergoing hematopoietic cellular therapy (HCT) are at increased risk of developing central line-associated bloodstream infections (CLABSI). Despite the long-standing efforts to reduce CLABSI rates, healthcare disparities, particularly in minority populations, continue to contribute to preventable harm. The role of language barriers in CLABSI risk has not been well-explored, especially in pediatric HCT populations. This study aimed to evaluate the association between limited English proficiency (LEP) and CLABSI risk in pediatric HCT patients. Methods: This retrospective cohort study analyzed patients admitted to the transplant and cellular therapy unit of a pediatric oncology center between January 2021 and June 2024. Data collected from the electronic health records included patient demographics, preferred language, underlying primary diagnosis, types and dates of cellular therapy, and central line days (CLD) in the transplant unit. CLABSI events were identified through the hospital infection prevention and control surveillance database and classified as mucosal barrier injury laboratory confirmed bloodstream infection (MBI-LCBI) or non-MBI CLABSI based on NHSN definitions. CLABSI rates were calculated as events per 1,000 inpatient CLD and were compared between patients with LEP (defined as preferred language other than English) and those proficient in English. Multivariate regression model was used to evaluate the independent risk factors for CLABSI. Results: During the study period, 280 patients contributed a total of 12,325 CLD and 93 CLABSI events; of these 57 patients with LEP contributed 3,113 CLD and 29 CLABSI. The crude CLABSI rate in patients with LEP was significantly higher (9.32/1000 CLD) than that in English proficient patients (6.95/1000 CLD) Conclusions: This study highlights the increased risk of CLABSI in pediatric HCT patients with language barriers, the risk of which likely extends beyond this patient group. Addressing these barriers through novel equitable strategies, such as language support services and culturally competent care, is crucial for reducing healthcare disparities, improving clinical outcomes and promoting a more inclusive healthcare environment for diverse patient groups.

Background: Racial and ethnic disparities have been demonstrated across a range of healthcare outcomes and services, including infectious disease burden. Individuals who reside in communities with increased social vulnerability are more likely to experience worse infection-related outcomes. These disparities are likely exacerbated by structural and systemic inequities experienced during inpatient care, even for common diagnoses, such as urinary tract infections. We explored the relationship between race, population-level social vulnerability, and urine culture results in the inpatient setting. Methods: We conducted a retrospective cohort study at Stanford Health Care from January–December, 2023. We included all adult inpatients who had a urine culture collected. The Center for Disease Control’s Social Vulnerability Index (SVI) was used as a composite measure of social vulnerability. Patient addresses from electronic health records (EHR) were geocoded to determine census tract-level SVI designation using the California-specific SVI database, and out-of-state addresses were excluded. Unhoused patients were identified by a discrete field in the EHR. We included demographics, urine culture results, and time of urine culture collection. Community-associated positive urine cultures were defined by a collection time ≤48 hours from admission, while healthcare-associated positive cultures were collected >48 hours from admission. Results: There were 5,374 admissions with urine cultures collected in 2023. The overall median SVI was 0.34. Compared to the statewide median overall vulnerability of 0.50[IQR: 0.25–0.75], our inpatient population resided in less vulnerable areas. When comparing patients with positive and negative urine cultures, the overall SVI, the four-specific SVI themes and SVI quartiles were similar. Unhoused patients were more likely to have a negative culture than a positive culture. Patients who identified as Asian were more likely to have a healthcare-associated positive urine culture than a community-associated positive culture. Patients who identified as Hispanic were more likely to have a community-associated positive culture than a healthcare-associated positive urine culture. Patients who identify as white or black had similar likelihood of developing a community-associated or healthcare-associated positive culture. Discussion: We did not find any differences in SVI among patients based on urine culture positivity. However, when stratified by community- vs healthcare-associated we found that patients who identify as Asian or Hispanic may be more likely to have a positive urine culture. These differences in outcomes are likely complex and multifaceted, potentially related to various social drivers of health present both before and during admission. Further exploration is needed to understand what is contributing to these findings.

