Background: Stenotrophomonas maltophilia isolated from urine cultures often reflects colonization, however true urinary tract infection (UTI) can occur. At Massachusetts General Hospital, antimicrobial susceptibility testing (AST) is routinely performed on urinary S. maltophilia isolates when present in at least moderate amounts or is the predominating organism from a non-sterile culture source. We evaluated patients with S. maltophilia urinary isolates to characterize treatment practices, determine the proportion of isolates representing definitive UTI, and assess recurrence by treatment status to evaluate whether limiting routine AST could reduce laboratory workload and avoid unnecessary antibiotic prescribing. Methods: We performed a retrospective cohort study of patients with positive urine cultures containing S. maltophilia between May 1, 2021 and May 1, 2024. Patients were excluded if they were treated for asymptomatic bacteriuria due to pregnancy or an upcoming urologic procedure, had a repeat urine S. maltophilia isolate within 14 days of index culture, had concomitant systemic infection treated with an antibiotic active against S. maltophilia, or died before recurrence evaluation. The primary objective was to characterize treatment decisions when S. maltophilia was isolated in urine culture. Secondary objectives included determining the frequency of true S. maltophilia UTI and evaluating recurrence based on whether the infection was treated. We defined definitive UTI as localized urinary symptoms with pyuria; possible UTI as systemic symptoms not explained by other causes or localized symptoms with an alternative etiology, with pyuria; and unlikely UTI as no symptoms reported or documented with or without pyuria. Results: A total of S. maltophilia directed therapy, despite only 19 (15.6%) meeting criteria for definitive UTI. In 11 cases, treatment was administered despite UTI being classified as unlikely. Among total untreated urine cultures (n=83) and definitive infections that were untreated (n=7), recurrent S. maltophilia infection was uncommon (3.6% and 0%, respectively). Conclusion: In our cohort, few urinary S. maltophilia isolates were reflective of definitive UTI, and withholding targeted therapy was associated with low recurrence. These findings suggest many isolates reflect colonization, particularly in patients with urinary instrumentation, and support consideration of a more selective approach to AST and antibiotic prescribing when isolated in urine culture.

Background: The 2024 blood culture (BCx) bottle shortage highlighted the importance of BCx stewardship. During the shortage period, an electronic medical record alert (Figure 1) was implemented to conserve BCx bottle supply and subsequently maintained after shortage conclusion. An alert fired when repeat BCx were ordered within 48 hours of prior BCx and required written justification of the order to proceed. Sustainable mechanisms to implement BCx stewardship using clinical decision support are needed. This study evaluates whether written justification for bypassing the alert adhered to institutional BCx guidance. Methods: A retrospective cohort study of repeat BCx orders where the alert fired and was bypassed in adult patients in first 6 months after implementation (8/12/2024-2/11/2025) was evaluated at a single academic hospital. Primary outcome was the adjudicated adherence to institutional BCx guidance for alert-triggered BCx. Additional outcomes included true positive and contamination rates based on adherence, timing of repeat BCx, and whether repeat blood cultures were obtained <40 hours from initial BCx, serving as a measure of appropriate timing. Falsely triggered alerts were defined as initial BCx orders that were canceled yet triggered the alert or when clinicians added BCx to initial orders within <6 hours. Results: Among 162 BCx episodes, 130 were included (exclusions: 7 pediatric, 25 falsely triggered alerts). These 130 BCx episodes consisted of 247 repeat BCx sets in 105 patients. Characteristics of initial and repeat blood culture episodes are in Figure 2. The median time from initial to repeat BCx was 45.6 hours (IQR 35.5-49.3) (Figure 3). Repeat blood cultures were obtained after 40 hours in 67.7% of episodes (Figure 4). Repeat BCx adhered to local guidance for appropriate repeat BCx in 79/130 (60.8%) of episodes with higher yield of true pathogens in adherent indications (20/79, 25.3%) compared to nonadherent indications (3/51, 5.9%) (Figure 5). The indications with highest positivity were retained infected central venous catheters (35.7%) and Staphylococcus aureus bloodstream infection (35.3%). Repeat BCx obtained ≥40 hours had higher adherence compared to those obtained <40 hours (70.5% vs 40.5%). Conclusion: Overall adherence to local BCx guidance for repeat BCx via an alert was 60% with higher positivity when ordered for appropriate indications and with appropriate timing. The alert did create falsely triggered alerts, and clinician judgement outside the guidance identified rare cases of persistent bloodstream infection.

