The WikiGuidelines organization seeks to improve the process of guideline writing. WikiGuideline consensus statements use a dichotomized approach to recommendations, such that recommendations are made only when sufficient randomized controlled data are available. In the absence of such data, a clinical review is provided. After applying this approach to the care of patients who inject drugs (PWID), this consensus statement recommends that patients with opioid use disorder (OUD) be offered treatment in the form of opioid agonist therapies. Patients with stimulant use disorder, specifically amphetamine use disorder, should be offered mirtazapine. Patients with stimulant use disorder, regardless of drug of choice, do best when offered behavioral therapies, such as contingency management. For hospitalized patients admitted with complications of substance use, the addition of substance use care teams has demonstrated improved outcomes. Further, patients who inject drugs with hepatitis C should be offered treatment, which can be completed in a variety of low-barrier settings. Several other questions did not meet the threshold for clear recommendations; and therefore, clinical reviews are offered instead.

The 2022 Mpox outbreak affected many non-endemic countries worldwide and disproportionately impacted men who have sex with men (MSM). By May 2023, over 80,000 cases and 140 deaths were reported from 111 countries and territories. The unprecedented human-to-human transmission highlighted the need to assess system responses. This study evaluates institutional handling of Mpox through a survey of individuals responsible for outbreak protocols. A cross-sectional survey was conducted between December 2024 and April 2025 among infectious disease specialists across America. Institutions were recruited through the Society for Healthcare Epidemiology of America (SHEA) Research Network. Descriptive statistics were used to summarize the data. Key results are reported in Table 1. The cohort included 45 institutions across 20 states representing various roles and institution types (Figure 1). Main challenges included delays in test results, access to supplies, and communicating policy changes (Figure 2). To mitigate these challenges, institutions enhanced communication, coordination, and staff training programs. Only 21% reported resources limitations based on geographical region. COVID-19 experiences moderately to strongly influenced 81% of institutions’ responses to the outbreak, and most institutions either moderately modified existing protocols or developed new ones. These reported findings highlight the variability in institutional response to the 2022 Mpox outbreak across the US and emphasize the challenges related to resource allocation and timely communication during public health emergencies. Understanding the experiences of those directly involved in protocol implementation provides valuable insight into systemic strengths and gaps, offering guidance for more coordinated and efficient responses in future outbreaks. All Authors: No reported disclosures

Identifying fungi to the genus or species level provides valuable insight for guiding antifungal therapy. We evaluated the performance and clinical utility of the Roche cobas eplex blood culture identification fungal pathogen panel (BCID-FP). Although used in fewer than 1% of patients with blood cultures drawn, BCID-FP identified fungal pathogens in more than 96% of tested samples within 72 hours. Over a 3-year period, BCID-FP demonstrated a positive percent agreement (PPA) of 91.7% compared to culture (n = 327). PPA was 100% for Candida auris, Candida kefyr, Candida krusei, Candida tropicalis, Candida parapsilosis, and Candida neoformans; slightly lower for Candida albicans (90.3%) and Candida glabrata (91.1%); and lowest for Candida lusitaniae (55.6%) and Fusarium spp. (0%). To assess clinical impact, we compared patient records from preimplementation (results withheld from providers; n = 31) and postimplementation (results released; n = 68). Compared to the T2Dx Candida panel, BCID-FP showed superior accuracy (PPA 98.0% vs 61.7%). It also reduced time to fungal identification by 1.36 days relative to culture (P < .0001). Postimplementation, there was also a significant increase in infectious disease physician recommendations for antifungal deescalation (39.7% vs 16.1%; P = .0219), typically shifting from micafungin to fluconazole in C. albicans and C. parapsilosis cases. However, no significant differences were observed in time to antifungal optimization, empiric therapy duration, length of stay, or mortality. Although BCID-FP offers clear diagnostic advantages, timely implementation of expert recommendations remains essential to improving outcomes.

Description: The American College of Physicians' Population Health and Medical Science Committee (PHMSC) developed this best practice advice to inform clinicians about what is currently known about the benefits and harms of cannabis or cannabinoids in the management of chronic noncancer pain and to provide advice for clinicians counseling patients seeking this therapy. Methods: The PHMSC considers areas where evidence is uncertain or emerging or practice does not follow the evidence to provide clinical advice based on a review and assessment of scientific work, including systematic reviews and individual studies. Sources of evidence included a living systematic review on cannabis and cannabinoid treatments for chronic noncancer pain and a series of living systematic reviews and primary studies. Best Practice Advice 1a: Clinicians should counsel patients about the benefits and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain. Best Practice Advice 1b: Clinicians should counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: young adult and adolescent patients, patients with current or past substance use disorder, patients with serious mental illness, and frail patients and those at risk for falling. Best Practice Advice 2: Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive. Best Practice Advice 3: Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain.

