To analyze state healthcare-associated infection (HAI) laws and examine the transition from state-driven surveillance to regulatory frameworks substantially shaped by federal policy.

We conducted a systematic public health law review of statutes, administrative regulations, and policies governing HAI surveillance across 50 U.S. states and the District of Columbia as of March 1, 2024. We analyzed the HAI surveillance framework in each jurisdiction to assess the federal influence. To supplement the legal review and clarify state-specific reporting requirements, we administered a survey to state HAI program coordinators.

As of March 2024, 38 jurisdictions (74.5%) mandate HAI reporting. Early laws were primarily state-driven, while later enactments increasingly incorporated federal standards. Among jurisdictions with HAI reporting laws, 23 (60.5%) reference or incorporate Centers for Medicare & Medicaid Services (CMS) mandates into the state law, enabling sharing of federally reported data. Overall, 41 states (80.4%) modified reporting requirements in response to CMS mandates; nearly all jurisdictions with HAI reporting laws (97.4%) adopt other forms of federal policies.

The majority of states have adopted HAI legislation, with state-level reporting laws and policies demonstrating continuous development from 2002 to 2024. Early HAI surveillance efforts, while guided by emerging federal government influences, were primarily based on state policy. However, since 2009, new state laws and policies have increasingly adopted federal policies. Over time, state reliance on federal standards has created a policy shift: state HAI reporting frameworks have expanded and adapted to federal policy, creating a legal environment marked by growing federal-state integration.

Surgical site infections (SSIs) remain a significant source of morbidity in children. Elevated standardized infection ratios (SIRs) for pediatric gastrointestinal (GI) procedures persist nationally and at our institution. We assessed pediatric-specific risk factors and the applicability of the adult SIR model.

Case–control study of pediatric patients undergoing GI surgery (2019–2022) with 82 SSI cases matched 1:2 with 164 controls by prematurity, age, National Healthcare Safety Network (NHSN) procedure category and year. Data was collected via chart review; socioeconomic risk was assessed using the Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Bivariate and multivariate conditional logistic regression analyses used to estimate adjusted odds ratios (aOR) with 95% confidence interval (CI).

A tertiary pediatric referral center.

Ages 0–21; NHSN reportable GI SSI procedures (appendix, gastric, small bowel, colon, laparotomy).

Cases were more likely to speak a language other than English or Spanish aOR 4.26 (95% CI, 1.06–17.11; P = .041) compared to controls. Adult SIR risk factors such as diabetes mellitus, were not significant predictors. Cases had longer hospitalizations (median 17.5 vs 7 days) and higher 30-day readmission rates (26% vs 10%) compared to controls.

These findings highlight the importance of language-concordant care and consideration of other social vulnerabilities in pediatric GI surgical care. Adult-based SIR models may not be applicable to children, highlighting the need for pediatric-specific measures that ensure equitable access to preventive care.

The purpose of surgical hand antisepsis before surgical or invasive procedures is to suppress microbial flora on the hands. This study aimed to evaluate the effect of a modified surgical hand antisepsis technique on recolonization of microbial flora on surgeons’ hands over time.

Participating surgeons were randomly assigned to one of two study groups. In both groups, surgical hand antisepsis was performed using 10% povidone-iodine followed by rinsing of the hands and forearms. In Group 1, surgeons dried their hands after rinsing according to the conventional method. In Group 2, surgeons applied an additional layer of 10% povidone-iodine to the still-wet hands and forearms after rinsing and then allowed the solution to dry without further rinsing. Hand cultures were obtained immediately after antisepsis (0 hour) and at 1 and 2 hours thereafter. Colony-forming units (CFUs) were counted and compared between groups and sampling periods.

Fourteen surgeons participated in the study, with seven surgeons allocated to each group. No significant difference in bacterial growth was observed between the groups at 0 hour (Group 1: mean CFU 41.59 ± 72.53 vs Group 2: 18.63 ± 24.27, P = .27). At 1 hour, bacterial growth was significantly lower in Group 2 compared with Group 1 (8.43 ± 20.65 vs 25.44 ± 53.62 CFU, P = .001). Similarly, at 2 hours, Group 2 demonstrated significantly lower bacterial growth than Group 1 (16.37 ± 34.25 vs 32.88 ± 52.55 CFU, P = .022).

Compared with the conventional surgical handwashing technique, reapplication of povidone-iodine without a final rinse resulted in significantly reduced bacterial recolonization on surgeons’ hands at 1 and 2 hours after hand antisepsis. These findings suggest that this modified technique may provide prolonged antimicrobial activity during surgical procedures. Further large-scale studies are warranted to confirm its clinical utility.

