Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures.

A before-after, quasi-experimental trial with a baseline (July 2020–June 2022), an implementation (July 2022), and an intervention period (August 2022–July 2023).

Three participating medical centers.

We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing.

1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02–0.45). There was no significant increase in post-procedural unplanned visits at any of the sites.

Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.

This trial was registered on clinicaltrials.gov, NCT04196777.

An alternative to an “all or none” approach to contact precautions for patients with MRSA carriage may be a “risk-tailored” approach – using gloves and gowns only for certain high-risk activities, locations, or roles.

We distributed a discrete choice experiment to healthcare personnel (HCPs) in three cities. Respondents were presented with eight choice sets, each consisting of two hypothetical policy options for glove and gown use to prevent MRSA transmission. In each comparison, respondents selected their preferred option. Using mixed logit modeling we calculated utility derived from each policy component, probability of uptake for the most favored policies, and heterogeneity in preferences based on HCP role.

In total, 326 HCPs completed the survey. 237 (54%) respondents reported wearing gloves and gowns ‘all the time’ when required. Respondents’ preferred policy with the highest utility score was to use gloves and gown for all HCPs roles (utility, 0.17; 95% CI, 0.12 to 0.23), in high-risk settings (utility, 0.12; 95% CI 0.07–0.18), when touching the patient (utility, 0.11; 95% CI 0.06–0.17). Sixty-three percent (95% CI 60–66) would support a risk-tailored approach over an approach where contact precautions are used by all HCPs in all settings and for all activities. Support varied by HCP role (p < 0.02), with the strongest probability of support from physicians and advanced practice providers (77%, 95% CI 72%–82%) and the least support from environmental services personnel (45%, 95% CI 37%–53%).

This discrete choice survey demonstrates that most HCPs prefer a risk-tailored approach to contact precautions when caring for patients with MRSA.

To understand healthcare workers’ (HCWs) beliefs and practices toward blood culture (BCx) use.

Cross-sectional electronic survey and semi-structured interviews.

Academic hospitals in the United States.

HCWs involved in BCx ordering and collection in adult intensive care units (ICU) and wards.

We administered an anonymous electronic survey to HCWs and conducted semi-structured interviews with unit staff and quality improvement (QI) leaders in these institutions to understand their perspectives regarding BCx stewardship between February and November 2023.

Of 314 HCWs who responded to the survey, most (67.4%) were physicians and were involved in BCx ordering (82.3%). Most survey respondents reported that clinicians had a low threshold to culture patients for fever (84.4%) and agreed they could safely reduce the number of BCx obtained in their units (65%). However, only half of them believed BCx was overused. Although most made BCx decisions as a team (74.1%), a minority reported these team discussions occurred daily (42.4%). A third of respondents reported not usually collecting the correct volume per BCx bottle, half were unaware of the improved sensitivity of 2 BCx sets, and most were unsure of the nationally recommended BCx contamination threshold (87.5%). Knowledge regarding the utility of BCx for common infections was limited.

HCWs’ understanding of best collection practices and yield of BCx was limited.

Patients with chronic kidney disease suffer from immune dysfunction, increasing susceptibility to infections. The aim of the study was to investigate air contamination with respiratory viruses in a dialysis unit at a quaternary hospital using molecular detection techniques and to analyze airflow dynamics through computational fluid dynamics (CFD) simulations for a comprehensive assessment of air transmission risks.

We conducted dialysis unit air sampling using AerosolSense™ samplers. Air and clinical sampling occurred during three periods in 2022: winter, early, and late fall. A technical team maintained the dialysis unit’s ventilation system during mid fall. Ventilation system capacity and airflow rates were measured. CFD simulations were used to evaluate airflow dynamics.

The investigation collected 144 air samples, revealing heterogeneous virus detection rates across locations and study periods. Virus positivity correlated with the presence of patients and the effectiveness of the ventilation system. The ratio of virus air positivity to virus patient positivity was 1.84 and 3.35 during the first and the second periods, respectively, and collapsed to 0.64 after maintenance. Airflow rate measurements highlighted a ninefold discrepancy between actual and theoretical airflow (393 m3/h vs. 3530 m3/h), which was rectified by maintenance actions. Airflow dynamics and particle dispersion visualization through CFD simulations contributed to a better understanding of transmission risks.

