Background: Globally, Antimicrobial Resistance is a growing threat to global health security and economic development. Due to multidrug resistance, bloodstream infections (BSI) are a growing public health concern and a common cause of morbidity and mortality, especially among non-malarial febrile children Method: This study assessed laboratory BC process outcomes among non-malarial febrile children below five years of age at five AMR surveillance sites in Uganda between 2017 and 2018. Secondary BC testing data was reviewed against established standards. Result: Overall, 959 BC specimens were processed. Of these, 91% were from female patients, neonates, infants, and young children (1-48 months). A total of 37 AMR priority pathogens were identified; Staphylococcus aureus was predominant (54%), followed by Escherichia coli (19%). The diagnostic yield was low (4.9%). Only 6.3% of isolates were identified. AST was performed on 70% (18/26) of identified AMR priority isolates, and only 40% of these tests adhered to recommended standards. Conclusion: Interventions are needed to improve laboratory BC practices for effective patient management through targeted antimicrobial therapy and AMR surveillance in Uganda. Further research on process documentation, diagnostic yield, and a review of patient outcomes for all hospitalized febrile patients is needed.

Background: Duplicative laboratory testing is prevalent in health care. Prior research surrounding repeat urine cultures showed that when a negative index culture is repeated within 48 hours, less than 5% of repeat urine cultures show a new bacteriuria. We evaluated the diagnostic yield of repeating urine cultures at longer time intervals, and of repeating a positive urine culture. Methods: We conducted a retrospective study of adult inpatients at Stanford Healthcare who had more than one urine culture collected during hospitalization between January 2023 and February 2024. We included urine cultures that were collected with or without urinary catheters; nephrostomy tubes were excluded. Urine cultures were classified as index or repeat. We analyzed the diagnostic yield of the repeat urine culture, defined as the percent of repeat urine cultures that detected a new bacteriuria not detected in the index culture. Bacteriuria was defined as growth of a bacterial species in quantities >100,000 CFU/mL. A negative urine culture was defined as one that did not have bacteriuria meeting this threshold. Sensitivity analyses used a threshold of 10,000 CFU/mL as the threshold for significant bacteriuria. Results: Overall, 6,955 urine cultures were performed from 6,058 patients. Of these, 864 (12%) urine cultures were repeats. Of the 864 index cultures, 75% were negative. The median time to repeat urine culture was 4 days. When negative index cultures were repeated at 0-3 days, the diagnostic yield for detecting a new bacteriuria was only 9%. Diagnostic yield at 3-6 days was 10%, not significantly higher compared to 0-3 days (p=0.620). Diagnostic yield at 6-9 days was 19%; this increase was significant compared to the 0-3 days group (p=0.014). When positive index cultures were repeated at 0-3 days, the diagnostic yield for detecting a new bacteriuria was only 8%. Diagnostic yield at 3-6 days was also 8%. Yield increased significantly to 15% at 6-9 days from index culture (p=0.013). When the threshold for significant bacteriuria was adjusted to 10,000 CFU/mL, more bacteriuria was detected overall, but primarily of gram-positive organisms. Whether the threshold for significant bacteriuria was 100,000 CFU/mL or 10,000 CFU/mL, the rate of detection of new gram-negative bacteriuria was similar, and remained less than 10% until 6-9 days from index culture (Figure 1). Conclusions: Among inpatients, most urine cultures repeated at less than 6 days provide redundant information. This unnecessary retesting offers an opportunity for diagnostic stewardship.

Background: Follow-up blood cultures (BCx) are ordered after an initial positive culture in many instances. The number of follow-up cultures needed is not clear. Obtaining unnecessary BCx may cause unintended consequences. The optimal balance between stewardship and patient safety warrants investigation. We sought to assess the frequency with which a third set is positive after a negative second BCx. Methods: We conducted a retrospective study of BCx submitted to the microbiology laboratory from 1/1/18-11/1/23. We included all patients ≥18 years who had at least two follow-up BCx drawn 24-72 hours after an initial positive culture. Data were collected from electronic medical records. Cultures obtained within two hours of each other were counted as one set. Different strains of an organism were considered to be different organisms. Patients were divided into four groups based on BCx positivity, with a focus on the cohort with a positive culture after a negative follow-up set. Results: 28,875 patients had an initial positive BCx, of which 2,636 had at least two follow-up cultures drawn in the selected timeframe. Within this group, 585 (22.2%) had two positive follow-up sets, 1500 (56.9%) had two negative, 431 (16.4%) had a positive followed by a negative, and 120 (4.6%) had a negative followed by a positive. Of this cohort, 71 (2.7%) grew the same organism in the initial and second follow-up cultures, while 49 (1.9%) did not. In the same-organism subset, the most commonly identified bacteria were coagulase-negative staphylococci (n=21; 0.8%), gram-negative bacteria (n=17; 0.6%), methicillin-sensitive Staphylococcus aureus (n=13; 0.5%), and methicillin-resistant S. aureus (n=7; 0.3%). The most frequently isolated organisms in this subset were S. aureus (n=20; 0.8%), Staphylococcus epidermidis (n=16; 0.6%), and Escherichia coli (n=11; 0.4%). In the different-organism subgroup, 35 (1.3%) of the second follow-up sets had suspected contamination, though true bacteremia from skin/soft tissue (n=4; 0.2%), central line (n=4; 0.2%), unknown (n=3; 0.1%), and other sources was observed, often due to S. aureus (n=4; 0.2%), E. coli (n=2; 0.1%), and Candida (n=2; 0.1%). Conclusion: The number of patients with ongoing bacteremia that would have been missed with one follow-up BCx was small. The skip phenomenon has been described with S. aureus but was seen with gram-negatives as well. The second follow-up cultures were sometimes positive for contaminants. Further data are needed to determine when two follow-up sets should be obtained rather than one.

