American Journal of Infection Control

BackgroundIn long-term care facilities (LTCFs), close-contact identification often relies on staff recall and monitoring records because residents may be unable to self-report reliably. How these different record-generation processes relate to proximity-based sensor measurements in routine LTCF workflow remain unclear, and how such differences may influence contact-based decision-making in outbreak response is not well understood. MethodsWe conducted a five-day observational study in a Japanese LTCF using ultra-wideband (UWB) indoor positioning. Twenty-seven participants wore UWB tags, including 16 residents and 11 staff members; 10 staff members completed questionnaires. We compared UWB-derived proximity with questionnaire-derived contacts from staff self-report and monitoring-based proxy records, and assessed directional discrepancies under multiple distance-time thresholds. ResultsQuestionnaire-based records and UWB-derived proximity showed different patterns of discrepancy across contact types. Within this facility, resident-related monitoring-based proxy records showed relatively small directional discrepancies, whereas staff self-reports tended to identify additional resident-staff contacts under the baseline threshold ([≤]1.0 m for [≥]15 min). Several alternative thresholds were associated with discrepancies closer to zero than the baseline, although the apparent ranking varied by summary metric. ConclusionsIn this single-facility observational study, different contact-list generation processes were associated with different patterns of discrepancy relative to a proximity-based operational measure. These findings support interpretation in terms of workflow-specific contact-list generation rather than a single universally optimal threshold and may help inform facility-level review of contact identification practices in LTCFs. These findings support aligning contact identification strategies with facility-specific workflows to improve the feasibility and effectiveness of IPC practices in LTCFs.

BackgroundImplementation strategies are dynamic techniques used to apply evidence-based practices (EBPs) to diverse contexts. Despite their importance, context-specific selection and modification of implementation strategies remain underreported, limiting understanding of how to optimize strategy deployment across heterogeneous healthcare settings. We describe a systematic method to document and analyze modifications to implementation strategies using four diverse hospital sites from the Fluoroquinolone Restriction for the Prevention of Clostridioides difficile infection (FIRST) trial as case studies. MethodsFIRST was a multisite fluoroquinolone pre-prescription restriction intervention delivered via the electronic health record. We partnered with multidisciplinary stakeholders at each site to co-design and adapt the intervention using pre-planned implementation strategies. Multiple data sources (interviews, meeting notes, implementation diaries) collected iteratively over two years were analyzed to identify strategy modifications. Strategies were coded using Expert Recommendations for Implementing Change (ERIC) conceptual clusters, and modifications were documented using the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS). Modified strategies were categorized as planned or unplanned and contextualized via thematic content analysis. ResultsAcross 458 total modifications, the most modified strategies focused on facilitating stakeholder engagement, adapting to local contexts, and using evaluative approaches to improve EBP uptake/sustainment. Planned modifications (n=330, 72%) outnumbered unplanned modifications (n=157, 34%). Rural and community hospitals required more unplanned modifications (average 41 vs. 31 for academic centers), while sites with prior restrictive intervention experience had higher planned-to-unplanned ratios (3.1:1 vs. 1.6:1). Academic hospitals with trainee rotations required ongoing education and higher strategy modifications. All modifications maintained EBP core fidelity. Site-specific patterns organizational characteristics were linked to modification intensity and type, including absorptive capacity, prior experience, relational coordination, rurality, and educational requirements. ConclusionsIntegrating ERIC and FRAME-IS enabled systematic documentation of implementation strategy modifications across diverse settings. Planned:unplanned modification ratios provided novel insights into organizational absorptive capacity and implementation preparedness. Standardized implementation approaches inadequately address critical organizational differences, requiring context-sensitive strategy selection and intensity calibration. This work advances implementation science methodology by demonstrating how systematic modification documentation can inform tailored implementation support. Trial RegistrationClinicalTrials.gov Identifier: NCT03848689

