Clostridioides difficile infection (CDI) is a common and often nosocomial infection associated with increased mortality and morbidity. Antibiotic use is the most important modifiable risk factor, but many patients require empiric antibiotics. We estimated the increased risk of hospital-onset CDI with one daily dose-equivalent (DDE) of various empiric antibiotics compared to management without that daily dose-equivalent.

Using a multicenter retrospective cohort of adults admitted between March 2, 2020 and February 11, 2021 for the treatment of SARS-CoV-2, we used a series of three-level logistic regression models to estimate the probability of receiving each of several antibiotics of interest. For each antibiotic, we then limited our data set to patient-days at intermediate probability of receipt and used augmented inverse-probability weighted models to estimate the average treatment effect of one daily dose-equivalent, compared to management without that daily dose-equivalent, on the probability of hospital-onset CDI.

In 24,406 patient-days at intermediate probability of receipt, parenteral vancomycin increased risk of hospital-onset CDI, with an average treatment effect of 0.0096 cases per daily dose-equivalent (95% CI: 0.0053—0.0138). In 38,003 patient-days at intermediate probability of receipt, cefepime also increased subsequent CDI risk, with an estimated effect of 0.0074 more cases per daily dose-equivalent (95% CI: 0.0022—0.0126).

Among common empiric antibiotics, parenteral vancomycin and cefepime appeared to increase risk of hospital-onset CDI. Causal inference observational study designs can be used to estimate patient-level harms of interventions such as empiric antimicrobials.

We describe the implementation, outcomes, and challenges of a complex outpatient oral antimicrobial therapy program (COpAT) in Canada to provide a framework for those interested in establishing such a program.

Outpatient ambulatory clinic led by infectious diseases physicians, serving patients from a tertiary hospital and a small community hospital.

Retrospective observational study that evaluated the efficacy, safety, and cost savings of patients enrolled in the program from August 2023 to June 2024.

One hundred three patients were included, of which 84.4% achieved successful clinical outcomes. Mean age of the patients was 62 years and 30% had diabetes. The top three sources of infections were bone and joint, intra-abdominal, and skin-and-soft tissue. Mean duration of COpAT was 37 days. Seventy-five percent of patients required only a single agent, and amoxicillin/clavulanic acid was most commonly used. Twenty-two patients developed an adverse reaction, of which three required a change in therapy and one resolved with antibiotic dose reduction. No C. difficile infections or mortality were reported 30-days post COpAT discharge. Twelve patients were re-admitted to the hospital; 50% of the cases were unrelated to infections. Compared to outpatient intravenous therapy, the total cost savings from COpAT were estimated to be $255,000 Canadian dollars (CAD), which translated to an average cost savings of $2500 CAD per patient per year.

We demonstrated favorable clinical and safety outcomes with our COpAT program and substantial cost savings using existing infrastructure. COpAT allows efficient use of healthcare resources including decongestion of hospitals.

To evaluate the impact of implementing a clinical care guideline for uncomplicated gram-negative bloodstream infections (GN-BSI) within a health system.

Retrospective, quasi-experimental study.

A large academic safety-net institution.

Adults (≥18 years) with GN-BSI, defined by at least one positive blood culture for specific gram-negative organisms. Patients with polymicrobial cultures or contaminants were excluded.

Implementation of a GN-BSI clinical care guideline based on a 2021 consensus statement, emphasizing 7-day antibiotic courses, use of highly bioavailable oral antibiotics, and minimizing repeat blood cultures.

The study included 147 patients pre-intervention and 169 post-intervention. Interrupted time series analysis showed a reduction in the median duration of therapy (–2.3 days, P = .0016), with a sustained decline (slope change –0.2103, P = .005) post-intervention. More patients received 7 days of therapy (12.9%–58%, P < .01), oral antibiotic transitions increased (57.8% vs 72.2%, P < .05), and guideline-concordant oral antibiotic selection was high. Repeat blood cultures decreased (50.3% vs 30.2%, P < .01) without an increase in recurrent bacteremia. No significant differences were observed in 90-day length of stay, rehospitalization, recurrence, or mortality.

Guideline implementation was associated with shorter antibiotic therapy durations, increased use of guideline-concordant oral antibiotics, and fewer repeat blood cultures without compromising patient outcomes. These findings support the effectiveness of institutional guidelines in standardizing care, optimizing resource utilization, and promoting evidence-based practices in infectious disease management.

