Bonnie Lansing

A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices: A Randomized Clinical Trial

IMPORTANCE Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. OBJECTIVE To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. INTERVENTIONS Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. MAIN OUTCOMES AND MEASURES The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a residents participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. RESULTS In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. CONCLUSIONS AND RELEVANCE Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01062841.

New Acquisition of Antibiotic-Resistant Organisms in Skilled Nursing Facilities

ABSTRACT The epidemiology of new acquisition of antibiotic-resistant organisms (AROs) in community-based skilled nursing facilities (SNFs) is not well studied. To define the incidence, persistence of, and time to new colonization with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CAZr) and ciprofloxacin-resistant (CIPr) Gram-negative bacteria (GNB) in SNFs, SNF residents were enrolled and specimens from the nares, oropharynx, groin, perianal area, and wounds were prospectively cultured monthly. Standard microbiological tests were used to identify MRSA, VRE, and CAZr and CIPr GNB. Residents with at least 3 months of follow-up were included in the analysis. Colonized residents were categorized as having either preexisting or new acquisition. The time to colonization for new acquisition of AROs was calculated. Eighty-two residents met the eligibility criteria. New acquisition of AROs was common. For example, of the 59 residents colonized with CIPr GNB, 28 (47%) were colonized with CIPr GNB at the start of the study (96% persistent and 4% intermittent), and 31 (53%) acquired CIPr GNB at the facility (61% persistent). The time to new acquisition was shortest for CIPr GNB, at a mean of 75.5 days; the time to new acquisition for MRSA was 126.6 days (P = 0.007 versus CIPr GNB), that for CAZr was 176.0 days (P = 0.0001 versus CIPr GNB), and that for VRE was 186.0 days (P = 0.0004 versus CIPr GNB). Functional status was significantly associated with new acquisition of AROs (odds ratio [OR], 1.24; P = 0.01). New acquisition of AROs, in particular CIPr GNB and MRSA, is common in SNFs. CIPr GNB are acquired rapidly. Additional longitudinal studies to investigate risk factors for ARO acquisition are required.

Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices.

The objective of this prospective surveillance study was to quantify colonization with antimicrobial-resistant organisms (AROs) and infections attributable to indwelling devices in skilled nursing facility (SNF) residents. The study was conducted in 15 SNFs in Southeast Michigan. Residents with (n = 90) and without (n = 88) an indwelling device were enrolled and followed for 907 resident-months. Residents were cultured monthly from multiple anatomic sites and data on infections were obtained. The device-attributable rate was calculated by subtracting the infection rate in the device group from the infection rate in the non-device group. A total of 197 new infections occurred during the study period; 87 in the device group (incidence rate [IR] = 331/1,000 resident-months) and 110 infections in the non-device group (IR = 171/1,000 resident-months), with a relative risk of 1.9 (95% confidence interval [CI]: 1.4–2.6). The attributable rate of excess infections among residents in the device group was 160/1,000 resident-months, with an attributable fraction of 48% (95% CI: 31–61%). Prevalence rates for all AROs were higher in the device group compared with the no-device group. The prevalence of the number of AROs per 1,000 residents cultured increased from no-device to those with only feeding tubes, followed by those with only urinary catheters and both these devices. In conclusion, the presence of indwelling devices is associated with higher incidence rates for infections and prevalence rates for AROs. Our study quantifies this risk and shows that approximately half of all infections in SNF residents with indwelling devices can be eliminated with device removal. Effective strategies to reduce infections and AROs in these residents are warranted.

Multidrug-Resistant Organisms on Patients' Hands: A Missed Opportunity.

Multidrug-Resistant Organisms on Patients’ Hands: A Missed Opportunity Multidrug-resistant organisms (MDROs) are increasingly prevalent in post–acute care (PAC) facilities.1,2 Increased contact between health care workers, the environment, and patients in PAC facilities can increase the risk of MDRO cross-transmission3,4 because PAC patients may need assistance with activities of daily living and are encouraged to be mobile outside of their room for rehabilitation, dining, and other recreational activities. Much more than other anatomic sites, patients’ hands are more likely to come in contact with environmental surfaces, health care workers’ hands, and other patients in PAC facilities. Our objective was to evaluate baseline, new acquisition, and duration of MDRO hand carriage among patients newly admitted to PAC facilities from acute care hospitals.

Impact of health care worker policy awareness on hand hygiene and urinary catheter care in nursing homes: Results of a self-reported survey

Utilizing a self-administered questionnaire in 440 health care workers (81% response rate), we evaluated the impact of health care workers policy awareness on hand hygiene and urinary catheter care in nursing homes. We show that health care workers aware of their nursing home policies are more likely to report wearing gloves and practicing hand hygiene as per evidence-based recommendations during urinary catheter care compared with those who are unaware of their facility policies.

The 24-hour report as an effective monitoring and communication tool in infection prevention and control in nursing homes.

Twenty-four-hour reports are filled out by nurses daily to monitor nursing home residents and document any changes in resident status. Semistructured interviews conducted with ICPs from 12 southeast Michigan nursing homes showed that although 24-hour reports were used, they were not standardized for infection prevention activities. Our results indicate 24-hour reports can be an effective communication tool and potentially aid in early recognition of infections and outbreaks.

Long-Term Carriage of Ciprofloxacin-Resistant Escherichia coli Isolates in High-Risk Nursing Home Residents.