Detection of viruses in the air, combined with CFD, revealed deficiencies in air renewal. Maintenance interventions significantly improved airflow dynamics and particle dispersion, reducing airborne virus spread.

To better understand clinicians’ rationale for ordering testing for C. difficile infection (CDI) for patients receiving laxatives and the impact of the implementation of a clinical decision support (CDS) intervention.

A mixed-methods, case series was performed from March 2, 2017 to December 31, 2018.

Yale New Haven Hospital, a 1,541 bed tertiary academic medical center.

Hospitalized patients ≥ 18 years old, and clinicians who were alerted by the CDS.

CDS was triggered in real-time when a clinician sought to order testing for CDI for a patient who received one or more doses of laxatives within the preceding 24 hours.

A total of 3,376 CDS alerts were triggered during the 21-month study period from 2,567 unique clinician interactions. Clinicians bypassed the CDS alert 74.5% of the time, more frequent among residents (48.3% bypass vs. 39.9% accept) and advanced practice providers (APPs) (34.9% bypass vs. 30.6% accept) than attendings (11.3% bypass vs. 22.5% accept). Ordering clinicians noted increased stool frequency/output (48%), current antibiotic exposure (34%), and instructions by an attending physician to test (28%) were among the most common reasons for overriding the alert and proceeding with testing for CDI.

Testing for CDI despite patient laxative use was associated with an increased clinician concern for CDI, patient risk for CDI, and attending physician instruction for testing. Attendings frequently accepted CDS guidance while residents and APPs often reinstated CDI test orders, suggesting a need for greater empowerment and discretion when ordering tests.

Racial and ethnic variations in antibiotic utilization are well-reported in outpatient settings but little is known about inpatient settings. Our objective was to describe national inpatient antibiotic utilization among children by race and ethnicity.

This study included hospital visit data from the Pediatric Health Information System between 01/01/2022 and 12/31/2022 for patients <20 years. Primary outcomes were the percentage of hospitalization encounters that received an antibiotic and antibiotic days of therapy (DOT) per 1000 patient days. Mixed-effect regression models were used to determine the association of race-ethnicity with outcomes, adjusting for covariates.

There were 846,530 hospitalizations. 45.2% of children were Non-Hispanic (NH) White, 27.1% were Hispanic, 19.2% were NH Black, 4.5% were NH Other, 3.5% were NH Asian, 0.3% were NH Native Hawaiian/Other Pacific Islander (NHPI) and 0.2% were NH American Indian. Adjusting for covariates, NH Black children had lower odds of receiving antibiotics compared to NH White children (aOR 0.96, 95%CI 0.94–0.97), while NH NHPI had higher odds of receiving antibiotics (aOR 1.16, 95%CI 1.05–1.29). Children who were Hispanic, NH Asian, NH American Indian, and children who were NH Other received antibiotic DOT compared to NH White children, while NH NHPI children received more antibiotic DOT.

Antibiotic utilization in children’s hospitals differs by race and ethnicity. Hospitals should assess policies and practices that may contribute to disparities in treatment; antibiotic stewardship programs may play an important role in promoting inpatient pharmacoequity. Additional research is needed to examine individual diagnoses, clinical outcomes, and drivers of variation.

Prior reports of healthcare-associated respiratory syncytial virus (RSV) have been limited to cases diagnosed after the third day of hospitalization. The omission of other healthcare settings where RSV transmission may occur underestimates the true incidence of healthcare-associated RSV.

Retrospective cross-sectional study.

United States RSV Hospitalization Surveillance Network (RSV-NET) during 2016–2017 through 2018–2019 seasons.

Laboratory-confirmed RSV-related hospitalizations in an eight-county catchment area in Tennessee.

Surveillance data from RSV-NET were used to evaluate the population-level burden of healthcare-associated RSV. The incidence of healthcare-associated RSV was determined using the traditional definition (i.e., positive RSV test after hospital day 3) in addition to often under-recognized cases associated with recent post-acute care facility admission or a recent acute care hospitalization for a non-RSV illness in the preceding 7 days.

