Introduction: Blood culture result provides a crucial information for patient care. Contaminated blood culture samples may result in inappropriate antimicrobial prescription, increase the cost and unnecessary prolonged hospitalization. In our hospital, the blood culture contamination is high in the emergency department. This initiative aims to improve the emergency department’s blood culture contamination rate which will eventually improve the patient care and benefit the hospital financially. Methods: This quality improvement initiative used the Planning, Doing, Checking and Acting (PDCA) models, which provides a simple yet effective approach for problem solving and managing changes. A workgroup consist of Infection control team and emergency department representatives was formed to work on this initiative. Weekly blood culture contamination rate was closely monitored. Root causes were identified, and series of retraining were performed. Blood culture contamination rate before and after the initiative were compared. Results: Focus group discussion and site visit reinforcement showed that the high blood culture contamination rate is contributed by many factors. Among the factors included were the inadequacy of blood culture sets, improper use of skin disinfectant, improper hand hygiene techniques and improper aseptic techniques practice by some of the house officers. Blood culture contamination rates 6 months before and during feedback intervention showed significant decrease (3.52% before intervention and 2.95% after intervention; P < .05. Discussion: Blood culture contamination rate reduced significantly after the joint initiative continued to decrease with the use of a predisinfection process with 2% Chlorhexidine gluconate cloth before blood sample collection process. Practice improvement also was evident with effective feedback mechanism.

Conclusion:

Background: Ventilator-associated pneumonia (VAP) primarily occurs due to the aspiration of secretions containing microorganisms from the oropharynx or stomach into the lungs. Preventing aspiration is a critical strategy for reducing VAP incidence. This study analyzed the impact of aspiration prevention measures—head-of-bed elevation (HOBE) and enhanced oral care—on VAP rates in adult intensive care units (ICUs). Method: This interventional study was conducted in the adult ICU of a 2,734-bed tertiary care hospital. A total of 8 ICUs (medical, surgical, cardiology, cardiovascular, neurology and neurosurgery) with 112 beds observed an increase in VAP incidence from January to April 2023, prompting enhanced measures in May 2023. The first intervention involved revising and reinforcing indications for head-of-bed elevation (HOBE) while strengthening monitoring and on-site feedback. During clinical procedures such as positional changes requiring a supine position, oropharyngeal suctioning was performed before lowering the head of the bed, and staff were trained to ensure prompt restoration of the HOBE to the appropriate position afterward. The second intervention improved oral care by replacing chlorhexidine and gauze with tooth brushing. A protocol was developed requiring 2 minutes of brushing teeth, artificial airways, tongue, and palate using a silicone toothbrush moistened with saline or sterile water, excluding patients with contraindications such as bleeding risks. Monitoring revealed missed areas during brushing, necessitating additional simulation training using dental models and colored toothpaste to confirm plaque removal. The pre-intervention period was conducted over 9 months (August 2022 to April 2023), while the intervention period lasted 17 months (July 2023 to November 2024). VAP incidence rates were compared before and after the intervention. Additionally, the incidence of VAP associated with pathogens such as Klebsiella pneumoniae, Acinetobacter baumannii, or Pseudomonas aeruginosa, often isolated from dental plaques of ICU patients, were analyzed. Results: The incidence rate of VAP per 1,000 ventilator days among adult ICU patients decreased from 3.9 (66/16,849) before the intervention to 2.4 (78/32,185) after the intervention (IRR, 0.62, 95% CI, 0.45-0.86; P = 0.007). Similarly, the incidence rate of VAP associated with pathogens K. pneumoniae, A. baumannii, or P. aeruginosa were 1.6 (27/16,849) before the intervention, and 1.0 (31/32,185) after the intervention (IRR, 0.60, 95% CI, 0.36-1.01; P = 0.07). Conclusion: As a result of implementing enhanced head-of-bed elevation and oral care protocols for ventilated patients in the adult ICU, the incidence of VAP significantly decreased. Further multicenter studies are needed to validate our findings.

This retrospective cohort study evaluated the proportion of inpatients initiated and successfully discharged on fidaxomicin for Clostridioides difficile infection. Nearly, all patients (96.4%; 27/28) were able to obtain fidaxomicin to complete their treatment course, although there was variability in copays among patients with Medicare.

