Background: Central line-associated bloodstream infections (CLABSIs) are monitored in U.S. hospitals using the National Healthcare Safety Network (NHSN) surveillance definitions. This standardization has enabled interfacility comparisons of CLABSI rates and established CLABSIs as a nationally recognized healthcare quality and patient safety indicator. Since CLABSI prevention efforts focus on infections meeting the NHSN definition, fewer resources are allocated to address other bacteremia sources, potentially missing opportunities for improvement. Methods: The review included hospitalized patients with an eligible central line and ≥1 positive blood culture on hospital day ≥ 3 in 2024. Trained infection preventionists (IPs) applied the NHSN surveillance definitions to classify positive blood cultures. IPs then gathered clinical information by reviewing the patients’ medical history, interventions, imaging tests, antimicrobial treatments, and direct caregiver engagement, used it to determine the likely clinical sources for bacteremia, and classified them according to NHSN categories. The concordance in classifying positive blood cultures using the NHSN surveillance definition alone versus with clinical input were compared. Results: Of the 136 eligible cases that IPs reviewed in 2024, 92 (67%) had concordant classifications as CLABSI (24), mucosal barrier injury (MBI) (13), secondary bacteremia (28), contaminant (25), or other (2). Of the 29 CLABSIs that met only the NHSN surveillance definition, 15 were associated with a clinical secondary source, 8 with a clinical MBI episode, 5 as continuation of previous infection or present on admission, and 1 as clinical contaminant. The 83 non-CLABSI bacteremia included 38 infections at other sites and 27 contaminants. Conclusion: Our analysis suggests that using NHSN surveillance definitions results in significant overreporting of CLABSIs in pediatric patients. Overreporting may be due to factors unique to the pediatric population, such as the inability to communicate clinical symptoms and the normal physiologic lack of signs needed to meet NHSN definitions. A focus on all BSIs could provide a greater benefit towards hospital harm reduction activities by focusing on the likely true source of bacteremia. Compared to CLABSIs, patient harm from contaminated blood cultures and infections with secondary bacteremia may be more prevalent and require a greater focus on prevention.

Background: Central line-associated bloodstream infections (CLABSIs) are preventable infections associated with poor outcomes. Nationally, the CLABSI standardized infection ratio (SIR) decreased from 2018 to 2019, but those positive results were derailed by the COVID-19 pandemic. From FY21 to FY22, the CLABSI SIR in our facility’s medical intensive care unit (MICU) more than doubled. In March 2021, we created a multidisciplinary central venous access device (CVAD) rounding team to decrease CLABSI in the MICU. Method: We conducted a prospective pre-post quality improvement study in an academic, quaternary care hospital with a 30-bed MICU. The decision to implement a multidisciplinary CVAD rounding process was based on a review of published best practices. The study was approved by the UNC Institutional Review Board.

Our team included MICU clinicians, registered nurses, an infection preventionist, a vascular access registered nurse and a “CVAD Liaison”. The CVAD liaison role is a registered nurse trained maintaining aseptic technique during CVAD insertions and educating staff on CVAD maintenance. Each teammate had assigned responsibilities (Fig. 1).

The team rounded weekly on every MICU patient with a CVAD. Components of the rounding process were compliance audits of all CVADs; evaluation of line necessity; targeted education and process improvement. Result: This study evaluated the intervention’s impact on CLABSI, CVAD utilization, and maintenance bundle compliance rates. Data were collected for five fiscal years (FY19 to FY23). Following the intervention, the MICU experienced a 57% decrease in CLABSI rates between FY21 and FY22. This reduction was meaningful for patient care, although not statistically significant. Infection rates rose slightly in FY23 but remained lower than from FY19-21 (Table 1). There was no statistically significant difference in the CVAD utilization rate between FY21 and FY22. There was an improvement in the percentage of intact dressings (Fig.2). Conclusion: Following the implementation of a multidisciplinary CVAD rounding team, there was a 57% decrease in the MICU’s FY22 CLABSI infection rate from the prior fiscal year. This decrease in CLABSI was sustained with a similar CLABSI rate in FY23. One potential explanation for the CLABSI reduction was increased awareness of the importance of maintaining CVAD dressings (Fig. 2). The primary challenge for this team has been sustaining staff availability. Staff shortages and burnout have made it challenging to find coverage for rounds. Our team began addressing staffing challenges by expanding the pool of interested staff. Sustainment of rounding and CLABSI reduction will require continued monitoring and recruitment.

Background: Patients with cirrhosis often experience coagulopathy, which can result in profound bleeding at intravenous insertion sites. This makes maintaining dry, intact central venous catheter (CVC) dressings particularly challenging. At our 2,247-bed acute care tertiary referral hospital, the Medical-Surgical Intensive Care Unit (MSICU) specializes in hepatic care.

