Background: The rapid clinical translation of human gene therapy products, particularly those utilizing replication-deficient viral vectors such as adenovirus and adeno-associated virus, has introduced novel biosafety considerations regarding "shedding"—the dissemination of the vector through patient urine, saliva or stool. While therapeutic protocols focus on patient outcomes, unintentional exposure of healthcare workers, caregivers, or other close contacts to these viral vectors represents a critical, yet under-analyzed, epidemiological event. Objective: To critically evaluate the hazards posed by accidental exposure to recombinant viral vectors from an epidemiological perspective, focusing on risks of horizontal transmission and immunological interference. Discussion: Although modern viral vectors are engineered for safety, unintentional exposure via mucosal contact or accidental inoculation poses multiple risks that warrant critical evaluation. First, immunological priming or seroconversion in an exposed individual can induce development of neutralizing antibodies against the specific vector capsid. Such "silent" immunization may preclude an individual from receiving future gene therapies, creating a long-term public health barrier. Second, while rare, the risk of in vivo recombination with wild-type viruses (e.g., a natural adenovirus infection) could theoretically result in the rescue of replication-competent viral variants. Third, the biodistribution and persistence of a transgene in non-target populations remains poorly characterized. Identifying and tracking these events is essential for refining risk to public health, the environment and development of adequate containment guidelines for human gene therapy treatments utilizing viral vectors. Conclusion: Unintentional exposure to recombinant viral vectors represents a significant, under-recognized epidemiological hazard. To ensure the safe expansion of genetic medicine, it is imperative to move beyond patient-centric monitoring and treat unintentional exposures as epidemiological data points. Systematic surveillance of these events is vital for establishing a real-world safety profile of genetic medicines, refining biosafety protocols and safeguarding public health.

Background: Cook Children's has two hospitals in North Texas and a network of clinics extending to the West, where a measles outbreak totalling 762 cases began on January 20, 2025. Measles symptoms include fever, cough, coryza, and conjunctivitis before the onset of the morbilliform rash. Timely isolation is recommended for measles. Isolation should continue from four days before to four days after the onset of rash. We hypothesized that contact, travel, and symptom-based screening could prevent amplification of measles in our healthcare settings and avoid positive screens in most neonates with febrile URI. Administratively, screening is unpopular because screening leads to longer registration times, more manpower requirements, and lower patient satisfaction scores. Methods: We selected five measles screening questions employing an adjustable scoring system in which a total score of 5 triggered a positive registration screen, rapid isolation, and further clinician assessment to determine actual testing needs. We scored practice patients by trial and error to settle upon a scheme, then deployed screening at all registration points. We adjusted questions based on evolving local measles epidemiology and redeployed the questions. We monitored throughput. Results: Screening for the first iteration started network-wide on March 31, 2025 (Table 1). Scoring included: 1 point for travel to/living in a measles area; 2 points for case exposure; 1 point for no measles vaccination; 2 points for fever; 1 point for ALL 3 C's – cough, congestion, and red eyes. Not anticipating that parents would answer "UNKNOWN" to some questions, a point counted for those instances. Initially, screen positivity was 0.32% (256 of 80,071), while there were 0 PCR-positive cases. The second iteration (55,603 screens) mended the oversight, reducing positive screens to 0.01%. During a third iteration (70,018 screens) following a visitation to a resort by an outbreak-linked case, "ANY," rather than "ALL of the 3 Cs," and/or rash was counted, increasing screen positivity to 0.03%. After a worrisome non-network case presented without travel or known exposure, a fourth iteration (215,957 screens) increased the maximum to 2 points for each 3C or rash (1/2 point for each), so children without travel or known exposure could have a positive screen. Positivity was 0.01%. For iterations 2-4 (341,578 screens), using measles PCR (n=27) positive as the gold standard, sensitivity was 100%, specificity 96%, PPV 50%, & NPV 100% (Table 2). Using "clinician felt PCR was needed" as a gold standard, clinicians ordered PCR in only 5.7% of positive screens and 0.01% of negative screens, including 3 children with fever and vaccine-associated rash only (Table 4). Registration throughput climbed by 117% but returned to baseline by 2 months (Graph). However, managers were pressed into service directing traffic until screening ended July 27, 2025. Conclusion: Exposure and symptom-based measles screening can avoid positive screens among low-risk febrile neonates with URI. This model should be employed in other areas to prevent measles transmission before the onset of rash.

