Background: Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes serious, difficult-to-treat infections in hospitalized patients. C. auris cases in the United States have been linked to receipt of healthcare overseas. Outbreaks have also occurred in New York City, New Jersey, Illinois, Nevada, and California. We provide care to patients from all 50 states and 138 countries and are therefore, at risk for encountering C.auris within our facility. Methods: A case-finding tool was created by Infection Prevention and Control (IPAC) within the electronic medical record (EMR) to identify patients for screening. Inclusion criteria was centric to patients who were admitted in the previous 24 hours with a primary address in a foreign country or in areas of the United States with known C. auris transmission. Patients who are positive for Carbapenamase-producing organisms (CPO) are also included in screening criteria. In 2020, Clinical Microbiology validated a polymerase chain reaction (PCR) test in partnership with the State Health Department and IPAC. In January 2022, IPAC created a protocol that allows IPAC staff to order C. auris screening directly in the EMR utilizing the validated PCR test. The order is paired with communication from IPAC alerting the patient care team that C.auris screening is indicated. Instructions on test collection and information on C. auris are also included in messaging. The patient’s primary nurse then obtains verbal consent from the patient to collect a composite axilla–groin skin swab. Swabs are sent to Clinical Microbiology for testing, and results are reported directly into the EMR. Results: Since the introduction of the nursing protocol in January 2022, 2,660 patients have been identified for C. auris screening through November 2025. Of the 2,660 patients identified for testing, 1,111 patients had screening completed. Two patients tested positive for C. auris on screening. Both patients had prolonged travel to regions with known C. auris transmission. Conclusion: The EMR can be leveraged for early identification and screening of patients at risk of C.auris colonization. Case finding tools, combined with nursing protocols and communication strategies within the EMR can be effectively replicated and modified to respond to emerging infections.

Background Illinois has one of the highest regional Candida auris burdens nationwide. Our hospital has a surveillance protocol for Candida auris that dictates all patients with an admission in the prior 6-months to a skilled nursing facility (SNF), long-term acute care hospital (LTACH), and/or inpatient rehab (IR) be tested on hospital admission. Additionally, three high-risk units at our institution have an increased surveillance protocol that includes testing all patients on admission, transfer, and weekly for C. auris. Two years of first-positive C. auris cases were reviewed to investigate if our surveillance protocol was capturing all patients with C. auris present on admission. Method A retrospective chart review was conducted using our electronic database and medical record (EMR). All admitted inpatients between January 1, 2023 to December 31, 2025 with a first-positive Candida auris laboratory specimen were included. Prior positive laboratory tests and outside facility encounters or transfers were manually reviewed from the EMR. Results A two-year data review identified 121 unique patients with positive Candida auris clinical or surveillance results. Of the 121 patients, 99 (81.8%) had no documented history (NDH) or prior positive laboratory results for C. auris. These cases were categorized as hospital onset (HO) 74/99 (74.7%) or present on admission (POA) 25/99 (25.3%). Of the 25 POA/NDH patients, 14 (56%) were directly admitted from a SNF, LTACH, or IR. Of the 25 POA/NDH patients, 17 (68%) had exposure to SNF, LTACH, and/or IR in the 6 months prior to admission. There were 8/25 (32%) patients admitted directly from home or outside hospital (OSH) and had no SNF, LTACH, or IR admissions 6 months prior. These 8 patients did not qualify for surveillance testing when screened for admission. Of the 8 patients, 6 (75%) had an admission to an OSH in the 6 months before surveillance screening. Conclusion The 8 POA/NDH cases without exposure to SNF, LTACH, or IR raise the question of whether including OSH encounters into our screening questionnaire could increase the accuracy of our C. auris surveillance protocol. We have demonstrated that exposure to SNF, LTACH, and IR is a risk factor. Other regional hospitals should be encouraged to evaluate or begin surveillance protocols to help define whether hospital admissions are a risk factor for C. auris acquisition. Validating the accuracy of risk factors will help us better understand the epidemiology of C. auris and potentially prevent HO transmissions from missed POA cases.

Background: Rates of Candida auris are rising across the US, particularly in New York. Due to C. auris’ affinity for environmental contamination and prolonged skin colonization, rapid implementation of comprehensive infection prevention & control (IP&C) measures is essential. Given the complexity and multidisciplinary involvement required for these efforts, we developed the C.A.R.E (Candida Auris Response & Engagement) framework in response to an inpatient outbreak to guide multidisciplinary efforts and provide a model for other facilities facing similar challenges with C. auris or other pathogens with extensive contact transmission. Methods: A C. auris cluster was identified in an 862-bed New York City academic medical center between July and October 2025. 23 cases were found involving a medical stepdown unit and adjacent intensive care unit. Baseline IP&C C. auris efforts include isolation precautions (gown and gloves), twice-daily room cleaning/disinfection, dedicated equipment, ATP testing of high touch surfaces (HTS) post terminal room cleaning, observations of personal protective equipment (PPE) use and hand hygiene, and screening of exposed roommates. After an August point prevalence surveillance (PPS) identified additional cases, we expanded interventions across various categories. The C.A.R.E. framework (Fig. 1) summarizes baseline and expanded efforts during this cluster. Figure 1. The C.A.R.E. (Candida Auris Response & Engagement) Framework to approaching a rise in C. auris cases. Results: Of 23 cases, 83% (19/23) were detected through surveillance. Clinical cases included bloodstream (3/4) and respiratory (1/4) sources. Shared rooms, either roommates or subsequent room occupants, were associated with 52% (12/23) of cases. Following implementation of the C.A.R.E. framework, further transmission ceased, confirmed by two negative rounds of PPS on each unit (Fig. 2). Figure 2. A timeline of C.auris cases identified on 2 units with corresponding IP&C effort implementation. To address identified gaps, a C. auris task force was created to improve IP&C processes. Key actions included clarifying equipment cleaning responsibility in collaboration with Environmental Services and Nursing, reevaluating the C. auris isolation category, and expanding screening for high-risk patients. Further, we incorporated fluorescent marker audits alongside ATP testing into routine practices to monitor environmental and equipment cleaning. While not all measures in the C.A.R.E. framework may be needed for every outbreak, facilities can adapt and scale interventions based on feasibility and outbreak severity. Conclusions: Effective prevention of C. auris transmission requires coordinated and multidisciplinary efforts. Establishing a structured response after early case detection can help close gaps in infection prevention that contribute to spread.