Upon completing a root cause analysis of our elevated central line associated blood stream infections (CLABSIs), we found patients with coagulopathy had poor CVC dressing adherence. Our goal was to reduce CLABSIs by improving dressing integrity through innovative strategies aimed at mitigation of bleeding and enhanced adhesion. Method: In November 2022 a review was completed of hemostatic and adhesion products to address bleeding at CVC insertion sites and improve dressing adherence to skin. In December 2022 we developed a tiered intervention program using three products tailored to the severity of bleeding at CVC insertion sites. We then selected an adhesive product to bond the perimeter of the dressing to the skin. We disseminated education to the nursing team on product use according to patient CVC dressing condition and manufacturer instructions for use. The tiered intervention program was evaluated by comparing pre-intervention (January 2021 to November 2022) CLABSI rates and standardized infection ratios (SIRs) to post-intervention (December 2022 to October 2024) outcomes. Data was obtained from the National Healthcare Safety Network (NHSN), and analysis was completed using the NHSN statistics calculator. Result: Following implementation of the tiered intervention program, the CLABSI rate decreased from 1.67 to 0.62, a 62.9 percent decrease. The CLABSI SIR decreased from 1.481 to 0.553, a 62.7 percent decrease. The CLABSI SIR reduction was statistically significant (p-value of 0.0318; one tailed Z-test). Conclusion: Patients with coagulopathy issues pose unique challenges in infection prevention. Their abnormal clotting factors increase the risk of bleeding, making it difficult to maintain an intact and occlusive CVC dressing. Hemostatic and adhesive products are effective strategies for maintaining CVC dressing integrity and facilitating CLABSI reduction.

Background: Healthcare associated infections (HAIs) are important areas of concern as they increase length of hospital stay, increase hospital costs, and have high morbidity and mortality. For instance, central line associated bloodstream infections (CLABSIs) approximately increase length of stay by 13.4 days and increase hospital costs by $43,975. Studies also suggest a 1.5-2.5x increase in mortality in patients who develop CLABSIs. In 2013, the REDUCE MRSA trial compared universal MRSA decolonization to targeted MRSA decolonization in the ICU and found superiority ini reducing positive MRSA cultures and all cause bloodstream infections. We aim to decrease central line associated bloodstream infections at our institution by adopting the REDUCE MRSA trial protocol. Methods and Outcomes: All patients admitted to the medical/surgical ICU and cardiac ICU at St Francis Hospital starting in December of 2023 received daily intranasal mupirocin and chlorhexidine bathing regardless of their MRSA status. The primary outcome assessed was the CLABSI rate per month. The secondary outcomes were the standard infection ratio and CLABSI per central line day. We compared data from 2020-2023 to data after initiation of the protocol in 2024. We used unpaired t testing to assess the CLABSI rate per month and used a negative binomial regression model to calculate the standard infection ratio according to the NHSN 2015 national baseline. Results and Discussion: We had a total of 6 CLABSIs in the ICU this year after initiating universal MRSA decolonization. The number of CLABSIs per month decreased from 0.65 per month from 2020-2023 down to 0.50 per month in 2024. These results, while not statistically significant, are limited by the small sample size since the protocol was just initiated this year. One interesting finding was 5 of the 6 CLABSIs occurred during January through March, which brings up the question if introducing these new changes required time for nursing education and compliance to improve. Conclusions: Our results suggest that universal MRSA decolonization in the ICU may decrease the number of CLABSIs. We will continue to collect more data in the coming years to assess for statistical significance. We recommend further research to assess for potential benefits of universal MRSA decolonization in other areas of the hospital where MRSA infection rates are high like step down units.

Introduction: With the expanding use of non-culture based tests (NCTs), the CDC’s National Healthcare Safety Network (NHSN) incorporated NCTs into the surveillance definition for central line-associated bloodstream infections (CLABSI) in 2016. However, there are limited data available on the impact of NCTs on CLABSI surveillance since that time. In this study, we aim to describe the test performance characteristics of a NCT which detects microbial cell-free DNA (Karius® Test [Redwood City, CA: Karius, Inc]) for bloodstream infection diagnosis and to determine the impact on CLABSI surveillance within a pediatric healthcare facility. Method: This study was performed at a 654-bed quaternary care pediatric healthcare facility in central Ohio from January through December 2024. All patients with Karius® Testing performed on or after hospital day 3 were included. Sensitivity, specificity, and positive predictive value (PPV) for Karius® Tests to diagnose bloodstream infections were determined from patients with paired blood cultures collected within 2 days of the Karius® Test. Patients with positive and negative Karius® Tests were compared using Fisher’s exact test and Wilcoxin rank sum test. Analyses were completed using Stata version 18 (College Station, TX: StataCorp LLC). Viral data were excluded from the analysis. Single growth of common commensal organisms on blood culture were treated as contaminants. Result: Eighty-six patients with a total of 91 Karius® Test results were included in the analysis (Table; Figure). Patients with a positive Karius® Test were younger and more likely to have a positive blood culture (p Conclusion: In our cohort, the Karius® Test lacked specificity and PPV for the diagnosis of bloodstream infections. This was especially pronounced in afebrile patients in whom clinicians did not suspect bloodstream infection. Inclusion of NCT methods within the CLABSI definition may bias national surveillance rates by including patients with low post-test probability as well as impact diagnostic stewardship efforts to reduce inappropriate blood culture collection.