Background: Effective integration of antimicrobial resistant organism (ARO) admission screening into clinical information systems (CIS) can facilitate prompt identification of patients at risk of an ARO and interrupt transmission. However, ARO admission screening remains suboptimal in Alberta, Canada following implementation of the ARO admission screening tool in the provincial CIS. We sought to understand the determinants of adherence with the use of the ARO admission screening tool in the CIS. Methods: A mixed-methods study was conducted using a survey, human factors observations, and qualitative focus groups. Eligible participants included nursing staff and physicians from emergency departments and inpatient units in acute care and acute rehabilitation facilities where the ARO admission screening tool was utilized in the CIS in Alberta, Canada from September 6, 2023 to June 18, 2024 (n=100). A survey (REDCap) explored staff perceptions and experiences using the tool in the CIS. Observations and interviews of nursing staff completing the tool were guided by the Systems Engineering Initiative for Patient Safety model. Virtual (Zoom) semi-structured focus groups explored barriers and enablers of using the tool guided by the Theoretical Domains Framework. Descriptive analysis of survey responses was conducted using Microsoft Excel (Version 2409). Field notes and focus group transcripts were used for a rapid qualitative, thematic analysis. A weaving narrative by theme was used to integrate survey results with findings from the observations and focus groups. Results: There were 527 survey respondents representing all 5 health zones, 5 nurses observed and 20 interviews conducted by the human factors team, and 24 participants in 6 focus groups. Focus group participants represented different sized hospitals (12-1,099 beds) with varying ARO admission adherence rates (29-83%). Three emergent themes arose: context, the ARO admission screening tool, and the individual. Contextual factors included time constraints, increasing nursing workload, competing priorities, lack of patient cooperation, and a need to increase interactions with infection prevention and control programs. Attributes of the tool impacting completion included location of the tool within the CIS, lack of prompts, and multiple sources of information required to complete the tool. At an individual level, themes arose related to experience, perceptions of ARO screening, and lack of training that influenced completion of the tool. Conclusions: Among the emergent themes, multiple determinants were identified influencing the use of the ARO admission screening tool in the provincial CIS. These findings will help inform future strategies to improve ARO admission screening and reduce ARO transmission.

Introduction: During the years 2018-2019, Nan Hospitalhad tuberculosis screening rates of 69.15% and 74.24%, respectively, which were lower than the target (target > 90%). Consequently, tuberculosis patients were referred for further examination in various hospital units and treated in general rooms without proper isolation. Also, one and four healthcare personnel were diagnosed with pulmonary tuberculosis in 2018 and 2019, respectively. Additionally, the treatment success rates for pulmonary tuberculosis patients were 74.63% and 79.92%, respectively (target >85%). Therefore, to achieve these target goals, actions were taken following the national tuberculosis strategy using the FCD Nan model, which comprises of Fast screening (F), Cure (C), and do not spread (D). Objectives: To develop the tuberculosis patient-care system at Nan Hospital and assess the outcomes of the tuberculosis patient-care system in terms of FCD Nan model Methods: We used the PDSA quality improvement process as follows.

1. 1. Plan: Planning to implement the national tuberculosis strategy including fast screening, cure, and prevention of transmission.

2. 2. Do: Implementing the FCD Nan modelas follows.

   1. 1) Fast screening. We used a fast-track system, enhanced screening efficiency in both OPD and IPD units, established a Line group alert pop-up and AI CXR.

   2. 2) Cure. We adhered to treatment protocols,closely monitored cases, consulted specialists, utilized risk scoring for mortality, and nutritional alert.

   3. 3) Do not spread. We administered 3 measures for preventing transmission including administrative, environmental, and PPE measures.

3. 3. Study: Evaluating the FCD Nan model.

4. 4. Action: Identifying household contacts as a high-risk group and implementing screening for all household contacts due tothe discovery of new tuberculosis patients in the household contacts.

Acknowledgments : This study has been partially funded by the Nursing Association for Prevention and Control of Infections (NAPCI)