Background: Calls within the clinical community for revising guidance on the appropriate durations of antibiotic therapy (i.e., shorter is better) and adherence (i.e., no longer advising to always finish a course), reflect important gains in evidence-based prescribing. However, changing medical guidance can have negative public effects (e.g., frustration, distrust, and disengagement) when not communicated in ways that resonate with patients. To inform efforts to effectively communicate evolving evidence on appropriate antibiotic use, we examined US adults’ perceptions and preferences regarding antibiotic durations and adherence. Methods: From March to April 2024, we invited US adults, aged ≥18 years, to an online survey about antibiotics. Question topics included durations of antibiotic therapy, adherence to a prescribed course of antibiotics, and demographic characteristics. Results: Table 1 shows the characteristics of the 1,476 respondents [completion=89%]. Most respondents reported they preferred to take a longer course of antibiotics (≥7 days) than a shorter one (3-5 days) for a bacterial respiratory infection (60.4% vs. 39.5%) and rated longer courses as both safer and more effective (Table 2). In open-text questions, respondents who preferred shorter courses described a general aversion to medication and concerns about side effects and resistance, whereas those who preferred longer courses saw them as familiar and a ‘better safe than sorry’ approach, associating longer durations with greater efficacy. In addition, 88.4% of respondents agreed that ‘it is important to always finish a prescribed course of antibiotics, even if you start to feel better’ and had either been told this by a medical professional (76.3%) or seen this guidance in a public health message (61.2%). Conversely, only 17.5% said they had ever been told they could stop taking antibiotics early. Preference for longer antibiotic courses was associated with older age, trusting their doctor’s advice about antibiotic therapy durations, having been told by their doctor to ‘always finish a course of antibiotics’, less worry about antibiotic side effects, discomfort about potentially being asked by a clinician to stop taking antibiotics when they start to feel better, and perceiving the clinician suggesting that as less competent. Conclusions: Many US adults prefer longer durations of antibiotic therapy for respiratory infections than are likely necessary. Almost all survey respondents believed it important to always finish a course and many were uncomfortable with advice to the contrary. These findings highlight the need for evidence-based communication strategies for aligning US adults’ antibiotic duration and adherence preferences with current guidance.

This survey study compares demographic characteristics, beliefs, and antibiotic preferences of US adults who frequently use antibiotics with those who have not used antibiotics over the past year.

Abstract Background Kaizen-Education is an app-based, formative question bank infused with gamification for a fun, yet competitive learning environment. This provides an engaging and flexible way to learn new competencies and test retention. Originally developed at University of Alabama at Birmingham (UAB), it has been used in multiple areas of medical education with high learner engagement. Optional participation, team-based competition, leaderboards, and prizes are game elements used to motivate completion of the formative questions. We created two educational games, one for UAB Antimicrobial Stewardship Program (ASP) and another for Infection Prevention (IP), to see if we could engage learners within the hospital system surrounding these topics. Methods For the IP game, infection preventionists developed questions for nursing staff. For the ASP game, ID pharmacists developed questions for providers. Both occurred within special weeks: National Nurses Week and U.S. Antibiotic Awareness Week. Recruitment strategies for both games included email invitations and peer-to-peer communication. Teams for the IP game were nursing units, while the ASP game allowed creation of teams of 4 providers. Winning teams were awarded prizes and were recognized via email, certificate, and highlighted on the institution's website. At the conclusion of the games, participants were invited to provide feedback through a post-game survey. Participant Survey Results Results 61 and 156 participants answered at least one question in the ASP and IP games respectively. Retention, defined as completing all questions, was 80% of players in ASP game and 69% in IP game. Across both games, 4,182 questions were answered representing unique teaching moments. Reviewing accuracy based of learning domains (Figure 1), we were able to identify knowledge gaps at our institution. Finally almost all learners who responded to feedback survey agreed the activity increased knowledge in relevant domains (Figure 2). Conclusion We found a group of both nurses and providers interested in participating in quality educational activities within Antibiotic Stewardship and Infection Prevention. Retention was high in those that began the activity. Finally, feedback from question performance could be used to identify knowledge gaps for future interventions. Disclosures All Authors: No reported disclosures

Clinicians are constantly bombarded with an onslaught of newly published data, yet they must make clinical decisions despite a dearth of clinical data. Sometimes, they may fall back on clinical practices entrenched by experience, unaware that they are upheld by dogmatic tradition rather than robust evidence. Ideally, the totality of evidence must be assessed and utilized for clinical decision-making, irrespective of entrenched orthodoxy. Here, we explore the questions, how much evidence is needed to revise established clinical practices? and, more fundamentally, can data alone truly catalyze such shifts?