Background: Central line-associated bloodstream infections (CLABSIs) remain an important, preventable healthcare-associated infection. Prolonged catheterization is a major risk factor, and avoidance and prompt removal of unnecessary central lines (CL), including peripherally inserted central catheter (PICC), can reduce CLABSIs. We aimed to evaluate potential opportunities to reduce PICC utilization and associated harm. Methods: This was a cross-sectional observational study of hospitalized patients with PICCs from June 1 to June 30, 2024 at an 877-bed tertiary care hospital in Detroit. CL indications using evidence-based and institutional guidelines, duration of catheterization, and complications of line were evaluated. Results: 145 patients had PICCs (Table 1). Of these, 114 (78.6%) were placed at bedside in the general practice unit, 31 (21.3%) in the ICU and the majority (57.5%) were double lumen. Common indications included total parental nutrition (TPN) (59, 40.7%) and outpatient parenteral antimicrobial therapy (OPAT) (58, 40%). 22 (15%) patients did not have an established indication for PICC placement. Among patients receiving PICC for TPN, 9 (15%) did not meet criteria, and 9 (15%) were on TPN for < 5 days. Amongst those discharged on OPAT, 14 (24%) had opportunity for oral sequential therapy; 11 (19%) patients only received treatment for < 28 days. Although 26 (18%) patients had CL placed for difficult access, half of them had a concurrent or subsequent PIV or midline. Median duration of CL was 25 days (range: 2-499), and a third had CL placed for < 1 4 days. Overall, 22 (15.7%) patients were identified to not meet any indication for PICC and of those who received double or triple lumen catheter, 62 (73%) qualified for single lumen catheter only. Complications occurred in 13 (9%) patients, including CLABSI (6, 4.1%) and thrombotic events (4, 3%). Eight (5.5%) patients had line-related readmission. Conclusion: Upon review, PICC lines were commonly overutilized, and contributed to increased CLABSI rates. Several opportunities to reduce CLABSIs were identified, including reinforcement of appropriate CL indications, increase midline utilization for shorter duration of therapy and difficult access. These findings also encourage use of oral sequential therapy instead of OPAT, and placement of single lumen catheters where indicated.

Background: Central line associated bloodstream infections (CLABSIs) are a preventable healthcare-associated infection. Evidence shows implementation of evidence-based bundled infection prevention strategies can reduce CLABSIs. We reviewed the impacts of a CLABSI prevention toolkit on CLABSI rates as well as compliance with key prevention practices. Methods: A CLABSI Prevention Bundle Toolkit was implemented in December 2023 at a quaternary care academic medical center. The toolkit delineated the elements of the bundle, including hand hygiene, daily review of line necessity, daily chlorhexidine gluconate (CHG) topical treatment, aseptic technique for insertion and maintenance, along with the responsible party for each task and educational resources for staff and patients. Additionally, the toolkit required weekly audits of CLABSI bundle by individual units and a multidisciplinary meeting to debrief each CLABSI to identify opportunities and successes. Analysis of compliance with key prevention practices, CLABSI rates and clinical details was completed before (December 2022 – November 2023) and after (December 2023 – November 2024) implantation of the toolkit. Results: Compliance with key prevention practices pre- and post-toolkit implementation is detailed in Table 1. There was a 37% reduction in CLABSI rate pre- and post-toolkit implementation as shown in Table 2. Clinical details including CLABSI classification as preventable, end-of-life or definition-based (Hsueh, Maurice and Uslan, ICHE 2022), organism, dialysis, transplant status and patient race are detailed in Table 2. Conclusions: CLABSI prevention bundles have been shown to reduce CLABSI, but implementation and compliance of the bundle can be challenging. A toolkit which outlines required tasks, responsible parties, regular audits and debriefs after CLABSI can help support healthcare teams in successful implementation of the full CLABSI bundle. Following the bundle toolkit implementation there was improvement in rates of CHG treatment and line necessity review with an overall decrease in CLABSI rates. Not all process measures included in the toolkit are able to be quantified so likely additional factors contributed to the reduction in CLABSI rates. Overall, there did not appear to be a difference in the types of CLABSIs, organisms or patient demographics in the pre and post-toolkit groups although there were more CLABSIs in transplant patients post-toolkit suggesting a complex patient population. A comprehensive toolkit can aide in implementation of a multi-faceted prevention bundle, provide a structure for accountability and help improve patient outcomes.

Objectives: To characterize the incidence and contributing factors related to hospital-onset bloodstream infection (HOBsi) in a nine hospital healthcare system. Background: Bloodstream infections that develop during hospitalization are critical measures of healthcare quality. Though these events are measured in part through CMS reports of central line-associated bloodstream infections (CLABSIs) and MRSA bloodstream infections. A newer metric has been introduced by National Healthcare Safety Network (NHSN) to measure any case of bloodstream infection with onset on or after hospital day four. There is no established benchmark rate for HOBsi and its clinical understanding remains complex. Methods: Positive blood cultures obtained on or after hospital day four from nine hospitals across northeast and central Pennsylvania were included in this study, spanning July 2021 to June 2024. Cases were classified based on NHSN criteria: primary bloodstream infections (BSIs), CLABSIs, mucosal barrier injury-related infections, and secondary bacteremia with identified sources (e.g., pneumonia, urinary tract infections, gastrointestinal infection or surgical site infection). Results: A total of 739 HOBsi cases occurred in 1,186,510 patient days over three years, for a rate of 6.13 (95% confidence interval 5.69 to 6.59). The rates varied significantly by hospital unit type (p=0.002) (Figure). Oncology wards had the highest HOB rate (21.1 infections per 10,000 patient days), followed by critical care units at 11.5. Behavioral health and obstetric wards had the lowest HOB rates. When location type was considered, the rates between hospital campuses were not significantly different. In multivariate regression, the central-line device use ratio further influenced the HOBsi rate (p=0.002). Primary BSIs accounted for 49.3% of cases, while 22.1% met the criteria for CLABSI. When NHSN-defined source was found (secondary BSIs), pneumonia was the most common source (6.5%), followed by urinary tract infections (5.5%), gastrointestinal tract infections (3.5%), surgical site infections (3%), and other sources (6%). Mucosal barrier injury-related HOBsi comprised 4.2% of cases. Conclusion: This quality measure significantly expands the scope of infection events over CLABSI. HOBsi is closely associated with the hospital location type. Device use may further stratify for severity. This study establishes some initial benchmarks. Understanding the likely source of bacteremia will be important in finding ways to target strategies to reduce HOBsi.

