Background: Candida auris and methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in nursing homes, and both are known to shed profusely from the skin. We evaluated the degree of differential shedding during caregiving activities versus at rest in nursing home residents. Methods: Residents at two nursing homes were screened for C. auris and MRSA using nares, axilla/groin, and peri-rectal swabs. Carriers of C. auris, some of whom also carried MRSA, were evaluated for proximal shed around their bed during rest and caregiving activities using chromogenic settle plates. Morning caregiving activities (e.g. hygiene care, linen/clothing change) were noted to generally take 12 minutes. For rest, settle plates were placed for a 12-minute period prior to the resident awakening in the morning. For caregiving, settle plates were placed for the 12-minute period of morning activity shortly after awakening. Twin rest-caregiving measurements were taken on three separate days per C. auris carrier. In addition, prior to caregiving, bilateral nares, hands, axilla, groin, and perirectal swabs were taken for C. auris and MRSA culture, along with an axilla/groin swab for measuring chlorhexidine concentration (CHG used for routine bathing). Logistic regression with person-level clustering analyzed associations between positive settle plates (“shedding”) and activity (caregiving versus rest), along with other adjusters. Results: The study included 23 C. auris carriers, 15 of whom carried MRSA. 65% were male, 91% had an indwelling device, 39% had wounds. Mean number of positive body sites was 2.3 for C. auris and 1.2 for MRSA. Median CHG concentration was 156 µg/mL (IQR=39-1250). Shedding occurred more frequently during caregiving versus rest for both C. auris (8/69 vs 1/69, P=0.02) and MRSA (15/69 vs 3/69, p=0.002). In multivariable models (Table), caregiving was associated with increased odds of shedding for both C. auris (OR: 9.25 (95% CI: 1.07-80.35), P=0.04) and MRSA (OR: 6.52 (95% CI: 1.72-24.78), P =0.01). Higher CHG concentrations were non-significantly associated with reduced shedding of both pathogens. Conclusion: C. auris and MRSA shedding increased significantly during caregiving activities, supporting CDC’s current recommendations for enhanced barrier precautions in nursing homes, which involve gown and glove use during high-contact care for carriers of multidrug-resistant organisms. Remarkably, shedding was readily detected within 12 minutes of morning caregiving, highlighting a rapid “plume effect” during resident care.

Background: A survey was conducted to understand the current state of infection prevention (IP) in Missouri (MO) long-term care facilities (LTCF) following the COVID-19 pandemic. The survey focused on staffing, training and education, and program elements. Method: The survey was developed and managed in Qualtrics™. It was distributed via email to 1468 individual email addresses for 1122 unique LTCF across Missouri in partnership with the Missouri Department of Health and Senior Services. The survey was available from July 29, 2024 through August 16, 2024. Survey results were anonymized; participants had the option to provide facility or contact information if desired for follow up. Results: The survey response rate was 11.1%, with 164 responses collected. Participants worked in LTCF categorized as long-term care, assisted living, memory care, short-term skilled nursing, short-term rehabilitation, residential, and behavioral health. The size of LTCF varied in numbers of residents and employees. Most respondents (82%) reported having a dedicated IP professional for their facilities, but only 2% stated they were allocated full-time to IP responsibilities. Job titles also varied widely. Over 50% of respondents stated their IP professionals had less than five years of IP experience, but 80% stated the person received specific training for the IP role.

Most respondents reported having policies for monitoring and improving hand hygiene, managing communicable illnesses, and screening for infectious diseases (ID). Nearly all respondents (99%) reported that policies remain for managing residents, employees, and visitors with COVID-19. However, most programs lack a dedicated budget for IP initiatives and a defined relationship with an ID clinician or healthcare epidemiologist. Conclusions: This is, to our knowledge, the first statewide survey of infection prevention in Missouri long-term care facilities. One limitation of this study is the small response rate, and another is a response bias in which facilities with robust IP programs are more likely to respond.

There are employees and programs dedicated to preventing infections in residents of MO LTCF. The workforce varies in IP experience, though considerable IP-specific training is occurring which fosters competency advancement. Lack of full-time allocation to IP responsibilities and variation in job titles may indicate role overlap of IP with other specialties. Limited funding and partnerships with ID clinicians may affect the scale and scope of IP programs. This survey demonstrated that IP resources are available in MO LTCF, and there may be opportunities to enhance their impact through increased staffing, funding, and professional collaborations.

Background: Patient bathing plays a vital role in patient care and cleanliness, as well as in the prevention of infections, assisting in the removal of transient skin flora, which are predominately gram-positive organisms, particularly Staphylococci. However, there are inherent risks that come with the use of water in healthcare facilities, particularly the potential for acquisition of pathogenic bacteria from surfaces by residents. Current cleaning and disinfection protocols encourage the disinfection of the shower facilities in between each patient, but adherence to this practice can be a challenge with the staffing shortages seen in environmental services linked to long-term care facilities. The purpose of this point-prevalence study was to identify Staphylococci contamination in shower facilities at a long-term care and rehabilitation center Methods: Five shower room facilities in a long-term care and rehabilitation center were cultured on one day in July 2024. Five surfaces in the shower facility/room were cultured: the shower bench, the faucet, the floor drain, the grab bar, and the shower curtain. A total of 25 cultures were obtained using sterile transport swabs with liquid Stuart’s medium (Fisherbrand, Fisher Scientific, Suwanee, GA) and immediately placed in ice for transport to a microbiology lab. At the lab, the swabs were plated onto two different agars: CHROM MRSA agar and mannitol salt agar (MSA) and incubated for 48 hours. Plates were then read and assigned a qualitative “Yes/No” value if at least 1 colony forming unit of interest was seen. Results: Of the five surfaces cultured in the shower facilities, the bench shower seats were the most heavily contaminated. All of the bench shower seats tested positive for coagulase-negative Staphylococcus (CoNS) and Staphylococcus aureus (MSSA), and 40% of the bench seats tested positive for Methicillin-Resistant Staphylococcus aureus (MRSA). The floor drains were the second most contaminated surfaces, with 80% of surfaces testing positive for both CoNS and MRSA, respectively. Grab bars were the least contaminated surface examined, with only 40% of surfaces testing positive for MSSA and CoNS. Conclusion: This study showed that there was a high prevalence of Staphylococci organisms in the shower facilities, including showers that were marked “clean”. Finding 40% of shower benches contaminated with MRSA is concerning, particularly for some of the elderly patients using these showers. These findings highlight the lack of adherence to the cleaning and disinfection protocols. Further research should be done if adherence to their protocols will reduce Staphylococci surface burden.