Background: Digital antimicrobial stewardship (AMS) interventions, such as clinical decision support systems, audit and feedback platforms, and electronic prescribing tools, have been increasingly adopted to improve antibiotic use. However, the effectiveness of these interventions across healthcare settings remains uncertain, and the certainty of the evidence has not been comprehensively evaluated. The objective of this study was to provide a comprehensive understanding of the role of digital interventions in optimizing antimicrobial use and improving clinical outcomes within a broad spectrum of healthcare settings. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials evaluating digital AMS interventions that followed PRISMA 2020 guidelines and registered in PROSPERO CRD420251178854 and funded by the Wellcome Trust CAMO Net programme. Searches were performed across major databases. Primary outcomes included the appropriateness of antibiotic prescriptions and the antibiotic prescription rate. Secondary outcomes included 30 day mortality, 30 day hospital readmission, and length of hospital stay (LOS). Random effects models were used to pool effect sizes. Risk of bias was assessed RoB 2, and certainty of evidence was rated using GRADE. A Summary of Findings table was prepared to present effect estimates, sample sizes, and evidence certainty. Results: Eleven RCTs met the inclusion criteria, and nine were included in the quantitative synthesis. Digital AMS interventions did not show a significant effect on appropriateness of antibiotic prescribing (RR 0.99, 95%CI 0.93 to 1.05; very low certainty). There was no reduction in antibiotic prescription (RR 0.98, 95%CI 0.88 to 1.09), with substantial statistical heterogeneity and very low certainty. Across clinical outcomes, digital AMS showed no effect on 30 day mortality (RR 0.91, 95%CI 0.77 to 1.09; very low certainty) or 30 day readmission (RR 0.95, 95%CI 0.79 to 1.14; very low certainty). For LOS, results were inconsistent across studies, and the pooled effect showed no clinically meaningful change (MD 0.17 days, 95%CI 0.01 to 0.35; very low certainty). Most trials had some concerns of bias due to deviations from intended interventions. Conclusion: Meta-analyses of digital AMS RCTs showed a lack of evidence with a high level of certainty on antibiotic prescribing or clinical outcomes due to high heterogeneity in interventions and study designs, as well as RCTs' limitations (no adoption/fidelity metrics).

Conventional air filtration relies on passive mechanical capture without pathogen inactivation, where viral reduction must be balanced with airflow and energy performance. We developed an Ablative Polymer Coated (APC) filtration system that converts passive filters into active pathogen-reducing surfaces while maintaining low airflow resistance. Unlike conventional approaches requiring denser, higher-resistance media, this strategy enhances biological performance at the filter surface without equivalent aerodynamic penalties. The coating incorporates benzalkonium chloride within a polyvinyl acetate/acrylate matrix for controlled ablative exposure. Performance was evaluated using transmission electron microscopy (TEM), aerosol challenge testing, and HVAC-scale filtration. Ablative exposure caused progressive structural disruption of MS2 bacteriophage, the SARS-CoV-2 simulant. In aerosol challenge testing, coated media achieved up to 99.997% viral filtration efficiency under respiratory airflow conditions. In HVAC (Heating, Ventilation, and Air Conditioning)-scale testing, coated filters achieved >85% viral filtration efficiency with minimal pressure-drop increase. Computational fluid dynamics modeling confirmed uniform airflow distribution without significant turbulence generation. Energy analysis suggested coated filters may reduce energy demand relative to conventional higher-resistance configurations while improving biological performance. These findings support ablative polymer-coated media as a strategy for reducing airborne viral burden without aerodynamic penalties of higher-efficiency passive filtration, suggesting an approach that complements rather than depends solely on tighter filter design.

ObjectivesRising temperatures are a major climate-related hazard for U.S. workers, increasing heat-related illness and a broad range of occupational injuries through indirect pathways often overlooked in economic evaluations. We examined the association between temperature and occupational injury and illness and quantified heat-attributable injuries (including illnesses) and costs in New York State. MethodsWe conducted a time-stratified case-crossover study of 591,257 workers compensation (WC) claims during the warm season (2016-2024). Daily maximum temperature was linked to injury date and county and modeled using natural cubic splines, with effect modification by industry and worker characteristics. ResultsInjury risk increased with temperature, becoming statistically significant at approximately 78{degrees}F. Relative to 65{degrees}F, injury odds increased to 1.06 (95% CI: 1.01-1.10) at 80{degrees}F, 1.12 (1.07-1.18) at 90{degrees}F, and 1.17 (1.11-1.23) at 95{degrees}F. Overall, 5.0% of claims (2,322 annually) were attributable to heat. At temperatures [≥]80{degrees}F, an estimated 1,729 excess injuries occurred annually, generating approximately $46 million in WC costs. An estimated $3.2 million to $36.1 million in medical expenditures were associated with incomplete claims, likely borne outside the WC system. ConclusionsThese findings demonstrate substantial economic costs not fully captured within WC and support workplace heat protections as a cost-containment strategy that can reduce health care spending and strengthen workforce resilience.

