Background: Most laboratories diagnose Clostridioides difficile infection (CDI), using a nucleic acid amplification test (NAAT) or an enzyme immunoassay (EIA) for detecting the toxins in the stool. Adoption of a two-step testing method where a positive NAAT is folowed by a negative toxin EIA may lead to underreporting of patients with CDI healthcare-associated infections (HAIs). The possibility that patients with an active infection may be underreported has been suggested by data, that NAAT positive/Toxin negative patients are sometimes treated. Therefore a new surveillance definition has been adopted by NHSN, healthcare facility-onset antibiotic-treated C. difficile infection (HT-CDI). To date, the impact of adopting this new metric on the number of CDI cases that would qualify for HAI surveillance reporting remains unknown. We chose to explore this by retrospectively evaluating CDI cases using the current and proposed HT-CDI surveillance definition over a two year period in a sample of VA Medical Centers. Method: The above HT-CDI definition was applied to all acute care inpatients tested for CDI from July 1, 2022 through June 20, 2024 in 25 volunteer acute care VA medical centers. Centers were chosen based on the use of NAAT alone, NAAT followed by toxin EIA, GDH followed by toxin EIA with discordant results arbitrated by NAAT, GDH plus toxin EIA, toxin EIA alone, or GDH plus NAAT. A HT-CDI was defined according to NHSN as any qualifying C. difficile-positive asssay collected in an inpatient location on day 4 or greater after admission, along with administration of new qualifying antimicrobial therapy in a time frame window. Qualifying therapeutic agents for CDI were defined as enteral vancomycin, metronidazole, or fidaxomycin or intravenous metronidazole. Results: Analysis of the 789 CDI cases in 25 VA facilities collected over two years showed that adoption of the HT-CDI definition could potentially increase the number of reportable cases by 23.3%. The impact was most pronounced for patients diagnosed with two-step testing where presumably the patient would not be reported to a national database on the last test done. Conclusion: Application of the HT-CDI definition to Veterans Affairs patients could lead to an estimated 23% increase in the number of cases identified and eligible for reporting to a national database such as NHSN. These cases may be a better indicator of the true burden of CDI in an acute healthcare system.

Background: Carbapenem-resistant Acinetobacter baumannii (CRAb) and carbapenem-resistant Pseudomonas aeruginosa (CRPa) are critical priority MDROs. They can develop resistance to last-line antibiotics, complicating infection treatment, leading to longer hospital stays, higher costs, and mortality. Objectives: To describe trends in CRAb and CRPa prevalence and antibiotic susceptibility in the access, watch, and reserve groups of positive blood cultures. Methods: This was a descriptive observational study using data from positive blood cultures at Dr Sardjito General Hospital from 2020-2023. Bacterial identification and antibiotic susceptibility testing were performed using the Vitec-2 Compact system. Patient demographics and clinical data were obtained from the microbiology LIS and electronic medical recods. Results: A total of 3603 positive blood cultures were obtained. CRAb rates were 85%, 62%, 68%, 78%, while CRPa were 26%, 21%, 12%, 25% respectively. CRAb antibiotic susceptibility in access group: 2%, 8%, 5%, 3%, in watch group: 27%, 28%, 27%, 22% and in reserve group: 33%, 58%, 37%, 30%. CRPa susceptibility was reduced in all groups: 13%, 30%, 13%, 6% in access, 0%, 4%, 0%, 19% in watch, and 13%, 7%, 13%, 14% in reserve group. CRPa was more susceptible in the access group, while CRAb was more susceptible in the watch and reserve groups suggesting that CRPa infections were more difficult to treat. The highest prevalence was in 2020, possibly due to failure to control antibiotic use during the early Covid-19 pandemic. A decrease in both MDR pathogens in 2021 was associated with intense ASP activities in the second year of the pandemic. Increasing prevalence in the following years may be due to a lack of stewardship following a change in the internal antimicrobial stewardship team structure. Conclusions: These data indicate that consistent ASP had important role in controlling CRAb and CRPa. Changing the structure of antimicrobial stewardship team should be well prepared to ensure a good adaptation.

