Abstract Objective: Antimicrobial stewardship programs (ASPs) are difficult to implement in hospitals with limited access to infectious disease (ID) specialists. Electronic consultation–based tele-stewardship may offer a scalable solution; however, evidence regarding its implementation and impact remains limited. This study evaluated the impact of an eConsult-based remote antimicrobial stewardship program on antimicrobial consumption and resistance patterns. Design: Single-center retrospective observational study. Setting: A 500-bed tertiary care hospital without on-site ID specialists. Patients: In total, 27,863 patients were hospitalized. Interventions: An asynchronous eConsult-based tele-stewardship program using the ExpertTWIN system was implemented in February 2025. Data from February 2024 to January 2026 were analyzed using a Bayesian structural time-series model. Results: During the intervention period, 145 cases were reviewed. Carbapenem use decreased; use of antipseudomonal and narrow-spectrum agents showed evidence of increases, whereas use of anti-MRSA agents and total oral and intravenous antimicrobial use showed evidence of reductions. The incidences of carbapenem-resistant Pseudomonas aeruginosa, two-drug-resistant P. aeruginosa, and MRSA showed evidence of reductions, whereas third-generation cephalosporin-resistant Escherichia coli increased. Culture specimen submission showed evidence of an increase. There was no clear evidence of reductions in all-cause in-hospital mortality or length of stay. Total antimicrobial costs were unchanged. Conclusions: The eConsult-based tele-stewardship program reduced carbapenem use and was associated with favorable changes in several antimicrobial-use, resistance, and diagnostic measures, although third-generation cephalosporin-resistant E. coli increased. No clear changes in clinical outcomes were observed. This model may offer a practical and scalable ASP strategy for hospitals without on-site ID specialists.
Abstract Objective: To investigate clinicians’ rationale for low-value ordering of urine cultures (UC). Design: Qualitative descriptive study. Setting: A public tertiary acute hospital in New Zealand. Participants: Doctors and nurses working in the Emergency Department, General Medicine, and General Surgery. Methods: In-depth structured interviews were conducted with 18 doctors and 8 nurses. We analyzed the data using inductive thematic analysis focused on exploring the behavioral and psycho-socio-cultural influences behind ordering of low-value UC. Results: We generated four main themes encompassing patient and non-patient factors behind low-value testing. (1) In the grey zone: described patient presentations which were considered clinically ambiguous, such as undifferentiated infectious symptoms, delirium, communication challenges, and catheters. (2) The pressure to act: illustrated how the fear of uncertainty and expectations of patients and families, colleagues, healthcare systems, and hierarchies impacted clinician decision-making and defensive testing practices. (3) It depends on who you talk to: highlighted how inconsistent knowledge, communication, and perceptions of harm between individuals, services, and professions contributed to unnecessary tests. And (4) It’s just how we do things here: reflected dogma and inertia behind institutional conditions and a culture of over-testing. An additional theme, (5) Solutions to change the culture, explored participants ideas to improve UC ordering behaviors. Conclusion: Diagnostic stewardship interventions to reduce low-value UC requests must address the multiple, often compounding, patient and non-patient factors that influence clinicians’ behavior.
Abstract Objective: To evaluate the effect that discontinuing contact precautions for children with methicillin-resistant Staphylococcus aureus (MRSA) had on MRSA healthcare-associated infections (HAIs). Design: Retrospective, nonrandomized, observational, quasi-experimental study. Setting: A large pediatric healthcare system including two tertiary children’s hospitals with level 4 neonatal intensive care units (NICUs). Patients: Hospitalized children. Methods: Contact precautions for children infected or colonized with MRSA was discontinued in October 2018. Prospective surveillance for MRSA HAIs was performed using standard definitions. Control charts monitored changes in annual MRSA HAI rates from 2014 to 2025. In March 2024, active surveillance cultures for MRSA were initiated in NICU A primarily for antibiotic stewardship purposes. MRSA nasal cultures were obtained upon admission and repeated every two weeks unless a patient was positive for MRSA. Healthcare-associated (HA) conversion was defined as a positive MRSA culture after one or more negative surveillance cultures. Results: Annual MRSA HAI rates/1000 patient days decreased for the System, Hospital A and Hospital B. Rates remained stable for NICU A and NICU B. Between March 2024 and December 2025, there were 1904 MRSA surveillance cultures from 682 patients in NICU A. Thirty-seven patients (5.4%) had a positive MRSA surveillance culture. HA conversion occurred in 21 patients (3.1%). Conclusion: After seven years, discontinuing contact precautions for MRSA did not result in increased MRSA HAI rates in a large pediatric healthcare system. NICU MRSA HAI rates remained stable, and HA conversion of MRSA was low.
