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background: the covid-19 pandemic placed infection prevention and control (ipc) units at the center of hospital crisis response. beyond operational overload, ipc managers were required to make rapid decisions, adapt standards in real time, and lead teams under sustained uncertainty. these conditions highlighted the importance of managerial autonomy, self-efficacy, and leadership, and provided a unique opportunity to examine how extreme crisis reshapes managerial capacity in practice. objectives: to examine how the covid-19 pandemic influenced managerial self-efficacy, autonomy, and leadership among ipc physician managers and ipc nurse managers, and to explore associations between these managerial traits and ipc implementation-related activities during the pandemic. Methods: a mixed-methods study was conducted across israeli public hospitals. the quantitative component included 50 senior ipc unit managers(19 physician managers and 31 nurse managers) from 29 of 31 israeli public hospitals, reflecting broad national representation(table 1). the qualitative component included semi-structured interviews with 10 ipc managers(5 physicians and 5 nurses) from 9 hospitals. study instruments included the managerial self-efficacy questionnaire (α=0.91–0.97), managerial autonomy questionnaire (α=0.68–0.89), leadership evaluation questionnaire (α=0.65–0.97), organizational change implementation questionnaire (α=0.78–0.92), and the covid-19 managerial impact questionnaire (α=0.86–0.94). all instruments underwent pilot testing and expert review to ensure content validity and reliability. quantitative data were analyzed using analysis of variance and pearson correlation coefficients, while qualitative data were analyzed thematically to capture experiential and contextual insights. Result: mean managerial scores during the pandemic were high and comparable between physician and nurse managers across autonomy, conflict management, leadership during crisis, and overall managerial performance, with no statistically significant differences between groups (figure 1). perceived covid-19 impact demonstrated significant positive correlations with multiple managerial traits, including autonomy (r=0.473), self-efficacy (r=0.388), strategy and vision (r=0.458), process management and intervention boundaries (r=0.463), and transformative leadership (r=0.320) (p<0.05)(figure 3). correlations were also observed between covid-19 impact and core ipc activity domains, particularly research, consultation, training, and infection monitoring, while weaker or negative associations were noted for investigative and event-driven activities(figure 2). qualitative findings reinforced these patterns, revealing accelerated decision-making capacity, increased managerial autonomy, and strengthened leadership identity. physician managers emphasized maintaining operational continuity, whereas nurse managers highlighted increased assertiveness alongside substantial personal and emotional burden. Conclusion: the covid-19 pandemic functioned as a catalyst that reshaped managerial skills in ipc units, strengthening autonomy, self-efficacy, and leadership under crisis conditions. while managerial growth was evident, the findings also underscore the personal cost borne by ipc leaders, particularly nurses. investment in leadership development and organizational support systems
Background: Contact precautions were used during COVID-19 to reduce nosocomial transmission, though these practices have environmental impacts. We sought to examine the effect of de-implementing contact precautions in a regional healthcare system. Methods: We utilized the electronic medical record to identify all hospital-onset COVID-19 cases among hospitalized patients in nine regional hospitals from Results: There were 88,963 patient-days of isolation during implementation, and 23,378 patient-days of isolation after implementation. Conclusions: Despite de-implementing glove/gown use, we observed no increase in HO COVID-19; however, we benefited from a considerable decrease in both global warming potential and waste.
