OBJECTIVES:Pediatric patients undergoing hematopoietic transplant or cellular therapy (TCT) are at increased risk of developing central line-associated bloodstream infections (CLABSI). The role of language barriers in CLABSI risk has not been well-explored in this population. This study aimed to evaluate the risk for CLABSI in pediatric TCT patients with limited English proficiency (LEP). DESIGN AND PATIENTS:A retrospective cohort study of patients hospitalized in the TCT unit in a single pediatric oncology center between January 2021 and June 2024. INTERVENTIONS:Clinical data was abstracted from the electronic health records and CLABSI events from the hospital infection prevention and control surveillance database. CLABSI rates were calculated as events per 1,000 inpatient central line days (CLD) and compared between patients with LEP and those English-proficient. Cox proportional hazard analysis was used to evaluate independent risk factors for CLABSI. RESULTS:Two hundred and eighty patients contributed a total of 12,325 CLD and 93 CLABSIs; of which 57 patients were with LEP contributing 3,113 CLD and 29 CLABSIs. The unadjusted CLABSI rate in patients with LEP was significantly higher (9.32/1,000 CLD) than that in English-proficient patients (6.95/1,000 CLD, P < .001). Patients with LEP had twice the risk of developing CLABSI compared to English-proficient patients (Adjusted HR 2.03, 95% CI [1.23, 3.34]). CONCLUSIONS:This study identified a significantly increased risk of CLABSI in pediatric TCT patients with language barriers. Addressing these barriers through equitable strategies is crucial for improving clinical outcomes and promoting an inclusive healthcare for diverse patient groups.
OBJECTIVE:The impact of adopting the proposed National HealthCare Safety Network healthcare facility-onset antibiotic-treated Clostridioides difficile infection (HT-CDI) surveillance definition on the number of CDI cases that would qualify for healthcare-associated infection (HAI) surveillance reporting from US Veterans Affairs (VA) facilities is unknown. METHODS:We retrospectively evaluated CDI cases from 25 acute care VA medical centers from July 2022 through June 2024 using the proposed HT-CDI surveillance definition. RESULTS:A total of 789 cases were analyzed. Use of the HT-CDI surveillance definition increased the number of reportable CDI HAIs by 23%. CONCLUSION:In VA, adoption of the proposed HT-CDI surveillance definition increased the number of reportable cases.
OBJECTIVE:To reduce frequency of endotracheal aspirate culture (EAC) collection and decrease antibiotic days of therapy (DOT) for ventilator-associated tracheitis (VAT). DESIGN:Quality improvement intervention. SETTING:Tertiary-care pediatric intensive care unit (PICU). PATIENTS:Admitted to the PICU with an endotracheal tube (ETT) or tracheostomy. INTERVENTIONS:A clinical decision-support tool was implemented to provide clinical criteria for culture collection and microbiologic criteria for diagnosis, and to reduce treatment duration to 3 days. Key stakeholders were engaged, a nurse champion was identified, and a protocol was implemented. Culture rates (overall and serially repeated) and antibiotic DOT for VAT, each per 100 ETT/tracheostomy days, were analyzed. The proportion of VAT episodes treated for 3 days was also evaluated. Balancing measures included PICU mortality, ventilator-associated events, ventilator days, and length of stay. Statistical process control methods were used to analyze the data. RESULTS:Across 1072 EACs sent and 213 VAT cases diagnosed, interventions led to a 23% reduction in monthly cultures (9.2 to 7.1 per 100 ETT/tracheostomy days) and a 53% reduction in serial culture use (1.5 to 0.7 per 100 ETT/tracheostomy days). There was a 53% reduction in monthly antibiotic DOT for VAT (10.8 to 5.1 per 100 ETT/tracheostomy days) and a 13-fold increase in the proportion of 3-day antibiotic prescriptions (5 to 65%). There was no increase in mortality, ventilator-associated events, ventilator days, or length of stay. CONCLUSIONS:Standardized VAT guidelines in critically ill children can safely and effectively decrease culture and antibiotic use.
South Korean CRE notifications more than doubled between 2020 and 2024, with no inflection in the trajectory. Imipenem resistance in long-term care facilities reached 52.3% for Klebsiella pneumoniae and a 12.93-fold higher risk ratio than small/medium hospitals for Escherichia coli. Current surveillance cannot identify individual facility reservoirs, requiring structural reform.
