Carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) transmission studies incorporating clinical and genomic data from hospitals in India are lacking. We prospectively enrolled surgical intensive care unit (SICU) patients in a tertiary-care hospital in India (July 29 to November 30, 2023) and collected peri-rectal swabs at SICU admission, SICU discharge, and hospital discharge, alongside SICU environmental sampling. CP-CRE isolates were whole-genome sequenced to investigate differences between community-acquired (CA), healthcare-associated (HCA), hospital-acquired (HA), and environmental isolates. Twenty-seven percent of participants were CP-CRE-colonized on SICU admission, with risk factors of previous hospitalization and exposure to ≥2 antimicrobials. Among 148 admission-negative patients, 115 had repeat PRS; 42 (36.5%) acquired CP-CRE (27 upon SICU discharge, 15 upon hospital discharge). blaNDM (84%, n = 103) and blaOXA (29%, n = 36) carbapenemase genes were present in the sequenced isolates; 20 isolates (16%) carried both. Highly similar E. coli and K. pneumoniae clusters suggest hospital transmission, although the sample size limited network inference.

The quality of CHG bathing for infection prevention in HO/HSCT units is uncertain, as patients are often self-bathing. We assessed CHG bathing quality by measuring patients’ CHG skin concentrations at baseline and then evaluated whether feedback of results to unit leadership/staff could guide improvement.Table.Demographics and Clinical Factors for Patients in Hematology-Oncology/Hematopoietic Stem Cell Transplant Units from Six Hospitals (N=736)Figure 1.Baseline Chlorhexidine Gluconate Skin Concentrations in Six Hematology-Oncology/Hematopoietic Stem Cell Transplant Units (N=379) We conducted 6 point prevalence surveys from 9/2023 – 10/2024 in HO/HSCT units that performed routine CHG bathing at 6 hospitals. During each survey, we collected swab samples of patients’ skin (neck, axilla, inguinal region) and clinical data. We used a colorimetric assay to measure CHG skin concentrations (detection range ≥4.9 to 20,000 µg/ml). During surveys 1-3 (baseline period), CHG concentrations were measured but not shared. During surveys 4-6 (intervention period), summary CHG concentrations from baseline and after each intervention period survey were shared with unit leadership/staff, who led local quality improvement initiatives. We used linear and logistic regression to model outcomes, controlling for clustering as appropriate.Figure 2.Modeled Chlorhexidine Gluconate Skin Concentrations between Baseline and Intervention Periods in Hematology-Oncology/Hematopoietic Stem Cell Transplant Units from Six Hospitals (N=736) Six units participated (median 34 beds/unit); 3 units only used 2% CHG-impregnated cloth, and 3 units used bathing approaches that included other CHG formulations (4% CHG liquid or foam). Of 949 eligible patients, 83% consented to participate; after deduplication, 736 unique patients were analyzed (Table). 87% of patients reported using CHG. At baseline, 22% of 379 patients had undetectable CHG skin concentrations on all 3 body sites; CHG concentrations varied by unit (P< .001, Figure 1). In adjusted analyses, there was no difference between baseline and intervention periods in CHG skin concentration levels (P=.73; Figure 2) or CHG detection on any body site (P=.40). CHG-impregnated cloth-exclusive units had 4-fold higher CHG skin concentrations than non-cloth exclusive units (P=.005). Patients who had CHG baths performed by staff only or with staff assistance had 31% higher CHG skin concentrations than those without staff involvement (P=.02). We found significant variation in CHG bathing quality among HO/HSCT patients and between units; unit-level feedback of CHG measurements did not lead to improvement. We identified CHG formulation and staff assistance with CHG bathing as potential modifiable factors. Erik Dubberke, MD, MSPH, AstraZenca: Advisor/Consultant|AstraZenca: Grant/Research Support|Pfizer, Inc.: Advisor/Consultant|Pfizer, Inc.: Grant/Research Support|Theriva Biologics: Grant/Research Support|Vedanta Biosciences, Inc.: Advisor/Consultant|Vedanta Biosciences, Inc.: Grant/Research Support

