AUGUST 2026

Isolation, Interrupted: Why the Rules Governing PPE and Contact Precautions No Longer Match the Evidence

A SHEA Town Hall convened four infection prevention leaders to confront an uncomfortable reality: the nation’s foundational isolation guidance is 19 years old, its update process collapsed in 2025, and a growing body of research suggests hospitals and long-term care facilities may be isolating far more than the evidence supports.

Every infection preventionist and environmental services professional in the country is, in some sense, still working from a 2007 rulebook. That is the year the CDC published its Guideline for Isolation Precautions, the document that still defines when a patient goes behind a closed door, when a nurse dons a gown, and when a room gets flagged for terminal clean. Nineteen years, several pandemics, and an entire generation of resistant organisms later, that guideline has not been revised — and the body responsible for revising it no longer exists.

That was the sobering starting point for SHEA’s August 2026 Town Hall webinar, “Isolation Precautions,” part of the Society for Healthcare Epidemiology of America’s ongoing “Safe Healthcare for All” series. Moderated with panelists Dr. Bernard Camins (Mount Sinai), Dr. Chris Nyquist (Children’s Hospital Colorado), and Dr. Tom Talbot (Vanderbilt University), the session featured two presentations that, together, made the case that infection prevention’s most basic tool — isolation — has outrun its evidence base in one direction and lagged behind it in another.

A Guidance Vacuum, By Design

Dr. Katie Passaretti, chief infection prevention officer at Advocate Health, opened by cataloguing just how much scaffolding has been removed from underneath isolation practice in the past two years. The Healthcare Infection Control Practices Advisory Committee (HICPAC) — the federal advisory body that had shaped CDC infection control guidance for 34 years — was terminated in March 2025. A draft update to Part 1 of the isolation guideline had been ready for Federal Register comment as recently as November 2024. It is now halted and archived.

As Talbot and colleagues warned in a 2025 JAMA commentary quoted during the session: “Without such a body, the infrastructure essential for effective infection prevention within the US health care system risks fragmentation, inconsistency, and weakening.”

Into that vacuum has stepped the Healthcare Infection Prevention Advisory Group (HIPAG), a joint APIC-SHEA national advisory group launched June 1, 2026. HIPAG’s stated mission — reviewing and contextualizing evolving evidence, supporting rapid-response approaches to emerging threats, and closing the expertise gap across acute, ambulatory, and long-term care settings — is essentially an attempt to rebuild, through professional-society collaboration, the coordinating function the field lost when HICPAC ended. Representatives named to HIPAG span health systems, academic medical centers, state health departments, and long-term care, including co-chairs Sharon Wright (Beth Israel Lahey Health) and Cindy Prins (University of Central Florida) as vice-chair, alongside APIC chair Tania Bubb.

Isolate More, Isolate Less: A Decision With No Free Lunch

The heart of Passaretti’s presentation was a framework she described as two imperatives in tension. On one side: preventing infection harm to the population, which argues for isolating more. On the other: preventing isolation harm to the individual patient, which argues for isolating less. Both sides, she emphasized, are backed by real evidence — and both carry real costs.

The case for isolation is familiar to anyone in infection prevention: multidrug-resistant organism (MDRO) transmission drives genuine morbidity, mortality, and outbreaks, and colonized patients can serve as a transmission reservoir across a unit. But the case against unnecessary isolation has grown substantially harder to ignore. Isolated patients have 40% higher adjusted odds of delirium-related outcomes, receive 36% fewer clinician visits, and get 18% less direct contact time, alongside higher anxiety and depression scores and decreased satisfaction. The financial and operational costs are just as concrete: isolation adds an estimated $31 to $47 per patient-day, and donning and doffing PPE adds roughly 31 minutes of staff time per isolated patient-day — a burden that also constrains throughput in multi-patient rooms. At one hospital, removing unnecessary isolation freed up 4,087 isolation-days and avoided more than $141,000 in costs, while targeted PPE use cut time, waste, and carbon impact by more than half.

Passaretti’s framing was deliberately not a call to abandon isolation, but a call to stop treating it as costless. “Isolation is neither universally beneficial nor uniformly harmful,” she noted. “The evidence of harm has limitations, and the infection prevention benefit differs by pathogen and setting. The question is whether the expected benefit outweighs the burden.”

What Facilities Actually Do: Twelve Years of the Same Inconsistency

To illustrate how unresolved that question remains, Passaretti presented new 2026 data from the SHEA Research Network (SRN) on clearance protocols — the criteria facilities use to decide when to discontinue contact precautions for a given organism. The variability is striking. Ninety-seven percent of facilities have a protocol for clearing MRSA precautions and 95% for C. difficile, but that falls to 82% for VRE, 75% for ESBL organisms, and just 20% for carbapenem-resistant Enterobacterales (CRE) — despite CRE representing one of the highest-consequence resistance threats in acute care. Among facilities that do have a protocol, the criteria themselves vary wildly, from clearance “at end of discharge” to precautions maintained for “more than a year,” and time-based criteria are more common than culture-based clearance for nearly every organism.

The unsettling part, Passaretti noted, is that this is not a new problem. A 2012 APIC survey found 64 distinct MRSA de-isolation strategies and 48 for VRE across responding facilities. A 2014 SHEA Research Network survey found no shared definition of “multidrug-resistant” at all, with a fifth of facilities isolating for neither MDR-Pseudomonas nor MDR-Acinetobacter. “Same variability in approach, same limited data guiding it in 2026 as in 2012 and 2014,” the slide read — a blunt acknowledgment that more than a decade of survey data has not converged on consensus practice.

Organism-Based Isolation May Be the Wrong Question

One proposed way out of that variability: stop asking which organism a patient carries, and start asking what that specific patient, pathogen, environment, and facility actually require. Passaretti outlined an individualized, risk-stratified model that weighs patient vulnerability and care intensity, pathogen transmissibility and environmental persistence, outbreak context, and facility infrastructure and infection prevention capacity — sorting isolation decisions into high-, medium-, and low-priority tiers rather than applying a blanket rule by organism name. It is, she acknowledged, operationally challenging to implement, but many facilities are already making these trade-offs informally.

Enhanced Barrier Precautions (EBP) in skilled nursing facilities were offered as a working example of what individualized isolation can look like in practice. Rather than isolating a resident colonized with an MDRO to their room, EBP calls for gown and glove use only during high-contact care activities — bathing, dressing, transfers, wound care — while the resident keeps full facility access for meals, therapy, and socialization. CMS folded EBP into existing infection prevention regulation in 2024, and surveyors now assess resident identification and PPE use for high-touch activities directly. The implementation barriers that keep coming up, notably, are not about the underlying concept: they’re gown use, staff education, workflow integration, and signage. As one slide in the presentation put it, when isolation precautions have no defined endpoint — as is currently the case for organisms like Candida auris and carbapenemase-producing organisms, where no standard deisolation timeframe exists — the practical result is precautions that continue indefinitely, restricting therapy, dining, and rehabilitation with no criteria to work toward.

The De-Isolation Evidence Is Piling Up

Perhaps the most consequential portion of the session was the accumulating evidence that scaling back contact precautions does not appear to increase transmission — at least for some organisms, in some settings. Three separate MRSA/VRE de-isolation studies, spanning three academic medical centers, 15 acute-care hospitals, and 121 VA hospitals covering more than 900,000 admissions, each found no statistically significant increase in infection rates after facilities discontinued routine screening and contact precautions. ESBL organisms told a similar story across four separate studies, including a cluster-randomized crossover trial published in Lancet Infectious Diseases that found no added benefit from contact isolation with extensive screening in non-critical-care wards.

The COVID-19 experience offered two of the most concrete data points. A SHEA Spring 2026 abstract from nine Emory hospitals found that removing gown-and-glove requirements for COVID-19 patients cut isolation-days by 74% — from 88,963 to 23,378 — with no increase in hospital-onset COVID. Separately, when Singapore made a national shift to N95-alone PPE for routine COVID care in September 2022, staff infection rates did not rise, and the change avoided roughly 440,500 gowns over 12 months. Notably, current CDC guidance still calls for N95, gown, gloves, and eye protection for COVID-19 — a maximal-PPE posture set early in the pandemic that this data suggests may now exceed what’s actually needed for routine (non-aerosol-generating) care.

Passaretti’s conclusions were measured rather than sweeping: strong horizontal infection prevention strategies — hand hygiene, standard precautions, cleaning and equipment practices, and care bundles — should remain the foundation for contact isolation decisions, precisely because they benefit all patients regardless of colonization status. She also pointed to whole genome sequencing as a tool that may eventually resolve some of the remaining uncertainty about when contact precautions actually interrupt transmission, citing an ongoing four-year prospective study that has sequenced 2,660 multidrug-resistant isolates.