Background: Clostridioides difficile infections (CDI) are associated with patient morbidity and mortality and also may impact reputational and financial metrics. CDI was identified as a healthcare-associated infection of concern at several of the hospitals in our healthcare system and set as a target for improvement. We sought to create an easily interpretable tool to help select hospitals with the greatest opportunity to benefit from this work. Methods: The National Healthcare Safety Network’s (NHSN) data (infection counts and number of predicted infections) for LabID CDI from Oct 2023-Sept 2024 were exported for 3 academic and 8 community hospitals in our healthcare system in eastern Massachusetts and New Hampshire. Using published source code from the Centers for Disease Control and Prevention recreated in R software (v.4.3.3), we calculated the statistical significance of the Standardized Infection Ratio (SIR) relative to 1.0 using the p-value. We then performed the statistical test iteratively by adjusting the number of infections by one in each direction from the true observed number of infections, to establish thresholds for significantly improved or worsened performance. Data were displayed as gauge charts with indication of current SIR statistical significance defined by color (red, yellow and green) and distance to threshold that would alter that significance (See Figure). Viable opportunities for improvement were defined as being within 5 or fewer infections of calculated thresholds. Results: Review of CDI data across all 11 sites demonstrated more improvement opportunities at some sites than others. Four sites were in green ranges, seven in yellow and none in red. All opportunities for viable improvement were identified in the yellow range; 5 of 11 sites had potential for improvement in SIR (Hospitals C, D, E, I, K) and 2 for worsening of SIR (Hospitals G, J); see Figure. Conclusion: In our healthcare system, this model provided insight into site-specific opportunities for improvement in CDI by highlighting sites closest to achieving a statistically significant change in SIR. Although factors such as morbidity and cost may influence selection of targets for improvement, visual depiction of viable thresholds for change in SIR may provide an indicator of facilities likely to yield the most benefit relative to investment required for reduction efforts.

Background: WHO estimates over 700,000 deaths globally annually due to antimicrobial resistance. One of the main factors of antimicrobial resistance is non-compliance with infection control measures. Contact alert markers must be installed in the patient area to remind officers to carry out infection transmission prevention to prevent the failure of infection control practices. The provision of red markers and information on the infection suffered by patients creates a stigma that is less accepted because of patient privacy. This study aimed to evaluate the modified marker with a batik design as local wisdom without infection information, as a reminder of infection control practices by officers, and to maintain patient privacy. Method: The Committee for Infection Prevention and Control modified the design of markers of patients with antimicrobial resistance. Batik markers were designed with hand hygiene reminders and batik motifs as local wisdom so as not to cause negative stigma. Batik markers were implemented in the patient’s bed area so that it was easy for officers to understand how to implement infection control practices and supervise patients with antimicrobial resistance. Results: Modifying the marker design was more acceptable to the patient’s family than the previous one. Adherence to supervision filling of antimicrobial resistance patients was performed in all patients. Adherence to Hand Hygiene increased by up to 4% in one month. With the Batik Marker, officers could easily recognize the marker so that infection control practices could be carried out according to hospital regulations. Conclusion: Antimicrobial resistance is an increasing health threat. A type A hospital requires an intradisciplinary approach and collaborative efforts to prevent and control it. Implementing Batik Markers at inpatient areas with antimicrobial resistance makes it easier for staff to implement increased contact awareness, supervision recording, and improved hand hygiene without causing rejection from the patient’s family.

Case Presentation: A 68 year old man. Hospitalized with decreased consciousness. Experienced severe shortness of breath 3 days before entering the hospital. The patient also had wounds on his right and left legs since 1 month ago. But then became more widespread. The patient has kidney failure and routinely undergoes hemodialysis. The patient had diabetes since 6 years ago. Laboratory: Hemoglobin 7.5 Leukocytes 17.8 Netrophils 91.70 Lymphocytes 4.20 Albumin 2.2 Creatinine 2.5 Ureum 61 Artery 2.30, urine bacteria+++. Pus culture results: Enterobacter cloacae with the antibiotic meropenem. Sputum culture results Klebsiella pneumoniae ss. Pneumoniae with amikacin. After 1 week pus culture results: Pseudomonas aeruginosa with amikacin. Blood culture results: Staphylococcus epidermidis suggested vancomycin. The patient underwent debriment in the operating room. However, the condition did not improve. Discussion: This patient experienced sepsis with MDRO. Apart from geriatric age, the patient also has diabetes with complications of kidney failure. This worsens the patient’s immune system. So the patient’s diabetic ulcers and decubitus ulcers worsened with the results of cultures with various antibiotic-resistant multiorganisms. And also the respiratory infections increase the risk of mortality. Conclusion : MDRO is a risk factor for inappropriate antibiotic therapy, which is undoubtedly associated with increased mortality.

Figure :

Diabetic ulcers and decubitus ulcers in patient

The overuse and inappropriate use of antimicrobials have led to environmental waste and drug shortages. This challenges the ecological and economical sustainability of our healthcare system and worsens antimicrobial resistance.