Among the 900 laboratory-confirmed RSV-related hospitalizations, 41 (4.6%) had traditionally defined healthcare-associated RSV. Including patients with a positive RSV test obtained in the first 3 days of hospitalization and who were either transferred to the hospital directly from a post-acute care facility or who were recently discharged from an acute care facility for a non-RSV illness in the preceding 7 days identified an additional 95 cases (10.6% of all RSV-related hospitalizations).

RSV is an often under-recognized healthcare-associated infection. Capturing other healthcare exposures that may serve as the initial site of viral transmission may provide more comprehensive estimates of the burden of healthcare-associated RSV and inform improved infection prevention strategies and vaccination efforts.

To improve the understanding of appropriate antibiotic de-escalation and stewardship by consolidating the evidence on screening for methicillin-resistant Staphylococcus aureus (MRSA) colonization of the nares to predict MRSA in acute skin and soft tissue infections (SSTIs).

This meta-analysis was performed according to PRISMA guidelines. Six databases were searched by two reviewers for articles on MRSA detection in the nares and acute SSTIs. The quality and risk of bias of the articles were then assessed. The primary outcomes of interest were pooled sensitivity and specificity. Sub-analyses were also performed to test for heterogeneity.

After screening 1040 records, 15 articles (n = 1,970) were included in the meta-analysis. Using MRSA nares screening to predict MRSA in acute SSTIs had an overall specificity of 0.949 and sensitivity of 0.474. With a prevalence of 29.1%, the calculated NPV was 0.815. There were sub-analyses on various study variables, such as study location, participant age, and detection by polymerase chain reaction versus culture. The only significant finding was an increased sensitivity for adults (0.543) compared to pediatric participants (0.285).

To our knowledge, this is the first meta-analysis that focuses on the performance of MRSA nares screening for predicting MRSA infection in patients presenting with acute SSTIs. The baseline prevalence of MRSA SSTIs is important for interpreting the screening results, and the prevalence is influenced by geography and patient factors. This clinical context must be considered before utilizing MRSA nares screening for acute SSTIs.

We introduced a urinary tract infection (UTI) panel requiring symptom documentation and identification of special populations linked to reflex urine culturing and evaluated its impact on catheter-associated UTI (CAUTI) including during the COVID-19 pandemic.

Quasi-experimental encompassing 3 periods: pre-panel (January 2014–March 2015), post-panel (April 2015–March 2020), and post-panel COVID (April 2020–June 2022).

Tertiary care center inpatients.

Poisson regression and interrupted time series (ITS) analysis evaluated changes in catheter days (CD), urine cultures (UC), and CAUTI measured by 1,000 CD and patient days (PD). National Health Safety Network standardized infection ratio (SIR) and standardized utilization ratio (SUR) data were analyzed.

UC per 1,000 PD decreased after implementation (pre-panel 36.9 vs 16.6 post-panel vs 14.4 post-panel COVID, all P < .001). CD declined pre-panel versus post-panel (RR 0.37, P < .001) but not from post-panel to post-panel COVID (RR 0.94, P = .88). UTI panel implementation was associated with a 40% decrease in CAUTI rates per 1,000 CD (P < .001). During the COVID-19 pandemic (post-panel COVID), a nonsignificant increase of 13% (P = .61) in CAUTI was noted but remained 32% lower than pre-panel (P = .02). The slope of change using ITS changed from negative to positive but was nonsignificant (P = .26). CAUTI rates per 1,000 PD demonstrated greater reductions (pre- vs post-panel (RR 0.37; 95% CI, 0.29–0.47) and pre- vs post-panel COVID (RR 0.35; 95% CI, 0.26–0.46)). SIRs were unavailable before 2016, but median SIRs post-panel compared to post-panel COVID were similar (1.05 vs 1.56, respectively, P = .067).

Implementation of the UTI panel was associated with a reduction in both UC and CAUTI with the impact maintained despite the COVID-19 pandemic.

Many post-acute and long-term care settings (PALTCs) struggle to measure antibiotic use via the standard metric, days of therapy (DOT) per 1000 days of care (DOC). Our objective was to develop antibiotic use metrics more tailored to PALTCs.

Retrospective cohort study with a validation cohort.

PALTC settings within the same network.