Background Implementation of diagnostic stewardship is a key strategy in antimicrobial stewardship to improve use of antimicrobials and human resources to promote value-based care. Pediatric urinary tract infections represent the most common pediatric infection with increasing antibiotic resistance and high utilization of diagnostic testing. The purpose of this study is to examine the impact of implementing a reflex urine culture (UCx) algorithm to reduce unnecessary UCxs in a pediatric emergency department. Methods: This is a pre/post study from April 1st, 2022 through March 31st, 2025, with the UCx algorithm intervention implemented in July 2023. A urinalysis (UA) and UCx report was generated from EPIC, placed in Excel, and analyzed descriptively and statistically via Wizard 2.0, Version 2.0.14. Data included age, gender, weight, race, ethnicity, payor status, language, zip code, and UA and UCx results. Children 2-18 years of age were included. Patients <2 years of age and any patient with only a point of care test (POCT) UA, UCx, or urine microscopic test, or duplicate test within 24 hrs were excluded. The reflex criteria was defined as a UA with ≥5 WBC/hpf and excluded children <2 years of age or who are immunocompromised. Results A total of 17,502 unique patients with a UA were evaluated. Both pre (n=6,956) and post (n=10,597) were similar for demographics including gender (female 69.7% vs 69.4%) and average age (9.93 years vs 9.97 years). Percent of UA’s with ≥5 WBC/hpf in the pre (n=1,567) vs post (2,361) were also similar at 22.5% vs 22.3% (p=0.7). 3,453 total UCxs were completed in the pre compared to 3,170 post. The UCx to UA ratio was 49.6% pre compared to 29.9% post (p<0.001). An improvement in UCx positivity rate from 11% pre to 20.3% post (p<0.001) was also shown. Cost savings further justifies the intervention as a projected $300,960 was saved by preventin 2,090 unnecessary UCx ($144 /culture). No differences were found by demographics except for race. While all races (black, white, other) saw a significant improvement in urine culture obtainment (p<0.001), white patients had a larger decrease from 48% to 27.2% compared to black from 49.9% to 33.4%. Conclusions A reflex UCx algorithm can be a successful implementation tool in diagnostic stewardship. Next steps will include exploring more stringent reflex criteria, lowering the age to 1 year, assessing the impact on health equity, and evaluating the impact in other health care locations to promote further value-based care.

Background: Multiplex syndromic polymerase chain reaction (PCR) panels can rapidly identify pathogens in patients with diagnosis of pneumonia, but they may also detect colonizing bacteria, which can lead to diagnostic uncertainty. Their utility in sputum samples remains unclear, as most evidence comes from higher-quality bronchoscopy specimens. To ensure these tests are used in scenarios with the greatest clinical impact, such as when results can be returned quickly and guide treatment, we developed a clinical decision support tool. The tool restricts ordering of multiplex pneumonia PCR panel on sputum samples to patients with severe illness or immunocompromise. Methods: The study was conducted at a New York City hospital system. Beginning in December 2024, the pneumonia PCR panel decision support tool was implemented and restricted ordering on sputum samples to patients who were admitted to the intensive care unit (ICU), prescribed vasopressors, required at least high flow nasal cannula for supplemental oxygen, had solid organ or hematopoietic transplant, received Gram negative coverage with meropenem or broader for 48 hours without improvement, and/or infectious diseases or pulmonary attending consult recommendation. We analyzed the total number of sputum pneumonia PCR panels and associated positivity rates prior to and after implementation of the decision support tool during quarters 1 through 3 of 2023, 2024 and 2025. Results: After intervention implementation, the overall number of sputum pneumonia PCR panels ordered decreased by 34%. At $200 per PCR panel, this represents a cost savings of at least $208,000. The greatest change was on non-ICU inpatients, where the total decreased from 1267 in 2024 to 504 in 2025 (60%, Figure 1). The emergency department had a decrease from 266 in 2024 to 125 in 2025 (53%). There was minimal change in PCR panel usage in the ICU and outpatient, which are areas not targeted by the intervention. The positivity rate was consistent over the three years (70-75%). Most sputum PCRs detected multiple bacterial organisms (57-70%, Figure 2a) and 5-11% of samples detected bacteria at a quantity of only 10^4, with or without viral co-infection (Figure 2b). After reviewing post-implementation quarter 1 2025 data, broad Gram-negative coverage was removed as a testing criterion since it was selected frequently (32%) but not accurately (10% accuracy). Conclusion: Implementation of a clinical decision support tool in Epic led to more appropriate diagnostic stewardship of the multiplex pneumonia PCR, improving care and reducing costs. Future interventions will target improving stewardship in the ICU.

Introduction: The BioFire® FilmArray® meningitis/encephalitispanel can be a helpful test for early diagnosis of community acquired central nervous system infection. However, excessive ordering can lead to patient harm, increased healthcare costs, and excessive environmental impact. Despite a diagnostic stewardship algorithm in place at our institution, ME panels are frequently nondiagnostic, prompting inquiry into whether our diagnostic stewardship algorithm could be improved and if a ME panel ordering decision rule could improve test utility. Objective: Review ME panels performed over a one month period and evaluate for adherence to our institution’s diagnostic stewardship pathway. Methods: We performed a retrospectivechart review of ME panels performed on adult patients over a one month time period at our institutionfor order indication,progress note clinical indication, other cerebrospinal fluid (CSF) test results, ME panel result, and patient outcome. Adherence to our current microbiology lab diagnostic stewardship algorithm and clinical utility were evaluated. The current algorithm calls for ME panels to be performed only on CSF collected via lumbar puncture (LP) with CSF total nucleated cells (TNC) <5, low glucose (<40 mg/dL), or abnormal protein (<15 mg/dL or <45 mg/dL) in non-neutropenic adults. Our electronic medical record (EMR) also provides hard stops if order indication for ME panels include “Evaluate for ventriculoperitoneal shunt infection” or “Evaluate for brain mass/abcess.” An “other” option was made available to prompt an infectious disease consult to discuss clinical indication for the test. Results: Twenty-three ME panels were performed on adult inpatients and outpatients at our healthcare system over the month reviewed. All 23 ME panels resulted as normal for all 14 pathogens. Eleven out of 23 ME panels met clinical indication outlined in our microbiology lab’s diagnostic stewardship algorithm. Ten out of 23 were ordered for meningitis in an immunocompromised host, although none of the patients had WBC <1 or ANC <0.5. Five out of 10 panels were ordered on immunocompromised individuals who did not were not appear immunocompromised upon chart review. Two out of six ME panels were run for community acquired meningitis despite completely normal CSF parameters. Conclusion: There is a discrepancy between our institution’s diagnostic stewardship algorithm indications for for ME panels and actual ME panel ordering and completion. There is also a high rate of negative ME panel test results which may indicate test overuse. Re-evaluation of our ME panel algorithm and the utility of a clinical decision rule are warranted.