The GeneXpert® MTB/RIF nucleic acid amplification test has been proposed as an alternative method to smear microscopy in guiding de-isolation for patients with suspected pulmonary tuberculosis, given its convenience and higher diagnostic accuracy. Currently, there is no comprehensive review summarizing the evidence on the isolation duration using GeneXpert. This systematic review and meta-analysis addressed the length of airborne infection isolation in hospitalized patients initially suspected of having pulmonary tuberculosis where de-isolation decisions were guided by GeneXpert nucleic acid amplification test compared to traditional smear microscopy.

We conducted a comprehensive search in databases (Medline, Embase, and Scopus) from January 1, 2001, to April 1, 2026, and applied median-based quantile estimation methods to determine the pooled difference in median times of isolation. We also assessed diagnostic accuracy as well as hospital length of stay as secondary outcomes.

We screened 746 titles and abstracts, of which 7 were eligible for inclusion. Five studies included in the meta-analysis involved 1,409 patients, all within low-incidence tuberculosis settings. The meta-analysis demonstrated that use of a single unconcentrated GeneXpert versus serial acid-fast bacilli smear microscopy resulted in a pooled reduction in median isolation duration by 38.8 hours (95% confidence interval 20.2–57.3 hours).

Compared to serial microscopy, GeneXpert done on a single unconcentrated respiratory specimen reduces airborne infection isolation duration by over 1.5 days, on average, making it an attractive strategy for optimizing healthcare facility resources while evaluating persons for pulmonary tuberculosis.

Protocol Registration (PROSPERO, CRD42024538644)

To assess whether wind-driven natural ventilation in the Infectious Diseases Treatment Module (IDTM) can achieve ventilation performance consistent with airborne precaution requirements [160 liters per second (L/s)] and to estimate associated pathogen-specific infection risks.

An experimental campaign of air velocity measurements and CO2 decays were conducted to validate the developed computational fluid dynamics (CFD) model. The validated CFD model simulated wind-driven natural ventilation (1–4 m/s) for an L-shaped IDTM configuration under four structural scenarios defined by the presence or absence of patient porches and mosquito nets. Airborne infection risk was estimated using a Wells–Riley quanta-based model for seven representative airborne pathogens under short-duration healthcare worker exposure and prolonged patient co-exposure.

Ventilation performance varied widely based on wind speed and structural configuration. Airflow ranged from 7 L/s in the most restricted configuration (porch and mosquito nets present at 1 m/s) to over 3,100 L/s when mosquito nets were removed at 4 m/s.

When mapped to infection-risk estimates, ventilation rates at 160 L/s substantially reduced short-duration healthcare worker infection risk for all pathogens (≤1%), whereas prolonged co-exposure remained associated with high risk for high-emission pathogens despite high ventilation.

Under favorable wind conditions and optimized configurations, the IDTM can achieve ventilation rates consistent with the 160 L/s recommendation for airborne precautions. While this provides substantial protection for healthcare workers, individual-room isolation remains essential for patient management. Operationally, removing window-mounted nets is the most effective way to ensure safety targets are met; hybrid ventilation measures should be considered during low-wind conditions.

Single-use supplies stored in bedside supply carts with paper packaging cannot be wiped with disinfectants. We aimed to determine the prevalence of pathogens on these unused supplies.

Prospective study over 7 weeks in 2025.

Two pediatric ICUs at a university affiliated children’s hospital.

The unit of analysis was the bedside supply cart from each discharged ICU patient.

One swab was used to swab three supply items contained in a single drawer in a room’s bedside cart. Carts had two drawers sampled, each with a swab for bacterial culture and respiratory viral nucleic acid amplification testing (NAAT).

Paper-packaged supply items (n = 840) from 70 consecutive bedside carts were swabbed after patient discharge. All bacterial swabs had no growth of pathogen [0/140 (0%), 95% CI 0%, 2.3%)]. A non-pathogen was cultured from 8/140 (5.7%) swabs [7/70 (10.0%) carts], most with scant growth [7/8 (87.5%) only one colony]. Non-pathogens (common commensal skin and oral flora) included coagulase-negative staphylococci (n = 5), Actinomyces oris (n = 1), aerobic spore-forming Bacillus (n = 1), and viridans group streptococcus [non-anginosus] (n = 1). Of viral swabs, 3/140 (2.1%, 95% CI 0.5%, 6.4%) were NAAT positive (3/70 (4.3%) carts). Room isolation status, length of stay, and ICU were not associated with a positive bacterial or viral swab.

Bacterial pathogen detection on supplies, a necessary step in transmission, was extremely low. Viral NAAT detection on supplies was low and likely exaggerated the risk of fomite transmission, as whether there was viable virus at sufficient concentration to transmit infection is unknown.

