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By stopping unnecessary antibiotics before they start, clinicians can avoid unnecessary harm to the patient and the population. 

"Antibiotic Never Events": The Ideal Target to Reduce Antimicrobial Exposure

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

This article was originally published on our sister site, 

Use of an artificial intelligence (AI)–guided infection prevention bundle may support 

 prevention and antimicrobial stewardship in hospital settings, according to findings from a recent study.

The prospective, single-center quality improvement study was conducted at Michigan Medicine, the academic medical center affiliated with the University of Michigan, and compared patient outcomes before and post implementation of a previously validated institution-specific AI model for CDI risk prediction. Results showed that although use of the AI bundle was not associated with a significant reduction in CDI incidence, it was linked to substantial reductions in CDI-associated antimicrobial use.

“Numerous artificial intelligence models have been developed to predict CDI risk in hospitalized patients with the goal of identifying high-risk patients who may potentially benefit from targeted infection prevention resources,” Jenna Wiens, PhD, an associate professor of computer science and engineering at the University of Michigan in Ann Arbor, and colleagues wrote.

 “Although these models have shown promise in prospective validation and in identifying patients prior to colonization, their association with patient outcomes in clinical care remains unknown.”

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 United States each year.

 can live on people's skin and is resistant to alcohol-based hand sanitizers, effective CDI prevention often includes handwashing with soap and water. Receipt of certain antimicrobials is also associated with increased susceptibility to CDI.

Applying these practices at scale can be challenging due to resource constraints at most hospitals, necessitating targeted prevention efforts for patients at the greatest risk of acquiring CDI.

To evaluate the association between an AI-guided infection prevention bundle and CDI incidence in a hospital setting, investigators evaluated adult inpatient hospitalizations before and after the integration of a previously validated institution-specific AI model into clinical workflows at Michigan Medicine. The CDI risk score is calculated by an L2-regularized logistic regression model with time-varying parameters and leverages routinely collected electronic health record data to estimate the daily risk of a patient acquiring CDI in the remainder of their hospitalization.

The pre-AI period was from September 2021 to August 2022, and the post-AI period was from January to December 2023. Of note, investigators excluded the 4-month implementation rollout period from September 2022 to December 2022 from the analysis.

The primary outcome was CDI incidence rate. Secondary outcomes included antimicrobial use and qualitative assessments of bundle implementation.

Pre- and post-AI samples included 39,046 and 40,515 hospitalizations, respectively. In the pre-AI group, the majority of patients were female (55.4%) and White (78.8%) with a median age of 58 (IQR, 36-70) years. In the post-AI group, the majority of patients were female (55.7%) and White (79.6%) with a median age of 58 (IQR, 37-70) years. Investigators called attention to significant differences in age, COVID-19–related hospitalizations, and recent hospitalization history between the groups.

There were 127 CDI cases for 255,017 patient-days in the pre-AI period and 148 CDI cases for 261,892 patient-days in the post-AI period. After adjusting for differences in clinical characteristics, the incidence CDI rate per 10,000 patient-days was 5.76 (95% CI, 4.87-6.69) in the pre-AI period and 5.65 (95% CI, 4.78-6.56) in the post-AI period (absolute difference, −0.11; 95% CI, −1.43 to 1.18; 

Investigators called attention to significant reductions in the use of ampicillin-sulbactam (−2.82; 95% CI, −4.59 to −1.03; 

 = .03), piperacillin-tazobactam (−9.64; 95% CI, −12.93 to −6.28; 

 < .001), and clindamycin (−1.04; 95% CI, −1.60 to −0.47; 

 = .03), measured in antibiotic days per 1000 days present. Of note, reductions were more prominent in high-risk hospitalizations alerted by the AI tool.

Using qualitative assessments via semistructured interviews and field observations, investigators found health care staff’s experiences with AI-guided workflows varied. Results showed an overall low compliance rate for the enhanced hand hygiene sign whereas pharmacists consistently engaged with the alerts and contacted the patients’ care team based on the alerts.

“Despite limitations of our single-center, quasi-experimental design, the insights gained from this study are broadly applicable to other institutions seeking to use AI models to improve clinical outcomes,” the investigators concluded.