Background: Resilient healthcare systems prevent, absorb, and learn from stressors. Identifying resilient performance in healthcare systems can be challenging due to complex underlying processes and associated outcomes. This study aimed to identify resilient performance in US outpatient hemodialysis (HD) facilities during the COVID-19 pandemic by characterizing associated operational factors and classifying longitudinal patterns in bloodstream infections (BSI) rates using machine learning. Methods: This study used longitudinal BSI data reported to National Healthcare Safety Network (NHSN) by outpatient HD facilities during pre-pandemic (April 1, 2018–April 30, 2019) and pandemic (April 1, 2021–April 30, 2023) periods. For each period, facilities were classified into distinct patterns based on facility-level BSI rates (cases per 100 patient months) using k-means clustering for longitudinal data (KmL), an unsupervised machine-learning method. CMS Dialysis Facility data provided key facility characteristics and NHSN Annual Dialysis Facility Surveys provided use of Core Interventions for Dialysis BSI Prevention. Facility resilience was operationalized as classification in a lower BSI rate cluster during the pandemic period. Associations between KmL classification during the pandemic and facility operational factors were assessed using multivariable logistic regression. Result: Of 7084 outpatient HD facilities, 4907 (69%) reported BSIs to NHSN during both periods and linked to CMS data. KmL grouped facilities into two clusters for each period. During the pandemic, a lower-rate cluster (n=4132, 84%) and a higher rate cluster (n=775, 16%) had mean BSI rates of 0.19 and 0.76 per 100 patient-months, respectively. Both clusters reported strong implementation of Core Interventions; however, the higher-rate cluster had increased odds of implementing ≤64% of interventions. In the multivariable model, facilities in the higher-rate pandemic cluster were associated with being in the higher-rate pre-pandemic cluster, structural factors (non-profit ownership, non-chain facility status, having <20 dialysis stations), processes (increased central vascular catheter use, lower use of antiseptic-impregnated catheter end caps, rarely administering antibiotics before obtaining blood cultures for suspected BSIs), and geography (Northeast or Midwest US location, rurality). Conclusion: Using machine learning, two distinct BSI rate trajectories emerged before and during the COVID-19 pandemic, with key operational differences between facility groups. Facilities demonstrating lower and stable BSI trajectories during pandemic could be interpreted as exhibiting more resilient performance under system stressors. This approach can inform resilient performance across other patient safety processes, healthcare settings, and system stressors. Understanding structures and processes associated with patient safety outcomes during disruption can support public health prioritization and targeted interventions to strengthen healthcare system resilience.

Objective: To address the recurrent contamination of handwashing sinks with Pseudomonas aeruginosa (PA) in the Pediatric Intensive Care Unit (PICU), evaluate the PA elimination efficacy of different disinfectants and disinfection methods, and optimize disinfection strategies to prevent PA colonization and transmission, thereby reducing the risk of healthcare-associated infections (HAIs)? Methods: Nine handwashing sinks in the PICU (August–December 2024) were selected, meeting the criteria of three consecutive positive PA detections, usage frequency ≥20 times/day, and no prior special disinfection interventions (excluding those with recent pipe replacement or structural damage). They were divided into three groups (3 sinks per group). Three disinfectants were prepared: 500 mg/L chlorine-containing disinfectant, 0.5% benzalkonium chloride disinfectant, and 75% ethanol stock solution. Three disinfection methods were applied: rinsing method (disinfectant flushing for 1 minute twice daily at 5 L/min), soaking method (full coverage soaking with disinfectant for 30 minutes every morning followed by flushing), and slow-release soaking method (slow injection of disinfectant into the trap for 30-minute soaking, 10-minute standing, then flushing at 2 L/min). Samples were collected from the overflow outlet, drain, and other sites before disinfection, 1 minute after disinfection, and 24 hours after disinfection. Colony counting was performed using the pour plate method, PA was identified via the VITEK 2 system and mass spectrometry, and statistical analysis was conducted with SPSS 26.0 (α=0.05). Results: 75% ethanol showed the best immediate effect (colony count <0.1 CFU/cm² and PA detection rate 0% 1 minute after disinfection, P<0.001) but PA reoccurred at 24 hours. Chlorine-containing disinfectant performed stably (colony count reduced to 0.2 CFU/cm², PA detection rate 0%, P=0.002) with the optimal 24-hour bacteriostatic effect. Benzalkonium chloride had weak efficacy (colony count reduced to 5.0 CFU/cm², PA detection rate 33.3%). The soaking method and slow-release soaking method were significantly more effective in biofilm removal than the rinsing method (e.g., no PA detected with chlorine-containing disinfectant soaking method and <10% recurrence rate at 24 hours, compared to 66.7% PA positivity rate with the rinsing method at 24 hours), and the soaking method was more operable. Conclusion: For PA-contaminated handwashing sinks in the PICU, the chlorine-containing disinfectant soaking method has the best comprehensive effect, combining strong bactericidal power, good long-term bacteriostatic effect, and high operability. It is suitable as a routine disinfection scheme to prevent PA colonization in the ward, providing support for HAI prevention and control. Future research can explore more disinfection methods for ward sinks.