Background: Candida auris is an emerging, healthcare?associated pathogen that persists on skin and in the environment. Early identification of colonized patients is central to interrupting transmission, but the optimal screening cadence in cluster settings is uncertain. We evaluated whether intensifying targeted screening and transitioning to in?house PCR were associated with changes in clinical cases at a large quaternary academic medical center. Methods: We conducted a retrospective study from November 2022 through March 2024 in hospital units experiencing C. auris clusters. Screening frequency was escalated in phases—from biweekly to weekly—and later transitioned to in?house PCR to enable faster turnaround and earlier implementation of infection?prevention actions (e.g., isolation/cohorting and enhanced environmental cleaning) per institutional protocol. The primary outcome was the monthly number of new clinical C. auris cases, defined as non?screening clinical isolates with urine and sputum excluded. The secondary outcome was colonization detected by screening PCR or by urine or sputum cultures. Monthly outcomes were monitored with statistical process control (control charts centered on phase?specific means), and effects across phases were summarized as percentage changes versus baseline. Results: Thirty?eight clinical cases were identified; median age was 55 years (IQR 44–65), and 66% were male. Most clinical isolates originated from blood and wound/tissue sources. Fifteen cases (39%) had a prior positive surveillance test; the median time from first positive screen to subsequent clinical isolate was 27 days (IQR 17–120). Monthly clinical cases decreased from 2.5 during biweekly screening to 2.0 with weekly screening (?20%) and to 1.7 after adoption of in?house PCR (additional ?15%; -32% overall vs baseline) (Figure 1). Colonization detections increased when screening frequency changed from biweekly to weekly (5.3 to 13.8 per month; +160%) and then declined after in?house PCR (to 10.2 per month; -26%). These patterns were concordant with control?chart signals at the phase changes. Conclusions: Targeted, more frequent screening coupled with rapid in?house PCR was associated with fewer clinical C. auris cases and with higher detection of colonization, consistent with earlier identification and response. Because the clinical?case metric is less sensitive to testing intensity and speciation practices than colonization counts, it may better capture the impact of hospital interventions on transmission. Findings are limited by the single?center, retrospective design, potential confounding from concurrent infection?prevention measures, and use of monthly counts rather than rates; nonetheless, the phased approach provides actionable evidence to guide surveillance strategies during C. auris clusters.

Background: Contaminated endoscopes are a recognized source of nosocomial transmission of infection. Endoscope-associated Salmonella transmission was once common, however, as a result of stringent reprocessing guidelines, including high-level disinfection, a 2018 review indicated that no cases were reported since 1987. Methods: In July 2024, the Illinois Department of Public Health identified and notified the local health department (LHD) of a cluster of three Salmonella Enteritidis (SE) cases from the same jurisdiction that were related by whole genome sequencing (WGS). The LHD investigated the cluster, as well as other Salmonella cases that were pending WGS, to identify a common source. The investigation included case interviews, interviews of patients with a common exposure, medical record reviews, isolate serotyping and whole genome sequencing (WGS), scope culture, and site visits for Infection Control Assessment and Recommendations (ICAR). Results: Index case reported symptoms including fever, nausea, vomiting, and urgent diarrhea. Two weeks prior to symptom onset, the case-patient had an esophagogastroduodenoscopy (EGD) and colonoscopy at an outpatient gastroenterology and endoscopy center. 56 patients had EGDs performed with the same scope, 48 of whom were interviewed regarding gastrointestinal symptoms post procedure. Six patients reported experiencing symptoms following their procedure, five of whom were already included in the investigation. The sixth case tested positive for Salmonella Newport and was excluded. Seven total cases of Salmonella were identified as associated with this investigation with illness onset between May 3, 2024, and September 20, 2024. Six were confirmed to be SE and closely related (0 SNPs) by WGS; one specimen was not sent to the state lab for WGS. ICAR identified several opportunities for improvement however there was not a clear gap in the disinfection or other processes that were observed. Namely, the scope passed the facility’s leak test. Scope culture was negative for Salmonella and other gram-negative organisms. The scope was sent to a third-party endoscope repair company; it did not pass their leak test, and the scope was refurbished. The facility planned to prospectively have all scopes inspected routinely. Staff was also retrained by the consultant company on reprocessing procedures. Conclusion: Scope-associated Salmonella transmission may be rare, but it is not entirely bygone. Cases may be under-reported if symptoms are attributed to the procedure itself or the underlying condition which prompted the procedure or are self-resolving and do not lead to diagnosis. Because scopes are complex in design and require fidelity to strict reprocessing, prospective maintenance routines, and re-training and auditing of reprocessing processes may be prudent.

Background: After CDC and local surveillance identified an increase in Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacterales (KPC-CRE) caused by multiple organisms, an investigation was conducted at an acute care hospital. Cases clustered around an intensive care unit (ICU) and step-down unit (SDU), where wastewater plumbing was a suspected transmission source. Whole genome sequencing (WGS) was used to investigate this outbreak. Methods: A case was defined as detection of KPC-CRE or KPC (no organism cultured) from specimens collected at the hospital between 01/2019 to 10/2025. Clinical cases were identified via carbapenemase testing of CRE isolates using PCR (Xpert Carba-R) or by multiplex PCR panels and screening cases through PCR with reflex to culture. ICU sink and hopper samples and SDU sink samples were tested using selective media, MALDI-TOF, and multiplex PCR for KPC-CRE detection. Isolates underwent short and long-read sequencing. Result: Overall, 64 cases (37 clinical; 27 screening), involving 54 patients, were identified; 28 patients had ICU/SDU admissions during their hospitalization. The 52 cases with an organism identified included seven species, of which the most common were Citrobacter (26), Klebsiella (14), and Raoultella (5); 24 harbored blaKPC-2 (37.5%), 18 blaKPC-4 (28.1%), 5 blaKPC-3 (7.8%), 1 blaKPC-160 (1.5%), and 16 were not subtyped (25%). Seventeen isolates from five species carried blaKPC-2 on a 42 kb IncP6 plasmid, while ten isolates from five species carried blaKPC-4 on a 69 kb plasmid with Col440I and IncM1 replicons. Environmental sampling in 05/2025 found KPC-CRE in 10/12 sinks and 2/12 hoppers in the ICU and 1/22 SDU sinks (fig1). KPC-CRE environmental isolates were closely genetically related to the Citrobacter, Klebsiella, and Roultella clinical isolates and harbored similar KPC-carrying plasmids. Infection prevention and control (IPC) rounding identified patient items within the sink splash zone, including placing bath-in-a-bag in the sink. In 05/2025, a campaign was initiated to remove items from the splash zone, switch to chlorhexidine wipes, and implement daily use of an EPA-registered, sodium dichloroisocyanurate-based biofilm drain disinfectant product. Starting 07/2025, pouring of lipids and total parenteral nutrition down drains was stopped. While repeat environmental sampling in 6/2025 also found KPC-CRE in sink drains, no additional cases were identified in the ICU or SDU following these remediation activities (fig2). Conclusion: ICU sinks served as a reservoir for KPC-CRE, with transmission to patients. KPC-CRE persisted in drains following initial drain disinfection measures; therefore, changes in sink and splash-zone IPC practices appear to be important for interrupting transmission.

