Background: Extrapulmonary nontuberculous mycobacteria (ENTM) infections are difficult to treat and often require prolonged therapy or surgery. Few population-based studies describe ENTM epidemiology, though well-known healthcare-associated outbreaks have occurred. Using the first year of multi-site ENTM surveillance, we characterized rates and how frequently ENTM infections may be related to healthcare. Methods: CDC’s Emerging Infections Program conducted active, laboratory- and population-based surveillance for ENTM cases in 4 sites (Colorado [5 counties], Minnesota [statewide], New York [1 county], and Oregon [statewide]) in 2021. An incident ENTM case was NTM isolation from a non-pulmonary specimen, excluding stool or rectal swabs, in a resident of the surveillance area without either medical record documentation of prior ENTM infection or isolation of ENTM in the prior 12 months. Demographic, clinical, information on selected healthcare and community exposures, and laboratory data were collected via medical record review. We calculated incidence per 100,000 population using U.S. Census population estimates and performed descriptive analyses. Results: A total of 180 incident ENTM cases were reported in 2021. The crude annual incidence rate was 1.3 per 100,000 persons. Incidence increased with age (from 0.95 per 100,000 among 0–17 year-olds to 2.65 per 100,000 among persons ≥65), ranged from 0.8 among non-Hispanic Asian persons to 1.6 per 100,000 in non-Hispanic Black persons, and was similar among males (1.3 per 100,000) and females (1.4 per 100,000; Figure 1). Mycobacterium avium complex (64 [35.6%]) was the most frequently isolated species group, followed by Mycobacterium chelonae complex (31 [17.2%]). Skin and soft tissue infections were the most frequent infection type (37 [20.6%]); 27 cases (15.0%) were associated with disseminated and/or only bloodstream infection, and 56 cases (31.1%) had no infection type documented. Among 93 cases with localized ENTM infections (i.e., infections that were not disseminated and/or only bloodstream infections), 38.7% had only healthcare-related exposures, 14% had only community-related exposures and 6.5% had both exposure types at the site of infection (Figure 2). Healthcare-related exposures at the infection site included surgery (23.7%), injection/infusion (21.5%), and medical devices (18.3%). The most frequent community-related exposure at the infection site was trauma (17.2%). Only one case was part of a known outbreak, which was healthcare-associated. Conclusions: ENTM infections are relatively rare, but nearly half of patients with localized ENTM infections had prior healthcare-related exposures. This indicates that the burden of ENTM infections related to healthcare may be much larger than what has been suggested from reported outbreaks.

Background: Chlorhexidine gluconate bathing (CHGB) prevents healthcare associated infections (HAIs). CHGB quality is rarely assessed; prior studies identified that concentrations of CHG can be suboptimal, particularly at the neck, and if rinsed after application. In the setting of increased HAI rates on 3 high-risk units, we evaluated CHG skin concentrations, comparing results to bathing documentation and patient reports as part of a quality improvement initiative. Methods: All patients admitted to 3 high-risk units were swabbed for CHG concentration testing at the neck, bilateral upper arms, and groin. Swabs were processed using a semi-quantitative colorimetric CHG assay. A threshold of 0.001875% CHG was used to determine adequacy based on prior studies. Adequacy was assessed by body site, timing of bath, and patient-reported skin care activities using Chi-square tests in SAS 9.4. Per hospital policy, all admitted patients are bathed daily with 2% CHG pre-packed wipes. Patients without a documented CHGB for the duration of the admission were excluded. Results: CHG testing was completed on 63 patients: 23 on medical ICU, 18 surgical ICU, 22 oncology ward, yielding 249 samples. Only ward patients could report the time of last CHGB, which agreed with nursing documentation for 12/21(57%) Adequacy by sample was no different across units: 59/88(67%) Oncology, 68/90(76%) MICU, 56/71(79%) SICU, p=0.2091. Site adequacy was different by site: neck 36/63(57%), left arm 49/62(79%), right arm 50/62(81%), groin 48/62(77%), p=0.0083. Samples taken from the 11 patients with > = 24 hours since last CHGB were more likely to be below threshold concentration: 19/47(40%) versus 47/202(23%) not adequate in the recent treatment grouping. Three patients reported showering soon after the CHGB and 8 patients used moisturizing lotion. The percent of samples below threshold for the showering patients (6/12, 50%) and lotion-users (11/32, 34%) were not significantly different from the non-showering or non-lotion using patient samples (p=0.0588 and 0.2800 respectively). Conclusion: In a facility with longstanding daily CHGB policies in place, 66/249 samples from 63 patients lacked adequate concentrations of CHG for optimal HAI prevention. Even in patients with recent CHGB, 23% of sites tested revealed inadequate levels of CHG, while 60% of those overdue for CHGB kept adequate concentrations. Reliable implementation strategies are required for CHGB so as to ensure maximal infection prevention impact.