Background: Healthcare produces 10% of US carbon emissions. Diagnostic stewardship can improve patient care while reducing emissions from unnecessary testing. In the Bronx, community outbreaks of Legionella pneumophila result in frequent testing, yet, most testing for Legionella and Pneumococcus are negative. The institution is transitioning from separate tests for Streptococcus pneumoniae and L. pneumophila to a single combined test. We evaluated the environmental impact of this change. Methods: To approximate emissions from separate versus combined testing kits, each kit component was weighed and converted to CO2 emission equivalents using the US Environmental Protection Agency (EPA) greenhouse gas equivalencies calculators. Using data from the previous 12 months and projecting similar future testing patterns, we estimated an emissions reduction based on combined testing. By multiplying waste emissions before and after combined testing, we were able to estimate the emissions diverted by this institutional change. Results: From January 2023 to November 2024, 13906 urine Legionella tests were performed and 62 (0.45%) were positive, while 12796 urine Pneumococcal tests were performed and 479 (3.74%) were positive. Separate testing kits generated 218.2 kg of plastic waste and 749.1 kg of paper waste. Projected plastic waste from January 2025 to November of 2026 using the combined test is 48.5 kg of paper waste and 64.2 kg of plastic waste. The total estimated emissions reduction is 4.34 Kg of CO2. Conclusions: Diagnostic stewardship via a combined urinary antigen test can reduce waste from unnecessary testing without altering workflow. This institutional change is projected to reduce the plastic waste equivalent to 8480 water bottles and reduce emissions equivalent to using 11 gallons of gasoline or charging 340 smartphones. Our calculations are likely an underestimate of total emissions diverted since we only estimated emissions produced by waste in the landfill and did not account for other associated emissions such as those produced by transporting the waste. While the impact is modest, diagnostic stewardship applied broadly is a step towards a goal of net zero.

Objectives: The recent experience of the COVID-19 pandemic emphasized the critical need for a surveillance system to alert healthcare facilities about the admission of patients with emerging infectious diseases (EID), thereby preventing nosocomial transmissions. Methods: Tan Tock Seng Hospital, an 1800-bed acute tertiary-care hospital in Singapore, transitioned to a new- generation electronic medical record system, Epic, in August 2022. Leveraging the system’s capabilities, we developed an algorithm to generate the line-list of suspected Middle East Respiratory Syndrome (MERS) patients, in alignment with the screening guidelines provided by Singapore’s Ministry of Health. The algorithm first identifies patients who presented within 14 days (maximum incubation period) of their travel to Arabic peninsular countries. This information is documented by the emergency department’s triage nurses. Additionally, patients with suspected MERS indicated in the problem list or diagnosis by attending clinicians, particularly emergency-medicine physicians or infectious-disease physicians, are included. Furthermore, patients who are ordered for a MERS- Coronavirus polymerase chain reaction test, are identified. The algorithm can also be further modified as and when the case definition of the EID changes. Results: The surveillance report constructed with Epic algorithm can be scheduled for daily generation or generated on demand within a few minutes. This newer approach is more time- and resource-efficient compared to the manual surveillance process, which necessitates at least three staff members to engage in a series of prolonged manual processes. The report, by extracting information directly from Epic in near real-time, also minimizes the likelihood of errors that may occur during the manual process. Subsequently, the team of epidemiologists identifies the suspected MERS patients form the generated report and efficiently follow up them until a diagnosis of MERS is excluded. Conclusions: Harnessing Epic’s capabilities, we constructed an algorithm to efficiently and swiftly identify suspected MERS patients, enabling the timely implementation of infection prevention strategies to prevent nosocomial transmission.

This project was initiated in a large pediatric intensive care unit to reduce catheter-associated urinary tract infections (CAUTIs). Implementing removal of diapers and a urine collection device that prevented urine backflow in March 2021 decreased the rate from 3.3 to 0.9 CAUTIs/1000 catheter-days. These interventions could augment CAUTI prevention strategies.