Background: Acute gastroenteritis and diarrheal illnesses have a significant burden on the United States healthcare system, with over 500,000 estimated hospitalizations annually. Testing for these conditions is often ordered inappropriately at significant cost to the healthcare system. This study aimed to determine the appropriateness of ordering of gastrointestinal PCR panel (GIP) testing in our hospital system to guide improvements in ordering practices. It also aimed to evaluate the impact of a GIP in our system. Method: This was a retrospective chart review with the objective of quality improvement. The appropriate measures for ordering a GIP test included documentation of diarrhea in addition to fever, blood in stool, signs of sepsis or immunocompromise and without history of laxative use in preceding 48 hours. The result of a positive versus negative GIP test was measured in terms of its effect on isolation time and appropriate de-escalation of antibiotics. Result: Of the 402 records which were reviewed, 204 (50.7%) were deemed to have had an appropriately ordered test per our criteria. However, of these patients, 21 were noted to have either been on tube feeds or had received bowel regimen medications within the past 48 hours. When these patients were excluded, this left 183 (45.5%) patients with an appropriately ordered GIP test. Of note, 16 of these patients had a positive concomitant C. difficile test. Of the 93 (23.1%) positive tests, only 36 positive results were from appropriately ordered tests of which 9 tests impacted clinical management. Of the 57 remaining tests, 11 impacted clinical management. A negative test led to discontinuation of isolation precautions in 159 (76.1%) patients who had isolation placed for diarrheal illness prior to testing. Negative tests also led to discontinuation of antibiotics in 51 (39.5%) patients. There was no difference between these groups regardless of whether the test was ordered appropriately or not. Conclusion: The GIP test to detect a variety of gastrointestinal pathogens is not being ordered appropriately in our health system over half the time. It bears further investigation as to whether the monetary cost to patients and the health system of this test is offset by the apparent antibiotic stewardship and cost benefits in discontinuing isolation precautions and antibiotics. Interestingly, testing appeared to have utility regardless of appropriateness. Based on this finding, an updated set of guidelines to educate physicians in the appropriate ordering and interpretation of this test is required.

Background: The dimorphic fungus Coccidioides is endemic in the Southwestern USA and most commonly causes respiratory infection (“Valley Fever”). While the true community prevalence of this respiratory infection is unknown, experts estimate that 30% of community-acquired pneumonia (CAP) cases in Southern Arizona are due to Coccidioides. We were interested in determining how often patients admitted for CAP are tested for coccidioidomycosis. Methods: We identified patients who were admitted to Banner University Medical Center – Phoenix with community-acquired pneumonia from 1/1/2019-6/30/2024 by the ICD-10 code J18.9. Among this patient population, we determined the percentage tested for coccidioidomycosis (via serological test) and the percentage that tested positive. Regarding management, we elicited whether an infectious diseases consultation occurred during the hospitalization and if treatment included the antifungal fluconazole versus ceftriaxone and Azithromycin. Results: We identified 9,677 patients admitted with an ICD-10 code J18.9 between 1/1/2019 and 06/30/2024. The mean age (SD) was 60.3 (17.2) years and 56.3% were males. 3,536 (36.5%) patients were tested for coccidioidomycosis, and 389/3,536 (11%) had a positive serology. 14.2% of CAP patients were seen by an ID specialist. Among those with coccidioidomycosis, 56.3% (n=219) were seen by an ID specialist. Only a small fraction (n=974, 10.1%) of all CAP patients received fluconazole. Among the 389 with Valley Fever, 52.2% received fluconazole, while almost 70% were given ceftriaxone and/or azithromycin at any point during the admission. Transfer to the ICU, length of stay and hospital mortality were not significantly different in those with detected coccidioidomycosis versus others. Conclusions: In this large observational study in an area endemic for coccidioidomycosis, only 36.5% of those admitted for community-acquired pneumonia were tested for coccidioidomycosis 11% of those who got tested were found to have Valley Fever. Positing a similar coccidioidomycosis prevalence in the remaining 63.5% of CAP patients who were not tested for it, one could extrapolate a total of 676 missed cases based on 11% positive serology rate. To determine the true prevalence of coccidioidomycosis in our region, broader testing should be implemented. Our data also indicate that antifungals are rarely offered for coccidioidal CAP, while unnecessary use of antibacterials for this endemic mycosis is a target for antimicrobial stewardship.