Background Decolonization decreases risk of healthcare-associated and post-discharge infections. Most decolonization data are derived from methicillin-resistant Staphylococcus aureus (MRSA) studies, although results have been extended to other multidrug-resistant organisms (MDRO). Understanding MDRO target outcomes and preferred product characteristics may inform new decolonization protocols, products, and strategic integration into infection prevention practices. Methods We surveyed 134 Society for Healthcare Epidemiology of America (SHEA) Research Network-affiliated US healthcare facilities on MDRO surveillance, isolation, and deisolation practices. The survey asked about decolonization practices, needs, and gaps. The survey was administered via REDCap from 1/7/25-2/25/25, and responses were de-identified. Frequencies and proportions were analyzed in REDCap and Excel. This survey was considered nonhuman subjects research by the Mass General Brigham Institutional Review Board. Results Of 134 facilities surveyed, 52 (39%) completed the decolonization section of the survey. 38/52 (73%) facilities reported performing some form of decolonization. Of these, 87% said the most important decolonization outcome is reduced risk of progression to infection. Lab-based clearance (8%) and reduced risk of transmission (5%) were considered less important. Using carbapenem-resistant Enterobacterales (CRE) as an example of an MDRO without established decolonization products or protocols, respondents’ interest in decolonization increased with patient vulnerability to invasive disease (Figure 1). Preferred decolonization agent characteristics varied by patient population, e.g. a majority selected transmission interruption in the non-intensive care unit compared to patient-specific efficacy in the transplant population (Figure 2). Half of the surveyed facilities reported having unmet decolonization needs. Across all patient types, the most commonly reported reasons not to decolonize were “efficacy not worth the effort”, “wouldn’t protect the patient” and “effect won’t last” (Figure 3). Approximately one quarter of respondents said they would not want to decolonize for “other” reasons including, “no established protocol” and “unclear evidence”. Conclusions Facilities reported valuing decolonization as a means to prevent progression to infection, but transmission prevention was rarely selected as an important outcome of decolonization. Due to reported preferences of agent characteristics by patient population, there may be opportunities for development of population-specific products. Product design should prioritize decolonization agents that are easy to administer, highly effective, and provide long-lasting impact. Evidence-based, standardized decolonization protocols, particularly for gram negative MDRO, are needed to address barriers and support decolonization in prevention of transmission as well as infection.
Background: Up to 33% of methicillin-resistant Staphylococcus aureus (MRSA) colonized patients will subsequently develop an invasive MRSA infection. Intranasal treatment is necessary to eliminate MRSA in the nose, which is recognized as a primary carriage site. In our 542 bed, community, teaching hospital, we had implemented CHG daily bathing for targeted patient populations (patients in ICU and with central lines), but struggled to reduce MRSA bacteremia rates. We proposed adding nasal decolonization and expanding the target population to include MRSA-positive patients, as a method of reducing MRSA bloodstream infections. Methods: On July 21, 2025, a formal MRSA decolonization protocol, including twice daily mupirocin for five days, and daily CHG bathing was recommended for all ICU patients, regardless of MRSA history, and MRSA positive patients, on any inpatient unit. A MRSA decolonization order set went live on October 27th, 2025, and was automatically added to pre-existing ICU admission and central line maintenance order sets. Pre-and post-intervention National Healthcare Safety Network (NHSN) hospital-onset MRSA bacteremia standardized infection ratios (SIR) were compared, in addition to a monthly review of MRSA bacteremia rates per 1000 patient days and mupirocin administration. NHSN antimicrobial resistance module standardized resistant infection ratios (SRIRs), were also compared between 2024 and 2025. Result: The pre-intervention (January-June 2025) MRSA bacteremia SIR was 0.853, compared to a post-intervention (August-December 2025) MRSA bacteremia SIR of 0.405. This represents a 53% reduction in SIR (p=0.398). The outpatient MRSA BSI prevalence rate from emergency department visits stayed steady between the pre and post-intervention periods, at 0.095 and 0.094. Figure 1 shows the inverse relationship between the increase in mupirocin administration (utilizing a threshold of < 5 administered doses) and decrease in hospital-onset MRSA bacteremia. Figures 2 and 3 show the prior years’ variation and current decline in SRIRs for both MRSA bacteremia and lower respiratory tract specimens. A decreasing trendline was not observed for other organisms’ SRIRs, including vancomycin-resistant Enterococcus. Conclusion: MRSA bacteremia contributes to significant morbidity, mortality, and financial penalties for hospitals. CHG bathing alone for ICU and central line patients was inadequate to reduce MRSA bacteremia rates. A default order set for MRSA decolonization, including nasal mupirocin, added to all ICU admissions and central line maintenance orders, improved compliance with the recommended protocol. Our hospital experienced a reduction in MRSA bacteremia following the implementation of a standardized decolonization protocol, including the nares, for all ICU, central line, and MRSA positive patients.