Background: Deviations from expected relative humidity ranges in operating room (OR) sterile cores raise concern for compromise of sterile supply packaging and frequently result in large-scale disposal of supplies. Data guiding salvage versus discard decisions following humidity exposure are limited. Following two humidity events, we performed a two-experiment bench study to evaluate whether elevated ambient humidity or direct moisture exposure results in moisture penetration or microbial contamination of Tyvek-packaged sterile supplies. Methods: Experiment 1 evaluated direct moisture exposure by applying saturated compresses to package exteriors for 0.5, 1, 5, 30, or 60 minutes. Experiment 2 evaluated elevated ambient humidity by incubating packages at 37°C and 70% relative humidity without direct moisture contact. For Experiment 1, ambient temperature and relative humidity were continuously monitored, with humidity documented at swab timepoints (4, 8, 24, and 48 hours). For both experiments, moisture content of package exteriors and interiors was measured at baseline and serial timepoints up to 48 hours. Internal package surfaces were aseptically swabbed at each timepoint, plated onto general culture media, and incubated for 48 hours at 37°C. Negative controls without moisture or humidity exposure were included. Results: In Experiment 1, ten items were evaluated, including five exposed to direct compress application and five controls. External moisture content increased following compress exposure (range: 0.9–2.2) and decreased over time. Internal moisture content remained low across all samples, including controls (range: 0–1.4). No microbial growth was detected from any internal swab across all samples and timepoints (0/10 items; 0 CFU recovered). In Experiment 2, ten items were incubated under elevated ambient humidity. Occasional low-level external moisture readings were observed (maximum: 1.2), while internal moisture content remained 0 throughout the study period. All internal cultures were negative (0/10 items; 0 CFU recovered). Conclusion: Differences in absolute internal moisture measurements between experiments 1 and 2 reflect the use of a moisture meter reporting relative units influenced by ambient conditions and the fact that experiments were not conducted in parallel. Interpretations were therefore within experiments. Tyvek-packaged sterile supplies-maintained barrier integrity under both direct moisture exposure and sustained elevated ambient humidity, with no evidence of internal microbial contamination. These findings suggest that, in the absence of visible package compromise or internal condensation, salvage of Tyvek-packaged sterile supplies following humidity excursions may be reasonable. These findings provide bench-level evidence to support data-informed infection prevention decisions during OR humidity events and may help reduce unnecessary waste and operational disruption.

Background: Clostridioides difficile is a spore-forming bacterium that causes severe healthcare-associated infections, especially in immunocompromised patients and those exposed to antibiotics. C.difficile spores can persist in the environment, making routine use of sporicidal disinfectants essential for reducing contamination and infection risk. Surgical and patient mattresses, while impervious, are soft and flexible and generally do not meet the U.S Environmental Protection Agency (EPA) definition of a hard, nonporous surface, which is the surface type typically used to test disinfectant efficacy. Assessing spore survival and disinfectant performance on these soft surfaces is important for minimizing transmission risk, especially since they are often treated like hard surfaces. Methods: Antimicrobial efficacy testing was conducted using common healthcare disinfectants against C.difficile, following standard operating procedures typically required for EPA registration. Spores were inoculated and dried onto stainless steel coupons (hard surface control) and multiple soft surface coupons made of common mattress cover materials. Each disinfectant formulation represented a common active ingredient or blend of active ingredients, ranging from ready-to-use sprays to wipes. Products were tested at approximately 90% of the manufacturer-defined contact times to stress the chemistry and reveal any efficacy differences between the different surface types. Results: Significant C.difficile Log reductions were observed with disinfectant Products 1, 2, 3, and 4, demonstrating high efficacy against C.difficile. Product 5, a non-sporicidal disinfectant commonly used on mattress covers, demonstrated little to no reduction of C.difficile. Conclusion: Using standard benchtop testing methods, this study aimed to understand the efficacy of sporicidal healthcare disinfectants against C.difficile on common soft surface materials. While EPA-registered disinfectants may be intended for hard, nonporous surfaces, the use of sporicidal disinfectants on mattresses may be more effective at reducing the risk of infection than traditionally thought, especially since these soft surfaces cannot be laundered. This is particularly important during outbreaks and underscores the proactive use of sporicidal disinfectants to mitigate C.difficile and other emerging pathogens.

