Background: The 2024 blood culture (BCx) bottle shortage highlighted the importance of BCx stewardship. During the shortage period, an electronic medical record alert (Figure 1) was implemented to conserve BCx bottle supply and subsequently maintained after shortage conclusion. An alert fired when repeat BCx were ordered within 48 hours of prior BCx and required written justification of the order to proceed. Sustainable mechanisms to implement BCx stewardship using clinical decision support are needed. This study evaluates whether written justification for bypassing the alert adhered to institutional BCx guidance. Methods: A retrospective cohort study of repeat BCx orders where the alert fired and was bypassed in adult patients in first 6 months after implementation (8/12/2024-2/11/2025) was evaluated at a single academic hospital. Primary outcome was the adjudicated adherence to institutional BCx guidance for alert-triggered BCx. Additional outcomes included true positive and contamination rates based on adherence, timing of repeat BCx, and whether repeat blood cultures were obtained <40 hours from initial BCx, serving as a measure of appropriate timing. Falsely triggered alerts were defined as initial BCx orders that were canceled yet triggered the alert or when clinicians added BCx to initial orders within <6 hours. Results: Among 162 BCx episodes, 130 were included (exclusions: 7 pediatric, 25 falsely triggered alerts). These 130 BCx episodes consisted of 247 repeat BCx sets in 105 patients. Characteristics of initial and repeat blood culture episodes are in Figure 2. The median time from initial to repeat BCx was 45.6 hours (IQR 35.5-49.3) (Figure 3). Repeat blood cultures were obtained after 40 hours in 67.7% of episodes (Figure 4). Repeat BCx adhered to local guidance for appropriate repeat BCx in 79/130 (60.8%) of episodes with higher yield of true pathogens in adherent indications (20/79, 25.3%) compared to nonadherent indications (3/51, 5.9%) (Figure 5). The indications with highest positivity were retained infected central venous catheters (35.7%) and Staphylococcus aureus bloodstream infection (35.3%). Repeat BCx obtained ≥40 hours had higher adherence compared to those obtained <40 hours (70.5% vs 40.5%). Conclusion: Overall adherence to local BCx guidance for repeat BCx via an alert was 60% with higher positivity when ordered for appropriate indications and with appropriate timing. The alert did create falsely triggered alerts, and clinician judgement outside the guidance identified rare cases of persistent bloodstream infection.

Abstract Objective: We examined five common targets for diagnostic stewardship that have been associated with improved patient outcomes. For each, we estimated the financial and reputational impact of each intervention on a typical 200 bed community hospital. These estimates can be adjusted for individual hospital estimates. Results: We found consistent savings and potential improvements in hospital metrics associated with these different diagnostic stewardship interventions. Clostridioides difficile (CDI) diagnostic stewardship showed ＄125,617 expected savings plus a likely additional 75% reduction in the hospital-acquired condition (HAC) CDI metric. Urine culture stewardship showed ＄34,111–＄92,361 in savings with an additional 30% reduction in the HAC catheter-associated urinary tract infection metric. Procalcitonin de-implementation showed ＄78,938 expected savings from test discontinuation. Expanded respiratory pathogen panel stewardship showed ＄383,650–＄668,000 in savings, depending on degree of reduction and replacement with focused viral testing. Blood culture stewardship showed ＄1,860,800 in savings with an additional 33%–80% reduction in HAC central line associated bloodstream infection and MRSA bacteremia metrics. Conclusions: In total, a 200-bed hospital implementing all five interventions could expect an approximate ＄2,482,616–2,825,216 in laboratory and clinical savings. These interventions would also improve many HAC metrics, providing an additional ＄200,000–＄600,000 in savings, depending on baseline performance. Finally, reputation metrics, such as Leapfrog grades, would also improve.