Background: Implementation of transmission-based precautions has predominantly been performed in inpatient acute care settings. Limited guidance is available on applying these precautions in ambulatory clinics, especially for patients with suspected or confirmed COVID-19. This timed analysis of empiric isolation precautions for COVID-19 in walk-in clinics (WIC) aimed to identify unintended impacts that are underappreciated with inpatient use. Methods: An observational analysis at four WIC sites in an academic hospital network was conducted in July-October 2024. Patients who screened positive at check-in with cough, sore throat, congestion, or recent COVID-19 positive testing triggered an electronic notification on the need for airborne and contact isolation precautions with eye protection. A timed evaluation of healthcare personnel (HCP) to don and doff personal protective equipment (PPE) upon patient room entry and exit was performed by two observers using a standardized process with a stopwatch. HCP were surveyed regarding attitudes and barriers using a 5-point Likert scale on REDCap. Results: Sixty patient encounters requiring COVID-19 isolation were observed, representing 30.4% of the total WIC patients seen during the observation periods (N=197 over 36.5 hours). Cough and sore throat were the most common symptoms triggering isolation (both 55%). The mean time to don and doff PPE per room entry and exit was 1.58 and 0.57 minutes, respectively (2.16 minutes per don and doff cycle; Table 1). HCP performed donning and doffing an average of 1.8 times (range 1-4) per patient. Extrapolated to a 12-hour shift, this adds 1.3 hours to daily activities and encompasses 35 sets of PPE (e.g. gowns, gloves, eye protection, respirators), contributing to WIC waste volumes (Table 2). HCP survey respondents (N=26/49) indicated a majority strong agreement that PPE increased the time required, burden to HCP, and waste. Conclusions: Multiple workflow, resource, and HCP burdens of using full COVID-19 isolation precautions for WIC patients suggest that refining isolation criteria for ambulatory settings may help preserve clinic efficiency and limit waste. This pilot occurred during a period with low COVID-19 and influenza-like illness incidence, underscoring the challenges of scaling empiric transmission-based precautions to high-volume clinics during surges of respiratory virus season. Further studies are needed to evaluate the impacts of eliminating the gown and gloves components of PPE for COVID-19 in ambulatory settings, which may be unnecessary given the lower likelihood of transmission by non-airborne routes, short duration of outpatient clinic encounters which limits environmental contamination with SARS-CoV-2 virus, and lack of aerosol-generating procedures.

During the COVID-19 pandemic, Uganda’s healthcare system was significantly strained resulting in economic losses and increased morbidity and mortality. implementing rigorous Infection Prevention and Control (IPC) interventions were crucial to safeguard patients and healthcare workers from nosocomial infections and ensure continuity of essential services. Although faith-based health facilities contribute to 15% of Uganda’s healthcare system, most IPC programs have predominantly focused on public health facilities. This study describes a champion-led cascade model for IPC capacity building designed to strengthen IPC at Private Not-for-Profit health facilities bolstering responses to pandemics like COVID-19 and Ebola. Between October 2020 to May 2021, a Champion-led cascade model was implemented in 213 faith-based health facilities in Uganda. We identified health workers from each health facility to participate in a 3-day IPC Training of Trainers (ToT) based on Uganda’s National IPC training package. The training focused on improving knowledge, and practices in establishing IPC leadership at health facilities, developing guidelines, environmental cleaning, hand hygiene, use of personal protective equipment (PPE), screening and isolation, waste management. The trainees underwent a pre and posttest evaluation and were considered to have passed as national trainers if they obtained at least 70% in the post-test evaluation. They were then assigned to champion IPC improvement at one health facility each through monthly mentorship visits. The Mentorship focused on improving IPC practices suchas environmental hygiene, waste management, use of PPE, screening and isolation. Monthly facility IPC assessments were conducted using a digitalized Ministry of health assessment tool. Facilities with low scores were consecutively profiled for targeted quality improvement. We analyzed improvement in IPC knowledge of the champions, frequency of mentored health workers and improvements in IPC capacity at end line versus baseline using Stata 14.0. A total of 240 champions were trained and they cascaded IPC mentorship to 213 faith-based health facilities (Hospitals=17%, primary healthcare facilities=83%). The champions’ average knowledge improved from 36% at pre-test to 70% at post-test, reflecting a 34% improvement. Overall, 2,963 healthcare workers (1,727 females) were trained in 8 months. Average IPC performance at health facilities improved from 38.6%(SD=12.3) at baseline to 51.3% (SD=10.4) (p < 0 .05). IPC improvements were registered in availability of screening and isolation facilities from 6.8% to 8.4% (SD=3.1) at end line, and PPE use from 3.5% to 4% (SD=1.5). Availability of water remained low (1.6% at baseline versus 1.66% at end line).

The champion-led cascade approach facilitated expansion of IPC mentorship to health workers and enhanced IPC capacities in faith-based facilities across the country.

