Background: Antimicrobial resistance (AMR) in Neisseria gonorrhoeae (NG) is an emerging public health crisis. Whole-genome sequencing (WGS) is an efficient way of predicting AMR determinants and their spread in the population. In a previous study, genotype–phenotype correlation analyses among NG isolates to determine antimicrobial resistance revealed discordance for azithromycin (AZM) and ceftriaxone (CRO) compared to other antibiotics. We investigated the evolutionary relatedness of NG isolated from patients with sexually transmitted infection (STI) using WGS in southeastern Michigan. Methods: Isolates, corresponding demographic data, and minimum inhibitory concentrations (MIC) via E-test (CRO) and broth microdilution (AZM) were obtained from the Michigan Department of Health and Human Services. Whole-genome libraries were prepared using the QIAseq FX kit followed by sequencing on a NovaSeq6000 (>200X Coverage); samples were aligned to NG reference strain TUM19854 (NZ_AP023069.1) using Snippy before phylogenetic tree generation using Neighbor-joining clustering on the core.aln files. Phylogenetic trees were visualized using ATGC:PRESTO. Results: In total, 38 isolates were analyzed. Demographic data and susceptibility testing results are noted in Table 1. Most isolates were from males (63%), Blacks (44.7%), individuals living in Detroit City proper (47.3%), and those with unknown HIV status (55.2%). More than one-third had prior STI, including NG. All isolates were susceptible to CRO (CLSI susceptible breakpoint MIC, 1). Within the phylogenetic tree, 8 main branches were identified (Fig. 1). Moreover, 1 branch contained a cluster with 12 closely related isolates, which included the 9 isolates with nonsusceptible AZM. Nearly all isolates in that cluster had been collected from Detroit City proper and Wayne County, suggesting epidemiological overlap and potential spread of resistant strains in those counties.

Conclusions: Comparative whole-genome and phylogenetic analyses among a subset of NG isolates revealed clustering of AZM resistance strains, suggesting a genomic component to AMR. Further studies are needed to determine the utility of WGS in diagnosis, outbreak investigations, and management of NG infections.

Disclosures: None

Background: After 3 years, we discovered that a high-value instrument, rigid endoscopes, needed to be used and cleaned properly. If those instruments are damaged from inappropriate handling or reprocessing, they can pose infection risks to patients. Furthermore, the hospital incurs additional repair costs. Objectives: We sought to ensure that specialized instruments are handled and used appropriately in accordance with the manufacturers’ recommendations and that all related units handle and use instruments appropriately. Methods: A meeting was convened to establish the purposes and scope of the work, and related data were collected. As a result, we created registration forms for high-risk instruments as well as a survey list for rigid endoscopes. These forms were distributed to appropriate units. We analyzed outcomes, monitored the indicators, and audited work processes. The operating room registered high-value instruments on a form that included instructions for use. A dealer demonstrated how to handle the rigid endoscopes. The CSSD team visited the operating room to emphasize the importance of handling and reprocessing to ensure compliance. The BEM team inspected all endoscopes after use. We created group communication within the software. Using T-DOC, we analyzed and monitored outcomes. We measured the rate of high-risk instrument registration as well as the completeness of registration. We also measured the rate of damage to rigid endoscopes. Results: We collected data related to rigid endoscopes and educated the staff to handle and reprocess the instruments appropriately, including instructions for use. High-risk instrument registration forms and surveys were created to record information in the T-DOC system. The staff was invited to educational workshops. The rates of registration, registration completeness, and readiness were measured using the plan–do–check–act (PDCA) method. The results of every indicator reached the expected rates of 100%. Conclusions: We achieved our goal of 100% compliance with the new program. All high-value instruments should be registered, and all related staff should be trained to use them appropriately.