Background: It is challenging to identify a pathogen in most cases of community acquired pneumonia (CAP) as most available diagnostic tests either lack sensitivity or require an invasive specimen. S. pneumoniae urine antigen test (SPUAT), which detects the most common cause of bacterial CAP, has been used due to its higher sensitivity, non-invasive specimen collection, and more rapid turnaround time. However, the most recent IDSA/ATS guidelines only weakly recommend obtaining SPUAT as results have limited effects on clinical management given current CAP treatment guidelines. Our study aimed to determine whether use of the SPUAT resulted in meaningful changes in clinical management within the Emory Healthcare system. Method: We studied all patients within our 6-hospital healthcare system who had a SPUAT performed between 12/1/2023 and 11/30/2024 (n = 1258). Chart review for each positive SPUAT case was performed by two separate reviewers to identify change in management based on SPUAT, alternative diagnostic tests that identified S. pneumoniae, and time to positivity of alternative diagnostic tests. Disagreements were adjudicated by discussion between the two reviewers. Proportions and 95% confidence intervals were calculated using prop.test in R version 4.3.1. Result: There were a total of 66 positive SPUAT out of 1258 total tests resulted (5.3%, 95%CI 4.1% – 6.6%) over 12 months. In 18 of the 66 positive SPUAT cases, an alternative diagnostic test was also positive for S. pneumoniae. In these cases, blood cultures were the most common alternative positive test (14/18) while the second most common alternative test was the pneumonia pathogen panel (11/18). In the majority (13/18) of cases with positive alternative tests, the alternative test resulted prior to the SPUAT. The median time to result for the first alternative test was 9.5 hours sooner than the SPUAT (IQR -0.2 hours - 37.9 hours). In 15 cases, a positive SPUAT resulted in a change in antibiotic management (1.2%, 95%CI 0.7%-2.0%). In cases where there was a change in management, de-escalation of antibiotics was the most common change in management identified (Table). The number of tests required for one management change was 84 tests at an estimated cumulative cost of $2100. Conclusion: In our healthcare system, SPUAT had a low test-positivity rate and an even lower rate of management changes per test ordered at a high cumulative cost per management change.

Introduction: Grouping of medical tests in an order panel or set may facilitate standardized care but could have the unintended consequence of increasing unnecessary testing. At our institution, one such panel includes studies performed on stool for the purposes of diagnosing infectious diarrhea (Figure 1). We removed stool enterovirus polymerase chain reaction (PCR) from this order panel given limited data supporting its use in the diagnosis of the etiology of diarrhea. Objectives: We aimed to evaluate the impact of removing the stool enterovirus PCR from this panel and whether there were associated decreased costs from this intervention. Methods: We conducted an interrupted time series to estimate the initial impact of implementing this order panel, followed by the later removal of the enterovirus order from the panel, using gastrointestinal (GI) bacterial PCR orders as a control. Additionally, we conducted a cost-savings analysis by multiplying the cost per test by the decrease in tests/month after removing the order from this panel averaged over a year. Results: After the panel’s creation, there was an immediate significant increase in enterovirus stool PCR ordering from a predicted mean of 28 tests/month to 43 tests/month (difference of 15 tests/month, p < 0 .0001) (Figure 2, blue). Similarly, the bacterial stool PCR ordering increased from a predicted mean of 98 tests/month to 136 tests/month (increased by 37 in the month following panel creation, p < 0 .0001). Conversely, after the removal of enterovirus PCR from the panel, there was an immediate significant decrease in testing from a predicted mean of 60 tests/month to 17 tests/month (decreased by 43 tests/month, p < 0 .0001), without a significant change in bacterial stool PCR ordering (16 test/month decrease, p=0.10) (Figure 2, red). We estimate that this simple intervention will save an average of $8,500 annually in direct costs each year. Discussion: Enterovirus PCR ordering significantly increased after the introduction of an order panel bundling stool studies targeted at diagnosing diarrhea. When this order was removed from the panel, there was a significant decrease in ordering without a change in infectious stool testing overall, as evidenced by no significant change in GI bacterial panel ordering. We hypothesize that clinicians utilize this panel to craft a differential for acute-onset diarrhea. Therefore, when the stool enterovirus PCR option was removed from this panel, it is possible that it was no longer considered on the differential. Reviewing such order panels may be helpful in reducing unnecessary testing and costs to healthcare systems.

Background: Data in adults and older children demonstrate repeat blood cultures (BlCx) are not always necessary. Indications for repeat BlCx include Staphylococcus aureus or yeast in the initial blood culture, or the presence of a central venous catheter (CVC). Blood collection in premature babies can be challenging and there are little data regarding when repeat BlCxs are necessary after an initial positive. The goal of this study is to determine risk factors for persistent bloodstream infection (BSI) to determine when unnecessary blood cultures can be avoided. Methods: The Yale New Haven Children’s Hospital NNICU is a 68-bed level 4 unit. Babies in the NNICU with a positive blood culture from 8/1/16 to 12/31/21 were included. Persistent BSI was defined as a repeat positive BlCx with the same organism >48 hrs. after the original culture. A BlCx > 7 days after the original BlCx was considered a new event. Babies who died within 48 hrs. of the initial culture were excluded. In preliminary analysis we did not distinguish between true BSI and contamination. Data were extracted from the medical record by the Yale Data Analytics Team and by manual chart review. Data were stored in excel for descriptive statistics. Additional statistical analysis in SPSS is on-going to account for multiple variables. Results: 142 babies had a positive BlCx with 122 babies alive at 48 hrs. and included in the study. These 124 babies had 139 positive BlCx growing 145 organisms. Persistent BSI occurred in 17.3% (24/139) of BlCxs. Factors associated with persistence in univariate analyses included the presence of a CVC and recovery of S. aureus. (Table 1) No babies with either streptococcal infection or early onset sepsis had persistent BSI. (Table 1) Additional variables under evaluation in a multiple regression model to determine the probability of persistent BSI include other sources of infection, white blood cell count at the time of BlCx, congenital heart disease, immunosuppressive agents such as steroids and whether empiric antibiotic therapy was appropriate. We will also define probable contaminants and repeat the analyses with and without these BSI episodes. Conclusions: Preliminary analysis shows that neonates have similar risk factors for persistent BSI as adults including the presence of a CVC and the recovery of S. aureus that require repeat BlCx to confirm clearance. For babies with streptococcal infection, repeat BlCx may not be routinely required. Current work is examining additional potential risk factors in multi-variable models.

