Inpatient antimicrobial stewardship (AMS) programs combat inappropriate antibiotic use, increased resistance, and adverse outcomes. However, stewardship monitoring is limited at transitions of care (TOC), especially for patients being discharged on parenteral antimicrobials. Additionally, discharge planning processes for these patients are often complex, prolonging length of stay (LOS). This highlights an opportunity to optimize outpatient parenteral antimicrobial therapy (OPAT) regimens following inpatient admissions.

To compare LOS in patients discharged with OPAT before versus after a stewardship initiative targeting TOC parenteral antimicrobial therapy (TOC-PAT).

Prepost cohort study.

Urban, non-teaching, community medical center.

Adult patients discharged or planned to be discharged on OPAT.

The AMS team developed a novel program monitoring patients being discharged on OPAT. Pharmacists were deployed to identify AMS intervention opportunities. This study evaluated outcomes before and after program implementation. The primary outcome compared inpatient LOS. The secondary outcome assessed antimicrobial appropriateness using the National Antimicrobial Prescribing Survey.

The pre- and postimplementation cohorts included 167 and 100 patients, respectively. There was no statistically significant difference in median LOS (9 [6, 13] vs 10 [6,15] days; P = .27). The proportion of appropriate regimens increased from 51.5% to 58%. A total of 68 pharmacist-led AMS interventions were made, 66% of which were accepted by treating teams, primarily modifications in antimicrobial choice and IV to PO conversions.

This study serves as a foundation for future OPAT and TOC-PAT stewardship programs. The results of this study highlight pharmacist impact in assessing OPAT regimens to increase antimicrobial appropriateness.

To characterize clinician approach to diagnosis and treatment of UTIs in outpatient men.

Cross-sectional survey.

Tertiary academic Veterans Affairs hospital.

Internal medicine, family medicine, emergency medicine, and urology clinicians surveyed between September 2024 and January 2025 (N = 206, 61% response rate).

Our survey assessed outpatient clinicians’ diagnostic and management decisions regarding UTIs in men, and we hypothesized these decisions would vary by clinician characteristics. We studied factors associated with 1) reliance on non-specific symptoms/signs to diagnose UTI, 2) clinician confidence in UTI diagnosis/treatment, and 3) choice of longer treatment duration (>7 days) via separate logistic regressions.

Most respondents relied upon non-specific symptoms such as cloudy (59%) and foul-smelling urine (63%). Emergency department clinicians were significantly more likely than outpatient internal medicine clinicians to view cloudy or foul-smelling urine as indicative of UTI (OR 4.07, CI 1.32–12.52, P = .01). Advanced practice professionals (APPs) were significantly more likely than attendings to identify cloudy (OR 3.62, CI 1.29–10.18, P = .02) or foul-smelling urine (OR 2.93, CI 1.05–8.22, P = .04) as indicative of UTI. Two factors were associated with clinician intention to treat for >7 days: less confidence in managing UTIs in men (OR 2.33, CI 1.01–5.56, P = .05) and belief that other clinicians treat for >7 days (OR 17.77, CI 6.55–48.17, P < .001).

APPs and emergency department clinicians were more likely to rely on non-specific symptoms/signs to diagnose UTIs in men. As less confident clinicians prescribe longer antibiotic durations, an improved evidence base of UTI management in men may decrease antibiotic use.

Healthcare-associated infections (HAIs) remain a major global public health challenge, with a disproportionately higher burden in low- and middle-income countries (LMICs), including Zambia, where infection prevention and control (IPC) systems face resource and capacity constraints. Effective IPC programs are essential for reducing HAIs, limiting the emergence and spread of antimicrobial resistance (AMR), and improving patient safety. This study assessed the implementation status of IPC programs in Zambian hospitals.

A descriptive multicenter cross-sectional survey was conducted from June 1–30, 2025, in 18 public hospitals across Zambia. The World Health Organization Infection Prevention and Control Assessment Framework (IPCAF) tool was used to evaluate IPC implementation across eight core components. Descriptive statistics and Welch’s independent-samples t-test were used to compare IPC implementation levels across hospitals.