The PPE Pop Quiz: Do We Actually Know What We’re Wearing, and Why?

If Passaretti’s talk addressed when to isolate, Dr. Rachael Lee of UAB’s Heersink School of Medicine addressed what to put on once that decision is made — and did so by putting the audience through a running quiz. For each of five common respiratory pathogens — influenza, RSV (and its close relatives parainfluenza and human metapneumovirus), rhinovirus, adenovirus, and COVID-19 — she asked what PPE a healthcare worker actually needs, then revealed the CDC-recommended answer.

The pattern that emerged was instructive. For influenza, rhinovirus, RSV, and parainfluenza, current CDC guidance calls for droplet and standard precautions — essentially a surgical mask, plus gloves and gown only when contact with secretions is anticipated — not the full respirator-gown-face-shield ensemble many clinicians reflexively don. Adenovirus pneumonia adds contact precautions given documented outbreaks in pediatric and institutional settings. COVID-19 remains the outlier: current CDC guidance still specifies N95 or higher respiratory protection, gown, gloves, and eye protection for routine care — the full complement — a holdover from the early pandemic’s maximum-caution posture that, as Passaretti’s Emory and Singapore data suggested, may no longer be justified by transmission risk for most patient encounters.

Lee grounded the discussion in decades-old but still-relevant transmission science, including the classic 2000 Clinical Infectious Diseases study in which volunteer “cuddlers,” “touchers,” and “sitters” were exposed to RSV-infected infants through direct contact, contaminated surfaces, and simple proximity — a study that helped establish contact, not droplet, as RSV’s dominant transmission route. She also reviewed surface-persistence data showing meaningful differences across pathogens: RSV viable for roughly 1.5 hours on gloves but only 20 minutes on skin; influenza persisting on steel or plastic for 24 to 48 hours with a practical transfer window of 2 to 8 hours; rhinovirus self-inoculation risk documented from contaminated fingerpads even hours after contact; and SARS-CoV-2 remaining viable on plastic or steel for up to 72 hours, though viable titer declines exponentially over that period.

The Bottom Line for Infection Prevention and EVS Teams

Taken together, the two presentations point toward the same conclusion from different directions: current isolation and PPE practice is not well calibrated to current evidence, and the institutional mechanism that used to keep it calibrated — HICPAC and a living CDC guideline — is currently offline. For infection preventionists, that means the burden of evidence review, protocol design, and de-isolation decision-making is shifting toward professional societies, health-system committees, and individual facilities, at least until HIPAG or a successor body produces updated national guidance. For environmental services professionals, the stakes are equally direct: isolation-day counts, PPE consumption, room-turnover protocols, and terminal-clean triggers are all downstream of decisions that, as this Town Hall made clear, are being made with wide variability and, in some cases, without much data at all.

The message from SHEA’s panel was not that isolation and PPE don’t matter — it’s that treating them as automatically protective, regardless of organism, setting, or duration, may be doing as much harm as good. Until updated national guidance arrives, individualized, evidence-driven decision-making — organism by organism, unit by unit, patient by patient — appears to be where the field is heading.

This article is based on SHEA’s August 2026 Town Hall webinar, “Isolation Precautions,” featuring presentations by Katie Passaretti, MD, (Advocate Health) and Rachael Lee, MD, MSPH (UAB Heersink School of Medicine), with panelists Bernard Camins, MD (Mount Sinai), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University). Full citations for the studies referenced are available in the original SHEA presentation.

JULY 2026

Water Safety Is Patient Safety: Inside Healthcare’s Most Underappreciated Infection Risk

SHEA’s July 2026 Town Hall turned its attention from patients to plumbing, examining how hospital water systems become reservoirs for Legionella and multidrug-resistant organisms — and why the bacteria hiding in that water may be harder to detect, and harder to kill, than standard testing assumes.

Infection preventionists spend enormous energy tracking what happens at the bedside — hand hygiene compliance, isolation precautions, device-associated infections. SHEA’s July 2026 Town Hall webinar, part of the Society for Healthcare Epidemiology of America’s “Safe Healthcare for All” series, made the case that some of the highest-consequence infection risk in a hospital isn’t generated at the bedside at all. It’s generated in the pipes.

The session paired two presentations that approached the same problem from different altitudes. Bernard Camins, MD, MSc, of the Icahn School of Medicine at Mount Sinai, laid out the operational and regulatory case for treating water as an infection prevention priority in its own right. Abraham C. Cullom, PhD, of Pace Analytical, then took the discussion into more technical territory, examining why the standard laboratory method for detecting Legionella may be systematically undercounting the bacteria actually present in a building’s water system. Panelists Chris Nyquist, MD (Children’s Hospital Colorado) and Tom Talbot, MD (Vanderbilt University) joined the discussion.

Why Water Belongs on the Infection Prevention Agenda

Camins opened with a simple but easily overlooked observation: water touches nearly every point of patient care. Hand hygiene, bathing, drinking, dialysis, endoscopy, and medical device reprocessing all depend on it. That ubiquity is precisely what makes it dangerous. Hospital plumbing — sinks, drains, showerheads, ice machines — can harbor biofilm-forming organisms that standard disinfection protocols simply do not reach, and immunocompromised, elderly, and critically ill patients face disproportionate morbidity and mortality when those organisms find their way into patient care. CDC data cited in the presentation found that the vast majority of healthcare-associated Legionella outbreaks stemmed from preventable water management gaps — not novel or unavoidable contamination, but process failures.

Four pathogen groups accounted for most of the clinical concern outlined in the session. Legionella species, spread through aerosolized potable water, showers, cooling towers, and respiratory equipment, cause Legionnaires’ disease with an overall case fatality rate of roughly 9–10%, higher still in healthcare-associated cases. Nontuberculous mycobacteria (NTM), carried in tap water, ice, bronchoscopes, and heater-cooler units, drive pulmonary, wound, bloodstream, and surgical-site infections. Pseudomonas aeruginosa, harbored in sinks, drains, faucet aerators, and hydrotherapy equipment, causes bloodstream, wound, and respiratory infections that are often multidrug-resistant. And a broader group of Gram-negative organisms — Stenotrophomonas, Acinetobacter, Burkholderia — living in sink drains and biofilm have been linked to outbreaks tied specifically to sink splashing.

The mechanics of exposure, Camins explained, follow a predictable chain: municipal water enters a facility with a chlorine residual that decays as it moves through large, complex plumbing systems; low-flow branches, dead legs, and suboptimal temperatures allow biofilm and pathogens to proliferate in stagnant sections; point-of-use devices — faucets, showerheads, ice machines, sinks and drains — amplify that exposure; and patients ultimately encounter the contaminated water through ingestion, aspiration, aerosolization, or direct contact during hygiene, dialysis, or device use. Colonization, he noted, can take hold in the proximal infrastructure, the distal outlets, or both — a distinction that matters for where facilities should focus sampling and remediation efforts.

Legionella by the Numbers

The session’s data on Legionella specifically was stark. CDC surveillance shows legionellosis cases per 100,000 population climbing from roughly 0.4 in 2000 to 1.6 in 2014 — a trend that has continued, with overall U.S. Legionnaires’ disease incidence increasing approximately 6.5-fold between 2000 and 2019. Of CDC-investigated Legionnaires’ outbreaks between 2000 and 2014, 33% were healthcare-associated; strikingly, 85% of all outbreak-associated deaths in that period occurred in healthcare-associated outbreaks. About two in three outbreaks traced back to process failures — a missing or unfollowed water management program — with roughly half involving straightforward human error such as missed maintenance.

That data underpins a regulatory and accreditation framework that has been building since 2015. ANSI/ASHRAE Standard 188 established the industry standard for Legionella risk management in building water systems; CMS followed in June 2017 with Directive S&C 17-30, requiring hospitals, critical access hospitals, and long-term care facilities to maintain water management policies addressing that standard. CDC published a companion toolkit in 2016 to help facilities implement it, and The Joint Commission now surveys specifically for documented water management policies, risk assessment, and monitoring, on top of the foundational recommendations already embedded in CDC/HICPAC’s Environmental Infection Control Guidelines.

The Sink Is Not Just a Sink

One of the more operationally pointed segments of Dr. Camins’ talk concerned sinks specifically — and how routine clinical workflow, not just plumbing defects, drives contamination. Citing the 2022 SHEA/IDSA/APIC hand hygiene practice recommendation, he noted that handwashing has been observed in only 4% of total sink interactions; the rest of the traffic at a hospital sink is workflow that can spread contamination directly into patient care — filling or emptying water glasses, medication cups, and tube feed bags; draining IV bags; food or beverage preparation; and setting patient care items on nearby countertops. Slow drainage compounds the problem by increasing contamination of sink bowls and adjacent surfaces, and medication preparation near splash zones is a recognized exposure pathway in its own right. Facilities that restricted sink use strictly to handwashing and disinfected basins daily with bleach saw contamination drop.