To improve adult vaccinations rates, we implemented a Virtual Vaccine (ViVa) clinic that provided concise vaccine recommendations for patients with an upcoming primary care visit. Among Veterans ≥50, 36% of patients reviewed by the ViVa clinic received ≥1 of the recommended vaccines, compared to 23% of those in control groups.
Analytics of antimicrobial stewardship applications (ASApp) from two pediatric hospitals over 24 months revealed an average of 4922 monthly sessions. A survey of users reported use in all clinical areas with 30% exclusively in outpatient settings. Overall, >70% reported using the recommendations and almost all self-reported an impact on practice.
Antibiotic overuse at hospital discharge is common and often overlooked. We conducted interviews with 91 clinicians across 9 Veterans Health Administration hospitals to assess perceptions of a metric comparing discharge antibiotic-prescribing. Clinicians found the metric valid and meaningful, but successful implementation will require more granular contextual data and quality-improvement framing.
Infection prevention and antimicrobial stewardship (IP/ASP) leaders serve as content experts within their health systems, yet they rarely have direct managerial authority over the personnel and budgets needed to implement change. Success in these roles depends not only on clinical and scientific expertise but also on the ability to persuade: to secure buy-in from frontline clinicians, nursing leadership, hospital administrators, and other stakeholders. Despite the importance of persuasion to these roles, most IP/ASP leaders receive no formal training in influence or negotiation. This review synthesizes evidence from social psychology, behavioral science, and organizational leadership to provide IP/ASP leaders with a practical framework for effective persuasion. Key topics include building relational power, framing and contrast, credibility, concreteness, social proof, urgency, and consistency. Each principle is illustrated with examples drawn directly from IP/ASP practice. Applied ethically and strategically, these techniques can greatly enhance a leader’s impact on patient safety, institutional culture, and program success.
In this retrospective study, fungal blood cultures rarely detected fungal pathogens not found in paired standard blood cultures, with added findings in only 0.4% of cases. Given the low diagnostic yield and high cost, results support reserving fungal blood cultures for select high-risk patients to improve diagnostic stewardship.
Abstract Background: Ralstonia species are environmental Gram-negative bacilli increasingly linked to healthcare-associated bloodstream infection (BSI) outbreaks from contaminated medical solutions. We describe an outbreak of Ralstonia mannitolilytica BSI in which the source was identified and withdrawn within 24 hours. Methods: Following an unusual cluster of R. mannitolilytica blood cultures on 29 September 2024 at a 700-bed tertiary-care hospital in Oman, we conducted a multidisciplinary investigation including chart review, hospitalwide surveillance, environmental and product sampling, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis (PFGE) of clinical and product isolates. Results: Between 29 September and 8 October 2024, 21 patients met the case definition (median age 9 yr; 62% pediatric; 62% male; 95% immunocompromised; 86% with central venous access). Newly introduced pre-filled 10 mL 0.9% sodium chloride vials from a single manufacturer yielded R. mannitolilytica with concordant clinical and product antimicrobial susceptibility profiles. PFGE of 18 clinical isolates and one product isolate demonstrated 100% genetic relatedness, confirming a single-clone outbreak. The implicated product was withdrawn within 24 hours of cluster recognition. Thirteen of 21 patients had their central catheters removed; all received intravenous trimethoprim–sulfamethoxazole. Two patients experienced bacteremia recurrence after initial line retention; no outbreak-related deaths occurred. Conclusions: Prefilled saline vials can serve as the source of clonal R. mannitolilytica BSI outbreaks in immunocompromised patients. Laboratory-driven cluster detection, multidisciplinary coordination, and rapid product suspension enabled source identification within 24 hours and limited outbreak size and severity. Vigilance after introduction of new pharmaceutical products and prompt catheter removal in catheter-associated Ralstonia BSI are essential.
In over 380,000 U.S. veterans from 2014 to 2024 with a listed penicillin allergy, we report the characteristics and potential antimicrobial stewardship implications of 2781 veterans that could have undergone direct removal of the penicillin allergy label based on the receipt of a penicillin-class antibiotic since the index allergy listing.