Background: In 2024, US hospitals were affected by the Becton Dickinson (BD) BACTEC blood culture bottle shortage with little time to respond and conserve supply. The extent of the impact of this shortage on clinical practice has not been explored. Methods: We developed a 7-question online poll with the Emerging Infections Network (EIN) exploring the extent to which facilities were impacted by the shortage, geographic distribution and facility type of institutions affected, actions taken to mitigate the shortage, and the impact on clinical management of fever and Staphylococcus aureus bacteremia. The link was sent to >3100 EIN listserv members 3 times during September 2024. Descriptive and thematic analyses were performed on quantitative and qualitative responses. Results: Of 202 respondents from 39 states, 129(64%) responded their hospital had limited blood cultures available, 8(4%) were unsure how their hospitals were affected, and 65(32%) indicated their hospitals were not affected (Fig1). The most affected hospital facility types with >10 respondents were Community (27/39, 69%), University (48/72, 67%), Children’s (7/11, 67%), Non-university teaching (33/52, 65%), and the VA/DOD was least affected facility type (3/11, 27%). Respondents not affected by the shortage most commonly used alternate blood culture media. Top mitigation strategies included publishing algorithms for best practice use (103/202, 51%), restricting follow-up blood cultures (88/202, 44%), using single blood culture sets (86/202, 43%), and implementing EMR-based alerts on blood culture orders (71/202, 36%). Important clinical themes identified by affected respondents included limitations on blood culture use (147 responses), concerns with overall treatment and care including delays and disruptions in discharges or prolonged antibiotic use (15 responses), concerns with bacteremia management (15 responses), and increased diagnostic stewardship opportunities (21 responses) (Fig2). The most prevalent theme in S. aureus bacteremia management was limitations in repeat blood cultures (61/163, 37%) with concerns about confirming bacteremia clearance, while the most common theme in inpatient/ER management of fever was limitations in initial blood cultures (64/159, 40%), with common comments about reducing inappropriate blood cultures. 61/202 respondents commented in the open-ended question with the most common theme highlighting increased diagnostic stewardship as a positive outcome of the shortage (19/61, 31%). Conclusion: The BD BACTEC blood culture bottle shortage caused widespread clinical impact. The themes identified highlight the challenges placed on healthcare systems during times of shortage as well as the effects on patient care. Mitigation strategies implemented during the shortage may create future opportunities for diagnostic stewardship.

Background: The adult bone marrow transplant (BMT) unit at an urban academic medical center in the Midwest reported the highest number of central line-associated bloodstream infection cases across the health system in 2022 and 2023 and notably had the second-highest volume of blood culture specimens collected when compared with other patient care units. Statistical analysis comparing BMT patients to a sample group of oncology patients with the same length of stay and central line days demonstrated that BMT patients had a median of 17 blood cultures per admission compared to 7 in the sample group (p-value 0.000). Moreover, a review of 21 weeks of BMT patient blood culture specimen results suggested that patients were undergoing cultures who were unlikely to have bacteremia or sepsis. Method: An interdisciplinary team created a nurse-driven, clinical decision-making algorithm to refine the release of blood cultures from a conditional order set for BMT patients. The objective of the algorithm was to safely reduce the number of blood culture specimens. It includes an updated fever threshold to align with national neutropenic fever guidelines, consideration for new-onset clinical instability, source of specimen collection, and time from the most recent blood culture. Analysis was completed on 827 cultures over 102 patient admissions in the pre-intervention period and 527 cultures over 162 patient admissions in the post-period. Balancing measures based on escalation of care were assessed by chart review. Results: When comparing blood culture specimens among BMT patients, the median specimen count per admission in the pre-intervention period was 6.0 (IQR = 3.5, 10.0), compared to 2.5 (IQR = 0.0, 5.0) specimens in the post-intervention period (p-value = 0.000). 37.7% of patient admissions were not cultured in the post-intervention period whereby 100% of patient admissions were cultured in the pre-intervention period. Of the 48 rapid responses, 10 intensive care unit transfers, and 1 code blue events in the 23-week post-intervention period, none were attributed to delayed detection of bacteremia or sepsis. Conclusions: Messaging that ordering providers should order fewer cultures is overly simplistic with consideration for the BMT patient population, yet diagnostic stewardship is essential to optimizing patient experience and outcomes. Attention to new clinical instability among BMT patients is important in detecting bacteremia. Stable symptoms in continuously observed BMT inpatients are unlikely to represent bacteremia.