Introduction: Transmission of New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) is stochastic in nature. Largescale NDM-CRE outbreaks have been observed throughout the world. Within the United States (US), the incidence of NDM-CRE infections increased by 5-fold between 2019 and 2023, highlighting concern for large outbreaks. Given this, estimating how large an NDM-CRE outbreak is likely to be (i.e., the probability of final cluster size) is a valuable first step in characterizing NDM-CRE transmission dynamics and informing outbreak response. Methods: The National Center for Biotechnology Information (NCBI) Pathogen Detection database is a global, public tool that identifies clusters of bacterial pathogen genomes based solely on genetic relatedness. We included all NDM-CRE genomes associated with a US cluster and uploaded between January 2009 and September 2025. Using cluster data, we estimated the dispersion parameter (k), which reflects transmission chain variance. Because we assume that NCBI does not capture all NDM-CRE cases in a cluster, we compared the estimated k values for the NDM-CRE clusters to simulated k values. Our simulations varied the probability of case identification and assumed the average number of new cases from each infection was 1.1 (based on literature; see Figure 1A). Using these simulated k values, we estimated the probability of final cluster size (see Figure 1B). Results: We included 1,104 clusters with a mean size of 5 genomes (standard deviation=20). The estimated k value was comparable to, but higher than, simulated k values, supporting our assumption that NCBI cluster data are incomplete (Figure 1A). Comparing the probability of the final cluster size between estimated k values, which were likely biased (<0.3), to simulated values k values <=0.3, final cluster sizes are most likely to have two cases and a low probability of clusters <=10 cases (Figure 1B). Conclusions: Unlike many other infectious diseases, NDM-CRE cluster dispersion values remain unknown, which is a critical gap. We estimated dispersion to show that US NDM-CRE clusters have a high probability of being small. However, additional analysis is needed since standardized NCBI cluster data may be subject to biological, technical, and sampling limitations and do not allow for assessing why US clusters were small. Strong infection prevention and control practices and assessment of patient travel history continue to be best practices for mitigating NDM-CRE outbreaks. Moreover, as the NDM-CRE epidemiology continues to evolve, monitoring US NDM-CRE clusters will provide insight into outbreak dynamics, including emergence of highly successful clones.

Background: In 2025, 50 measles outbreaks drove 87% of confirmed cases reported in the United States. As a highly infectious virus with an estimated R ranging from 12-18, we sought rapidly scalable and implementable measles preparedness measures for our facilities. Methods: The electronic health record (EHR) has flags that can be placed on patient records to denote the presence of, or concern for, active, transmissible infections. These flags are highly visible in the EHR and represent a good usability heuristic as front line providers are already trained to look for this information. Infection Prevention and Control (IPAC) worked with nursing informatics to develop measles-specific flags for suspected, confirmed and exposed patients in the EHR, expanding flagging functionality in preparation for potential measles cases and exposures. The flagging was tied to registry functionality to allow for tracking of exposed and confirmed cases longitudinally for supporting IPAC investigations in addition to clinical operations. Results: Three different flags were developed in the EHR to address measles. Specific criteria were created for each flag, as shown in Table 1. Table 1: Attached as Image Conclusion: As a highly contagious virus, measles presents unique challenges to healthcare facilities managing both cases and exposures. Measles flags within the EHR can be leveraged to assist facilities with case tracking, exposure management, and infection prevention and control.