Introduction: NDM-producing Carbapenem-resistant Acinetobacter baumannii (CRAB) is an emerging concern globally due to extensive antimicrobial resistance and high mortality, although less common in the United States. We describe the epidemiology of this pathogen at our academic medical center over a 5-year period. Methods: Observational study and epidemiologic investigation at two campuses (800-bed hospital (“A”) including 7 adult ICUs and 144-bed hospital (“B”) including 1 ICU and 1 long-term post-acute unit) with patient-sharing. Patients with CRAB in clinical or surveillance cultures from January 2021 to April 2025 were included. Active surveillance was conducted in select units using rectal swabs, and available isolates underwent genomic sequencing. Results: We identified 13 unique patients with 61 NDM-CRAB clinical (7 [11%]) or surveillance (54 [89%]) cultures. Two of 10 colonized patients subsequently developed clinical infection. NDM-CRAB constituted 25% of all sequenced CRAB isolates during this time. Among the 13 patients, median age was 62 years, 6 (46%) were female, all had prior healthcare exposure and 10 (77%) had colonization or infection with other multidrug-resistant organisms (MDROs). None reported international travel. Nine patients (69%) had prior exposure to carbapenems, 9 (69%) had central venous catheters, and 7 (54%) required mechanical ventilation. Sites of infection included pneumonia, urinary tract, and wound. Following sporadic cases from 2021-2023, a cluster of 2 cases occurred on the post-acute unit in 2024 followed by a prolonged outbreak (n=10) detected via weekly rectal surveillance cultures (Figure). With the exception of the index case, all other post-acute unit outbreak cases had a prior negative surveillance screen, suggesting transmission among long-stay patients. Observations revealed suboptimal environmental surface-cleaning and deficiencies in use of personal protective equipment. No additional cases were identified on other units including ICUs undergoing routine weekly surveillance. Twenty-five NDM-CRAB isolates underwent genomic sequencing. All belonged to the same A. baumannii multilocus sequencing typing (MLST) lineage (STPas2, STOxf 218/2164). Long-read sequencing of select isolates identified blaNDM-1 and blaOXA-23 integrated in the chromosome. Notably, one isolate additionally acquired blaOXA-72 on a r3-T60 Acinetobacter plasmid, suggesting continuing genetic evolution. Conclusion: Over a 5-year period, we found NDM-CRAB transmission in a post-acute care unit within an acute care hospital, among long-stay patients with invasive devices and antibiotic exposure. We did not observe sustained transmission in other parts of the hospital, underscoring the contribution of long-term acute care in MDRO dissemination. Genomic analysis helped distinguish this cluster from other non-NDM CRAB cases, supplementing epidemiologic findings.

Background: Candida auris (C. auris) is an emerging pathogen that is often resistant to antifungal treatments and is exceptionally transmissible in the healthcare environment. C. auris colonization confers risk for invasive infections, such as bloodstream infections, surgical site infections and hardware-associated infections. Further, colonization or infection frequently delays or disrupts access to various healthcare venues. Infection prevention (IP) measures including strict contact isolation, specific cleaning and disinfection protocols, and surveillance testing are commonly used strategies to decrease the risk of C. auris transmission. Early identification of patients with C. auris is critical to prevent transmission in the healthcare setting. Methods: PCR-based C. auris surveillance testing via surface E-swab of the axillae and inguinal folds was implemented in April 2024 at our large midwestern academic hospital. Testing strategies include Ring Surveillance (targeting patients admitted to adjacent rooms of index patients with C. auris), Travel Screening (i.e., recent hospitalization outside the U.S.), and long-term accute care (LTAC) Screening (targeting recent admission to a long-term acute care or inpatient rehabilitation/nursing facility). A retrospective review of adult patients who underwent C. auris surveillance testing between May 1, 2025 – October 31, 2025, was performed. Patient demographics (sex, race, ethnicity, mean age at admission) were analyzed along with admission source, comorbidities, and admission diagnosis. Patients with positive results were compared based on testing indication; specifically, those tested as part of Ring Surveillance and those tested on admission due to Travel or LTAC Screening. Results: In the 6-month study period, 4624 patients were tested for C. auris and only 170 (0.6%) had positive results; 118 through ring surveillance and 52 found with an admission testing indication. Positive patients had a mean age was 59 years old and 67% identified as male. 73.5% of positive patients were hospitalized within the last 6 months. Conclusions: Prevention of C. auris transmission in the healthcare setting remains an IP challenge. The prevalence of C. auris was low in our cohort of patients who were primarily tested as part of a Ring Surveillance program. Development of a predictive model to optimize early identification of patients colonized with C. auris is important to guide surveillance testing and decrease transmission risk to other patients in the healthcare setting.