Background: In May 2022, New York City (NYC) experienced a large outbreak of human mpox (clade IIb). Data on mpox transmission following exposure in healthcare facilities in nonendemic settings are limited. Because mpox was previously not seen in NYC, our healthcare staff may not always recognize a suspected case and therefore may neglect to implement timely infection prevention and control measures, leading to infectious exposures. The risk of transmission from unrecognized mpox may be higher in inpatient psychiatric units where direct physical contact is more common in the setting of common spaces for patients. In July 2022, a patient was admitted to NYC Health + Hospitals–Bellevue (Bellevue) psychiatry with signs and symptoms of mpox that were not recognized for 4 days, at which point the patient was tested for mpox and was isolated. We describe the investigation of staff and patients exposed during the 4 days prior to diagnosis and isolation of the index patient, and we report on the outcome mpox infection among those exposed. Methods: This study was a retrospective chart review of adult patients admitted to and staff working on an inpatient psychiatric unit where the patient with mpox was admitted to Bellevue, the largest municipal hospital in NYC. Each individual was classified regarding degree of exposure, based on criteria from the CDC, and was offered postexposure mpox vaccination where indicated. We describe the nature of contact with the patient for those with high-risk exposures. The outcome of interest was development of mpox infection during 21 days after last exposure. Results: In total, 29 patients and 84 staff members were identified to have been on the psychiatric unit prior to isolation of the index case of mpox. All exposed individuals were monitored for signs and symptoms of mpox for 21 days after last exposure. The exposed and unexposed patients were kept apart in the psychiatric unit. All patients who had contact were classified as having a low-to-intermediate risk exposure. Among 23 staff members exposed, 8 had high-risk exposures, 4 had intermediate-risk exposures, and 11 had low-risk exposures. Those with high-risk exposures were offered Jynneos as postexposure vaccination, but they declined. None of the exposed staff or patients developed mpox during the follow-up period. Conclusions: Mpox transmission was not observed despite several exposures in a congregate psychiatry unit. Given limited data, further studies are needed to better understand transmission risk in congregate healthcare settings.

Disclosures: None

A novel pharmacy residency rotation was created to meet the needs of patients enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program but not yet discharged from the inpatient setting. This service resulted in a high number of antimicrobial stewardship interventions identified and accepted by the primary team(s).

Background: Candida auris is an emerging pathogen that exhibits broad antimicrobial resistance and causes highly morbid infections. Prolonged survival on surfaces has been demonstrated, and standard disinfectants may not achieve adequate disinfection. Persistent patient colonization and constant environmental recontamination poses an infection risk that may be mitigated by no touch disinfection systems. We evaluated the efficacy of continuous dry hydrogen peroxide (DHP) exposure on C. auris environmental contamination. Methods: The study was conducted in a large tertiary-care center where multiple patients were identified as either infected or colonized with C. auris. DHP-emitting systems were installed in the ventilation systems dedicated to the adult burn intensive care and children’s cardiac intensive care units. Composite surface samples were collected in a sample of patient rooms and shared clinical workspaces among units with current C. auris patients, before and after installation of the DHP system, and from areas with and without exposure to DHP. The samples included “high touch” surfaces near the patient, the general area of the patient room, shared medical equipment for the unit, shared staff work areas, and equipment dedicated to individual staff members (Table 1). Presence of C. auris was determined by polymerase chain reaction (PCR). Association between DHP exposure and C. auris contamination was determined using the Fisher exact test. Results: In the presence of C. auris patients, 5 baseline samples per unit were taken before DHP was installed, and then 5 samples per unit were taken on days 7, 14, and 28 after installation. Prior to initiation of DHP, 7 (70%) of 10 samples were PCR positive for C. auris. After DHP installation, a statistically significant decrease to 5 (16.7%) of 30 samples (P <.05) was observed. In total, 20 samples (5 before installation and 15 after installation) were collected from units without DHP on the same days. At baseline, 2 (40%) of 5 samples were PCR positive for C. auris. During subsequent periods, 4 (27%) 15 samples were positive (P = .66). No adverse effects were reported by patients, visitors, or personnel in association with the operation of the DHP systems. Conclusions: These findings suggest that DHP is effective in reducing surface C. auris contamination in a variety of patient and healthcare worker surfaces.