Background: Carbapenem-resistant Enterobacterales (CRE) are significant healthcare-associated pathogens. Liver transplant (LT) recipients are particularly vulnerable to CRE acquisition due to frequent hospitalizations, extensive antibiotic exposure, and prolonged stays in intensive care units. This study aimed to develop and evaluate prediction models for CRE acquisition in LT recipients at a hospital where more than 500 LT surgeries are performed annually. Method: This case-control study retrospectively analyzed the electronic medical records of 1,250 adult LT recipients (250 CRE-positive and 1,000 CRE-negative cases) at a 2,768-bed tertiary hospital in Seoul, Korea, from February 2020 to February 2024. Data imbalance was addressed using the synthetic minority over-sampling technique, and missing values were handled through median imputation and k-nearest neighbor imputation methods. Prediction models were developed using logistic regression, random forest, and extreme gradient boosting (XGBoost) algorithms, with optimal models selected through 5-fold cross-validation and recursive feature elimination. Model interpretability was enhanced using Shapley additive explanations and partial dependence plot analyses. Result: Of the CRE isolates, 94% were carbapenemase-producing Enterobacterales, with Klebsiella pneumoniae comprising 55.7% of all CRE isolates. Univariate analysis revealed significant differences between groups in LT month (June-September, p<.001), mechanical ventilation over 72 hours (p=.002), and model for end-stage liver disease (MELD) score (p=.041). The XGBoost model, selected as the final model, demonstrated strong specificity (0.848) and a high negative predictive value (NPV 0.830) for identifying non-carriers, although its overall predictive power was limited. Features used in the XGBoost model included LT month, third-generation cephalosporins, and the presence of hepatocellular carcinoma, all of which showed a positive correlation with CRE acquisition. In contrast, mechanical ventilation over 72 hours and living donor LT exhibited negative correlations. Viral hepatitis and body mass index were included in the model, but their impact on CRE acquisition risk remained unclear. Notably, the negative association of mechanical ventilation contrasts with findings from previous studies, highlighting the need for further investigation. Conclusion: This study demonstrates the clinical relevance of machine learning models in predicting CRE acquisition among LT recipients. The XGBoost model showed high specificity and NPV, indicating its potential to effectively identify low-risk patients. Future studies could benefit from adopting prospective, multicenter designs to clarify causal relationships and improve model performance.

Background: Since the intensive care unit (ICU) is a high-risk area for healthcare-associated infections, effective infection control in the ICU is crucial. Carbapenem-resistant Enterobacterales (CRE) infections have been increasing and have become a significant concern for ICU patients. While CRE colonization does not require treatment, as it represents a carrier state, early detection is crucial to minimize CRE transmission. This study aims to identify the CRE colonization rate and its risk factors in ICU patients to provide a basis for CRE infection control in the ICU. Method: This retrospective cohort study was conducted at a university hospital in Korea from July 2023 to December 2023. Adult patients aged ≥18 years who were admitted to five ICUs (i.e., surgical 1 and 2, medical, cardiopulmonary, and emergency ICUs) and underwent active surveillance cultures for CRE using rectal swabs within 2 days of admission were included. Re-admissions and patients with confirmed CRE prior to admission were excluded. General, clinical, and environmental factor data were retrospectively collected using the hospital’s electronic medical records and nursing documentation system. Multivariate logistic regression was performed on variables with p Results: Out of a total of 1,473 ICU admissions, excluding duplicate admissions, 10 patients with confirmed CRE colonization prior to ICU admission and 722 patients who did not undergo active surveillance cultures within two days of admission were excluded. Among the remaining 741 included patients, 25 (3.37%) patients were colonized with CRE. Klebsiella pneumoniae was the most frequent isolate (n=18, 72%) and 12 patients (48%) were identified as having carbapenemase-producing Enterobacterales. In the multivariate logistic regression analysis, the following were identified as independent risk factors for CRE colonization: age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.01-1.11; p=0.036), admission from other hospitals (OR, 8.77; 95% CI, 2.43-31.59; p Conclusion: Based on the results of this study, early detection of patients with CRE colonization, followed by target screening and proactive infection control measures such as preemptive isolation, could play a key role in preventing the spread of CRE in the ICU.