Background: Mycobacteria are widely distributed in the environment, and colonization of medical devices using water poses a risk in healthcare settings. Hospital outbreaks linked to ventilators and extracorporeal systems have been reported. At our hospital, dental unit water is routinely cultured every three months. In January 2024, unexpected mycobacterial detection prompted an investigation of dental unit waterlines, tanks, and water sources. Objective: To investigate the presence of mycobacteria in dental unit waterlines and evaluate clinical implications. Methods: Water samples (300ml) from six dental unit waterlines were tested by culture before and after changes in flushing frequency, heater use, and filter replacement. Additional samples from the hospital annex water tanks, main building tank, and nearby parks sharing the same water source were analyzed. Results: Mycobacteria were isolated from all six dental unit waterlines, including M. frederiksbergense, M. chelonae complex, M. mageritense, and M. mucogenicum/phocaicum, with concentrations up to 25 CFU/mL. Increasing flushing from weekly to daily and discontinuing heater use did not eliminate contamination. However, quantitative cultures after filter replacement showed marked reduction, with most lines becoming negative or <0.5 CFU/mL. Mycobacteria were also detected in external water sources: annex water tank (10 CFU/mL), main building tank (<2.5 CFU/mL), and nearby parks (<5 CFU/mL). These findings suggest mycobacteria are not unique to dental units but are ubiquitously present in tap water. Discussion: Detection in both dental units and external water sources indicates widespread colonization rather than isolated contamination. Filtration proved effective in significantly reducing mycobacterial load, emphasizing its role in infection control. Given the pathogenic potential of environmental mycobacteria, especially in immunocompromised patients such as those with neutropenia or hematopoietic cell transplantation, exposure via dental unit water may carry clinical risks. For these patients, use of sterile water instead of tap water during dental treatment is strongly considered. Conclusion: Mycobacteria are present in tap water and dental unit waterlines. Filter replacement effectively reduces contamination. Strict precautions, including sterile water use, are warranted to protect vulnerable patients from opportunistic mycobacterial infections.

Background: Candida auris (C. auris) is a pathogen that causes high morbidity in patients due to its resistance to antimicrobials. Endemic patient colonization poses an infection risk that may be mitigated by no touch disinfection systems through interruption of the infection chain reservoir step. We evaluated the efficacy of continuous dry hydrogen peroxide (DHP) exposure on C. auris hospital onset colonization to evaluate the interruption of the transmission post hospital admission. Methods: The study was conducted in two intensive care units within a large tertiary-care center from October 2024 to January 2025. DHP-emitting systems were installed in the Medical Intensive Care Unit (MICU) HVAC system. Trauma Surgical Intensive Care Unit (TSICU) had no DHP installed. Admission and post admission testing was completed on all patients present in both units. All non-positive patients were tested twice per week and removed from testing if positive. Presence of C. auris was determined by polymerase chain reaction (PCR) from composite swabs from axillae and groins. Patients were screened for C. auris risk factors according to a standard risk assessment (Figure 1). The study goal was to determine if there was a statistically significant difference (PC. auris days to critical care days for TSICU and MICU patients with hospital-onset C. auris using the N-1 Chi-squared test (proportion comparison). Results: Risk assessments for MICU (268) and TSICU (297) were evaluated. The MICU population showed a higher risk for C. auris in each category compared to TSICU (Figure 1). MICU had double the dialysis, triple the admissions from group environment, and 5 times more wounds present on admission. The length of stay in TSICU was about 2.3 days less than MICU. There is a statistically significant difference (PC. auris days to critical care days for TSICU and MICU. No adverse effects were reported by patients, visitors, or personnel associated with the DHP systems. Conclusion: This study demonstrates that DHP was effective in reducing the proportion of hospital-onset C. auris colonization when comparing the MICU (DHP installed) to the TSICU (without DHP). This effect was observed despite the MICU having a longer average length of stay and a higher percentage of patients with known risk factors for C. auris. The findings support DHP as a valuable no-touch disinfection method. Figure 1: Risk assessment results by location, MICU or TSICU

Background: There is an increased recognition of importance of quality of environmental cleaning services and its impact on hospital associated infections rates in healthcare facilities. In the era of growing prevalence of multidrug resistance organisms, a strong focus on high environmental services becomes even more important. From January 2024 to December 2024, our 400-bed acute care hospital with single patient room design located in capital of Slovakia has implemented a digital assessment tool of quality environmental cleaning services and measured its impact on hospital associated infections (HAI) rates. Methods: During a calendar year of 2024, two-hundred inpatient rooms were marked with fluorescent marker, fifty per quarter. These rooms were in adult intensive care unit and neonatal intensive care unit, general inpatient units, labor and delivery and mother and baby units. There were pre-defined 8 high touched surfaces marked in general inpatient rooms with 6 additional high touched surfaces in adjunct bathrooms and 10 high touched surfaces marked in intensive care unit’s patient rooms. The presence of fluorescent markings was evaluated using torch 24 hours after cleaning was performed and reported in digital tool downloaded on a mobile phone that provided almost real time data analysis of quality of cleaning based on the percentage of cleaned surfaces, by hospital, by units as well as by type of high touched surfaces. At the end of each quarter, results were discussed with units’ leadership and environment of care manager with quality improvement plan creation and implementation. Due to resource constraints, HAI surveillance relied on point prevalence surveys conducted in December 2023 and December 2024 rather than continuous incidence-based surveillance. Results: Our goal was to achieve 80% of effectively cleaned high touched surfaces, showing no residuals of fluorescent marking. The environmental cleaning quality improved substantially, with adequately cleaned surfaces increasing from 40% in first quarter to 82% in fourth quarter. HAI prevalence decreased from 6.30% (13/202 patients) in 2023 to 5.43% (11/206 patients) in 2024, representing a 0.87 percentage-point absolute reduction (13.8% relative decrease). This difference was not statistically significant (Fisher’s exact test, p ≈ 0.66). Conclusions: The limited sample size inherent to point prevalence methodology likely reduced statistical power and although the reduction in HAI prevalence did not reach statistical significance, we believe that the direction and magnitude of change, together with a marked improvement in environmental cleaning performance, proves a clinically meaningful reduction in HAI burden and increasement in patient safety.