Background: Daily toothbrushing is recommended for all hospitalized patients and long-term care facility (LTCF) residents because it has been associated with significantly lower rates of healthcare-associated pneumonia. However, limited information is available on effective strategies to improve education of patients on oral hygiene. Methods: We surveyed a convenience sample of 60 patients hospitalized on medical/surgical or rehabilitation wards at a Veterans Affairs medical center regarding oral hygiene education and practices. Medical records were reviewed to determine if education on oral hygiene was documented by nursing staff as is recommended by facility protocols. Based on the initial survey results, we piloted an intervention in which educational posters were placed beside the mirror in patient bathrooms and small educational placards were placed on meal trays. Patients were surveyed to determine the impact of the intervention. Results: Of the 60 patients completing the initial survey, 55 (92%) practiced oral hygiene at home, and 19 (32%) had partial or complete dentures. Nursing notes documented oral hygiene education for 39 (65%) patients, but only 18 (30%) recalled receiving education, and none were aware that oral hygiene reduces the risk for pneumonia. After the intervention, 35% of patients were aware of the sign by the sink, 62% were aware of the reminder on meal trays, and 35% were aware that oral hygiene reduces the risk for pneumonia (Figure). Conclusions: Simple visual educational tools can improve awareness of oral hygiene and its role in reducing the risk for hospital-acquired pneumonia. Studies are needed to determine if interventions using these tools will improve oral hygiene practices by patients.

Background: Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). Outbreaks of HBV infection in healthcare settings have been linked to lapses in infection control, including unsafe injection practices, such as reuse of needles, fingerstick devices, and syringes. In December 2024, an acute case of hepatitis B in a patient without traditional risk factors was reported to the Connecticut Department of Public Health (CTDPH). We investigated a potential healthcare exposure as part of a multidisciplinary investigation. Methods: Acute hepatitis B is reportable to CTDPH. Immunization Program staff interviewed the patient with hepatitis B to determine risk factors for infection. Immunization and Healthcare-Associated Infections and Antimicrobial Resistance (HAI-AR) team members assessed potential healthcare exposures via medical chart review. Upon identification of a potential healthcare exposure, HAI-AR staff conducted an on-site Infection Control Assessment and Response (ICAR). Results: Patient interview and medical chart review identified potential high-risk procedures at an outpatient clinic that performs aesthetic procedures. Among 15 procedures performed during the six months prior to HBV infection, the highest risk procedures were injection of platelet rich plasma and invasive hormone replacement therapy. ICAR identified the following breaches in infection prevention and control (IPC) practices: poor hand hygiene, failure to label and improper handling of blood products, and improper operation of a sterilizer. Environmental cleaning/disinfection practices were inconsistent, and disinfectants were improperly labeled and stored. HAI-AR staff recommended training on and auditing of hand hygiene, training on proper cleaning/disinfection practices for office staff and environmental services (EVS), and discontinuation of sterilizer use until such time that biologic monitoring could be performed and staff could be properly trained on use. The clinic stopped all operations until IPC oversight was in place, changed all equipment to single-use, and trained staff on disinfection. Providers received bloodborne pathogen training. In response to IPC breaches, the clinic also notified 118 patients who had received high-risk procedures in the prior year to recommend bloodborne pathogen testing. Conclusion: Outpatient healthcare environments where aesthetic procedures are performed may have limited regulatory oversight and no requirement for an individual responsible for IPC. In these settings, healthcare providers might perform a large number and variety of invasive procedures, which may require education and training on specialized equipment, such as sterilizers. Improved oversight of these settings with a focus on education and training of outpatient providers on IPC could improve infection prevention and patient safety.

Background: High-level disinfection (HLD) of ultrasound probes is a required patient safety and regulatory practice. Automated vaporized hydrogen peroxide (VHP) systems, widely implemented for HLD since 2011, involve sizable capital costs, substantial maintenance requirements, and lengthy probe turnaround times. Chlorine dioxide foam has been used for ultrasound probe HLD in Europe since the late 1990s and received U.S. Food and Drug Administration clearance in 2023, consistent with the ANSI/AAMI ST58 standard. Evidence describing operational impact and feasibility in U.S. outpatient practice remains limited. Objective: To compare workflow and probe turnaround times between two ultrasound probe HLD methods and to evaluate the feasibility of chlorine dioxide foam implementation, including staff training requirements and adherence to reprocessing protocols. Methods: From October 2025 to January 2026, we conducted a quality improvement study examining the transition from automated VHP to manual chlorine dioxide foam for transducer HLD in an outpatient urology practice. A total of six registered nurses and four medical assistants participated in the study. Training provided to staff included manufacturer-provided online training, 1:1 in-person instruction, and direct observation to confirm competence with the new reprocessing protocol. Workflow steps for both HLD methods were mapped and compared. Outcomes measured included probe turnaround time (defined as the interval from immediate post-use handling to readiness for subsequent clinical use); number of workflow steps; feasibility of protocol-specific staff training; and adherence to the reprocessing protocol. Results: Each of the methods had a comparable number of workflow steps. Average probe turnaround time for chlorine dioxide was four minutes, while the automated VHP system required 14–15 minutes. Most participants completed manufacturer-provided online training. All participants received 15 minutes of 1:1 in-person instruction and direct observation. Overall, direct observation demonstrated high adherence to the reprocessing protocol. The manual foam process was integrated into routine clinical workflows without disruption to patient care. Conclusion: In a single outpatient urology practice, manual chlorine dioxide foam disinfection was feasible to implement and integrated into existing workflows with considerably shorter probe turnaround time while maintaining staff adherence. Results informed our policy on workflow steps, training, and documentation. Observations were conducted over a limited period, and findings may not be generalizable to other clinical settings.