We obtained census data and pharmacy dispensing data for 13 community PALTCs (January 2020–December 2023). We calculated antibiotic DOT/1000 DOC, DOT per unique residents, and antibiotic starts per unique residents, at monthly intervals for community PALTCs. The validation cohort was 135 Veterans Affairs Community Living Centers (VA CLCs). For community PALTCs only, we determined the DOT and antibiotics starts per unique residents cared for by individual prescribers.

For community PALTCs, the correlation between facility-level antibiotic DOT/1000 DOC and antibiotic DOT/unique residents and antibiotic courses/unique residents was 0.97 (P < 0.0001) and 0.84 (P < 0.0001), respectively. For VA CLCs, those values were 0.96 (P < 0.0001) and 0.85 (P < 0.0001), respectively. At community PALTCs, both novel metrics permitted assessment and comparison of antibiotic prescribing among practitioners.

At the facility level, the novel metric antibiotic DOT/unique residents demonstrated strong correlation with the standard metric. In addition to supporting tracking and reporting of antibiotic use among PALTCs, antibiotic DOT/unique residents permits visualization of the antibiotic prescribing rates among individual practitioners, and thus peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC residents.

Urgent care centers (UCCs) have reported high rates of antibiotic prescribing for acute respiratory tract infections. Prior UCC studies have generally been limited to single networks. Broadly generalizable stewardship efforts targeting common diagnoses are needed. This study examines the effectiveness of an antibiotic stewardship intervention in reducing inappropriate prescribing for bronchitis and viral upper respiratory tract infections (URTIs) in UCCs.

A quality improvement study comparing inappropriate antibiotic prescribing rates in UCCs after the introduction of an antibiotic stewardship intervention.

Forty-nine UCCs in 27 different networks from 18 states, including 1 telemedicine site.

Urgent care clinicians from a national collaborative of UCCs, all members of the Urgent Care Association.

The intervention included signing a commitment statement and selecting from 5 different intervention options during 3 plan-do-study-act cycles. The primary outcome was the percentage of urgent care encounters for viral URTIs or bronchitis with inappropriate prescribing, stratified by clinician engagement and diagnosis. A 3-month baseline and 9-month intervention period were compared using a regression model using a generalized estimating equation.

Among 15,385 encounters, the intervention was associated with decreases in inappropriate antibiotic prescribing for bronchitis (48% relative decrease, aOR = 0.52; 95% CI, 0.33–0.83) and viral URTIs (33%, aOR = 0.67; 95% CI, 0.55–0.82) among actively engaged clinicians compared to baseline. The intervention did not result in significant changes for clinicians not actively engaged.

This intervention was associated with reductions in inappropriate prescribing among actively engaged clinicians. Implementing stewardship interventions in UCCs may reduce inappropriate antibiotic prescriptions for common diagnoses; however, active clinician engagement may be necessary.

To describe the effect of a Stenotrophomonas maltophilia (SM) respiratory culture nudge on antibiotic use in colonized patients.

IRB-approved quasi-experiment.

Five acute-care hospitals in Michigan.

Adult patients with SM respiratory culture between 01/01/2022 and 01/27/2023 (pre-nudge) and 03/27/2023–12/31/2023 (post-nudge). Patients with active community/hospital/ventilator-acquired pneumonia or who received SM-targeted antibiotics at the time of culture were excluded.

A nudge comment was implemented 02/2023 stating: “S. maltophilia is a frequent colonizer of the respiratory tract. Clinical correlation for infection is required. Colonizers do not require antibiotic treatment.” The primary outcome was no treatment with SM-therapy; secondary outcomes were treatment with SM-therapy ≥72 hrs, length of stay, and in-hospital, all-cause mortality. Safety outcomes included antibiotic-associated adverse drug events (ADEs).

94 patients were included: 53 (56.4%) pre- and 41 (43.6%) post-nudge. Most patients were men (53, 56.4%), had underlying lung disease (61, 64.8%), and required invasive ventilatory support (70, 74.5%). Eleven (11.7%) patients resided in a long-term care facility. No treatment with SM therapy was observed in 13 (23.1%) pre- versus 32 (78.0%) post-nudge patients (P <0.001). There were no differences in secondary outcomes. Antibiotic-associated ADEs were common (33/41, 76%) in patients who received ≥72hrs of SM-therapy: fluid overload (18, 44%), hyponatremia (17, 42%), elevated SCr (12, 29%), hyperkalemia (5, 12%). After adjustment for confounders, post-nudge was associated with 11-fold increased odds of no treatment with SM-therapy (adjOR, 11.72; 95%CI, 4.18–32.83).