Background: The prevalence of Carbapenemase-Producing Enterobacterales (CPE) has been increasingly reported worldwide in the past 10 years, representing a serious threat to public health. CPE has become a considerable concern in treatment and infection prevention and control. This study aims to determine the prevalence and risk factors of CPE colonization in the Adult and Pediatric intensive care units (ICUs) in one of the largest military hospitals in Saudi Arabia. Method: A cross-sectional study included all new patients admitted to Adult and Pediatric ICUs from December 2022 until December 2023. Rectal swabs were collected upon admission, and CPE was screened using molecular tests (CARBA-R). Demographic, medical-surgical history and clinical data were recorded and analyzed using SPSS 20.0. Risk factors were determined through Multivariate analysis with logistic regression. Odds ratio (OR) confident intervals (CI 95%) were calculated, and a P value less than 0.05 was considered statistically significant. Result: A total of 994 patients were included, 70.7% (n=693) of whom were from the Adult ICU. The prevalence rate of CPE colonization was 18.5%, and most cases were recorded in adult ICU (84.4% versus 15.6%; p Keywords; screening – CPE – Risk factors – PICU- ICU

Background: Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to the Minnesota Department of Health (MDH) Public Health Laboratory (PHL), where carbapenemase production and mechanism identification is confirmed. MDH reviews all detected carbapenemase-producing organisms (CPOs) for potential transmission. Suspected transmission clusters are assessed for relatedness using whole genome sequencing (WGS). In 2022, increased detection of multiple bacterial genera of Klebsiella pneumoniae carbapenemase (KPC)-CRE occurred at acute care hospital-A, (ACH-A) and in 2023 the increase in KPC-CRE was accompanied by an increase in New Delhi metallo-β-lactamase (NDM)-CRE detection. Methods: MDH partnered with ACH-A to review increased CPO detection. MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis on isolates. WGS suggested clusters of relatedness spanning multiple years and epidemiologic data revealed common room occupancy. Infection prevention and control (IPC) principles were reinforced in cluster areas and audits verified adherence, prompting consideration of an environmental reservoir. An environmental screening plan was developed focusing on sink drains from common rooms. In May 2024, 94 swabs from sink drains were collected and CPO culture-based screening was conducted using selective media followed by molecular testing of bacterial growth by MDH-PHL. Results: There was detection of CPOs from 28 of 94 (29.8%) sink drains. Eight environmental KPC-CRE isolates and one NDM-CRE isolate appeared genetically related to 22 unique patients over a 10-year period (Figure 1). Three sink drain isolates showed genetic similarity to each other, but not to patient isolates. Three CPO clusters, representing 14 patients, had genetically similar isolates without an associated environmental isolate. However, isolates were collected over months to years suggesting an undetected reservoir. In August 2024, ACH-A initiated mitigation strategies to prevent CPO transmission from environmental reservoirs, including modification of sink plumbing, maintaining a splash zone, refraining from disposal of bodily fluids in sinks, optimizing sink hygiene, and monthly screening of inpatients in units with known CPO sink contamination. From August to December 2024, 325 patients were screened with 1.2% of specimens detecting KPC-CRE colonization. Conclusion: Sink drains containing CPOs on multiple hospital units that correlated with patient cases were identified at ACH-A. WGS suggests intermittent transmission of different CPOs over 10 years, and clusters of transmission appear to be related to environmental sources. Strict implementation and adherence to IPC measures, including those that minimize the spread of CPOs from facility premise plumbing, are critical to prevent CPO transmission despite widespread premise plumbing contamination.

Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) can cause healthcare-associated infections associated with poor outcomes. Unlike other carbapenem-resistant organisms, CRPA is often susceptible to at least one traditional anti-pseudomonal β-lactam antibiotic including cefepime, ceftazidime, and piperacillin-tazobactam (“S-CRPA”). This study aimed to determine if treatment of S-CRPA infections with a novel β-lactam/β-lactamase inhibitor (βL/ βLI) as opposed to a traditional antipseudomonal β-lactam which may increase the likelihood of resistance, was associated with improved clinical outcomes. Methods: We retrospectively analyzed all incident S-CRPA isolates in a four-hospital academic healthcare system in Atlanta, GA from 1/1/2013 to 9/30/2022. Patients receiving either a βL/ βLI or a traditional antipseudomonal β-lactam for definitive antibiotic therapy, defined as having received at least 3 days of the specified antibiotic between 4-14 days after the culture was obtained, were included. We excluded patients with cystic fibrosis. We compared patients who received definitive treatment with a βL/ βLI to those who received definitive therapy with a traditional anti-pseudomonal β-lactam. The primary outcome was mortality (in-hospital mortality and those discharged to hospice). We performed univariable and multivariable logistic regression analysis using SAS 9.4. A causal diagram was created to a priori to identify potential confounders for inclusion in a multivariate analysis including Elixhauser comorbidity score, specimen source, β-lactam resistance pattern, and whether the patient had a hospital-onset infection (culture obtained ≥3 days after admission) Results: There were 258 patients with S-CRPA who received definitive treatment with either βL/ βLI (n=22) or traditional anti-pseudomonal β-lactams (n= 236). Those who received definitive βL/ βLI therapy had higher Elixhauser comorbidity scores, longer lengths of stay, were more likely to have bacteremia, and more likely to have resistance to one or more traditional anti-pseudomonal β-lactams than those treated with traditional anti-pseudomonal β-lactams (Figure 1). In the univariable analysis, patients who received definitive BL/BLI therapy had increased mortality and patients without bacteremia and hospital-onset infection had decreased mortality, but the associations were not statistically significant (Figure 2). In the multivariable analysis, treatment with traditional anti-pseudomonal β-lactams was not significantly associated with mortality (OR 1.9 95%CI 0.6 – 5.7). Conclusions: In patients with S-CRPA we did not observe a significant difference in mortality comparing definitive antibiotic treatments. A low number of S-CRPA isolates treated with a βL/ βLI limited our ability to assess the true effect of traditional anti-pseudomonal β-lactams versus βL/ βLI on mortality.