Background: After CDC and local surveillance identified an increase in Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacterales (KPC-CRE) caused by multiple organisms, an investigation was conducted at an acute care hospital. Cases clustered around an intensive care unit (ICU) and step-down unit (SDU), where wastewater plumbing was a suspected transmission source. Whole genome sequencing (WGS) was used to investigate this outbreak. Methods: A case was defined as detection of KPC-CRE or KPC (no organism cultured) from specimens collected at the hospital between 01/2019 to 10/2025. Clinical cases were identified via carbapenemase testing of CRE isolates using PCR (Xpert Carba-R) or by multiplex PCR panels and screening cases through PCR with reflex to culture. ICU sink and hopper samples and SDU sink samples were tested using selective media, MALDI-TOF, and multiplex PCR for KPC-CRE detection. Isolates underwent short and long-read sequencing. Result: Overall, 64 cases (37 clinical; 27 screening), involving 54 patients, were identified; 28 patients had ICU/SDU admissions during their hospitalization. The 52 cases with an organism identified included seven species, of which the most common were Citrobacter (26), Klebsiella (14), and Raoultella (5); 24 harbored blaKPC-2 (37.5%), 18 blaKPC-4 (28.1%), 5 blaKPC-3 (7.8%), 1 blaKPC-160 (1.5%), and 16 were not subtyped (25%). Seventeen isolates from five species carried blaKPC-2 on a 42 kb IncP6 plasmid, while ten isolates from five species carried blaKPC-4 on a 69 kb plasmid with Col440I and IncM1 replicons. Environmental sampling in 05/2025 found KPC-CRE in 10/12 sinks and 2/12 hoppers in the ICU and 1/22 SDU sinks (fig1). KPC-CRE environmental isolates were closely genetically related to the Citrobacter, Klebsiella, and Roultella clinical isolates and harbored similar KPC-carrying plasmids. Infection prevention and control (IPC) rounding identified patient items within the sink splash zone, including placing bath-in-a-bag in the sink. In 05/2025, a campaign was initiated to remove items from the splash zone, switch to chlorhexidine wipes, and implement daily use of an EPA-registered, sodium dichloroisocyanurate-based biofilm drain disinfectant product. Starting 07/2025, pouring of lipids and total parenteral nutrition down drains was stopped. While repeat environmental sampling in 6/2025 also found KPC-CRE in sink drains, no additional cases were identified in the ICU or SDU following these remediation activities (fig2). Conclusion: ICU sinks served as a reservoir for KPC-CRE, with transmission to patients. KPC-CRE persisted in drains following initial drain disinfection measures; therefore, changes in sink and splash-zone IPC practices appear to be important for interrupting transmission.

Following the introduction of doxycycline post-exposure prophylaxis (doxy PEP), concerns regarding associated antimicrobial resistance have emerged. In this piece, we discuss a range of collaborative strategies between the historically siloed fields of antimicrobial stewardship and sexually transmitted infections to guide the stewardship of doxy PEP and diagnostics for STI care.