Background: Trypan blue is commonly used during mature cataract surgery to improve visualization of the anterior capsule. Although FDA-approved since 2004, it remains unapproved in Japan. Many clinics perform sterile filtration prior to use; however, no standardized sterilization protocol exists. Methods: This retrospective case series included all patients diagnosed with Sarocladium kiliense endophthalmitis after cataract surgery at Kyorin University Hospital between 2015 and 2025. Results: In 2025, six microbiologically confirmed cases of S. kiliense endophthalmitis were identified; none occurred before 2024. One case originated from Clinic A and five from Clinic B. All cataract surgeries used trypan blue, which had been sterile-filtered at each institution. Discussion: Endophthalmitis is a rare postoperative complication of cataract surgery, and S. kiliense is an uncommon pathogen. We were informed that similar cases occurred sporadically in 2025 from a reference laboratory center. One institution confirmed contamination of the trypan blue product (unpublished data). The same organism was isolated from dye obtained from Clinic B. All affected clinics used trypan blue from the same manufacturer. Off-label product use may pose significant safety concerns due to limited data. While other off-label dyes (e.g., Lugol’s solution, India ink) are widely used in Japan, they are applied superficially. We hypothesize that contaminated trypan blue migrated into the vitreous cavity via lens zonules, causing the outbreak. Physicians bear responsibility for off-label use and should employ unapproved products only when benefits clearly outweigh risks.

Background: Advanced planning and adaptable response strategies are essential for preventing measles transmission in healthcare facilities. Objective: To describe a measles management plan and subsequent modifications in response to a cluster of measles cases. Methods: Drawing on previously published work (doi:10.1017/ice.2025.49), the Infection Prevention and Control (IPAC) team initiated a multi-disciplinary team and developed a measles preparedness plan with the following domains: Guidance and education; early detection and testing; isolation and patient movement; contact tracing and exposure management (Table 1). In October 2025, a patient was admitted during their fifth healthcare encounter and was diagnosed with measles. Two family members were later hospitalized with measles. Delayed recognition of the first case prompted enhancements to our preparedness framework (Table 1). Results: The first case resulted in 539 exposed patients. The second resulted in 87 exposures, and the third resulted in no exposure. Despite the extensive exposure, zero secondary measles were reported. Conclusion: Proactive planning enabled rapid response to our first case and controlled secondary transmission. Despite extensive planning, delayed identification of the first case caused significant exposures. As the cluster unfolded, we refined our plan, resulting in zero exposures from the last patient and zero secondary cases, despite over 850 exposures. These efforts may guide other healthcare facilities in improving their measles preparedness and response.

Background:?The incidence of Candidozyma auris (C. auris) is growing in healthcare settings internationally. International healthcare exposure, compromised skin integrity, lengthy intensive care unit stays all increase risk of C. auris colonization. In Massachusetts, clusters and outbreaks related to C. auris have mostly been characterized by transmission in long term care settings. Over the course of 1.5 years, our institution experienced a cluster of C. auris cases initially hypothesized to be linked to one long stay index patient. Method:?At our tertiary academic medical center, one long stay patient with international healthcare exposure developed a hospital-onset C. auris bloodstream infection. In accordance with public health guidance, any time a clinical isolate is identified, point prevalence screening (PPS) is conducted on impacted unit(s). When possible, we also attempted to proactively screen patients with known recent international healthcare exposure for C. auris, though this was not implemented systematically. Given the protracted nature of our cluster and significant overlap in inpatient spaces and time of several patients, we used Nanopore and Illumina genomic sequencing to identify chains of transmission and to inform infection prevention related interventions. Result:?Over the course of the we identified clinical isolates, positive PPS isolates, and positive screening isolates for patients with international healthcare exposure, for a total of 19 isolates. Of these 19 isolates, genomic sequencing was performed on 15 isolates. Genomic analysis revealed three separate introductions of C. auris into our facility, representing subclades Ib, Ic, and III. The largest cluster involving 1 isolates (7 clinical, 4 PPS) comprised of subclade Ic was related to the long stay index patient. The second cluster involved isolates from subclade Ib and was related to a patient who was screened pro-actively for international healthcare exposure. Conclusion: In healthcare settings where C. auris is an emerging but not yet an endemic threat, genomic sequencing can play a critical role in understanding transmission events. At our institution, discovering multiple introductions of C. auris into our facility was unexpected. Genomic sequencing provided reassurance in our infection control interventions and demonstrated the need for serious consideration of a targeted pro-active screening program.

Background: Airborne infection isolation rooms (AIIRs) are a highly restricted environment in which patients’ physical and emotional care needs are intensified. In AIIRs, nurses spend the most time in close contact with patients, rendering the nurse-patient relationship particularly important. However, empirical research exploring nurse-patient relationships among patients isolated for infectious diseases remains limited. The Fundamentals of care (FOC) framework conceptualizes patients' physical and psychosocial needs and the nursing activities required to address them, positioning the nurse-patient relationship as the core dimension through which care is integrated and delivered within specific care contexts. This study aimed to explore nurse–patient relationships as experienced by patients in AIIRs and to interpret these experiences from the perspective of the FOC framework. Methods: Participants were adults aged 18 years or older who had been hospitalized for infectious diseases in AIIRs for at least three days. To ensure voluntary participation and authenticity of responses, patients who were not directly cared for by the researcher were recruited. Data were collected from 11 patients residing in AIIRs at a tertiary general hospital through semi-structured, one-on-one in-depth interviews conducted between July 6 and August 31, 2025. Interviews were audio-recorded and transcribed. Data were analyzed using thematic analysis following Braun and Clarke, employing a hybrid approach that integrated deductive coding based on pre-established FOC concepts with inductive coding derived from participants’ narratives. Results: The nurse–patient relationship experienced by patients in AIIRs was characterized by an overarching theme, a relationship of striving together along a long journey until returning to the world. Five main themes, comprising twelve subthemes, were identified: (1) feeling safe enough to entrust oneself, (2) experiencing continuous and attentive care, (3) experiencing prepared care, (4) recognizing the nurse as the one who understands me best, and (5) a relationship built together. Analysis revealed that patients in AIIRs experienced positive nurse–patient relationships through the development of trust and nurses’ attentive responses to their needs, which facilitated a shift from isolation-related anxiety to emotional stability. Furthermore, relationship development was described as a mutual process, with both nurses and patients actively engaged. Conclusion: This study suggests that nurse-patient relationship formation grounded in the FOC framework within AIIRs contributes to patients’ psychological stability and perceived recovery. The findings indicate the need for FOC-based nursing education, structured communication practices, and consideration of the AIIRs environment and institutional policies to support relationship-centered care in isolation settings.