Introduction. Climate change is increasing the frequency and intensity of heatwaves, creating critical challenges for social care settings where both staff and residents face heightened heat related vulnerability. This study examined the impact of heatwaves on UK care homes using a national survey of staff experiences, challenges, and adaptation strategies. Methods. Care home staff (N = 225) in managerial (N = 88) and caregiving roles (N = 137) completed an online survey investigating staff perceptions of heatwaves impact on thermal comfort, health and vulnerability of themselves and residents, alongside current heat resilience strategies and the barriers to their implementation. Results. Two thirds (66%) of the surveyed staff complained of being too hot three or more times per day resulting in a perceived impact on their ability to perform tasks (90%) and on residents' comfort and health (92%). Staff demonstrated strong awareness of older adults' heightened heat vulnerability (95%) and signs of heat illness (87%). Thematic analysis identified five key barriers to providing effective cooling: funding limitations, inadequate equipment, building constraints, staffing pressures, and individual resident needs; and four priority improvement areas: increased access to cooling equipment, improved temperature control, strengthened strategy and policy, and support for staff needs. Conclusions. Heatwaves place considerable strain on care homes, challenging staff capacity to maintain comfortable thermal conditions, despite good knowledge of heat risks. Financial, infrastructural, and staffing constraints limit effective heat resilience practices. Evaluating and implementing affordable, accessible, and context appropriate cooling strategies will be essential to protect both residents and staff as extreme heat events become more frequent.

PURPOSE: As the armamentarium of BPH therapies continues to expand, it remains imperative to maximize patient satisfaction and minimize decisional regret. We sought to determine the impact of time from BPH diagnosis to index treatment on symptom improvement and subsequent procedural events. MATERIALS AND METHODS: We queried the American Urological Association Quality Registry for men [&ge;] 40 years old with BPH, available IPSS data, and no receipt of prior BPH treatment. Index treatment included medication, surgery, or minimally invasive surgical therapy (MIST). Outcomes included IPSS over 3 years of follow-up, change in percentage of mild lower urinary tract symptoms (LUTS) by 3 months, and time to procedural event. Patients were stratified by time from index diagnosis to treatment by <12 months, 1-3 years, and >3 years. Outcomes were compared across time-to-treatment cohorts with appropriate statistical tests with p < 0.05 as significant. RESULTS: 43,919 patients met criteria with 19,642 pursuing treatments. Patients pursued treatment at comparably lower baseline IPSS compared to prior prospective series. Patients undergoing surgery and MIST had significantly higher baseline IPSS, while medical comorbidities were significantly more common among men initiating pharmacotherapy. Early surgery and MIST were associated with significant improvement in IPSS within 6-12 months and an increase in mild LUTS by 3 months. All forms of early treatment were associated with delayed time to procedural events, including catheterization and fulguration. CONCLUSIONS: Early procedural intervention for BPH is associated with early symptom improvement and delayed time to procedural events among real-world, contemporary practice.

This study aimed to clarify aerosol exposure risks throughout the workflow of a Biosafety Level 2 (BSL-2) polymerase chain reaction (PCR) laboratory, validate the suitability of the {Phi}X174 bacteriophage as an indicator virus, and provide evidence for biosafety control measures. The {Phi}X174 bacteriophage was used to simulate viral samples, and a concentration-bacteriophage plaque standard curve was constructed (R2=0.998). Five operational steps in a simulated PCR laboratory were quantitatively monitored for aerosol concentration using double-layer agar plates, with blank controls used to eliminate interference. Statistical analysis was employed to identify risk differences. Sample homogenization ((5.67 {+/-} 1.23) x 104 plaque-forming units (PFU)/m3) and nucleic acid extraction ((3.45 {+/-} 0.89) x 104 PFU/m3) were identified as high-/very high-risk steps. The viral load in the samples was strongly positively correlated with the aerosol concentration (r = 0.926, P <0.001), with aerosol levels linearly decreasing with increasing distance in high-risk steps. The {Phi}X174 bacteriophage demonstrated high detection sensitivity (101 PFU/ml) and demonstrated safety compatibility with BSL-2 laboratories. Aerosol risks in PCR laboratories exhibit step-specific differentiation, and {Phi}X174 serves as an ideal indicator virus. Proposed strategies such as equipment upgrades and personal protective equipment (PPE) grading can reduce exposure risks.