Background: The prevalence of multidrug-resistant organisms (MDROs) in the post-acute care setting is well-documented in adults. Few studies have investigated the prevalence in children. Methods: We performed a prospective, single-center study including children with tracheostomy tubes age 2 months to 17 years admitted to a 24-bed post-acute care unit within a quaternary care children’s hospital. Index respiratory and stool specimens were obtained within two weeks of admission. Subsequent specimens were obtained weekly thereafter for up to eight weeks. MDROs were identified using methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase Enterobacterales (ESBL-E), and carbapenem-resistant Enterobacterales (CRE) selective media (CHROMagar, Hardy Diagnostics). ESBL-E and CRE colonies were additionally plated onto MacConkey agar and only lactose fermenting organisms were considered positive. Index MDRO status was defined using week one samples; if not available, week two results were substituted. New MDRO acquisition was defined as a negative index MDRO culture with a subsequent positive culture. Results: A total of 47 children were enrolled. Median age was 9 months (interquartile range [IQR], 5-31 months) and median hospital length of stay prior to post-acute care admission was 89 days (IQR 27, 158). The most common pre-existing medical conditions were congenital heart disease (19, 40%), severe neurologic impairment (19, 40%), and prematurity Conclusion: MDROs are common in children hospitalized in the post-acute care unit. Nearly half of this cohort acquired CRE following admission, highlighting the need for strict infection prevention and control measures and tailored empiric antibiotic strategies.

Background: Rapid identification of patients with carbapenem-resistant Enterobacterales (CRE) on admission to an acute care hospital is critical to prompt initiation of infection control measures. Clinical risk prediction tools can assist in identifying high risk patients and allow facilities to perform targeted CRE screening. We aimed to prospectively validate a previously developed CRE risk prediction tool which incorporates data from current and prior hospital encounters and was incorporated into our electronic medical record (EMR). Method: From 6/2024 – 12/2024 we used an automated daily EMR report to calculate a CRE risk score (probability of a CRE clinical culture within 3 days of hospitalization) for all admissions from the previous day at two hospitals in an academic healthcare network in Atlanta, GA. On select days of the week, we approached a convenience sample of approximately 10 patients with the highest risk scores and obtained a peri-rectal swab on consented patients. Swabs were broth enriched and tested on CHROMagarTM ESBL plates. We used MALDI-TOF and/or the Vitek®2 GN74 panel for species identification and antibiotic susceptibility testing. To evaluate testing accuracy, we defined individuals as high-risk if they had a CRE risk prediction score in the top quartile of scores among patients approached. We calculated the sensitivity, specificity, and positive and negative predictive value of this threshold to predict patients with CRE peri-rectal carriage. Results: 9,422 admissions occurred on sampling days; we approached 720 of which 282 (39%) were consented and tested (Figure 1). Ten patients (3.5%) were positive for CRE: 4 Klebsiella pneumoniae, 3 Escherichia coli, 2 Enterobacter cloacae, and 1 Pantoea species. Among tested individuals, patients with CRE had a higher median CRE risk score (0.19% vs 0.04%), more healthcare exposures, a higher Elixhauser score, and more antibiotic days of therapy (Figure 2). Of the 72 (25%) patients at high-risk (CRE risk prediction ≥0.1%) 6 (8.3%) were CRE positive; using this threshold the sensitivity and specificity were 60% and 80%, respectively, and the positive and negative predictive value were 8% and 98%, respectively. Conclusion: Utilizing an EMR-based risk prediction tool can help identify patients at high-risk for CRE colonization. In healthcare facilities with a low CRE-prevalence, identifying a high-risk subset of patients, even with an 8% probability of CRE, could be a clinically meaningful infection prevention measure. Individual healthcare facilities could adjust the testing threshold based on the hospital and population needs.

Background: Multi-drug resistance is increasing, and insects may serve as critical reservoirs for these bacteria. While insects are part of the world’s natural flora and exist even in healthcare settings, their presence is often overlooked or disregarded. Current healthcare safety guidelines focus on keeping insects out but fail to address their potential contribution to nosocomial pathogen transmission, This study aims to determine the extent of knowledge regarding microbial transmission by insects in a healthcare setting. Methods: The systematic literature search utilized subject headings and preferred index terms such as “insects,” “microbial transmissions,” “insect vector,” “insecta,” and “cross infection” to construct a reproducible MEDLINE search within PubMed. This search was translated across Embase, CENTRAL, and select supplemental resources. Retrieved studies exceeded 1000 records, which were deduplicated using Covidence software, leaving 655 eligible articles for screening. A total of 36 peer-reviewed studies documenting insects in healthcare settings (e.g., hospitals, clinics, rehabilitation centers, ambulatory centers) were included and underwent data extraction and analysis. Excluded studies were non-English without translation or irrelevant to healthcare. Outcomes included identification of colonizing organisms, evidence of microbial transmission, and prevalence of multidrug-resistant pathogens carried by insects. Risk of bias was evaluated using the LEGEND criteria, and extracted data were synthesized following the Cochrane Review for Systematic Reviews in conjunction with the Joanna Briggs Institute (JBI) frameworks. Results: Of the analyzed studies the majority were from low- to middle-income countries and included the study of common insects such as cockroaches, ants, and various classes of flies. Studies included the examination of external surfaces and internal contents of the insects via evidence-based, aseptic collection and laboratory processes. Few studies demonstrated the likely transmission of bacteria via insect vector, though all studies demonstrated robust colonization of insect vectors with pathogenic microbes including multi-drug resistant bacteria. Conclusion: This review highlights the potential role of insects in microbial transmission in healthcare settings. However, most studies failed to establish a direct link between insects and pathogen transmission. Further research into areas such as multi-drug resistance transmission via insect vectors is needed.

