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The globalization of antibiotic stewardship programs is necessary in the fight against antibiotic resis&shy;tance.

Globalization of Antibiotic Stewardship Programs: The World Is Waiting

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

UNC’s Benjamin Smith, MD, provides some insights into the logistics and steps behind these complicated and serious missions.

Transporting High-Consequence Infectious Disease Patients to Special Treatment Centers

, where we spotlight individual medical institutions and infectious disease (ID) programs. Today, we spotlight the University of North Carolina (UNC)’s Institute for Global Health and Infectious Diseases.

When the call comes in that a patient with a suspected high-consequence ID (HCID) needs to be transported, UNC’s Benjamin Smith, MD, is contacted. Smith is a board certified emergency medicine physician and the medical director for Carolina Air Care, which is a specialty transport program for UNC Health. Their fleet has multiple rotor-wing aircraft and ground ambulances.

In addition to Smith being contacted in such a scenario, leadership at the UNC Special Pathogens Response Center (SPARC) at UNC Hospitals is alerted. Whoever is on call at that moment, including 

William A. Fischer II, MD; or David Wohl, MD,

 will work with Smith and other local and state health agencies to assess the patient based on suspicion of symptoms or tests and whether they need to elevate the seriousness of the transport. If they deem the patient may have an HCID, then several steps take place to prepare for transport and to receive the patient.

Within UNC’s hospital, they need to set up a biocontainment area, which likely involves moving some patients out of the space. Laboratory technicians set up a specialty laboratory so they can run tests for the patient.

And as with any important project, communication is key and members of the emergency department become involved.

"All the people who are involved in emergency management, emergency preparedness, and emergency response, they'll know what's going on,” Smith said. “They'll help coordinate. That includes our communications department, but it's really communicating within the hospital to the other people who are there working—but also the community at large—if needed. I imagine this would be something that would probably make the news, and so [it's about] making sure that our community understands that we're here to keep them safe.”

“Behind the scenes, we'll start coordinating logistics of what providers [are involved], and nurses will be at the bedside to care for the patient when that initial phone call comes in,” Smith said. “We also have flight watch, which is our communication center for air care. Air care will also be looped in to start coordinating logistics of moving the patient.”

If it is a ground transport, Smith’s role is to go with a crew in a chase vehicle, providing support and oversight to the team during the transports. He will have personal protective equipment (PPE) just in case he needs to administer clinical care at the bedside.

Ultimately, UNC’s teams have the training and on-the-ground experience to handle such serious situations.

For example, earlier this summer, UNC's SPARC team conducted a test for a patient with HCID using a mannequin. This training exercise focused on "interdisciplinary coordination among pediatric specialists, infectious disease experts, and transport teams. The simulation also included a mock surgical procedure within the biocontainment unit, allowing the team to exercise infection control, communication, and clinical workflows required to safely perform emergency interventions in a high-risk environment."

Smith participated in this exercise with not only a mannequin patient but actors as well. "We did like we do in real life, where we would activate our receiving area, activate our team air care, get our ambulance ready, and so we went and met the patient out at RDU [Raleigh-Durham International Airport] on the tarmac to transfer the patient from the back of the aircraft to our ambulance,” Smith said. “In this case, [we] also transitioned them from the transport ventilator to our transport ventilator, transported their drips to our drips, packaged the patient in our ambulance, and then took them back over here to UNC and did that patient handoff.”

“We can really take any patient with any illness from wherever, and we bring the expertise of UNC out to that patient, whether it's at a referring hospital or on the side of the road,” Smith said.



In the next episode, Joseph Eron, MD, discusses UNC’s clinical trial research, including the PURPOSE study.

1. Tranquil Passport: testing the nation’s special pathogen readiness ahead of the FIFA World Cup. National Emerging Pathogens Training and Education Center. July 2, 2025. Accessed August 26, 2025. https://netec.org/2025/07/02/tranquil-passport-testing-the-nations-special-pathogen-readiness-ahead-of-the-fifa-world-cup/

Transporting Patients With High-Consequence Infectious Disease to Special Treatment Centers

Leaders from the UNC Special Pathogens Response Center (SPARC) discuss how they plan and carry out biopreparedness trainings to address any serious individual episodes of highly infectious patients as well as addressing larger outbreaks.  