Background: After CDC and local surveillance identified an increase in Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacterales (KPC-CRE) caused by multiple organisms, an investigation was conducted at an acute care hospital. Cases clustered around an intensive care unit (ICU) and step-down unit (SDU), where wastewater plumbing was a suspected transmission source. Whole genome sequencing (WGS) was used to investigate this outbreak. Methods: A case was defined as detection of KPC-CRE or KPC (no organism cultured) from specimens collected at the hospital between 01/2019 to 10/2025. Clinical cases were identified via carbapenemase testing of CRE isolates using PCR (Xpert Carba-R) or by multiplex PCR panels and screening cases through PCR with reflex to culture. ICU sink and hopper samples and SDU sink samples were tested using selective media, MALDI-TOF, and multiplex PCR for KPC-CRE detection. Isolates underwent short and long-read sequencing. Result: Overall, 64 cases (37 clinical; 27 screening), involving 54 patients, were identified; 28 patients had ICU/SDU admissions during their hospitalization. The 52 cases with an organism identified included seven species, of which the most common were Citrobacter (26), Klebsiella (14), and Raoultella (5); 24 harbored blaKPC-2 (37.5%), 18 blaKPC-4 (28.1%), 5 blaKPC-3 (7.8%), 1 blaKPC-160 (1.5%), and 16 were not subtyped (25%). Seventeen isolates from five species carried blaKPC-2 on a 42 kb IncP6 plasmid, while ten isolates from five species carried blaKPC-4 on a 69 kb plasmid with Col440I and IncM1 replicons. Environmental sampling in 05/2025 found KPC-CRE in 10/12 sinks and 2/12 hoppers in the ICU and 1/22 SDU sinks (fig1). KPC-CRE environmental isolates were closely genetically related to the Citrobacter, Klebsiella, and Roultella clinical isolates and harbored similar KPC-carrying plasmids. Infection prevention and control (IPC) rounding identified patient items within the sink splash zone, including placing bath-in-a-bag in the sink. In 05/2025, a campaign was initiated to remove items from the splash zone, switch to chlorhexidine wipes, and implement daily use of an EPA-registered, sodium dichloroisocyanurate-based biofilm drain disinfectant product. Starting 07/2025, pouring of lipids and total parenteral nutrition down drains was stopped. While repeat environmental sampling in 6/2025 also found KPC-CRE in sink drains, no additional cases were identified in the ICU or SDU following these remediation activities (fig2). Conclusion: ICU sinks served as a reservoir for KPC-CRE, with transmission to patients. KPC-CRE persisted in drains following initial drain disinfection measures; therefore, changes in sink and splash-zone IPC practices appear to be important for interrupting transmission.

ImportanceBlood culture (BC) use benchmarks in US hospitals have not been defined.ObjectiveTo characterize BC use in adult intensive care units (ICUs) and wards in US hospitals.Design, Setting, and ParticipantsA retrospective cross-sectional study of BC use in adult medical ICUs, medical-surgical ICUs, medical wards, and medical-surgical wards from acute care hospitals from the 4 US geographic regions was conducted. Critical access hospitals, less than 6 months of BC data, and non-US hospitals were excluded. The study included BC use data from September 1, 2019, to August 31, 2021. Data were analyzed from February 23 to July 14, 2024.Main Outcomes and MeasuresThe primary outcome was BC use per 1000 patient-days. Adjusted means with 95% CIs were calculated using mixed-effects negative binomial regression models adjusted for unit type, hospital bed size, geographic region, seasonality, and state COVID-19 case load, with random intercepts accounting for clustering at unit and hospital levels. Secondary outcomes included blood culture positivity, single BCs, BC contamination, and minimum threshold for BC use where blood culture positivity would be optimized.ResultsA total of 362 327 blood cultures were analyzed from 27 medical ICUs, 35 medical-surgical ICUs, 121 medical wards, and 109 medical-surgical wards from 48 hospitals in 19 states and the District of Columbia. The adjusted mean BC use per 1000 patient-days was 273.1 (95% CI, 270.2-275.9) for medical ICUs, 146.0 (95% CI, 144.5-147.5) for medical-surgical ICUs, 80.3 (95% CI, 79.8-80.7) for medical wards, and 65.1 for medical-surgical wards. Blood culture use was significantly higher across all 4 unit types in hospitals with more than 500 beds compared with 500 or less beds and in the West-Midwest compared with other regions. Single blood culture and positive blood culture rates were below 10% across all 4 unit types. Of the 292 units, 97% had a mean BC contamination rate within 3% of the recommended threshold, and 51% were within 1%. The minimum BC use thresholds (ie, BC use below this number may represent undertesting) were 120 BCs per 1000 patient-days for medical ICUs, 80 BCs per 1000 patient-days for medical-surgical ICUs, and 30 BCs per 1000 patient-days for medical-surgical wards.Conclusions and RelevanceThe findings of this study suggest that blood culture positivity may help determine appropriate BC use for individual unit types.

Rapid blood culture identification is most effective with antimicrobial stewardship feedback, which is limited during non-business hours. We implemented overnight review of Blood Culture Identification 2 panel results by intensive care unit pharmacists and demonstrated reduced time to evaluation (3.6 vs 9.3 hours, P < .01).