Background: Multidrug-resistant organisms (MDRO), including those producing extended-spectrum beta lactamases (ESBL) are increasing. Infections, especially with MDRO, lead to increased healthcare costs. Bloodstream infections (BSI) caused by ESBL-producing Klebsiella pneumoniae increased at our institution in 2021-2022. An assessment as to whether these organisms were acquired during hospitalization or other healthcare exposures was conducted. Methods: The rates of ESBL-producing Klebsiella BSI per 1000 hospitalizations in 2021 and 2022 in transplant recipients and non-transplant patients were compared. From 1/1/2021 to 06/30/2023, 49 adult patients at an academic medical center had Klebsiella pneumoniae BSI with ceftriaxone resistance and a high probability of carrying an ESBL. Of these, 20 were transplant recipients and 29 were non-transplant patients. We performed whole-genome sequencing on the 28 available unique patient isolates (12 transplant; 16 non-transplant) to assess relatedness. Additional data were collected by chart review on transplant recipients. BugSeq bioinformatics pipeline and refMLST were utilized on the sequenced isolates to assess clonality, defined as ≤20 allele difference between two isolates. Results: The rate of ESBL-producing Klebsiella BSI increased universally from 2021 to 2022 but impacted the transplant cohort (0.3 to 3.6 per 1000 hospitalizations) more than the non-transplant cohort (0.2 to 0.5 per 1000 hospitalizations). Kidney and liver transplants were most often involved (5 out of 49 patients each). In the transplant cohort, bacteremia alone (45%, 9 out of 20) and urinary source (35%, 7 out of 20) were the most frequently identified etiologies. The most common sequence type was ST-307, accounting for 64% of total sequenced isolates (67% of transplant; 63% of non-transplant). The most common ESBL gene identified was blaCTX-M-15, identified in 24 isolates (86%). Less common resistance genes included blaSHV-12 (N=3) and blaCTX-M-3 (N=1). While there were 5 isolates within 20 allele differences (3 transplant; 2 non-transplant), they were separated in time and did not have obvious epidemiologic connections. While there was a change in TMP-SMX prophylaxis protocol during this time in kidney transplant recipients, it did not explain the increase observed in other transplant groups. Conclusions: There was a sharp increase in the number of BSI caused by ESBL-producing Klebsiella pneumoniae in the transplant population between 2021 and 2022. A molecular epidemiologic analysis ruled out clonal transmission from breakdown of infection prevention practices as the cause. No other common epidemiologic link was identified. This demonstrates the application of whole-genome sequencing in excluding a clonal outbreak from a common source within an institution.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a reportable hospital -acquired condition that can cause significant harm to hospitalized patients. Our facility, a 629 bed acute tertiary care hospital, continued to observe Healthcare Facility-Onset (HO) MRSA bacteremia rates above the corporate goal despite our housewide MRSA decolonization protocol consisting of daily chlorhexidine gluconate bathing (CHG) and an alcohol nasal antiseptic twice per day for all adult inpatients ≥ 18 years of age. This prompted us to conduct a gap analysis and evidence-based practice review to address our current MRSA decolonization practices. Methods: In January 2024, a revised MRSA decolonization protocol was implemented for our adult inpatient population consisting of the addition of nasal mupirocin twice per day for 5 days for all Intensive Care Unit (ICU) patients, MRSA nasal screening for high-risk patients, and implementation of contact precautions (gown, gloves) for patients identified or known with MRSA colonization and/or infection. The nasal alcohol antiseptic was removed from the revised protocol. Multidisciplinary education on the protocol changes (MRSA screening, isolation, and discontinuation of the nasal antiseptic) were disseminated to nursing, pharmacy, and the medical staff. Mupirocin was added to the standing ICU order set in the electronic medical record (EMR). Pre-intervention (February 2023 - January 2024) and Post-intervention (February 2024-October 2024) time periods were used to assess the impact on the rate of HO MRSA bacteremia and were obtained from The National Healthcare Safety Network (NHSN) standardized infection ratio (SIR) 2015 baseline with analysis using the NHSN statistics calculator. Results: Following implementation of the decolonization protocol, the MRSA bacteremia cumulative SIR decreased 91% from 1.077 to 0.096 which was statistically significant with a two-tailed p-value of 0.0021 (95% Confidence interval: -99.6, -49.5). The housewide MRSA bacteremia rate decreased from 1.05 infections per 10,000 patient days to 0.090 per 10,000 patient days which reflected a significant decrease (p: 0.0016). The ICU MRSA bacteremia rate also showed statistical significance with a decrease from 4.2 per 10,000 patient days to 0.00 per 10,000 patient days (p: 0.0477). Conclusion: Revising the MRSA decolonization protocol significantly decreased our MRSA bacteremia rates. This included re-implementation of contact precautions, screening high-risk patients that could be carriers of MRSA, and mupirocin decolonization for ICU patients. Facilities should consider evaluation of their MRSA decolonization, isolation, and screening practices if unable to decrease their HO MRSA bacteremia rates.

