Lisa Pineles

Background: Candidozyma auris is an emerging pathogen. We sought to understand risk factors for C auris transmission in acute care hospitals, using transfer of C auris to healthcare personnel (HCP) gloves and/or gowns as a surrogate measure of transmission potential. Methods: This was a prospective, multicenter cohort study of HCP gloves and gowns cultured for C auris during routine patient care. Patient samples from 5 body sites and environmental surfaces were also cultured for C auris. Results: Among 109 C auris–colonized patients, we found C auris transfer to HCP gloves and/or gowns in 29% of 1083 HCP interactions. Transfer was highest among nursing assistants/patient care technicians (odds ratio [OR], 5.2 [95% confidence interval {CI}, 2.4–11.6]), occupational/physical therapists (OR, 4.8 [95% CI, 1.4–16.7]), and respiratory therapists (OR, 4.7 [95% CI, 1.9–11.7]). Transfer was high when HCP touched the patient (OR, 3.32 [95% CI, 2.3–4.9]) compared to touching only an environmental surface. Patients who were colonized at 5 body sites were 15 times more likely to transfer C auris to HCP gloves and/or gown than those colonized at only 1 site (OR, 15.1 [95% CI, 7.5–30.5]). Conclusions: This study demonstrates that transfer of C. auris to HCP gloves and/or gowns, a surrogate for transmission potential, occurs frequently during patient care. Certain HCP and patient care tasks or interactions are associated with higher rates of transfer. Strategies to interrupt transfer of C auris to HCP during patient care are needed to prevent C auris transmission in healthcare facilities.

Background: Respiratory illness is the most frequent reason for unnecessary antibiotic use among hospitalized adults. In randomized trials, procalcitonin and respiratory virus testing without guidance on test interpretation do not influence antibiotic decision-making. Methods: We conducted a pragmatic, randomized, controlled trial of antimicrobial stewardship-guided test interpretation versus usual care among hospitalized adults receiving antibiotics for suspected respiratory infection with either low procalcitonin or positive respiratory virus testing at 2 hospitals. The intervention involved a templated note in the electronic health record interpreting test results in terms of the post-test probability of bacterial pneumonia and antibiotic decision-making. When probability of bacterial pneumonia was low, discontinuation of antibiotic therapy was recommended. The primary outcome was in-hospital antibiotic days of therapy. Results: Between 1 November 2023 and 10 January 2025, 107 adults were enrolled, including 65% with low procalcitonin, 30% with positive respiratory virus testing, and 5% with both. The intervention decreased antibiotic use by an average of 4.1 in-hospital days of therapy (7.5 versus 11.6, P = .006). All respiratory antibiotics were discontinued within 5 days of initiation for 76% of intervention patients versus 49% with usual care (P = .004). Length of stay (5.5 days intervention versus 6.6 days usual care, P = .16) and 30-day readmission (7% intervention versus 19% usual care, P = .079) did not significantly differ between groups. Conclusions: In this proof-of-concept study, antimicrobial stewardship-guided interpretation of laboratory tests for viral infection using a simple template safely decreased unnecessary antibiotic use for hospitalized adults with community-acquired respiratory illness. Clinical Trial Registration. NCT05976581.

Contact precaution policies are used to prevent the spread of pathogenic organisms. We aimed to test whether AI-assisted cameras could monitor aspects of compliance with these policies. Testing in both simulated and real patient care settings yielded exceptional sensitivity and good specificity, indicating potential to monitor adherence to contact precautions.

Background: Central line–associated blood stream infection (CLABSI) surveillance is mandated and publicly reported in United States hospitals but requires manual chart review. Generative artificial intelligence (AI) may facilitate CLABSI identification. Methods: We performed a retrospective cohort study of CLABSI surveillance using standardized prompts, clinical data, and Centers for Disease Control and Prevention definitions. In 11 hospitals, 24 infection control nurses and physicians retrospectively reviewed 220 CLABSI/non-CLABSI bacteremias. Three methods of review were compared to original facility expert review: (1) AI-assist review, (2) AI-alone review, and (3) repeat expert review. Disagreement between any method of review was adjudicated by a 2-expert physician referee panel. Results: AI-assisted review had a 93.2% (205/220; 95% confidence interval [CI], 89.0–96.1) overall accuracy (agreement with facility reporting or refereeing panel) versus AI-alone review, 90.0% (198/220; 95% CI, 85.3–93.6) overall accuracy or repeat expert review, 88.2% (97/110; 95% CI, 80.1–93.6) overall accuracy. Inter-site variability was greater for repeat expert review than AI-assist. AI-assisted review required a median of 14 minutes (interquartile range 6–25.5) versus 25 minutes (interquartile range 11–43) for repeat expert (P = .0001). AI-assisted review was reported as low effort in 52% of cases versus 21% of repeat expert cases (P < .0001). AI-assisted review was reported as somewhat or very objective in 72% of cases versus 61% of repeat expert cases (P = .092). Conclusions: CLABSI detection by AI methods was at least as accurate as traditional methods, better liked by experts, faster and less variable. AI-assisted review could improve healthcare-associated infection reporting.