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a common approach to treating complex infections, offering benefits of higher patient satisfaction, reduced risk of hospital-acquired infections, and lower healthcare costs. However, limited information exists regarding how OPAT is delivered across U.S. healthcare systems. We sought to understand OPAT practices and identify facilitators and barriers to OPAT delivery at Veterans Affairs (VA) medical centers (VAMCs), which constitute the largest integrated healthcare system in the U.S. Methods: We conducted a national survey of VAMCs between January-April 2025. OPAT providers were invited via email to complete an online Qualtrics survey. Topics included care delivery, patient monitoring, and perceived challenges to safe, effective OPAT care. Data were summarized using descriptive statistics. Results: Of 139 surveys, 106 (76.3%) were completed and analyzed. Most VAMCs offered OPAT (78/106; 73.6%). Among those, 60/78 (76.9%) designated OPAT providers to monitor and manage care, often Infectious Disease (ID) physicians (54/60; 90.0%) and ID pharmacists (44/60; 73.3%). Dedicated time for OPAT care activities varied by site and role. Guidelines for OPAT care were reported at 45/78 (57.7%) VAMCs, typically outlining eligibility criteria as well as protocols for patient monitoring and follow-up. Generally, VAMCs required ID consultation prior to discharge and discharged 1-10 patients on OPAT per month, most of whom were followed by ID providers. OPAT-related outcomes were measured by about half of VAMCs (40/78; 52.6%); adverse events were most frequently measured. OPAT delivery extended beyond VAMCs through referrals to outside healthcare systems and collaboration with contract infusion pharmacies and home health agencies (Table 1). Respondents noted challenges to providing safe OPAT care, including dedicated time, communication with organizations outside the VA, and timeliness of labs (Figure 1). Conclusions: While individual VAMCs varied in delivery practices, key elements across programs included designated providers and defined OPAT care components. Challenges were driven by fragmented care, which hindered communication and coordination. Expanding VAMC capacity to provide OPAT and monitor patients may streamline communication, delivery, and continuity. A process map for referrals outside the VA may help designate roles and responsibilities for monitoring and providing OPAT care.

Background: Approximately one in ten US children report an allergy to antibiotics. However, ~95% of these pediatric allergy labels are inaccurate upon evaluation. Inaccurate allergy labels lead to suboptimal antibiotic prescribing, increasing patients’ risk of treatment failure and adverse effects. Successfully removing inaccurate pediatric allergy labels (i.e., delabeling) requires engagement from primary caregivers. This study examined caregiver (e.g., parents, stepparents) perceptions and attitudes toward delabeling in pediatric care. Methods: We invited US adults to an online survey about antibiotics (March-April, 2024). Respondents identifying as a primary caregiver for a child with an antibiotic allergy answered questions about the child’s allergy (e.g., type, severity), their willingness to try methods to assess whether the child was non-allergic (oral medication vs. skin-scratch challenge), and their anticipated reaction to a negative skin-scratch test result for the child (i.e., indicating no allergy). Results: Table 1 shows characteristics of the 37 caregivers of a child with an antibiotic allergy, 31 described the child’s allergies as mild/moderate (83.8%), 5 as severe (13.5%), and 1 as life-threatening (2.7%). Penicillin was the most common allergy (27 of 37 [73.0%]). More caregivers were willing to try skin-scratch testing (33 of 37 [89.2%]) than were willing to try oral challenge (26 of 37 [70.3%], p=.02). Yet, 21.6% of caregivers (n=8) would not accept the results of a negative skin-scratch test for the child and 29.7% (n=11) would not agree to remove the allergy from the child’s medical record based on that test. Almost all caregivers (35 of 37 [94.6%]) said they would try to re-add the child’s allergy onto their medical record if removed following a negative skin-scratch test. Caregivers listed various concerns about delabeling in free-text boxes including fear of harm or distress to the child, negative past experiences, distrust of clinicians, and belief that, as caregivers, they know the child best and should not knowingly do something that could harm them. Other concerns included keeping allergy labels as a safety net, worrying allergies could return, and preferring to be ‘safe than sorry’. Conclusions: In this survey of US adults, caregivers of children with self-reported antibiotic allergies expressed hesitancy toward delabeling efforts. Findings suggest increased testing efforts alone are likely insufficient as caregiver attitudes may present a major barrier to effective antibiotic allergy delabeling in pediatric care. Strategies for addressing caregiver concerns that persist after negative test results are needed to ensure safe, guideline-concordant antibiotic prescribing through childhood and beyond.