Background: Nonsterile ice is frequently used in healthcare settings for a wide array of patient care activities and clinical procedures. However, this ice can harbor pathogenic organisms which can threaten patient safety and cause outbreaks. We sought to characterize recent Centers for Disease Control and Prevention (CDC) consultations involving ice leading to healthcare-associated infections (HAIs). Methods: We reviewed internal CDC records from the Division of Healthcare Quality Promotion (DHQP) to identify investigations of outbreaks and potential outbreaks involving the use of ice in healthcare facilities. We searched records from January 1, 2016, through November 30, 2023, for keywords related to ice. We excluded consultations in which ice was not thought to be a potential transmission pathway as well as those in which only sterile ice products (e.g., saline slush) were investigated. Results: We identified 45 consultations for ice-related investigations, involving a total of 533 patients. Nontuberculous mycobacteria were the most frequently implicated organisms, appearing in 40% (n=18) of investigations. Eighty-four percent (n=38) of investigations occurred in acute care hospitals. The most frequently implicated hospital settings were intensive care units (13%, n=6), operating rooms (13%, n=6), and bronchoscopy suites (13%, n=6). We identified a variety of plausible exposure pathways, including direct ingestion of ice by patients, use of ice during the bronchoscopy procedure, use of nonsterile ice in heater-cooler devices during cardiothoracic surgery, and the use of ice to chill saline for respiratory care. Environmental sampling directly of ice machines was performed in 62% of investigations (n=28) and nonsterile ice from these machines was sampled in 9% of investigations (n=4). Among those investigations in which ice machines were sampled, the organism implicated in the outbreak was isolated in 54% of investigations (n=15). Among those investigations in which ice itself was sampled, the organism implicated in the outbreak was isolated in 75% of investigations (n=3). These organisms included Mycobacterium mucogenicum, Burkholderia multivorans, and Acanthamoeba spp. Conclusions: The use of nonsterile ice during clinical care is a potential source of pathogens that cause patient infections and HAI outbreaks. Healthcare personnel should be aware of the risk posed by nonsterile ice and consider avoiding its use, especially when caring for patients who are critically ill or immunocompromised. Healthcare facilities should ensure regular cleaning and disinfection of ice machines to decrease their microbial burden. When HAI outbreaks involving water-associated organisms are identified, nonsterile ice should be considered as a potential mode of transmission.

Background: Appropriate antibiotic use has been described as one of the key strategies in tackling antibiotic resistance. Although the majority of antimicrobial therapy is completed following discharge, there lacks clear guidance in addressing antibiotic stewardship in the outpatient setting. Particularly, broader coverage as well as longer durations of therapy are often encountered following hospitalization. In our study we examine the various antibiotic prescribing practices on hospital discharge for management of urinary tract infections (UTI). Methods: We conducted a single-center, retrospective observational chart review of patients discharged from St. Francis Hospital and Medical Center in Hartford between May and July 2022. Medical records were reviewed for patients who were prescribed antibiotic therapy for management of UTI and met inclusion criteria. Variables of interest included type of UTI treated, antibiotic used, duration of antibiotics during and following hospitalization, fluoroquinolone use, as well reported adverse events. Total duration of therapy was defined as days on susceptible antimicrobials with appropriate source control. Results: A total of 84 patients met inclusion criteria. 44 received treatment for simple UTI (sUTI) and 40 for complicated UTI (cUTI). Figure 1 shows the various organisms identified on culture. The most common antimicrobials prescribed on discharge were cefpodoxime and ciprofloxacin [figure 2]. Quinolones were prescribed in 11.4% of sUTIs and 39.1% of cUTIs on hospital discharge. Of those, only one patient had no alternative to quinolone use due to drug allergies. The mean duration of therapy for treatment of sUTI was 6.4 days total (SD 2.40) with 3.9 days outpatient (SD 1.78). The mean duration of therapy for treatment of cUTI was 10.9 days total (SD 3.62) with 6.7 days outpatient (SD 2.99). Comparison of mean durations is shown in figure 3. In 49% of all cases (including both sUTI and cUTI) patients received greater than 7 days of antimicrobial therapy. Conclusion: There is increased evidence favoring shorter courses of antimicrobial therapy for management of both simple and complicated UTIs. A 7-day course has been shown as effective duration of therapy for cUTI with appropriate source control, regardless of presence of bacteremia. Results from our single center-study show both sUTI and cUTI are subject to unnecessarily prolonged durations of therapy on hospital discharge. In addition we noted a significant use of fluoroquinolones in cUTI treatment. We believe stewardship interventions at time of discharge may particularly benefit shorter courses of therapy for cUTI as well as reduced quinolone use.