Disclosures: None

Objectives: We aimed to provide sufficient equipment to effectively and efficiently track all equipment. Advanced management procedures are available for the treatment of any patients with infections or immunodeficiency as well as those who need special treatment or isolation from others. This management plan can be beneficial for the hospital by promoting process improvement and achieving cost effectiveness. Methods: The instruments used were surveyed in all departments of Bangkok Hospital and these data were analyzed. We used a plan–do–check–act (PDCA) strategy to improve the management by moving from a manual system to a collaborative innovation project that used 4 technological systems: (1) storage identification and identification codes for equipment; (2) request, return, and delivery using the Nsmart system; (3) transportation, receiving, and delivery; and (4) an HIS system for tracing and NSterile version 4.0 software for reporting. Results: The BHQ isolation cart management system helped the hospital control inventory and prevent infection and helped standardize patient services to improve quality at the hospital. Conclusions: This report confirms earlier findings that sufficient equipment can be made available to patients with no extra cost to management. Our findings can contribute to efforts to prevent the virus from spreading within the hospital.

Objectives: We sought to reduce waiting time for instruments in the operating room, to develop technology for communication between zones, to record data in real time for planning instrument management, and to increase trust and satisfaction of customers. Methods: The central sterile supply department (CSSD) provides sterilization of instruments and medical devices, mostly to the following departments: operating room, dental unit, outpatient otolaryngology, and obstetrics and gynecology. The CSSD processes 557,588 units per month, among which 30.05% are for the operating room. In the normal process when the operating room send instruments for decontamination, the operating room staff places stickers on the item or uses a form to document the request. The normal turnaround time was 3 hours and 9 minutes and urgent turnaround time was 2 hours and 14 minutes. For color control, we used white color for normal requests and pink for urgent requests. We redesigned our record keeping using Google forms and sent data on dashboards with real-time alerts in the CSSD application to notify staff of an urgent request. Results: Staff in the dirty zone placed an urgent tag on the instrument baskets of the auto-washer. After the door was opened in the clean zone, staff noted the urgent tag and marked a validation sheet, then placed a red unilock on the rigid constrainer. Peel pouches were marked “urgent,” advising sterile storage zone staff to separate the basket from normal baskets and to apply the “urgent” paper form and labelling. Conclusions: Turnaround time improved by 15 minutes for urgent instruments. Lead time to export data for analysis increased from 80% to 95.49%. Because of facility design, it was difficult to ensure communication between separate dirty, clean, and sterile storage zones. We redesigned our process using new technology to improve turnaround times, reduce waste, improve communication, and increase productivity.

The 2007–2018 National Health Interview Survey data linked with Medicare claims were used to examine older adults’ characteristics and assess their associations with receiving an antibiotic prescription. This analysis shows variation in antibiotic prescribing among adults enrolled in Medicare Part D by race and ethnicity, sex, geography, and health status.

Background: Environmental cleaning is critical in preventing pathogen transmission and potential consecutive healthcare-acquired infections. In operating rooms (ORs), multiple invasive procedures increase the infectious risk for patients, making proper cleaning and disinfection of environmental surfaces of paramount importance. A human-factors engineering (HFE) approach emphasizing the impact of the entire work system on care processes and outcomes has been proposed to improve environmental cleaning. Using the lens of this HFE approach, we conducted a systematic review to synthesize existing evidence and identify gaps in the literature on OR cleaning. Methods: The systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and limited to English-written, peer-reviewed journal articles reporting empirical studies on OR cleaning. Figure 1 shows the flowchart of study search and screening. The following data were extracted from each included article: (1) general information of the article (eg, first author, title, journal, year of publication) and (2) characteristics of the study (eg, country, objectives, design, outcome measures and measuring techniques, findings, funding source). In addition, work-system elements (eg, people, tasks, tools and technologies, physical environment, organizational conditions) and cleaning processes (eg, turnover cleaning, terminal cleaning) addressed in each included studywere coded based on the Systems Engineering Initiative for Patient Safety (SEIPS) model. The methodological quality of included studies using a (non)randomized controlled design was assessed using the version 2 of the Cochrane risk-of-bias tool for randomized trials. Results: In total, 35 studies were included in this review, among which 10 examined the effectiveness of OR cleaning in reducing environmental contamination (Fig. 2), 1 examined the compliance of OR cleaning practices (Fig. 3), and 24 examined interventions for improving OR cleaning effectiveness and/or compliance (Fig. 4). Figure 5 summarizes the characteristics of the included studies. Conclusions: In this review, OR cleaning was inconsistently performed in practice, and mixed findings were reported regarding the effectiveness of OR cleaning in reducing environmental contamination. No study has systematically examined work-system factors influencing OR cleaning. Efforts to improve OR cleaning focused on cleaning tools and technologies (eg, ultraviolet light) and staff monitoring and training. Interventions targeting the broader work system influencing the cleaning processes are lacking. The scientific rigor of the included studies was modest. Most studies were either commercially funded or did not reveal their funding sources, which might introduce a desirability bias.