Background: Antibiotic-resistant gram-negative (RGN) bacteria pose a significant threat to child health, leading to use of contact precautions to limit nosocomial transmission. While adult data increasingly support selective discontinuation of precautions, pediatric-specific guidance remains limited due to uncertainty around the duration of RGN colonization. Based on institutional expert opinion, on November 19th, 2021, our institution implemented a policy allowing removal of contact precautions after one year for patients without subsequent RGN culture positivity. This study aimed to characterize RGN carriage duration, identify risk factors for prolonged carriage, and evaluate the impact of the policy change on hospital-associated RGN incidence. Methods: We conducted a retrospective chart review of patients ages 0-21 years with identified RGNs in the hospital electronic medical record system from May 2021 to November 2025. RGNs of interest included extended-spectrum-beta-lactamase (ESBL) Enterobacteriaceae along with multidrug-resistant (MDR) Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter species. Patients with carbapenem-resistant isolates or cystic fibrosis were excluded based on ineligibility for removal of precautions. Data extraction focused on each patient’s first documented RGN infection during the queried timeframe including organism, resistance pattern, and specimen source. Additional evaluation included whether the isolate was treated as an active infection, subsequent positivity with any RGN isolate, and potential risk factors for recurrent RGN positivity. Categorical exposure variables were assessed via ?² test of association and Wilcox ranked sum test to determine differences in duration of RGN carriage (R v4.5.1). Results: We identified 232 patients with RGN isolates. Of these, 158 met inclusion criteria with most exclusions (53/232) due to carbapenem-resistance in the initial RGN isolate. Most patients (91/158, 57.6%) did not have subsequent positivity with any RGN. Of those with durable carriage of the same RGN species (49/158, 31.0%) the median was 269 days (range 39 – 1463). Only presence of underlying genitourinary complexity was associated with risk of subsequent positivity with the same RGN (?² = 10.045, p = 0.001527) and prolonged median duration of RGN carriage of 396 days (Wilcox ranked sum test of identical distributions, W = 428, p = 0.01004). When comparing the seven months leading up to and following the policy change implementation period, there was no increase in incident hospital-associated RGN infections per 100,000 inpatient days. Conclusions Current hospital epidemiology supports a policy of removal of contact precautions after one year of no further RGN positivity and may serve to inform broader pediatric policy decisions.

Background: Invasive Staphylococcus aureus (SA) infections are a common cause of sepsis in premature infants admitted to the neonatal intensive care unit (NICU). While a quality improvement team effectively reduced methicillin resistant (MRSA) invasive infections, methicillin susceptible (MSSA) infections remained problematic. As a result, there was a renewed effort to understand MSSA infection transmission and reduce invasive MSSA infections. Methods: The primary outcome was invasive MSSA infection, most commonly bacteremia, in the NICU. Environmental cultures identified MSSA on high touch point areas and whole genome sequencing (WGS) confirmed there were both endemic strains and independently introduced strains. New interventions to reduce invasive SA infections included additional environmental cleaning of clinical workstations with effectiveness measured by fluorescent marking and a start of shift chlorhexidine (CHG) /alcohol (Avaguard) below the elbow wash for NICU staff. Babies were screened weekly for MSSA/MRSA colonization. Results: In 2023 and 2024 when there were no MRSA infections, there were nine MSSA infections (Figure 1). WGS confirmed that environmental MSSA strains were recovered from infants. Increased screening for MSSA with selective decolonization with mupirocin for high risk infants did not temporally change invasive infection rates and the mupA gene for high level mupirocin resistance was identified in a subset of colonizing strains. There were no significant changes in rates of new colonization for either MSSA or MRSA in 2025. After 1697 days there was one MRSA infection in September 2025. Introducing enhanced environmental cleaning and below the elbow disinfection for staff was temporally associated with a reduction in invasive MSSA infections with only two MSSA infections in 2025, most recently in March. As of January 1, 2026 the NICU has gone nine months without a MSSA infection. Conclusions: Increased environmental cleaning of clinical workstations with a start of shift below the elbow staff disinfection has resulted in a sustained reduction in invasive MSSA infection without a significant reduction in colonization rates. Additional work is ongoing to further understand if SA environmental colonization is reduced and whether current strains colonizing infants are identical to those that have caused invasive infection in the past.