BackgroundTransfer of Streptococcus agalactiae, or Group B Streptococcus (GBS) from parent to newborn during delivery can produce life-threatening infections in neonates. Probiotics could potentially prevent GBS colonization in pregnant individuals. We conducted a systematic review and meta-analysis to evaluate the effectiveness of probiotic administration in treating Group B Streptococcus colonization. MethodsMEDLINE, ClinicalTrials.gov, PROSPERO, and the Cochrane, Wild Card, Central Register of Controlled Trials were searched from the July 2015 of each database until July 2025 that completed a randomized controlled trial which compared Probiotic versus control. We utilized the Cochrane Risk of Bias 2.0 (RoB 2) tool to assess bias in the systematic review. Results14 randomized controlled clinical trials met our inclusion criteria. The trials used oral probiotic administration compared to either a placebo or a control group. A meta-analysis showed that probiotic administration produced a statistically significant decrease in the rate of GBS colonization in pregnant individuals. The individual studies ranged from four showing great effectiveness, while the other 10 studies showed a range of effectiveness, from partially effective to no effectiveness in preventing GBS colonization. ConclusionOverall, probiotics were effective in lowering infection rates of GBS, but individual studies showed great variability. Probiotics show promise in decreasing GBS colonization in pregnant people, but more studies need to be performed in order to use them effectively and decrease antibiotic usage.

Background Antibiotic use is prevalent in hospitals, driving the emergence of drug-resistant pathogens. We investigated the contextual influences on antibiotic prescribing behaviour across hospitals in high, middle, and low-income countries in Asia with an aim to provide actionable insights to improve prescribing behaviour. Methods We conducted a large qualitative study across ten institutions in Singapore, Nepal, and Thailand. Semi-structured interviews and ethnographic observations involving physicians, nurses, pharmacists, and management staff were conducted. Data were analysed thematically using QSR NVivo 14. Findings A total of 194 interviews were conducted amongst physicians (54{middle dot}1%), nurses (19{middle dot}6%), pharmacists (12{middle dot}4%), and management staff (13{middle dot}9%). Structural factors such as limited microbiology laboratory capabilities, concerns about antibiotic quality, weak infection prevention and control policies, and the lack of relevant, updated guidelines were prominent drivers for prolonged and broad-spectrum antibiotics prescriptions. Where these system supports were in place, prescribing decisions were less defensive and more targeted, although prescriber responsibility and concerns about immediate patient deterioration continued to influence practice. Across settings, clinicians tended to prioritise short-term perceived benefits of antibiotic treatment over the longer-term risks of antimicrobial resistance.

Endocavity ultrasound transducers, particularly transvaginal ultrasound (TVUS) probes, contain intricate structures such as notches, grooves, lens surfaces, and handle edges that are highly susceptible to microbial contamination yet difficult to disinfect using conventional high-level disinfection (HLD) methods. This study evaluated the efficacy of a novel ultraviolet-C light-emitting diode (UV-C LED) HLD system in eliminating microbial contamination from these complex probe surfaces. Two TVUS probes were sampled from predefined high-risk regions before and after disinfection following clinical use. Probe A was sampled at the top and bottom notches and both sides of the handle, while Probe B was assessed at the lens, edges, and bent groove regions. Microbial contamination was quantified using swab sampling, culture on agar plates, and identification via MALDI-TOF. Environmental sampling of examination and disinfection rooms was also performed. To assess this system robustness, probe sites were repeatedly inoculated with Bacillus subtilis spores and evaluated following UV-C treatment. Before UV-C treatment, contamination rates ranged from 25% to 57% across sampled regions, with microbial loads reaching up to 3.9 log CFU. Identified organisms included Staphylococcus epidermidis, Pseudomonas koreensis, Bacillus cereus, and Propionibacterium spp. Probe sheaths were also predominantly contaminated with Staphylococcus epidermidis., with counts reaching up to 4.3 log CFU, Environmental sampling revealed diverse microbiota, with higher contamination levels in examination rooms compared to disinfection areas. Following 90 seconds of UV-C exposure, no microbial growth was detected on any sampled site, indicating 100% decontamination. Additionally, UV-C treatment achieved >6.7 log reduction of B. subtilis spores across all tested regions. These findings demonstrate that UV-C LED technology provides rapid, effective, and consistent high-level disinfection of complex TVUS probe surfaces, supporting its potential as a rapid and reliable disinfection modality in clinical setting.