The overall mean IPC score was 558 out of 800, indicating an intermediate level of implementation. Half of the hospitals (50%, n = 9) achieved advanced implementation, 39% (n = 7) intermediate, and 11% (n = 2) basic levels. Tertiary hospitals performed better than secondary hospitals (mean score 622 vs 507). The highest-scoring components were IPC programs (86%) and guidelines (88%), while the lowest were workload, staffing, and bed occupancy (60%) and IPC education and training (63%). Despite established IPC committees and guidelines, gaps remained in staff training, HAI and AMR surveillance, and infrastructure.

Most Zambian hospitals have achieved intermediate to advanced IPC implementation. However, sustained investment in workforce capacity, surveillance systems, and infrastructure is required to strengthen IPC practices and support national AMR containment efforts.

Healthcare-associated infections (HAIs) contribute substantially to morbidity and mortality among hospitalized neonates. Many hospitals have transitioned from the traditional open-bay NICU layout to single-family room (SFR) designs. However, evidence regarding the association between unit design and neonatal HAI incidence or microbial colonization remains limited and inconclusive.

We conducted a scoping review to evaluate the association between NICU design (SFR versus open-bay) and HAIs, to inform evidence-based design and infection prevention strategies.

In February 2025, we searched MEDLINE via PubMed for studies on neonatal unit designs. We included English-language studies that directly compared HAI or colonization outcome measures between open and SFR room designs in neonatal units. We excluded studies that did not assess neonates, were based on outpatient settings or non-neonatal wards, used animal models, only focused on impact on families and/or healthcare workers or were summary statements or reviews.

Our search yielded 610 studies, of which 45 progressed to full-text review; we ultimately included 10 studies in this review all of which utilized observational designs. Eight compared outcomes before and after moving to a new ward while two compared units within the same hospital. All but three included studies were from the United States. Studies assessed a variety of infection and colonization measures, including but not limited to sepsis, catheter-associated infections, and multidrug resistant organisms, with widely varying results.

The current evidence regarding the association between NICU design and HAIs is mixed and context dependent.

European carbapenemase-producing Enterobacteriaceae (CPE) screening guidelines recommend preventive contact precautions (PrevCP; contact precautions before screening test results) and rapid, sensitive screening for high-risk hospitalized patients (HRHP) upon hospital admission. This analysis assessed the cost impact of adopting on-demand molecular PCR CPE screening in HRHP versus current standard of care (SoC) in Spain.

Decision-tree model.

Spain.

HRHP defined as those admitted to high-risk units or with a history of previous admission(s) with detected CPE carriage.

SoC was defined as a weighted average of the strategies “PrevCP & Screen” by culture, “No PrevCP & Screen” by culture, and “No PrevCP & No Screen.” A decision-tree model was developed to quantify the cost of replacing current SoC with PrevCP+rapid PCR screening for all HRHP at admission. Additional screening strategies versus SoC were also analyzed. A time horizon of 60 days was considered, and the payer perspective adopted. Inputs were from the literature, co-authors’ own data, and expert opinion. Costs per hospital stay are reported per HRHP, in Euros 2024. Due to lack of robust evidence on nosocomial transmission costs, such costs were excluded from the analysis. Extensive sensitivity analysis was performed.

The average total cost/HRHP with SoC was 11,949€. Implementing screening for all HRHP with culture increased the average total cost/HRHP by 502€. However, implementing screening for all HRHP with PrevCP+rapid PCR, when compared with SoC, generated savings of 1,092€/HRHP.

Implementation of PrevCP+rapid molecular PCR screening for CPE in HRHP leads to cost savings in Spain.

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections. The existing literature has revealed several risk factors for the development of VAP, but only a few studies show an association between endotracheal tube (ETT) repositioning and a risk of VAP.