Antimicrobial stewardship programs (ASP) commonly consider the cost of drug acquisition but may be failing to recognize the hidden costs of multi-dose intravenous regimens including additional nursing administration time, tubing and fluids, and potentially increased hospital length of stay. They also rarely consider the environmental impact of medical waste creation and disposal, which contributes to the global antimicrobial resistance crisis. These costs are harder to calculate but crucial to a comprehensive assessment of a medication’s total impact. In this invited commentary, we provide an example of a stewardship evaluation at our institution focused on changing from meropenem (MER) to ertapenem (ETP) for infections caused by extended-spectrum beta-lactamase producing organisms. We found that despite an increase in acquisition costs, changing from MER to ETP is associated with overall savings and decreased waste production. A secondary analysis suggests that stay length may also be improved with this substitution.

We present a holistic approach to antimicrobial stewardship that considers the total cost of an antimicrobial. By broadening their view to include hidden costs and secondary effects, ASPs can further demonstrate their value to the healthcare system, reduce resistance, and improve their environmental impact.

Background: Hospitals experienced increased demand for acute care and specialty services during recovery following COVID-19 epidemics. Internal analysis identified potential inaccuracies in NHSN location unit designations across a large healthcare system with 2,249 mapped NHSN locations. Findings revealed inconsistencies in how location change decisions were determined mainly from the type of data applied. Facilities utilized finance data to determine NHSN location mapping creating limitations. NHSN locations defined by patient populations, associated with baseline risk adjustments to provide comparison performance and impacts CMS metrics. Methods: Decision Support Tool (DST) based on NHSN to evaluate patient populations for acuity, service line data indicating specialty services, financial billing codes, DRG and surgical or non-surgical populations. The DST outlines data elements for review when validating mapped locations. Each tab represents a unique data element to analyze as part of the NHSN decision algorithm (Figure 1). Unit level data aggregates in DST tabs (Figure 2). Implementation consisted of a pilot followed by a regionally phased implementation via coaching calls and follow-up touchpoints. Although all units were reviewed, specific activities focused on non-CMS reportable units such as telemetry, step-down, mixed acuity. As a part of the defined change control process facilities followed an internal standardized workflow to document changes, dates and reasons for change for historical reference (Figure 3). NHSN facility population changes were applied to vendor surveillance software utilized for CDA direct reporting to NHSN. System and facility internal record keeping promotes a standardized process for data validity, associated software maintenance and CMS reporting compliance. Results: The majority of changes were made to units mapped as telemetry with a 62% reduction overall. Figure 4 illustrates the non-CMS reporting locations with notable location mapping changes. Patients in an ‘observation’ status were found to be housed within any inpatient unit and required another data tool for analysis. Overall, the number of mapped 24-hour observation units is low (1.7%) across the healthcare system. Conclusions: The initiative standardized objective data and competency which elevated the trained infection preventionists on this topic. Admission orders offer telemetry for evaluation and treatment requiring continuous cardiac monitoring. NHSN definition is specific requiring 80% of unit patients to have a cardiac centered DRG/care and cardiac specialty treatment to meet telemetry definition. NHSN recommends at minimum annual mapping evaluation. As a large healthcare system, the DST analysis is managed continuously due to growing service lines, acquisitions and construction projects.

Objective: Open surgical wound is prone to surgical site infection due to contamination of surrounding environment. Therefore, routine air sampling and culture of two operating rooms (OR) was performed from 2018 to 2023 to monitor and evaluate air quality and provide appropriate infection control measures. Method: 2 OR regularly performing prosthetic insertion were selected for routine air sampling every 6 months due to high risk of surgical infection associated with the procedure. Air sampling was performed by collecting 1000 litre of air over 10 minutes using air sampler (MAS-100 Eco, Merck). Collected air was cultured on blood agar plate and Sabourand dextrose agar for 30 days, and pathogen identification and quantification was performed upon positive culture result. This study employed a cut-off point of 17.6 colony forming unit (CFU) as specified by federal standards on biological particles published by National Aeronautics and Space Administration. Results: 12 air samplings was performed from 2018 to 2023. A single case of positive bacterial air culture was reported (20 CFU, coagulase-negative Staphylococcus). Infection control measures were provided upon reporting of positive bacterial air culture, including inspection of positive pressure ventilation system and high efficiency particulate air filter, disinfection of OR and the equipment, and more strict regulation of temperature and humidity. Air sampling was repeated after imposing the measures to evaluate their effectiveness. Cases of surgical site infection caused by the identified pathogen were monitored for 90 days, after which it was determined that there was no surgical site infection related to positive air culture. Conclusion: The six-year monitoring of OR air sampling confirmed that detection of positive air culture in routine sampling was not associated with surgical site infection. Based on this result, the hospital decided to conduct air sampling and culture only in outbreak of surgical site infection as part of epidemiologic evaluation.