Background: Portable medical equipment is a potential source for transmission of healthcare-associated pathogens. However, cleaning and disinfection of equipment is suboptimal in most healthcare facilities. Methods: On a long-term care facility (LTCF) ward, we examined the impact of an intervention in which a far ultraviolet-C wand was used to provide low-level disinfection of portable equipment and high-touch items in common areas. The surrogate markers bacteriophage MS2 and cauliflower mosaic virus DNA were inoculated onto 5 portable medical devices in the morning on day 1; in the afternoon on days 1, 3, and 7 swabs for recovery of the markers and culture for pathogens were obtained from 50 surfaces including portable equipment, common areas, and resident rooms. The percentages of sites with contamination were compared for the week of the intervention versus for a control week without far UV-C exposure. Results: In the control period, the DNA marker and bacteriophage MS2 disseminated widely and were detected on non-inoculated equipment, the nursing station, and in resident rooms. In comparison to the control period, there was a significant reduction in contamination with the DNA marker during the far UV-C intervention period (P<0.01), and a trend toward reduced contamination with bacteriophage MS2 (P=0.20) and pathogens (P=0.11) (Figure). Conclusions: Surrogate markers inoculated onto portable medical equipment disseminated widely throughout a LTCF ward. Daily low-level disinfection using a far UV-C wand reduced dissemination of the surrogate markers and there was a non-significant reduction in pathogen contamination.

Background: Environmental services (EVS) programs may choose dilutable (i.e., concentrate diluted manually or with an automated dispensing system) or ready-to-use (RTU) disinfectant products. Dilutable products are less expensive but have greater potential for incorrect use. Methods: We conducted a time and motion evaluation of EVS cleaning and disinfection practices before and after a facility-wide switch from dilutable to RTU quaternary ammonium disinfectant products. Observations were completed to determine the time required to complete tasks and the appropriateness of product use (e.g., correct product, contact time). Personnel were graded using a standardized compliance scale (17-20, highly compliant; 14-16 moderately compliant; 10-13, needs improvement). Results: We conducted 40 total hours of observations of 8 EVS personnel before and 10 after the product substitution. Mean compliance scores increased from 14.3 to 18.2 after the substitution. Noncompliance when dilutable products were used was most often due to incorrect use of products, including inappropriate mixing of disinfectant products (e.g., dilutable quaternary ammonium plus sodium hypochlorite) and inadequate contact time. During post-discharge and daily cleaning before the substitution, activities other than cleaning and disinfection accounted for 50% and 55% of total EVS personnel time, respectively (Figure), with similar time distribution after the substitution. Conclusions: Switching from dilutable to RTU disinfectants improved compliance with recommended cleaning and disinfection practices. EVS personnel spend a substantial proportion of their time doing activities other than cleaning and disinfection.

Background: Candidozyma auris is an emerging healthcare-associated pathogen that colonizes human skin and survives on healthcare surfaces for up to two weeks. As C. auris re-contaminates the healthcare environment within hours of disinfection, a continuously active disinfectant may provide an advantage over traditional disinfectants in healthcare environments with high rates of C. auris colonization. Water-stable organosilanes (WSOs) have demonstrated continuously active disinfection against bacterial and viral species but have not been studied against C. auris. Goldshield® GS75 (Locust Valley, NY) is a WSO composed of a siloxane bonding agent providing surface coating, a nitrogen molecule for organism attraction, a long carbon chain for cellular penetrance, and a quaternary ammonium compound for disinfection. We tested the efficacy and duration of effect of GS75 on survival of C. auris in vitro. Methods GS75 was applied to C. auris colony forming units (CFUs). After one hour, coupons were swabbed using premoistened sponge-sticks (Neogen Sponge-Stick with proprietary neutralizing buffer active against chlorine and QACs; Neogen, Lansing, MI), processed using the stomacher method and plated quantitatively to Sabouraud Dextrose agar (RemelTM, Lenexa, KS) then incubated for 48 hours at 37°C in ambient air. Duration of GS75 activity was assessed using the same method, with C. auris re-inoculated daily to simulate repeated contamination from a C. auris colonized or infected patient, and recovery attempted at 4 hours, 24 hours, 48 hours, 72 hours, 7 days, 14 days, 21 days, and 28 days after coupon treatment. (Figure). A separate set of coupons was wiped daily with a dry microfiber cloth or a 10% sodium hypochlorite bleach wipe (Sani-Cloth®, PDI, Woodcliff Lake, NJ) before daily re-inoculation to simulate routine environmental cleaning practices that might be necessary even with use of a continuously active disinfectant. Results Mean C. auris CFUs recovered from untreated coupons exceeded 145 at all sampling times, while GS75-treated coupons showed significantly reduced C. auris recovery. The addition of daily bleach or microfiber cloth wiping had minimal effect on GS75 activity (Table). Conclusion One application of GS75 reduced survival of C. auris on a common healthcare facility surface material for up to 28 days, despite repeated C. auris challenge and with minimal reduction in activity after physical or chemical cleaning. These findings support evaluation