The Primary objective was to evaluate repositioning of ETT as a risk factor for ventilator-associated pneumonia in children admitted for more than 48 hours for non-pulmonary indications in the pediatric intensive care unit (PICU). The secondary objective was to assess the role of reintubation as a risk factor for VAP in the same cohort.

Hospital-based cross-sectional study.

Tertiary care facility equipped with pediatric intensive care.

Children aged less than 15 years.

Repositioning of ETT was done in 11 patients, of whom 8 had VAP. Patients with ETT repositioning had twice the odds of developing VAP, although this was not statistically significant (OR = 2.22; P = .2). Reintubation was done in 27 patients, out of which 22 (57.9%) had VAP (P < .001), and it increased the risk of VAP by 6.3 times (OR = 6.3; P < .001). Multivariate regression analysis revealed that reintubation was the only independent risk factor for the development of VAP.

Although our analysis did not find ETT repositioning to be an independent risk factor, the observed results indicate that it would be beneficial to look further in larger pediatric cohorts. These results need to be regarded as hypothesis-generating. Prevention of VAP is an important factor in decreasing morbidity and mortality.

Antimicrobial stewardship programs (ASPs) have been required in Canadian hospitals since 2013 to address antimicrobial resistance. We evaluated ASP structure, resourcing, and strategy implementation across Ontario.

We conducted a cross-sectional survey of inpatient hospitals (January–March 2026) in Ontario assessing funding and implementation of selected stewardship strategies. Results were summarized descriptively and stratified by hospital type and compared to national recommendations on resourcing.

Of 128 eligible hospitals, 93 (73%) responded, of which 89/93 (96%) reported having a formal or planned ASP. Designated funding was reported by 63%, varying by hospital type (89% of teaching vs. 21% of small hospitals). Among larger hospitals, the average ASP staffing was 0.19 pharmacist and 0.04 physician full-time equivalents (FTE) per 100 beds, below national recommendations of 0.3 pharmacist and 0.1 physician FTEs per 100 beds. Thirty-six percent (32/89) reported inclusion of goals to improve antimicrobial stewardship practices or antimicrobial use into the strategic or quality improvement plan. While 75% tracked hospital-wide antimicrobial use, only 44% routinely shared data with prescribers. Common strategies included antibiograms (84%), IV-to-PO conversion (67%), prospective audit and feedback (PAF) (65%), and facility-specific guidelines (62%). Newer interventions included allergy assessment (46%) and clinical decision support (50%). PAF varied considerably in scope, frequency, and target populations, with lower uptake and greater variability in smaller hospitals.

Ontario hospital ASPs are advancing in areas such as allergy assessment and clinical decision support; however, under-resourcing continues to be a significant challenge. Greater investment and system-level support are needed to meet evolving standards and optimize impact.

Identifying non-prescriber-related factors related to antibiotic consumption is a critical first step to increasing confidence in surveillance results and targeting audit and feedback interventions.

This study analyzed data from 11,402 patients hospitalized across 3 internal medicine departments between January 2020 and November 2021. The outcome variable was the proportion of patients treated and the daily days of therapy (DOT) per 100 hospitalization days (HD). Independent variables included demographic data, admission laboratory results, nursing assessments (dementia, bedridden status), a chief complaint of fever, bacteriuria, and a discharge diagnosis of infection. A multivariate logistic regression model was developed using 2020 data and validated with 2021 data to determine factors associated with antibiotic consumption.

The cohort had a mean age of 73 ± 18 years, and 43.0% of patients received antibiotics, resulting in a consumption rate of 51.8 DOT per 100 HD. Significant predictors included a discharge diagnosis of infection, chief complaint of fever, elevated white blood cell count and neutrophil proportion, bacteriuria, and short or prolonged hospital length of stay. The model in 2020 was confirmed in 2021 and achieved a C-statistic of 0.907 (0.902–0.912).

Adjusting for non-modifiable patient factors establishes a more accurate baseline for surveillance, increases the reliability of clinical performance audits, and suggests targets for intervention. Although the model demonstrated high predictive power, these results require validation in other clinical settings.