 “Future research should focus on developing novel strategies of ongoing education and stakeholder engagement to overcome implementation barriers, exploring the scalability of these efforts across diverse health care settings, identifying optimal alert thresholds that balance sensitivity and alert burden, and conducting randomized clinical trials to assess their effect on clinical outcomes.”

1. Tang S, Shepard S, Clark R, et al. Guiding 

 infection prevention efforts in a hospital setting with AI. 

2. About C. diff. Centers for Disease Control and Prevention. December 18, 2024. Accessed June 12, 2025. 

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

Use of an AI-guided infection prevention bundle did not significantly reduce CDI incidence but was associated with increased antimicrobial stewardship.

AI Tool Demonstrates Potential to Support Antimicrobial Stewardship and Reduce C difficile in Hospitals

A real-world, multicenter study of 67 evaluable patients treated with fecal microbiota, live-jslm (Rebyota; RBL) demonstrated a 77.6% treatment success rate at 8 weeks for preventing recurrent 

 infection (rCDI), with 87% maintaining remission at 6 months. These findings support RBL’s safety and efficacy beyond controlled clinical trials in an older population with comorbidities frequently exposed to multiple rCDI risk factors.

RBL, FDA approved in November 2022 as the first microbiota-based product for rCDI prevention in adults, is administered rectally after standard-of-care antibiotics. The study population had a median age of 74 years and a median Charlson comorbidity score of 4, with over half having 3 or more prior CDI recurrences. Risk factors were prevalent, including advanced age (72%), gastric acid suppressant use (55%), immunocompromise (24%), and recent non-CDI antibiotic exposure (21%).

All patients received prior antibiotics, most commonly fidaxomicin (58%), before RBL administration. Adverse events were minimal, limited to minor leakage in 5 patients. Age of 65 years or more was significantly associated with higher recurrence risk. Among patients experiencing recurrence within 8 weeks, median time to relapse was 28 days. Of 30 patients with 6-month follow-up data, 26 (87%) sustained treatment response.

These data provide important evidence for clinicians managing complex rCDI cases, highlighting RBL as a valuable and well-tolerated intervention to reduce recurrence risk in routine practice.

In relation to RBL, in a recent interview with 

, he emphasized that beyond effectively reducing recurrent CDI, the treatment plays a crucial role in improving patients’ overall quality of life. Feuerstadt described how recurrent CDI often leads to significant anxiety, fear, and social isolation, likening the emotional burden to posttraumatic stress. He noted that RBL not only targets the infection but also helps restore patients’ mental, physical, and social well-being, allowing them to regain confidence and normalcy in their daily lives.

1. Seo S, Hengel R, Krishnan S, et al. Real-world experience with fecal microbiota treatment (live-jslm) for the prevention of recurrent 

 infection. Abstract presented at: Making a Difference in Infectious Diseases Annual Meeting; May 28-31, 2025; Orlando, FL. Abstract 85 E.

2.Improved Symptoms and Health-Related Quality of Life in Adults with Recurrent 

 Infection after Fecal Microbiota, Live-jslm (RBL) Administration by Colonoscopy. Abstract presented at DDW 2025, May 3-6, 2025. Accessed July 1, 2025.

Findings from a multicenter US study confirm that RBL is a safe and effective microbiota-based therapy with sustained remission in a high-risk population with comorbidities.

Real-World Use of Fecal Microbiota, Live-Jslm Shows High Success in Preventing Recurrent C difficile Infection

Adding oral vancomycin to a systemic antibiotic treatment of a non–

 infection (CDI) to prevent CDI recurrence in at-risk patients was associated with a lower rate of recurrence than in those not receiving vancomycin in a placebo-controlled trial,

 but the difference was not statistically significant and the rates were high in both groups.

"Interventions to prevent recurrent CDI during exposure to systemic antibiotics in a person with prior but not current CDI are needed in clinical practice," Julie Keating, PhD, from the Department of Medicine at the School of Medicine and Public Health at the University of Wisconsin-Madison, and colleagues indicated.

Although the study was underpowered due to challenges in recruiting participants, the investigators found the lack of clear advantage suggested "that other interventions should be investigated for their effectiveness in preventing CDI recurrence after non–CDI-indicated antibiotic therapy."