Background: Building water systems are known reservoirs for Legionella species, which can lead to healthcare-acquired infections, particularly among immunocompromised patients. Ice machines present complex internal surfaces and components that can support biofilm formation, which makes remediation challenging. This study evaluated the number of mitigation cycles required to eliminate Legionella from hospital water sources, with a focus on ice machines. Methods: A retrospective review of environmental Legionella testing from 2024-2025 was conducted. This included positive results identified from ice machines, sinks, and showers through routine surveillance and outbreak investigations. For each contaminated source, the number of mitigation cycles required for each source to achieve negative results was assessed. A total of 18 ice machines and 25 sinks and showers that tested positive for Legionella species were included in the analysis. Results: A total of 367 water sources were sampled during the study period, including 55 ice machines and 312 sinks and showers. 25 sinks and showers tested positive (8% of total samples) over a two-year period and required a mean of 1.66 mitigation cycles, with no fixture requiring more than five cycles to achieve negative results. In comparison, 18 positive ice machines (33% of total samples) required a mean of 2.67 mitigation cycles to achieve negative Legionella results, with one machine requiring eight cycles. Overall, the ice machines required, on average, one additional mitigation cycle to achieve negative results compared to the sinks and showers. ANOVA testing revealed no statistically significant differences in the number of cycles to clear Legionella between the different sources (F(2,40)=2.65, p=0.083). Conclusion: Ice machines demonstrated a higher frequency of persistent Legionella positivity and required more remediation cycles compared with sinks and showers. While the results were not statistically significant, additional data may demonstrate clearer differences in Legionella clearance across different sources. The persistent positive ice machines prompted implementation of an enhanced sanitization process beyond manufacturer recommendations. This highlights the challenges associated with biofilm control in these devices. Standard cleaning practices based on ice machine manufacturer’s instructions for use (MIFU) may be insufficient at eliminating contamination. These findings support the need for enhanced mitigation strategies and routine environmental surveillance.

Background: Healthcare environmental services (EVS) staff play a critical role in infection prevention and control (IPC) through environmental cleaning and disinfection. However, EVS staff are often excluded from structured, role-specific IPC education. Insufficient IPC knowledge among EVS staff may compromise environmental hygiene and increase the risk of healthcare associated infection transmission. This study aimed to assess IPC knowledge and education needs among EVS staff to provide an evidence-based foundation for targeted IPC education programs. Methods A descriptive cross-sectional study was conducted among EVS staff at a tertiary-care university hospital in Seoul, Republic of Korea. Participants completed a self-administered questionnaire assessing demographic characteristics, IPC knowledge, and perceived IPC education comprehension (current level) and education need (required level). IPC knowledge was measured using a 20-item instrument developed based on national IPC guidelines. Education needs were analyzed using the Borich’s needs assessment model and the Locus for Focus model to identify priority education topics. Descriptive statistics and nonparametric analyses were performed. Results A total of 81 EVS staff participated. The median IPC knowledge score was 17.0 (IQR, 16.0-18.0) out of 20. Notably, despite the high overall score, critical knowledge deficits were identified in high-risk IPC areas, including personal protective equipment (PPE) doffing protocols after cleaning an isolation room (42.0% correct) and management of infectious medical waste (17.3%). Education comprehension scores were lowest for management of suspected infection in staff, blood spill disinfection, and the safe use of disinfectants, whereas education need scores were highest for PPE related to various transmission-based precautions, as well as responses to needlestick injuries. Needs assessment using the Borich and Locus for Focus model identified procedures for managing suspected infection in staff (Borich score, 2.47), PPE for airborne precaution (2.00), and PPE for contact precaution (1.94) as the highest-priority IPC education topics, all of which were located in the high importance–high discrepancy (HH) quadrant; needlestick injury management and blood spill disinfection were also identified as high-priority areas. Conclusions Despite relatively high overall IPC knowledge, EVS staff demonstrated significant knowledge–practice gaps in high–risk IPC practices and expressed a substantial need for clearer guidelines essential for self-protection. The discrepancy between current understanding and perceived educational needs underscores the importance of structured, role–specific IPC education. Targeted IPC education programs focusing on isolation precautions, PPE donning and doffing, and occupational exposure management are crucial to enhancing both staff safety and the integrity of hospital-wide infection prevention.