Background: Daptomycin-nonsusceptible Enterococcus faecium (DNS E. faecium) is an emerging multidrug-resistant pathogen associated with poor clinical outcomes. Prompted by an increase in DNS E. faecium at our institution in 2023 (Figure 1), we sought to characterize patient characteristics and generate hypotheses about potential risk factors. Methods: We conducted a retrospective case series of 75 patients with confirmed DNS E. faecium (MIC ≥6) across 10 hospitals (served by a single Microbiology laboratory) within the University of Maryland Medical System between January 1, 2023, and November 30, 2024. Data collected included demographics (age, gender, race, ethnicity), clinical history (prior Enterococcus or VRE infections, immunosuppression), infection characteristics (site, Healthcare-associated (defined as onset >48 hours from admission) vs. Community-onset), and antibiotic exposure (vancomycin, daptomycin, linezolid, rifaximin) within 90 days. Immunosuppression was defined as corticosteroid use (≥10 mg prednisone for ≥5 days), chemotherapy, transplant, neutropenia (ANC < 1 500), or other immunosuppressive conditions. Patients with repeated infections were included once, for their first episode. Results: An increase in the incidence of DNS E. faecium was observed at our healthcare system starting in August 2023 (Figure 1). Of 75 patients, 55% were male, 52% were White, 33% were Black, with 92% identifying as non-Hispanic. The mean age was 65 years. A total of 57% of infections were healthcare-associated, with 27% occurring in ICU settings. Specimen sources included blood (20%), urine (5%), and abdominal (48%). Only 5 cases (7%) were considered colonization, while 10 cases (13%) with bacteremia had an ongoing intra-abdominal process. Prior antibiotic exposure was documented in 84% of cases, including vancomycin (51%), daptomycin (15%, high-dose (8-12 mg/kg daily) in 9% of cases), linezolid (13%), and rifaximin (5%). Immunosuppression was present in 39% of patients, and 72% had underlying gastrointestinal pathology (Table 1). Enterococcus was recovered from a previous culture in 20 cases (27%), with 9 (12%) being VRE. Among DNS E. faecium isolates, 59% were vancomycin-resistant, and 48% of those patients had prior vancomycin exposure within the preceding 90 days. Conclusion: Patients with DNS E. faecium frequently exhibit prior antibiotic exposure, immunosuppression, and gastrointestinal pathology. However, significant prior exposure specifically to daptomycin was not found. Approximately 40% of isolates were susceptible to vancomycin; therefore, clinicians need to be alert to the possibility of daptomycin resistance in vancomycin-susceptible E. faecium infections. Further study, including case-control analyses, to identify specific risk factors and clarify the role of prior antibiotics vs transmission in the healthcare setting is needed

Background: The Republic of Korea ranks second among OECD countries for tuberculosis (TB) incidence. National TB control guidelines mandate latent TB infection (LTBI) screening and treatment for healthcare workers (HCWs), especially those in high-risk departments. At our 2,700-bed tertiary hospital in Seoul, annual LTBI screening and treatment have been actively implemented since 2017, targeting HCWs at elevated risk of TB exposure. This study evaluates LTBI conversion rates among high-risk HCWs and characteristics of HCWs with conversion (converters) over the past five years. Methods: Following national guidelines, HCWs were classified into three high-risk groups: those likely to have routine contact with pulmonary TB patients (Group A), those caring for immunocompromised patients (Group B), and those at risk of respiratory infections despite no routine TB contact (Group C). Annual screening included interferon-gamma release assay (IGRA) and chest radiography. HCWs with positive IGRA results (≥0.35 IU/m) were strongly encouraged to undergo latent tuberculosis treatment. We analyzed data from HCWs working in high-risk tuberculosis units who had worked for more than five years from 2020 to 2024. HCWs with prior IGRA positivity were excluded. Results: Among, 1467 HCWs, 15.9% (233/1,467) had been diagnosed with LTBI before 2020, while the cumulative LTBI conversion rate between 2020 and 2024 was 5.3% (65/1,234). The annual LTBI conversion rates ranged between 0.7% and 1.5%. The median age of converters was 42 years, significantly older than non-converters (median 38 years; P = 0.02). Male converters comprised 24.6% (16/65) compared to 14.6% (171/1,169) in the non-converter group (P = 0.03). Longer tenure was observed among converters (median 16 years) than non-converters (median 12 years; P = 0.01). Although medical technicians and emergency room staff exhibited higher conversion rates, these differences were not statistically significant. Among LTBI cases, 78.8% completed treatment, with 9.1% demonstrating reversion. The annual incidence of active tuberculosis among HCWs at our hospital significantly declined to an average of 0.2 cases per year between 2020 and 2024, compared to 4.4 cases per year between 2015 and 2019 Conclusions: Annual LTBI screenings revealed conversion rates of approximately 1%, primarily affecting older, long-tenured, and male HCWs. Active LTBI treatment effectively reduced the risk of active TB among hospital staff.