The resulting best-practice list was concrete: restrict sinks to handwashing only and keep medication preparation away from splash zones; use sterile water for device rinsing and cleaning and for the care of immunocompromised patients; avoid tap water and ice machine ice for patient care during outbreaks; remove decorative fountains from healthcare settings entirely; disinfect sink basins daily with bleach; keep water flowing by regularly flushing low-use or stagnant outlets; treat hand hygiene as the single most important measure against waterborne gram-negative transmission; and maintain aggressive clinical surveillance for Legionellosis and other waterborne infections.

Reprocessing added a second, newer regulatory thread to the discussion: ANSI/AAMI ST108, an ANSI-approved standard enforceable by both The Joint Commission and CMS, now sets binding water quality and testing requirements for medical device reprocessing, replacing the prior AAMI TIR34 technical information report, which offered only optional guidance. ST108 requires a dedicated water management team spanning sterile processing, facilities engineering, and infection prevention, along with a documented water management program, testing across pH, alkalinity, conductivity, hardness, and appearance, and microbial and endotoxin testing appropriate to three defined water categories: Utility Water (flushing and washing, tested quarterly), Critical Water (final rinse of critical and semi-critical devices, requiring multi-step reverse osmosis or deionization treatment, conductivity below 5 microS/cm, and endotoxin testing, checked monthly), and Steam (sterilization water, with condensate required to meet Critical Water criteria). Poor water quality, Camins noted, doesn’t just create infection risk — it damages the devices themselves, causing staining, corrosion, pitting, blocked lumens, and reduced mobility of moving parts. He closed with a line that doubled as the session’s thesis: water safety is patient safety.

The Bacteria That Won’t Grow on a Plate — But Aren’t Dead

If Camins’ presentation established why water matters, Dr. Cullom’s presentation complicated how confident anyone can be about measuring the risk inside it. His subject was viable but non-culturable, or VBNC, Legionella — bacterial cells that are still alive and metabolically active but that no longer grow on the standard culture media labs use to detect them.

Cells enter this VBNC state under several kinds of stress: starvation, heat, chlorine exposure, and copper exposure — precisely the conditions a water management program’s own interventions (shock chlorination, temperature adjustments, copper-silver ionization) are designed to create. That creates an uncomfortable possibility: the very tools facilities use to control Legionella may be pushing surviving cells into a state where they escape detection by culture-based testing, without actually killing them.

The evidence that VBNC cells remain dangerous is not hypothetical. Cullom cited published research showing that VBNC Legionella pneumophila cells retain the ability to produce virulence proteins, that amoebae such as Acanthamoeba castellanii can resuscitate VBNC Legionella back into a culturable, replicating state, and that starved VBNC Legionella strains can infect and replicate inside both amoebae and human macrophages. In other words, a negative culture result does not necessarily mean the water is free of infectious Legionella — it may mean the Legionella present has simply gone quiet.

Cullom was careful, however, not to overstate the epidemiological case. As one slide put it directly, quoting a 2025 review in the journal Water: “No waterborne Legionella infections have been directly attributed to VBNC cells.” The gap between plausible biological mechanism and confirmed clinical causation remains open — cells that can theoretically resuscitate and cause infection in laboratory conditions have not yet been definitively linked to a real-world human case. That gap is precisely why VBNC testing matters most in specific, targeted circumstances rather than as a wholesale replacement for culture: testing in proximity to water treatment processes, particularly after shock chlorination, and testing following periods of stagnation, when standard culture methods are most likely to miss cells that stress has pushed into dormancy.

Measuring viability in cells that won’t grow on a plate requires different tools, each with its own limitations. PMA-qPCR assesses membrane integrity but can be confounded by viable cells with damaged or permeable membranes, generating results that don’t cleanly separate living from dead. PVT-Viable measures changes in DNA levels after liquid enrichment but runs into a different complication: bacteriostatic cells that are alive but not actively replicating can be missed. Neither method, in other words, fully resolves the question a facility actually needs answered.

And Legionella is not the only organism this applies to. Cullom’s presentation identified confirmed or very likely VBNC behavior in drinking water for Pseudomonas aeruginosa, Aeromonas hydrophila, and Klebsiella pneumoniae, with plausible but more limited evidence for nontuberculous mycobacteria, Acinetobacter baumannii, and Burkholderia cepacia complex — several of the same organisms Camins had already flagged as hospital water system risks earlier in the Town Hall.

What This Means for Infection Prevention and Facilities Teams

Taken together, the two presentations left attendees with a two-part message. First, water management in healthcare facilities is no longer optional best practice — it is layered regulatory obligation, from ASHRAE 188 and CMS’s 2017 directive through to the newly binding ANSI/AAMI ST108 for device reprocessing, and the clinical stakes behind that regulation are real: a nearly fourfold rise in reported Legionnaires’ disease incidence over two decades, with healthcare-associated outbreaks accounting for a disproportionate share of deaths. Second, and more unsettling, the testing infrastructure facilities rely on to verify that their water management programs are working may itself have a blind spot. If VBNC cells retain virulence and can be resuscitated inside amoebae and human macrophages, a clean culture result cannot be treated as complete reassurance — particularly right after the disinfection interventions, like shock chlorination, that water safety plans depend on.

Neither presenter suggested abandoning culture-based surveillance, which remains the regulatory standard and the best-validated tool available. But the session’s throughline was a call for humility: the pipes, sinks, and reprocessing systems running quietly behind every unit in a hospital carry infection risk that is well documented, increasingly regulated, and — where VBNC organisms are concerned — not yet fully measurable by the tools currently in routine use.

This article is based on SHEA’s July 2026 Town Hall webinar, part of the “Safe Healthcare for All” series, featuring presentations by Bernard C. Camins, MD, MSc (Icahn School of Medicine at Mount Sinai) and Abraham C. Cullom, PhD (Pace Analytical), with panelists Chris Nyquist, MD (Children’s Hospital Colorado) and Tom Talbot, MD (Vanderbilt University). Full citations for the studies referenced are available in the original SHEA presentation.

MAY 2026

Inside SHEA’s May 2026 Town Hall: A Conference Recap and the Future of Antimicrobial Stewardship

SHEA’s May 2026 Town Hall turned to a wide-ranging recap of the Society’s Spring 2026 conference — including a candid look at why the antimicrobial stewardship role no longer fits the “antimicrobial police” label it’s carried for three decades.

Not every SHEA Town Hall webinar centers on a single deep-dive topic. The Society for Healthcare Epidemiology of America’s May 2026 installment, part of the ongoing “Safe Healthcare for All” series, functioned more as a survey of the field’s current moment, handing the floor to Chris Nyquist, MD, MSPH, of Children’s Hospital Colorado, for an extended recap of SHEA Spring 2026, the Society’s flagship conference held in Chicago. Panelists Bernard Camins, MD (Mount Sinai), Katie Passaretti, MD (Advocate Health), and Tom Talbot, MD (Vanderbilt University) joined, along with invited panelists Matt Ziegler, MD (Hospital of the University of Pennsylvania), Marisa Holubar, MD, MS (Stanford University School of Medicine), and Surbhi Leekha, MBBS, MPH (University of Maryland School of Medicine) — all three members of the SHEA Spring 2026 Planning Committee.

SHEA Spring 2026: A Conference Finding Its Next Decade

The bulk of the Town Hall was devoted to Nyquist’s recap of SHEA Spring 2026, held under the banner “The Bug: No One Is Immune, It’s Infectious” — a meeting that drew more than 70 sessions and 850 registered attendees, and one the Society is already using as a template for structural change.

The thematic throughline, set by the opening plenary “Turning Point or Tipping Point? Infection Prevention and Antimicrobial Stewardship in the Current Landscape,” was that caring and competence are both prerequisites for institutional trust — a framing echoed in sessions on deimplementation science (the deliberate work of unwinding practices no longer supported by evidence) and in “Tiny Hosts and Tough Bugs,” a session on multidrug-resistant organisms in pediatric populations that included a specific look at Candida auris in children. The middle plenary, “Crossing the Communication Divide” with Umair Shah, MD, MPH, offered two lines that Nyquist singled out as resonating with attendees: that change is constant and resilience is what makes it survivable, and that leadership isn’t about choosing sides in a disagreement but about navigating the trade-offs underneath it. A companion session, “The Art of Influencing Without Formal Authority,” reinforced the point operationally: relationships, the session argued, matter more than the org chart, and influence is built through credibility, listening, and communication skill rather than positional power — a message clearly aimed at infection preventionists and stewardship pharmacists who routinely need to change clinician behavior without the authority to mandate it.