ObjectiveRecurrent urinary tract infections (rUTIs) significantly decrease quality of life and antibiotics are becoming increasingly less effective due to antimicrobial resistance. Alternative effective treatment strategies are urgently needed for rUTIs. Prior studies have indicated that women can experience resolved or improved rUTI following electrofulguration (EF). To further investigate these findings, we report on the design and methodology behind a randomized trial examining two treatment arms: standard prolonged antibiotic treatment with nitrofurantoin (NF) alone or in combination with EF. Patients and MethodsThe aim of this randomized trial is to determine, at two institutions, the efficacy of two interventions for rUTI associated with early stages of chronic cystitis (stages 1 and 2): conventional 6 months low-dose (100mg) NF daily antibiotic suppression alone (NF) or conventional NF with EF (EF + NF). The study is also designed to analyze changes in the urinary microbiomes in the two different treatment arms and to determine the durability of clinical outcomes in both treatment arms at 2 years after the end of each intervention. The primary outcomes will be obtained from 6 to 18 months, as well as 18 - 30 months following completion of the original 6-month intervention. Failure is defined based on UTI symptoms documented by a validated questionnaire with a documented urine culture confirming a bacterial strain at each UTI episode following the end of the 6-month intervention. ConclusionsThis randomized trial is designed to examine the efficacy and durability of treating women with rUTIs using the standard of care of NF alone, or an EF procedure with NF.

Objective. To evaluate the effectiveness of a bundle of interventions involving a clinical pharmacologist aimed at changing surgeons approach to perioperative antibiotic prophylaxis (PAP) in an oncourology department. Materials and Methods. A single-center retrospective observational study was conducted. Data from 226 patients who underwent prostatectomy or nephrectomy in the oncourology department of Regional Clinical Hospital No. 2 (Krasnodar, Russia) between 2023 and 2025 were analyzed. Periods before (n=125) and after (n=101) the implementation of an Antimicrobial Stewardship (AMS) strategy bundle with active participation of a clinical pharmacologist (pre-authorization, audit with feedback, education, handshake stewardship) were compared. The primary endpoint was the proportion of surgeries performed in compliance with the PAP protocol. Secondary endpoints included the incidence of infectious complications, antibiotic consumption (DDD/100 bed-days), direct costs of antibacterial drugs, dynamics of the microbial landscape, and the Drug Resistance Index (DRI). Results. After AMS implementation, the proportion of surgeries performed in accordance with the PAP protocol increased from 0% to 47.7% for prostatectomies and to 55.6% for nephrectomies. The mean duration of antibiotic use decreased from 7 to 2 days (p<0.001). Antibiotic consumption decreased by 31.2%, and costs were reduced by a factor of 4.3. The proportion of ESKAPE organisms in the microbial profile decreased from 26.3% to 16.4%. There was no statistically significant increase in the frequency of infectious complications (2.4% vs. 3.0%; p=1.000) or mortality (0% in both groups). Conclusions. AMS implementation integrating a clinical pharmacologist into the oncourology department workflow significantly improved adherence to clinical guidelines, reduced irrational antibiotic use and financial costs without compromising patient safety. This approach can serve as a model for optimizing PAP in other surgical departments. Keywords: antibiotic prophylaxis, antimicrobial stewardship, drug resistance, clinical pharmacologist, cost-benefit analysis, oncourology

Background The COVID-19 pandemic has caused significant global mortality. Despite declining infection rates, new variants of SARS-CoV-2 continue to emerge, necessitating new prevention strategies. Objective This study aimed to evaluate the effect of four over-the-counter (OTC) antiseptic mouthwash/gargling solutions in the U.S., compared with a distilled water control, on SARS-CoV-2 viral load across multiple oral and oropharyngeal sample types. Methods This pilot single-center randomized controlled clinical trial enrolled adults in the San Francisco Bay Area, California, who tested positive for COVID-19. Participants were randomized to distilled water, chlorine dioxide, hydrogen peroxide, cetylpyridinium chloride, and essential oils. Participants were instructed to rinse and gargle four times daily for four weeks using standardized instructions to ensure protocol adherence. Samples were collected on Days 1, 7, and 28 and analyzed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The primary outcome was the change in SARS-CoV-2 viral load from baseline to Day 28, assessed using cycle threshold (Ct) values. Secondary outcomes included self-reported clinical symptoms and hospitalization. Results Forty-nine participants completed the study. No mouthwash demonstrated a statistically significant reduction in SARS-CoV-2 viral load over time. Cetylpyridinium chloride showed a transient increase in Ct values on Day 7 that was not sustained on Day 28. At baseline, throat swab samples had the lowest Ct values across all sample types. Due to limited subgroup sample sizes for secondary outcome measures, no statistical or moderator analyses were conducted. Conclusion Further large-scale randomized trials are needed before recommending antiseptic mouthwashes for SARS-CoV-2 prevention or management.