Financial support: This study was funded by the Centers for Disease Control and Prevention.

Disclosures: None

The optimal management of bacteriuria/pyuria of clinically undetermined significance (BPCUS) is unknown. Among 220 emergency department patients prescribed antibiotics for BPCUS, we found frequent readmissions, which were mitigated by outpatient follow-up visits. Observation and follow-up for an unknown diagnosis should be emphasized over antibiotics due to high likelihood of readmissions.

Background: Transmission of multidrug-resistant bacteria to patients from colonized hospital sink drains has prompted attempts to interrupt transmission through a variety of interventions directed at the wastewater environment. We previously found that use of a heating device designed to disrupt biofilm formation between the P trap and the sink drain, which is the major point of dispersal of bacteria to the patient-care environment, was associated with reduced risk of detectable gram-negative organisms on hospital sink drains. However, there was no observed effect on some important pathogens, including Pseudomonas aeruginosa and Stenotrophomonas maltophilia. We hypothesized that heating to a higher temperature would provide additional efficacy in preventing drain colonization. Methods: As part of a previous randomized study, 54 tailpiece heaters were installed in 3 intensive care units in an academic hospital and 2 acute-care units in an associated regional hospital; half of these devices were shams (ie, no heat). The devices were programmed to heat for 1 hour every fourth hour. Prior to this study, a device update increased the heating temperature (during the previous study the median heated temperature was 65.9°C). Sink drains and P traps were sampled monthly. Samples were assessed for semiquantitative growth of gram-negative bacteria on MacConkey agar, looking especially for P. aeruginosa and S. maltophilia. Frontline personnel were blinded to device assignment. Results: The mean heated temperature reached was 74.4°C. Based on proportional odds logistic regression (wherein the odds ratio reflects the likelihood of a given sample falling in a lower microbiologic burden level versus the levels above it), the heating device was associated with increased likelihood of lower microbiologic burden at the drain level for general growth on MacConkey agar (OR, 2.47; 95% CI, 1.11–5.51) and for growth of S. maltophilia (OR, 5.39; 95% CI, 2.20–13.18). The device did not have an effect on burden of Enterobacterales (OR, 1.38; 95% CI, 0.58–3.24). For P. aeruginosa, there was a trend toward decreased likelihood of lower microbiologic burden (OR, 0.41; 95% CI, 0.18–1.07) that did not reach statistical significance at the drain level, and the heating device was associated with decreased likelihood of lower microbiologic burden of P. aeruginosa at the P-trap level (OR, 0.20; 95% CI, 0.10–0.39). Conclusions: Heat disruption of biofilm between the P trap and sink may be a promising strategy for prevention of hospital sink drain colonization; however, the impact is variable across different bacterial species. Further understanding of the dynamics of the microbiome within wastewater is needed.