Abstract Objective: To evaluate outcomes in patients with ceftriaxone-non-susceptible, non-extended-spectrum beta-lactamases (ESBL), Enterobacterales bacteremia treated with carbapenem and non-carbapenem treatment options. Methods: This pilot retrospective chart review evaluated adult patients admitted between January 2021 and November 2024 with a bacteremia caused by a non-ESBL, ceftriaxone-non-susceptible, piperacillin/tazobactam-sensitive, cefepime-sensitive, Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Proteus mirabilis. Patients were stratified into 3 groups depending on the administered targeted treatment (cefepime or piperacillin/tazobactam vs carbapenem vs other). Results: Of the 76 patients who were screened, 40 patients were analyzed. There were 28 patients in the cefepime or piperacillin/tazobactam group, 8 patients in the carbapenem group, and 4 patients in the other antibiotics group. The median age of the cohort was 77 years, most patients were female, and 30% of patients were in septic shock. The most common source of infection was genitourinary (63%). Thirty-day mortality was 3.8% in the cefepime or piperacillin/tazobactam group, 14.3% in the carbapenem group, and 0% in the other antibiotic group (P = .611). There was no significant difference in any of the secondary outcomes. Conclusions: In this pilot retrospective chart review, there was no difference between carbapenem and non-carbapenem treatment for ceftriaxone-non-susceptible, non-ESBL Enterobacterales bacteremia. Better understanding of the resistance mechanisms and collaboration with other healthcare systems to increase sample size may help assess optimal treatment of these organisms.
Abstract Objective: To evaluate antibiotic prescribing knowledge and confidence before versus after deployment of a web-based clinical decision support tool at an academic dental center. Design: Pre and post survey instrument. Setting: Academic dental center in the United States. Patients: Dental students, residents, and faculty. Methods: Participants completed a series of seven clinical vignettes assessing their antibiotic prescribing knowledge and confidence using 5-point Likert scale questions pre (2022) and post (2025) deployment of a web-based educational tool. The survey questions included content about antibiotic prophylaxis and treatment for dental infections. Mean Likert scale responses were compared before and after deployment of the tool. The responses were analyzed individually, pooled, and stratified by training level. Sensitivity analyses were conducted comparing results between tool users and non-users. Results: Two hundred and thirteen participants completed the pretool deployment survey, and 116 participants completed the post survey. Respondents were slightly less likely to prescribe antibiotics after having access to the tool (median pooled 5-point Likert Scale score 2.55 vs 2.67; P = .07). However, antibiotic prescribing confidence did not change significantly (median pooled score 3.37 vs 3.24; P = .21). Stratified results showed substantial variability based on individual vignette. Self-reported users of the tool (n = 37) demonstrated no differences in knowledge versus non-users (n = 97; P = .76) but did demonstrate a trend toward more confidence in their decisions (P = .07). Conclusions: Uptake of a web-based antibiotic prescribing tool was low overall and was not associated with any change in antibiotic prescribing knowledge and confidence. Additional interventions are needed to improve tool use in dental settings.
Abstract Background: Management of shigellosis is increasingly complicated by antimicrobial resistance, yet susceptibility testing is rarely performed, and the role of broad-spectrum empiric therapy in hospitalized adults remains unclear. Methods: We conducted a multi-center retrospective cohort study of adults hospitalized with stool-confirmed Shigella spp. from October 2023 to August 2024 across five hospitals in the Portland metropolitan area. The primary outcome was time from antibiotic initiation to symptom resolution (less than 3 stools in 24 h) and the secondary outcome was length of hospital stay. Results: Of 45 patients included in the outcome analyses, 29 (64%) received carbapenems and 16 (36%) received non-carbapenem antibiotics. Median time from antibiotic initiation to symptom resolution was 18 hours (IQR 9–37) in the carbapenem group and 29 hours (IQR 15–36) in the non-carbapenem group, with no significant difference between groups (P = .89). The median length of hospital stay was significantly longer in the carbapenem group, at 5.4 days (IQR 3.6–8.3), compared with 3.9 days (IQR 2.6–4.4) in the non-carbapenem group (P = .02). Only 26% of patients had susceptibility testing ordered. Conclusions: Carbapenem use was not associated with faster symptom resolution and was associated with significantly longer hospitalization. Susceptibility testing was underutilized and may be essential to guide local empiric and targeted therapy decisions.