Biopreparedness Exercises Look to Address Highly Contagious Disease Outbreaks

, spotlighting individual medical institutions and infectious disease (ID) programs. Today, we spotlight the University of North Carolina (UNC)’s Institute for Global Health and Infectious Diseases (IGHID).

UNC’s Special Pathogens Response Center (SPARC) is one of 13 centers across the US responsible for building regional preparedness. This means these special centers interact and coordinate training with other health care facilities, such as local and regional hospitals, to aid them in dealing with individuals with high-consequence ID (HCID).

“While there is not a standardized definition for [HCIDs] or special pathogens, expert consensus defines these as novel or reemerging infectious agents that are easily transmitted from person to person, have limited or no medical countermeasures (such as an effective vaccine or prophylaxis), have a high mortality, require prompt identification and implementation of infection control activities—for example, isolation, special personal protective equipment—and require rapid notification to public health authorities and special action,” said William A. Fischer II, MD, director of emerging pathogens at IGHID.

 Examples of these would be Ebola virus, SARS-CoV-2, and Middle East respiratory syndrome coronavirus.

“We lead regional trainings to better prepare other health care facilities, because we're trying to make sure that anywhere a patient can present, they are prepared to identify and initiate safe delivery of care and then transfer that individual to a regional treatment center,” Fischer said.

Part of the training is to ensure any necessary quarantining of individuals is done in a way that minimizes the risk to the greater public. To prepare for big events such as the FIFA World Cup in the US next year, national readiness exercises have been conducted this summer for HCID threats.

 These exercises have been named Tranquil Passport and are led by the US Department of Health and Human Services’ Administration for Strategic Preparedness and Response. Specifically, they tested a coordinated national response to an HCID scenario.

In June, UNC's Medical Center SPARC team conducted a test for a patient with HCID using a mannequin. This training exercise focused on "interdisciplinary coordination among pediatric specialists, infectious disease experts, and transport teams. The simulation also included a mock surgical procedure within the biocontainment unit, allowing the team to exercise infection control, communication, and clinical workflows required to safely perform emergency interventions in a high-risk environment."

"The country is in much better shape right now than they were before we did this exercise, because now a lot of us in this country know how to handle this much better," said David Wohl, MD, professor of medicine in the Division of Infectious Diseases at UNC.

As individuals with HCID will not know about these special pathogen centers, these trainings between the centers and the regional hospitals are critical, explained Wohl.

“We really have to prepare this network of regional hospitals,” Wohl said. “One thing that's really important to understand is infectious diseases that are emerging and reemerging are becoming much more common and frequent—and they're becoming bigger in scope.”

He referenced the West Africa Ebola outbreak of 2014 to 2016 that infected over 28,000 people with the deadly disease.

 Wohl said this is massive compared with previous large outbreaks, which were thought of in terms of 100 to 200 people being infected. 

As part of their experience, both Fischer and Wohl have been in hot zones in Africa treating patients who have had Ebola and Lassa fever. They have set up field treatment units during outbreak settings to isolate and care for patients. Their work in Liberia has directly informed emerging pathogen response and preparedness in North Carolina.

 will cover their work in Africa in a future episode.)

Although Ebola has not had an impact in the US, Wohl used mpox as an example that has seen outbreaks in the US in recent years. 

Fischer said the concept of specialized medical centers is not a new one.

“These centers of specialization…parallel what's been done for trauma. They parallel what's been done for sepsis, what's been done for ARDS [acute respiratory distress syndrome],” Fischer said. “If you can develop expertise at specific centers and then educate and increase awareness among all providers, we can then identify individuals who might have a special pathogen, get them to the center of specialty where that specialized care can be provided, and we know that model works.”

In the next episode, Ben Smith, MD, discusses logistical and safety challenges in preparing for the transport of patients with infection from outside facilities to UNC.

References
1. What are the key points to understand when defining processes that support preparedness for high-consequence infectious diseases or special pathogens? Joint Commission. Accessed August 27, 2025. https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000002503
2. Tranquil Passport: testing the nation’s special pathogen readiness ahead of the FIFA World Cup. National Emerging Special Pathogens Training & Education Center. July 2, 2025. Accessed August 26, 2025. https://netec.org/2025/07/02/tranquil-passport-testing-the-nations-special-pathogen-readiness-ahead-of-the-fifa-world-cup/
3. Ebola outbreak 2014-2016. World Health Organization. Accessed August 26, 2025. https://www.who.int/emergencies/situations/ebola-outbreak-2014-2016-West-Africa

Leaders from the UNC Special Pathogens Response Center discuss how they plan and carry out biopreparedness trainings to address transport and care of patients with high-consequence infectious diseases, such as Ebola or Lassa fever.   