This population-based cohort study examines the appropriateness of antibiotic prescribing in South Carolina via aggregated pharmacy claims data matched with diagnosis codes from medical claims. Inappropriate antibiotic prescribing decreased from 30.2% in 2012 to 22.6% in 2017 (P < 0.001) and was more common in adults >40 years old.

Background: Surgical site infections (SSIs) are a serious complication following surgery. The emergence of multidrug-resistant pathogens has diminished the effectiveness of traditional antimicrobials necessitating a new approach to prevention and treatment. We are developing an innovative device (xIP) that uses UV-C to inactivate pathogens in surgical incision sites, mitigating the risk of developing an SSI.

Irradiation in the UV-C range (200-280 nm) is known to inactivate surface and airborne pathogens by damaging nucleic acids. However, there is a limited research on its effectiveness for surgical sites. Methods: A Krypton-Chloride Excimer (KrCl*) lamp (λpeak = 222 nm), a pulsed Xenon (PX) emitter (broad spectrum), and a UVC LED (λpeak = 282 nm) were evaluated. Inactivation of E. coli ATCC 29425 and MRSA USA300 was determined by in vitro exposure to UV-C at doses of 0 (control), 2, 5, 10, 15, and 20 mJ/cm2. Dosing was controlled by measuring irradiance (mW/cm2) from each lamp and calculating the time to reach desired exposure levels.

Microbial suspensions of log-phase cultures were pelletized and resuspended in phosphate buffered saline three times and diluted to 107 CFU/mL. After UV exposure, suspensions were plated on an agar substrate using a grid-based method. After incubating for 48 hours at 37°C, remaining viability was determined. Results: PX and KrCl* emitters exhibited 5+ log reduction for both microorganisms, while LED showed 4 and 4.5 log reduction against E. coli and MRSA, respectively. PX demonstrated the highest inactivation efficiency (log-reduction per unit dose), followed by KrCl* and LED. Conclusions: In-vitro data suggest that surgical sites could be effectively treated in less than a minute with a small hand-held device and in less than 10 seconds with a larger device. Inactivation of MRSA using a superficial wound model in hairless SHKI1-elite mice (Charles River strain code 477) is in progress. In-silico modelling using optical raytracing is in progress to understand the impact of wound and skin micro-environment on the performance of the device. These data will inform ex-vivo testing using porcine or cultured human skin (EpiDerm FT) models to evaluate the performance in different wound types including incisions, abrasions, and burns, as well as the impact of fluids like saline and blood. Development of the xIP device is underway in collaboration with healthcare professionals to produce a product that is effective, fits into current practice, and user friendly. Upon successful completion of a prototype device, clinical efficacy will be explored.

Background: Our Candida auris surveillance protocol dictates that all patients who have been admitted to a skilled nursing facility (SNF), long-term acute care hospital (LTACH), and/or acute inpatient rehab (AIR) in the prior six months be screened on hospital admission. When hospital-onset (HO) cases are identified, point prevalence surveys (PPS) are conducted. Despite this, we identified two units with high prevalence of C. auris and an increasing number of HO cases. To investigate, we initiated an expanded C. auris screening pilot. Methods: Infection prevention (IP) verified that two units, the medical intensive care unit (MICU) and the pulmonary medicine unit (PMU) had the highest C. auris prevalence and number of HO cases. We formed a multidisciplinary process improvement team (MPIT) to develop recommendations. A pilot was launched to implement universal admission and transfer screening by PCR and weekly screening by culture on MICU and PMU. Screening consisted of two swabs: bilateral nares and bilateral axilla/groin. For patients with a tracheostomy or endotracheal tube, an endotracheal aspirate was collected. Pilot data were analyzed and shared with executive leadership. Results: In the 15 months prior to the pilot, 24/47 (51%) of the hospital-wide HO C. auris cases occurred on the pilot units resulting in 17/40 (43%) of all PPS performed. The pilot, conducted between 5/7/24 – 8/24/24, screened 868 unique patients and detected 9 present-on-admission (POA) C. auris cases and 8 HO C. auris cases (Figure 1). This surveillance avoided a minimum of 7 PPS and identified a cluster of C. auris on MICU. Notably, 9/9 (100%) of the POA cases were exposed to a SNF, LTACH, and/or AIR within 6 months prior to admission. Of the HO cases, 7/8 (88%) were epidemiologically linked with another C. auris patient, and 4/8 (50%) were co-colonized with at least one other multidrug-resistant organism at the time of collection. The pilot was established as routine practice on the two units. Conclusion: Our screening pilot identified POA and HO C. auris cases and demonstrated that HO cases decreased over time. This suggests that active surveillance allows for rapid identification and isolation of patients, preventing transmissions and outbreaks. In our experience, IP education and hospital-wide admission screening did not stop cases on units with a high prevalence of patients with C. auris. The pilot confirmed that our current hospital-wide admission screening protocol identifies cases on admission but alone will not prevent nor capture HO cases.