Background: The prioritization of U.S. health care personnel (HCP) for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) allowed for the evaluation of the effectiveness of these vaccines in a real-world setting among a high-risk population. The purpose of this study was to summarize the sociodemographic characteristics of HCP in Oregon eligible to receive COVID-19 vaccination and estimate vaccine effectiveness (VE) of a mRNA COVID-19 vaccine booster dose. Methods: We conducted a case-control study involving HCP from 5 hospitals in Oregon. Cases were defined as those with a positive antigen test or nucleic acid amplification test (NAAT) for SARS-CoV-2. Controls were defined as those with a negative antigen test or NAAT result and were matched to cases by site and within a 2-week interval of test date. Using conditional logistic regression with adjustment for age, sex, race and ethnicity, educational level, underlying conditions, and reported exposure to COVID-19, we estimated VE for a 3rd COVID-19 vaccine booster dose (with the 3rd dose more than 150 days after the 2nd dose). VE was estimated using the screening method as 1-odds ratio x 100%. Results: Among 865 HCP, 374 (43%) were included as case-participants and 491 (57%) as control-participants. Overall, the adjusted VE of a booster dose was 62.6% (95% CI: 37.6%, 77.6%), compared to vaccination with 2 mRNA doses. Logistic regression analysis indicated that HCP with a college degree (vs. no degree, OR: 3.26, 95% CI: 1.96, 5.45), private insurance (vs. government/military, OR: 3.32, 95% CI: 1.28, 8.59), and an income level $200K+ (vs. <$50K, OR: 3.25, 95% CI: 1.60, 6.60) were more likely to have received the booster vaccine. Conclusions: The mRNA COVID-19 booster vaccines conferred approximately 63% protection against COVID-19 among Oregon HCP and were found to be effective under real-world conditions. These findings indicate moderate initial protection against SARS-CoV-2 infection and encourage remaining up-to-date with subsequent COVID-19 vaccines. The identification of sociodemographic characteristics of HCP who are more likely to have received a booster vaccine provides insight into those at higher risk for adverse COVID-19 outcomes due to lower vaccine coverage. While understanding these characteristics is valuable for directing ongoing vaccination efforts towards these populations, further research is needed to understand the mechanisms that contribute to variations in vaccine uptake.

Background: Many practitioners relied on SARS-CoV-2 RT-PCR cycle thresholds (Ct) to remove COVID-specific isolation given data correlating Ct values with the ability to culture live virus. Standardly, Ct values of 28-32 were used to remove isolation. However, many labs stopped reporting these values given lack of clinical validation based on a joint IDSA/AMP statement. VA Boston Healthcare System (VABHS) developed and implemented a clinical algorithm to replace Ct values to determine a need for isolation. We aimed to compare our algorithm performance to the unreported Ct results. Methods: We conducted a retrospective cohort study of COVID-19 PCR positive patients at VABHS between 10/1/23 and 3/31/24. During this time, VABHS required COVID-19 PCR testing (either via Cepheid Xpert Xpress CoV-2 plus or Cepheid Xpress Sars-CoV-2/flu/RSV plus) for admission regardless of symptoms. Included were all patients for whom Infectious Diseases (ID) was contacted to take off isolation using our algorithm (Fig 1). Ct values were later obtained from the lab as part of IRB-approved research to determine sensitivity of the algorithm to correctly classify isolation requirements. Ct values of 28 and 30 were used as the gold standard test for determining need for isolation. Results: ID was contacted to determine isolation requirements for 56 patients for whom the algorithm was applied and Ct values were later available for review. Using a Ct threshold of 28, 44 patients (78.6%) were admitted with appropriate isolation classification via the algorithm; 34 patients off isolation and 10 requiring isolation. Incorrect algorithm classification occurred for 10 patients who were isolated when not required due to lack of additional data; 2 patients who required isolation were not isolated. The algorithm failed in these 2 patients at the use of antibody results for determining time from infection; mean Ct value was 25.6 (range 23.6- 27.6). Both patients had COVID within the last 30 days and positive antibody testing. The true positive rate/sensitivity for algorithm driven isolation was 83.3% (51.6-97.9%) and the true negative rate/specificity for algorithm driven removal of isolation was 77.3% (62.1-88.5%). When the Ct threshold is modified to 30, the sensitivity and specificity of the algorithm were 78.6% (49.2-95.3%) and 78.6% (63.2-89.7%) (table 1). No transmissions occurred using the algorithm during this study period. Conclusions: Strategic use of an algorithm using history, antigen and antibody results was moderately accurate compared to Ct values for assessing isolation requirements. No known transmissions occurred with use of the algorithm in lieu of Ct values.

Objectives: Multiple barriers exist for COVID-19 vaccination in high-risk individuals especially adults over the age of 65. Each healthcare visit represents a critical opportunity for vaccination, yet many patients who do seek vaccination receive their vaccines in locations other than their routine health care providers and healthcare sites often lack the capacity for vaccine administration. Here-in we conducted a needs assessment to identify hospital system specific barriers and facilitators to COVID-19 vaccine access in individuals 65 and older in 2024. Methods: We conducted six semi-structured interviews (June-July 2024) with seven healthcare leaders in Yale New Haven Enterprise. We transcribed and analyzed interviews to develop a larger-scale survey targeting healthcare professionals including vaccine leadership of individual clinics across the healthcare systems. The survey was distributed to 42 healthcare leaders (physicians, administrators, and practice supervisors) across 52 ambulatory locations. Results: The survey received twenty responses (47% response rate). Four primary challenges to COVID-19 vaccination among older adults were identified: (1) Patient Hesitancy, driven by misinformation about vaccine contents, concerns about side effects, polarized attitudes, and waning interest in booster doses; (2) Challenges Related to Staff, including distrust in vaccine motives, mandates, and efficacy, as well as a shortage of personnel available to administer vaccinations; (3) Operational and Logistical Barriers, including complex vaccine schedules, vaccine storage, and reliance on retail pharmacies, which led to lower vaccination rates at primary care sites; and (4) Policy and Financial Constraints, such as insufficient financial incentives for on-site vaccinations, Medicare coverage limitations, and high administrative costs. The main proposed actions to address vaccination hesitancy and challenges include enhancing education sessions for patients and staffs, modifying streamlining administration by simplifying the workflows including on-site vaccination process for employees, and centralizing vaccine delivery in primary care or hubs, improving accessibility via routine (home) visits and flexible hours, and partnering with pharmacy department to ensure greater access to vaccination. Conclusion: Through semi-structured interviews and surveys, we identified targets for future quality improvement efforts. Multiple overlapping barriers to COVID-19 vaccination in older adults exist within one U.S. based health care system. Some of these barriers, such as improving vaccine administration workflows or enhancing patient education, can be more readily addressed, while others involve larger structural issues that would require larger societal change. We are seeking a subspecialty clinic partnership to pilot an implementation project, using high-impact intervention tailored to clinic needs and iterative Plan-Do-Study-Act (PDSA) cycles to refine and optimize outcomes.