Objective. To evaluate the diagnostic and prognostic significance of C reactive protein (CRP) level dynamics within the first five days after surgery for the early detection of surgical site infections (SSI) and to identify independent risk factors, taking into account regional specifics of surgical management (types of surgeries, duration of procedures), as well as the local hospital microbial landscape. Materials and Methods. A single-center retrospective cohort analysis of data from 127 patients who underwent surgical procedures between 2022 and 2024 was conducted. CRP levels on postoperative days 1, 3, and 5 were assessed, and delta values were calculated. Descriptive statistics, ROC analysis, and multivariate logistic regression were used to identify predictors of SSI. Results. Patients with SSI lacked the physiological decrease in CRP levels by day 5. The most informative indicator was the CRP level on day 3: a threshold of >106 mg/L was associated with a high risk of SSI (AUC=0.76; sensitivity 85%, specificity 63%). Independent predictors of SSI included surgery duration (OR=1.015 per 1 min; p<0.001) and the increase in CRP between days 3 and 5 (delta CRP3-5: OR=1.027; p=0.023). A combined model (clinical parameters + CRP) demonstrated the highest predictive ability (AUC=0.79). Conclusion. Monitoring CRP dynamics, particularly on days 3 and 5, is a highly informative and accessible method for the early diagnosis of SSI. A CRP threshold of >100 mg/L on day 3 and its subsequent increase should serve as a trigger for in-depth diagnostic investigation and rationalization of antimicrobial therapy. Keywords: C reactive protein, postoperative complications, surgical site infection, antibiotic therapy, predictive factors, diagnosis

BackgroundMetronidazole (MTZ) is a first-line antibiotic for several enteric infections. Its use is common in low-income countries, where most primary-care consultations are conducted by nurses. However, increasing resistance among some enteric pathogens is a growing concern. Using WHO guidelines, we conducted a register-based cross-sectional study to assess MTZ prescribing practices and their determinants in public and private primary healthcare facilities in South Benin. MethodsWe performed a register-based cross-sectional study covering the year 2020 in 11 primary healthcare facilities (5 public and 6 private) in Abomey-Calavi, South Benin, following WHO recommendations. In total, 200 visits per facility were selected using systematic random sampling. The primary outcome was the prevalence of MTZ prescription. Determinants of MTZ prescription were identified using multivariable logistic regression analysis. ResultsIn total, 2,200 medical visits were analyzed. The median age of patients was 19 years, and 57% were female. Antimalarials were prescribed in 52% of visits. Antibacterial agents were prescribed in the majority of visits, with MTZ being the second most frequently prescribed antibiotic (18%), after aminopenicillins (27%). In multivariable analysis, digestive symptoms (adjusted odds ratio [aOR], 8.65; 95% confidence interval [CI], 6.49-11.6), genitourinary symptoms (aOR, 6.84; 95% CI, 3.18-15.0), and skin lesions (aOR, 2.39; 95% CI, 1.58-3.60) were independently associated with increased odds of MTZ prescription. In contrast, fever (aOR, 0.66; 95% CI, 0.49-0.87), respiratory symptoms (aOR, 0.44; 95% CI, 0.26-0.71), and malaria (aOR, 0.21; 95% CI, 0.15-0.28) were associated with decreased odds. Visits in the private sector were also associated with higher odds of MTZ prescription compared with the public sector (aOR, 2.31; 95% CI, 1.78-3.02). ConclusionMTZ is the second most commonly prescribed antibiotic in primary care in the study area, with its use largely driven by digestive symptoms. Further studies are needed to assess the appropriateness of this prescription. Additionally, research is warranted to understand better the determinants of higher antimicrobial prescribing in the private healthcare sector. Highlights- MTZ is the second most prescribed antibiotic in the study area. - MTZ prescription is primarily driven by digestive symptoms. - The private healthcare sector is independently associated with higher MTZ prescription rates. - Antimicrobial prescribing is generally higher in private healthcare facilities than in public facilities.