SHEA 2026 also debuted a new interactive session format, the Education Carnival, built around gamified, hands-on learning: escape rooms, tabletop exercises, Jeopardy- and Kahoot-style quiz games, hands-on simulations, and virtual infection control tools, led respectively by Sara Dong, MD; Brooke Brewer, BSN, MS, CIC; Rachael Lee, MD; Ann Marie Pettis, BSN, RN, CIC; and Chloe Green, MURP. A companion pre-conference workshop, “From Algorithms to Action,” tackled AI’s growing footprint in the field directly, with sessions on AI platforms in healthcare broadly (Rachael Lee), AI applications specific to infection prevention (Krishna Rao, MD), and AI in antimicrobial stewardship (Bradley Langford, PharmD, MPH, BCIDP) — a strong signal that SHEA views AI literacy as core infrastructure for its membership going forward, not a niche interest.

The conference’s general sessions leaned into two important topics — care settings beyond the traditional acute-care ward, and the tooling now available for outbreak detection. On the settings side, sessions covered infection control in immunocompromised patients, MDROs in pediatrics, and — in a session pointedly titled “Ambulatory Minefields” — the infection prevention challenges specific to behavioral health, dental, veterinary, and home care settings, areas that receive a fraction of the guidance attention acute care does. On the tooling side, sessions on genomic epidemiology (Egon Ozer, MD, PhD, Northwestern) and genomic sequencing for HAI surveillance (Ahmed Babiker, MBBS, MSc, Rush) pointed toward the same whole-genome-sequencing direction referenced in SHEA’s other 2026 Town Halls as a way to resolve open questions about transmission and de-isolation. A session marking two decades of the National Healthcare Safety Network covered NHSN’s digital measures push and efforts to integrate antimicrobial use and resistance module data directly into stewardship and infection prevention action — a practical reminder that surveillance infrastructure built twenty years ago is still being actively modernized.

Perhaps the most pointed content came from a new session format SHEA is calling “Philosophical Conundrums in Infection Prevention” — structured pro/con debates on questions the field argues about but rarely stages formally. “Regulate or Repeal? Public Health Oversight and Pandemic Readiness” pitted Stephanie Black, MD, against Michael Stevens, MD; “Hospital Quality Rankings and Patient Outcomes” set Hilary Babcock, MD, against Lauren DiBiase, MS; and “The Problem With ‘Getting to Zero'” had John Jernigan, MD, arguing both sides against Gonzalo Bearman, MD, MPH — a structural choice that itself makes a point: the field’s most confident-sounding policy positions, including the “zero harm” framing common in HAI prevention rhetoric, remain genuinely contested even among experts, and are healthier for being argued out loud rather than assumed.

Looking ahead, SHEA announced Spring 2027 for March 30 through April 2 in Washington, D.C., with an explicit goal of growing attendance to 1,000 by 2028 and deliberately widening the audience beyond physician epidemiologists to public health professionals, pharmacy and stewardship teams, nursing and infection preventionists, clinical researchers, and hospital administration and quality leaders — a signal that SHEA sees its flagship meeting evolving into a broader infection-prevention-ecosystem event rather than a specialty-physician conference.

Thirty Years In, the Stewardship Role Gets a Rewrite

A separate segment of the Town Hall, drawing on SHEA Spring 2026’s Antimicrobial Stewardship track, took on a more introspective question: what does an antimicrobial steward actually do now, more than three decades after antimicrobial stewardship programs began? The session opened with a pointed juxtaposition — a 2025 commentary asking why stewardship pharmacists are perceived as “antimicrobial police,” set against a word cloud generated live at a 2025 national conference when clinicians were asked for their one-word stewardship identity. The results skewed away from enforcement entirely: communicator, educator, innovator, mediator, negotiator, and strategist dominated, with “detective” and “hopeless” appearing only as minor outliers.

SHEA’s stewardship curriculum has been restructured to match that shift. The 2025 track organized programming around three identity pillars — educator/influencer, antimicrobial expert, and program manager/leader — while the 2026 track reframed those same functions around messaging (how a program is perceived), expertise (what establishes its credibility), and approach (the vision-plan-execution arc of actually leading change). Track chairs’ standout picks from the three days made the behavioral-science emphasis explicit: “Fighting Fair: How to Disagree Better” (Alyssa Castillo, MD) on day one, the more traditionally clinical “Tough Bugs and New Drugs” (Jason Pogue, PharmD) on day two, and “The Complete Steward: Building Credibility, Capability, and Culture” (Lauren O’Brien, MD) closing day three.

Track chairs reported that attendees specifically valued cohesive, cross-setting programming, protected interactive time, and a deliberate mix of soft-skills content (communication technique, leadership) alongside hard clinical content (penicillin allergy evaluation, managing common MDRO infections) — and that the audience, notably, pushed back against being treated as universally new to the field, asking for more advanced content in areas where data remains sparse. Cynthia Nguyen, PharmD (University of Chicago), Hayden Schwenk, MD, MPH (Stanford Children’s Hospital), and Meghan Jeffres, PharmD (University of Colorado) will chair the 2027 track.

The Town Hall closed with a look at a joint SHEA-SIDP (Society of Infectious Diseases Pharmacists) initiative to formally set the outpatient antimicrobial stewardship research agenda — a multi-year process moving from expert panel discussion through literature review, priority consolidation, and now a live sticker-vote survey of the ASP community at SHEA Spring 2026, ahead of eventual white paper publication. The clear front-runners from that vote point directly at the gaps practicing stewards feel most acutely: scalable ASP strategies that integrate into clinical workflow without depending on the electronic health record and without adding clinician burden (29 votes), setting-specific ASP metrics that would allow real benchmarking across different practice types (29 votes), and a formal definition of the role nurses, pharmacists, and dentists should play in outpatient stewardship, which today remains largely undefined (28 votes). Evaluating outpatient diagnostic stewardship strategies and identifying high-prescribing outpatient settings — including emerging, nontraditional care platforms — rounded out the top five.

Why This Matters Beyond the Conference Hall

Taken together, the two threads of this Town Hall — a conference recap built around communication and de-implementation as much as clinical data, and a stewardship field actively rewriting its own job description — point at a common current running through infection prevention in 2026: the technical core of the discipline (isolation protocols, surveillance systems, antimicrobial selection) is increasingly understood to be inseparable from the relational That means the professional development pipeline — SHEA’s own training track included — is shifting investment toward exactly the influence-without-authority skills that EVS leaders have had to build for years, largely without formal curricula to support them. As one of the Town Hall’s own presenters put it: the science tells you what to do, but the conversation is what actually gets it done.

This article is based on SHEA’s May 2026 Town Hall webinar, part of the “Safe Healthcare for All” series, featuring a conference recap presentation by Chris Nyquist, MD, MSPH (Children’s Hospital Colorado), with panelists Bernard Camins, MD (Mount Sinai), Katie Passaretti, MD (Advocate Health), and Tom Talbot, MD (Vanderbilt University), and invited panelists Matt Ziegler, MD (Hospital of the University of Pennsylvania), Marisa Holubar, MD, MS (Stanford University School of Medicine), and Surbhi Leekha, MBBS, MPH (University of Maryland School of Medicine). Full citations and session details are available in the original SHEA presentation.

APRIL 2026

The New Rulebook for Reprocessing: Inside SHEA’s Update on Sterilization and High-Level Disinfection

A new multisociety guidance document — the first major update to sterilization and high-level disinfection practice in years — was the focus of SHEA’s April 2026 Town Hall, alongside a practical framework for the question every sterile processing and infection prevention team eventually runs into: what do you do when the guidance says “no recommendation”?

Reusable medical device reprocessing sits at the intersection of infection prevention, sterile processing, EVS-adjacent facilities operations, and regulatory compliance — which is exactly why it generates some of the most persistent operational headaches in any healthcare facility. SHEA’s April 2026 Town Hall webinar, part of the Society’s “Safe Healthcare for All” series, devoted its full session to the topic, with two presentations: Katie Passaretti, MD, chief infection prevention officer at Advocate Health, walked through the newly updated mult-society guidance for sterilization and high-level disinfection (HLD) and the regulatory hierarchy it sits within, and Emily Sickbert-Bennett, PhD, MS, CIC, FSHEA, executive director of infection prevention at UNC Health, followed with a deeper look at implementation — where, in her words, “the real work begins.” Panelists Bernard Camins, MD (Mount Sinai), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University) rounded out the discussion.

Whose Guidance Wins? A Hierarchy for Conflicting Instructions

Passaretti opened with a structural point that shapes everything downstream: when guidance documents conflict, The Joint Commission’s infection prevention hierarchy tells facilities which source takes precedence. In descending order, that hierarchy runs: federal, state, and local laws and regulations; manufacturers’ instructions for use (MIFU); evidence-based guidelines and standards; consensus documents and professional standards (such as those from AAMI); and, at the base, organizational policies and procedures. Within that stack, it matters what kind of document is issuing a recommendation. A SHEA Expert Guidance Document is a synthesis of scientific evidence, theoretical rationale, current practice, practical considerations, and writing-group judgment, including explicit consideration of potential harm — it is not a binding standard. AAMI/ANSI documents, by contrast, come in two flavors: a Standard (ST), a consensus document specifying requirements and reviewed every five years, and a Technical Information Report (TIR), an interim document that is explicitly barred from using “must” or “shall” language and is reviewed every three years. Knowing which category a given piece of guidance falls into is often the first step in resolving a practice dispute.