A targeted SM nudge was associated with a significant reduction in treatment of colonization, with similar patient outcomes. SM-treated patients frequently developed antibiotic-associated ADEs.

To describe the real-world clinical impact of a commercially available plasma cell-free DNA metagenomic next-generation sequencing assay, the Karius test (KT).

We retrospectively evaluated the clinical impact of KT by clinical panel adjudication. Descriptive statistics were used to study associations of diagnostic indications, host characteristics, and KT-generated microbiologic patterns with the clinical impact of KT. Multivariable logistic regression modeling was used to further characterize predictors of higher positive clinical impact.

We evaluated 1000 unique clinical cases of KT from 941 patients between January 1, 2017–August 31, 2023. The cohort included adult (70%) and pediatric (30%) patients. The overall clinical impact of KT was positive in 16%, negative in 2%, and no clinical impact in 82% of the cases. Among adult patients, multivariable logistic regression modeling showed that culture-negative endocarditis (OR 2.3; 95% CI, 1.11–4.53; P .022) and concern for fastidious/zoonotic/vector-borne pathogens (OR 2.1; 95% CI, 1.11–3.76; P .019) were associated with positive clinical impact of KT. Host immunocompromised status was not reliably associated with a positive clinical impact of KT (OR 1.03; 95% CI, 0.83–1.29; P .7806). No significant predictors of KT clinical impact were found in pediatric patients. Microbiologic result pattern was also a significant predictor of impact.

Our study highlights that despite the positive clinical impact of KT in select situations, most testing results had no clinical impact. We also confirm diagnostic indications where KT may have the highest yield, thereby generating tools for diagnostic stewardship.

To assess the frequency of and motivations for acute respiratory illness (ARI) presenteeism in healthcare personnel (HCP) during two waves of COVID-19.

Survey.

Large academic medical center, both ambulatory and acute care settings.

All HCPs (n = 11,429) at the University of North Carolina Medical Center were eligible for two voluntary, electronic surveys: pre-Omicron (n = 591, recall period March 2020 - December 2021) and Omicron BA.1 (n = 385, recall period January - April 2022).

We compared self-reported ARI presenteeism (working despite feeling feverish plus cough and/or sore throat) and motivators across time and demographics. We also estimated effects of workplace perceptions and culture on ARI presenteeism with log-binomial regression, adjusting for age, gender, HCP role, and patient interaction.

In the pre-Omicron and Omicron BA.1 eras, 24% and 34% of respondents respectively reported at least one instance of ARI presenteeism. In both eras, clinical frontline HCP were more likely to report ARI presenteeism than other roles, as were HCP primarily providing direct patient care vs not. Pre-Omicron motivators included disciplinary action and sick leave concerns, whereas workplace culture predominated during Omicron. Feeling professional obligation to attend work and observing colleague presenteeism increased ARI presenteeism in both eras. During Omicron, COVID-19 burnout, fatigue, and unclear call-out procedures increased ARI presenteeism.

ARI presenteeism was common and had diverse motivations, including workplace culture, disciplinary action, and sick leave. Efforts to reduce presenteeism should address these factors and prioritize frontline clinical personnel with direct patient interaction.

Diagnostic stewardship of urine cultures from patients with indwelling urinary catheters may improve diagnostic specificity and clinical relevance of the test, but risk of patient harm is uncertain.

We retrospectively evaluated the impact of a computerized clinical decision support tool to promote institutional appropriateness criteria (neutropenia, kidney transplant, recent urologic surgery, or radiologic evidence of urinary tract obstruction) for urine cultures from patients with an indwelling urinary catheter. The primary outcome was a change in catheter-associated urinary tract infection (CAUTI) rate from baseline (34 mo) to intervention period (30 mo, including a 2-mo wash-in period). We analyzed patient-level outcomes and adverse events.

Adjusted CAUTI rate decreased from 1.203 to 0.75 per 1,000 catheter-days (P = 0.52). Of 598 patients triggering decision support, 284 (47.5%) urine cultures were collected in agreement with institutional criteria and 314 (52.5%) were averted. Of 314 patients whose urine cultures were averted, 2 had a subsequent urine culture within 7 days that resulted in a change in antimicrobial therapy and 2 had diagnosis of bacteremia with suspected urinary source, but there were no delays in effective treatment.