Examine randomized-controlled trials (RCTs) that form the evidence basis for chlorhexidine to evaluate industry influence on trial outcomes and conclusions.

Cross-sectional study.

RCTs in humans from January 2000 to March 2024 evaluating chlorhexidine for preventing healthcare-associated infections.

We analyzed trials to determine if investigator conflicts of interest (COI) or industry funding were associated with favorable outcomes. Predictors were trial funding by a chlorhexidine manufacturer or reported investigator COI. Primary outcomes were primary result favoring chlorhexidine and/or conclusion favoring chlorhexidine.

Among 172 trials, industry funding (n = 44) was associated with the primary result (n = 30/44) favoring chlorhexidine (univariate analysis odds ratio (OR) 2.73 [95% CI 1.24–6.01, P = .01]; multivariate OR 2.85 [95% CI 1.15–7.02, P = .02]) and the conclusion (n = 33/44) favoring chlorhexidine (univariate OR 2.92 [95% CI 1.28–6.68, P = .01]; multivariate OR 3.25 [95% CI 1.24–8.54, P = .02]). Investigator COI (n = 28) was associated with the primary result (n = 20/28) favoring chlorhexidine (univariate analysis odds ratio 2.77 [95% CI 1.10–6.93, P = .03]; multivariate OR 2.36 [0.81–6.88; P = .10]) and the conclusion (n = 21/28) favoring chlorhexidine (univariate OR 2.40 [0.93–6.21, P = .07]; multivariate OR 2.32 [0.77–6.99; P = .12]), which was not statistically significant.

Trials funded by chlorhexidine sponsors were more likely to report favorable outcomes compared to trials not funded by chlorhexidine sponsors, suggesting an industry bias that may have influenced these trials.

We examined five common targets for diagnostic stewardship that have been associated with improved patient outcomes. For each, we estimated the financial and reputational impact of each intervention on a typical 200 bed community hospital. These estimates can be adjusted for individual hospital estimates.

We found consistent savings and potential improvements in hospital metrics associated with these different diagnostic stewardship interventions. Clostridioides difficile (CDI) diagnostic stewardship showed ＄125,617 expected savings plus a likely additional 75% reduction in the hospital-acquired condition (HAC) CDI metric. Urine culture stewardship showed ＄34,111–＄92,361 in savings with an additional 30% reduction in the HAC catheter-associated urinary tract infection metric. Procalcitonin de-implementation showed ＄78,938 expected savings from test discontinuation. Expanded respiratory pathogen panel stewardship showed ＄383,650–＄668,000 in savings, depending on degree of reduction and replacement with focused viral testing. Blood culture stewardship showed ＄1,860,800 in savings with an additional 33%–80% reduction in HAC central line associated bloodstream infection and MRSA bacteremia metrics.

In total, a 200-bed hospital implementing all five interventions could expect an approximate ＄2,482,616–2,825,216 in laboratory and clinical savings. These interventions would also improve many HAC metrics, providing an additional ＄200,000–＄600,000 in savings, depending on baseline performance. Finally, reputation metrics, such as Leapfrog grades, would also improve.

To optimize the appropriateness and timing of healthcare associated infection (HAI) time frame Clostridioides difficile (CD) testing and reduce misdiagnosed CD HAIs (CDIs) in pediatric patients.

Two phases of interventions were implemented in a tertiary pediatric acute care hospital. Daily batch testing for CD was introduced in 3/2023 to allow for prereview of CD orders falling in the HAI-time frame. Electronic medical records (EMRs) were reviewed to determine appropriateness using standardized criteria. Discussions were held with providers when testing was deemed inappropriate; testing was canceled if they agreed with reviewer’s feedback. Automated hard stops on CD ordering began in 2/2024 for patients receiving laxatives or enemas within 24 hours prior to test order. EMR pop-up messages prompting consideration of CD testing were initiated May 2024 for patients admitted with diarrhea. Pre and postintervention outcome data were compared.