Background: In summer 2024, our institution implemented enhanced blood culture (BCx) stewardship due to a global BCx shortage. Centers for Medicare and Medicaid Services’ (CMS) SEP-1 quality measure requires BCx. We evaluated whether the BCx shortage and stewardship impacted SEP-1 compliance. Methods: A retrospective review of SEP-1 data from an academic and a community hospital (1/1/2022-9/30/24) was performed and grouped by quarter. SEP-1 compliance was abstracted per CMS criteria. Failures due to BCx were categorized by timing of antibiotics prior to BCx: short delay (0-3 hours after antibiotics), long delay (>3 to 24 hours or no BCx). SEP-1 failures due to no BCx underwent manual chart review to determine infectious source, alternative culture obtainment, and adjudication if BCx would have changed clinical management. BCx failures were compared descriptively by quarter with emphasis on the BCx shortage (quarter 3 of 2024). Results: Over 11 quarters, 690 cases were abstracted for SEP-1 review (mean 62.7 cases/quarter). The mean SEP-1 success rate pre-shortage was 51.1%, while SEP-1 success rate during BCx shortage was 40.3%, the lowest rate since 2022. SEP-1 failures due to improper BCx obtainment were the cause of SEP-1 failure in a mean of 12.3% of cases reviewed pre-shortage, but this increased to 30.6% during the BCx shortage (Figure 1). Pre-shortage BCx failures were due to short delays (77.9%), long delays (15.6%), and no BCx (6.5%). During the shortage, BCx failures were more commonly due to long delays (31.6%) or no BCx obtained (31.6%) (Figure 2). The majority (7/12) of cases with no BCx obtained were during the shortage. Upon adjudication of no BCx cases, positive BCx would have significantly changed management in only 2/12 cases. Reasons BCx would not have changed management included urinary tract infection with positive urine culture (5/12), non-infectious/non-bacteremic diagnoses (3/12), and community-acquired peritonitis with surgery (2/12). Specifically during the shortage, 5 were UTIs (4 had positive cultures), 1 with peritonitis (positive intra-abdominal cultures), and 1 without bacterial infection. Conclusion: SEP-1 failures increased during the BCx shortage, possibly driven by efforts to reduce unnecessary BCx use. Use of alternative culture sites with higher yield than blood cultures resulted in SEP-1 failures that did not result in patient harm. SEP-1 should be re-evaluated, as BCx are not the only means of diagnosing the microbiologic etiology of infection and are often low yield in select patients with sepsis.

Background: In 2024, US hospitals were affected by the Becton Dickinson (BD) BACTEC blood culture bottle shortage with little time to respond and conserve supply. The extent of the impact of this shortage on clinical practice has not been explored. Methods: We developed a 7-question online poll with the Emerging Infections Network (EIN) exploring the extent to which facilities were impacted by the shortage, geographic distribution and facility type of institutions affected, actions taken to mitigate the shortage, and the impact on clinical management of fever and Staphylococcus aureus bacteremia. The link was sent to >3100 EIN listserv members 3 times during September 2024. Descriptive and thematic analyses were performed on quantitative and qualitative responses. Results: Of 202 respondents from 39 states, 129(64%) responded their hospital had limited blood cultures available, 8(4%) were unsure how their hospitals were affected, and 65(32%) indicated their hospitals were not affected (Fig1). The most affected hospital facility types with >10 respondents were Community (27/39, 69%), University (48/72, 67%), Children’s (7/11, 67%), Non-university teaching (33/52, 65%), and the VA/DOD was least affected facility type (3/11, 27%). Respondents not affected by the shortage most commonly used alternate blood culture media. Top mitigation strategies included publishing algorithms for best practice use (103/202, 51%), restricting follow-up blood cultures (88/202, 44%), using single blood culture sets (86/202, 43%), and implementing EMR-based alerts on blood culture orders (71/202, 36%). Important clinical themes identified by affected respondents included limitations on blood culture use (147 responses), concerns with overall treatment and care including delays and disruptions in discharges or prolonged antibiotic use (15 responses), concerns with bacteremia management (15 responses), and increased diagnostic stewardship opportunities (21 responses) (Fig2). The most prevalent theme in S. aureus bacteremia management was limitations in repeat blood cultures (61/163, 37%) with concerns about confirming bacteremia clearance, while the most common theme in inpatient/ER management of fever was limitations in initial blood cultures (64/159, 40%), with common comments about reducing inappropriate blood cultures. 61/202 respondents commented in the open-ended question with the most common theme highlighting increased diagnostic stewardship as a positive outcome of the shortage (19/61, 31%). Conclusion: The BD BACTEC blood culture bottle shortage caused widespread clinical impact. The themes identified highlight the challenges placed on healthcare systems during times of shortage as well as the effects on patient care. Mitigation strategies implemented during the shortage may create future opportunities for diagnostic stewardship.