Background: Quality improvement (QI) efforts within Infection prevention and control (IP&C) programs to reduce risk of device-related infections in the acute care setting are well described. However, less focus has been placed on continued prevention in the homecare setting. This QI project illustrates the benefits of IP&C involvement in reducing tracheitis in pediatric homecare patients. Methods: The homecare multidisciplinary IP&C team implemented a series of QI initiatives aimed at reducing incidence of tracheitis beginning in 2016. Initial interventions included increasing oral care frequency to every four hours, inpatient training for new tracheostomy patients and families before discharge, and an optional inpatient simulation training resource to provide hands-on practice. Enhanced educational interventions included caregiver learning modules and competencies completed with their primary nurse in the home every ninety days and following a tracheitis infection. Practice changes and education efforts were further sustained with the creation and distribution of laminated tracheostomy care teaching sheets to patient homes. Quarterly tracheitis infection rates were tracked using a U-chart. Organism distribution in tracheitis cases were compared across the baseline (2015-2018) and post-intervention periods (2019-2023) using the Chi square test. Analyses were performed using Stata Statistical Software: Release 18 (College Station, TX: StataCorp, LLC) with two-tailed alpha level of 0.05. Results: Quarterly tracheitis infection rates from 2015 through 2023 are displayed in the Figure. Notably, the baseline period, established Q1 2015 through Q4 2017, revealed a consistent rate of 1.08 tracheitis infections per 1000 tracheostomy days. During this initial phase, changes in oral care frequency and enhanced educational resources were implemented to decrease rates. Following these interventions, a significant shift was observed in Q1 2019, with the new baseline rate drastically reduced to 0.32 infections per 1000 tracheostomy days. This denotes a remarkable 70% improvement from the prior average infection rate which has been sustained through Q4 2023 with the laminated teaching sheets. The most frequently identified organisms across both time periods are displayed in the Table. Pathogen distribution was similar following QI interventions (p = 0.50). Conclusions: Tracheitis infections were reduced by 70% through implementation of multidisciplinary homecare IP&C QI efforts. IP&C programs are integral to pediatric homecare.

Background: The use of antibiotics and the occurrence of antimicrobial resistance in Bangladesh are very high. Inappropriate use of antibiotics among hospitalized children has contributed to a high rise in antimicrobial resistance in Bangladesh. Data on the rational use of antibiotics in Bangladeshi hospitals are limited. This study documented current antimicrobial usage among children under five in selected tertiary hospitals in Bangladesh. Methods: From August to September 2022, we conducted a point prevalence survey in four tertiary hospitals in Bangladesh. We used the World Health Organization’s Point Prevalence Survey (PPS) methods and guidelines to conduct the study. Study participants were hospitalized under the age of five years children, and we collected information from the pediatric and neonatal wards of each hospital. Antibiotic-suggesting shapes were analyzed according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification. Results: The assessment included 189 children under the age of five, with the majority (78.8%, 149/189) being under one year children. Approximately three-fourths (75.1%) of children had peripheral vascular catheters following admission. Overall, 86.2% (163/189) of children were given antibiotics after being admitted to the hospital, with infants receiving the most (81.0%, 132/163). The majority of antibiotics were administered by parents (84.7%). Antibiotics from the Watch Group were most commonly prescribed (73.0%, 119/163), followed by a combination of the Watch and Access Groups (23.3%) to treat the children. Ceftriaxone (63.8%), Meropenem (16.0%), and Ceftazidime/Amikacin (8.0%) were the most regularly prescribed antibiotics. Young children (< 1 year) were more likely to get antibiotics (AOR: 3.54, p-value: 0.003) than the other children under the age of five. Conclusion: The data showed that most children received empirical antibiotics during hospitalization, and overuse of broad-spectrum Watch group antibiotics was common practice in hospital settings. Developing and implementing antibiotic use guidelines is critical to limit the inappropriate use of antibiotics for young children