Background: There are numerous ways to measure social markers of health. One reliable method for predicting health outcomes is the social vulnerability index (SVI) which assesses multiple themes, including housing insecurity, socioeconomic status, and minority status. As a part of Multi-site Gram Negative Surveillance Initiative (MuGSI), surveillance of Extended-Spectrum Beta-Lactamase (ESBL)-producing Enterobacterales was conducted in four Tennessee counties (Maury, Marshall, Wayne, and Lewis). This study examines the association between social vulnerability and infection rates for ESBL-producing Enterobacterales within the surveillance area. Method: ESBL incident cases reported from July 2019 to December 2023 were analyzed. Cases were defined as the first isolation of Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca resistant to at least one extended-spectrum cephalosporin (ceftazidime, cefotaxime or ceftriaxone) and non-resistant to all carbapenem antibiotics from urine or normally sterile sites in residents of the surveillance area within a 30-day period. Pearson correlation analysis was conducted to evaluate the association between SVI scores and ESBL infection rates per 1,000 residents at the census tract level, as well as the four SVI ranking variables (socioeconomic status, household characteristics, racial & ethnic minority status, and housing type & transportation). Analysis was conducted using SAS 9.4. Geospatial analysis in ArcGIS Pro v2.9.7 produced a bivariate choropleth map, illustrating the interaction between SVI and ESBL infection rates. Result: From 2019–2023, 2,166 ESBL cases were reported. Cases were 21% male and 79% female, with mean age of 66 years. Incidence rates ranged from 0.19 to 19.5 per 1,000 population. The analysis revealed a significant positive relationship between SVI and tract-level ESBL infection rates. Higher vulnerability scores are associated with higher infection rates, as evidenced by the positive correlation coefficient (ℝ? = 0.38427, ℝ? = 0.0272). Pearson correlation analysis revealed that household type and transportation demonstrated statistically significant positive correlation with ESBL infection rates (ℝ? = 0.431, ℝ? = 0.0121). Conclusion:Information from geocoding surveillance data can be used to identify social groups at increased risk of infections with drug resistant pathogens. In this study, ESBL infection rate is significantly associated with SVI. Among the four themes, only household type & transportation status is found to be significantly associated with ESBL infection rates. Further research is needed to understand the role housing plays in the spread of ESBL infection, especially looking at both urban and rural populations. Using SVI scores as a risk assessment tool, infection preventionists and antibiotic stewards can prioritize high risk areas for intervention.

Background: The Texas Epidemic Public Health Institute (TEPHI) aims to safeguard public health and bolster the economy by preparing for infectious disease outbreaks. The Infection Prevention and Control Webinar (IPC) 200 series of the Small Rural Healthcare Preparedness offers free educational resources and continuing education for public health and healthcare personnel responsible for infection prevention programs across ten lectures from requested topics from TEPHIs IPC 100 series. Methods: Data from the second year of the Infection Prevention and Control lecture series were collected using attendee registration and attendance data, knowledge assessments, and post-lecture evaluation surveys via WebEx®, QuestionPro®, and Microsoft Teams®. The modules were developed using resources from the Association for Professionals in Infection Control and Epidemiology (APIC), the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), The Joint Commission (TJC), and Centers for Medicare and Medicaid Services. Results: The series had 1,088 attendees to the live lectures and generated 3,103 YouTube views. Lectures were accredited for 1.0 hours of public health education and a-IPC certification, with 8 of 10 sessions offering 1.0 continuing education hours for CIC certifications for infection preventionists. Of the 286 participants completing knowledge assessments, the average score was 91% (range: 81% in Module 201 to 96% in Module 206). Post-evaluations (n=280) rated the content highly (mean: 4.83/5) for beneficial, easy to understand, and clear/concise. Additionally, 90.4% of respondents indicated plans to implement the knowledge gained, and 98.9% expressed interest in attending future sessions. Conclusion: The Infection Control lecture series improved participants’ knowledge of infection prevention and control best practices. By disseminating evidence-based education and providing no-cost continuing education, the series equips healthcare personnel with the tools to foster safer environments for patients and staff in healthcare settings.