A diagnostic stewardship intervention was associated with an approximately 50% decrease in urine culture testing for inpatients with a urinary catheter. However, the overall CAUTI rate did not decrease significantly. Adverse outcomes were rare and minor among patients who had a urine culture averted. Diagnostic stewardship may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures among patients with indwelling urinary catheters.

To identify risk factors for methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) nasal carriage and surgical site infection (SSI) among patients undergoing fracture fixation procedures who were included in a quality improvement protocol involving screening patients for S. aureus nasal carriage and treating carriers with intranasal mupirocin and chlorhexidine bathing.

Retrospective cohort study.

Level 1 trauma center.

1,254 adults who underwent operative fixation of 1,298 extremity or pelvis fractures between 8/1/2014 – 7/31/2017.

We calculated rates of S. aureus nasal carriage and SSI. We used multivariable stepwise logistic regression and selected the final models based on Akaike information criterion.

Of the 1,040 screened first procedures, 262 (25.19%) were performed on S. aureus nasal carriers: 211 (20.29%) on MSSA carriers and 51 (4.90%) on MRSA carriers. Long-term care facility residence (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.17–9.76) was associated with MRSA nasal carriage. After adjusting for statistically and clinically significant variables, MRSA carriage was significantly associated with any SSI (OR 4.58; 95% CI 1.63–12.88), S. aureus SSI (OR 10.11; 95% CI 3.25–31.42), and MRSA SSI (OR 27.25; 95% CI 5.33–139.24), whereas MSSA carriage was not. Among S. aureus carriers, any chlorhexidine use was documented for 232 (88.55%), and any intranasal mupirocin was documented for 85 (40.28%) MSSA carriers and 33 (64.71%) MRSA carriers.

MRSA carriage was associated with a significant risk of SSI after operative fracture fixation. Many carriers did not undergo decolonization, suggesting that a simplified decolonization protocol is needed.

Antibiotic stewardship programs (ASPs) target hospitalized children, but most do not routinely review antibiotic prescriptions at discharge, despite 30% of discharged children receiving additional antibiotics. Our objective is to describe discharge antibiotic prescribing in children hospitalized for uncomplicated community-acquired pneumonia (CAP), skin/soft tissue infection (SSTI), and urinary tract infection (UTI).

Retrospective cohort study.

Four academic children’s hospitals with established ASPs.

ICD-10 codes identified 3,847 encounters for children <18 years admitted from January 1, 2021 to December 31, 2021 and prescribed antibiotics at discharge for uncomplicated CAP, SSTI, or UTI. After excluding children with medical complexity and encounters with concomitant infections, >7 days hospital stay, or intensive care unit stay, 1,206 encounters were included.

Primary outcomes were the percentage of subjects prescribed optimal (1) total (inpatient plus outpatient) duration of therapy (DOT) and (2) antibiotic choice based on current national guidelines and available evidence.

Of 226 encounters for CAP, 417 for UTI, and 563 for SSTI, the median age was 4 years, 52% were female, and the median DOT was 9 days (8 for CAP, 10 for UTI, and 9 for SSTI). Antibiotic choice was optimal for 77%, and DOT was optimal for 26%. Only 20% of antibiotic courses included both optimal DOT and antibiotic choice.

At 4 children’s hospitals with established ASPs, 80% of discharge antibiotic courses for CAP, UTI, and SSTI were suboptimal either by choice of antibiotic or DOT. Discharge antibiotic prescribing represents an opportunity to improve antibiotic use in children.

Multiplex polymerase chain reaction (PCR) panels for stool testing may be used to diagnose Clostridioides difficile, which can circumvent more appropriate targeted C. difficile testing, resulting in treatment of incidentally detected colonization. We sought to reduce C. difficile diagnosis via a gastrointestinal pathogen panel (GIPP).

Quasi-experimental, pre/post, retrospective cohort study from January 1, 2022, to January 31, 2024.

Mayo Clinic Arizona—a single academic medical center and associated clinics.

Adult patients receiving C. difficile testing and/or treatment.