Blood culture over-ordering is a recognized diagnostic stewardship challenge, contributing to contamination, inappropriate antimicrobial escalation, and laboratory burden. Validated tools to guide culture ordering at initial patient assessment are lacking.

We aim to derive and externally validate a two-step diagnostic stewardship rule for blood culture ordering in the emergency department (ED) patients with suspected infection.

We derived the Stepwise Culture Assessment with NEWS and NLR in ED (SCANNED) rule using consecutive blood cultures from a Singapore ED (April–July 2025) and validated it in Vancouver, Canada (2016–2019). The rule uses age-stratified National Early Warning Score (NEWS) thresholds (Step 1), followed by neutrophil-lymphocyte ratio (NLR) ≥5 for remaining patients (Step 2). Thresholds were selected via exhaustive grid search, optimizing culture reduction while constraining the false-negative rate to <5%.

We included 1,224 derivation and 808 validation encounters. Blood culture positivity was 9.6% (117/1,224) and 13.8% (112/808), respectively. The optimal rule (NEWS ≥5 if age <75 or NEWS ≥3 if age ≥75; NLR ≥5 for remainder) reduced cultures by 18.8% (95% CI 16.6–20.9%) in derivation and 15.1% (95% CI 12.8–17.6%) in validation, missing <5% of bacteremia cases in both cohorts. Performance was consistent across infection sources, including unclear/occult infections (17.5% reduction, 3.7% false-negative rate).

The SCANNED rule represents a practical diagnostic stewardship intervention that can reduce unnecessary blood cultures by 15–19% while maintaining >95% sensitivity for bacteremia. It requires no electronic health record integration and can be applied at triage. Prospective validation is needed before clinical implementation.

Antimicrobial Stewardship Programs (ASPs) need healthcare economic analyses to support and inform ASP strategies. This work aimed to determine whether widely available artificial intelligence (AI) platforms like Microsoft CopilotTM could facilitate healthcare economics analyses for ASP programs without dedicated healthcare economic supports.

AI (Microsoft CopilotTM) was prompted to develop a cytomegalovirus prophylaxis protocol for lung transplant recipients using only PubMed-indexed articles. CopilotTM was then prompted to produce probabilistic samples of simulated patients from aggregate statistics of a 165-patient cohort from Vanderbilt University Medical Center and to analyze cost-effectiveness across four distinct cytomegalovirus prophylaxis protocols, including its own.

Tertiary care academic medical center, including outpatient and inpatient environments.

Simulated patient data was developed via random, single-blind, probabilistic selection from pre-defined aggregate cohort statistics.

The AI-generated prophylaxis protocol was evidence-based without hallucination, but this conservative protocol relied on outdated evidence and was associated with significant increases in expected per-patient cost (mean +$4740, P < .01) compared to recent guideline-based and institutional protocols. AI independently identified and executed sensitivity analyses, which revealed that in this simplified model, letermovir use had a large impact on expected per-patient cost.

The AI-proposed protocol was less cost-effective, but data suggest that careful prompting can provide appropriate PubMed-indexed literature to support ASP protocol development. Additionally, CoPilotTM provided a thorough cost-effectiveness analysis comparing all potential and existing protocols. With appropriate oversight, AI and Microsoft CopilotTM can conduct healthcare economic analyses suitable for ASP strategic planning and implementation.

Patients receiving maintenance hemodialysis are frequently exposed to antibiotics, a proportion of which may not be necessary thereby increasing the risk of antibiotic-associated adverse events. Antimicrobial stewardship programs remain underdeveloped in outpatient dialysis facilities. This study aimed to quantify antibiotic prescribing trends across in-center dialysis units and identify patient- and facility-level factors associated with decreased antibiotic use to inform the future stewardship strategies.

Retrospective observational cohort study among 16 in-center hemodialysis units

Antibiotic prescribing patterns and patient- and unit-level characteristics were analyzed among patients receiving maintenance hemodialysis from April 1, 2021, to March 31, 2024. Antibiotic prescribing trends were analyzed using general linear models. Generalized estimating equations were used to identify factors associated with decreased prescribing.

A total of 937 (26.4%) among 3,549 patients received ≥1 antibiotic dose, with an average of 15.36 doses per 100 patient-months, ranging from 4.82 to 30.87 doses/100 patient months. Types and frequency of antibiotics prescribed among units varied considerably. Trends in antibiotic prescribing did not decrease among 10 (62.5%) of the in-center hemodialysis units. Patient-level characteristics in units associated with a decrease in prescribing included Black race, Hispanic ethnicity, age 56–65, and diabetes as the cause of kidney failure.

There is substantial variability in antibiotic prescribing across dialysis units. Decreasing trends in prescribing were observed in a subset of units and were associated with patient-level factors. These findings support the need for developing and implementing antimicrobial stewardship programs targeting the outpatient dialysis setting.