Biopreparedness Exercises Look to Contain High-Consequence Infectious Disease Outbreaks

 found that fecal microbiota transplantation (FMT) and standardized microbiome therapeutics such as SER-109 and RBX2660 demonstrate significantly higher cure rates and favorable safety profiles compared with standard antibiotic therapy for recurrent 

Across 7 studies involving 1030 patients, FMT achieved clinical cure rates of 70% to 91%, compared with 23% to 62% for antibiotics or placebo. Donor FMT outperformed autologous FMT (90.9% vs 62.5%; 

 = .042) and standard regimens, including fidaxomicin (33% resolution) and vancomycin (19%; 

< .01). Microbiota-based products showed similar efficacy, with relative risk reduction of recurrence up to 68%. Safety outcomes were favorable over a 5-year follow-up, with most adverse events limited to mild gastrointestinal symptoms and no new safety concerns identified.

The review followed PRISMA 2020 guidelines and included 6 randomized controlled trials and one cohort study published between January 2015 and May 2025. Bias assessments were conducted with the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Heterogeneity in administration routes (capsules vs colonoscopy) and donor material (fresh vs frozen) was noted.

Investigators concluded that FMT and standardized microbiome-based therapies provide highly effective treatment options for patients with recurrent or refractory CDI. They emphasized the need for further research to standardize treatment protocols and evaluate outcomes in higher-risk populations.

This emphasis on microbiome therapies reflects a broader trend in 2025, with multiple studies highlighting both opportunities and challenges. For example, Clemson University researchers reported in 

 that FMT failures may stem less from microbial engraftment and more from functional incompatibility between donor microbes and the recipient gut environment. In mouse models, human donor stool successfully colonized but failed to clear 

, whereas mouse donor stool proved effective. These findings help explain why up to 10% of rCDI patients do not respond to FMT, and why failure rates are even higher in more complex conditions such as inflammatory bowel disease or irritable bowel syndrome.

In addition, a large real-world cohort study from Aarhus University Hospital examined more than 1100 adults treated with FMT between 2016 and 2023. The most successful strategies involved administering FMT via multiple-dose capsules or colonoscopy after prolonged antibiotic pretreatment, with repeated FMT outperforming antibiotics alone for recurrent cases. Overall, 81% of patients achieved cure by 8 weeks, supporting clearer guidance on FMT dosing, delivery, and pretreatment duration.

Together, these studies illustrate a consistent trend in rCDI research this year: while FMT and microbiome-based products are proving highly effective and generally safe, optimizing their functional compatibility, delivery strategies, and treatment protocols remains essential for maximizing clinical benefit.

1. Weerakoon S, Avula S, Mandefro BT, et al. Microbiota-based therapies for recurrent clostridium difficile infection: a systematic review of their efficacy and safety. 

. 2025;17(8):e90737. doi:10.7759/cureus.90737

2. Landrum, C. Clemson research could lead to improved treatment for C. diff and other GI illnesses. Clemson University, College of Science. June 16, 2025. Accessed August 24, 2025. 

https://news.clemson.edu/clemson-research-could-lead-to-improved-treatment-for-c-diff-and-other-gi-illnesses/

3. Paaske SE, Baunwall SMD, Rubak T, et al. Clinical management of Clostridioides difficile infection with faecal microbiota transplantation: a real-world cohort study. 

. 2025;85:103302. doi:10.1016/j.eclinm.2025.103302

Systematic review finds FMT and standardized microbiome products outperform antibiotics in efficacy and safety.

Microbiota-Based Therapies Show Superior Outcomes for Recurrent C difficile Infection

This article was originally published on our sister-site, 

New research is shedding light on the need for 

 strategies beyond antibiotic stewardship, highlighting antibiotic exposure’s minimal impact on infection risk in asymptomatic carriers.

The retrospective cohort study examined more than 33,000 hospitalizations among 23,001 patients and found asymptomatic carriers had a greater hazard of CDI, with antibiotic exposure, particularly to amoxicillin and clavulanate and piperacillin and tazobactam, linked to increased infection risk. Of note, antibiotic exposure was not significantly associated with additional hazard among carriers, suggesting antibiotic stewardship may not effectively reduce CDI risk in this population.