What’s Actually New in the 2025 Multisociety Guidance

The centerpiece of Passaretti’s talk was “Multisociety Guidance for Sterilization and High-Level Disinfection,” published online in Infection Control & Hospital Epidemiology in April 2025 (Shenoy, Weber, McMullen, et al., ICHE 2025;46(6):561–583, doi:10.1017/ice.2025.41) and endorsed by five societies: SHEA, APIC, the American Society for Gastrointestinal Endoscopy (ASGE), IDSA, and the Society of Gastroenterology Nurses and Associates (SGNA). The document’s foundational principles remain unchanged from prior guidance: it reinforces the Spaulding Classification scheme (critical items require sterilization; semi-critical items require, at minimum, high-level disinfection), it emphasizes — and re-emphasizes — adherence to manufacturers’ instructions for use, and it explicitly weighs feasibility and potential harm rather than treating every recommendation as achievable in every setting. Just as notably, it is candid about where the evidence simply isn’t there yet, an approach that carries real practical consequences discussed later in the session.

Among the substantive new or revised content: guidance on how to use and interpret MIFUs; how to perform point-of-use treatment of reusable devices; revised criteria for when and how to assess sterilization and HLD effectiveness; factors to weigh when evaluating a sterilization method for a new device or switching processes; considerations specific to investigational reusable devices and 3D-printed devices or implants; clarity on when semi-critical devices or their components may not require high-level disinfection at all; guidance on processing ultrasound probes used on intact skin; considerations for devices used with lubricating or defoaming agents; storage considerations after processing; guidance on when sterile single-use components or accessories are appropriate augments or alternatives to HLD; and a section specifically addressing implementation. Notably absent from the update: Rutala and Weber’s widely used 2008 table of sterilization and disinfection methods, which readers are now directed to a 2023 companion publication to find, since the newer document does not attempt to reproduce it.

Ultrasound Probes: A Concrete Clarification

One of the more immediately actionable pieces of the update concerns ultrasound probes, an area where practice has historically varied. Between the 2025 multisociety document and a companion AAMI technical report, TIR99, two points are now clarified. First, probe sheaths do not eliminate the need for high-level disinfection unless the device’s own MIFU specifically says otherwise — a sheath is not, on its own, a substitute for reprocessing. Second, sterilization or HLD is not required for probes applied to intact skin for the purpose of guiding a percutaneous procedure, such as central line placement — the rationale being that in that scenario, the needle is the invasive device, not the probe itself, which never breaches skin.

The MIFU Problem, and a Framework for Resolving It

Manufacturers’ instructions for use occupy the second rung of the Joint Commission’s hierarchy, but in practice they are frequently the source of the most friction. Passaretti walked through a five-step process for resolving MIFU conflicts that facilities can apply directly: first, identify the specific issue — conflicting instructions, unclear language, a referenced product that’s unavailable, or a MIFU that’s missing altogether; second, contact the manufacturer’s technical services (engaging both the device manufacturer and the manufacturer of any accessory, such as a sterilizer or HLD product, where relevant) and document every communication; third, assess validation — a process is acceptable if either manufacturer validates it, but should not be used if no validation exists at all; fourth, clarify or escalate ambiguity directly with the manufacturer, and escalate to the FDA’s Division of Industry and Consumer Education (DICE) if the conflict remains unresolved; and fifth, if the issue still can’t be resolved, conduct a formal risk-based review weighing patient safety, regulatory exposure, and legal risk, with explicit leadership awareness of the decision. Key resources facilities can lean on throughout this process include manufacturer technical services, FDA DICE, and the FDA’s MAUDE database of device experience reports. If a facility ultimately cannot implement a MIFU because of irresolvable challenges and has exhausted its options for recourse, it has to consciously weigh the safety, legal, and regulatory risk of noncompliance — there is no guidance-document escape hatch from that decision.

Water Quality: Two Documents, Two Philosophies

Water quality emerged as a genuine point of tension between guidance sources. Both the AAMI standard and the multisociety guidance document agree that water quality matters, but they diverge sharply on how prescriptive to be. The multisociety guidance, built on limited evidence, does not specify how to operationalize water quality management or prescribe water testing protocols. AAMI ST108 — which has replaced the prior TIR34 — takes the opposite approach: it is a prescriptive, consensus-based standard requiring critical water for the final rinse after HLD, routine water testing at defined frequencies and locations, and specific microbial and endotoxin limits. Facilities have found ST108 genuinely difficult to implement operationally, which is why AAMI has a companion implementation document, TIR119, in development.

Where the Guidance Runs Out — and What to Do About It

Perhaps the most practically important segment of the Town Hall concerned the areas where the 2025 multisociety document explicitly declines to make a recommendation, because the evidence doesn’t yet support one. Those areas include: methods of cleaning verification beyond external visual inspection; the use of surrogate tests such as ATP, protein, or heme assays to verify adequate cleaning; the use of microbial cultures to routinely assess HLD effectiveness; the maximum time a properly processed device can be stored before facilities must repeat HLD; the use of “double” HLD; criteria for when to replace an aging device; the appropriate frequency of training for HLD and sterilization staff; and whether reprocessing should be centralized or decentralized.

Sickbert-Bennett’s presentation dug into the quality-assurance items on that list specifically, and the reasoning behind the “no recommendation” designation is more nuanced than it first appears. Borescopic examination of lumened devices before processing has not been well studied in routine clinical use and imposes real cost and training burden — hence no blanket recommendation for its routine use. Yet the evidence isn’t neutral: outbreaks associated with contaminated endoscopes have specifically been linked to luminal damage and retained debris identified via borescope, and debris found in processed endoscopes has been significantly correlated with microbiological contamination. The inverse doesn’t hold as cleanly, though — the absence of visible debris has not been similarly correlated with a negative culture result. That leaves two open research questions the field still needs answered: which specific borescopic findings actually predict higher post-procedure infection risk, and can a validated method for monitoring endoscope cleaning be established with thresholds tied to real infection risk, rather than to inspection alone?

The same evidentiary gap and the same operational bind apply to surrogate cleaning-verification tests (ATP, protein, heme) and to routine microbial culturing of HLD-processed devices — none currently correlate reliably enough with reduced transmission risk to support a blanket recommendation, even though facilities still need some way to verify their processes are working.

Critically, “no recommendation” does not mean facilities are free to do nothing, or free to do anything. A companion 2025 commentary from the same multisociety writing group (Schaffzin, McMullen, Kyle, Deloney, Rutala, Shenoy, Weber; ICHE, published online Dec. 22, 2025, doi:10.1017/ice.2025.10383) lays out a structured process for exactly this situation. First, identify the specific unresolved issue in the guidance. Second, review all relevant materials and sources, and if the practice remains genuinely unclear after that review, proceed to a formal process rather than defaulting to inaction. Third, assemble a multidisciplinary team that explicitly includes infection prevention and all relevant stakeholders, sharing the initial review and expanding it as needed. Fourth, that team should recommend a specific resolution to the issue, explicitly weighing the risk of both adopting and not adopting a given practice, and confirming the resulting decision doesn’t conflict with law, regulation, or any applicable MIFU. Fifth, facilities should apply a systematic quality improvement framework to the decision and consider publishing their findings — turning a local resolution into evidence that can inform the next round of national guidance.

When Something Goes Wrong: Assessing a Lapse

The session closed with a nod to a foundational document that predates the new guidance by nearly two decades but remains the operative framework when reprocessing actually fails: Rutala and Weber’s 2007 ICHE paper, “How to Assess Risk of Disease Transmission to Patients When There Is a Failure to Follow Recommended Disinfection and Sterilization Guidelines.” That paper’s 14-step protocol still guides how infection prevention teams evaluate a disinfection or sterilization breach, determine transmission risk, and decide how and whether to notify affected patients — a reminder that even as the underlying guidance gets a major update, the process for responding when practice falls short of it hasn’t changed.

The Practical Takeaway

For infection preventionists, sterile processing leaders, and the facilities and EVS teams who support them, this Town Hall’s real value was less in any single new rule and more in the framework it offered for operating amid genuine, acknowledged uncertainty. The 2025 multisociety guidance is more forthcoming than prior documents about where the evidence stops, which means facilities can no longer treat a “no recommendation” designation as someone else’s problem to solve. The five-step MIFU resolution process and the structured risk-assessment approach to guidance gaps both point toward the same conclusion: local, well-documented, multidisciplinary decision-making — grounded in the regulatory hierarchy, weighed against real transmission risk, and ideally shared back with the field — is now an explicit and expected part of the reprocessing quality program, not a workaround for when the guidance falls short.