Introduction: Athletes in contact sports have a higher rate of Staphylococcus aureus nasal carriage than the general population, leading to an increased risk of skin and soft tissue infections (SSTIs). These infections can have a significant impact on individual players and teams. This study aimed to assess the effectiveness of adding a nasal decolonization protocol in reducing S. aureus colonization among a Division I (D1) college football team to chlorhexidine gluconate body wash. Methods: A total of 113 athletes were screened for S. aureus nasal carriage at two time points during intensive summer training. During the first screening, athletes were universally prescribed intranasal mupirocin twice daily using clean Q-tips for five consecutive days. Players were also educated on proper hygiene and adherence to the decolonization protocol. Four weeks later, all players were screened again for S. aureus nasal carriage. Protocol success was defined as either detection of Staph aureus in the first round of screening but not in the second (elimination) or a persistently negative result (lack of acquisition). Protocol failure was defined as either the isolation of the same organism in the first and second rounds (lack of elimination) or a positive second-round culture following a negative first-round culture (acquisition). Select S. aureus isolates were submitted for multilocus sequence typing (MLST). Results: At the initial screening, 2 players (1.8%) were colonized with methicillin-resistant Staphylococcus aureus (MRSA), 23 players (20.4%) with methicillin-susceptible Staphylococcus aureus (MSSA), and 4 players (3.5%) with both MRSA and MSSA. After decolonization, follow-up screening identified 0 players with MRSA and 12 players (10.6%) with MSSA, representing a 58.6% reduction in overall S. aureus nasal carriage. Based on study definitions, the decolonization protocol was successful in 101 (89%) players (Figure 1).

MLST was performed on 11 of the 27 initial MSSA-positive isolates and 6 of the 12 second-round MSSA-positive isolates. Based on limited molecular typing data, at least 1 player may have acquired MSSA from another team member within the athletic environment. Discussion: Our findings suggest that implementing a nasal decolonization protocol in a D1 college football team is feasible and effective, resulting in a significant reduction of S. aureus nasal carriage. While initial screening effectively identified carriers, a small subset of athletes acquired MSSA colonization, indicating potential re-exposure or incomplete protocol adherence. Further research should explore decolonization adherence strategies and expand decolonization efforts across contact sports programs to reduce S. aureus-related SSTIs among athletes.

Background: Chlorhexidine gluconate (CHG) bathing reduces skin bacterial colonization and reduces the risk of hospital-acquired bloodstream infections, central venous catheter-related bloodstream infections, and transmission of multidrug-resistant organisms. Although mild skin irritation to CHG is common, true IgE-mediated allergy is rare. We implemented a program to delabel low-risk CHG allergies in hospitalized patients. Methods: Patients ≥ 18 years of age admitted to inpatient cardiology or hematology-oncology units with an allergy to CHG documented in the electronic medical record were identified. A hospital epidemiologist contacted primary care teams directly, providing a personalized and collaborative approach to evaluate the listed CHG allergy. Using an algorithm devised in partnership with dermatology and allergy experts (Figure 1), guidance was tailored to the reported type of reaction. Each point of contact with care teams was considered an intervention. The primary endpoint was the number of patients for whom a CHG allergy or intolerance was removed from the medical record. Results: During a two-month period, 42 interventions for 31 unique patients reporting an allergy to CHG were performed. The cohort was fairly evenly distributed between hematology-oncology and cardiology units (52% vs 48%, respectively), and was 51% male with a median age of 63 (IQR, 20.5 years). Rash was the most frequently listed concern (58%), followed by nonspecific burning or irritation (35%). 5 patients (16%) were delabeled; of these, 2 were directly delabeled due to tolerance of other CHG products (e.g., CHG dressing), and 3 were delabeled by dermatology patch testing. There were no adverse reactions reported after CHG allergy de-labeling. Conclusion: Similar to handshake rounds for antimicrobial stewardship, collaborative and targeted education can be an effective strategy to delabel CHG allergies and intolerances.