BACKGROUNDInfection is an important complication of implanted devices and prosthetics. Identifying infections sufficiently early to salvage implants and avoid reconstructive failure is a persistent medical challenge.METHODSTwo cohorts of women 21 years and older undergoing breast implant reconstruction were recruited. Seroma fluid (82 breasts, 70 patients) was collected upon implant removal for infectious or noninfectious causes. Postimplantation drain fluid (100 samples, 44 breasts, 32 patients) was collected at routine visits prior to implant removal. A liquid chromatography/mass spectrometry-based metabolomic approach was used to identify infection correlates.RESULTSIn seroma fluid specimens, infection was associated with a diverse set of small molecules, including acetylated polyamines, defensins, glucosyl-sphingosine, and several peptide-like features (all P < 0.001, diagnostic areas under the receiver operating curve 0.82-0.93). Notably, a subset of these markers were significantly elevated (P < 0.05) in postimplantation drain fluid before recorded infection symptoms and diagnosis. Pseudomonas aeruginosa and its specialized exometabolites in drain specimens were also associated with subsequent P. aeruginosa infections.CONCLUSIONTissue fluid from infected patients has a distinctive metabolome reflecting human and bacterial physiologic processes that often precede clinical diagnoses. A diagnostic based on these findings has potential to improve patient outcomes through early recognition of infection.FUNDINGThis work was supported by U54CK000609 from the CDC and by an unencumbered research gift from Sientra. Metabolomic approaches were supported by NIH grants R01 DK125860 and R01 DK111930.

BACKGROUND:Wound complications are known to occur after nipple-sparing mastectomy (NSM), especially in procedures involving a periareolar incision. We sought to determine the independent risk of infection and overall wound complications associated with NSM vs skin-sparing mastectomy (SSM) in a contemporary cohort of women undergoing immediate implant reconstruction. STUDY DESIGN:We identified 352 women 21 years of age or older undergoing mastectomy and immediate implant reconstruction from September 2021 to December 2022 using electronic health records from 2 hospitals. The relative risk (RR) of surgical site infection (SSI) and of serious wound complication (infection or noninfectious wound complication [NIWC; dehiscence or tissue necrosis] requiring surgical treatment in the operating room) within 180 days after surgery associated with NSM vs SSM was determined using a modified Poisson regression model, controlling for established risk factors for SSI. RESULTS:NSM was performed in 128 women (36.4%), most commonly via an inframammary fold incision (73.4%). SSI occurred in 49 (13.9%) women within 180 days after surgery, whereas 70 (19.9%) women developed an SSI or NIWC. Although the incidence of SSI and the composite SSI/NIWC outcomes was similar after NSM vs SSM (14.8% vs 13.4% and 21.1% vs 19.2%, respectively); in multivariable analysis, NSM was associated with increased risk of both SSI (RR 2.13, 95% CI 1.26 to 3.59) and SSI/NIWC (RR 2.19, 95% CI 1.40 to 3.43). CONCLUSIONS:NSM was associated with increased risk of both SSI and NIWCs requiring surgical treatment after controlling for other established risk factors, despite uncommon use in this cohort of a periaerolar incision. This information should be communicated to women at the time of presurgical counseling to facilitate shared decision-making.

A COVID-19 pandemic gown conservation strategy for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) asymptomatically colonized patients caused no significant difference in healthcare-associated MRSA (HA-MRSA) bacteremia, healthcare-associated VRE (HA-VRE) bacteremia, or healthcare-associated Clostridioides difficile infections (HA-CDI) versus prepandemic contact precautions (CP). Postpandemic HA-VRE and HA-CDI rates mirrored national trends.

Infection prevention observations in clinic and procedure areas is a growing area of interest and concern. Infection prevention guidance for observations in an in vitro fertilization clinic are challenging. This is related to care of the mom and the embryo. This article introduces an in vitro fertilization clinic and areas of consideration when performing an observation of best practices.