Abstract Background Adults ≥65yrs are at high risk of harm from antibiotic overuse due to misdiagnosis of asymptomatic bacteriuria (ASB) as urinary tract infection (UTI). Alongside strategies to improve clinician prescribing, patients should be educated on ASB and empowered to discuss harms and benefits of antibiotic treatment. Previously, we used a user-centered design process to develop a patient-focused educational leaflet on UTI, ASB, and antibiotic use (Figure 1). Here, we tested whether the leaflet improved patients’ knowledge about ASB and willingness to avoid unnecessary antibiotics.Figure 1.A three-page antibiotic education designed with patients, caregivers, and clinicians. Methods In an online survey experiment of US adults ≥65yrs, respondents read a scenario of themselves as an asymptomatic patient with a positive urine test during prescreening for non-urologic surgery. Respondents were randomized to one of four experimental conditions which varied educational leaflet provision and the surgeons’ treatment recommendation (Figure 2). Outcome measures included whether respondents thought they (as the patient described in the case) had a UTI, how comfortable they would be not taking antibiotics, and their knowledge about UTIs, ASB, and antibiotics Results Figure 2 shows characteristics of the 504 study respondents [completion=89%]. Compared to those not provided the educational leaflet, respondents shown the educational leaflet were less likely to believe they had UTI (p< .001), were more comfortable not taking antibiotics (p< .001), and answered more knowledge questions correctly (p< .001) (Figures 3&4). Conversely, respondents who were told the surgeon recommends antibiotics were more likely to believe they had UTI (p< .001) and less comfortable with not taking antibiotics (p=.013) but did not differ in their knowledge (p=.096). Conclusion A patient-centered educational leaflet, designed with patients, caregivers, and clinicians, was effective in aligning antibiotic treatment preferences with clinical guidelines and improving knowledge about UTI, ASB, and antibiotics. Findings offer important preliminary evidence on the potential for patient/caregiver-focused education to help prepare patients/caregivers to engage in treatment decisions and contribute to reducing antibiotic overuse and its associated harms. Disclosures All Authors: No reported disclosures

Objective: We aimed to determine if implementation of universal nasal decolonization with daily chlorhexidine bathing will decrease blood stream infections (BSI) in patients undergoing extracorporeal membrane oxygenation (ECMO).Design: Retrospective cohort study.Setting: Tertiary care facility.Patients: Patients placed on ECMO from January 1, 2017 to December 31, 2023.Intervention: Daily bathing with 4% chlorhexidine soap and universal mupirocin nasal decolonization were initiated for all ECMO patients May 2021. The primary outcome was rate of ECMO-attributable positive blood cultures. Zero-inflated Poisson regression analysis was performed to estimate rate ratios (RRs) for the association between decolonization with BSI rates.Results: A total of 776 patients met inclusion criteria during the study period, 425 (55%) preimplementation and 351 (45%) post-implementation. Following implementation of decolonization, the overall incidence rate of BSI increased nonsignificantly from 10.7 to 14.0 infections per 1000 ECMO days (aRR 1.09, 95% CI 0.74-1.59). For gram-positive cocci (GPC) pathogens, a nonsignificant 40% increased rate was observed in the post-implementation period (RR 1.40, 95% CI 0.89-2.21), due mostly to a significant increase in the crude rate of Enterococcus BSI (RR 1.89, 95% CI 1.01-3.55). Excluding Enterococcus resulted in a nonsignificant 28% decreased rate (aRR 0.72, 95% CI 0.39-1.36) due to a nonsignificant 55% decreased rate of MRSA (aRR 0.45, 95% CI 0.18-3.58).Conclusions: Implementation of a universal decolonization protocol did not significantly reduce rates of certain BSIs, including MRSA and other gram-positive pathogens. Although nonsignificant, reduction in BSI rates in this patient population has important implications on surveillance metrics, such as MRSA, and in the future, hospital-onset bacteremia.

Effective health communication is critically important in times of emergency. From the outset of the COVID-19 pandemic, officials at the University of Alabama at Birmingham (UAB) delivered health announcements that were timely, transparent, trustworthy and proportional to the crisis. Moreover, each announcement contained one or more messages with guidance corresponding to varying levels of the Intervention Ladder. Our team analysed messages based on the eight levels of the Intervention Ladder and compared health outcomes between UAB employees and residents of Alabama, USA. Results suggested that announcements played an essential role in raising situational awareness about the severity of the pandemic and may have led to greater compliance by the UAB community, as demonstrated through comparative rates of hospitalisation, vaccination and mortality.