Preferred C. difficile testing consisted of glutamate dehydrogenase and toxin antigen immunoassay, followed by toxin gene testing for discrepant results. The GIPP contained 22 targets during the baseline period with C. difficile removed during the postintervention period. Surveys were provided to provider and nursing groups, separately, to identify C. difficile ordering practices and knowledge gaps.

At baseline, from January 1, 2022, to January 31, 2023, 2,772 GIPPs were completed for 2,307 unique patients (∼7 per day), primarily for outpatients (1,805 of 2,772, 65%). The most common positive target was C. difficile (517 of 1,018, 51%), which resulted in treatment for C. difficile infection in 94.9% (337 of 355) of cases. Following GIPP C. difficile target removal, GIPP orders decreased from 3.23 to 2.7 per 1,000 patient visits (P < .001). Prescribing of C. difficile treatments decreased in the postintervention period in inpatient and outpatient settings. There were no cases of delayed C. difficile diagnosis during the postintervention period.

Removing C. difficile from the GIPP resulted in effective diagnostic and antimicrobial stewardship without resulting in delayed diagnoses.

Evaluate impact of COVID-19 prevention training with video-based feedback on nursing home (NH) staff safety behaviors.

Public health intervention

Twelve NHs in Orange County, California, 6/2020-4/2022

NHs received direct-to-staff COVID-19 prevention training and weekly feedback reports with video montages about hand hygiene, mask-wearing, and mask/face-touching. One-hour periods of recorded streaming video from common areas (breakroom, hallway, nursing station, entryway) were sampled randomly across days of the week and nursing shifts for safe behavior. Multivariable models assessed the intervention impact.

Video auditing encompassed 182,803 staff opportunities for safe behavior. Hand hygiene errors improved from first (67.0%) to last (35.7%) months of the intervention, decreasing 7.6% per month (OR = 0.92, 95% CI = 0.92–0.93, P < 0.001); masking errors improved from first (10.3 %) to last (6.6%) months of the intervention, decreasing 2.3% per month (OR = 0.98, 95% CI = 0.97–0.99, P < 0.001); face/mask touching improved from first (30.0%) to last (10.6%) months of the intervention, decreasing 2.5% per month (OR = 0.98, 95% CI = 0.97–0.98, P < 0.001). Hand hygiene errors were most common in entryways and on weekends, with similar rates across shifts. Masking errors and face/mask touching errors were most common in breakrooms, with the latter occurring most commonly during the day (7A.M.–3P.M.) shift, with similar rates across weekdays/weekends. Error reductions were seen across camera locations, days of the week, and nursing shifts, suggesting a widespread benefit within participating NHs.

Direct-to-staff training with video-based feedback was temporally associated with improved hand hygiene, masking, and face/mask-touching behaviors among NH staff during the COVID-19 pandemic.

Skin and soft tissue infections (SSTIs) account for over 2.8 million annual emergency department (ED) visits and often result in suboptimal antibiotic therapy. The objective of this study was to evaluate a set of interventions in minimizing inappropriate prescription of antibiotics for presumed SSTIs in the ED.

Case vignette survey.

A national sample of emergency medicine (EM) physicians.

Each vignette described a clinical scenario of a presumed SSTI (cellulitis or abscess) and included a unique combination of zero to five interventions (outpatient follow-up, inappropriate antibiotic request flag, thermal imaging for cellulitis or rapid wound MRSA PCR for abscess, patient education/shared decision-making, and clinical decision support). Out of 64 possible vignettes, we asked participants to respond to eight vignettes. Following each vignette, we asked participants if they would prescribe an antibiotic in their everyday practice (yes/no). We built adjusted hierarchical logistic regression models to estimate the probability of prescribing an antibiotic for each intervention and vignette.

Surveys were completed by 113 EM physicians. The thermal imaging, rapid wound MRSA PCR, and patient education/shared decision-making interventions showed the largest decrease (15–20%) in antibiotic prescribing probability. Vignettes with a combination of both a diagnostic intervention (thermal imaging or rapid wound MRSA PCR) and a patient education/shared decision-making intervention had the lowest prescribing probabilities.

We recommend future research focuses on the development and integration of novel diagnostic tools to identify true infection and incorporate shared decision-making to improve diagnosis and management of SSTIs.