OBJECTIVE:To determine whether split septum needleless connector prevent central line-associated bloodstream infection (CLABSI) better than mechanical valve in very preterm or very low-birth-weight (VLBW) neonates. DESIGN:This is an open-label, parallel, randomized controlled trial. Participants were followed up to 48 hours after central line removal for the primary outcome. SETTING:This is a single-center study conducted at level III neonatal intensive care unit in public tertiary hospital. PARTICIPANTS:Very premature or VLBW neonates requiring central access. INTERVENTION:Participants were randomized to receive either a split septum or mechanical valve needleless connector. PRIMARY OUTCOME:The primary outcomes were CLABSI incidence rate and the estimated hazard ratio of CLABSI between the two groups. RESULTS:A total of 60 neonates were included in the analysis, in which 30 neonates were allocated to each intervention (split septum) (mean±SD gestational age, 27.37 ± 7.7 weeks; 15 [50%] male) and control (mechanical valve) group (mean±SD gestational age, 30.27 ± 2.7 weeks; 17 [56.7%] male). The CLABSI incidence rate was lower in the intervention group (3.0 vs 16.2 per 1,000 catheter days). The adjusted hazard ratio for the intervention compared to control group was 0.153 (95% CI 0.02-1.52; P = .109). Although not statistically significant, the control group demonstrated higher CLABSI-related mortality (7% vs 0%), length of stay (49.8 ± 24.2 vs 42.3 ± 23.8), and hospital cost (130.5 (79.4-215.9) vs 104.1 (86.4-152.7). CONCLUSIONS:Split septum demonstrated a trend in lower incidence of CLABSI. This result should be weighed carefully in determining the needleless connector type best suited for very preterm or VLBW neonates.
OBJECTIVE:Compare characteristics of community-associated (CA) versus healthcare-associated (HCA) extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) urinary tract infection (UTI) cases and assess associations between ESBL-E UTI prevalence and census-tract social vulnerability. DESIGN:Retrospective cohort study. SETTING:Monroe County, NY, January 2020-December 2023. PATIENTS:Population surveillance of first urinary ESBL-E isolate among county residents. METHODS:ESBL-E, defined as resistance to ≥1 third-generation cephalosporin, was identified from inpatient and outpatient urinary specimens. Demographic, clinical, and healthcare exposure data were abstracted; cases were classified as CA or HCA using standardized definitions. Addresses were geocoded to census tracts and linked to CDC Social Vulnerability Index (SVI) scores. Characteristics were compared using χ2 and Wilcoxon tests. Generalized linear models assessed associations between SVI themes and ESBL-E prevalence by epidemiologic classification. RESULTS:Of 3,100 ESBL-E UTI cases, 1,621 (52.3%) were CA and 1,468 (47.4%) HCA. CA cases were younger (median 56 vs 71.5 years), more often female (89.5% vs 68.4%), and less medically complex than HCA cases. HCA prevalence increased with SVI score, while CA prevalence remained stable across SVI levels. The HCA association was mainly driven by SVI Theme 2 (household composition/disability; P = .0011). CONCLUSIONS:CA and HCA ESBL-E UTIs exhibit distinct epidemiology. No association was observed between SVI and CA ESBL-E UTI prevalence. HCA prevalence increased with social vulnerability, largely driven by SVI Theme 2, potentially reflecting healthcare exposure and medical complexity. Factors driving CA ESBL-E differ, and ESBL-E reduction efforts should consider broader structural and community factors beyond those captured by the SVI.
Genomic surveillance detects healthcare-associated outbreaks that are often missed by traditional methods, offering substantial benefits for infection prevention. However, its use introduces complex ethical questions regarding patient notification and disparities in outbreak detection between institutions with and without genomic capabilities. In this commentary, we apply the Centers for Disease Control and Prevention's 2020 ethical considerations regarding patient notification and the Ethical Infection Prevention and Control (EIPAC) framework to two hypothetical scenarios involving genomic surveillance programs. We identify ethical justifications for patient notification when both genomic and epidemiologic evidence suggest transmission, as well as considerations militating for and against notification when epidemiologic evidence supporting genomic findings is absent. Our analysis, informed by qualitative research reporting the types of harm experienced by patients across detected and undetected outbreaks, includes a matrix illustrating physical, psychological, and ethical harms associated with different detection and disclosure conditions. We also discuss ethical concerns arising from institutional disparities in genomic capability such that patients in hospitals without genomic surveillance may suffer preventable harm and remain uninformed due to lack of detection. We recognize that hospitals adopting genomic surveillance face new ethical duties to disclose transmission events, while those that do not engage in such surveillance risk perpetuating inequities in patient safety and transparency. We argue that national guidance is needed to ensure consistency in notification and promote ethical use of genomics. Coordinated frameworks from professional societies should define genetic thresholds warranting disclosure, address disparities in pathogen genomic detection methods, and uphold patient trust in the genomic era.