Judgment is an aspect of executive functioning that is critical to many aspects of daily functioning, and often affected in older adults with cognitive decline. The Test of Practical Judgement (TOP-J) evaluates judgment related real-world issues that may arise in aging populations. The current study investigates the incremental validity of the TOP-J—i.e., the degree to which the TOP-J adds unique and meaningful information to a clinical assessment beyond other executive functioning tests which are often used as proxies for judgment. Participants (N = 97, M age = 74.73; 74.2%female) who were classified as cognitively unimpaired (CU), subjective cognitive decline (SCD), or mild cognitive impairment (MCI) completed comprehensive neuropsychological evaluation, which included the Wisconsin Card Sorting Test (64-card version) and Delis-Kaplan Executive Function System tests of Verbal Fluency and Trail Making Test, Condition 4. Incremental validity was assessed through hierarchical linear regression analysis and was measured by the addition of the TOP-J (Forms A, B, a composite of A + B), above these widely used executive functioning tests, with clinical diagnosis (CU, SCD and MCI) as the outcome. The addition of the TOP-J A was statistically significant (R 2 = .299, F(1,90) = 3.95, p = 0.05) and added incremental validity to predict diagnosis (∆R 2 = .031, p = 0.05). The addition of the TOP-J forms A + B composite also was significant (R 2 = .307, F(1,90) = 4.99, p = 0.03, and added incremental validity(∆R 2 = .038, p = 0.03), while the TOP-J B trended toward significance (∆R 2 = .024, p = 0.08). Our results suggest that including the TOP-J within neuropsychological evaluations of older adults can enhance diagnostic accuracy and provide clinically valuable information beyond what is derived from traditional executive functioning tests. Considering potential adverse impacts of impaired judgement abilities in the context of neurodegenerative disease, it is of utmost importance to improve the detection of diminished practical judgment skills to increase the protection of vulnerable populations and to prevent potential financial, social, and other areas of exploitation that may occur.

Importance:Hospital-onset bacteremia and fungemia (HOB) are common and potentially preventable complications of hospital care. Objective:To assess whether nonindividual patient features, which summarize interactions with other patients and health care workers (HCWs), can contribute to predictive and causal machine learning models for HOB. Design, Setting, and Participants:This prognostic study included adult patients admitted to Barnes-Jewish Hospital, an academic hospital in St Louis, Missouri, in 2021. Analyses were developed between October 2023 and August 2024 and in April 2025. Exposure:Individual patient features were extracted from electronic health records and used to engineer nonpatient features, including interactions with HCWs and direct or indirect (consecutive room occupancy) patient contact. Main Outcomes and Measures:HOB was defined as a positive blood culture after the third day of hospitalization. Patients who were hospitalized for more than 3 days were considered at risk for the outcome. We developed 3 gradient boosting models: 2 predictive (with patient features only and with both patient and nonpatient features to predict the occurrence of HOB) and 1 causal to test the association of nonpatient features and HOB. Predictive performance is reported using area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC), and the results of the causal model are reported as difference in average effects. Sensitivity analyses separated intensive care unit-onset and ward-onset HOB and included a methicillin-resistant Staphylococcus aureus-specific model to adjust for colonization pressure. Results:Among the 52 442 patients, 34 855 (66.5%) had admissions longer than 72 hours and were included for analysis; of these, 556 (1.6%) developed HOB. The median age for the included patients was 60 (IQR, 44-70) years, 50.5% were female, and obesity was the most frequent comorbidity (25.0%). Nonpatient features, such as a prior occupant of the same room receiving antipseudomonal beta-lactams and the mean number of HCWs per day for the 7 days preceding HOB, improved the model's performance (AUROC, 0.88 [95% CI, 0.88-0.89]; AUPRC, 0.20 [95% CI, 0.20-0.22]) compared with the patient-only model (AUROC, 0.85 [95% CI, 0.85-0.86]; AUPRC, 0.13 [95% CI, 0.12-0.14]) (P < .001). These 2 features were also associated with a higher likelihood of HOB in the causal gradient boosting model. Conclusions and Relevance:These findings suggest that nonindividual patient features may contribute to a comprehensive analysis of HOB when integrated with individual patient features in a machine learning model.