Introduction: In the setting of the BACTEC BCx bottle shortage in 8/2024, we established a clinical standard for BCx stewardship using evidence-based best practices. Specifically, we implemented clinical decision support (CDS) within the electronic medical record (EMR) across the health system to prompt reflection on the indication for BCx collection and discourage low-yield testing. Our primary objective was to compare blood culture event (BCE) rates before (8/2022-7/2024) and after (8/2024-8/2025) CDS implementation. Secondary objectives included comparing all-cause mortality, 30-day readmission, BCx contamination rates, antimicrobial use, central line–associated bloodstream infection rates, and hospital-onset Clostridioides difficile infection rates before and after CDS implementation. Methods: This study was conducted within an academic health system comprising 3 inpatient hospitals. In 8/2024, we integrated CDS into the EMR (Epic Systems, Verona, WI). (Figure 1) CDS was displayed whenever a provider ordered a BCx set. Providers were prompted to document the clinical indication for the BCx, stratified as high-, medium-, or low-yield based on the algorithm developed by Fabre et al. in the DISTRIBUTE study. If the selected indication was categorized as low-yield, the CDS displayed a message noting the likelihood of low-diagnostic yield and required additional justification documentation. Providers retained discretion to proceed with the order. We used an interrupted time series (ITS) analysis to compare BCE rates in the pre- versus post-intervention periods. Results: The preintervention period had a rate of 52.8 BCE per 1000 inpatient days compared to 46.5 BCE per 1000 inpatient days in the postintervention period (0.88 95% CI 0.87-0.89 p< 0.01). (Figure 2) ITS analysis demonstrated a significant decrease in BCE rate by 17.5% (95% CI -20.7%, 014.2%, P-value < 0.01) at the time of the intervention, but a significant increase in BCE rate of 1.0%% (95% CI 0.6%, 1.4%, p-value <0.01) in the post-intervention period. (Figure 3) We also saw a significant increase in days of antibiotic therapy and BCx contamination rates. (Figure 2) 37,418 BCEs were placed when the CDS was active. Of these, 22,994 BCE (61.5%) were ordered for sepsis. Of the remaining 14,424 BCE, 3,127 (22.0%) occurred for low-risk clinical scenarios. (Figure 4) Conclusions: We implemented hospital systemwide CDS during a critical BCx bottle shortage. While we saw an initial decrease in BCE rates, BCE rates increased following implementation. Specifically, many BCE occurred for low-risk clinical scenarios. Thus, while electronic CDS can be helpful, additional feedback mechanisms are necessary for persistent change in BCx stewardship practices.
Background: Beta-D-glucan (BDG) is a blood test that supports invasive fungal infection diagnoses, but is often over-ordered approximately 50% of the time, particularly in low-risk patients or for fungi not associated with BDG production. High rates of inappropriate use and frequent false positives, often driven by certain clinical scenarios or medication interactions, can lead to repeat testing and unnecessary procedures and treatment. While audit-and-feedback interventions can reduce test misuse, they are not feasible or sustainable for most hospitals. We implemented diagnostic stewardship of BDG through a guideline-based order panel with embedded decision support and interruptive alerts to replace a standalone test (figure 1). This quality improvement (QI) study aimed to reduce the use of BDG in the adult inpatient setting by 20% by 3/2026. Methods: From 3/5 -10/25/25, a multi-disciplinary team implemented this QI project at 8 campuses using iterative Plan-Do-Study-Act cycles. The primary outcome was the number of weekly BDG tests ordered across all campuses. Process measures included the number of interruptive alerts, the rate of duplicate tests, and adherence to order panel recommendations regarding appropriate host factors for BDG testing. Data was collected via the electronic health record. Statistical process charts (SPC) were used to display and analyze data, and Associate Process Improvement rules were applied to detect special cause variation. Results: Across the health system, the average weekly serum BDG orders decreased by 17% (figure 2). The false-positive and repeat-test alerts fired on average 76 and 8 times/week, respectively. Due to frequent false-positive alerts, low-impact factors (e.g., piperacillin-tazobactam) were removed, reducing average weekly false positive alerts from 101 in the first half of the intervention to 52. 77% of the false positive alerts were among patients on internal medicine, critical care, and oncology services. Based on chart review of 50 medicine, critical care, and oncology patients, approximately 51% of false-positive OPAs led to successful test interruption (i.e. delayed BDG ordering by ≥6 hours). The percentage of weekly duplicate tests decreased from 23% pre-intervention to 20% during the intervention. Accurate adherence to the order panel in this subset was 76%. Conclusion: In this study, we successfully implemented scalable BDG diagnostic stewardship, achieving a sustained 17% reduction in weekly BDG orders and nearly reaching the 20% target after 32 weeks. Further optimization of OPAs, along with provider feedback and education, may yield additional improvements.