Abstract Objective: To determine if hospital characteristics were associated with rates of healthcare-associated (HA) viral respiratory infections (VRIs) in a large Canadian acute care hospital network. Design: Survey of hospital characteristics and prospective surveillance of HA-VRI. Setting: The Canadian Nosocomial Infection Surveillance Program is a sentinel surveillance system with 89 hospitals participating in adult and pediatric VRI surveillance. Patients Patients with laboratory confirmed infection from SARS-CoV-2, Influenza A/B or RSV associated with their hospitalization from participating hospitals between January 1-December 31, 2024. Methods: A 15-item survey was distributed to hospitals to collect information on hospital infrastructure, infection prevention and control practices, and occupational health measures for healthcare workers. HA-VRI rates/10,000 patient-days were analyzed alongside survey responses using univariable and multivariable negative binomial regression models in R to determine associations. Hospitals without case data were excluded. Results: Of 89 hospitals, 93% (n = 83) responded to the survey, with 79 included in the analysis. The national HA-VRI rate was 8.15/10,000 patient-days. Pediatric hospitals had a 56% lower HA-VRI rate than adult/mixed hospitals ( P < .001) that increased with the exclusion of SARS-CoV-2. Each 10% increase in the percentage of single-bed rooms corresponded to a 12% reduction in infection rate ( P < .001). Teaching vs. Non-teaching hospitals were associated with a 32% lower HA-VRI rate. Universal masking was not associated with a statistically significant reduction in HA-VRI rates (RR 0.82, 95% CI: 0.56–1.19). Conclusions: In a large surveillance network, lower HA-VRI rates were seen in pediatric hospitals, teaching hospitals, and in hospitals with higher proportions of single-bed rooms.
Abstract Objective: 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. Design: 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). Setting: A tertiary pediatric referral center. Patients: Ages 0–21; NHSN reportable GI SSI procedures (appendix, gastric, small bowel, colon, laparotomy). Results: 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. Conclusions: 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.
OBJECTIVE: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. METHODS: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. RESULTS: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). CONCLUSION: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.
Following a global 2024 blood culture bottle shortage, we implemented a multidisciplinary stewardship intervention to reduce utilization. Upon supply normalization in 2025, a durable 34.8% reduction in utilization was maintained without increasing sepsis-related mortality, demonstrating that crisis-driven shifts can successfully establish a sustainable "new steady state."
Antimicrobial stewardship programs (ASP) serve as a valuable resource to healthcare institutions. This commentary explores a real world demonstration of the potential advantages and pitfalls of using artificial intelligence (AI) in ASP, both in supporting the development of institutional guidelines and in providing a cost-effectiveness analysis of these protocols, as well as the caution that should be exercised when involving AI in stewardship.
OBJECTIVES:To analyze state healthcare-associated infection (HAI) laws and examine the transition from state-driven surveillance to regulatory frameworks substantially shaped by federal policy. METHODS: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. RESULTS: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. CONCLUSIONS: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.
In this single-center, retrospective cohort study of 1169 patients requiring outpatient parenteral antimicrobial therapy, complications (i.e., bloodstream infections or venous thrombosis) occurred more frequently in patients with midlines (6.4 per 1,000 line-days) than peripherally inserted central catheters (1.1 per 1,000 line-days), adjusted hazard ratio 3.60 (95% confidence interval 1.66-7.81).
Background: Approximately one in ten US children report an allergy to antibiotics. However, ~95% of these pediatric allergy labels are inaccurate upon evaluation. Inaccurate allergy labels lead to suboptimal antibiotic prescribing, increasing patients’ risk of treatment failure and adverse effects. Successfully removing inaccurate pediatric allergy labels (i.e., delabeling) requires engagement from primary caregivers. This study examined caregiver (e.g., parents, stepparents) perceptions and attitudes toward delabeling in pediatric care. Methods: We invited US adults to an online survey about antibiotics (March-April, 2024). Respondents identifying as a primary caregiver for a child with an antibiotic allergy answered questions about the child’s allergy (e.g., type, severity), their willingness to try methods to assess whether the child was non-allergic (oral medication vs. skin-scratch challenge), and their anticipated reaction to a negative skin-scratch test result for the child (i.e., indicating no allergy). Results: Table 1 shows characteristics of the 37 caregivers of a child with an antibiotic allergy, 31 described the child’s allergies as mild/moderate (83.8%), 5 as severe (13.5%), and 1 as life-threatening (2.7%). Penicillin was the most common allergy (27 of 37 [73.0%]). More caregivers were willing to try skin-scratch testing (33 of 37 [89.2%]) than were willing to try oral challenge (26 of 37 [70.3%], p=.02). Yet, 21.6% of caregivers (n=8) would not accept the results of a negative skin-scratch test for the child and 29.7% (n=11) would not agree to remove the allergy from the child’s medical record based on that test. Almost all caregivers (35 of 37 [94.6%]) said they would try to re-add the child’s allergy onto their medical record if removed following a negative skin-scratch test. Caregivers listed various concerns about delabeling in free-text boxes including fear of harm or distress to the child, negative past experiences, distrust of clinicians, and belief that, as caregivers, they know the child best and should not knowingly do something that could harm them. Other concerns included keeping allergy labels as a safety net, worrying allergies could return, and preferring to be ‘safe than sorry’. Conclusions: In this survey of US adults, caregivers of children with self-reported antibiotic allergies expressed hesitancy toward delabeling efforts. Findings suggest increased testing efforts alone are likely insufficient as caregiver attitudes may present a major barrier to effective antibiotic allergy delabeling in pediatric care. Strategies for addressing caregiver concerns that persist after negative test results are needed to ensure safe, guideline-concordant antibiotic prescribing through childhood and beyond.
OBJECTIVE: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. METHODS: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. RESULTS: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. CONCLUSION: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.