Disclosures: None

Objectives: The central sterile services department (CSSD) offers a variety of procedures, including collecting contaminated medical equipment from various agencies through a process of washing, cleaning, packing, and sterilization, followed by storage and distribution to internal and external departments. Plans to expand and open service to the Center of Excellence continue, which will result in a rapid increase in the processing of specialized medical devices. The Center of Excellence is a source of education, learning, teaching, and practice in the cleaning, disposal, and sterile treatment of medical devices. We sought to improve the quality of sterile medical equipment to satisfy international standards of safety. Methods: We implemented a 7-stage process in the CSSD and we developed a checklist with 8 categories of environmental development based on APSIC guidelines. We provided knowledge to CSSD employees, developed their skills, and promoted attitudes in various areas, including sterile work standards, the use of sterilization machines, and infection prevention and control both inside and outside the facility. Results: We established inventory control systems, storage guidelines, and disbursement of medical supplies and equipment in the CSSD. To improve machine use in sterilization treatment or disposal, we educated staff and provided practice of machine skills according to instructions for use. Information technology (IT) was used for the distribution process, medical device identification, recording sterilization, and statistical logging of sterilization and sterile services. Conclusions: Overall, we improved the quality of CSSD services and knowledge and practice of CSSD staff, and we achieved compliance with international standards. These measures ensure the safety of service providers and patients and build trust in the quality of CSSD services and output.

Background: Pattani Hospital in southern Thailand has 540 beds and a network of 22 family clinical practice and community locations and 13 primary-care hospitals. We care for patients and soldiers who have wounds from guns and bombs of varying wound size. The central sterilization services department (CSSD) prepares dressing sets with 1 size dressing procedures. Objectives: We sought to improve the sizing of dressing sets within Pattani Hospital and network, to reduce preparation time to ≤3 minutes per set, and to reduce the cost of dressing sets by 8,000 Thai baht (US $240) per month. Methods: We convened a problem-solving meeting to address the sizes of dressing sets in the hospital. We decided that 3 sizes were needed (small, medium, and large) following the size of the wound. We performed a pilot project and evaluated its progress every 2 months. Results: Unique dressing sets were used in 68.18% of cases before the intervention and 88.5% after the sizing changes. Time to prepare the dressing sets decreased from 3 minutes to 1 minute per set. The intervention reduced the costs related to dressing sets from 39,952.50 Thai baht (US $1,194) per month to 25,641 baht (US $766) per month. Furthermore, infectious waste was reduced from 31.8 kg per day to 7.99 kg per day. Conclusions: Multiple sizes of dressing sets were prepared for use with wounds of varying size. The CSSD prepared the dressing sets using medical supplies such as gauze, cotton, and top gauze. This project reduced waste and improved cost-effectiveness, and this procedure will be extended to other care facilities in our network.

Background: To estimate hand hygiene compliance using electronic hand hygiene monitoring, the number of hand hygiene opportunities (HHOs) per period must be known in a given setting. Data on the number of HHOs in a neonatal ICU (NICU) are limited. We measured HHOs per hour and identified factors that may influence the number of HHOs per hour to calibrate compliance estimates for electronic hand hygiene monitoring. Methods: The study was conducted in 2 large NICUs in Ontario, Canada (72 and 42 beds, respectively). We centrally trained observers to identify HHOs using the Ontario-based “Four Moments of Hand Hygiene,” which is similar to combining moments 4 and 5 of the WHO “Five Moments of Hand Hygiene.” To apply the moments of hand hygiene to the NICU setting, the following modifications were made: moment 1 was entering the incubator or contact with anything within the ‘baby space’ directly around the incubator, and moment 4 was when hands exited the incubator and, as such, the ‘baby space.’ Using a standardized tool, the investigators conducted direct observation of HHOs during randomized observation periods from July 1, 2022, to January 9, 2023. In addition to HHOs, data on covariables potentially associated with the frequency of HHOs were collected: time and day of the week, acuity, additional precautions, corrected gestational age, and private versus multibed room or open pod. Results: We audited HHOs for 146 hours including 26 at site A and 120 at site B. Overall, 804 HHOs (69.2%) occurred during weekdays and 739 (63.6%) occurred during day shifts from 7:00 a.m. to7:00 p.m. The most frequent moments of hand hygiene were moment 1 (47.8%, before contact) and moment 4 (36.8%, after contact). The average numbers of HHOs were 7.8 per hour overall, 7.6 per hour on weekdays, 7.7 per hour on weekends, 8.8 per hour on day shifts, and 6.8 per hour on night shifts. The breakdown of HHOs by profession was 92.8% nurses, 0.6% physicians, 4.5% allied health, and 2.1% for others. Discussion: The rate of HHOs in NICU varied over a 24-hour period and was similar between 2 different NICUs. Evenings and weekends had considerably fewer average HHOs, and peaks were observed following nursing shift changes. The rate of HHOs may be influenced by other factors including unit design, patient acuity, and use of transmission-based precautions. Further analysis using a Poisson regression model will help to explore these factors and to calibrate electronic monitoring for this population.