Background: Surgical site infections (SSIs) are associated with increased morbidity, monetary loss and mortality. The physical aspects of the operation room (OR) including airflow, humidity, pressure, and particulate counts are essential part of SSI prevention. Humidity control is vital to avoid static electricity buildup.Temperature control helps prevent hypothermia. Limiting OR traffic and door opening are essential to prevent airflow disturbance and minimze particles in OR environment. We have recently studied electronic monitoring of OR traffic and the traffic was higher than what was expected. Our aim was to evaluate our real-life measurement of these OR parameters as part of SSI prevention bundle. Methods: This is a prospective study focused on the OR physical environmental factors as part of operative SSI prevention bundle. The study was conducted for 4 weeks at an academic medical center. The study was conducted in two different generations of OR for neurosurgical and ophthalmologic procedures. We performed direct observation of OR traffic as well as environmental parameters (temperature, humidity, pressure, and particulate count) for the entire length of the procedure. We used both directly measured data as well as automated data generated by facilities. Results: The study showed that temperature, humidity, and pressure wer tightly controlled in the OR. This observation was consistent between manual data and automatically generated data. The OR traffic was not easily monitored by the current automatic data and was measured by direct observation. The correlations between particulate count and OR traffic was strongest for 0.3μm (0.7370, and weakest for 1.0μm ( 0.087). The 5.0μm particulate size had a moderate positive correlation of 0.344, Additionally, shorter procedures had less particulate matter in the OR environment. Automated data were only available in the new ORs but could not predict traffic without automated door monitors. But the automated data could easily portray the temperature, humidity and pressure minute by minute. Conclusion: OR traffic increases the particle count particularly the small size. Other physical aspects of the OR environment were tightly controlled. The ability to automatically monitor OR parameters could be extremely helpful for assuring patient safety as well as reviewing OR factors in SSI cases.

The unmanned aerial vehicle (UAV) system for composite vertical take-off and landing (VTOL) is a complex, highly coupled, and nonlinear system which is sensitive to external disturbances and model uncertainties. The composite VTOL UAV system consists of a multi-rotor section and a fixed-wing section. To improve observation accuracy, the compensation function observer (CFO) uses a new structure that includes velocity information. The CFO is utilised to estimate the uncertainty and the external disturbances of the system model, which performs superior estimation accuracy compared to the extended state observer (ESO). In the modeling process of the VTOL UAV, the aerodynamic moment is calculated by means of the cross-product operation of force and force arm, which solves the problem of over-reliance on aerodynamic parameters in the traditional modeling approach. The controlled object is refined by CFO, and model compensation control (MCC) is used to realise the velocity and attitude control of the composite VTOL. The numerical simulation of MATLAB/Simulink and hardware-in-loop simulation (HIL) of Rflysim were implemented, and which were used to compare the MCC, active disturbance rejection control (ADRC), and proportion integration differentiation (PID). The simulation results confirm the superiority of MCC in controlling composite VTOL UAVs in terms of anti-disturbance and tracking speed.