Background: Urinalysis (UA) with reflex to urine culture (UARC) protocols aim to optimize diagnostic testing and reduce unnecessary antibiotic use in hospitalized patients. By limiting urine cultures to cases where initial urinalysis results meet predefined criteria, UARC protocols can minimize false-positive results and reduce overtreatment. This study examines the impact of a UARC protocol implemented across a hospital system on urine culture volume and antibiotic utilization. Methods: A UARC protocol was implemented at our institution, performing urine cultures for UA specimens with ≥5 WBC/HPF. This study was an interrupted time-series analysis that compared the pre-implementation period (October 2022–June 2023) and the post-implementation period (January 2024–September 2024), with data elements abstracted from the electronic medical record. Antibiotic exposure within 48 hours before and 168 hours after urine specimen collection was evaluated. Comparisons were made using chi-square and Wilcoxon rank-sum tests, with p-values A total of 107,646 urine specimens were analyzed with 49,504 in the pre-implementation period and 58,142 post-implementation. Following UARC introduction, only 51.3% of reflex orders continued on to urine culture (29,836/58,142). Overall urine specimen orders resulting in antibiotic utilization decreased from 39.2% to 33.5% (p Implementing a UARC protocol significantly reduced urine culture volumes and antibiotic utilization, demonstrating its effectiveness in diagnostic and antimicrobial stewardship. While overall antibiotic use decreased, the unchanged treatment duration among recipients suggests complete courses were maintained with the reduction in culture orders serving as the mechanism driving this change. These findings support UARC protocols as valuable tools for reducing antibiotic use and optimizing healthcare resources. Further research should refine reflex criteria and assess long-term clinical outcomes.

Background: Overdiagnosis of C. difficile in hospitalized patients is common and contributes to misdiagnosis, unnecessary treatment, and overestimation of nosocomial infection rates. Many institutions, including ours, have implemented computerized clinical decision support (CCDS) with reductions in testing rates, but long-term data on the impact of such interventions are limited. Methods: A previously reported CCDS intervention paired with education campaign and trainee financial incentive was implemented December 2016. A laxative alert was added in 2018 and testing changed from NAAT only to two-step testing in 2020. Hospital-onset C. difficile cases have been reviewed by members of the antimicrobial stewardship team in real time for diagnostic and antimicrobial prescribing opportunities for improvement (OFIs) since 2016, with a stable workflow for unit leadership notification and data entry in RedCap since June 2023. Diagnostic OFI categories are based on themes from early iterations of this case-based review process and include: clinical criteria not met, stool criteria not met, alternative explanation for diarrhea, smells like C. difficile, test of cure, duplicate test, delayed collection, delayed testing, and other. We analyzed reviews from 6/1/2023-12/31/2024 and further classified diagnostic OFI determinations as “No OFI”, “Inappropriate”, or “Appropriate with process OFI”. During the study period there was no ongoing financial incentive or concerted diagnostic stewardship educational campaign, though feedback continued to be provided to individuals and groups based on case reviews, and a single question regarding C. difficile testing was maintained in annual re-training. Results: There were 144 HO-CDI cases reviewed with no diagnostic OFI in 98 (68%). Testing was inappropriate in 16 (11%). Testing was appropriate with process OFIs in 30 (42%). The most common process OFIs were other-stool documentation (11), delayed testing (7), other-lack of discussion with preexisting ID consult (6), and delayed sample collection (5). In cases with delayed testing, earlier testing was not prevented by CCDS in any case. Conclusions: We found relatively low rates of inappropriate testing (11%) over a time period seven years out from initial implementation of CCDS without ongoing active house wide diagnostic stewardship initiatives. Carefully designed and implemented CCDS can be a valuable tool that facilitates sustained improvement and allows resources to be allocated to new efforts. We additionally observed no cases of delayed diagnosis attributable to CCDS with combination of established institutional criteria for testing and two-step testing.

Background: Blood cultures are essential for the accurate diagnoses of sepsis and bacteremia and have been recommended and used liberally as part of the diagnostic workup. Previous studies have shown that judicious use of blood cultures is safe in both adults and children (PMID 31942949). In the summer of 2024, BD BACTEC experienced a national shortage of blood culture media bottles, prompting institutions nationwide to implement measures to conserve supplies. Our institution rapidly implemented a blood culture diagnostic stewardship program, adopting a tiered approach including refining guidelines for blood culture orders via institution-wide education, and leveraging EMR both via best practice advisories (BPAs) on appropriate culturing and ordering restrictions. In this study, we evaluate the impact of these interventions and the post-restriction effects of EMR-based education. Methods: Prior to the shortage, no clinical decision support existed in the EMR to guide the blood culture ordering process. Initial measures implemented in July 2024 included a BPA highlighting appropriate indications for ordering initial and follow-up blood cultures (PMID 39136555; ASM Blood Culture Bottle Inventory Management and Clinical Conservation During Supply Shortages). In August 2024, restrictions were introduced, limiting orders to one set per 72 hours, with case-by-case overrides managed by an Infectious Diseases-led diagnostic stewardship team. After supplies improved in November 2024, restrictions were lifted, but the BPA-based clinical guidance was retained. Blood culture volumes were monitored across three phases: pre-shortage, during restrictions, and post-restriction. Results: Blood culture volume decreased by approximately 50% immediately following the introduction of BPAs and further decreased to 75% of pre-shortage levels during the restriction period. Post-restriction, at 2 months follow-up, culture volume has stabilized and sustained at over 50% lower than pre-shortage levels. Conclusion: The implementation of in-EMR best practice guidance, and temporary restrictions during a blood culture media shortage, led to significant reductions in blood culture order volume, even after lifting restrictions. These findings support the role of diagnostic stewardship interventions in promoting lasting changes in provider behavior. Utilizing EMR to support best practices and aligning blood culture practices with evidence-based indications, can reduce unnecessary testing and improve resource utilization. Further research is needed to evaluate the impact of these changes on patient outcomes.