This article is based on SHEA’s April 2026 Town Hall webinar, part of the “Safe Healthcare for All” series, featuring presentations by Katie Passaretti, MD (Advocate Health) and Emily Sickbert-Bennett, PhD, MS, CIC, FSHEA (UNC Health), with panelists Bernard Camins, MD (Mount Sinai), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University). Full citations are available in the original SHEA presentation.

MARCH 2026

The Right Test, Right Patient: SHEA’s March Town Hall Makes the Case for Diagnostic Stewardship

SHEA’s March 2026 Town Hall turned to a discipline that operates one step upstream of antimicrobial prescribing entirely: the decision to order a test in the first place — and made the case, through a real institutional case study on advanced molecular sequencing, for why that decision deserves its own stewardship infrastructure.

Antimicrobial stewardship asks whether a drug is the right choice once an infection is suspected or confirmed. Diagnostic stewardship asks the question that comes before that one: whether the test that led to the suspicion, or the diagnosis, was the right test to order, on the right patient, at the right time. SHEA’s March 2026 Town Hall webinar, part of the Society for Healthcare Epidemiology of America’s “Safe Healthcare for All” series, devoted its session to that upstream discipline, with Dan Morgan, MD, MS — Director of the Center for Innovation in Diagnosis at the University of Maryland School of Medicine and the VA Maryland Healthcare System — walking through both the conceptual case for diagnostic stewardship and a detailed, real-world example of what building a program around it actually looks like. Panelists Bernard Camins, MD (Mount Sinai), Katie Passaretti, MD (Advocate Health), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University) were joined by invited panelist Dan Diekema, MD (University of Iowa Carver College of Medicine) for the discussion.

What Diagnostic Stewardship Actually Means

Morgan grounded the talk in a definition he helped establish nearly a decade ago: diagnostic stewardship, as described in a 2017 JAMA viewpoint he co-authored with Preeti Malani and Dan Diekema, is coordinated guidance and interventions to improve appropriate use of microbiological diagnostics, in order to guide optimal treatment decisions — covering test ordering, collection, and reporting. That framing matters because it positions diagnostic stewardship as something broader than “test less.” A 2023 conceptual model published in Infection Control & Hospital Epidemiology by Fabre and colleagues makes the same point visually, mapping the full arc a specimen travels — pre-analytic decision-making, test ordering, specimen collection and transport, the analytic process itself, and post-analytic interpretation and reporting — as a cycle that surrounds two constants: the patient, and the institutions and systems the testing process runs through.

The goal Morgan described is optimization, not restriction for its own sake. Sometimes that means decreasing overuse — the classic example being urine cultures ordered without a clinical indication for one. Sometimes it means assuring a needed test actually gets used, such as rapid blood identification or timely HIV testing. And sometimes, counterintuitively, stewardship means adopting a newer, more expensive test — a multiplex molecular panel, say — because it gets a clinician to the right answer faster than the cheaper alternative would. In every case, the north star is the same: better patient outcomes, not a lower testing bill. Morgan illustrated the reframe with an analogy to the car safety movement — seatbelts, blind-spot detection, and crash testing didn’t make driving impossible, they made it survivable by engineering guardrails into a behavior people were going to keep doing anyway. Diagnostic stewardship, in his telling, is the same move applied to test ordering: not eliminating the test, but engineering the systems around it so the right test reaches the right patient.

The Evidence That a Test Order Matters as Much as a Prescription

The clinical stakes behind that framing are already well documented across several specific infection types, Morgan noted, citing a body of published literature connecting diagnostic stewardship interventions to measurable downstream effects on both NHSN-reportable healthcare-associated infections and antibiotic use — spanning catheter-associated urinary tract infection, C. difficile infection, and central line-associated bloodstream infection specifically. The citations he pointed to — including Trautner, et al. in JAMA Internal Medicine (2015), Mullin et al. in ICHE (2017), Rock et al. in Clinical Infectious Diseases (2022), Woods-Hill et al. in JAMA Pediatrics (2022), Vaughn et al. in JAMA Internal Medicine (2023), and his own 2023 JAMA commentary — collectively make the point that how and when a culture gets ordered is not a laboratory-workflow footnote. It’s a variable that shows up directly in infection surveillance data and antibiotic utilization, which puts diagnostic stewardship squarely inside the same outcomes infection prevention and antimicrobial stewardship programs are already accountable for.

Morgan also connected the discipline to a newer federal framing: the CDC’s Core Elements of Diagnostic Excellence, or DxEx, which consolidates a range of previously separate efforts under three overlapping goals — reducing over-testing and overdiagnosis, promoting diagnostic stewardship specifically, and preventing missed, delayed, and mis-diagnosis. He noted that CDC is actively looking for hospital examples to build out a new series supporting DxEx programs — exemplary diagnostic stewardship or diagnostic excellence programs, ideally spanning multiple tests and organized as a committee or full program, with documentation of which tests were addressed, what impact resulted, how the program was built, and who staffs and funds it. That CDC is still actively soliciting examples is itself telling: unlike antimicrobial stewardship, which has three decades of accumulated program models and CMS Conditions of Participation behind it, diagnostic stewardship is still in the phase of collecting its own case studies.

A Case Study in Real Time: Stewarding Advanced Molecular Testing

Rather than stay at the level of principle, Morgan walked the Town Hall attendees through a detailed, scenario-based case study built around one specific test: plasma metagenomic next-generation sequencing, commercially available as the Karius test, which sequences microbial cell-free DNA circulating in a patient’s blood plasma. The workflow, as he laid it out, runs from a standard 5-mL blood draw in a plasma preparation tube, through DNA extraction and library preparation, to sequencing of microbial cell-free DNA, analysis against a curated pathogen database, and finally a report quantifying clinically relevant pathogens detected.

The scenario opened with a familiar pressure point: a lab director reporting that plasma mNGS has become the fastest-growing send-out test at her institution, that its cost is mostly absorbed by the lab rather than billed cleanly, and that after reviewing a subset of cases, she’s worried the results aren’t changing therapy — or, worse, are actively misleading clinical teams. That concern is not hypothetical. Real published data on 1,000 Karius tests performed at UCLA, cited during the session, found no clinical impact in 82% of cases — most commonly because the result simply wasn’t acted upon, or because it only confirmed a diagnosis already established by other means. Only 16% of tests had a positive clinical impact, whether by establishing a new diagnosis, prompting additional workup that changed management, or enabling de-escalation of therapy; a further 2% had a documented negative impact, including unnecessary additional workup or treatment. Positive impact wasn’t randomly distributed, either — it was significantly associated with clinical concern for a fastidious, zoonotic, or vector-borne pathogen, and with suspected culture-negative endocarditis, two categories where standard culture-based diagnostics are known to underperform.

When New Diagnostics Complicate the Old Definitions

The case study then introduced what Morgan called an unwelcome wrinkle, and it is arguably the piece of this Town Hall most directly relevant to infection prevention practice. Two ICU patients with central venous catheters in place tested positive on Karius — one for Enterococcus, one for Candida glabrata. Both had multiple negative standard blood cultures, but none of those cultures had been drawn within the two-day window that central line-associated bloodstream infection surveillance criteria require. The infection preventionist raising the case wanted to know two things: do these cases meet NHSN CLABSI criteria, and does the institution now need to conduct a broader look-back for cases it may have missed by not testing this way before.

That scenario is a clean illustration of a problem diagnostic stewardship exists to manage: a new, more sensitive diagnostic modality doesn’t just generate more information, it can generate information that doesn’t map cleanly onto surveillance definitions built around older, less sensitive testing methods. A positive mNGS result sitting alongside negative cultures that weren’t timed to satisfy a definition originally written for culture-based diagnosis creates exactly the kind of ambiguity that can distort HAI reporting — either by manufacturing false positives against definitions never designed to accommodate this data, or by exposing genuinely missed cases that cruder testing simply never would have caught. Either direction has real consequences for a facility’s reported infection rates.

What Works: Restriction, Review, and the University of Utah Model

Morgan framed the range of institutional responses to that kind of pressure as a spectrum, from restricting the test to infectious disease approval only, to restricting it to laboratory director approval, to convening stakeholders to build literature-informed use criteria embedded directly into clinical decision support, to simply leaving the test open while accumulating institutional data for publication. The data he presented argues fairly clearly for the more structured end of that spectrum. Comparing clinical impact of mNGS testing under three levels of institutional oversight, positive clinical impact rose from 5.6% with no review at all, to 15.9% under manual ID review, to 17.8% under EMR-based ordering restriction — while the negative-impact rate simultaneously declined, from 11.1% down to 9.1%. Restricting who can order the test, in other words, didn’t just reduce volume; it measurably improved the ratio of results that actually helped patients.