Background: Pediatric oncology patients receive significant care in outpatient settings using central venous catheters (CVC) for chemotherapy, blood product transfusions, parenteral nutrition, and blood tests. Data about the rate of ambulatory central line associated bloodstream infection (CLABSI) is limited and its prevention activities have been derived from the inpatient setting with potentially limited applicability to the outpatient care. In this quality improvement project, we used apparent cause analysis (ACA) to better identify barriers and facilitators to reduce ambulatory CLABSI in a pediatric oncology center. Methods: Since January 2024, ambulatory CLABSI events were identified by reviewing positive blood culture reports in an electronic surveillance system. The infection preventionist (IP) classified events as CLABSI or mucosal barrier injury (MBI) laboratory confirmed bloodstream infection (LCBI) using modified NHSN definitions. Ambulatory CVC-days were reported electronically for active patients with CVC and outpatient encounters. In March 2024, ACA investigation of patients admitted for ambulatory CLABSI was implemented using an electronic tool designed to address questions related to CVC care in the outpatient or home care setting. The ACA team consisted of an IP, outpatient nurse, and inpatient nurse. The team visited with the caregiver and/or patient for an interview and used this opportunity for just-in-time teaching to patient caregivers and staff. The results were entered into a database for lessons learned. Results: From January to November, there were 70 events classified as CLABSI in 67% and MBI-LCBI in 33%. Median (range) age was 5.0 (0.5-22.0) years. 39% had leukemia, 43% solid organ or brain tumor, and 14% were transplant recipients. 53% were neutropenic. Coagulase-negative staphylococcus was the most frequently isolated organism in 21% of patients followed by Escherichia coli in 17%. 47% had an in-person ACA interview; of which, 43% reported caregivers performing CVC care at home and 67% reported having been trained in the past 90 days. Table shows lessons learned from the ACA of the ambulatory CLABSI. Conclusion: ACA of ambulatory CLABSI is an important strategy to identify challenges of CVC care in the outpatient or home setting and to guide the design of a targeted improvement plan to reduce ambulatory.

Background: Adherence with antimicrobial resistant organism (ARO) admission screening is suboptimal, despite clinical support tools in clinical information systems (CIS) to facilitate the process. Behaviour change techniques to improve adherence are needed. However, in a resource-constrained healthcare system, strategies that motivate healthcare workers (HCWs) to align their practices with infection prevention and control (IPC) policies need to be prioritized. Methods: An online survey (REDCap) and a virtual (Zoom) consensus meeting using a modified nominal group technique with online voting was conducted among HCWs, IPC, and the CIS staff in September and October 2024, respectively, to achieve consensus on a prioritized list of interventions to improve ARO admission screening at acute care and acute rehabilitation facilities (n=100) in Alberta, Canada. Interventions from the Behaviour Change Wheel were mapped to barriers/enablers influencing screening adherence. Each intervention was judged across the APEASE criteria (Acceptability, Practicality, Effectiveness, Affordability, Side Effects, Equity) using a 5-point Likert Scale. Consensus to include interventions required >4 criteria with >80% agreement, consensus to exclude required >4 criteria with 80%. Interventions that did not reach consensus were discussed to determine whether to include in the final candidate list. Attendees were asked to vote on their top three interventions from the final candidate list. Results: There were 15 barriers and one enabler to ARO admission screening, mapped to 43 unique interventions. Of these, 16 interventions addressed more than one barrier/enabler, while 27 interventions only addressed a single barrier. Fifty-nine respondents completed the survey. Most respondents (63%) were IPC staff, 20% were nurses, and 17% were other HCWs (including IPC physicians). Nine interventions met criteria to include in the candidate list, 26 were excluded, and 8 interventions did not reach consensus in the survey and were discussed. There were 32 attendees at the consensus meeting (53% IPC staff and physicians, 34% clinical staff, 13% other provincial teams). Three interventions were selected: 1) creating a nursing task to complete the tool in the CIS when an admission order is signed, 2) add a banner on the CIS Storyboard when the tool is not complete, and 3) develop a best practice guideline for frontline staff on ARO admission screening. Conclusions: The survey and consensus meeting were efficient methods to determine a prioritized list of interventions, which will be implemented and evaluated, to improve ARO admission screening in Alberta.