Emergency departments in tertiary care are critical areas for decision-making regarding antimicrobial use,however, they are often underrepresented in antimicrobial stewardship (AMS) interventions. This study evaluates the impact of a nurse-driven antimicrobial stewardship intervention in a medical emergency unit of a tertiary care facility.

A quasi experimental pre–post study was conducted in the Emergency Medical Outpatient department in a tertiary care center. Following a baseline assessment of antimicrobial use patterns conducted by a team of trained stewardship nurses, salient intervention targets were identified and implemented. AMS nurses actively reviewed antimicrobial prescriptions, reinforced adherence to institutional guidelines, monitored device- related practices and diagnostic utilization, and participated in audit and feedback with clinical teams. Data on patient characteristics, infection type, culture practices, antibiotic use, and guideline adherence were collected and compared between pre-intervention and intervention phases.

Following the intervention, compliance with hospital antibiotic guidelines improved from 82.4% to 91.0%. The proportion of cultures collected before initiating antibiotics increased from 23% to 40.3%, with a corresponding rise in culture positivity from 8% to 22%. An increase in antibiotic de-escalation practices was also noted.

This nurse-driven antimicrobial stewardship intervention was associated with more rational antimicrobial use, improved diagnostic utilization, and strengthened infection control practices. Integrating stewardship activities into nursing workflows represents a feasible approach to strengthening AMS in high-volume acute care settings.

Benchmarking hospitals on their antibiotic use may be facilitated by metrics that adjust for inter-hospital differences in patient case-mix, such as types of infections, procedures, and comorbidities. Metrics that capture antibiotic spectrum [e.g., days of antibiotic spectrum coverage (DASC)] can be more sensitive to stewardship activities than metrics based on days of therapy (DOT). In this study, we developed risk-standardized metrics for both DOT and DASC.

We performed a mixed-methods study to build risk-standardized metrics for inpatient antibiotic use, using a modified Delphi process integrating expert- and data-driven strategies to identify nonmodifiable risk factors associated with appropriate inpatient antibiotics. These factors were used to create risk-standardized ratios (RSR) for DOT and DASC. A standardized antimicrobial administration ratio (SAAR)-like metric was also constructed.

In 2021, there were 497,061 patient-admissions across 121 Veterans Health Administration (VHA) hospitals. The median hospital RSR was 1.00 (interquartile range (IQR) 0.95–1.05) for DOT and 1.00 (IQR 0.96–1.04) for DASC; the median ratio for the SAAR-like metric was 0.85 (IQR 0.68–1.03). The Kendall’s tau for RSR-DOT and the SAAR-like metric was 0.48; RSR-DASC and the SAAR-like metric was 0.33; and RSR-DOT and RSR-DASC were 0.48. Compared to the SAAR-like metric, 60 (49.6%) and 80 (66.1%) hospitals ranked in a different quartile for RSR-DOT and RSR-DASC, respectively.

Hospital performance on the SAAR-like metric was weakly correlated with the RSR-DASC and moderately correlated with the RSR-DOT. Hospitals’ performance on the SAAR-like metric differed from that of the RSR metrics, suggesting the RSR metrics may have added value over the SAAR.

A diagnosis code-based algorithm classifies outpatient antibiotic prescribing as almost always (Tier 1), sometimes (Tier 2), and almost never (Tier 3) appropriate. This algorithm has been leveraged to quantify antibiotic appropriateness and direct stewardship initiatives for adults and children, primarily based on Tier 3 encounters receiving antibiotics, but has not been validated.

To assess the performance of the algorithm for assessing antibiotic appropriateness in pediatric outpatients.

Using a pediatric care network of primary care, urgent care, and emergency departments from January 1–December 31, 2024, encounters were classified into tiers using the ICD10 algorithm. Manual chart review was performed on a stratified random sample of 300 (100 per setting) Tier 3 encounters with antibiotics using a structured protocol derived from local and national guidelines to determine antibiotic appropriateness overall and by location. Survey weights were applied to obtain estimates for all Tier 3 encounters with antibiotic prescriptions. The positive predictive value (PPV) for Tier 3 in identifying inappropriate antibiotic prescribing was calculated.

Of 272,698 encounters, 115,508 (42%) had an antibiotic prescription. The algorithm classified 10,370 (9%) as Tier 3. In the stratified manual validation sample, 170/300 were classified as appropriate, corresponding to a survey-weighted estimate of 58% appropriate (95% CI, 52%–64%) and a PPV of 42% for Tier 3 as a marker of inappropriate antibiotic use.

The established algorithm did not reliably predict antibiotic appropriateness in this pediatric outpatient population, demonstrating a need for pediatric-focused algorithms for measuring outpatient antibiotic stewardship.