Background: Central line-associated bloodstream infections (CLABSIs) remain a significant source of preventable harm in hospitalized patients, often resulting from missed dressing changes and mislabeled tubing. Research indicates that most CLABSIs occur more than five days after catheter insertion, highlighting the importance of maintenance practices. This project, conducted at Atrium Health Union/Union West, aimed to reduce CLABSI rates by improving adherence to central line care protocols through innovative use of secure chat photography. Methods: Using the Plan-Do-Study-Act (PDSA) framework, the team identified procedural gaps in dressing changes and tubing labeling. A novel intervention was implemented: frontline nurses sent secure chat photos of central line dressings and tubing labels to leadership at each shift change via the electronic medical record (EMR). This real-time visual verification system enhanced compliance monitoring and accountability. Stakeholder engagement was prioritized through shared governance, pilot testing, and feedback loops. Pre- and post-intervention audits measured compliance, and statistical analysis validated the impact. Results: Pre-intervention compliance with central line maintenance protocols was 83%. Post-intervention, compliance improved to a range of 92.4% to 100% across seven units, averaging 95.5% with sustained results for a year thus far. This improvement correlated with a reduction in CLABSI rates, contributing to better patient outcomes and potential cost savings, as each CLABSI can cost between $16,000 and $45,000. The project is on track to meet its goal of ≥99% compliance, supported by ongoing audits, leadership feedback, and integration of the secure photo process into standard workflows. Conclusion: This initiative successfully leveraged digital tools to address a persistent clinical challenge. Secure photo documentation via EMR messaging proved to be an effective, scalable, and low-cost strategy for improving central line care compliance. The intervention not only enhanced patient safety and reduced infection risk but also promoted health equity by standardizing care across units. Its replicability across other healthcare settings makes it a valuable model for broader dissemination. The project demonstrates how technology-driven solutions can transform infection prevention practices and support institutional goals of safety, quality, and equity in care delivery.
Background: Antibiotic allergies are frequently reported in children, yet most reactions are mild and should not preclude first-line therapy. Inaccurate allergy labels contribute to increased healthcare costs, Clostridioides difficile infection, and suboptimal or unnecessary antibiotic use. We aimed to characterize the incidence and features of inpatient antibiotic-associated allergic reactions, including serious events, and to determine the proportion of antibiotic regimens that were inappropriately modified in response to reported allergies. Methods: We conducted a retrospective study of patients ≤18 years admitted to Severance Children’s Hospital (Republic of Korea) during 2022–2024 who received oral or intravenous antibacterials and had an antibiotic-related adverse drug reaction (ADR) documented as “allergy” in the electronic health record. ADRs to antiviral, antifungal, or antiparasitic agents and reactions occurring in outpatient or emergency settings were excluded. Each discrete sign or symptom attributed to an antibiotic was counted as one allergic-reaction event. Management was considered appropriate if first-line therapy was continued for mild reactions, discontinued when unnecessary, aligned with international or national guidelines, or reflected pediatric infectious diseases expert opinion. Results: Among 31,164 admissions, 17,614 (56.0%) patients received antibiotics. A total of 215 antibiotic-related ADRs (0.92%) were documented, including 161 allergic-reaction events in 122 patients (0.7%) associated with 143 antibiotic prescriptions. Males accounted for 59.0% of cases; median age was 7.8 years (IQR, 2.8–12.4). The most common indications were surgical prophylaxis (34.3%), systemic febrile illness (14.0%), and pneumonia (11.2%). Frequent manifestations included nausea/vomiting (32.3%), urticaria (23.6%), and non-urticarial rash (18.1%). ?-lactams accounted for 67.3% of implicated agents; the most frequent drugs were ceftriaxone (26.8%), vancomycin (15.7%), and ampicillin/sulbactam (5.9%). Anaphylaxis occurred in 6 patients (5.0% of reactions; 0.002% of antibiotic prescriptions). Overall, 28.7% of allergy-labeled reactions were managed inappropriately, and 8.4% resulted in unnecessary escalation to broader-spectrum antibiotics (Table 1). Surgical prophylaxis was associated with reduced odds of inappropriate management compared with therapeutic use (OR, 0.46; 95% CI, 0.22–0.99; P Conclusion: True antibiotic allergy in hospitalized children is uncommon, yet nearly one third of reported allergies led to suboptimal or inappropriate antibiotic use. With the recent launch of the national antimicrobial stewardship pilot program in Korea (November 2024), we plan to develop an evidence-based clinical pathway for antibiotic allergy management and incorporate de-labeling strategies into the hospital electronic system to optimize antibiotic selection.
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.