Background: Rising antibiotic resistance challenges empirical therapies for urinary tract infections (UTIs). This study evaluated the microbial etiology, susceptibility profiles, and multidrug resistance (MDR) patterns of uropathogens among outpatients at the Berekum Holy Family Hospital, Ghana. Methods: This cross-sectional study (February to August 2021) screened 263 symptomatic outpatients. Mid-stream urine samples underwent quantitative culture, biochemical identification, and antimicrobial susceptibility testing via the Kirby-Bauer disc diffusion method following the 2021 CLSI guidelines. Results: Significant bacteriuria prevalence was 22.8% (60/263). UTIs predominated in females (78.3%, 47/60; p = 0.1501) and individuals [&ge;]45 years (33.3%, 20/60). Gram-negative rods accounted for 90.0% of isolates, primarily Escherichia coli (26.7%), Citrobacter spp. (25.0%), and Enterobacter spp. (21.7%); Staphylococcus aureus (10.0%) was the only Gram-positive pathogen. Extreme phenotypic resistance was observed against piperacillin/tazobactam (98.3%), cefotaxime (93.3%), tetracycline (88.3%), and cefoperazone (85.0%). Conversely, highest therapeutic susceptibilities were retained by amikacin (78.3%), levofloxacin (61.7%), and gentamicin (58.3%). Conclusion: The high prevalence of MDR uropathogens against advanced beta-lactamase inhibitor combinations and cephalosporins necessitates an immediate re-evaluation of regional empirical protocols. Amikacin, levofloxacin, and gentamicin remain viable options prior to culture confirmation. These findings establish a crucial phenotypic baseline to guide localized prescribing policies and regional antimicrobial resistance tracking strategies.

BACKGROUNDAutomated antimicrobial susceptibility testing (AST) systems are crucial for accurate, timely detection of drug-resistant microbial isolates. This meta-analysis assessed the performance of the BD Phoenix ("Phoenix", BD Diagnostic Solutions), Vitek(R) 2 ("Vitek 2", bioMerieux), and DxM MicroScan WalkAway ("MicroScan", Beckman Coulter, Inc.) AST systems relative to common reference methodology. METHODSA systematic literature search in Ovid (MEDLINE and Embase) yielded 275 unique (not duplicated) records, with 44 additional records retrieved from handsearching; 39 studies met inclusion criteria. Categorical agreement (CA), essential agreement (EA), very major errors (VMEs), and major errors (MEs) for the three instruments were compared to a common reference method. Ratios of proportions were analyzed using random-effect meta-regression. RESULTSThe instruments did not differ significantly in CA, EA, or ME. Vitek 2 showed a higher overall VME rate than Phoenix ([~]44% higher; Vitek 2-to-Phoenix ratio = 1.44; p=0.062 [approaching significance]) and MicroScan (74% higher; ratio = 1.74; p=0.045). No appreciable difference was observed for VME between Phoenix and MicroScan. Subgroup analyses should be interpreted cautiously due to limited overall significance indicating varying performance across systems. Vitek 2 generally had higher relative VMEs for gram-negative organisms and lower relative VMEs for gram-positive organisms, whereas Phoenix showed the opposite pattern. MicroScan had relatively low VMEs when stratified by Clinical and Laboratory Standards Institute (CLSI) criteria; no differences in VMEs were observed using European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. CONCLUSIONAlthough some VME differences were noted, overall performance of the three systems was comparable. Organism- and drug-specific VME patterns--and updates to CLSI criteria over time--highlight the importance of continued monitoring of current breakpoints for all three instruments.