Background: Treprostinil, a prostacyclin analog, is used to manage pulmonary hypertension (PH) through continuous intravenous (IV) infusion via a central venous catheter (CVC) or continuous subcutaneous (SC) infusion via a small infusion pump connected to a catheter. This study compares the incidence and the types of infections between IV and SC administration in a single-center cohort. Methods: We analyzed 49 PAH patients receiving treprostinil at the Hartford Hospital PH Center, all managed under standardized hygiene protocols by the same healthcare team. Of these, 34 received IV administration and 15 SC, based on patient preference and PH specialist recommendations. The primary outcome was the incidence of infection in each group during the study period. The secondary outcome was the type of infection, including bacteremia, cellulitis, or other skin infections, associated with IV or SC administration. Results: The incidence of bacteremia was significantly higher in the IV group, with 7 cases (5 isolated bacteremia and 2 bacteremia with cellulitis), representing 20.6%. In contrast, there were no bacteremia cases in the SC group. Cellulitis was more common in the SC group (20%; 3 out of 15 patients) compared to the IV group (8.8%; 3 out of 34 patients). Notably, 2 cases of cellulitis in the IV group were associated with bacteremia, while all 3 cases in the SC group were isolated, with 1 progressing to an abscess requiring incision and drainage. The overall infection rate (bacteremia and cellulitis combined) was higher in the IV group (29.4%) compared to the SC group (20%). These findings emphasize the higher risk of bacteremia in the IV group and reveal that while cellulitis occurred more frequently in the SC group, the overall infection burden was greater in the IV group. Conclusion: Previous studies show comparable efficacy between IV and SC remodulin when properly dosed. Our findings, despite a small sample size, reveal a higher overall risk of infections, particularly bloodstream infections (BSIs), with IV therapy due to CVC use. This aligns with existing literature identifying catheter-related infections as a key concern. These results support SC remodulin as a safer option, especially for reducing BSI risk. We plan to incorporate these findings into our counseling protocol, acknowledging the need for further validation.

Background: The transmission of plasmids carrying antimicrobial resistance (AMR) genes between patients poses a significant global health challenge. The New Delhi metallo-β-lactamase (NDM) carbapenemase is associated with high mortality and limited therapeutics. Traditional Infection Control surveillance for intra-institutional organisms carrying AMR genes relies on retrospective clinical and epidemiologic review. Whole-genome sequencing (WGS) has been utilized to detect outbreaks, including those not clinically apparent within healthcare settings. In this study, we sought to identify related NDM-carrying Escherichia coli using WGS. Method: NDM-carrying E. coli isolates in clinical cultures were identified between November 2023 and October 2024. Bacterial genomic DNA was extracted directly from clinical microbiology laboratory plates. Sequencing was performed using the Oxford Nanopore Technologies MinION platform with an R10.4.1 flow cell. Assembled FASTA files from the in-house Flyest pipeline were analyzed with AMRFinderPlus to detect AMR genes. Plasmid replicons were identified using staramr. Horizontal plasmid transfer annotation was conducted using Roary, which incorporates Prokka, and pairwise single nucleotide polymorphism distances were assessed with snps-dist. Results: Nine E. coli strains producing blaNDM-5 were identified from eight patients. Two isolates from one patient showed high genetic similarity, indicating they were likely the same strain. The identified sequence types (STs) were ST361 (4 strains), ST167 (3 strains), ST205 (1 strain), and ST405 (1 strain). Four strains harbored a hybrid IncFIA/IncFIB(AP001918) plasmid, demonstrating 99.8%–99.9% nucleotide similarity. This plasmid carried blaNDM-5, blaCTX-M-15, blaOXA-1, and efflux pump-related genes, contributing to multidrug resistance. Despite the high plasmid similarity, no obvious epidemiological links, such as overlapping patient admissions or common procedures, were identified among the four patients carrying this hybrid plasmid. Conclusion: WGS presents a novel modality to identify highly genetically related strains of organisms within a healthcare institution that may reflect silent outbreaks or AMR dissemination not detected by conventional Infection Control methods.