Background: Approximately half of antibiotics used in nursing home (NHs) are initiated in acute care hospitals prior to NH admission. Optimizing antibiotic prescribing on hospital discharge to these facilities presents an opportunity to improve NH antibiotic use. We aimed to identify intervention targets to optimize antibiotic use on discharge from the hospital to NHs. Methods: This was a multicenter, cross-sectional study across 9 acute care hospitals in Oregon, Wisconsin, and Washington. We selected a 20% random sample of adult (age >18) inpatients prescribed at least one antibiotic on discharge from the hospital to a NH between 2016-2018. We excluded patients discharged from the emergency department or an intensive care unit. Study data were electronically extracted from patients’ electronic health records and supplemented with manual chart review. Antibiotic optimization opportunities were determined by an infectious diseases (ID) physician or ID pharmacist and classified as definitely, possibly, or unlikely. Expert reviewers also recorded the type of optimization opportunity and the rationale for each determination. A gamma lasso algorithm was used to identify patient-level characteristics associated with definite optimization opportunity, which were then included in a logistic regression model. Results: There were 2761 antibiotic prescriptions among 2215 patients. Mean (standard deviation) age was 71.9 (14.3) years and 48.8% were male. Most discharges (83.1%) were prescribed one antibiotic, 15.2% were prescribed two antibiotics, and 1.8% were prescribed three antibiotics. The most frequently prescribed antibiotics were cephalexin (10.4%), vancomycin (9.8%), and amoxicillin clavulanate (8.4%). Among the 2761 antibiotic prescriptions, expert reviewers determined that 18.4% could definitely be optimized, 36.0% could possibly be optimized, and 45.3% unlikely could have been optimized. Among the 508 definite antibiotic optimization opportunities, 25.2% were to subtract the antibiotic, 56.3% were to change the antibiotic, 11.0% were to change the dose, 25.0% were to change the duration, 0.8% were to change the route, and 1.8% were to change the schedule. Patient-level characteristics found to be associated with definite antibiotic optimization opportunity included age over 80 years (odds ratio (OR)=1.44, 95% confidence interval (CI): [1.14, 1.82]), length of stay < 8 days (OR=1.40, 95% CI: [1.09, 1.81]), discharge with multiple antibiotic prescriptions (OR=1.92, 95% CI: [1.39, 2.63]), and discharge with prescription for oral vs intravenous (IV) antibiotics (OR=2.08, 95% CI: [1.49, 2.95]). Conclusion: We identified several patient and antibiotic characteristics which may serve as intervention targets to optimize antibiotic prescribing on discharge from the hospital to nursing homes.

Our interviews of inpatient clinicians (physicians, physician assistants) modeled after the Capability, Opportunity, and Motivation Model of Behavior model revealed opportunity and motivation as important drivers for overdiagnosis and overprescribing for asymptomatic bacteriuria in older adults. Understanding these barriers is an important step toward implementing age-friendly stewardship interventions.

Background: While Streptococcus agalactiae (Group B Streptococcus [GBS]) infections in infants usually result from maternal transmission, healthcare-associated cases, particularly in the neonatal intensive care unit (NICU), can occur. Whole genome sequencing (WGS) can aid in investigating GBS outbreaks among infants in hospital settings. The aim of the study is to describe the investigation of GBS infections in NICU using WGS. Methods: Infection prevention and control (IPAC) at our hospital monitors the occurrence of late-onset GBS disease (LOD) in our 57-bed NICU, which consists of all private rooms. The occurrence of 2 cases of LOD within 2 weeks triggered an investigation, including WGS of the two isolates and isolates causing invasive GBS during the last 6 months in the unit. GBS isolates underwent WGS using Illumina at Canada’s National Microbiology Laboratory. All affected patients underwent chart-review. Outbreak description and investigation: In August 2023, two NICU neonates (patients 2,3) experienced LOD two weeks apart, one with bacteremic meningitis and the other with two bacteremic episodes three weeks apart. While WGS was pending two additional cases of late-onset GBS bacteremia (patients 4,5) occurred. Isolates from Pts 2,3 and 5 were indistinguishable from each other and from an isolate from an infant admitted to the NICU with early onset bacteremia on July 27, 2023 (day 1 of life) (patient 1). Weekly point prevalence for throat and rectal colonization over 3 weeks identified five infants colonized with unrelated strains. An additional long-stay infant (patient 6) developed GBS conjunctivitis due to a strain indistinguishable from (patient 4) by pulse field gel electrophoresis, WGS for the second cluster is pending. IPAC interventions: Lapses in IPAC practices were observed, with no commonalities among cases other than similar geographic location within the unit. We hypothesized transmission was due to horizontal transmission between babies due to these lapses. Basic IPAC measures, including hand hygiene and environmental cleaning, were reinforced; Additional Precautions were not used due to private rooms’ unit structure. No environmental samples were taken due to lack of an obvious environmental point or common source. Point prevalence monitoring persisted until no new cases related to the outbreak strains were further identified in three consecutive weekly point prevalence. Conclusions: Increased awareness of healthcare-associated transmission is crucial in NICU as LOD GBS emerges. WGS plays a key role in identifying transmission. Detecting a multi-strain outbreak can appropriately redirect investigations. Legend: Figure 1: Timeline of stay at NICU and infection timing for patients 1-6