Background: Faced with a national blood culture (BC) bottle shortage, our institution implemented a diagnostic stewardship intervention relying on multidisciplinary teams' education to enhance provider awareness, along with technological checkpoints. This initial effort resulted in a 60% reduction in BC orders and an estimated monthly savings of approximately $145,000, with no change in in-hospital sepsis mortality. The initial report covered the post-intervention period up to January 2025. As bottle availability normalized, acute-phase restrictions ended, while key stewardship components were deliberately maintained. The electronic medical record (EMR) best practice advisory (BPA) remained active, paired with continued clinician education and ongoing monitoring of blood culture utilization to reinforce appropriate practice. We subsequently evaluated the durability of this stewardship approach, focusing on long-term utilization drift and the net sustained reduction in blood culture use after the acute supply crisis resolved. Methods: We conducted a retrospective review of BC utilization at a 438-bed tertiary care academic center. The study compared the Pre-Intervention Baseline (P1: January 2023-July 2024) against the two post-intervention phases: the acute shortage (P2: August 2024–January 2025) and the sustainability phase (P3: February 2025–September 2025). The stewardship intervention in P3 included an EMR-based BPA, along with ongoing education and monitoring. The primary outcome was the mean monthly BC orders. Statistical stability in P3 was assessed using 95% confidence intervals (CI). Results: Blood culture utilization averaged 2,777 sets per month during the pre-intervention period (P1). Following the acute shortage (P2), utilization partially rebounded and then stabilized at a lower plateau during the eight-month sustainability phase (P3) at 2,098 monthly orders. This represents a sustained 24.45% reduction compared with the pre-intervention baseline. The stability of P3 is supported by a narrow 95% confidence interval (1,909.92 to 2,186.08) and a low margin of error of ±88.08 orders, confirming that the reduction reflects a reliable new steady state. Conclusion: Our long-term evaluation shows that a diagnostic stewardship intervention implemented during an acute supply shock resulted in a durable shift in practice. Even after the shortage was resolved, monthly blood culture utilization remained nearly one-quarter below baseline and stabilized with minimal variability, indicating the establishment of a reliable new steady state. These findings highlight that targeted education and system-level checkpoints can drive lasting reductions in unnecessary testing and recalibrate ordering behavior well beyond the immediate crisis.
Background Use of automated antimicrobial susceptibility testing (AST) instruments are common in clinical microbiology laboratories, in part due to the quick turnaround time and automated result reading. Given the wide variability in validation and each individual instrument’s algorithms and parameters, AST data between clinical laboratories is not guaranteed to be comparable. Accurate AST is critical to ensure appropriate antimicrobial prescribing practices. In Tennessee little is known about the comparability of AST testing amongst clinical labs. This study aims to quantify differences in clinical automated testing instrument (ATI) performance when compared to broth microdilution (BMD). Methods Clinical laboratory AST data from Phoenix (PHX) and Microscan (MS) instruments were obtained for carbapenem-resistant Enterobacterales (CRE) and carbapenem-resistant Acinetobacter baumannii (CRAB) via the Multi-site Gram-Negative Surveillance Initiative. Data were received from the residents of seven select counties in Tennessee from 2019–2024. Identified isolates were sent to the Tennessee State Public Health Laboratory’s Antimicrobial Resistance Lab Network (ARLN) program for additional testing, including BMD AST, which was used as the reference standard. Agreement between ATIs and BMD breakpoint interpretations were measured using a weighted Cohen’s Kappa calculated in SAS 9.4. Results There were 401 isolates included in this study. Eleven antibiotics were evaluated for agreement between MS and BMD, and ten were evaluated for agreement between PHX and BMD, shown in Table 1. Six antibiotics and four antibiotics showed lower agreement to BMD for PHX and MS respectively. Both MS and PHX showed near perfect agreement (κ<0.81) for four antibiotics. Additionally, MS and PHX both showed moderate agreement (κ<0.41) for five antibiotics, two of which were imipenem and meropenem. Agreement between ATI and BMD was poor for ertapenem across both MS and PHX, with the data showing clinical ATI are over-reporting resistance compared to BMD. Agreement between MS and BMD was also poor for cefotaxime (0.39). Conclusion While this study only evaluated a subset of isolates tested at the clinical laboratory, it still demonstrates that clinical AST instruments results are not necessarily comparable, with half of the antibiotics evaluated showing moderate to poor agreement when compared to BMD. The poor agreement reported for ertapenem is particularly concerning, as these represent overreported carbapenem resistance, which impacts treatment options, transmission-based precaution implementation, and unnecessary confirmatory testing through ARLN. This study demonstrates the need for laboratories utilizing commercial AST instruments to perform frequent quality control checks to ensure instruments are functioning within an acceptable performance standard range.