Disclosures: None

Background and objectives: Patients with functional disabilities are at higher risk of adverse outcomes, including infections. Although healthcare worker hand contamination has long been recognized as an important source of pathogen acquisition, the role of patient hands has been less clearly defined. We sought to determine whether the presence of functional disabilities is correlated with patient hand contamination by multidrug-resistant organisms (MDROs) and thus a potential target for patient hand hygiene (PHH) interventions. Methods: Case–control study of hand contamination with methicillin-resistant S. aureus, vancomycin-resistant enterococci, and gram-negative bacilli resistant to cephalosporins, fluoroquinolones, and/or carbapenems in 2 acute-care hospitals in southeastern Michigan. Cases (n = 40) and controls (n = 359) were defined as patients with or without hand contamination by MDROs, respectively. We assigned 3 exposure categories based on Katz activities of daily living scores: no functional disabilities (independent, reference group), 1–3 functional disabilities (partially dependent), and 4+ functional disabilities (dependent). We used stepwise logistic regression to identify confounding variables. Logistic regression was then used to establish the relationship between a patient’s functional dependence level and their hand contamination by MDROs. Results: The distribution of hand contamination of each target MDRO by level of patient dependence is shown in the Table. Overall, methicillin-resistant Staphylococcus aureus (MRSA) was the most represented, followed by resistant gram-negatives and vancomycin-resistant enterococci (VRE). Hospital site, sex, and history of MDROs were included in the model based on stepwise regression. The odds ratio (OR) of MRSA hand contamination in the dependent category was 3.19 (95% CI, 1.18–5.54) compared to the independent category, and for any MDRO the OR was 2.77 (95% CI, 1.22–6.32) (Fig. 1). The OR of MRSA hand contamination in the partially dependent category was 1.38 (95% CI, 0.27–7.07) compared to the independent group, and for any MDRO the OR was 0.86 (95% CI, 0.24–3.10) (Fig. 1). Feeding dependence had the highest single association with hand contamination (OR, 3.79, 95% CI, 1.26–11.43), with dressing dependence having the second highest association with hand contamination (OR, 2.82; 95% CI, 1.31–6.05) (Fig. 2). Conclusions: Patients with more functional dependencies were more likely to have MDRO hand contamination. This finding suggests a need for targeted PHH interventions in patients with functional disabilities to help prevent the spread of MDROs in the acute-care setting.

Disclosures: None

COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.

Background: Hand-hygiene technology (HHT) intends to monitor and promote hand washing by healthcare workers, a critical measure of infection control. Healthcare worker noncompliance with HHT is a major limitation to its implementation and utility in clinical settings. We assessed perspectives on HHT in an academic hospital system. Methods: Hand-hygiene team members created an anonymous, 37-question, Likert-scale survey to assess healthcare worker attitudes toward HHT. Surveys targeted nursing staff, advanced practice providers, care partners, and internal medicine physicians. Clinical coordinators from 5 distinct nursing units and 1 physician department emailed surveys to eligible employees. Research coordinators and clinical coordinators also posted a QR code for survey fliers at nursing stations. Results: Overall, 120 surveys were completed. Most surveys were completed by nurses and physicians (66.4% and 14.0%). Most respondents (67.5%) do not find HHT useful. Additionally, 78.3% of respondents believe that HHT does not accurately record hand-washing events. Most (78.3%) do not like using HHT, and 75.8% find it annoying. Only 10.8% believe that patient care suffers because of HHT. Conclusions: Most healthcare workers dislike the HHT badges, primarily due to perceived inaccuracies, lack of utility, burden of use, and pressure to comply. Distrust and effect on patient care do not appear to be substantial factors contributing to negative perceptions of HHT. Weaknesses of the study include overrepresentation of nursing staff and potential bias because respondents may have provided exceptionally negative responses believing it could lead to the removal of HHT.

Disclosures: None

In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.