Background: Significant focus has been placed on healthcare worker hand hygiene, but little attention is has been assigned to the role of patient hand hygiene (HH) in reducing hospital acquired infections. Therefore, in this quality improvement study, we examined the impact of providing patients with hand hygiene products around mealtime on increasing patient HH adherence and on reducing acquisition of nosocomial antibiotic resistant organisms. Methods: Patients on two inpatient leukemia units at a tertiary oncologic center were provided with a single use pre-packaged alcohol wipe on their meal trays prior to every meal (three times daily). Additionally, an information card explaining to patients how and when to use the alcohol wipe was provided on the meal trays three times a week. Both the wipe and instructions were designed with input from patient representatives at the hospital. Two oncologic control units were selected where no specific intervention for patient hand hygiene was conducted. Patient hand hygiene adherence on the control and intervention units were measured through once monthly patient interviews conducted after meals where patients were asked to recall whether they washed their hands prior to eating (using any product). Vancomycin Resistant Enterococcus (VRE) incidence was compared on the intervention and control units during the 7 months prior and 7 months following initiating the intervention. Results: During the seven-month intervention period, more than 15 000 wipes were dispensed to patients on the intervention units. Through interview, 91% of 87 patients on the intervention units reported cleaning their hands before eating a meal using any cleaning product compared to 72% of 68 patients on the control units (X2 = 9.32, p = 0.002). Furthermore, on the intervention units, 30 (38%) patients endorsed using the provided hand hygiene product. During intervention period, the combined incidence rate of VRE the intervention units was 1.85 case/1000 patient-days compared to 5.35 cases/1000 patient-days during the 7 months prior to intervention (t = 3.24, p=0.007)(Figure 1). Conclusions: This patient-centered quality improvement intervention increased patient hand hygiene and potentially reduced VRE incidence in a vulnerable oncologic population. This practical intervention that incorporated the patient perspective provided accessible hand hygiene products with simple instruction and reminders required minimal participation of unit staff. Further application of the intervention in non-oncologic populations is needed to further establish the relationship between patient hand hygiene and the acquisition of nosocomial infections.

Background: Measuring and reporting antibiotic use are essential to antimicrobial stewardship activities. The most common metric to assess facility-level use is days of antibiotic therapy per 1000 days of care (DOT/1000 DOC). This metric may be difficult to calculate, not be readily comparable, or not provide actionable data to individual prescribers, particularly those that work in post-acute and long-term care (PALTC) settings. Here we use data from a centralized dispensing pharmacy to develop antibiotic use metrics suitable for offering individualized feedback to prescribers working in PALTC settings. Methods: We obtained medication dispensing data and resident census data for 13 PALTC settings within the same network. After omitting non-pharmacologic items and limiting the data to medications dispensed from 1/2020 – 12/2022, we determined the following metrics by month: days of antibiotic therapy (DOT), number of medications prescribed, number of antibiotic courses prescribed (antibiotic starts), and the number of individual residents issued a prescription for any medication (unique residents). These metrics were assessed for each facility (2020 – 2022) and for prescribers responsible for > 1% of prescriptions within that facility (2022 only). Prescriber-level unique residents was the number of residents issued a prescription by the given provider. We obtained facility-level census data to calculate antibiotic DOT/1000 resident days of care (DOC) as a standard to which we compared novel metrics. Results: During the 3-year study period, 1718 prescribers at 13 PALTC settings wrote for 672256 medications, including 31087 antibiotic courses. At the facility level, the correlation between monthly antibiotic starts (courses)/unique residents and antibiotic DOT/1000 DOC was 0.83 (p < 0 .0001). The correlation between monthly antibiotic DOT/unique residents and antibiotic DOT/1000 DOC was 0.98 (p < 0 .0001). Trends in monthly values of both novel metrics and DOT/1000 DOC were consistent across the examined period (Figure 1). For individual prescribers, both novel metrics permit assessment and comparison of antibiotic prescription rates over time (Figure 2). Conclusions: Pharmacy dispensing data can be used to determine antibiotic DOT/unique residents and antibiotic starts/unique residents at the facility level and for individual providers. The novel metric antibiotic DOT/unique residents demonstrated strong correlation with antibiotic DOT/1000 DOC at the facility level. In addition to supporting tracking and reporting of antibiotic use among PALTC settings, these new metrics permit visualization of the antibiotic prescribing rates of individuals prescribers, as well as peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC.