Background Blood cultures obtained in the emergency department (ED) are critical for diagnosing bloodstream infections but are frequently compromised by suboptimal sampling practices, contamination, and delays in transport to the microbiology laboratory. These limitations reduce diagnostic yield and may contribute to inappropriate antibiotic use. We evaluated the impact of a sustained, multicomponent quality-improvement intervention on blood culture quality, diagnostic yield, timeliness of transport to the microbiology laboratory, and time to culture growth. Methods We conducted a retrospective analysis of all blood cultures obtained in the ED of an acute-care hospital between January 2019 and December 2025. The ED treats approximately 85,000 patients annually. A multicomponent intervention was initiated in January 2021 and included repeated staff education, quarterly performance feedback, and workflow optimization. Blood culture transport was transitioned from manual delivery to a pneumatic tube system, and diversion tubes were introduced in January 2023 to decrease contamination. Outcomes included annual uptake of two-set sampling, pathogen detection, and contamination rates. Time from collection to incubation and growth was evaluated before and after the intervention. Trends across years were assessed using a test for linear trend. Results A total of 10,729 blood cultures were analyzed. Adoption of two-set blood culture sampling increased over time, from <3.2% (33/901) in 2019 to 45.9% (904/1,971) in 2025 (p<0.001; Figure 1). Overall, the proportion of blood cultures yielding a pathogen increased during the study period, rising from 6.8% (61/901) in 2019 to 12.2% (240/1,971) in 2025 (p for trend <0.001). Pathogen detection was significantly higher when two blood culture sets were obtained compared with a single set (12.9% [455/3,532] vs 8.8% [634/7,197]; p<0.001). In parallel, contamination rates declined markedly, from 13.9% (130/935) in 2019 to 6.0% (173/2,894) in 2025 (Figure 2). Among positive blood cultures, the distribution shifted over time, with contaminants predominating early and true pathogens predominating during the intervention period. (Figure 3) Timeliness of blood culture handling improved concurrently. Median time from collection to laboratory arrival decreased from 9.4 hours (IQR 2.8–14.9) to 2.3 hours (IQR 1.3–4.0; p<0.001). Concurrently, median time from collection to culture growth decreased from 27.7 hours (IQR 20.4–38.5) to 20.0 hours (IQR 14.6–29.3; p<0.001). Conclusions A sustained, multicomponent quality-improvement intervention in the ED was associated with improved blood culture diagnostic yield, reduced contamination, shorter laboratory processing times, and earlier growth detection. These findings highlight the value of coordinated process optimization to advance diagnostic stewardship and patient safety in high-acuity settings.
Background: Inappropriate urine cultures without a clinical indication are sent frequently. Previous work has demonstrated that clinical decision support (CDS) requiring an indication for culture can reduce the number of unnecessary urine cultures. Our multi-campus VA facility implemented requirement of an indication for urine culture orders and evaluated the rate of urine cultures over time as well as the indications. Methods: We implemented a previously developed CDS menu across inpatient and outpatient services within VA Boston healthcare system. The CDS implementation required assistance and approval from our laboratory and clinical applications coordinators. Clinicians were notified about the change in ordering process through email and focused educational sessions. We captured rates of urine cultures by location and by indication and compared rates before and after implementation. A run-in period was allowed for full roll-out of the intervention, which was set at 98% of urine cultures being ordered through the CDS menu. This was a quality improvement initiative. Result: The study period included a 5-month pre-intervention period and a 5-month post-intervention period that followed a 2 month run-in period. A total of 2955 urine cultures were ordered preintervention compared with 2028 cultures postintervention. The average rate of monthly urine cultures decreased from 591/month to 406/month (P Conclusion: We demonstrated a significant reduction in urine culture orders using a clinical decision support intervention that required the ordering clinician to indicate a reason for the order. This intervention only required a targeted modification in our lab orders and was simple for clinicians to comply with given a drop down click menu. One limitation is that we did not capture clinical outcomes - but we did have continuous feedback from clinicians that did not indicate any adverse events, either in efficiency of practice or in outcomes among patients. This approach has been more successful at our hospital compared with other approaches that require system wide changes in urine culture processing or resulting. It has the added benefit of direct clinician education regarding appropriate urine culture indications in different settings.