Background: Environmental hygiene (EH) plays a critical role in reducing healthcare-associated infection (HAI) risk, yet significant variability persists in hospital patient room cleaning and disinfection. While discharge cleaning compliance is frequently studied, real-world practices during daily occupied patient room cleaning remain poorly characterized. Furthermore, the time to complete Environmental Services (EVS) tasks is rarely reported in published literature, despite being linked to budget, facility throughput, and patient and employee satisfaction. Researchers conducted a multi-hospital, observational study about environmental cleaning processes. Methods: Across 3 large (<500 beds) teaching hospitals in 3 distinct US regions, researchers shadowed EVS technicians during daily and discharge patient room cleaning across diverse ward types. Direct practice observations documented total turnover time, time to complete tasks such as cleaning the patient and bathroom room surfaces, floor mopping and non-disinfection tasks using a standardized data collection tool (Figure 1). Cleaning compliance was also measured via visual assessment, defined as wiping a surface with a disinfectant wipe or cloth. Results: A total of 638 daily and 91 discharge cleans were evaluated. The average occupied daily room turnover time was 9 minutes. However, square footage, isolation needs, in-room equipment and EVS expectations varied across unit types and individual facilities. For daily occupied room cleaning, on average, more time was spent on non-disinfection tasks like removing waste, refilling consumables and patient engagement (see Table 1). High-touch surface (HTS) cleaning compliance during daily cleans was low (38–48%), whereas floor mopping occurred in <90% of rooms. Site Z spent approximately twice the average time performing a daily room clean compared to Sites X and Y, however, did not achieve greater than 50% HTS cleaning compliance. Discharge cleaning demonstrated markedly higher HTS compliance (87–92%) and longer average duration (Table 2). Conclusion: To date, EH research has been focused on cleaning compliance measured by fluorescent marking, ATP swabbing and/or environmental culturing. Less research, however, is available regarding daily occupied patient room cleaning and the time and resources needed to do it successfully. Our research revealed that EVS technicians across 3 large hospitals spent an average of 9 minutes on daily room cleaning and only a third of that time spent using a disinfectant. Many healthcare disinfectants used by EVS have a contact time of 5 minutes or more. Healthcare leadership should have realistic expectations of what can be accomplished in budgeted cleaning time and the impact of time on disinfectant efficacy, regulatory compliance and infection prevention.

Background: Recent research has investigated the role of sinks (including sink taps, filters, water traps, etc.) in the spread of multidrug-resistant organisms (MDROs) and other pathogens. As part of a larger study on hand hygiene (HH) and personal protective equipment (PPE) adherence, we explored healthcare professionals’ (HCP’s) interactions with water and wet surfaces during patient care processes in intensive care units (ICUs). Methods: We conducted ethnographic observations of HCP’s patient care processes in the medical and surgical ICUs of a large academic hospital, and we conducted mini-interviews (~ 3-7 minutes) with a subset of these HCP. Observations focused on HH and PPE adherence during contaminating tasks. We also captured additional relevant data (e.g., room layouts, care activities, fomite/device interactions). We documented observations and interview responses in fieldnotes that we imported into MAXQDA qualitative software and coded activities using a combined deductive-inductive approach. We conducted data collection and analyses iteratively, with early analysis informing later data collection. HCP interactions with water emerged inductively as a topic of interest during this process. Results: Between 3/2022-5/2023, we observed 104 HCP engaged in patient care and conducted 31 mini-interviews. Interactions with sinks and sink-adjacent counters were common. We observed HCP placing pillows and other items on wet counters, water remaining in sinks after use, HCP contacting water droplets on sink walls and counters, and HCP setting items (e.g., IV bags, used towels) in the sink that they later carried to trash or laundry bins. HCP also leaned against surfaces, including sink-adjacent counters and patient-adjacent areas (e.g., beds, bed rails). Such activities could transfer contaminated water droplets to HCP’s clothing, floors, or other surfaces. We also observed water splashing due to sink design or the water pressure when HCP did activities like filling drinking cups or rinsing containers. During mini-interviews, HCP discussed their preference for soap-and-water handwashing (versus hand sanitizer) in specific situations, which they often performed at the same in-room sinks they used during patient care activities as outlined above. Splash back from sink drains could spread pathogens to HCP’s hands. Conclusion: Our study focused on HH and PPE adherence, therefore, we did not systematically collect observations on water in ICUs. Nonetheless, we observed HCP interacting with sinks, water, and wet surfaces in ways that highlight the potential for water-borne pathogen transmission. Infection prevention programs and hospitals should consider these interactions when developing infection prevention guidelines and designing construction and renovation projects.