The University of Utah’s approach, led by Kim Hanson, MD, MHS, was offered as a concrete model of that principle in practice: an ID consult requirement built directly into clinical decision support, limited to specific indications — deep-seated infection or opportunistic pneumonia where invasive sampling isn’t feasible, suspected culture-negative endocarditis, and suspicion for a fastidious or zoonotic pathogen — paired with an order set that defaults to “collect and hold” pending that review rather than processing automatically. That combination pushed the positive clinical impact rate to roughly 33%, roughly double the UCLA cohort’s unrestricted rate.

Building a Program: Stakeholders, Workflow, and What Comes Next

Generalizing beyond the single-test case study, Morgan sketched a framework for stewarding advanced molecular testing across the full arc of the diagnostic process, drawing on a 2024 American Society for Microbiology Laboratory Practices Subcommittee report (Valencia-Shelton et al., Journal of Clinical Microbiology) and a companion review on syndromic molecular panels (Hitchcock, et al., Journal of Applied Laboratory Medicine, 2024). Pre-analytic interventions include education, clinical decision support, and order restriction; analytic interventions include refining lab technique, adopting alternative methods, or moving to panels with fewer or more customized targets; post-analytic interventions include suppressing certain targets from the report, adding interpretive comments or clinical nudges, and structured clinical correlation and result review. A companion implementation workflow from the same Valencia-Shelton paper organizes this work into three sequential stages — assess, implement, and monitor — running from identifying candidate tests and gathering measurable data, through securing stakeholder agreement on goals and activating an intervention, to tracking defined metrics at set intervals and either taking corrective action or feeding results back into continuous review. The workflow’s own explicit warning is worth repeating: stopping at any one stage without progressing to the next results in the loss of effective diagnostic stewardship. A program that only assesses, or only implements without monitoring, isn’t a partial win — it’s a program that doesn’t function.

None of this, Morgan emphasized, is a laboratory-only or infectious-disease-only effort. The stakeholder map he presented spans antimicrobial stewardship, infection prevention, information technology, the laboratory itself, clinical teams, institutional leadership, and patients — and he was candid that the right approach will vary meaningfully by institution, which is exactly why sharing successful models across facilities matters as much as building any one of them. Looking ahead, he named four priorities for the field: establishing and expanding diagnostic stewardship programs generally; building better stewardship specifically around advanced molecular diagnostics like the mNGS case study just presented; extending stewardship attention beyond acute care into clinics, long-term care, home health, and direct-to-consumer testing, where oversight infrastructure is thinnest; and effectively incorporating host-response assays as they mature.

The Practical Takeaway

This Town Hall’s central lesson is that the testing decision itself — not just the treatment decision it triggers — is now a recognized point of intervention, with its own emerging evidence base, its own CDC framework, and its own implementation science. The CLABSI ambiguity raised mid-session is a preview of a broader dynamic: as more sensitive molecular diagnostics enter routine use, infection prevention teams should expect more cases where a positive result and a surveillance definition don’t line up cleanly, and will need a seat at the table — alongside stewardship, laboratory, and IT colleagues — when institutions decide how to resolve that ambiguity. The University of Utah data makes the underlying case plainly: unrestricted access to a powerful new test does not automatically produce better care. Structured review, embedded criteria, and multidisciplinary ownership do.

This article is based on SHEA’s March 2026 Town Hall webinar, part of the “Safe Healthcare for All” series, featuring a presentation by Dan Morgan, MD, MS (University of Maryland School of Medicine and VA Maryland Healthcare System), with panelists Bernard Camins, MD (Mount Sinai), Katie Passaretti, MD (Advocate Health), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University), and invited panelist Dan Diekema, MD (University of Iowa Carver College of Medicine). Full citations for the studies referenced are available in the original SHEA presentation.

FEBRUARY 2026

Outside the Hospital’s Walls: SHEA’s February Town Hall Confronts the Ambulatory Infection Prevention Gap

Care has moved out of the hospital faster than infection prevention infrastructure has followed it — and SHEA’s February 2026 Town Hall spent its full session documenting exactly how wide that gap has grown, from outbreak data in ambulatory surgery centers to a central-line bloodstream infection problem hiding in plain sight in home infusion.

Outpatient visits are up more than 30% over the past two decades. Ambulatory surgery centers have absorbed a wave of procedures that used to require an inpatient stay. Hospital-level care is now routinely delivered in patients’ own homes — 419 hospitals across 147 health systems in 39 states had a hospital-at-home program as of September 2025, according to American Hospital Association data. And yet, as SHEA’s February 2026 Town Hall webinar made clear, that growth has mostly outrun the infection prevention resources built to match it. The session, part of the Society for Healthcare Epidemiology of America’s “Safe Healthcare for All” series, paired two presentations: Katie Passaretti, MD, chief infection prevention officer at Advocate Health, surveyed the scope of the ambulatory risk landscape using outbreak data, central-line surveillance gaps, and her own health system’s staffing response; Rebecca Stern, MD, medical director of adult ambulatory infection prevention at Vanderbilt University Medical Center, followed with a sharper look at the regulatory and surveillance gaps specific to ambulatory care and three concrete VUMC programs built to close them. Panelists Bernard Camins, MD (Mount Sinai), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University) joined the discussion, with Dr. Stern doubling as both presenter and invited panelist.

The Risk Has Moved Outpatient Faster Than the Infrastructure Has

Passaretti opened by naming the shift plainly: a growing share of healthcare-associated infection risk now sits outside acute-care walls entirely, in a landscape of clinics, ambulatory surgery centers, infusion centers, hemodialysis units, and home care — the very definition of a “shifting risk portfolio.” The drivers are structural and unlikely to reverse: chronic disease management in an aging population, procedural technology that keeps getting less invasive and more same-day, and a straightforward cost incentive pushing health systems to invest in outpatient capacity. The complication, as she put it, is that this growth has arrived with often limited trained infection prevention support and dedicated resources — the ambulatory setting has scaled in volume and complexity without scaling the workforce built to protect it.

What the Outbreak Data Already Shows

The evidence that this gap has real consequences is not theoretical. Passaretti cited a nationwide analysis of public health investigations from August 2019 through July 2023 (Penna et al.) finding that 8% of health department outbreak investigations involved one or more outpatient settings, and that 70% of those — 230 investigations — occurred exclusively in outpatient settings, with dental practices (17%), ambulatory surgery (9%), and urology (9%) the most frequently implicated. Infection prevention breaches were identified in 68% of the HAI investigations reviewed, and device reprocessing breaches were the single most common failure type. A companion heat map presented during the talk illustrated just how broad the exposure is: novel or targeted multidrug-resistant organisms and reportable pathogens — from carbapenem-resistant organisms and Candida auris to mpox, hepatitis B and C, and nontuberculous mycobacteria — turning up across dental offices, home care, urology clinics, wound care centers, hemodialysis units, and primary care alike.

A specific ambulatory surgery center case study made the mechanism concrete. Whole-genome sequencing linked two ambulatory surgery centers to 17 Mycobacterium fortuitum surgical site infections following hip and knee procedures — nine organ-space, five deep, three superficial — with symptoms surfacing anywhere from 5 to 306 days after the procedure, a lag that itself explains why outpatient infections are so difficult to trace back to their source before they’ve already spread further. Root-cause review at both centers (Godwin et al., Infection Control & Hospital Epidemiology, 2025) turned up strikingly ordinary process failures rather than anything exotic: an absent water management plan, inadequate operating-room cleaning and unsatisfactory terminal cleaning between patients, missed hand hygiene, noncompliance with PPE policy including head and beard coverings, and — at both centers independently — a breakdown in point-of-use treatment of surgical instruments before they reached sterile processing.

The Central-Line Blind Spot

Central-line-associated bloodstream infections that originate outside the hospital surfaced as a particularly stark example of a surveillance system built for the wrong setting. A multicenter study (Oladapo-Shittu et al., Clinical Infectious Diseases, 2024) identified 461 patients across three health systems and 11 hospitals presenting on admission with a CLABSI tied to a central venous catheter maintained outside acute care — nearly a third linked to home infusion therapy, another third to oncology clinic maintenance. A quarter of these patients had already had a prior CLABSI, 11% died during that hospital admission, and mortality risk climbed with age and lack of insurance while falling with catheter removal. The study’s own conclusion was direct: this infection burden is significant, and surveillance and targeted prevention initiatives are needed specifically outside acute-care settings, where none of the standard NHSN infrastructure currently reaches.