Develop a Staphylococcus aureus wound antibiogram among patients who use fentanyl (PWUF) presenting with acute S. aureus skin and soft tissue infections (SSTIs) in Philadelphia, Pennsylvania.

Retrospective, multisite cohort study.

Individuals presenting to emergency departments or admitted to inpatient units of four Penn Medicine hospitals with an acute S. aureus SSTI and illicit fentanyl use within the previous year.

We described susceptibilities of S. aureus isolated from wound cultures among the PWUF cohort and compared these to the health system’s wound antibiogram. We compared frequency of in-hospital medication treatment for opioid use disorder among patients who left the hospital prior to vs after the availability of S. aureus susceptibilities.

Among 131 S. aureus isolates from 131 PWUF, 35/131 (26.7%) were susceptible to oxacillin, 73/121 (60.3%) were susceptible to clindamycin, 77/122 (63.1%) were susceptible to tetracycline, and 119/126 (94.4%) were susceptible to trimethoprim-sulfamethoxazole. PWUF displayed significantly reduced susceptibility to oxacillin and tetracycline compared to the health system’s outpatient wound S. aureus antibiogram. Compared to patients discharged prior to susceptibility availability, more patients discharged after the reporting of susceptibilities were administered buprenorphine or methadone in the hospital (82.0% vs 51.4%, P < 0.001).

High nonsusceptibility to clindamycin and tetracycline suggests these agents should not be prescribed as empiric therapy for acute S. aureus SSTI in PWUF in Philadelphia. PWUF would benefit from joint management by infectious diseases and addiction medicine experts to ensure prescription of active therapy. Additional study is needed of PWUF in other regions.

We aimed to determine if implementation of universal nasal decolonization with daily chlorhexidine bathing will decrease blood stream infections (BSI) in patients undergoing extracorporeal membrane oxygenation (ECMO).

Retrospective cohort study.

Tertiary care facility.

Patients placed on ECMO from January 1, 2017 to December 31, 2023.

Daily bathing with 4% chlorhexidine soap and universal mupirocin nasal decolonization were initiated for all ECMO patients May 2021. The primary outcome was rate of ECMO-attributable positive blood cultures. Zero-inflated Poisson regression analysis was performed to estimate rate ratios (RRs) for the association between decolonization with BSI rates.

A total of 776 patients met inclusion criteria during the study period, 425 (55%) preimplementation and 351 (45%) post-implementation. Following implementation of decolonization, the overall incidence rate of BSI increased nonsignificantly from 10.7 to 14.0 infections per 1000 ECMO days (aRR 1.09, 95% CI 0.74–1.59). For gram-positive cocci (GPC) pathogens, a nonsignificant 40% increased rate was observed in the post-implementation period (RR 1.40, 95% CI 0.89–2.21), due mostly to a significant increase in the crude rate of Enterococcus BSI (RR 1.89, 95% CI 1.01–3.55). Excluding Enterococcus resulted in a nonsignificant 28% decreased rate (aRR 0.72, 95% CI 0.39-1.36) due to a nonsignificant 55% decreased rate of MRSA (aRR 0.45, 95% CI 0.18–3.58).

Implementation of a universal decolonization protocol did not significantly reduce rates of certain BSIs, including MRSA and other gram-positive pathogens. Although nonsignificant, reduction in BSI rates in this patient population has important implications on surveillance metrics, such as MRSA, and in the future, hospital-onset bacteremia.

Evaluate prescribing practices and risk factors for treatment failure in obese patients treated for purulent cellulitis with oral antibiotics in the outpatient setting.

Retrospective, multicenter, observational cohort.

Emergency departments, primary care, and urgent care sites throughout Michigan.

Adult patients with a body mass index of ≥ 30 kg/m2 who received ≥ 5 days of oral antibiotics for purulent cellulitis were included. Key exclusion criteria were chronic infections, antibiotic treatment within the past 30 days, and suspected polymicrobial infections.

Obese patients receiving oral antibiotics for purulent cellulitis between February 1, 2020, and August 31, 2023, were assessed. The primary objective was to describe outpatient prescribing trends. Secondary objectives included comparing patient risk factors for treatment failure and safety outcomes between patients experiencing treatment success and those experiencing treatment failure.