Background: Hemodialysis effectively treats acute kidney injury and end-stage kidney disease. However, hemodialysis patients, requiring vascular access, have an increased risk of bloodstream infections (BSIs). Gaps in infection prevention and control (IPC) practices further increase this risk. Philadelphia outpatient hemodialysis facilities with elevated BSI rates were prioritized for Infection Control Assessment and Response visits (ICARs). Methods: We used National Healthcare Safety Network (NHSN) 2019-2023 dialysis data to analyze BSI rates in Philadelphia facilities using SASv9.4. We mapped facilities using ArcGIS, and analyzed relationships of facility size, community income levels, and area deprivation index (ADI) on the state and national level with the BSI rates.

We conducted ICARs from August 2024-January 2025 in facilities with BSI rates in the 75th percentile during quarter 4 (Q4) of 2023. ICARs included on-site observations of IPC practices using the Centers for Disease Control and Prevention (CDC) audit tools for dialysis and facility leadership interviews using the CDC dialysis ICAR tool. Feedback was provided verbally and through written summary reports. Results: NHSN data for 2023 included 227 BSIs, with 44 in Q4. Eleven facilities were in the 75th percentile for BSIs. BSI rates were higher in patients with central lines compared to those with fistulas and grafts (1.56 v 0.16), however, high facility catheter utilization rates were not associated with higher BSI rates (p=0.4923). Geospatial mapping revealed targeted facilities were spread across the city and not associated with income levels or high ADI. No correlations were identified between BSI rates and facility characteristics. ICARs were completed for 9/11 (81.8%) prioritized facilities. Frequently identified IPC gaps included: glove changes without hand hygiene, medication preparation in patient care areas, inadequate catheter hub scrub and dry times, and inconsistent station disinfection practices. Opportunities for improvement were identified in 15-38 (20.5-52.1%) of the 73 audit tool steps across facilities. Repeated high BSI rates did not predict more IPC gaps (p=0.3799), although more previous quarters with BSI rates in the 75th percentile were associated with a higher likelihood of having a high BSI rate in Q4 of 2023 (p=0.0041). Conclusions: Quarterly NHSN data can be used to prioritize facilities for ICARs and those visited had multiple IPC gaps identified. Many facilities in the 75th percentile had recurring high BSI rates over previous quarters, which could help better target facilities for IPC support. Surveillance is underway to determine if ICAR interventions will reduce the BSI rates in future quarters.

Background: The continued rise of antimicrobial resistance (AMR) and reduction of pharmacological options has created an urgent need for new countermeasures to prevent the spread of multidrug-resistant organisms (MDROs) (1). Infections caused by the MDRO Candida auris (C. auris) have been proliferating since its discovery in 2009 and are associated with high mortality and AMR (2). Attention must be given to pathogen reservoirs, including surfaces of floors, which have an underappreciated potential to transfer pathogens to hands from objects in contact with the floor (3). Methods: An experimental study to explore the impact of advanced photohydrolysis (AP) technology on colony forming units (CFUs) of aerobic bacteria, fungi, and C. auris inside a hospital unit with active C. auris infections was performed from September 2023 to January 2024. Baseline pre-activation samples were compared to post-activation samples, which occurred every four weeks on Tuesday mornings prior to daily environmental services (EVS) cleaning. Patient outcomes of C. auris colonization and HAI rates were compared 8 months before and after AP technology installation. C. auris point-prevalence testing was performed during the 16-month observation period according to health department protocols and HAIs were evaluated by the same infection preventionist and defined by NHSN standards for catheter associated urinary tract infections (CAUTIs), central line associated bloodstream infections (CLABSIs), Clostridioides difficile (CDIFF), and methicillin resistant Staphylococcus aureus (MRSA) (4). Results: Pairwise comparisons with a Bonferroni correction found median floor fungal CFUs achieved a statistically significant reduction of 99% (p=0.11) from Baseline to Post-Activation #4 (Figure 1). Aerobic bacteria decreased 98% (Figure 2); C. auris by 66% (Figure 3) but did not achieve statistical significance. The rate of patient C. auris colonization after admission decreased 67% (Figure 4) and aggregate HAI rates decreased 75% (Figure 5). Additional Findings: High-touch surface samples showed reductions in mean CFUs of aerobic bacteria by 82% (6,456 to 1,161) and fungi by 99% (2,089 to 15). C. auris was reduced by 100% from Baseline to Post-Activation #3 (41 to 0) but increased in Post-Activation #4 due to two positive samples in a patient room with an active C. auris infection. Both samples tested under 500 CFU/cm2, which is associated with lower infection risk from environmental bioburden (5). Conclusion: These findings of significant reductions in microbial bioburden and abated pathogen acquisition demonstrate the positive impact that AP continuous disinfection technology can have on the environment and patient outcomes, without additional skilled labor or increases in cleaning and disinfection practices.