The spectre of severe invasive infections caused by Streptococcus pyogenes and Staphylococcus aureus haunt clinicians and patients alike. They are the quintessential causes of devastating high profile 'front page sepsis' cases affecting children and adults, often without recognized risk factors, and typically associated with toxic shock syndromes (TSS) and necrotizing soft-tissue infections (NSTI), as seen in the global surge of invasive S. pyogenes disease from late 2022 [1]. These fulminant clinical syndromes demand rapid empiric antibiotic treatment and urgent surgical intervention for source control.

We read with great interest the recent update on National Healthcare Safety Network (NHSN) survey data from antimicrobial stewardship programs (ASPs) by O'Leary et al. 1 In particular, we are impressed with the substantial improvement reported by critical access hospitals (CAHs) meeting the seven Core Elements (19.6% in 2014 vs 88.9% in 2021). 1 CAHs face unique barriers to building and maintaining ASPs, given their inherent rurality, resource limitations, and lack of access to infectious diseases expertise and training. 2,3These factors, among others, may explain the 8% gap that exists in meeting the Core Elements between CAHs and other acute care hospitals, for which we request further data to understand this critical gap, given the sparse literature available on this topic. 1First, the authors report the number of facilities that responded to the survey, but do not report the overall survey response rate.

Organic digital education (ODE) includes online medical education content that can take various forms, such as blogs, social media, videos, podcasts, or infographics. Multimedia ODE platforms have unique benefits and have quickly become an essential part of medical education. Modern medical educators with competency in digital teaching modalities can leverage these for teaching as well as career development and dissemination of scientific research. The ID Digital Institute is a digital education program with a curriculum designed to equip infectious diseases (ID) professionals with the skills to appraise, create, curate, and integrate ODE into their teaching and career. We share the structure, content, and lessons learned from the ID Digital Institute program. We also illustrate how digital education skills can present unique opportunities to align with current and future transplant and immunocompromised host infectious diseases education efforts.

The current manufacturing disruption of BACTEC blood culture bottles has drawn attention to diagnostic stewardship around blood culture utilization. In this perspective, we offer strategies for implementing blood culture stewardship using a graded approach based on a hospital's blood culture bottle supply. These strategies should inform plans to mitigate the impact of the shortage on patient care and reinforce fundamental principles of blood culture stewardship.

The negative predictive value of bla CTX-M on BCID2 for ceftriaxone resistance in E. coli and K. pneumoniae group was 97% and 94%, respectively. Creation of a genotypic antibiogram led to updated local guidance for clinicians to utilize for empiric treatment of Enterobacterales bloodstream infections identified via rapid diagnostics.