BACKGROUND Rates of multidrug-resistant gram-negative organisms are surpassing those of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in nursing homes (NHs). OBJECTIVE To characterize the incidence and duration of carriage of ciprofloxacin-resistant Escherichia coli (CipREc) in NHs and identify those in the O25b-ST131 lineage. METHODS We collected 227 CipREc isolates obtained by routine and regular surveillance of high-risk NH residents with indwelling devices. Repetitive element palindromic (REP)-polymerase chain reaction assay and multiplex polymerase chain reaction amplification for O25b-ST131 E. coli detection were performed using (GTG)5-primers and O25pabBspe and trpA2 primer pairs, respectively. RESULTS We found a high period prevalence of CipREc colonization (21.5%), high rates of recolonization with the same strain following clearing (0.46 recolonizations/ person/ year), and an acquisition incidence of 1.05 cases/1,000 person-days. Almost three-quarters of colonized residents carried strains in the O25b-ST131 E. coli lineage. Compared with isolates not in the lineage, O25b-ST131 isolates were carried significantly longer (10 vs 3 months). We identified 18 different REP-types; 2 occurred in 55% of the residents colonized with CipREc, and in more than 1 NH. Duration of CipREc carriage varied by REP-type and averaged 6 months. CONCLUSION CipREc occurred frequently in NH residents and is carried for long durations, and reacquisition following clearance is common Trial registration. ClinicalTrials.gov identifier: NCT01062841.

Making infection prevention education interactive can enhance knowledge and improve outcomes: Results from the Targeted Infection Prevention (TIP) Study

BACKGROUND The purpose of this study was to assess effectiveness of an interactive educational program in increasing knowledge of key infection prevention and control (IPC) principles with emphasis on indwelling device care, hand hygiene, and multidrug-resistant organisms (MDROs) among nursing home (NH) health care personnel (HCP). METHODS We conducted a multimodal randomized controlled study involving HCP at 12 NHs. Ten comprehensive and interactive modules covered common IPC topics. We compared intervention and control scores to assess differences in pretest scores as a result of field interventions, pre- and post-test scores to assess knowledge gain, and magnitude of knowledge gain based on job categories. RESULTS We conducted over 200 in-services across 10 topics at six intervention sites over 36 months. There were 4,962 tests returned over the course of the study, ranging from 389-633 per module. Participants were mostly female certified nursing assistants (CNAs). Score improvement was highest for modules emphasizing hand hygiene, urinary catheter care, and MDROs (15.6%, 15.9%, and 22.0%, respectively). After adjusting for cluster study design, knowledge scores were significantly higher after each educational module, suggesting the education delivery method was effective. When compared with CNAs, nursing and rehabilitation personnel scored significantly higher in their knowledge tests. CONCLUSIONS Our intervention significantly improved IPC knowledge in HCP, especially for those involved in direct patient care. This increase in knowledge along with preemptive barrier precautions and active surveillance has enhanced resident safety by reducing MDROs and infections in high-risk NH residents.

Longitudinal Assessment of Multidrug-Resistant Organisms in Newly Admitted Nursing Facility Patients: Implications for an Evolving Population.

Background The spread of multidrug-resistant organisms (MDROs) is a global concern, and much about transmission in healthcare systems remains unknown. To reduce hospital stays, nursing facilities (NFs) have increasingly assumed care of post-acute populations. We estimate the prevalence of MDRO colonization in NF patients on enrollment and discharge to community settings, risk factors for colonization, and rates of acquiring MDROs during the stay. Methods We conducted a prospective, longitudinal cohort study of newly admitted patients in 6 NFs in southeast Michigan using active microbial surveillance of multiple anatomic sites sampled at enrollment, days 14 and 30, and monthly thereafter for up to 6 months. Results We enrolled 651 patients and collected 7526 samples over 1629 visits, with an average of 29 days of follow-up per participant. Nearly all participants were admitted for post-acute care (95%). More than half (56.8%) were colonized with MDROs at enrollment: methicillin-resistant Staphylococcus aureus (MRSA), 16.1%; vancomycin-resistant enterococci (VRE), 33.2%; and resistant gram-negative bacilli (R-GNB), 32.0%. Risk factors for colonization at enrollment included prolonged hospitalization (>14 days), functional disability, antibiotic use, or device use. Rates per 1000 patient-days of acquiring a new MDRO were MRSA, 3.4; VRE, 8.2; and R-GNB, 13.6. MDRO colonization at discharge was similar to that at enrollment (56.4%): MRSA, 18.4%; VRE, 30.3%; and R-GNB, 33.6%. Conclusions Short-stay NF patients exhibit a high prevalence of MDROs near the time of admission, as well as at discharge, and may serve as a reservoir for spread in other healthcare settings. Future interventions to reduce MDROs should specifically target this population.

346Longterm carriage of Ciprofloxacin-Resistant E. Coli Isolates among Nursing Home (NH) Residents

346. Longterm carriage of Ciprofloxacin-Resistant E. Coli Isolates among Nursing Home (NH) Residents Miriam Ismail, MPH; Ting Luo, MPH; Usha Srinivasan, PhD; Lona Mody, MD, MSc; Sara Mcnamara, MT(ASCP), MPH; Bonnie Lansing; Betsy Foxman, PhD; Epidemiology, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI; Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI; Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Medical School, Ann Arbor, MI; Geriatrics, University of Michigan, Ann Arbor, MI