ABSTRACT Background: The UroLume endoprosthesis (AMS/Endo-care), commercially available 1988-2007 and FDA-approved in 1996, was positioned as a permanent minimally invasive solution for recurrent bulbar urethral stricture and benign prostatic hyperplasia (BPH). Despite early procedural success, long-term data revealed a catastrophic complication profile - including irreversible urethral destruction, spongiofibrosis, MDR infections, chronic kidney disease, and severe psychological morbidity - culminating in the clinical entity termed UroLume Cripple Syndrome. No systematic epidemiological analysis of surviving patients in 2026 currently exists. Objectives: To synthesise four decades of evidence on UroLume pathophysiology, complications, surgical management hierarchy, psychological burden, and cumulative multimorbidity; to perform a pooled meta-analysis of primary complication endpoints; and to present an original epidemiological model estimating surviving patients globally and in Greece in 2026. Methods: PRISMA 2020-compliant systematic review and meta-analysis of PubMed, Embase, and Cochrane Library (all dates to March 2026). Inclusion: peer-reviewed studies of UroLume implantation, explantation, or post-UroLume reconstruction; minimum 12-month follow-up; series n >= 10. Random-effects meta-analysis (DerSimonian-Laird estimator) was performed for three primary complication endpoints across all 43 included studies. An original bottom-up sequential filter epidemiological model was constructed integrating WHO 2021 actuarial tables, published explantation rates, multimorbidity excess mortality, age distributions, complete epithelialisation prevalence, and reconstruction failure rates. Results: Forty-three studies met inclusion criteria (n=3,847 patients). Pooled meta-analysis yielded: restenosis/tissue ingrowth 37.9% (95% CI 36.1%-39.8%, I2=0%); stent explantation 8.7% (95% CI 7.7%-9.8%, I2=0%); urinary incontinence 9.7% (95% CI 8.7%-10.9%, I2=0%). Complete epithelialisation, irreversible after 12 months, affects approximately 8-13% of long-term survivors and defines the UroLume Cripple endpoint. Post-UroLume buccal mucosa graft urethroplasty achieves 76.7% success at 5 years when explantation is feasible. Our epidemiological model estimates 2,500-5,000 surviving patients globally with UroLume in situ in 2026, reducing to fewer than 100 clinically active patients aged <60 years following full multimorbidity adjustment. A six-filter sequential model for Greece converges to a final estimate of 1 surviving patient aged <60 years with complete epithelialisation following failed reconstruction. Conclusions: UroLume Cripple Syndrome is a chronic iatrogenic disease with distinct pathophysiological, reconstructive, psychological, and social dimensions that has received insufficient recognition as a defined clinical entity. The surviving patient population is small but institutionally invisible: no registry exists, no dedicated follow-up protocol has been established, and specialist reconstructive capacity is confined to approximately eight centres worldwide. Registry creation, EAU guideline extension, and specialist referral pathways are the minimum adequate institutional responses. This preprint has been deposited on medRxiv simultaneously with journal submission.

Manufacturers are adopting propellants for use in pressurized metered-dose inhalers (pMDIs) that have lower global warming potentials (GWPs) than the propellants traditionally used in pMDIs. Hydrofluoroalkane (HFA)-134a has been used as the propellant in the pMDI used to deliver the fixed-dose triple combination of budesonide, glycopyrrolate and formoterol fumarate (BGF); following successful clinical evaluation, the BGF pMDI is now being transitioned to the next generation propellant hydrofluoroolefin (HFO)-1234ze(E), which has near-zero GWP. We describe formulation development efforts that led to selection of HFO-1234ze(E) over another propellant, HFA-152a, for reformulation. Propellant-specific studies evaluated active pharmaceutical ingredient (API) stability and aerodynamic particle size distribution (aPSD). Those analyses have been complemented by in silico regional lung deposition modeling conducted after the clinical evaluation of the reformulated BGF pMDI. HFO-1234ze(E) supported favorable stability and aPSD characteristics for BGF pMDI reformulation, compared with HFA-152a, and modeling predicted regional deposition consistent with therapeutic intent. Given that each pMDI is a unique combination of APIs, device, propellant, and excipients, propellant substitution requires product-specific evidence and regulatory approval, and typically takes several years. Targeted analyses, such as those described here, helped to identify the most suitable candidate propellant for successful substitution in the BGF pMDI. HighlightsO_LIFormulation development efforts that led to evaluation of a budesonide-glycopyrrolate-formoterol fumarate pressurized metered-dose inhaler (BGF pMDI) reformulated with the next generation propellant HFO-1234ze(E) in a clinical trial program are described; the suitability of another propellant, HFA-152a, was also assessed C_LIO_LIOver 6 months under accelerated storage conditions (40{degrees}C/75% relative humidity [RH]), the HFA-152a formulation approached and, in one replicate, fell below the 90% of formulation label claim threshold of evaluation, whereas the original HFA-134a product and the HFO-1234ze(E) formulation remained above that threshold C_LIO_LIOver 6 months under accelerated storage conditions (40{degrees}C/75% RH) and 18 months under long-term stability storage conditions (25{degrees}C/60% RH), the fine particle mass and fine particle fraction for all active pharmaceutical ingredients (APIs) showed that the HFO-1234ze(E) formulation tracked more closely than the HFA-152a formulation to the original HFA-134a product C_LIO_LILater in silico modeling, conducted after clinical testing, predicted a trend for greater deposition of APIs in early airway generations with HFA-152a, whereas HFO-1234ze(E) was predicted to more closely match HFA-134a, indicating a greater likelihood of achieving equivalence to the original HFA-134a product with HFO-1234ze(E) than with HFA-152a C_LIO_LIBased on these analyses and other formulation development efforts, HFO-1234ze(E) was identified as the most suitable propellant for reformulation of the BGF pMDI; for HFA-152a, analyses raised concerns about storage stability, and differences in aerosol characteristics that can impact API deposition in the lungs and, in turn, efficacy C_LI