IntroductionChanges in cognitive abilities including memory accompany normal aging, and certain types of memory are particularly susceptible to age-related change. The ability to link aspects of an experience to form one cohesive memory, called relational memory, is essential to normal memory throughout the lifespan. Relational memory facilitates the binding of arbitrarily related stimuli and encompasses all manner of relations (spatial, associative, sequential). Prior work has studied differences in relational memory associated with aging but has investigated specific aspects of relational memory in a siloed fashion: earlier studies typically have not simultaneously assessed multiple aspects of relational memory in the same participants in the same paradigm.MethodsIn the current study, multiple aspects of relational memory were simultaneously compared between healthy younger adults (19–35 years, n = 40) and healthy older adults (65–77 years, n = 40).ResultsWe found that older adults had reduced memory performance relative to younger adults on each condition of the memory task (item condition, space condition, re-pair condition, and time condition), and there was a condition-by-age group interaction such that differences were greatest for the time and space conditions.DiscussionWe found age-related differences between young and older adults on a task simultaneously testing multiple types of relational memory with young adults performing better overall. Additionally, we observed condition-level interactions such that the age-related differences were greater for the time and space conditions than the re-pair condition. Together, these findings underscore the importance of measuring memory for all manner of relations using the same study format to achieve a thorough characterization of the complex nuances of relational memory performance across the lifespan.

This study from a South Indian tertiary care hospital found a 41% peri-rectal Carbapenem-resistant Enterobacterales colonization prevalence at intensive care unit admission, with New Delhi metallo-β-lactamase as the predominant carbapenemase. It underscores the need for contextually appropriate, cost-effective infection prevention strategies to mitigate the spread of resistant organisms in Indian healthcare settings.

Orthostatic tremor is a rare movement disorder characterized by a sensation of unsteadiness and leg tremor while standing. It has been hypothesized that the disorder is attributable to dysregulation of a central oscillatory network in the brain. This putative network includes primary motor cortex, supplementary motor area, cerebellum, thalamus, and pontine tegmentum. We studied this brain network by recording resting-state functional MRI data from individuals with orthostatic tremor. For each participant, we measured resting-state functional connectivity using a seed-based approach. Regions of interest included were components of the putative central oscillatory network and a primary motor thumb region (identified via transcranial magnetic stimulation). A non-central oscillatory network region of interest-posterior cingulate cortex-was included for comparative analysis of a well-characterized intrinsic network, the default mode network. Demographic information, medical history, and tremor characteristics were collected to test associations with functional connectivity. For normative context, data from the 1000 Functional Connectomes Project were analyzed using an identical approach. We observed that tremor and demographic variables were correlated with functional connectivity of central oscillatory network components. Furthermore, relative to healthy comparison participants, patients with orthostatic tremor exhibited qualitatively different patterns of cerebellar resting state functional connectivity. Our study enhances the current understanding of brain network differences related to orthostatic tremor and is consistent with a hypothesized selective decoupling of cerebellum. Additionally, associations observed between functional connectivity and factors including medical history and tremor features may suggest targets for treatment of orthostatic tremor.

Background. Respiratory viral infections are common and are a major cause of morbidity and mortality. We evaluated the impact of universal masking implemented during the coronavirus disease 2019 (COVID-19) pandemic on other healthcare- associated respiratory viral infections (HA-RIs) in an academic medical center. Methods. A retrospective cohort study was performed among all inpatients aged >= 18 years admitted between 1 May 2019 and 30 June 2022. Universal masking was implemented in May 2020 at our hospital and state-level mask mandates had been lifted by May 2021. We evaluated and compared the HA-RI rates, adjusted for monthly community-onset viral infections, during the premasking period, universal masking period, and post-community mandate period. Results. We identified 3015 patients (median age, 58 years; 48.0% males) with a positive respiratory viral test within 14 days prior to, or during, their hospitalization; 441 (14.6%) patients had an HA-RI. Rhinovirus/enterovirus (51.0%), parainfluenza virus (14.3%), coronaviruses (229E, OC43, HKU1, and NL63; 13.2%) and influenza (10.0%) were the predominant HA-RI viruses detected. The monthly HA-RI rate decreased 34.9% (95% confidence interval, 8.8%-51.8%) after the implementation of universal masking (0.71 premasking period vs 0.19 universal masking period vs 0.35 infections per 1000 patient-days in the post-community mandate period) while accounting for a drop in the community-onset respiratory viral infections using a structural time-series model analysis (P < .001), with no significant change in HA-RI rates with the relaxation of community masking mandate. Conclusions. Implementation of universal masking at our hospital was associated with a significantly reduced incidence of HA-RIs.