Background Inappropriate urine culturing is a driver of unnecessary antibiotic use and treatment of asymptomatic bacteriuria. Diagnostic stewardship interventions, including clinical decision support(CDS), can reduce urine culture utilization; however, their impact on downstream testing patterns and antibiotic prescribing remains limited. In August 2024, Tufts Medical Center implemented an indication-based CDS requiring providers to select a guideline-concordant indication when ordering inpatient urinalysis(UA), UA with reflex to culture(UARC), or urine culture alone(UCx) We evaluated the impact of this intervention on urine testing utilization, ordering appropriateness, and associated antibiotic prescribing. Methods We conducted an interrupted time series analysis of monthly urine testing rates from August 2023 through July 2025, with CDS implementation in August 2024. The primary outcome was utilization of urine testing, measured as rates of UA, UARC, and UCx per 1000 patient days. Segmented regression models with a normal distribution and identity link were used to estimate baseline trends, immediate level changes at implementation, and post-intervention trend differences(ITS). As a secondary outcome, we retrospectively reviewed a random sample of 153 adult patients post-implementation UARC orders to assess urine testing appropriateness and antibiotic prescribing based on clinical documentation and predefined institutional criteria(Image 1). Results During the study, 124,762 urine tests were ordered across 225,614 census days. Prior to CDS implementation, UA, UARC, and UCx rates showed no significant secular trends(Figure 1-3). Following implementation, UARC and UCx rates showed immediate and significant level decrease. UARC utilization increased post-implementation but remained below pre-intervention levels, while UCx rates showed a sustained reduction without significant post-intervention trend change. In contrast, UA rates increased immediately after implementation, followed by a non-significant decline. Table 1 summarizes effect estimates. Of 153 audited UARC orders, 46.4% originated from the emergency department (ED), 41.2% from intensive care unit and 12.4% from inpatient floor units. Urinary signs or symptoms were the most frequently selected indication for UARC, particularly in the ED(95.8%). Documentation supported appropriate UARC testing in only 9.9% of ED orders, 19.2% of floor orders, and 27.8% of ICU orders. Antibiotics were initiated for presumed urinary tract infection(UTI) in 29 patients(19%), of whom 9(5.9%) had documented UTI. Conclusion Indication-based urine testing CDS intervention produced immediate and intended changes in testing utilization (decreased UARC and Ucx, and increased UA), followed by partial attenuation of the UARC effect over time. Post-implementation chart audit demonstrated persistent gaps in documentation-supported appropriateness and antibiotic initiation, underscoring the need for additional targeted stewardship interventions beyond CDS alone.
Background: Gram-negative bacteremia (GNB) accounts for a substantial proportion of both community-onset and nosocomial bloodstream infections and carries significant morbidity and mortality. The utility of follow-up blood cultures(FUBC) for GNB remains unclear. Prior studies have demonstrated associations with prolonged hospitalization and antibiotic duration without clear reinfection or mortality benefit. Methods: We conducted a retrospective cohort study of adults (<18 years) admitted to a three-hospital healthcare system with GNB from 4/1/2024 to 1/31/2025. Patients who died within 24 hours of the initial positive culture or had hospital stays < 35 days were excluded. Clinical variables including organism, infection source, presence of indwelling catheters or other devices, immunocompromising conditions, severity scores (qSOFA, PITT), as well as intensive care unit admission (ICU) were also collected. Primary outcomes were 30-day mortality and 90-day reinfection. We used chi-square and Fisher’s exact test to compare categorical variables and Mann-U Whitney to compare continuous variables based on repeat blood cultures. We used the univariate screen (p<0.1) and prespecified variables that we thought might impact repeat blood cultures in an inverse probability of treatment-weighted models using propensity scores. Results: There were 372 identified eligible patients with GNB. These patients were split based on whether they had FUBC or not. There were no significant differences in immunocompromised status, co-morbidities, or age between the two groups. The most common organisms detected were Enterobacterales, followed by Pseudomonas. The most common source of infection was overwhelmingly genitourinary, followed by gastrointestinal and hepatobiliary. There were no significant differences between those who did and did not undergo FUBC for odds of 30-day mortality (OR 0.74 (0.36-1.55)) or 90- day reinfection (OR 0.86 (0.16-4.47)). However, FUBC were associated with significantly longer median hospital stay (7 days vs 5 days, p < 0.001) and higher odds of receiving <7 days of antibiotics (OR 2.28, (1.23-4.25), p = 0.009). Persistent bacteremia despite appropriate therapy occurred more frequently among patients with ICU admission, though clinical impact could not be fully assessed. Additionally, patients with an Infectious Diseases consult were more likely to have FUBC. No other subgroup was significantly more likely to have blood cultures repeated. Conclusions: The use of FUBC in GNB did not demonstrate improvement in mortality or reinfection rates. Instead, FUBC correlated with prolonged hospitalization and extended antibiotic therapy. It remains unclear whether FUBC offers significant clinical benefit in higher-risk groups. Further research is needed to clarify the role of FUBC in critically ill patients.