Background: Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) are a growing public health concern. This study investigates antibiotic resistance patterns for ESBL-E (Escherichia coli and Klebsiella species) cases in Maury and surrounding counties in Tennessee as part of the Emerging Infection Program’s Multi-site Gram-negative Surveillance Initiative. Methods: ESBL-E cases are defined as extended-spectrum cephalosporin-resistant E. coli, Klebsiella pneumoniae, Klebsiella variicola, or Klebsiella oxytoca isolated from urine or normally sterile sites from residents of the surveillance area. Cases from July 2019 through December 2024 were included. Susceptibility data were collected from clinical laboratory reports. E. coli isolate resistance was compared to aggregated Klebsiella species isolate resistance using χ or fisher’s exact tests. Organism specific yearly resistance trends excluded the incomplete 2019 collection year and were examined via simple linear regression. Analyses were performed in SAS 9.4. Results: We identified 2,206 isolates including 1,915 E. coli isolates, of which 1,868 (97.5%) were from urine, and 291 Klebsiella isolates, of which 281 (96.6%) were from urine. Overall percent resistance for selected antibiotics were as follows: ciprofloxacin: 69.0%, levofloxacin: 64.3%, cefepime: 81.1%, cefazolin: 98.7%, cefotaxime: 85.9%, ceftazidime: 53.2%, ceftriaxone: 92.8%, piperacillin-tazobactam: 2.6%, nitrofurantoin: 9.0%, trimethoprim-sulfamethoxazole: 57.8%. During the study period, E. coli isolates displayed increased resistance to cefepime (3.0% per year, P<0.001), ceftriaxone (1.3% per year, P:P: 0.02); Klebsiella isolates demonstrated increased resistance to levofloxacin (5.9% per year, P: 0.002) and cefepime (5.7% per year, P: 0.003). Over the study period, E. coli isolates displayed higher rates of resistance than Klebsiella isolates to ciprofloxacin (74.0% vs. 36.4%, P<0.001), levofloxacin (71.4% vs. 19.0%, P<0.001), cefotaxime (87.0% vs. 79.0%, P<0.001) and ceftriaxone (93.5% vs. 87.9%, P<0.001). Klebsiella isolates had higher resistance to ceftazidime (59.9% vs. 52.1%, P: 0.01), piperacillin-tazobactam (8.9% vs. 1.6%, P<0.001), nitrofurantoin (18.6% vs. 7.6%, P<0.001), and trimethoprim-sulfamethoxazole (68.6% vs. 56.1%, P<0.001). There were no significant differences in resistance to cefepime or cefazolin between groups. Conclusion: In our data, ESBL-E pathogens demonstrated trends of increasing resistance to certain antibiotics over time. There were significant differences in resistance between species within different classes of antibiotics. These data support the idea that organism type is important for determining the best antibiotic for empiric treatment. Continued monitoring of antibiotic resistance in ESBL-E is imperative to understanding changes in antibiotic resistance patterns. The increasing trends in proportion of antimicrobial resistant strains warrants strengthening antimicrobial stewardship and infection prevention programs within the surveillance area.

Background: Candida auris (C. auris) is an emerging multidrug-resistant fungal pathogen that continues to spread across the United States and remains classified by the Centers for Disease Control and Prevention as an urgent public health threat. Due to its ability to persist on surfaces and spread easily in healthcare settings, early detection and rapid infection control measures are critical to prevent outbreaks. Based on surveillance data, we implemented targeted C. auris screening in 2024 for patients transferred from outside healthcare facilities. After one year, we assessed adherence, positivity, and clinical infection cases to determine our program’s success and identify potential gaps in screening criteria. Methods: All eligible transfer patients received composite axilla/groin swabs on admission that were sent for external laboratory Polymerase Chain Reaction (PCR) testing. Demographic, clinical, and epidemiological factors, including transferring healthcare facility origin and co-colonizing multidrug-resistant organisms (MDROs), were evaluated alongside clinical C. auris infections identified outside of admission screening (e.g., urine, blood, pleural fluid). These were used to compare characteristics between colonized and infected patients and determine whether expanded screening criteria were warranted. All C. auris-positive patients were placed on transmission-based precautions with rapid notifications to unit leadership. Result: Over the first year (Sept 2024–Sept 2025), 1,725 of 1,937 eligible patients were screened (89.1%), with a positivity rate of 1.50% (26 colonized patients). Patient refusal and screening cancellations were infrequent (18 events; 0.06%). An additional 212 eligible patients (11%) were not screened due to operational factors, with no subsequent positive C. auris clinical cultures during hospitalization. Eight additional patients were diagnosed with C. auris infection through clinical cultures. These patients were ineligible for screening as they were not transfers, though most had frequent readmissions to and from outside healthcare facilities. Demographic and clinical characteristics of colonized and infected patients are summarized in Table 1. Conclusion: Our findings demonstrate that a targeted admission screening program for interfacility transfers identified colonized C. auris patients and enabled timely implementation of infection control measures. However, patients with significant outside healthcare exposure who are not interfacility transfers remain high-risk, indicating a gap in our current screening criteria.