Introduction: In the Intensive Care Unit(ICU), healthcare-associated infections can arise from factors such as compromised patient immunity and the use of diverse medical equipment. Furthermore, inadequate awareness of infection control among ICU staff can further increase the risk of infections. Therefore, it is crucial for ICU staff to recognize and address infection risks proactively. To enhance infection control measures, designated infection control facilitators within the department have spearheaded infection control activities. Case Presentation: Internal assessments within the ICU identified areas requiring improvement in infection control, leading to the formulation of a self-improvement initiative. The evaluation results revealed deficiencies in pre- hub disinfection and the appropriateness of Chlorhexidine gluconate(CHG) bathing. To address this, ICU team members were tasked with monitoring hand hygiene and performing pre-hub disinfection at least 10 times before central venous catheter usage. The monitoring results were shared with department members monthly, encouraging performance improvement by rewarding outstanding employees. Additionally, protocols and educational videos for proper CHG bathing were developed within the ICU and reviewed by the Infection Control Department. Using this material, internal education sessions were conducted within the ICU to support all team members in achieving their goals. Discussion: Through various improvement initiatives, staff awareness of infection control has increased, leading to proper CHG bathing and hub disinfection. The incidence rate of central venous catheter-related bloodstream infections decreased from 4.25 in 2022 to 3.35 in 2023. Additionally, hand hygiene compliance increased from 92% in 2022 to 96% in 2023. For effective infection management, the participation of not only the Infection Control Department but also departmental members is crucial. Through effective collaboration and discussions between ICU staff and the infection control team, we were able to address departmental issues, improve staff awareness and performance in infection management. Sustained interest and participation in these activities require continuous staffing and support.

Introduction: Within our healthcare system, hospitalists receive feedback on antibiotic prescribing via an observed-to-expected ratio (OER) calculated by days of therapy (DOT) for CDC defined broad-spectrum, hospital-onset (BSHO) antibiotics and adjusted for patient characteristics and billing. In this sub-analysis, we quantify the impact of infectious disease (ID) consultations on OER. Methods: For each two-month period in five hospitals, encounters were assigned to each hospitalist if they billed for ≥1 day of care. The encounter was considered to involve an ID consult if an ID provider billed during the encounter. Percent of encounters with ID consultation (density) was calculated and stratum defined by gross ratios (e.g., 1 in 3 or 1 in 4 patients). We assessed whether consult density varied overtime, by facility, or by DOT. We assessed the effect of consult density on antibiotic DOT using established linear mixed effects model with random intercepts for both provider and facility (nested) and adjusted for patient characteristics and billing. Distribution of OERs were compared among strata to evaluate how ID consult changes OERs. Results: Between January and June 2023, 154 unique providers collectively received 458 bi-monthly OERs reflecting their care for 53,815 unique patients. Overall, 21% of hospital medicine patients were evaluated by an ID consultant during inpatient stay; median consultation density varied among providers by facility (19%-26%, Figure 1). Multivariate models (accounting for sepsis, UTI, renal disease) estimated significantly increased DOT for hospitalists having ~1:3 (+3.4 DOT, 95% CI 0.9 – 5.9) or 1:4 (+2.7 DOT, 95% CI 0.4-5.0) patients with ID consults compared to hospitalists with fewer than ~1:7 with an ID consult; however the effect was not significant in other strata and not linear (Table 1). Calculating the distribution of OERs both before and after adjusting for consult density resulted in small changes in OERs (Figure 1b). Discussion: The frequency of ID consults affected hospitalists’ BSHO-DOT in a non-linear fashion. Impact of ID consultation on prescribing metrics should be considered in building credibility of stewardship prescribing performance metrics.