Keating and colleagues recruited 81 participants with a documented diagnosis of 1 or more CDIs within the past 180 days, completion of a CDI treatment, and receipt of non–CDI-indicated systemic antibiotics for 2 weeks or less and not more than 72 hours at enrollment. The vancomycin group received 125 mg orally daily during and for 5 days after their systemic antibiotic regimen, whereas the control group received placebo in identical capsules. Recruitment challenges, including lack of interest in those with history of CDI to potentially receive placebo, left the size of the cohort one less than the minimum calculated to adequately power the study.

With that limitation on drawing conclusions, the investigators reported CDI recurred in 17 of 39 participants (43.6%) in the vancomycin group over the 8-week posttreatment follow-up period compared with 24 of 42 in the placebo group (57.1%). There was a statistically significantly higher rate of carriage of vancomycin-resistant 

(VRE) detected in the gut of those receiving vancomycin (15 of 30; 50%) than those without vancomycin exposure (6 of 25; 24.0%).

 Stuart Cohen, MD, from the Division of Infectious Diseases in the Department of Internal Medicine at the University of California Davis School of Medicine, remarked that although the difference in rate of CDI recurrence between the groups was numerical rather than statistically significant, "the reduction appears to be a clinically meaningful result."

"What is striking, however, is how high the rates of recurrence were in both the treatment (43.6%) and placebo (57.1%) groups," he observed.

Cohen noted that the number of prior recurrences in the participants was not provided, despite risk of recurrence increasing with the number of episodes. He also indicated he would have appreciated the study delving further than VRE colonization to assess overall effect of the vancomycin on fecal microbiota.

Keating and colleagues acknowledged that the study had not evaluated broader effects of the oral vancomycin on the gut microbiome, despite known effects including reduction of baseline commensals, which may facilitate 

"Additional research on patient populations, dosages, and dosing schedules may be needed to determine whether oral vancomycin may provide a greater protective effect within specific parameters while maintaining a low risk profile for patients," they remarked.

1. Keating JA, Xu T, Graham MB, et al. Oral vancomycin for prevention of recurrent 

 infection: a randomized clinical trial. 

. 2025;8(7):e2517834. doi:10.1001/jamanetworkopen.2025.17834

2. Cohen SH. Uncertain benefits of oral vancomycin for prevention of recurrent 

. 2025;8(7):e2521084. doi:10.1001/jamanetworkopen.2025.21084

The role of oral vancomycin in preventing recurrence of C difficile infection (CDI) in at-risk persons receiving systemic antibiotic for non-CDI infection remains unclear after randomized trial.

Effectiveness of Oral Vancomycin in Preventing C difficile Remains Uncertain After Trial

Sara Embry was newly pregnant and contracted 

 in a most unusual way. She picked up fecal spores at a local restaurant. She had not taken any antibiotics.

Like many people who get the infection, she initially struggled to find answers to her condition. She also lacked information from medical providers. She eventually found support through a 

, and became a peer volunteer, helping others experiencing the condition and seeking answers and comfort.

 to discuss her experience and her involvement with PLF. 

Can you share what it was like to be diagnosed with 

 while pregnant and how you managed both the infection and your pregnancy at the same time?

It was absolutely terrifying, because all the doctors and nurses whom I came in contact with didn't really have much experience with it. They misdiagnosed me. At first, I was extremely sick for a few weeks. 

I thought that I was going to lose my baby. 

For one, there was no information that I could find related to pregnancy and 

 online. I kept asking doctors about it, and no one could give me any information. They just told me that vancomycin was safe for my baby, and that was the extent of it. However, when I was experiencing 

, I was losing weight rapidly. I couldn't get out of bed. I couldn't keep any food down. And for anyone who has been pregnant, they know that nutrients are very important. Morning sickness is already hard, but then adding 

 on top of it—where you're rapidly losing the nutrients that you desperately need for your growing baby—the level of weakness that I experienced was something that I've never had before. My husband and I are modern-day homesteaders, so I'm used to being up and working, doing all the things that I need to do, and I just wasn't able to.