Generative artificial intelligence (GenAI) is becoming widespread in society but has had limited impact on medicine. GenAI can rapidly digest large documents, making it particularly well suited for healthcare-associated infection (HAI) surveillance that is largely based on clinical notes. In this article, we review evidence on the application of GenAI for HAI surveillance and highlight the necessary steps for changes to practice. Small studies of simulated patients and retrospective studies of patient records have found GenAI can isolate individual criteria for HAI and make HAI determinations with accuracy similar to that of human experts. GenAI tools are being developed to assist in HAI detection. Use of GenAI for HAI review could reduce variability between facilities, improve efficiency of HAI review. and lead to more time for direct prevention work. For widespread adoption, GenAI HAI detection must be safe and effective in prospective clinical studies.

Background: Overdiagnosis of urinary tract infections (UTIs) and unnecessary antibiotics are common. This is particularly true in older adult populations such as veterans. Diagnostic stewardship can decrease overdiagnosis and overtreatment, but optimal implementation of such interventions has not been fully studied. Methods: This was a multicenter hybrid type 2 effectiveness-implementation study of UTI diagnostic stewardship interventions at 3 participating Veterans Administration hospitals. Each hospital implemented 1 intervention at either the ordering, processing (conditional reflex urine culturing), or reporting stage. The primary outcome was inpatient UTI antibiotic days of therapy (DOTs) per admission evaluated using generalized estimating equations. Secondary outcomes included rates of urine cultures ordered and performed and a safety measure of secondary bacteremia from a uropathogen. Results: A total of 37 085 hospital admissions occurred in the preintervention phase and 17 221 in the postintervention phase. Of these, 6914 (12.7%) included UTI antibiotics. Hospital 3, which implemented conditional reflex urine culturing, had a 39.5% reduction in UTI DOT (95% confidence interval, 13.9–57.5) in the year following the intervention. Additionally, hospital 3 noted fewer urine cultures ordered (22.8% immediate and 35.7% slope reduction) and performed (38.9% immediate and 38.8% slope reduction). No change in UTI DOT was observed for ordering or results reporting interventions at other hospitals. There was no difference in the safety measure of uropathogen bacteremia. Conclusions: Conditional reflex urine culturing had a large decrease on UTI antibiotic DOTs and urine cultures performed. Health systems or medical centers starting urine culture diagnostic stewardship should implement conditional reflex urine culturing first. Article Summary: A multicenter pragmatic pre-/poststudy in Veterans Administration hospitals found that conditional reflex urine culturing significantly reduced urinary tract infection antibiotic use and urine cultures without increasing bacteremia, highlighting its potential as a high-value diagnostic stewardship intervention among older hospitalized adults.

A cross-sectional survey of 60 hospitalized patients on methicillin-resistant Staphylococcus aureus (MRSA) contact precautions found strong support (96%) for MRSA contact precautions. Most (72%) preferred policies requiring healthcare workers to always use contact precautions compared to other risk-tailored policies. Hospitalized patients on MRSA contact precautions favor consistent precaution use.

Background: In recent years, new broad-spectrum antibiotics targeting Gram-negative organisms have been introduced, including cefiderocol, ceftazidime-avibactam, ceftolozane-tazobactam, eravacycline, imipenem-relebactam, omadacycline, and meropenem-vaborbactam. This study aimed to describe new antibiotic use across a large national cohort. Methods: We performed a retrospective cohort study of hospital discharges from June 2022 to May 2023 using the Premier Healthcare Database. Antibiotic utilization was ascertained from daily charges. Clinical indication(s) were inferred from International Classification of Diseases, 10th revision, diagnosis codes. Antibiotic therapy was considered definitive if continued >3 days. Piperacillin-tazobactam was used as a comparator. Results: Across 832 hospitals, 3 890 557 admissions (61.9% of all admissions) included an antibiotic prescription. New antibiotics were prescribed in 9768 admissions (0.25% of antibiotic-prescribing admissions) across 537 hospitals. Ceftolozane-tazobactam was prescribed in 4157 admissions (42.6% of 9768), ceftazidime-avibactam in 3660 (37.5%), eravacycline in 1213 (12.4%), cefiderocol in 1060 (10.9%), meropenem-vaborbactam in 456 (4.7%), omadacycline in 104 (1.1%), and imipenem-relebactam in 99 (1.0%). In contrast, piperacillin-tazobactam was prescribed in 731 719 (18.8%) and colistin in 570 (0.01%) admissions. Forty-six percent (n = 4647/9768) of new antibiotics were started in the first 3 days of hospital admission, and 70% (n = 6799/9768) were used as definitive therapy. Sepsis (76%), pneumonia (46%), and urinary tract infection (39%) were the most common clinical indications. On average, patients treated with new antibiotics had 8 more comorbid conditions than patients receiving piperacillin-tazobactam. Conclusions: Ceftazidime-avibactam and ceftolozane-tazobactam remain the most frequently prescribed new antibiotics, with uptake of subsequently approved agents trailing. New antibiotics are most commonly used as treatment for sepsis among patients with multiple comorbidities.

Background: There are no systematic measures of central line–associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA). Methods: Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days. Results: A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20–44 years, 11.2 [95% confidence interval, 1.46–86.22]; 45–64 years, 20.88 [2.84–153.58]; ≥65 years, 22.50 [2.98–169.93]) and lack of insurance (2.46 [1.08–5.59]), and it decreased with CVC removal (0.57 [.39–.84]). Conclusions: CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.