Introduction: Studies examining carbapenemase producing carbapenem resistant Enterobacterales (CP-CRE) transmission incorporating clinical and genomic data in Indian hospitals are lacking. We investigated the prevalence, risk factors for CP-CRE peri-rectal colonization on admission and acquisition during hospital stay and genomic epidemiology of CP-CRE isolates in an adult surgical intensive care unit (SICU) in a tertiary-care hospital in India. Methods: SICU patients admitted from July 31 to November 30, 2023 were prospectively enrolled. Peri-rectal swabs (PRS) were collected at SICU admission and discharge, and hospital discharge. Environmental sampling of sinks was performed. Swabs were plated on selective agar (CHROMagarTMmSuperCARBATM) for CP-CRE isolation. Whole genome sequencing of CP-CRE isolates was performed to investigate antimicrobial resistance gene (ARG) abundance, strain typing (ST), and relatedness classified by community-associated (CA), healthcare-associated (HCA), hospital-acquired (HA), and environmental isolates. Results: 56 (28%) of 203 enrolled patients were colonized with CP-CRE on SICU admission. Among 147 admission-negative patients, 113 had repeat PRS testing > = 1 times during their stay; 43 (29%; 43/147) acquired CP-CRE (Figure 1). The predominant organism in admission and acquisition cases was Escherichia coli (52%) and Klebsiella pneumoniae (37%), respectively (Figure 2). Previous hospitalization = 2 antibiotics (aOR 2.77; 95%CI 1.12-6.82) were associated with admission CP-CRE colonization (Figure 3). In Cox regression analysis hospital stay before SICU admission was associated with CP-CRE acquisition in the SICU, but no risk factor was associated with acquisition during the entire hospital stay (Figure 4). Abundance of ARGs was lower in CA CP-CRE isolates compared to HCA, HA and environmental isolates (Figure 5). blaNDM and blaOXA genes were present in 79% (99/126) and 29% (36/126) of isolates, respectively; blaNDM-5 was the most common carbapenemase [65 (52%) of 126 isolates] (Figure 6A). E. coli ST410, which was associated with HA and HCA classifications was the most frequent ST (n=17) and 70% (12/17) carried NDM (Figure 6B). Twenty-seven E. coli and 17 K. pneumoniae isolates were separated by 20 or fewer core genome single-nucleotide polymorphisms, indicating potential relatedness amongst CP-CRE (Figure 7). Conclusion: More than 25% of SICU patients were colonized with CP-CRE on admission and also acquired CP-CRE during hospital stay. Healthcare-related CP-CRE isolates carried more resistances genes with NDM being the most commonly detected resistance gene in this cohort. Small sample size limited our understanding of risk factors associated with CP-CRE acquisition in hospital.

Background/Aim: The manual compilation of employees’ health information and record-keeping can be an arduous and distressing task. Therefore, it is essential to invest time and effort in finding a solution to collect, store, and retrieve data in real-time when required. Method: To address this challenge, the Infection Control Team collaborated with the IT department and relevant HODs to develop an integrated and digitalized record system known as the “Staff Health System.” This system can be easily accessed by all employees, supervisors, and the infection control team. The Infection Control (IC) team is responsible for updating and maintaining vaccination records, while HR takes charge of documenting the health records of new employees and monitoring staff health/vaccination in compliance with MOH requirements. Result: The implementation of the Staff Health System offers several benefits as: (1) Empowerment of staff: The system grants employees the autonomy to schedule and reschedule vaccination and mask fitting sessions at their convenience; (2) Enhanced accessibility: Staff and other stakeholders can readily access vaccination and mask fitting records, as well as pre-employment lab results through the system; (3)Real-time data: The system can generate up-to-date data that are relevant to stakeholders and management, improving decision-making processes; (4) Resource efficiency: The digitalized system reduces the consumption of resources such as paper, toner, and manpower required for collating, updating, storing, and retrieving data; (5) Data accuracy: With the Staff Health System, data accuracy is ensured, reducing the risk of errors and discrepancies in records. Conclusion: Overall, the implementation of this digitalized solution has elevated Mt Alvernia Hospital’s service standards by enhancing efficiency and compliance in record-keeping and updating processes.