Introduction: The healthcare sector contributes significantly to global greenhouse gas (GHG) emissions, accounting for 8.5% of the total emissions in the United States alone. Infection control practices designed to prevent disease transmission contribute to this substantial carbon footprint. These practices, which include enhanced ventilation requirements, extensive sterilization processes, and laundry services, inherently increase energy consumption and GHG emissions. The approach to making healthcare more sustainable has been multipronged, including initiatives to reduce waste and energy use. We explored environmental cleaning practices and the energy use associated with ultraviolent (UV) light disinfection. Methods: A retrospective analysis was conducted on the energy consumption of three different UV light disinfection machines used at Stanford Health Care from September 2023 to August 2024. Annual run time data was obtained from vendor-provided logs, and energy use was calculated using the equipment wattage specifications provided with each machine. Results: We found that UV light disinfection utilized approximately 7,300 kWh constituting less than 1% of Stanford Health Care total energy use for the period. This energy consumption equates to the charge required for 3.5 round trips from San Francisco to New York City in an electric vehicle. Discussion: UV light has been widely used in healthcare over the last decade. Recent data suggests that there may be no additional benefit to UV light disinfection when other enhanced cleaning methods, such as sporicidal cleaners, are utilized. Therefore, using UV light in addition to sporicidal cleaners may be redundant. Infection prevention practices often incorporate redundancies given the dependence on human behavior and the high consequences of practice failures. As the healthcare industry continues to work towards reducing greenhouse gas emissions it will be important to consider all energy reductions and any redundancies in practices. In the future, a life cycle analysis could be conducted to compare UV light disinfection and sporicidal cleaning methods to evaluate each practice’s impact on sustainability efforts. Our evaluation showed that UV light disinfection results in modest energy usage reductions. However, as the healthcare industry continues to work towards reducing greenhouse gas emissions it will be important to consider all energy reductions and any redundancies in practices.

Background: The risk of bacterial transmission through gastrointestinal endoscopes remains a critical concern in healthcare-associated infections, driven by the complex design of endoscopes and potential lapses in reprocessing protocols. Contaminated endoscopes can serve as vectors for multidrug-resistant organisms, posing significant threats to patient safety. Current U.S. guidelines for endoscope reprocessing and infection control do not mandate routine surveillance sampling; however, select facilities have successfully adopted routine surveillance cultures to monitor reprocessing efficacy. The Centers for Disease Control and Prevention (CDC) has published protocols to support facilities choosing to implement such practices, emphasizing the importance of identifying persistent transmission risks. Methods: This retrospective study was conducted at the University of Kentucky Healthcare (UKHC), a 1,086-bed academic medical center, from January 1, 2019, to June 30, 2024. UKHC implemented a surveillance program in July 2016 targeting endoscopic retrograde cholangiopancreatography (ERCP), esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS), and colonoscopy endoscopes. Weekly cultures were performed on ERCP scopes, while targeted cultures were conducted on all four scope types used for patients colonized with carbapenem-resistant organisms (CRO). Following manufacturer instructions for use (IFU), post-reprocessing cultures were performed, and pathogens were categorized as concerning or non-concerning based on CDC protocols. Manual chart reviews identified CRO-colonized patients, and match rates were calculated by comparing endoscope culture results with patient isolates. Results: A total of 163 ERCP scopes were cultured, comprising 94 from weekly surveillance and 69 from CRO-targeted surveillance (Figure 1). Weekly surveillance yielded a 9.6% (9/94) positivity rate, while CRO-targeted surveillance showed an 8.7% (6/69) positivity rate. Among six positive samples, no matching CRO was identified. Among 189 EGD scopes subjected to CRO-targeted surveillance, the positivity rate was 25.9% (49/189), with a 4.1% (2/49) match rate to patient isolates. For 27 EUS scopes, the positivity rate was 11.1% (3/27), with a 33.3% (1/3) match rate. Among 59 colonoscopy scopes, the positivity rate was 5.1% (3/59), with no matches to patient isolates. Conclusions: The UKHC surveillance program highlights ongoing risks of bacterial transmission despite adherence to manufacturer-recommended reprocessing protocols. Scopes yielding concerning organisms underwent additional reprocessing to mitigate patient risk. All scopes with positive organisms after the second reprocessing were sent back to the manufacturer. Surveillance programs provide valuable insights into disinfection efficacy, helping to identify gaps and guide infection prevention strategies. Further refinement and standardization of surveillance protocols are essential to mitigate transmission risks associated with gastrointestinal endoscopy and improve patient safety on a broader scale.