Introduction: Social determinants of health can impact healthcare-associated infections. Hospital-onset bacteremia (HOB) may lead to poor outcomes, increased length of stay, and increased cost of care. We explored the association of social determinants of health and HOB. Methods: We retrieved blood culture data at Stanford Health Care from May 2019 to October 2023. We identified blood cultures ordered ≥4 days of admission. To evaluate the association between social determinants of health and HOB, we employed an unsupervised machine learning approach (K-Means clustering) to discern patterns in HOB rates based on the Social Vulnerability Index (SVI). The SVI indicates the relative vulnerability of every U.S. Census tract. It ranks the tracts on 16 measures of vulnerability across 4 themes: socioeconomic factors, household characteristics, racial and ethnic minority status, and housing/transportation aspects. The number of clusters was determined using the Elbow Method (Figure 1). Results: Out of 209,947 blood cultures from 23,938 unique patients with a California address, we identified 81,653 blood cultures collected after 4 days (40%). The K-Means clustering algorithm identified 3 distinct clusters within the Californian census tracts, suggesting heterogeneity in the relationship between SVI and HOB (Figure 2). Cluster 1 had a higher SVI (median 0.73, range 0.46 – 0.99), with logistic regression indicating a positive SVI-HOB association (OR 4.84, 95% CI 4.02 – 4.81, p <.001). Cluster 2, had a median SVI of 0.29 (range 0.0009 – 0.78), also showed a positive association between SVI and HOB (OR 1.67, 95% CI 1.4 – 1.89, p <.001), aligning with trends of higher infection risks in more vulnerable groups. In contrast, Cluster 3 had a median SVI of 0.22 (range 0.002 –0.84). In this cluster, the SVI showed a negative association with HOB (OR 0.24, 95% CI 0.18 – 0.31, p <.001). Cluster 3 was the cluster with the least number of subjects (15,000, versus 21,761 for Cluster 1 and 29,762 for Cluster 2). Most subjects in Cluster 3 resided in Santa Clara County, whereas those in Clusters 1 and 2 were spread across Santa Clara, San Mateo, Alameda, Merced, and Sacramento Counties (Figure 3). Conclusions: Advanced techniques can be used to explore the complex interplay between social determinants of health and healthcare-associated infections and could guide the development of community-specific strategies to improve outcomes.

Background: Immediate use steam sterilization (IUSS) shortens the time from sterilization to the aseptic transfer onto the surgical sterile field. Published data incompletely defines the extent to which IUSS increases risk of surgical site infection (SSI), compared to standard sterile reprocessing methods. We aimed to measure the association between IUSS use for surgical instrument reprocessing and SSI risk in a facility where IUSS use increased due to staffing constraints and case volumes. Methods: In this retrospective observational study at a tertiary care hospital with a diverse mix of surgery types, we used sterile reprocessing logs and SSI outcomes defined using National Health and Safety Network definitions to compare SSI rates among surgeries using surgical devices sterilized using IUSS compared to standard terminal sterilization methods. We calculated a risk ratio (RR) and 95% confidence interval (95%CI), including stratification by eleven high-volume service lines. Results: Among 23,919 surgical procedures, 416 (1.74%) developed SSIs. IUSS was used to sterilize instruments prior to 1,524 (6.37%) surgical procedures, and of these procedures 39 (2.56%) developed an SSI, compared to 1.68% of non-IUSS procedures (377 SSI in 22,395 procedures; risk ratio [RR] 1.52, 95% confidence interval [95%CI] 1.10-2.11). Two surgical services had statistically significant RRs for SSI development after IUSS: transplant surgery (RR 2.47, 95%CI 1.32-4.60] and plastic surgery (RR 3.64, 95%CI 1.13-11.74; Figure). Conclusion: IUSS is associated with a significant increase in SSIs, including among varied surgery types. IUSS utilization should be minimized.