That gap is not unsolvable, though. Home infusion CLABSI rates run roughly 0.2 to 0.24 per 1,000 catheter-days, and a newer study (Hannum et al., Infection Control & Hospital Epidemiology, 2026) found that introducing a standardized dashboard and prevention toolkit across multiple home infusion agencies measurably brought rates down over time — proof that the same kind of measurement infrastructure hospitals take for granted can work in the home setting once someone builds it.

Naming the Barriers

Passaretti organized the underlying obstacles into eight named categories: scope (site count, geographic spread, pace of growth, evolving services), fragmented ownership (variable oversight and leadership, contracted or outsourced services), weak measurement and feedback (no standardized outpatient HAI metrics or denominators, and infections that are often only detected later, at a different facility entirely), lean staffing and turnover, workflow and space constraints, high-complexity tasks (high-level disinfection and sterilization processes that are unforgiving of shortcuts, now often decentralized into smaller sites), environmental variability (uncontrolled environments and caregiver-dependent care), and culture and communication — an “it’s not a hospital” mindset paired with unreliable reach of updates and education to a workforce spread across many sites.

Staffing data backed up the scale of the problem. A survey of 238 pediatric ambulatory and procedural sites (Weir et al., American Journal of Infection Control, 2025) found half had at least one complexity indicator and 9% had three or more, that infection preventionists covering these sites logged 181 hours per week collectively, and that the calculated staffing need across the surveyed sites came to 4.5 FTE — with consultation work alone consuming the largest single share of that time, well ahead of environment-of-care rounding, meetings, surveillance, policy work, projects, and professional development combined. Advocate Health’s own response was offered as a picture of what adequately resourced ambulatory infection prevention can look like at scale: more than 2,800 clinics covered by a dedicated team of 14 infection preventionists and 3.5 sterile processing specialists, a risk-tiering system, and an enterprise rounding and dashboard tool tracking compliance across categories including equipment management, cleaning, high-level disinfection, and sterilization. Notably, the dashboard’s own numbers showed sterilization compliance (81%) and administrative practices (80%) trailing every other category — an honest signal, even within a well-resourced program, of where the next round of attention needs to go.

A Parallel Track: Stewardship Outside the Hospital

The session also surfaced a growing body of ambulatory antimicrobial stewardship evidence running alongside the infection prevention data, and the throughline was consistent: passive interventions underperform active ones. A 2025 meta-analysis of 56 randomized controlled trials (Xu et al., Clinical Infectious Diseases) found audit and feedback linked to an 11% relative reduction in total antibiotic volume and fewer unnecessary or broad-spectrum starts in primary care. A cluster-randomized trial (Jeanmougin et al., Journal of Medical Internet Research, 2024) found a feedback visit outperformed clinical decision support paired with feedback, with no measurable benefit from feedback alone versus control — a reminder that CDSS by itself is not a substitute for direct feedback. Mailed peer-comparison feedback reduced prescribing across all age groups, not just the clinicians directly targeted, and cut prolonged courses as a secondary effect (Saqib et al., JAMA Network Open, 2025). In urgent care, a “Take 5” campaign promoting short-course defaults produced an 11% increase in guideline-concordant courses of five days or less (Jenkins et al., Open Forum Infectious Diseases, 2025), while tele-stewardship’s effects on outpatient antibiotic use remained described as variable rather than settled (Sanchez et al., Telemedicine and e-Health, 2024; Laein et al., PLOS ONE, 2025). And order sets paired with an awareness campaign shifted community-acquired pneumonia treatment patterns without producing an overall improvement in guideline concordance — evidence, the presenters noted, that stronger tactics such as audit and feedback are still needed on top of order sets alone (Asempa et al., Antimicrobial Stewardship & Healthcare Epidemiology, 2025).

Vanderbilt’s Emerging-Issues Checklist and Three Programs to Learn From

Stern’s presentation opened with a distinction she wanted the audience to sit with: inpatient does not equal outpatient. The same drivers Passaretti named — chronic care, an aging population, minimally invasive and same-day procedural technology, lower cost, fewer resources, and active health-system investment — are reshaping an evolving landscape spanning clinics, ambulatory surgery centers and office-based procedures, infusion centers, hemodialysis, and home care, across both academic and community health systems, each with its own operational logic.

She organized the field’s open gaps into four domains. On regulation, facility licensing and accreditation remain highly variable, and Joint Commission citations for noncompliance — including manufacturer’s instructions for use violations — are increasingly concentrated in ambulatory settings, arguing for aligning ambulatory MIFU policy and practice with inpatient standards rather than treating them separately. On HAI surveillance, ambulatory reporting to NHSN simply isn’t required in most cases, validated infection definitions are largely absent outside CLABSI in home infusion and a pediatric CLABSI definition extrapolated from the Solutions for Patient Safety collaborative, and basic questions about denominator capture, cross-system benchmarking, and incentives remain unanswered. Ambulatory surgery centers face their own specific gap: NHSN’s outpatient procedure component for surgical site infection surveillance is voluntary in most states and doesn’t apply to all ASCs. And on high-level disinfection, sterilization, and communicable disease control, the challenges Passaretti had already outlined — decentralized reprocessing, declining vaccination rates, inconsistent exposure and outbreak tracking across settings and EMRs, a lack of negative-pressure rooms for measles or tuberculosis, and real confusion about how to handle multidrug-resistant and extensively drug-resistant organisms and C. auris in a clinic setting — recurred as unresolved. Layered underneath all of it: limited ambulatory-specific guidance from professional societies, and chronic underfunding of the FTEs, dollars, and healthcare worker and IP resources the field needs. Stern’s call to action followed directly from that list: conduct risk assessments, advocate for investment in ambulatory infection prevention and control, and build a national network for shared resources and strategies — anchored, concretely, in SHEA’s own Ambulatory Special Interest Group.

Three VUMC-specific programs were offered as answers already in progress. First, an ambulatory COVID-19 isolation study (Stern, Bashaw, Shackelford, and Talbot, Infection Control & Hospital Epidemiology, 2025) found that PPE guidance, staff education, and a symptom check-in list flagged 60 of 197 walk-in clinic encounters — 30.4% — as requiring isolation, adding an average of 2.15 minutes of donning and doffing time per flagged encounter, or 3.9 minutes per patient encounter requiring PPE overall, totaling roughly 1.3 hours of added staff time daily system-wide. That data supported a deliberate de-escalation: VUMC dropped the routine gown-and-glove contact-precaution requirement for ambulatory COVID-19 care, while preserving full precautions for bronchoscopy and other aerosol-generating procedures. Second, a phased ambulatory isolation guidance rollout paired a refined communicable-disease screening tool — built into patient check-in and flagged through the EMR — with a detailed, condition-by-condition isolation reference specifying airborne, contact, droplet, eye-protection, and environmental-cleaning requirements across more than 20 named conditions, all consolidated into an “Ambulatory Isolation Toolkit” covering signage, EMR alerting, cleaning guidance, and point-of-care testing and specimen-transport guidance for frontline staff. Third, an environment-of-care survey flagged platelet-rich plasma therapy as a large-scope, high-risk procedure with no existing professional society guidance and highly variable technique across sites — prompting Stern’s group to publish a standardized five-stage process spanning room and tray setup, specimen collection and transport, centrifugation, treatment administration, and disposal and cleaning, all anchored in hand hygiene, standard precautions, aseptic technique, universal protocol, and EMR documentation as common core practices throughout (Stern, Andrews, Bashaw, and Talbot, Infection Control & Hospital Epidemiology, 2025). The session closed with an open invitation to join the SHEA Ambulatory Special Interest Group — a plain acknowledgment that this corner of the field is still building its own shared infrastructure from scratch.

The Practical Takeaway

This Town Hall’s takeaway is that every discipline hospitals already have dedicated programs, metrics, and staffing benchmarks for — surveillance definitions, cleaning and disinfection verification, sterile processing oversight, isolation and PPE protocols — now needs to be rebuilt, largely from zero, for a fundamentally different set of physical environments: ambulatory surgery centers, infusion suites, dialysis units, and patients’ own homes. The outbreak and surveillance data presented make clear that the risk in these settings is real and already measurable where anyone has bothered to measure it; what’s missing, consistently, is the infrastructure to see it before it becomes an outbreak investigation. Both presenters converged on the same prescription: build the dashboard, the staffing benchmark, and the standardized isolation guide before the gap forces the issue.

This article is based on SHEA’s February 2026 Town Hall webinar, “Emerging Issues in Ambulatory Infection Prevention,” part of the “Safe Healthcare for All” series, featuring presentations by Katie Passaretti, MD (Advocate Health) and Rebecca Stern, MD (Vanderbilt University Medical Center), with panelists Bernard Camins, MD (Mount Sinai), Chris Nyquist, MD (Children’s Hospital Colorado), and Tom Talbot, MD (Vanderbilt University). Full citations for the studies referenced are available in the original SHEA presentation.