Background: Universal decolonization using chlorhexidine gluconate (CHG) foaming soap in a hospital system has been shown to reduce healthcare-associated infections (HAIs) and colonization by multidrug-resistant organisms. Limited data exist on optimal strategies to improve compliance, and the impact of improved compliance on HAI rates. This study evaluates the effect of increasing CHG compliance on MRSA HAI rates. Methods: In 2022, our acute care VA hospital started universal CHG bathing treatment, by requiring a daily CHG bath for all patients in intensive care units and medical/surgical floors, unless contraindicated. Despite this, compliance was below goal. We performed root cause analyses to identify factors contributing to poor compliance, and then initiated a bundled intervention, including nursing staff education on the benefits of CHG bathing to reduce HAIs, how to reframe discussions with patients about refusals, removal of one alternative soap product from the inventory, and moving the CHG bathing product in clean supply rooms to be in proximity with other patient hygiene products for easier access. We evaluated the utilization of CHG bathing products through inventory data on utilization of 4 fluid ounce bottles of 4.0% weight/volume CHG solution, documentation of at least one CHG bath in the electronic medical record (EMR) per unique hospitalization, and HAI rates per National Healthcare Safety Network (NHSN) definitions for methicillin resistant Staphylococcus aureus (MRSA), before (08/2023-02/2024) and after (03/2024-12/2024) implementation of the bundle. Results: Identified barriers to CHG adherence included use of less effective alternative soap agents, perceptions of patient skin irritation from CHG, difficulty integrating CHG into existing workflows, and lack of understanding of the benefits of CHG bathing. After bundled interventions, inventory usage CHG bottles increased from 170 to 270 bottles per 1,000 bed days of care (BDOC) (p Conclusion: An intervention of staff education, removal of an alternative soap product, and improving access to CHG bathing products in supply rooms, resulted in improved CHG bathing adherence, and was associated with a reduction in MRSA HAIs in an acute care VA hospital. Interestingly, the decrease in MRSA HAIs was achieved despite an absence of complete adherence. Further data on additional strategies to improve compliance and strategies to improve healthcare worker documentation should be explored.

Background: Healthcare-associated infections (HAI) and multi-drug resistant organisms (MDRO) are a significant cause of morbidity and mortality in the hospital setting. Bacteria often colonize a patient’s skin and can become a source of infection. Bathing patients with chlorhexidine (CHG) has been shown to decrease colonization with MDROs, central-line associated bloodstream infection (CLABSI), and HAIs. The best method for applying CHG remains unknown and hospitals continue to employ different methods of CHG bathing. Methods: This was a nursing led quality improvement project due to staff shortages to reduce the workload burden of a 36-bed bone marrow transplant (BMT) and medical oncology unit. Prior to October 2023, all patients on the unit received a daily CHG bath with 4% CHG solution, which was the standard of care in the rest of the hospital. Beginning in October 2023 patients who were admitted or transferred to the unit had an initial bath with a 2% CHG wipe. Patients would then receive a daily CHG bath with a 4% CHG solution. If a patient were to refuse a bath with the 4% CHG solution, they would be offered a bath with the 2% CHG wipes. The goal of the quality improvement project was to improve compliance with daily CHG bathing, and to reduce HAIs. A pre/post analysis was performed assessing daily bathing compliance and HAIs and MDROS on the BMT unit for the 9 months before and after the intervention. Results: From January 2023 through September 2023, there were 9187 patient days on the unit, with 26 documented mucosal barrier injury (MBI) CLABSI (2.83 per 1000 patient days), 2 MRSA bloodstream infections, and 3 VRE bloodstream infections. From October 2023 through June 2024, there were 9176 patient days on the unit with 19 documented MBI CLABSI (2.07 per 1000 patient days), no MRSA bloodstream infections, and no VRE bloodstream infections. Daily CHG bathing compliance increased from 75% in the 3 months prior to the intervention, to 82% after the intervention. Conclusion: Utilizing a mixed method daily CHG bathing regimen that includes 2% CHG wipes increases compliance of daily CHG bathing, and decreases HAIs and MDROs compared to a regimen with only 4% CHG solution. HAI reduction could be accomplished through reducing microbial colonization on the skin, or possibly simply by increasing overall compliance. Further study on this could evaluate the reduction in workload burden, cost-effectiveness, and reduction in HAIs.

Introduction: Blood culture (BCx) diagnostic stewardship is crucial for optimizing health resources and ensuring appropriate clinical testing while minimizing unnecessary cultures that could lead to increased false positives and subsequent antibiotic overuse. BCx algorithms have effectively lowered BCx rates across various patient populations without compromising patient safety. However, patients with a durable left ventricular assist device (LVAD) represent a unique group where the safety and applicability of these algorithms remain underexplored. Methods: We adapted the BCx algorithm from the DISTRIBUTE study by Fabre et al (Figure 1) and retrospectively applied it to HeartMate 3 LVAD recipients with BCx testing performed between July 1, 2019, and April 30, 2024. Each BCx was reviewed and adjudicated according to the algorithm to determine the appropriateness of BCx indication. We also assessed the incidence of true positives, contaminants, and negative cultures among BCx testing deemed as inappropriate to evaluate the algorithm’s potential impact on clinical decision-making in this specialized patient population. We used the Centers for Disease Control and Prevention’s standard definition of a contaminated BCx. Results: We reviewed 1531 blood cultures in 121 unique LVAD recipients. The most common clinical indications for BCx collection were for documenting bloodstream clearance (363, 23.7%), suspected infective endocarditis or endovascular infection (260, 17.0%), and isolated fever and/or leukocytosis (217, 14.2%). We adjudicated 945 (61.7%) BCx collections as appropriate and 586 (38.3%) as inappropriate. Out of the 586 inappropriate BCx collections, 577 (98.5%) were negative and 8 (1.4%) resulted in a contaminant (Figure 2). Only 1 (0.2%) BCx adjudicated as inappropriate resulted in a true positive, which isolated Streptococcus infantarius in an LVAD patient receiving active chemotherapy for colorectal cancer and was felt to represent gastrointestinal translocation. Discussion: We retrospectively applied a BCx algorithm to LVAD recipients to determine the clinical impact of applying such an algorithm to a high-risk patient population. We found that the BCx algorithm missed only 1 true positive bloodstream infection in a patient with additional risk factors. This study provides preliminary support that a BCx algorithm could reduce BCx testing in LVAD recipients without compromising clinical safety. Future studies on BCx diagnostic stewardship in this population should prospectively collect data and monitor for additional adverse events, such as readmission, mortality, length of stay, and antibiotic days of therapy.