Purpose: Wastewater surveillance effectively monitors pathogens. This pilot study evaluated the feasibility and utility of hospital-level wastewater surveillance by integrating wastewater and electronic health record (EHR) data. Analyses focused on hospital-acquired infections (HAI) and temporal lags between wastewater and clinical detection. Methods: From August to December 2024, wastewater autosamplers operated across five hospital pavilions at Yale New Haven Hospital, collecting samples every five minutes during a 24-hour period three times per week. Samples were analyzed by dPCR for SARS-CoV-2, Influenza (A/B), and additional pathogens. Deidentified EHR data included admissions, diagnoses, and laboratory data. The primary focus was lab-confirmed HAI SARS-CoV-2 and Influenza. HAI was defined as infections diagnosed during hospitalization without evidence at admission. Clinical and wastewater data were used to calculate the proportion of positive samples, and correlation was assessed using Spearman’s rank correlation coefficient (rho). Correlations were evaluated for lagged associations across 1–3-week lags. A sensitivity analysis was conducted by including all SARS-CoV-2 encounters. Results: Among 33,579 patient encounters, 62 SARS-CoV-2 and 74 Influenza HAI encounters were identified. This corresponded to 97 and 148 tests for SARS-CoV-2 and Influenza, respectively. Of 187 wastewater samples collected 60 (31.1%) and 1 (0.5%) were positive for SARS-CoV-2 and Influenza respectively. Due to only a single detection of Influenza in the wastewater, correlation analysis was limited to SARS-CoV-2. A correlation test of the data found no statistically significant correlation between wastewater and clinical data when aligned temporally (rho: -0.21, p: 0.51). Lagged correlations between wastewater and clinical SARS-CoV-2 positivity were evaluated across 1–3-week temporal lags. These lagged correlations were not statistically significant, but rho increased in magnitude from a 1-week lag (rho: -0.04, p: 0.89) to a 3-weeks lag (rho: 0.46, p:0.21). The sensitivity analysis found no statistically significant correlation between wastewater and clinical positivity. Conclusions: Hospital-level wastewater surveillance shows potential as an early indicator of HAI SARS-CoV-2 infections, with exploratory trends suggesting a ~3-week lead time results in stronger associations between clinical and wastewater data. Although limited by small HAI sample sizes and a short wastewater sampling period, these findings support further evaluation in larger cohorts and highlights pathogen-specific limitations as observed for Influenza. Follow-up studies should employ longer wastewater sampling windows and further refine methods to account for community-associated SARS-CoV-2 contributions to hospital wastewater, an area of active investigation by our group.
Background: Many laboratories have shifted from traditional culture-based to molecular panel diagnosis of gastrointestinal (GI) pathogens for a broad array of reasons including simplicity and rapidity. The Portland VA Health Care System (VAPORHCS) implemented the Biofire® Film array® GI pathogen panel (Biofire GI panel) 05/2024. In 04/2024, a recall alert was issued regarding increased risk of false positive norovirus results alongside a recommendation to confirm positive results by another method. The aim of this quality improvement project was to evaluate the false positive rate for norovirus of this assay. Methods: We used microbiology laboratory records to identify all norovirus positive results on the Biofire GI panel from 05/2024-09/2025. Chart review was performed to determine confirmatory norovirus test results, testing location (outpatient, inpatient, or emergency department), compatible clinical symptoms (acute nausea/vomiting/diarrhea), and the presence of other positive stool testing results. False positive was defined as discrepant Biofire GI panel (positive) and dedicated norovirus PCR (negative) results on the same sample. Result: We identified 39 initial positive tests on the Biofire GI panel from 38 unique patients. One test was excluded due to specimen processing error on the confirmatory test, leaving 38 tests for analysis. Of these, 13 (34%) were confirmed as positive by single-plex PCR corresponding to a false positive rate of 66%. False positive rate stratified by test location are shown in Figure 1. Compatible symptoms stratified by test results are shown in Figure 2. Of the true positive group, 11/13 (85%) had diarrhea < 5 days compared to 6/25 (24%) in the false positive group (p<0.001). Similarly, in the true positive group, 11/13 (85%) of patients had nausea/vomiting compared to 5/25 (20/%) in the false positive group (p<0.001). An alternative enteric pathogen was identified in 8/38 (21%) cases. Conclusion: We found an alarmingly high rate of false positive norovirus results on the Biofire GI panel at our center, which is higher than previously reported. True positive tests were more likely to be accompanied by those that fit with typical symptoms. Positive norovirus results from the Biofire GI panel should be interpreted with caution as is recommended by the manufacturer, particularly in absence of a compatible clinical syndrome.