Background: Immunocompromised patients are at an increased risk of infections. With the introduction of the new Hospital Onset Bacteremia and Fungemia (HOB) quality metric, it remains uncertain whether the incidence would be higher within these vulnerable populations. Additionally, the rate of antimicrobial resistance (AMR), which complicates the infection management, is not completely understood. We aim to provide insights into the incidence of HOB in cancer, transplant and surgical patients as well as challenges posed by AMR. Method: Data from three multi-center retrospective studies are included: 1. Adult patients in 38 US hospitals between October 2015 and June 2019 with a procedure under the National Healthcare Safety Network (NHSN) surveillance for SSI to assess the incidence of SSI and SSI-HOB co-occurrence; 2. Adult patients in 41 US hospitals between October 2015 and June 2019 with DRG for myeloproliferative (MP) cancer, solid tumor cancer, transplant, and non-cancer/non-transplant (“reference group”) to quantify their association with HOB; 3. Evaluation of adult patients in 168 hospitals between April 2018 and December 2022 to assess the rate of AMR pathogens and the proportion of AMR among bacterial isolates in patients with and without cancer. Results: 1.Rate of hospital-reported SSI was 0.15 per 100 admissions and admissions with SSI had significantly higher incremental cost ($30,689) and length of stay (LOS) (11.6 days); further, the incidence of HOB was 6-fold higher in admissions with SSI and SSI admissions with HOB resulted in additional $24,586 to cost of care and 6.3 days to the LOS; 2. Rate of HOB in MP cancer was 2-7-fold higher and 57% to 4-fold higher in transplant patients compared to the reference group, depending on LOS. There were no statistically significant differences in the risk of HOB between solid tumor cancer and the reference; 3. AMR pathogen rates were higher in cancer patients than patients without cancer for most pathogen groups, including vancomycin-resistant enterococci (IRR 1.95), extended-spectrum beta-lactamase (ESBL) producers (IRR, 1.48), carbapenem-nonsusceptible Enterobacterales (IRR, 1.46) and multidrug-resistant Pseudomonas aeruginosa (IRR, 1.31). The percentage of nonsusceptible isolates in most pathogen groups was lower in patients with cancer versus without cancer except for ESBL producers among Enterobacterales and vancomycin resistance among enterococci, which were higher in cancer patients. Conclusion: Certain vulnerable patient populations were found to be at greater risk of HOB including those with SSI, MP cancer and transplant patients. The higher incidence of AMR in cancer patients further complicates management of high-risk infections.