Background: Sinks in hospital patient rooms are potential reservoirs of hospital acquired infections (HAI) pathogens and outbreaks; sink colonization can occur in new buildings soon after patient occupancy and persist. To control this source, it is important to understand how occurrence and concentrations of organisms in sinks and drains change over time. This study longitudinally measures the occurrence and concentration of Acinetobacter, Pseudomonas aeruginosa, and Klebsiella pneumoniae in sinks and drains of new inpatient hospital rooms after patient occupancy. Methods Three inpatient units of a newly constructed cancer hospital were studied. Ten randomly selected rooms per unit were sampled biweekly for seven months for Acinetobacter, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Surface samples were swabbed from a 4x4 cm section of the sink basin around the drain. Water was sampled from the p-trap via the drain. Results Approximately 400 sink and drain samples were taken. Acinetobacter was the most commonly detected organism, and Klebsiella the least. Based on the unit, 90-100% of sink and 50-90% of drain samples by the end of the study period had detectable Acinetobacter, 90-100% of sink and 50-80% of drain had Pseudomonas, and 0-10% of sink and 0-30% of drain had Klebsiella. In samples with detectable organisms, Acinetobacter concentrations ranged from 1.3-8 logCFU in sinks and 1.6-6.7 log CFU/mL in drains. Pseudomonas aeruginosa ranged from 2.8-7.4 log CFU in sinks and 2.2-6.1 log CFU/mL in drains, and Klebsiella from 2.6-4.5 logCFU in sinks and 1.6-4.9 logCFU/mL in drains. There was low to no correlation between occurrence of detectable bacteria in sink basin and drain water samples from the same room; median correlation estimates across ten rooms for the three units were -0.09 (-0.3; 0.46 95% CI), 0.21 (0.02; 0.67 95% CI) and 0.36 (-0.18; 0.52 95% CI) for Acinetobacter, 0.07 (-0.32; 0.45 95% CI), 0.09 (-0.32; 0.53 95% CI), and 0.18 (-0.21; 0.39 95% CI) for Pseudomonas and -0.25 (-0.3; -0.17 95% CI), 0.04 (-0.29; 0.55 95% CI), and 0.25 (-0.4; 0.54 95% CI) for Klebsiella. Conclusions Over 7 months, Acinetobacter and Pseudomonas aeruginosa were common in basins and drains of patient room sinks. Klebsiella was less common but still detected. Concentrations fluctuated over time but could reach levels up to 6-7 login the sink basin. These results suggest that sinks and drains in inpatient rooms are potentially a consistent source of HAI organisms in the hospital environment.

Background: Hand hygiene is the most important tool for preventing the spread of infections in the healthcare environment. Personal protective equipment (PPE) and nails policy are important additional measures for limiting infectious spread. Our facility typically performs both covert and overt hand hygiene, PPE and nail audits. Compliance rates with hand hygiene and PPE have declined since the COVID-19 pandemic. More information was needed on factors contributing to decreasing compliance rates. Methods An anonymous hybrid electronic and print survey was distributed at annual Infection Prevention fair across a 9-hospital system in Eastern North Carolina from April 2025-November 2025. The survey was conducted via Qualtrics. Results There were 432 total responses, 41% were registered nurses, 7% radiation technologists, 6% nursing assistants and 3% or less of a wide variety of other specialties/departments. Community hospitals represented 83% of responses and 17% were from a large academic medical center. Overall self-reported hand hygiene and PPE compliance was 96.10% and 94.3% whereas perceived compliance of peers was 89.29% and 88.7% respectively. Individual unit audits reported a rate of 89.9% hand hygiene compliance during this time period. When asked about specific scenarios, 84.6% of healthcare workers stated they would wear PPE for isolation precautions when entering the room, but patient contact was not anticipated. Conclusions Healthcare workers report high levels of compliance with hand hygiene and PPE but report lower numbers for perceived compliance of peers. In our health system opportunities to improve isolation precaution compliance include increasing availability of PPE and education on need for PPE even when patient contact is not anticipated. There is strong support for a natural nails policy among healthcare workers in our system, but among the minority that were opposed many left comments expressing strong opposition.

Background: Hand hygiene is the most effective way to prevent hospital acquired infections, and thus evaluating hand hygiene compliance is critical to ensure patient safety. The Leapfrog Group is a non-profit organization that, in part, evaluates organizations' commitment to hand hygiene as a component of their overall hospital safety grades. For those performing manual observations, Leapfrog requires most inpatient units to complete at least 200 observations per month to achieve an "A" grade. At our facility, hand hygiene observations are performed manually by trained unit-based caregivers as well as by Infection Preventionists (IPs) who serve as “validators.” Between January 2022 and June 2023, on average only 37.4% of inpatient units met their Leapfrog goals; IPs (n=10) performed an average of 294 validation observations per month. Our goal was to improve organizational commitment to hand hygiene compliance, increase IP validator rounds, and achieve <95% of units meeting their monthly Leapfrog goals systemwide throughout FY24 and beyond. Methods: ChristianaCare is a 3-hospital, <1400-bed community-based academic healthcare system based in northern Delaware. In March 2023, leadership committed to meeting and maintaining established Leapfrog goals for hand hygiene observations for inpatient units systemwide. Nursing leadership, in conjunction with IP and the Hand Hygiene Steer Committee, became actively involved with monitoring and meeting these goals. The Hand Hygiene Steer Committee initiated active conversations with individual units, as well as established real-time reporting of progress towards 95% goal to units. IP also initiated a robust recognition program, recognizing units as well as individual caregivers for their successes in hand hygiene observations and meeting goals. Results: Between Oct 2022-June 2023, the percentage of units meeting their Leapfrog observation goal rose from 37.4% to 96.2% (Figure 1). From July 2023 onwards, the average Leapfrog goal compliance for inpatient units was 96.2% (a 58.8% increase; Figure 2). In addition, the average monthly number of observations performed by the Infection Prevention Department was 690 (a 235% increase). A total of 8 inpatient units and 7 individual caregivers were recognized systemwide for their hand hygiene efforts, successes, and improvements. Conclusion: Maintaining hand hygiene compliance and a systemwide hand hygiene observation program requires commitment and significant effort throughout the organization. Continued monitoring, ongoing discussions, and targeted interventions have demonstrated ChristianaCare’s ability and commitment to hand hygiene and meeting The Leapfrog Group’s goals for patient safety.