Introduction: The estimated annual incidence of tuberculosis (TB)in the United States amongst health care personnel (HCP) is low at 2/100,000 persons. Current TB post exposure testing practices may result in many HCP being contacted and tested, with very low yield, thus leading to increased health care resource utilization and HCP anxiety. Based on CDC criteria, Mayo Clinic, Rochester is a medium risk facility. Given that the only transmission we have seen in the last decade is from smear positive, symptomatic patients, we present an alternative, risk-based approach to defining exposure risk to guide followup testing for health care personnel exposed to TB patients. Our goal was to account for the most common exposure follow up (EFU) scenarios and not the rarest situations, which would require case by case discussion. We present a novel risk stratification definition for EFU testing at Mayo Clinic, Rochester and present 12 months’ worth data pre and post initiative. Methods: Prior to July 2023, case exposure definition for screening was broad without clarity on duration of exposure or risk for acquisition of the disease. After the new definition was proposed in collaboration with Infection prevention and control (IPAC), Occupational safety and health, and Minnesota department of health, each case was reviewed to determine appropriateness of HCP exposure testing Results: In the time frame from July 2022 through June 2023, total of 5 EFUs were conducted, and 70 healthcare personnel were exposed (14 per EFU), and none developed TB infection [MS1] After implementation of new protocol, during July 2023 through June 2024, there were 11 EFUs, 102 healthcare personnel were identified as exposed (9 per EFU), and none developed TB. Of note, the low number of exposure investigations prior to July 2023 coincides with the universal [MS2] masking policy related to the COVID-19 pandemic. Conclusion: Existing public heath guidelines do not establish minimum exposure time warranting follow up testing for tuberculosis amongst HCP. However, not all cases need extensive case management as this may lead to excessive costs and resources for testing, conducting EFUs and anxiety amongst HCP. With our proposed exposure risk stratification, we aim to not only reduce resources and time needed to conduct EFUs, but also decrease incorrectly identified HCP to assure the correct ones are being tested. We will continue to audit and review our data at regular intervals with continued feedback and discussion with stakeholders to adopt a more data driven approach to TB exposure followup.

Background: The influence of variations in healthcare environments and cultural factors on the appropriate use and effectiveness of personal protective equipment (PPE) remains insufficiently explored. This study aimed to investigate complex PPE-related challenges and identify potential solutions through in-depth interviews with international healthcare providers. Methods: Study participants were recruited through invitation emails sent to international conference attendees who showed interest to the researcher, contacts from the researcher’s international networks, and authors of publications on PPE. After obtaining study consent and permission for recording, online interviews were scheduled for one hour per participant, except for one in-person interview. Participants were asked to complete an online pre-survey and, if possible, provide PPE pictures. An $80 incentive was offered unless declined by the participant. Narrative responses were transcribed, reviewed, and analyzed. Results: From October 17, 2024, to January 9, 2025, interviews were conducted with 13 participants representing 12 countries (Bangladesh, Brazil, Ethiopia, Ghana, Japan, Malaysia, Mongolia, Saudi Arabia, Singapore, South Korea, United States, and Vietnam). The participants were predominantly doctors (69.2%) and male (61.5%), with an average age of 47 years and an average of 21 years of clinical experience. In beard-growing countries (Bangladesh, Ghana, Malaysia, and Saudi Arabia), men with long beards faced challenges in properly covering them with masks and had to use beard covers. Tropical countries (Bangladesh, Brazil, Ghana, and Ethiopia) often lack air conditioning in most healthcare settings, and healthcare personnel (HCP) frequently experience heat-related issues when wearing PPE. Singapore and Japan showed good PPE compliance due to their collective cultures. In Singapore, it stemmed from shared agreement and rule-following, while in Japan, it was driven by group conformity and avoiding inconvenience to others. In Vietnam, PPE compliance was high as bosses evaluated HCP’ compliance, which could influence bonuses. Political issues impacted COVID-19 responses: in Brazil, parties debated masks; in the U.S., masks were seen as personal freedom; in South Korea, unions resisted lowering PPE standards later in the pandemic. In Saudi Arabia, HCP must complete training with PPE tests, including N95 fit testing, to receive a two-year national certification. Conclusion: This study identified PPE use characteristics and challenges across countries, influenced by factors such as emerging infectious diseases response capacity, PPE availability, religion, ethnicity, climate, and social context. Future research needs to include a larger-scale study involving more countries, with adequate samples across healthcare systems and hospitals of various sizes, to further investigate issues related to PPE use.

Background: Serratia marcescens, a recognized environmental pathogen, often contaminates hospital water systems. Infections are typically exogenous, with occasional human reservoirs. NICU outbreaks can result in serious nosocomial infections, including meningitis, bacteremia, and conjunctivitis. Sources include contaminated medical devices, solutions, and hospital water systems, specifically sink traps and outlets, with transmission occurring directly or indirectly via aerosolization. Outbreak Description: Between June 2023 and December 2024, an outbreak of S. marcescens occurred in our hospital’s neonatal facility (Figure 1). The facility has 3 main halls - the NICU, intermediate, and “cradle” rooms, along with a breastfeeding, medication, and incubator cleaning room, containing 17 sinks in total (Figures 2 and 3). The outbreak was identified following two Serratia bacteremia cases in early 2024 and a retrospective review revealing 8 positive ocular cultures since mid-2023. After initiating the outbreak investigation, enhancing infection control measures, and conducting engineering repairs, the case rate decreased significantly. However, three additional bacteremia cases, and a urine culture, were subsequently identified. Infection Control Measures: Control efforts targeted two reservoirs: patients (via healthcare worker transmission) and the environment. Key measures included reinforcement of hand hygiene, aseptic breastfeeding techniques, contact precautions, and environmental disinfection protocols. Bathing was standardized using sterile water. Environmental Sampling and Investigation: Given Serratia’s known association with waterborne contamination, environmental sampling focused on sink traps and outlets across all areas, revealing persistent contamination despite repeated treatment with concentrated chlorine (Table 1). Epidemiological data identified temporal and spatial correlations between contaminated sinks and clinical cases, notably involving faulty plumbing adjacent to NICU sink 3/4 (Table 2). Water leakage and back pressure from a blocked pipe were hypothesized to cause aerosolization from the connected sink causing infections. Microbiological biotyping clustered clinical and environmental isolates, further implicating aerosolized contamination, including from a sink in the incubator cleaning room used to dispose of hospital wastewater (Figure 4). Outbreak Control: Despite pipe repairs and decontamination, sink contamination recurred due to Serratia’s ability to colonize biofilms in water pipes. Expert consultation emphasized “sink hygiene,” including minimizing equipment storage near sinks, distancing neonates and incubators, and avoiding procedures adjacent to sinks. Outcome: This multifactorial approach significantly reduced clinical cases. Continuous environmental monitoring and education aim to eliminate Serratia as a recurring threat in our neonatal facility and broader hospital environment. Conclusion: This outbreak highlights the challenges of controlling waterborne pathogens in hospital settings and underscores the importance of combining engineering, environmental decontamination, and behavioral interventions to