Background: Immunocompromised patients in the ICU are at high risk of infection. Continuous renal replacement therapy (CRRT) masks fevers. At an institution where one blood culture is routinely obtained daily during CRRT, we evaluated the incidence of positive blood cultures during CRRT. Methods: All patients admitted to the NIH Clinical Center receiving CRRT from September 2016 to March 2023 were identified. Charts were abstracted for baseline covariates, laboratory values, microbiology, CRRT days, antimicrobial administration, and mortality. Results: A total of 111 patients received CRRT. Ninety-seven (87.4%) had at least one blood culture drawn. Mean age was 43.3 ± 15.8 years and 39 (35.1%) were female. Seventy-four (66.7%) had an underlying malignancy, 36 (32.4%) were neutropenic on CRRT initiation, 32 (28.8%) were post-hematopoietic cell transplant and 9 (8.1%) were post-CAR-T cell therapy. Median CRRT duration was 7 days (IQR 3-16.5). There were 41 separate positive blood culture events, each possibly representing a blood stream infection (BSI), in 27 (24.3%) patients. The most common organism was coagulase-negative Staphylococcus (CoNS) (n=14) followed by Enterococcus faecium (n=8), Candida spp (n=6), and Pseudomonas aeruginosa (n=5). Of 11 cases only growing CoNS, 5 (45.5%) had repeat same-day cultures, but only two grew the same organism. Median time to first positive culture was 13 days (IQR 8-18.5). Fourteen cases (34.1%) were not on matched empiric antimicrobial therapy, of which 4 (28.6%) grew only CoNS. The average number of blood cultures per CRRT day was 1.2. Total number of CRRT days per possible BSI was 34 days, with 98 days for one possible BSI not on matched empiric therapy, and 138 days for a non-CoNS BSI not on matched empiric therapy. Forty-nine (44.1%) patients survived their ICU stay. Of these, 33 (67.3%) continued to have surveillance cultures drawn after CRRT cessation with 16 (32.7%) continuing after ICU discharge. Median days of surveillance cultures after CRRT cessation was 7 days (IQR 5-10). Conclusion: While the total proportion of positive cultures not on matched empiric therapy was high at 34.1%, the total number of CRRT days for one non-covered positive culture was high at 98 days. These numbers go down to 24.4% and up to 138, respectively, if CoNS-only cultures are excluded. Routine daily blood cultures may detect a small number of unexpected BSIs in patients whose fever response is masked while on CRRT. However, it is a low yield practice that could benefit from a more targeted approach.

Background: Carbapenem-Resistant Enterobacterales (CRE’s) are an imminent and growing threat to our healthcare system, especially those in Long Term Care Facilities (LTCF). Most patients with CRE in the US are diagnosed in hospitals but often discharged to LTCF’s. But how willing and prepared are LTCF’s to take and effectively manage CRE patients? We conducted a multi-center survey of 200 LTCF’s across 4 states (CT, CA, PA, TX) to assess their willingness to admit and preparedness to manage CRE patients. Objective/methods: A questionnaire was sent to 200 consenting facilities asking about willingness and readiness to manage a CRE patient. We excluded LTAC’s and SNFv which tend to have more exposure to CRE and thus more open to accept CRE patients. Readiness was measured by capacity built around CDC recommendations for CRE management and prevention in LTCF. Survey results were analyzed using SAS inc. Results: Of the 200 surveys sent, 168 were completed and returned. Eighteen (18) were excluded for incompleteness or unclear responses. Of the 150 facilities included in the analysis, only 18 (12%) said they have had experience managing a CRE resident and 41(27%) said they would accept CRE patients. Most common reasons for unwillingness to accept CRE patients were lack of private rooms, fear of causing an outbreak and not being prepared to handle such cases. As for readiness to handle CRE patients 71(47%) said they had a CRE policy, 45 (30%) had contingent plans for how to effectively isolate CRE patients, 60 (40%) said they had isolation signage for CRE, 38 (25%) had cleaning and disinfection supplies for CRE, 21 (14%) had contingent plans for surveillance testing if that were needed. A majority 145 (97%) were aware to both notify public health if they have a case and to use an inter-facility form when transferring the patient to another facility. Conclusion: Our study, though small in size, highlights how unwilling and unprepared a lot of LTCF’s are to take on CRE patients. We also highlight some of the barriers and gaps in preparedness that can be addressed to build the capacity of LTCF’s to take in and manage CRE residents effectively.