Background: The terminal cleaning procedure for disinfection of a hospital room is an essential, yet difficult to monitor, step in infection prevention. Current methods for auditing require intensive human resources investment, depend on self-report, or employ spot checks using ATPase or glo gel audits. Inconsistent feedback and self-report are notoriously poor ways to drive behavior change or evaluate quality. Methods: We assessed a new AI platform developed by Myna Technologies that monitors cleaning and disinfection. The system incorporates thermal and optical cameras to detect percentage of total surface area cleaned including adequate contact time for two high touch surfaces: bedside table and mattress, in our Environmental Services (EVS) training suite. A researcher, trained by our hospital’s EVS team, performed 20 cleaning passes each for the mattress and bedside table. Each pass covered 25%, 50% 75% or 100% of total surface area; we compared the planned cleaning percentage to the device-observed results for both cameras. A Fisher’s exact test analysis was performed for fully clean (100% surface) and not clean Results: See Tables 1 and 2 for cleaning plan and device results. The mattress was 100% cleaned 6 times of 20 passes. The thermal camera correctly identified complete clean 100% of the time Discussion: Initial assessment of this novel AI technology to monitor disinfection in real time shows promise for detecting adequate cleaning. A formal validation trial comparing results of the automated system with direct observation, glo-gel marking and ATPase for all high touch surfaces, utilizing multiple cleaners is underway.

Background: Candida auris is an emerging multidrug-resistant fungus recognized as a global health threat. Despite increasing rates of colonization, no standardized protocol exists in the United States for C. auris screening upon admission. In February 2023, the University of Kentucky Healthcare (UKHC) implemented a targeted C. auris screening system for select high-risk patients. Methods: This retrospective observational study was conducted at UKHC, a 1,086-bed academic medical center, using data from patients aged ≥18 years screened for C. auris between July 1, 2021, and June 30, 2024. Prior to February 2023, C. auris screening occurred only during outbreak investigations. Post-implementation, screening was expanded to include ICU admissions, patients from external facilities with wounds or tracheostomies, and patients with a history of carbapenem-resistant organism infection. Axillary and groin swabs were tested via polymerase chain reaction (PCR). Cases were classified as community-onset (CO) Results: Of 13,642 C. auris tests performed, 70 positive cases were identified: 13 cases (6 CO, 7 HO) pre-implementation and 57 cases (31 CO, 26 HO) post-implementation (Figure 1). The mean age was 60.24 years, and males comprised 57.75%. The monthly positivity rate post-implementation ranged from 0% to 2.18% (with a mean of 0.96%). Among the 70 cases, 10 (14.29%) were classified as clinical infections, and 60 (85.71%) as colonization. The primary indications for C. auris screening included ICU admission (42.86%), point prevalence surveys (17.14%), and admission from external facilities with wounds (5.72%). No significant differences were observed between clinical and colonized cases by age, gender, race, or most other comorbidities. However, clinical cases were more likely to have diabetes (90% vs. 48.33%, p=0.0143) and medical device usage, including tracheostomy (80% vs. 45.00%, p=0.0404), gastrostomy tubes (90% vs. 53.33%, p=0.0293), central lines (60% vs. 41.67%, p=0.2799), and urinary catheters (60% vs. 46.67%, p=0.4348). Among ten clinical cases, seven patients received antifungal treatment. Three patients did not receive any treatment since C. auris was not considered clinically significant. 30-day mortality was higher among clinical cases compared to colonized cases; however, the difference was not statistically significant (30% vs. 25%, p=0.7377). Conclusions: The implementation of a targeted C. auris screening program at UKHC has provided critical insights into epidemiologic trends, patient demographics, and risk factors. Understanding these factors is essential for optimizing infection prevention strategies, refining screening protocols, and informing public health efforts to mitigate the spread of C. auris in healthcare settings.

Background: Candida auris (CA) is an urgent threat per CDC with rapidly increasing cases across the US. Patient rooms quickly recontaminate after daily cleaning due to skin shedding, CA persistence on environmental surfaces and resistance to surface disinfectants. Burn services experienced a sharp increase in 2023-2024 CA cases concurrently with statewide reported increases. Dry hydrogen peroxide (cDHP) is an environmental air technology augmenting daily room disinfection with activity against CA. Investigation: The 113 bed hospital treats complex burns and wounds as a Level 2 trauma center serving a large geographic region. Room design is single patient rooms with one semi-private ward. A total of 236 patient encounters were coded by quarter based on CA identification from clinical or surveillance cultures. cDHP was deployed in Burn ICU as of 3/2023 and nonICU as of 6/2024, with prioritization for cDHP in patients with an expected LOS of > 14 days. Surface disinfectants with CA label claim were implemented upon CA case identification. Patient skin surveillance cultures were taken upon admission burn/wound intake process and tested by the state department of health (DOH) starting in 3/2023. ATPase testing occurred as an indirect measure of cleaning and disinfection. Findings: Figure 1 displays the occurrence of CA burn service patients. The majority of initial positive culture sources were wound/tissue (43%) and skin surveillance (35%). Figure 2 displays when CA specific prevention actions were initiated and 63% CA cases were identified after admission. Six CA patients were in semi-private rooms. However, transmission was absent based on surveillance cultures. No statistical difference in ATPase pass/fails was found between cDHP and control room surfaces after daily cleans. In CA cases detected post discharge, all tested negative upon admission, were in single patient rooms and were more frequent within months of high CA case burdens. Conclusions: Surveillance testing is important for assessing burden of CA colonization, which fluctuated over this 2 year period. Despite increase in CA burden on admit, new hospital acquisition remained relatively constant Infection prevention resources shifted to observations of compliant practices. Next steps are to increase cDHP use as supplemental room disinfection, regardless of anticipated length of stay and investigate potential risks associated with silent CA acquisition identified post discharge.