Objective: To understand healthcare workers' (HCWs) beliefs and practices toward blood culture (BCx) use. Design: Cross-sectional electronic survey and semi-structured interviews. Setting: Academic hospitals in the United States. Participants: HCWs involved in BCx ordering and collection in adult intensive care units (ICU) and wards. Methods: We administered an anonymous electronic survey to HCWs and conducted semi-structured interviews with unit staff and quality improvement (QI) leaders in these institutions to understand their perspectives regarding BCx stewardship between February and November 2023. Results: Of 314 HCWs who responded to the survey, most (67.4%) were physicians and were involved in BCx ordering (82.3%). Most survey respondents reported that clinicians had a low threshold to culture patients for fever (84.4%) and agreed they could safely reduce the number of BCx obtained in their units (65%). However, only half of them believed BCx was overused. Although most made BCx decisions as a team (74.1%), a minority reported these team discussions occurred daily (42.4%). A third of respondents reported not usually collecting the correct volume per BCx bottle, half were unaware of the improved sensitivity of 2 BCx sets, and most were unsure of the nationally recommended BCx contamination threshold (87.5%). Knowledge regarding the utility of BCx for common infections was limited. Conclusions: HCWs' understanding of best collection practices and yield of BCx was limited.

Group A Streptococcus (GAS) necrotizing soft tissue infections and toxic shock syndrome remain high-mortality conditions. In vitro and animal model data, as well as multiple observational studies, suggest adjunctive clindamycin (ie, given with a beta-lactam) reduces invasive GAS infection mortality by inhibiting exotoxin production. Unfortunately, clindamycin resistance in GAS has been rapidly increasing in the United States since the mid-2010s, although the clinical significance of this remains unclear. Linezolid is a promising alternative adjunctive agent to which US GAS isolates remain near-universally susceptible, with a similar mechanism of action and similar in vitro evidence of GAS virulence factor attenuation. However, the clinical data supporting linezolid's value in severe GAS infections are far more limited. Here the authors review the data and reasoning behind a general preference for clindamycin or linezolid in a focused, pro-con debate format.

Abstract Background With the increasing incidence of infections from Enterobacterales resistant to commonly used antibiotics, rapid diagnostic tests, such as BioFire’s Blood Culture Identification 2 (BCID2) multiplex PCR panel, can be utilized to detect potential antimicrobial resistance more rapidly and help direct more appropriate empiric therapy. We describe the epidemiology of Enterobacterales bloodstream infection (BSI), associated antimicrobial resistance genes using BCID2, and subsequent susceptibility patterns at an academic medical center to develop a genotypic antibiogram. Methods We reviewed all positive BCID2 results at Nebraska Medical Center from 8/1/2021–11/1/2022. Only monomicrobial Enterobacterales BSI were included. Patient demographics, antimicrobial resistance markers, BCID2, culture, and susceptibility results were assessed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of blaCTX-M marker were compared to ceftriaxone susceptibility patterns. Results We reviewed 456 unique Enterobacterales isolates, of which 236 were from male patients (52%), 189 (41%) immunocompromised patients, and 342 (75%) community onset. The most common species identified were Escherichia coli (55%) and Klebsiella pneumoniae (17%). blaCTX-M was detected in 49 (11%) isolates, with 41 (84%) E. coli and 6 (12%) K. pneumoniae. blaKPC was detected in 2 isolates (1 K. oxytoca and 1 K. variicola), but no other carbapenemase genes were detected. blaCTX-M sensitivity and specificity for detection of ceftriaxone resistance was 83% and 100%, respectively. blaCTX-M PPV for ceftriaxone resistance was 100%, while the NPV of absent blaCTX-M for ceftriaxone susceptibility was 97%. Conclusion Locally, the majority of ceftriaxone-resistant E. coli and Klebsiella BSIs harbor blaCTX-M, while carbapenemases are rare. Utilization of rapid diagnostics can optimize antimicrobial therapy for Enterobacterales by creation of a genotypic antibiogram. Disclosures Scott J. Bergman, PharmD, bioMerieux, Inc.: Honoraria Trevor C. Van Schooneveld, MD, FSHEA, FACP, AN2 Therapeutics: Grant/Research Support|Biomeriuex: Advisor/Consultant|Biomeriuex: Grant/Research Support|Insmed: Grant/Research Support|Thermo-Fischer: Honoraria