Background: Inappropriate urine culture ordering among catheterized patients can result in overdiagnosis of catheter-associated urinary tract infections (CAUTI) and unnecessary antibiotic exposure. We sought to reduce inappropriate urine culture ordering at our 167 bed acute care hospital with targeted diagnostic stewardship educational initiatives to hospitalist, emergency room, and intensive care unit providers (ICU). Objective: Estimate the impact of educational workshops on appropriate urinary ordering practices among inpatient providers at a single small acute care hospital. Methods: Retrospective observational cohort study of all catheterized patients receiving a urinalysis with reflex to culture from March 2023-April 2025. Workshops were held during different months tailored to provider groups, and attendance was recorded. Categorization of order indications and appropriateness were assessed retrospectively by a study team member applying established algorithms (i.e., IDSA guidelines with minor modifications). Patient clinical and encounter data were extracted from the electronic health record. Indications and appropriateness of orders were compared between provider groups and by provider attendance at a workshop by univariate and multivariate analysis. Results: Of 139 urinalyses with reflex to culture orders, 63 (45%) were ordered by Hospitalists, 40 (29%) by critical care providers, and 36 (26%) by other provider groups; 81 (59.6%) were inappropriate, without differences in appropriateness by provider group (p=0.10). Frequency of ordering decreased over time (7.2/month prior to last workshop vs. 4.2/month after, Figure); however, the proportion categorized as inappropriate appeared stable over time (Figure). Appropriate orders were mostly for UTI symptoms without fever (14, 25.5%), with fever (10,18.2%), or sepsis (16, 29.1%). Provider workshop attendance was as frequent among appropriate orders as inappropriate (25/55, 46% vs. 26/81, 32%, p=0.12). There were no significant differences in catheter duration, comorbidity score, and various primary discharge diagnosis by order appropriateness. Conclusion: Over two years, a majority of urinalysis with reflex to culture orders among catheterized patients were inappropriate. While diagnostic stewardship workshop attendance did not appear to impact likelihood of an order to be appropriate, we did observe an overall decrease in orders suggesting educational efforts may have influenced ordering behavior.
Background: National guidelines recommend that anyone diagnosed with a sexually transmitted infection (STI) be tested for other STIs. However, in the majority of cases, appropriate STI co-testing is not performed. Additionally, STI diagnosis is often a missed opportunity for referral for HIV pre-exposure prophylaxis (PrEP). Order sets can be an effective tool within electronic medical records (EMR) to standardize diagnostic and therapeutic pathways. We sought to improve STI co-testing, PrEP referrals, and antimicrobial management through the implementation of a diagnostic and treatment order set within the Durham VA Health Care System (DVAHCS). Methods: An STI order set prompting co-testing was implemented in September of 2024 across DVAHCS. STI co-testing rates were analyzed one year pre- and post-implementation. Interrupted time series (ITS) analysis was performed using Gaussian regression to evaluate the effect of order set implementation for both co-testing of gonorrhea, chlamydia and syphilis (GCS) and additional cotesting for HIV (total STI). New starts and overall administration of HIV PrEP and order set utilization for therapeutics were analyzed using incidence rate ratios (IRRs) comparing incidence rates pre- and post-implementation. Result: The GCS cotesting IRR was 0.991 (p p p p p p p p p = 0.582). (Figure 3) The treatment order set was used on average 24.6% of the time after implementation. (Figure 4) Conclusion: The implementation of a STI co-testing order set did not change the rate of co-testing for chlamydia, gonorrhea, syphilis and HIV. An accompanying treatment order set was used to a significant degree, although in a minority of cases. There was no significant change in the initiation of PrEP after implementation of the order set as compared to prior. Our study was limited by small numbers of incident STI diagnoses. Further research is warranted to understand the optimal ways towards increasing recommended testing patterns and how tools within EMRs can assist with this goal.