Background: Carbapenemase-producing organisms (CPOs) can cause serious, difficult-to-treat infections and spread rapidly in healthcare settings. Although pediatric CPO cases are uncommon, they may be increasing in the United States. We describe CPO surveillance practices and patient and specimen characteristics among patients admitted to a California pediatric specialty hospital that regularly receives high-acuity patients referred from healthcare facilities outside the US. Methods: Carbapenem-resistant organisms identified from clinical specimens underwent molecular testing to identify the “big-5” carbapenemases (i.e., KPC, NDM, OXA-48 like, VIM, IMP); carbapenem-resistant Acinetobacter baumannii (CRAB) isolates were also tested for additional oxacillinase (OXA) variant carbapenemases at a public health laboratory. In August 2024, the hospital began screening patients upon admission from non-US healthcare facilities by collecting rectal swabs for molecular testing for big-5 carbapenemases, and culture-based screening for CRAB with molecular testing to identify the big-5 and additional OXA variant carbapenemases. We collected patient and specimen data from the hospital and public health case reports. We defined a case as carbapenemase(s) detected in a clinical or screening specimen from a pediatric patient (ages 1–18 years), either during admission or within 3 days of transfer from the hospital from January 2022 to August 2025. Result: Among 28 total cases, 17 (61%) were in clinical specimens (10 wound, 3 blood, 3 respiratory, and 1 tissue) and 11 (39%) in 34 rectal swab specimens (32% positivity) collected through admission screening starting in August 2024 (Figure 1). The most common carbapenemases were OXA-23-like (32%) and OXA-24/40-like (32%) and the most common organism was A. baumannii (79%). Of the 27 patients (one had two cases), the median age was 11 years; 20 (74%) were Hispanic and 21 (78%) were non-US residents. Twenty-two (82%) were admitted for burn injuries and 24 (89%) had international healthcare exposure. Conclusion: Admission screening based on international healthcare exposures had a high (32%) yield and identified more than half of all CPO cases since implementation. The majority of CPO cases were OXA variant-producing CRAB, highlighting the role of culture-based screening to identify carbapenemase-producing CRAB that otherwise would not be detected by screening with molecular testing for big-5 carbapenemases only. Risk-based admission screening is a key component of a comprehensive CPO prevention strategy by facilitating rapid detection of cases and timely implementation of focused infection prevention and control measures to prevent further spread among a vulnerable population.

Methicillin-resistant Staphylococcus aureus (MRSA) is associated with high morbidity, mortality, and outbreaks in neonatal intensive care units (NICU). For MRSA-colonized patients in the NICU, the Society for Healthcare Epidemiology in America recommends continuing contact isolation until NICU discharge, reflecting limited evidence to support safe discontinuation and recolonization concerns. We evaluated MRSA colonization dynamics in a NICU with an active surveillance program to better inform the evidence base for contact isolation practices. All patients in the 58-bed NICU at UCSF Benioff Children’s Hospital San Francisco undergo weekly or biweekly MRSA culture screening. Colonized patients are placed in single-patient rooms on contact isolation for the duration of their NICU admission and undergo decolonization with intranasal mupirocin and topical mupirocin or chlorhexidine wipes; parents are also offered decolonization. We conducted a retrospective review of MRSA surveillance data from January 1, 2021 through December 31, 2024. A patient colonization episode was defined as one or more consecutive positive screens, with multiple episodes separated by at least one negative screen. Comparisons between patients with single and multiple colonization episodes were performed using the Mann-Whitney U test. Among 2,352 patients screened, 111 (5%) had at least one positive MRSA screen and of these, 80 (72%) had a single positive screen. The median time to first positivity (TFP) was 20 days (interquartile range [IQR]: 6-59) and the median length of stay (LOS) was 65 days (IQR: 24-134). Ninety-three (84%) patients had a single colonization episode and 18 (16%) had multiple colonization episodes (Figure 1). Compared with patients with one colonization episode, patients with multiple colonizations had similar median TFP (18 vs. 21 days; p=0.25), but a longer median LOS (98 vs. 49 days; p<0.01) (Figure 2). Colonized patients were placed on a cumulative 5,180 contact isolation days (median: 26 days per patient, IQR: 12-63 days); of these, 2,543 contact isolation days (49%) were during weeks with a negative screen. In a NICU with active MRSA surveillance, targeted decolonization, and robust horizontal infection prevention practices (e.g. hand hygiene, personal protective equipment, and environmental cleaning), MRSA colonization and recolonization detection was lower than previously reported in the literature. Despite this, contact isolation days accumulated substantially, with almost half of the days occurring during periods of negative surveillance testing. These findings highlight the need for further studies to assess MRSA recolonization risk and optimize the duration of contact isolation in NICU patients, ideally guided by local epidemiology and active surveillance.

Background: Appropriate implementation of Transmission-Based Precautions (TBP) are necessary to decrease the risk of exposure to infectious pathogens and hospital-acquired infections (HAI). Through routine auditing, gaps were identified in the appropriateness of TBP orders within our institution. A multi-disciplinary quality improvement team was convened to implement a TBP stewardship pilot program with aim to increase TBP compliance and optimize use of personal protective equipment (PPE). Methods: Preintervention planning: A key-driver diagram (Figure 1) was created for the pilot program following multiple meetings with infectious diseases (ID) physicians, healthcare epidemiologists, infection preventionists (IP), and nursing leadership. Patients admitted to the ID ward and under the management of the ID service, consisting of 3 pediatrics residents, an ID Pharmacist, and the ID attending physician, were selected for the pilot program starting in October 2025. Protocol Design: Education materials were developed and distributed to members of the ID service, including nursing staff. The stewardship pilot program team, consisting of 4 IPs and 2 healthcare epidemiologists, conducted twice weekly chart reviews of ID ward patients to determine the appropriateness of TBP orders. The pilot program team would interface in-person to review the admitted patients with the ID service once weekly. To determine the impact of the pilot program, baseline and post-intervention TBP-appropriateness was compared using the chi-square test of proportions. Results: At baseline, 60% of patients were on appropriate TBP (n = 249). Following the implementation of the pilot program, the percentage of patients on appropriate TBP increased to 73% (n = 162), p < 0.01. During the interim analysis period, there were no noted outbreaks or documented HAIs on the ID ward. Conclusion: An interim analysis of the TBP stewardship pilot program demonstrated an improvement in the appropriateness of TBP applied to hospitalized patients. Based on qualitative comments from the physicians and nursing staff, the pilot program was well-received. Strengths of the program include real-time feedback, education, and review as well as increased visibility of the Infection Prevention & Control team. Future efforts will focus on increasing TBP-appropriateness to the 80% goal and quantifying the impact on PPE utilization.