Objectives: Energy devices (EDs), such as Harmonic, Ligasure, Thunderbeat and Trocar are widely used in Minimally Invasive Surgeries. They are expensive and designed for single use. However, due to the limitation of resources, they have been reused in some cases. Therefore, we aimed to assess the efficacy of EDs reprocessing by Adenosine Triphosphate (ATP) method. Methods: This was a cross-sectional description study. After first clinical using, EDs were taken to cleaning. Every ED was cleaned three times. Efficacy cleaning was assessed after each cleaning procedure by ATP method. ATP <200 RLUs (Relative Light Units) was benchmark as efficient cleaning process. Results: A total of 611 EDs were studied, including 269 of Harmonic, Ligasure, Thunderbeat, 298 of Trocar, and 44 other types. Detachable devices accounted for about 32.7%. Overall, after three consecutive cleanings, the median ATP values were decreased dramatically (957 RLUs, 160 RLUs, and 62 RLUs, respectively). This was a significant reduction in ATP levels between three stages (p < 0.05). There were 63.5%, 84.3%, and 92.8% EDs that had ATP < 200 RLUs after first, second, third cleaning respectively. Approximately 90% of EDs were still functional after three cleaning times. Nondetachable items were to be more difficult to clean than detachable ones (p = 0.0003, OR 1.3 [1.1 – 1.5]). Conclusions: Our data suggest that monitoring efficacy cleaning of surgical instruments in general and single-use energy devices in particular with ATP can identify a number of different influence factors, like the instrument condition, reprocessing procedure, or especially their structure. ATP measurement seems to be a valid technique that allows an immediate repeat of the manual cleaning if the results exceed the established cutoff of 200 RLUs.

Background: Burn injuries pose a significant risk for infections. Nasal decolonization with mupirocin nasal ointment (MNO) is an established method to prevent infections with Methicillin-resistant Staphylococcus aureus (MRSA). We compared the effectiveness of an alcohol-based nasal sanitizer (ABNS) to MNO against MRSA bacteremia in burn patients. Methods: This was a retrospective before/after study comparing the impact of an MNO (study arm 1; Bactroban 2%, GlaxoSmithKline, NC; application: twice daily for five days after admission) and an ABNS (study arm 2; Nozin, Bethesda, MD; application: twice daily for entire stay on Burn unit) on Healthcare Associated (HA-) MRSA bacteremia events in burn patients. The Burn unit consists of eight intensive care beds for burn care and 15 regular beds in an 885 bed, tertiary care, academic hospital. Inclusion criteria were all burn patients 18 years of age and older admitted under the burn service for more than four consecutive days. No mandatory MRSA screening was performed. Outcome measure was HA-MRSA bacteremia acquired > four days after admission. Patient characteristics included demographics, BMI, intensive care need, MRSA colonization at admission, type and degree of burn, inhalation injury, total burn surface area, Baux score, inpatient mortality, length of stay by total, burn mixed acuity and burn ICU were documented. Daily compliance with treatments was extracted from patient records (EPIC, Verona, WI). Continuous patient characteristics were compared using t-tests or Wilcoxon signed-rank test (for factors with skewed distributions), and chi-square tests for categorical factors. Product-limit time-to-event analysis and log-rank test were used to compare the outcome measure between groups. Results: From 08/01/2021 to 07/31/2024 a total of 920 patients were enrolled (MNO arm: 448; ABNS arm: 462) with 239 and 217 meeting inclusion criteria. No differences in patient characteristics were detected between the two groups at all patients and >80% treatment compliance levels (MNO: 121 encounters; ABNS: 98 encounters). Patients in the MNO arm encountered 14 events compared to one event in the ABNS arm (p=0.0021). The figure displays the product-limit time to event estimates for developing HA-MRSA bacteremia at the >80% adherence level (p= 0.021). Lower adherence levels (50%, 60%, 70%) did not show significance (p>0.05) in the time-to-event analysis. Conclusion: Providing ABNS >80% of the time resulted in a significant decrease in HA-MRSA bacteremia events in burn patients compared to an MNO. The daily application throughout hospitalization may offer additional protection against MRSA in patients hospitalized for extended periods of time.