Two hundred patients were included (Treatment success, n = 100; Treatment failure, n = 100). Patients received 11 antibiotic regimens with 26 dosing variations; 45.5% were inappropriately dosed. Sixty-seven percent of patients received MRSA-active therapy. Treatment failure was similar between those appropriately dosed (46.4%) versus under-dosed (54.4%) (P = 0.256), those receiving 5–7 days of therapy (47.1%) versus 10–14 days (54.4%) (P = 0.311), and those receiving MRSA-active therapy (52.2%) versus no MRSA therapy (45.5%) (P = 0.367). Patients treated with clindamycin were more likely to experience treatment failure (73.7% vs 47.5%, P = 0.030).

Nearly half of antimicrobial regimens prescribed for outpatient treatment of cellulitis in patients with obesity were suboptimally prescribed. Opportunities exist to optimize agent selection, dosing, and duration of therapy in this population.

Previous studies have linked social behaviors to COVID-19 risk in the general population. The impact of these behaviors among healthcare personnel, who face higher workplace exposure risks and possess greater prevention awareness, remains less explored.

We conducted a Prospective cohort study from December 2021 to May 2022, using monthly surveys. Exposures included (1) a composite of nine common social activities in the past month and (2) similarity of social behavior compared to pre-pandemic. Outcomes included self-reported SARS-CoV-2 infection (primary)and testing for SARS-CoV-2 (secondary). Mixed-effect logistic regression assessed the association between social behavior and outcomes, adjusting for baseline and time-dependent covariates. To account for missed surveys, we employed inverse probability-of-censoring weighting with a propensity score approach.

An academic healthcare system.

Healthcare personnel.

Of 1,302 healthcare personnel who completed ≥2 surveys, 244 reported ≥1 positive test during the study, resulting in a cumulative incidence of 19%. More social activities in the past month and social behavior similar to pre-pandemic levels were associated with increased likelihood of SARS-CoV-2 infection (recent social activity composite: OR = 1.11, 95% CI 1.02–1.21; pre-pandemic social similarity: OR = 1.14, 95% CI 1.07–1.21). Neither was significantly associated with testing for SARS-CoV-2.

Healthcare personnel social behavior outside work was associated with a higher risk for COVID-19. To protect the hospital workforce, risk mitigation strategies for healthcare personnel should focus on both the community and workplace.

COVID-associated pulmonary aspergillosis (CAPA) was described early in the pandemic as a complication of SARS-CoV-2. Data about incidence of aspergillosis and characteristics of affected patients after mid-2021 are limited.

A retrospective, nationwide cohort of US Veterans with SARS-CoV-2 from 1/1/2020 to 2/7/2024 was created. Potential cases of aspergillosis ≤12 weeks of a SARS-CoV-2 test were flagged electronically (based on testing results indicative of invasive fungal infection, antifungal therapy, and/or ICD-10 codes), followed by manual review to establish the clinical diagnosis of pulmonary aspergillosis. Incidence rates were calculated per 10,000 SARS-CoV-2 cases. Selected clinical characteristics included age >70, receipt of immune-compromising drugs, hematologic malignancy, chronic respiratory disease, vaccination status, and vaccine era. Multivariate logistic regression was used to estimate the independent effects of these variables via adjusted odds ratios (aOR).

Among 674,343 Veterans with SARS-CoV-2, 165 were electronically flagged for review. Of these, 66 were judged to be cases of aspergillosis. Incidence proportions ranged from 0.30/10,000 among patients with zero risk factors to 34/10,000 among those with ≥3 risk factors; rates were similar in the pre- and post-vaccination eras. The 90-day mortality among aspergillosis cases was 50%. In the multivariate analysis, immune suppression (aOR 6.47, CI 3.84–10.92), chronic respiratory disease (aOR 3.57, CI 2.10–6.14), and age >70 (aOR 2.78, CI 1.64–4.80) were associated with aspergillosis.

Patients with underlying risk factors for invasive aspergillosis continue to be at some risk despite SARS-CoV-2 immunization. Risk in patients without immune suppression or preexisting lung disease is very low.

This study analyzed the practice of switching intravenous antibiotics to oral dosage form in a tertiary care hospital of Nepal.