Introduction: Hand hygiene compliance in healthcare settings is significantly influenced by the acceptability and skin tolerability of hand sanitisers. Conventional alcohol-based hand rubs have been associated with increasing incidences of skin dryness, irritation, and contact dermatitis with repeated application, leading to reduced compliance and limited alternatives for staff with skin sensitivities. This challenge has become more prominent with the convergence of occupational skin health and environmental sustainability goals in healthcare settings worldwide, underscoring the need for alternative hand hygiene solutions that protect skin integrity whilst supporting compliance targets and staff well-being. Objectives: To assess healthcare workers' acceptance and tolerability of an organic bioethanol-based hand rub as a potential alternative to conventional alcohol-based hand sanitisers. Methods: A non-blinded study was conducted over one-month with 41 healthcare workers (29 nurses, 4 doctors, 6 ancillary staff, and 2 allied health workers) recruited through convenience sampling at Singapore General Hospital. Participants received a bioethanol-based hand rub (Saniswiss Sanitizer H1) containing bioethanol (72% concentration), moisturising agents, and super-fatting agents (perfume- and fragrance-free) in 100mL or 500mL bottles with ongoing replenishment. Data collection occurred at three time points: baseline (initial skin integrity assessment), 3-5 days post-implementation (follow-up questionnaire), and one month (final questionnaire and hand rub consumption calculation). Questionnaires were administered via FormSG platform with data analysed using Microsoft Excel. Results: Average consumption was 380mL per participant, with nurses demonstrating highest usage at 400mL. Initial skin assessment identified 17 participants with pre-existing dry skin and/or redness, which decreased to 6 participants reporting mild symptoms by study completion. User acceptance was high: 98% rated colour as pleasant or very pleasant, 95% approved of smell, 76% reported no sticky residue, 95% experienced no stinging sensation, 71% found the hand rub non-drying, and 90% rated drying speed as fast or very fast. Overall satisfaction reached 98% after 3-5 days and maintained 92% after one month. Notably, 82% believed the product could enhance hand hygiene compliance, and 68% preferred the bioethanol-based hand rub over conventional sanitiser. Conclusion: Bioethanol-based hand rub demonstrated excellent user acceptance and skin tolerability among healthcare workers. The significant reduction in skin-related complaints, combined with high satisfaction rates and improved skin condition despite frequent use, supports its potential implementation as an effective alternative hand hygiene solution for healthcare workers, particularly those with contact dermatitis. Figure 1: Progression of skin scale scores during study period Figure 2: Breakdown of Product Preferences Across Professional Group

Background: Proper hand hygiene (HH) is a fundamental practice for reducing healthcare-associated infection transmission and a cornerstone of infection prevention. Dietary technicians, non-clinical food service workers who deliver patient meal trays, routinely move between patient rooms. Although many healthcare institutions have established multimodal HH compliance programs, dietary staff have historically demonstrated lower HH compliance compared with clinical personnel. HH interventions targeting this group remain understudied. We implemented an infection prevention–led HH education class for onboarding dietary staff and evaluated its association with overall dietary HH compliance. Methods: We conducted a quasi-experimental study at a large academic medical center. The onboarding dietary HH class began on March 4, 2024, and was delivered intermittently, averaging twice monthly, with pauses due to operational constraints, through February 28, 2025. Newly hired dietary technicians attended a single in-person, one-hour session during orientation, with no subsequent reinforcement. Instruction was conducted in an empty patient room and emphasized HH upon room entry and exit, appropriate use of alcohol-based hand rub versus soap and water, and correct personal protective equipment use aligned with transmission-based precautions. HH observations for all dietary staff were collected by trained auditors using standardized direct observation protocols. Baseline data were obtained from March 1, 2022, to February 29, 2024, and intervention data from March 1, 2024, to February 28, 2025. Results: Approximately 80 newly hired dietary technicians participated across 21 total classes. Mean HH compliance increased from 80 percent at baseline (95 percent CI, 76.4–84.6; 4,971 observations) to 89 percent during the intervention period (95% CI, 87.2–90.4; 2,932 observations; p < 0.05 by Wilcoxon rank-sum test). Compliance variability decreased, with standard deviation declining from 9.7 percent to 2.3 percent and monthly minimum compliance increasing from 53 percent to 84 percent. In segmented linear regression analysis, HH compliance demonstrated a non-significant upward trend during the pre-intervention period (p = 0.07). Following the intervention, a small but statistically significant downward trend over time was observed (p < 0.01). Conclusions: An onboarding dietary HH education class was associated with higher mean HH compliance and reduced variability among dietary staff. However, improvements were not durable, likely reflecting the limited reach and lack of reinforcement inherent to an intermittently delivered, onboarding-only intervention and a potential ceiling effect within an existing multimodal HH compliance program. These findings emphasize the importance of reinforcement strategies when designing HH interventions for dietary staff to sustain improvements and enhance patient safety.