Background: The pharmaceutical industry is estimated to have a larger environmental footprint than the automotive industry. Discarded and unused doses of pharmaceuticals generate financial waste and pollution, and exacerbate antibiotic shortages. The antibiotic daptomycin is dispensed in standard-sized single-use vials and dosed based on patient weight. Residual daptomycin in the vial after dose preparation must be disposed of and cannot be used for another patient. We hypothesized that daptomycin dosing nomogram use would reduce daptomycin waste, environmental impact, and financial costs. Methods: We performed a retrospective chart review quantifying daptomycin waste, defined as disposed of unused daptomycin, at Harbor-UCLA Medical Center, a 400-bed Level 1 Trauma Center, from 1/1/2023 to 12/31/2023. We then adjusted dosing using a daptomycin dosing nomogram. We modeled the difference in daptomycin waste (mg of daptomycin disposed of unused), pharmaceutical waste (weight of excess daptomycin vials required due to wasted antibiotic), and cost between the two dosing strategies. Our model assumed a daptomycin vial weight of 16.8g and cost of $30 per 500mg daptomycin vial. We conservatively estimated pharmaceutical waste as waste only from daptomycin vials, ignoring all other supplies and materials necessary to prepare daptomycin. Results: During the 1 year time period at our Medical Center, 138,882mg daptomycin was wasted. This level of daptomycin waste equates 4671g excess pharmaceutical waste and $8332 spent on unused, discarded daptomycin. In our model, we found that nomogram implementation would have reduced mean monthly daptomycin waste from 11,002mg to 1387mg (p<0.001). This reduction would have decreased the proportion of daptomycin wasted from a mean of 19% to 3% of all consumed daptomycin (Figure 1). Nomogram use would also have saved $7333 and averted 4111g of pharmaceutical waste in 2023. Conclusion: A daptomycin dosing nomogram would have prevented 122,322mg of daptomycin from being wasted and saved over $7000 at a 400 bed Medical Center over one year. Given the 4111 g of pharmaceutical waste is a conservative estimate, and ignores waste from other supplies/materials as well as upstream waste and emissions from daptomycin manufacturing, the overall generated environmental impact prevented by nomogram use is likely significantly higher. Our findings demonstrate that intentionally designed dosing strategies aimed at reducing drug waste can save hospital costs and reduce the environmental footprint of clinical care. When implemented at large health systems these strategies are likely to result in substantial cost savings and reduction in the negative environmental impact associated with pharmaceuticals.

Background: Enhancing environmental hygiene resulted in a reduction of multidrug-resistant microorganisms colonization and healthcare-associated infections. There has been less studies to compare the effects of practice observation with other methods. This study aimed to compare correlations between visual inspection, practice observation and aerobic colony count (ACC) and verify the effectiveness. Methods: A prospective study was conducted in a medical intensive care unit from May 2021 to November 2022. High-touch surfaces were assessed by visual inspection (clean or not clean) and practice observation (compliant or not compliant) to compare the correlations by using ACC with the cut-off point of 2.5 CFU/cm2 as a golden standard. Results: Among 569 samples, the pass rate by ACC was 90.5%, the clean rate by visual inspection was 73.3%, and the compliant rate by practice observation was 47.1%. The concordance was 245 surfaces (43.1%) of the three methods. There was no correlation between visual inspection and ACC (p<0.001, φ=0.184). The correlations were weak positive between visual inspection and practice observation and between practice observation and ACC (p<0.001, φ=0.212, 0.233). The median aerobic colony count of “compliant” group (0.00 CFU/cm2) was significantly lower than “not compliant” (0.40 CFU/cm2) (p<0.001). The median aerobic colony count of “clean” groups (0.08 CFU/cm2) was also significantly lower than “not clean” groups (0.20 CFU/cm2) (p<0.001). Conclusion: Practice observation is more reliable than visual inspection. Therefore, visual inspection can be used for low risk area to maintain visibly clean. In high risk area, an integrated program is critical to combine practice observation with other methods to monitor cleanliness.

Background: The overuse of antimicrobials contributes to the development of antibiotic resistance, the development of Clostridioides difficile infections, and increased patient morbidity and mortality. The impact of U.S. News medical school ranking on provider antimicrobial prescription is largely unknown. Our study aimed to assess whether there was a relationship between graduating from higher-ranked medical schools and the rate of prescribing antibiotics among Medicare Part D providers in the US. Methods: The ecological study obtained data from the Medicare Part D Prescribers (FY2013-2021) and the Doctor and Clinicians National repositories. The study’s main outcome was antibiotic days supplied per 100 beneficiaries. Secondary outcomes included antibiotic claims per 100 beneficiaries, days per claim, and antibiotic cost per 100 beneficiaries. A regression model was fitted to assess the relationship between provider medical school ranking and study outcomes. The study controlled for several state, provider, and patient variables. Results: A total of 197,540 providers were included (Table 1). No association was found between the medical school ranking and the rate of antibiotics days supplied per 100 beneficiaries (Table 2, Figure). Instead, the type of provider is associated with the prescription rates. Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries than Family Medicine providers. In contrast, students, more experienced providers (>20 years since medical school graduation), and females had more days supplied per 100 beneficiaries. Higher-ranking medical schools [1, 35], EM providers and hospitalists (vs. FM), and academic locations had lower claim rates per 100 beneficiaries, while students and experienced providers had higher claims. Days per claim were higher among providers from higher-ranked medical schools, more experienced providers, students, and academic locations, whereas they were lower among males, EM Providers, and Hospitalists. Costs per 100 beneficiaries were higher among students, academic locations, IM providers, and males; however, it was lower among EM and hospitalists. Conclusion: Our study showed no impact of medical school ranking on the overall rate of outpatient antibiotic prescriptions among Medicare Part D providers. While the claim rate per 100 beneficiaries was lower among providers from higher-rank medical schools compared to other providers, claims were prescribed longer, leading to similar days supplied and costs compared with other providers. This highlights the need for robust outpatient stewardship interventions and incorporating an outcome-based approach to antibiotic stewardship curricula in medical and mid-level provider schools.