Abstract Background Respiratory viral infections are common and are a major cause of morbidity and mortality. We evaluated the impact of universal masking implemented during the coronavirus disease 2019 (COVID-19) pandemic on other healthcare-associated respiratory viral infections (HA-RI) in an academic medical center. Methods Retrospective cohort study was performed among all inpatients ≥18 years admitted between May 1, 2019, and June 30, 2022. Universal masking was implemented in May 2020 at our hospital and state-level mask mandates had been lifted by May 2021. We evaluated and compared the HA-RI rates, adjusted for monthly community-onset viral infections, during the pre-masking period, universal masking period and post-community mandate period. Results We identified 3015 patients (median age 58 years; 48.0% males) with a positive respiratory viral testing within 14 days prior to, or during, their hospitalization; 441 (14.6%) patients had an HA-RI. Rhinovirus/enterovirus (51.0%), parainfluenza (14.3%), coronavirus 229E/OC43/HKU1/NL63 (13.2%) and influenza (10.0%) were the predominant HA-RI viruses detected. The monthly HA-RI rate decreased 34.9% (95% CI 8.8%-51.8%) after the implementation of universal masking (0.71 pre-masking period vs 0.19 universal masking period vs 0.35 infections per 1000 patient-days in the post-community mandate period) while accounting for a drop in the community-onset respiratory viral infections (CO-RI) using a structural timeseries model analysis (p<0.001), with no significant change in HA-RI rates with the relaxation of community masking mandate. Conclusions Implementation of universal masking at our hospital was associated with a significantly reduced incidence of HA-RI.

Objective: To characterize the relationship between chlorhexidine gluconate (CHG) skin concentration and skin microbial colonization. Design: Serial cross-sectional study. Setting/participants: Adult patients in medical intensive care units (ICUs) from 7 hospitals; from 1 hospital, additional patients colonized with carbapenemase-producing Enterobacterales (CPE) from both ICU and non-ICU settings. All hospitals performed routine CHG bathing in the ICU. Methods: Skin swab samples were collected from adjacent areas of the neck, axilla, and inguinal region for microbial culture and CHG skin concentration measurement using a semiquantitative colorimetric assay. We used linear mixed effects multilevel models to analyze the relationship between CHG concentration and microbial detection. We explored threshold effects using additional models. Results: We collected samples from 736 of 759 (97%) eligible ICU patients and 68 patients colonized with CPE. On skin, gram-positive bacteria were cultured most frequently (93% of patients), followed by Candida species (26%) and gram-negative bacteria (20%). The adjusted odds of microbial recovery for every twofold increase in CHG skin concentration were 0.84 (95% CI, 0.80-0.87; P < .001) for gram-positive bacteria, 0.93 (95% CI, 0.89-0.98; P = .008) for Candida species, 0.96 (95% CI, 0.91-1.02; P = .17) for gram-negative bacteria, and 0.94 (95% CI, 0.84-1.06; P = .33) for CPE. A threshold CHG skin concentration for reduced microbial detection was not observed. Conclusions: On a cross-sectional basis, higher CHG skin concentrations were associated with less detection of gram-positive bacteria and Candida species on the skin, but not gram-negative bacteria, including CPE. For infection prevention, targeting higher CHG skin concentrations may improve control of certain pathogens.

Using intravascular catheter dressing audit data, we evaluated factors associated with noncompliant dressing. Male sex and gauze dressing had a higher risk of noncompliant dressing; presence of one or more lumens infusing, central venous catheter, peripherally inserted central catheters line, implantable port and contact precautions were associated with a lower risk of noncompliant dressing.

High-level disinfection and sterilization are complex processes, requiring initial and ongoing training of frontline staff.1 A key component of appropriate disinfection and sterilization is point-of-use precleaning performed by front-line staff. Our facility implemented an annual hospital-wide education and competency program for staff that perform precleaning of reusable medical devices.