From 4/1/2023 to 12/31/2025, 476 pending CDI tests were reviewed; 31.5% were deemed inappropriate; 69% of these were canceled. Thirteen percent of 400 completed HAI-time frame orders (including reviewed and unreviewed orders) were positive. Average monthly completed HAI tests and CDI rate decreased postimplementation of daily review protocol (P < .0001, and P = .153, respectively). Further significant decreases in average monthly completed HAI tests and CDI rate were observed following automated reduction initiatives (both P < .0001) compared to preimplementation period. Average standardized infection ratio for CD decreased with each implemented intervention.

Reduction of inappropriate testing and reduction of CDIs following this bundle implementation is evidence for effectiveness of daily review and automated initiatives.

To evaluate the clinical and safety outcomes associated with withholding empirical anti-MRSA therapy in patients with ventilator-associated pneumonia (VAP) whose endotracheal aspirate Gram stain showed no gram-positive cocci in clusters.

Post hoc analysis of the multicenter randomized controlled GRACE-VAP trial.

Intensive care units (ICUs) at 12 tertiary referral hospitals in Japan.

Patients enrolled in the GRACE-VAP trial with suspected VAP whose endotracheal aspirate Gram stain showed no gram-positive cocci in clusters.

Outcomes were compared between patients who did not receive empirical anti-MRSA therapy and those who did. The primary outcome was clinical response at day 7 after completion of antibiotic therapy. The association between empirical anti-MRSA therapy and clinical response was evaluated using multivariable logistic regression adjusting for age, Sequential Organ Failure Assessment score, and prior antibiotic therapy. Secondary outcomes included 28-day mortality, ventilator-free days, ICU-free days, and safety outcomes.

Seventy-four patients met the inclusion criteria; 37 received empirical anti-MRSA therapy, and 37 did not. In the primary multivariable analysis, empirical anti-MRSA therapy was not significantly associated with clinical response (adjusted odds ratio, 0.99; 95% confidence interval, 0.27–3.67). No significant differences were observed in secondary or safety outcomes.

Among patients with VAP without GPC clusters on Gram staining, empirical anti-MRSA therapy was not associated with improved clinical outcomes or an increased incidence of adverse events.

Diabetic foot infections (DFIs) are a major cause of hospitalization and antibiotic use, yet variation in diagnostic sampling and empiric therapy persists. We evaluated microbiologic findings and antibiotic utilization in hospitalized patients with DFIs over a five-year period.

We conducted a retrospective cohort study of adults hospitalized with diabetic foot ulcers who received systemic antibiotics at Montefiore Medical Center (Bronx, NY) from 2016–2021. We assessed timing of wound culture collection, microbiologic results, and antibiotic use. Associations between time to culture and length of stay (LOS), and temporal trends in prescribing, were analyzed using linear regression.

Among 637 patients (mean age 59 ± 13 years; 70% male; 53% Hispanic), median LOS was 7 days (IQR 4–11). Wound cultures were obtained in 450 patients (71%), typically on hospital day 1 (IQR 0–2). Time to first culture was positively associated with LOS (Pearson r = .47, P < .001) with each additional day associated with 1.18 day increase in LOS (P < .001). Methicillin susceptible Staphylococcus aureus (MSSA) and Streptococcus species predominated in wound cultures, while methicillin resistant S. aureus (MRSA) and Pseudomonas aeruginosa were each identified in <10% of cases. Among patients with blood cultures, 26% had bacteremia, most commonly MSSA and MRSA bacteremia occurred in 6.5%. Despite this, empiric anti-MRSA and antipseudomonal therapy were initiated in 91% and 80% of patients, respectively. Over the study period, vancomycin use declined (P < .01), and the use of non-antipseudomonal cephalosporins increased (P = .04).

In this large cohort of hospitalized patients with DFIs, MSSA predominated and resistant organisms were infrequent; however, empiric broad-spectrum antibiotic use was common. Earlier culture acquisition and alignment of empiric therapy with local microbiologic epidemiology represent key opportunities for antimicrobial stewardship.