Importance:Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. Objective:To create a clinical guideline for the diagnosis and management of urinary tract infections that addresses the gap between the evidence and recommendation strength. Evidence Review:This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In May 2023, new and existing members were solicited for questions on urinary tract infection prevention, diagnosis, and management. For each topic, literature searches were conducted up until early 2024 in any language. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were developed discussing the available literature and associated risks and benefits of various approaches. Findings:A total of 54 members representing 12 countries reviewed 914 articles and submitted information relevant to 5 sections: prophylaxis and prevention (7 questions), diagnosis and diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment and antimicrobial stewardship (10 questions), and special populations and genitourinary syndromes (10 questions). Of 37 unique questions, a clear recommendation could be provided for 6 questions. In 3 of the remaining questions, a clear recommendation could only be provided for certain aspects of the question. Clinical reviews were generated for the remaining questions and aspects of questions not meeting criteria for a clear recommendation. Conclusions and Relevance:In this consensus statement that applied the WikiGuidelines method for clinical guideline development, the majority of topics relating to prevention, diagnosis, and treatment of urinary tract infections lack high-quality prospective data and clear recommendations could not be made. Randomized clinical trials are underway to address some of these gaps; however further research is of utmost importance to inform true evidence-based, rather than eminence-based practice.

Ventilator-associated pneumonia (VAP) is a well-established cause of morbidity in critically ill patients. Current VAP criteria exclude patients on extracorporeal membrane oxygenation (ECMO). This retrospective analysis tests the validity of VAP in this population, as well as a new proposed diagnostic criterion for ECMO-associated pneumonia.

There is an increased risk of infection in patients with cancer that results in higher morbidity and mortality. Several risk factors can predispose these patients to infectious complications. Some such factors include immunocompromised states like neutropenia, allogeneic hematopoietic cell transplantation, and graft-versus-host disease, while others include immunosuppressive agents like corticosteroids, purine analogs, monoclonal antibodies, and other emerging cancer therapeutics like CAR T-cell therapy. The NCCN Guidelines for the Prevention and Treatment of Cancer-Related Infections address infection concerns that may be observed in these immunocompromised populations and characterize the major pathogens to which patients with cancer are susceptible, with a focus on the prevention, diagnosis, and treatment of major common and opportunistic infections. This paper highlights 2 recently updated sections of the guidelines, namely, infection concerns related to CAR T-cell therapy and antimicrobial prophylaxis recommendations, including vaccination, in patients at high-risk for infections.

There is an increased risk of infection in patients with cancer that results in higher morbidity and mortality. Several risk factors can predispose these patients to infectious complications. Some such factors include immunocompromised states like neutropenia, allogeneic hematopoietic cell transplantation, and graft-versus-host disease, while others include immunosuppressive agents like corticosteroids, purine analogs, monoclonal antibodies, and other emerging cancer therapeutics like CAR T-cell therapy. The NCCN Guidelines for the Prevention and Treatment of Cancer-Related Infections address infection concerns that may be observed in these immunocompromised populations and characterize the major pathogens to which patients with cancer are susceptible, with a focus on the prevention, diagnosis, and treatment of major common and opportunistic infections. This paper highlights 2 recently updated sections of the guidelines, namely, infection concerns related to CAR T-cell therapy and antimicrobial prophylaxis recommendations, including vaccination, in patients at high-risk for infections.

ImportanceTraditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.ObjectiveTo create a clinical guideline for the diagnosis and management of urinary tract infections that addresses the gap between the evidence and recommendation strength.Evidence ReviewThis consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In May 2023, new and existing members were solicited for questions on urinary tract infection prevention, diagnosis, and management. For each topic, literature searches were conducted up until early 2024 in any language. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were developed discussing the available literature and associated risks and benefits of various approaches.FindingsA total of 54 members representing 12 countries reviewed 914 articles and submitted information relevant to 5 sections: prophylaxis and prevention (7 questions), diagnosis and diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment and antimicrobial stewardship (10 questions), and special populations and genitourinary syndromes (10 questions). Of 37 unique questions, a clear recommendation could be provided for 6 questions. In 3 of the remaining questions, a clear recommendation could only be provided for certain aspects of the question. Clinical reviews were generated for the remaining questions and aspects of questions not meeting criteria for a clear recommendation.Conclusions and RelevanceIn this consensus statement that applied the WikiGuidelines method for clinical guideline development, the majority of topics relating to prevention, diagnosis, and treatment of urinary tract infections lack high-quality prospective data and clear recommendations could not be made. Randomized clinical trials are underway to address some of these gaps; however further research is of utmost importance to inform true evidence-based, rather than eminence-based practice.