Background: We used human factors engineering (HFE) methods to define processes of care in LTCF and assess healthcare professionals’ (HCP) hand hygiene (HH). Methods: We created an HFE observation template on which to record the types of items and patient sites HCP touched during care sequences (CS) and the order in which they touched them. We filled out the template as we shadowed HCP at 3 LTCF during 198 CS and entered data into Excel. We did descriptive analyses of the CS and HH compliance for the 3 facilities together and separately. We used chi-square, Fisher’s exact, Kruskal-Wallis, and Wilcoxon tests as appropriate. We used first-order Markov transition probabilities from the step-by-step CS to estimate the probability of HH before entry and exit and before and after each touch type. Results: We observed 63 CS at both LTCF1 and LTCF3 and 72 at LTCF2. 83 (41.9%) CS were short (1-7 touches), 51 (25.8%) were medium (8-13), and 64 (32.3%) were long (14-103). HH on exit decreased significantly from 31.2% and 39.2% after long and medium CS, respectively, to 19.3% for short CS. HH opportunities during CS comprised 82.8% of all opportunities. HH compliance was 27.8% on room entry, 28.3% on room exit, and 1.7% during CS. Overall HH compliance was low at each LTCF but it was significantly lower at LTCF3 than at LTCF1. HH on entry and exit at LTCF1 (38.1%; 38.5%) was significantly higher than at LTCF3 (20.6%; 20.6%) and insignificantly higher than at LTCF2 (25%; 27.8%). Touches of the environment, supplies/equipment, and clean patient sites were the most common touches, accounting for 55.5-70.9% of touches. Dirty/contaminated touches comprised only 4.2%- 5.8%. We observed only 2 clean/aseptic touches at LTCF3. The highest transition probabilities from specific touches to HH were from the environment (0.460) and from supplies/equipment (0.264) touches and the lowest were from dirty/contaminated and from HCP’s sites (both 0.011). The highest transmission probabilities for touches immediately after HH were for dirty/contaminated sites (0.105) and for eating-related items (0.105) and the lowest were for clean/aseptic touches (0.000). Conclusions: Most CS are short and involve touches of the environment, supplies/ equipment, and clean patient sites. Low HH compliance on exit and entry increase the risk of pathogen transmission among residents. Although dirty/contaminated touches and clean/aseptic touches were rare, HH during CS was also rare and the transition probabilities indicate that HH compliance is low at critical care transitions.

Background: As of 2024, sexually transmitted infections (STI) cases remain 13% higher than they were a decade ago. Budget cuts affected 61.5% of local health department STD clinics, with 14.1% reducing clinic hours. Between 2008-2010 and 2011-2013, STI-related Emergency Department (ED) visits increased by 38.6% compared to 2% for all diagnoses. Reduced public STI funding and services have increased ED utilization. This study examined associations between social determinants of health (SDOH) and STI-related ED utilization. Methods: This retrospective cross-sectional study analyzed data from ED-based STI testing at three urban hospitals in Northwest Indiana between January 2021-March 2025. The dependent variable was STI-related ED visit. Independent variables were demographics, SDOH, behavioral, and health outcomes. Descriptive, bivariate (Chi-Square, Mann-Whitney U, Kruskal Wallis; p<0.05) and multivariate (Binary Logistic Regression; p<0.05) analyses were conducted using SPSS v31.0. Results: Conclusions: Specific SDOH are associated with STI-related ED utilization. Improving funding of publicly funded STI clinics can help to reduce healthcare costs and barriers disproportionately affecting marginalized patient populations. Future efforts should focus on strengthening ED-based SDOH screenings and referrals which may support efforts to redirect patients to cost-effective healthcare settings (e.g., public STI clinics), improving outcomes and reducing system burden.

Background: Older adults (≥65 years) commonly receive antibiotics in emergency departments (ED), where adherence to prescribing guidelines is inconsistent. The extent to which neighborhood disadvantage causally influences these prescribing patterns is unclear. We aimed to estimate the causal effect of community deprivation and vulnerability on guideline-concordant antibiotic selection and to disentangle the relative contributions of overuse and underuse. Methods: We analyzed 1,318,281 ED encounters for 790,562 adults aged ≥ 65 years seen at 119 sites across 15 states (2015–2024). The primary outcome was guideline concordance based on IDSA criteria. Secondary outcomes were overuse and underuse, defined using a three-tier diagnosis framework (tier 1 = antibiotics indicated, tier 2 = sometimes indicated, tier 3 = not indicated). Exposures were census-tract Social Vulnerability Index (SVI) and Social Deprivation Index (SDI). To mitigate confounding and reverse causality, we applied two-stage least squares instrumental-variable models using the maximum state Earned Income Tax Credit as the instrument, adjusting for patient, facility, state, and month-year covariates with patient-clustered robust standard errors. We additionally examined key SVI/SDI components and regional patterns in concordance. Results: Overall concordance was 83.2%; non-concordance comprised 9.5% overuse and 7.2% underuse. Concordance improved from 78.4% (2015) to 83.8% (2024), driven by declining underuse (16.2 to 5.4%) despite rising overuse (5.4 to 10.8%). Antibiotics were given in 80.8% of tier 1, 28.1% of tier 2, and 15.9% of tier 3 encounters. COVID-19 diagnoses accounted for 20.1% of overuse, and urinary-tract infection codes for 33.6% of underuse. The instrument was strong (first-stage F = 348 for SVI; 413 for SDI). In IV models, each 10-point increase in SVI corresponded to a 6.37-point lower concordance (SE 0.69; p < 0.001, Table 1); each 10-point SDI increase, 1.84-point lower (SE 0.20; p < 0.001). Associations were stronger for underuse than for overuse. Lower concordance was linked to longer travel time, higher tract non-employment, household crowding, and lack of vehicle access. Regions of high deprivation and lower concordance clustered predominantly in the South, whereas higher-concordance areas were concentrated in the Midwest (Figure 1). Conclusions: Community disadvantage was associated with lower guideline-concordant antibiotic prescribing for older adults, mainly through increased underuse and modest reductions in overuse. Stewardship programs should monitor both phenomena separately and target high-deprivation areas with enhanced diagnostics, follow-up, and locally tailored implementation to improve equity.