A prospective observational study was performed among patients admitted to medical/surgical wards in a private tertiary care hospital of Nepal.

Hospitalized adult patients who received IV antibiotics for at least 48 hours and met the eligibility criteria were enrolled in the study. The detailed information on use of antibiotics such as indication, duration, type time of switch etc. were collected and analyzed.

Among 335 patients, 282(83.9%) met the eligibility criteria for intravenous (IV) to oral conversion however, only 18.7% of patients were switched to oral regimen. Step-down conversion was the common type of IV to oral switch. Almost all patients were empirically treated with β-lactams antibiotics (n = 327). There was significant association between the antibiotic class and duration of IV therapy (P < 0.001). The length of hospital stays and duration of IV antibiotics therapy was lower in the timely converted group than in the non-converted groups (P < 0.001). The duration of IV antibiotics therapy was strongly correlated with duration of hospital stay (r = 0.743, P < 0.001).

The findings revealed a low prevalence of conversion from IV antibiotics to oral, despite a higher percentage of patients meeting the eligibility criteria for conversion. There is a need for the implementation of structured program to review patients on IV antibiotics and promote timely conversion to oral once they meet the conversion criteria.

Central line-associated bloodstream infections (CLABSIs) and surgical site infections (SSIs) are major healthcare-associated infections that can be prevented by consistently applying evidence-based infection prevention practices.

To assess equity in preventing CLABSIs and SSIs in pediatric patients at a free-standing pediatric hospital, where evidence-based infection prevention practices are consistently implemented.

This observational study evaluated 2 cohorts of pediatric patients under 18 years. The CLABSI cohort included inpatients with a central line between 1/1/2016 and 12/31/2022, and the SSI cohort included patients undergoing colon, ventricular shunt, or spinal fusion surgeries between 1/1/2016 and 10/31/2022. The CLABSI rate per 1000 central line days and SSI rate per 100 surgeries were compared across different racial, ethnic, and gender groups.

In the CLABSI cohort of 8575 patients, encompassing 243,803 central line days, there were 156 CLABSIs. There was no statistical difference in CLABSI rate across race, ethnicity, and/or gender groups. The SSI cohort included 68 SSIs among 1710 patients who underwent 2230 procedures, including 714 colon, 749 ventricular shunt, and 767 spinal fusion procedures. The SSI rate was statistically higher in multiracial (9.9) and Asian (8.6) groups, compared to Caucasian (2.4) and Black (2.2) groups. A nested case-control study of the SSI cohort showed a higher SSI rate in Asians, compared to Caucasians (Odds Ratio: 3.3; 95% CI: 1.3–8.3).

Equity in preventing CLABSIs is achievable through standardized central-line care. Further study is warranted to assess if improvement opportunities exist for achieving equity in preventing SSIs.

To characterize the clinical and microbiological features of carbapenem-resistant Enterobacterales (CRE) compared to carbapenem-susceptible Enterobacterales (CSE) in the Dominican Republic (DR), and to assess risk factors associated with CRE.

Retrospective case-control study.

Hospital General Plaza de la Salud, a tertiary teaching hospital in Santo Domingo, DR, from January 2015 to June 2024.

Patients with CRE infections were identified from microbiology records. For each year, a matched group of CSE cases was selected at a 2.5:1 ratio. A total of 101 CRE cases and 280 CSE cases were included.

Data were collected on demographics, comorbidities, infection sources, hospital stay duration, antibiotic use, and microbiology results. Statistical analysis included univariate and multivariate logistic regression to identify independent risk factors for CRE.

CRE cases showed higher prevalence of Enterobacter (36.5%) and Klebsiella (38.5%), while Escherichia predominated in CSE (65.5%). CRE patients had longer hospital stays (mean 18.7 vs 4.6 days, P < 0.001), higher ICU admission rates (34.7% vs 3.6%, P < 0.001), and increased invasive procedure use (eg central venous catheters, 36.6% vs 5.4%, P < 0.001). Key risk factors included antibiotic use (OR 3.09, P < 0.001) and ICU stay (OR 3.60, P= 0.012). The peak CRE resistance rate was 3.47% in 2022, a 64% increase from pre-pandemic levels.

CRE infections in the DR increased during the COVID-19 pandemic, associated with prolonged hospitalizations and critical care. Enhanced antimicrobial stewardship is essential to curb resistance.