Background: Vietnam has the national guidelines for infection control in hospitals and it also recommends the application of WHO’s IPCAF framework to do self-evaluation of infection prevention and control (IPC) activities and plan to improve them in hospitals. Objective: Our study aimed to implement the multimodal strategy for IPC, in which our expected outcome was the practices of doctors and nurses for pediatric ventilator-associated events (Ped-VAE). Design: We used the implementation research approach with the hybrid design of quasi-experimental pre-post comparison without control group. All 16 doctors and 32 nurses at the Department of PICU were observed 3 times that practicing the IPC packages for PedVAE guided by MOH. The implementation strategies used included Plan, Restructure, Train, and Quality Management. Results: Four over six steps practised by doctors and 5/10 steps practised by nurses for PedVAE were well practised after the intervention with significantly higher proportion of right practices (p<0.001). The practices of doctors had insignificant changes between pre-post intervention, including hand hygiene (85.4% and 83.3% of right practice at pre-post intervention, respectively) and daily assessment of weaning from mechanical ventilation (54.2%-68.7%). Most unchanged practices among nurses were steps of ensuring humidification and heating of inhaled gas for in patients with artificial airway.

All practice scores of the whole steps among doctors and nurses had statistically significant increase after intervention. Our implementation strategies were highly assessed by providers (doctors and nurses) and hospital managers in terms of the its acceptibility, feasibility and sustainability. Conclusion: The implementation of multimodal strategy in IPC for pediatric ventilator-associated events is effective and acceptable and feasible for hospitals at city/province level in Vietnam. In addition with improving practices of healthcare staffs, hospitals should regularly assess and upgrade ventilators machines to ensure the effectiveness of IPC.

Objectives: Chronic wounds are commonly manifested with biofilms that result in delayed healing and recurring infection episodes. Due to increasing antimicrobial resistance, antiseptics have played a significant role in wound infection management. To date, there is no standardised method to assess the ‘true’ antimicrobial efficacy of different antimicrobials, especially in testing condition that stipulate a high protein environment in the wound. As clinicians often rely on the antimicrobial efficacy profiles for product selection, a rigorous testing is warranted. Hypochlorous acid (HOCl)-based solutions have been introduced as a good alternative for wound cleansing but the assessment of its antimicrobial activities in a stipulate wound environment is limited. In this study, we assessed the in vitro bactericidal activities of 7 commercially available wound irrigation products commonly found in South-East Asia. Method: The evaluation was conducted using quantitative suspension method, EN 13727 in either low or high protein conditions. Results: Under low protein conditions, four out of the five HOCl products achieved bactericidal activity (≥ 5 log10 reduction factor; RF) within 2 to 5 minutes, and only one product achieved 5 log RF at 15 seconds. None of the HOCl achieved 5 log RF under high protein, even after 30 minutes of exposure time. In contrast, protein interference on the antimicrobial activities of polyhexamethylene biguanide-based product is less pronounced (low protein: 60 seconds vs. high protein: 2 minutes to attain ≥ 5 log RF). Octenidine dihydrochloride is the only active not affected by protein interference achieving ≥ 5 log10 RF within 15 seconds in both low and high protein conditions. Conclusion: These findings warrant the need to screen antimicrobial wound care products, especially HOCl-based products, in high protein condition to better reflect the antimicrobial activities in wound care.