According to the US Centers for Disease Control and Prevention, 

, a bacterium that causes diarrhea and colitis, is estimated to cause almost half a million infections in the US each year. Receipt of certain antimicrobials is associated with increased susceptibility to CDI.

, ie, individuals with positive test results for the bacterium without exhibiting symptoms, present unique challenges in health care settings. These carriers not only act as potential reservoirs for transmission but also are at an elevated risk of progressing to clinical CDI,” Mayan Gilboa, MD, Infectious Control Unit, Sheba Medical Center in Israel, and colleagues wrote.

 “However, the specific interactions among antibiotic use, type, and duration of treatment in this high-risk group remain poorly understood.”

To evaluate the risk of CDI among asymptomatic carriers vs noncarriers of 

 and whether it is associated with antibiotic exposure, investigators conducted a retrospective cohort study between June 2017 and June 2023, assessing hospitalizations from Sheba Medical Center in Ramat Gan, Israel, a center that routinely screens for 

 in high-risk patients admitted to internal medicine.

Eligible patients were adults who were hospitalized in internal medicine wards and deemed high risk for 

 carriage due to reasons like hospitalization within the past 6 months or transfer from another hospital or a long-term-care facility.

All patients were followed up from 2 days after hospitalization until death, discharge, day 21 of the hospitalization, admission to the ICU, or CDI, whichever was earliest. The primary outcome was the development of CDI, as confirmed by laboratory testing for 

. Antibiotic exposure was assessed as a time-varying variable.

In total, the study included 33,756 hospitalizations among 23,001 patients, the majority of whom were male (52.8%) with a median age of 78 (interquartile range [IQR], 68-87) years. A total of 1624 (4.8%) admissions had a positive screening result for 

 and were defined by investigators as carriers.

Overall, 67 of 1624 (4.1%) carriers and 47 of 32,132 (.1%) noncarriers with negative screening results developed CDI.

Among carriers, 251 CDI tests were sent (15.5%) compared with 2067 tests among noncarriers (6.4%). Despite more frequent testing in carriers, investigators noted the positivity rate was markedly higher at 26.7% (67 of 251) in carriers vs 2.3% (46 of 2067) in noncarriers.

Among the entire cohort, exposure to any antibiotic was associated with an increased risk of CDI (HR, 1.98; 95% CI, 1.24-3.16), with each additional day of exposure to antibiotics having an HR of 1.08 (95% CI, 1.03-1.13). Exposure to piperacillin and tazobactam was associated with increased risk (HR, 2.18; 95% CI, 1.41-3.36), with each additional day having an HR of 1.13 (95% CI, 1.07-1.20).

 screening result at admission was associated with a high risk of infection (HR, 27.5; 95% CI, 18.7-40.3). Among asymptomatic carriers, investigators pointed out that antibiotic exposure was not significantly associated with a further increase in CDI hazard (HR, 1.07; 95% CI, .73-1.58).

“While antibiotic stewardship is crucial for reducing CDI in general, additional approaches are needed for carriers to mitigate their substantially high baseline risk,” investigators concluded.

 “Further research should explore modifiable factors beyond antibiotic use to improve outcomes in patients with CDI and to reduce the overall burden of CDI in health care settings.”

1. Gilboa M, Regev-Yochay G, Meltzer E, et al. Antibiotic use and the risk of hospital-onset 

2. US Centers for Disease Control and Prevention. About C. diff. December 18, 2024. Accessed August 11, 2025. 

https://www.cdc.gov/c-diff/about/index.ht

C difficile carriers faced a higher baseline risk for hospital-onset infection compared to noncarriers, and this risk was not significantly influenced by antibiotic use.

Antibiotic Stewardship Alone May Be Insufficient for Preventing C Diff Infections

Christopher Sellers, MD, discusses its distinct program and diverse professional opportunities as well as many ID trainees and fellows stay at the University of North Carolina (UNC). 

UNC’s Infectious Disease Program Provides Diverse Career Paths

, where we spotlight individual medical institutions and infectious disease (ID) programs. Today, we spotlight the University of North Carolina (UNC)’s Institute for Global Health and Infectious Diseases (IGHID).

Christopher Sellers, MD, discusses its distinct program and diverse professional opportunities and provides some insights as to why many ID trainees stay at the University of North Carolina. 

ANGELIKI MESSINA, MSPHARM, BSPHARM

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