Background: In response to the 2014 Ebola outbreak, Regional Emerging Special Pathogen Treatment Centers (RESPTCs) were established across the 10 U.S. Health and Human Services regions to maintain a high-level of preparedness to care for patients with high consequence infectious diseases (HCID) in specially designed biocontainment units (BCU). The Johns Hopkins BCU purposefully integrated infection prevention and control principles and practitioners into operational plans as the foundation of healthcare worker safety in the high-level isolation environment. Infection preventionists (IPs) serve as Trained Observers (TOs) who are responsible for oversight of enhanced personal protective equipment (PPE) donning and doffing procedures and overall safety throughout the clinical shift. The TO role is fulfilled exclusively by IPs who are essential to maintaining BCU staff proficiency by facilitating ongoing quarterly training. Methods: A comprehensive training and validation framework was implemented to sustainably embed IPs as TOs into the BCU program. First, a dedicated IP BCU program manager role was established to integrate infection prevention into ongoing protocol development and operational decision-making. Next, TO candidates underwent a standardized competency-based process that required demonstration of proficiency in leading enhanced PPE ensemble donning and doffing procedures. Additionally, TO candidates were expected to confidently demonstrate effective use of structured checklists and standard operating procedures, navigate BCU workflow and infrastructure, and be familiar with Category A waste management protocols. Risk identification and mitigation skills were reinforced through peer coaching and drilled over the course of multiple practice and training sessions. TO validation required independent confirmation of candidate proficiency by two validated TOs to ensure inter-rater consistency. Results: Over 11 years, 23 IPs achieved TO validation and continued to revalidate and maintain their skill set throughout their IP tenure during BCU quarterly training. Currently, 8 of 17 IPs are active TOs. IP integration into BCU training and operations fosters increased trust and a heightened sense of safety across the team. Dedicated TOs with the sole responsibility to ensure healthcare worker safety allows for deeper specialization and improved adherence to safety standards, unburdening other clinicians from balancing multiple roles between bedside and operational safety. Conclusion: Embedding IPs as TOs within RESPTC preparedness plans and BCU response operations—beyond their traditional role in developing standard operating procedures, processes, and protocols—is a best practice to promote a culture of safety and an innovative approach to support operational efficiency for patient care in high-level isolation environments.

Background: Carbapenemase-producing organisms (CPO) are a serious public health threat. The Centers for Disease Control and Prevention (CDC) guidelines for combating CPO includes a recommendation to screen selected high risk patients. We describe a program to identify and screen patients at risk for CPO. Setting: An academic, tertiary care center with 2,059 licensed beds and 74,359 admissions a year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours who were from countries and states with known CPO transmission based on address and zip code. A nursing protocol was subsequently developed in the EMR to facilitate CPO screening for eligible patients at admission. After the CPO order is placed, an electronic communication is sent via the EMR alerting the patient care team of the order, the rationale for screening, details on swab collection, and links to a toolkit with resources to help answer patient questions. A single perirectal swab is obtained by the patient’s primary nurse and is tested for Klebsiella pneumoniae Carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Patients may refuse testing. Results: From May 2018 through November 2025, 6,039 patients were identified for CPO screening using case-finding report. Of these patients, 2,424 had CPO swabs completed. Eighteen patients with CPO were identified with an overall yield of 0.75% on admission screening. There was one patient who tested positive for KPC, 10 patients who tested positive for NDM, and 5 patients who tested positive for OXA-48. Two patients were identified to have both NDM and OXA-48. Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Use of the nursing protocol has enabled IPAC to complete timely CPO surveillance and prevent transmission to other patients. Protocols within the EMR can be effectively replicated for a timely response to emerging infections.

Background: Previous studies demonstrated that the addition of anterior nares to axilla/groin skin testing substantially improved the detection of Candidozyma auris colonization (Proctor et al., Nature Medicine, 2021; Sansom et al., CID, 2024), but these observations were limited by small sample sizes and reflected mostly nursing home residents. We aimed to assess the benefit of adding nares testing to axilla/groin testing among hospitalized patients participating in C. auris point prevalence surveys (PPSs). Methods We conducted a prospective observational study at three long-term acute care hospitals (LTACHs) in the Chicago region, one of which also included distinct inpatient rehabilitation floors. Facilities participated in quarterly public health-led C. auris PPSs from May 2024 to October 2025. Patients underwent swab sampling at two sites: composite bilateral axillae/groin (swab 1) and bilateral anterior nares (swab 2). Samples were processed at a central laboratory for C. auris detection by PCR using a validated assay with enzymatic preprocessing and automated DNA extraction. Primary analyses were restricted to patients with results available from both sampling sites; a positive C. auris test from either body site was considered the reference standard. Analyses were performed using R v4.5.2 (www.r-project.org) and Stata/SE v18.0 (Stata Corp., College Station, TX). Results Across 18 PPSs, 769 of 867 (89%) eligible patients participated. The overall C. auris prevalence was 46% (317/685) among LTACH patients and 15% (13/84) among rehabilitation patients. Among all patients who tested positive for C. auris, 64% were in Contact Precautions for any reason at time of PPS and 34% were previously known to be C. auris colonized. After excluding 16 patients who were missing a body site specimen, 753 patients were eligible for analysis (670 LTACH, 83 rehabilitation). Among 320 patients with C. auris detected at any body site, 301 were detected by axilla/groin screening (94% sensitivity; 95% confidence interval 91% to 96%) and 234 (73%) tested positive at the anterior nares for C. auris. Inclusion of nares swabbing identified 19 additional patients who would have been missed by axilla/groin screening alone, corresponding to an incremental increase of 6%. Conclusion Among LTACH and rehabilitation patients, C. auris colonization was common and PPSs identified a substantial number of patients not previously known to be colonized. The incremental benefit of adding nares screening was modest compared to axilla/groin screening alone. Testing more body sites can identify more C. auris colonized patients, but facilities should balance benefit versus cost of expanded screening approaches.