Background: Hospitalized patients colonized or infected with multidrug-resistant organisms (MRO) have historically been placed on contact precautions (CP) for months or indefinitely. However, the necessity of CP for MROs to prevent nosocomial transmission is controversial, and adult data show that standard precautions might suffice for select MROs. Data in pediatrics are lacking, and isolation practices vary between institutions. After literature review and benchmarking with peer institutions, we sought to decrease the amount of time patients in our institution with MROs spent on CP. We aimed to decrease the proportion of inpatient days on CP for patients with MROs while maintaining or decreasing the rate of healthcare associated (HA)-MROs. Methods: Between -12/, we completed a series of plan-do-study-act cycles. These included (1) major MRO policy update with new de-isolation criteria (Table 1), (2) frontline provider education, and (3) implementation of a secondary clinical review by infection prevention and control (IP&C) medical director, to appropriately expedite the removal of undue isolation of patients with MRO infection status. Eventually, infection preventionists no longer needed a secondary review, so the fourth PDSA cycle eliminated that secondary review. Our outcome measure was proportion of inpatient days in CP for patients with MROs. Our process measure was the number of medical director case reviews/month; balancing measure was number of total HA-MRO, HA resistant gram-negative rods (GNR) and HA Methicillin-resistant Staphylococcus aureus (MRSA)/month. Data were monitored on statistical process control charts. Results: Proportion of MRO isolation days decreased from 4.5% to 2.6% (figure 1). Number of medical director secondary reviews increased and was sustained for 8-months until no longer required (figure 2). No center line shifts were noted in the?rate of HA-MROs (figure 3). Conclusion: Shortening the duration of CP for select MROs can be safely implemented and did not increase HA-MDRO rate in our children’s hospital.

Background: During outbreaks of emerging infectious diseases, healthcare personnel (HCP) safety depends not only on PPE availability but also on correct donning and doffing. In real-world isolation care, inconsistent guidance, product variability, and workflow constraints contribute to self-contamination risk. Human-factors–driven PPE ensembles were developed and their performance was evaluated through a series of standardized, simulation-based randomized crossover studies. Methods: Three randomized crossover simulation studies were performed among HCP to evaluate PPE performance. The first study compared existing Level C/D PPE ensembles with prototype PPE ensembles during simulations (n=40). Participants performed two donning–simulation–doffing sequences with randomized PPE order, and self-contamination was assessed using fluorescent markers and ultraviolet light. Based on findings from the first study, the PPE ensembles were iteratively refined and re-evaluated in a second randomized crossover simulation focused on post-refinement performance among returning participants (n=29). A third randomized crossover simulation assessed the effect of structured donning/doffing education and brief coached practice when using the refined PPE ensembles compared with existing PPE among PPE-na HCP (n=20). Outcomes included objective self-contamination events, perceived protection, usability (donning, working, doffing), overall satisfaction, confidence, and intention to use. Results: In the initial randomized crossover simulation (n=40), self-contamination after doffing was observed in 42.5% of participants using existing PPE and 52.5% using the prototype PPE ensembles, despite higher perceived convenience with these ensembles (mean scores, 10-point scale: working 7.5 vs 5.9, doffing 6.6 vs 5.5). Following iterative refinement, the second simulation (n=29) demonstrated improved performance of the developed PPE ensembles, with self-contamination reduced to 37.9% compared with the initial prototype evaluation, and no severe contamination events observed. Usability ratings further improved (donning 8.0 vs 7.1, working 8.1 vs 7.5, doffing 7.8 vs 6.6), and intention to use was high (8.9/10). In the third randomized crossover simulation among PPE-na HCP (n=20), structured education and coached practice reduced self-contamination from 50% with existing PPE to 35% with the developed PPE ensembles and substantially improved usability (donning 8.6 vs 6.1, working 9.0 vs 6.4, doffing 8.4 vs 5.2) and confidence. Conclusions: Across three randomized crossover simulation studies, human-factors–driven PPE ensembles demonstrated improvements in usability and reductions in self-contamination. Importantly, early identification of increased self-contamination risk during prototype evaluation enabled design optimization, resulting in safer performance. Standardized simulation-based evaluation can identify early risks, guide PPE optimization, and support safer adoption of improved PPE ensembles in high-risk isolation care settings.