Abstract Background Early in the COVID-19 pandemic many healthcare facilities experienced shortages of personal protective equipment (PPE), which required them to conserve and prioritize PPE. We wanted to determine the effect a gown conservation strategy had on nosocomial methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff.) and infections with vancomycin-resistant enterococci (VRE). Methods Prior to the pandemic, isolation gowns were required for patients colonized or infected with multidrug-resistant organisms (MDROs) at BJC Healthcare, a 15-site hospital group with >3,000 acute care beds. In April 2020, we initiated a modified contact precautions (CP) strategy for acute care patients colonized with MDROs (identified via surveillance cultures or based on past MDRO infection). Healthcare workers were instructed to wear gloves and follow standard precautions when seeing patients on modified CP. Patients with active MDRO infection and C.diff. were excluded from modified CP. Rates of NHSN laboratory identified (LabID) MRSA bacteremia and C.diff., and nosocomial VRE from blood/urine cultures, were compared before and after the modified CP. The study period was divided into baseline CP (1/01/2019- 8/30/2019) and modified CP (1/01/2021-8/30/2021) periods. Results There was no difference in LabID MRSA bacteremia or LabID C.diff. rates in the baseline CP versus the modified CP period (MRSA: 0.069 baseline vs 0.062 modified CP per 1000 pt days, p=0.64, and C.diff.: 3.96 baseline vs 3.66 modified CP per 10,000 pt days, p=0.45), respectively. There was no difference in the nosocomial VRE bacteremia & bacteriuria combined rate (0.097 baseline vs 0.116 per 1000 pt days modified CP, p=0.37). There was no difference in the subsets of nosocomial VRE bacteremia (0.038 baseline vs 0.047 modified CP, p=0.51) or VRE bacteriuria (0.059 baseline vs 0.069 per 1000 pt days modified CP, p=0.54). Conclusion We limited gown use to cases of MRSA, VRE and C. difficile infection in a conservation effort, and no longer required it for MRSA or VRE colonization; this change was not associated with increases of MRSA or C.difficile LabID rates nor with nosocomial VRE cases. Our findings highlight the importance of monitoring and evaluating PPE conservation strategies to document their safety. Disclosures All Authors: No reported disclosures

In this quasi-experimental study, implementing a procalcitonin and Clinical Pulmonary Infection Score (CPIS) successfully reduced inappropriate antibiotic use among severely-to-critically ill COVID-19 patients, multidrug-resistant organisms, and invasive fungal infections during the intervention period in 2 medical centers. However, this strategy did not improve inappropriate antibiotic use among mildly-to-moderately ill COVID-19 patients.

Objective: To assess whether measurement and feedback of chlorhexidine gluconate (CHG) skin concentrations can improve CHG bathing practice across multiple intensive care units (ICUs).Design: A before-and-after quality improvement study measuring patient CHG skin concentrations during 6 point-prevalence surveys (3 surveys each during baseline and intervention periods).Setting: The study was conducted across 7 geographically diverse ICUs with routine CHG bathing.Participants: Adult patients in the medical ICU.Methods: CHG skin concentrations were measured at the neck, axilla, and inguinal region using a semiquantitative colorimetric assay. Aggregate unit-level CHG skin concentration measurements from the baseline period and each intervention period survey were reported back to ICU leadership, which then used routine education and quality improvement activities to improve CHG bathing practice. We used multilevel linear models to assess the impact of intervention on CHG skin concentrations.Results: We enrolled 681 (93%) of 736 eligible patients; 92% received a CHG bath prior to survey. At baseline, CHG skin concentrations were lowest on the neck, compared to axillary or inguinal regions (P < .001). CHG was not detected on 33% of necks, 19% of axillae, and 18% of inguinal regions (P < .001 for differences in body sites). During the intervention period, ICUs that used CHG-impregnated cloths had a 3-fold increase in patient CHG skin concentrations as compared to baseline (P < .001).Conclusions: Routine CHG bathing performance in the ICU varied across multiple hospitals. Measurement and feedback of CHG skin concentrations can be an important tool to improve CHG bathing practice.