What were some of the most challenging aspects of your recovery  from 

Well, physically, I am already a rather small person, and keeping weight on has always been hard for me but especially in the first part of pregnancy. This was my third pregnancy. At the time, I already struggled with morning sickness and losing weight and trying to maintain that, but I lost 17 lb in a matter of a few weeks. I was extremely weak. I could not get out of bed.  My arms didn't even look like they belonged to me. They look like a child's arms, and I was losing my muscles.

Walking across the house was expending all the energy that I had. That's something that I was absolutely not used to. And I had 2 other young children whom I needed to care for, and I wasn't able to. It was hard on everybody in the family. My husband had to take off work, and not being able to care for myself was something I was not used to experiencing. 

Emotionally, there's an isolation that comes along with 

 that no one really talks about, because you can't invite people over. At first, they'll start offering to bring you meals or help with the kids, but they couldn't be over the house. It was so contagious, and I was terrified of passing it along to anyone. I couldn't let my children sit around me. They couldn't come and talk to me and play with me. It was horrible. It was hard on them. I had an active infection for over a month, and I was completely alone. I couldn't let anyone come around me. And that's something that really messes with your head whenever you are that isolated. 

And when I finally got over the active infection, the fear of recurrence is something that's almost like PTSD [posttraumatic stress disorder], because everything that I eat, I was worried. Am I going to be feeding the infection? Am I giving it? What am I doing to make it worse? What am I doing to make it better? It was every thought that I had. What can I do today that will help me tomorrow and not make it worse? But the fear of recurrence, I mean, I still struggle with that. One of the things that I do, I'm very, very strict about what I eat. Even over a year later, I don't compromise on my diet. I stick to what I know is safe, and that's something that I'm not sure if I'm ever going to be able to look past, because the impact that 

 has on your body is something that you can't even describe to someone unless they've seen it themselves. Even thinking about it just makes my stomach churn, because there's just nothing like it.

It's like PTSD, and it stays with you, even after the experience.



 In talking about this traumatic experience that you had with 

, how did it inspire you to get involved with the Peggy Lillis Foundation?

Yes, well, as I said earlier, finding information on 

was extremely hard. And eventually I did come across the Peggy Lillis Foundation, and they had a handbook for how to deal with the active infection, and it had recipes for foods that were safe. And what to do, like warning signs, all the things that you need to know, and that was the most in-depth. 

Whenever I reached out to them, I couldn't believe that they actually wanted to talk to me. They had people who were checking in on me, and not only did they provide me with the information that I needed to get through the infection but [also] that level of isolation that I talked about. The Peggy Lillis Foundation really helped me with that, because they understood—Christian [Lillis, PLF cofounder,] losing his mom, he really understands—and speaking to them, it just made me feel like I wasn't alone, [when] I had felt alone throughout the whole process up until that point. And so with them, I believe that they're doing good work, and I'm just so incredibly thankful that I want to be able to do that for other people.

In terms of looking at a potential message, what do you hope to convey to the public as well as policy makers through your advocacy work with the foundation?

Yes, well, I stand behind the Peggy Lillis Foundation's vision of where we believe in a world where 

is rare, treatable, and survivable. We believe in spreading awareness and knowing what people are going through, that they're not alone, and that you can get through it [to] the other side. And with me being pregnant, for all those women out there who may have it and can't find any information like I did, my baby is happy and healthy and strong, and they can get through it, too.

 What are the biggest misconceptions about 

, and how can we build better awareness to improve prevention and treatment?

 I think that the biggest misconception is that it won't happen to me. We are people who eat the food that we grow; I'm very health conscious, and it happened to me. It can happen to anybody. The mindset that it won't happen to me. It's for [older] people or people with compromised immune systems or people who take antibiotics. I didn't take any antibiotics. I picked it up by going to a birthday dinner with someone at a restaurant. It can happen to anyone, and it can pull the rug out from underneath you faster than you believe.

Sara Embry discusses her experience with the infection while pregnant and as a mother to young children as well as finding the Peggy Lillis Foundation to help her cope with the infection and subsequently work as a peer support volunteer for the organization.

Kevin Schwartz, MD, MSc, FRCPC

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