Background: Inappropriate urine culture can lead to unnecessary antibiotic use, antimicrobial resistance, increased healthcare costs, and resource strain. Ensuring the appropriate use of urine cultures aligns with principles of diagnostic stewardship. Methods: Urine cultures ordered from ED in our hospital, for patients who were admitted during July and August 2024 were retrieved from the electronic medical records. Symptoms score based on IDSA guideline (Figure 1) and BLADDER score (Figure 2) were correlated with urine analysis (URE) and cultures for appropriateness. Results: Among 267 urine culture orders that were reviewed, 61 patients were excluded due to indwelling catheter, high-risk neutropenia, recent urological procedures, pregnancy, or recent renal transplantation. The median age of study population (n=206) was 64 years. 50.50% were women. 97 (47.3%) had significant pyuria, and 105 (50.97%) had a positive leukocyte esterase (LE), nitrite positivity was low 13 (6.3%). LE had better correlation with pyuria and culture positivity when compared to urine nitrites. Only 46 patients (22.3%) had culture positivity. Imaging evidence supportive of urinary tract infection was noted in 18 patients. Among 206, only 102 cultures (50.48%) were appropriate as per IDSA guidelines. Inappropriate cultures were ordered for fever (59.6%) without localisation, abdominal discomfort (8.6%), urinary frequency (2.8%), haematuria (1.9%), incontinence (0.9%). 10% were sent as part of order sets, who were asymptomatic and had no significant pyuria or cultures positivity. Among 87 patients with a BLADDER score ≥2, 95.4% of cultures were appropriate, 64.3% had significant pyuria, 36.8% had culture positivity. Among 119 patients with a score < 2, 15.9% of cultures were appropriate, 34.5% had significant pyuria, 11.8% had culture positivity. Positive predictive value (PPV) of BLADDER score for UTI was 77.0%, 89.3% along with pyuria and 88.23 % when combined with pyuria and positive LE. Negative predictive value (NPV) of BLADDER score for UTI was 88.2%, 100% along with absence of pyuria and 100% when combined with absence of pyuria and negative LE (Table 1). Based on our study the proposed algorithm for ordering urine culture, after excluding the high risk group is depicted in the Figure 3. Conclusion: Our study showed 50% of urine culture as inappropriate. BLADDER score can be a useful bedside screening tool for deciding urine culture, PPV and NPV increase when combined with presence or absence of pyuria and LE. Implementing a diagnostic stewardship protocol in urine culture has the potential to improve culture appropriateness, reduce unnecessary antibiotic use.

Background: While broad gastrointestinal (GI) multiplex polymerase chain reaction (PCR) panels can test for various bacterial, viral, and parasitic pathogens, their overuse may yield a high financial burden on hospital systems without clear clinical relevance of all covered organisms. This study aims to assess whether a multifaceted quality improvement intervention directing clinicians to a more limited panel and requiring several restriction criteria would reduce direct hospital costs for patients with suspected infectious diarrhea. Methods: Our quasi-experimental study included patients from a quaternary academic medical center in Texas. In the pre-intervention period (March 2024-June 2024), the Biofire® FilmArray® Gastrointestinal Panel (BioFire Diagnostics, Salt Lake City, UT) was the preferred test for patients presenting with suspected infectious diarrhea and had minimal ordering restrictions (Figure 1). In the post-intervention period (August 2024- November 2024), a second narrower panel (GI Common Pathogen PCR panel) was introduced as the preferred test with some restrictions, while the Biofire® FilmArray® GI Panel was only available to severely immunosuppressed patients and required Infectious Diseases consultation. The restriction criteria were built in the Epic electronic health system (Epic System Corporation, Verona, WI). Information on the intervention was distributed through email memorandums and an internal secure clinical messaging platform. Count control charts were used to visualize the number of FilmArray® GI Panels conducted, while individual control charts were used for the direct laboratory costs of both GI panels. Results: 893 patients had suspected infectious diarrhea in the study period (451 pre-intervention, 442 post-intervention). The average number of weekly FilmArray® GI Panel tests performed dropped from 24.8 to 1.9 (Figure 2), and an average of 21.9 GI Common Panel tests per week were performed in the post-intervention period. The average weekly testing cost decreased from $3,418.10 to $940.40 after the intervention (Figure 3). The two control charts demonstrated the presence of special cause variation for both outcomes (weekly FilmArray® GI Panel tests and combined costs), indicating a change after the intervention. Conclusion: Although the total number of tests did not change after adjusting the restriction criteria, this intervention significantly reduced the direct laboratory costs of the GI Panels after guiding clinicians to a more economical test (GI Common Panel), with an estimated annual savings of $128,840. This study provides a diagnostic stewardship opportunity for cost reduction in healthcare systems. Future evaluation will analyze its impact on antimicrobial utilization and infection control metrics.