Background: Distinguishing outbreaks from pseudo-outbreaks is essential in healthcare settings. Pseudo-outbreaks are defined by an increase in identified organisms without clinical evidence of infection. Here we report two cases involving Pseudomonas aeruginosa identified in clinical specimens, later determined to represent a pseudo-outbreak. Methods: Patient #1 had vertebral osteomyelitis and epidural abscess; intraoperative and blood cultures grew Streptococcus mitis/oralis. Four days post-surgery, one colony of P. aeruginosa grew from one of three intraoperative aerobic cultures. Patient #2 developed a fracture-related infection of the ankle and underwent debridement and hardware removal; all intraoperative cultures grew methicillin-susceptible Staphylococcus aureus. Four days later, two colonies of P. aeruginosa were detected in one of three intraoperative aerobic cultures. Both these findings were deemed unusual, leading to an outbreak investigation, including chart review and laboratory investigations, to identify a source of contamination. Results: The two cultures were received and set up one day apart by different staff. Subsequently, the WASPLab incubation system’s photographic record of the plates demonstrated no P. aeruginosa within the expected first 48 hours, suggesting contamination during culture collection or processing was unlikely. Further review revealed a heavily inoculated culture of P. aeruginosa was processed by the same laboratory technician on an open bench immediately before handling plates for patients #1 and #2. P. aeruginosa typically grows within 24 hours of incubation, and the colony morphology of the contaminated plates matched those of the heavily inoculated culture. Furthermore, both patients had monomicrobial growth of a likely pathogen causing their infection. Therefore, we concluded that this was cross-contamination, likely via aerosolization or improper plate handling. For patient #1, cefepime was discontinued on post-operative day six and switched to ceftriaxone, completed for six weeks, followed by suppressive therapy with amoxicillin, with no recurrence at three months. Patient #2 completed six weeks of cefazolin without anti-pseudomonal coverage, also without recurrence at three months. Conclusions: The pseudo-outbreak likely stemmed from cross-contamination caused by aerosolization or handling heavily inoculated P. aeruginosa cultures near the time and location of the two patients’ plates on an open bench. Awareness of such rare contamination pathways is critical for microbiology labs and clinicians, especially when handling hazardous isolates such as Brucella spp. Careful record keeping and digital storage of serial plate images can narrow the source of contamination, and active surveillance by trained epidemiology personnel is essential to detecting pseudo-outbreaks. Clinical and microbiological correlation should guide treatment to avoid unnecessary antibiotic treatment.

Background: In response to a second multistate extrapulmonary tuberculosis (TB) outbreak in 2023, linked to contaminated viable bone allografts, public health authorities conducted contact investigations (CIs) to assess TB transmission among healthcare personnel (HCP) potentially exposed to contaminated grafts during surgeries or draining infected surgical sites. Method: A HCP-CI was initiated after Centers for Disease Control and Prevention (CDC) notification that three San Diego county hospitals had received contaminated allografts. Healthcare facilities identified and tested HCP potentially exposed and reported results to the health department. We reviewed the CI processes of each facility and outlined challenges encountered and solutions implemented. Result: HCP-CIs were conducted at five facilities: three hospitals where nine patients received contaminated product; a hospital where revision surgery was performed; and a skilled nursing facility (SNF) that provided postoperative care. We encountered several challenges during the CIs. First, 234 HCPs were potentially exposed based on a framework used in a prior (2021) TB bone allograft investigation. We advised a tiered approach with targeted follow-up of 72 HCP with high-risk exposures (for example, staff directly handling the allograft). Second, the SNF CI was complicated by administrative staff turnover, no SNF point-of-contact, and investigations involving different HCPs during three separate admissions. Substantial public health resources were required over 7 months, including a site visit to interview HCP with positive TB tests and obtain accurate CI information. Third, obtaining CI data was slow and inconsistent. Reasons included lack of a standardized data collection tool during the initial phase of the CI, fragmented information gathering across clinical departments within facilities, lack of responses from licensed practitioners who were not employees (e.g., physicians), variability in notification of exposed HCP for testing, and follow up of HCP that weren’t tested. HCP-CI results were not readily available when requested, leading to confusion, repeated requests, and duplication of efforts. We countered these challenges by leveraging established (or new) relationships with facility leadership and involving multidisciplinary staff to obtain results. Public health recommended facilities contact non-responsive practitioners with high-risk exposures by certified letter notifying them of the exposure and testing recommendations. Conclusions: Close collaboration, communication, and coordination between public health and each healthcare facility’s clinical services and leadership were critical in this HCP-CI. Utilizing a tiered approach streamlined the CI. This complex HCP-CI spanned multiple facilities and could have benefited from early identification of consistent points-of-contact at each facility and use of a standardized data collection tool.