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Rankin DA, Walters MS, Caicedo L, Gable P, Moulton-Meissner HA, Chan A, Burks A, Edwards K, McAllister G, Kent A, Laufer Halpin A, Moore C, McLemore T, Thomas L, Dotson NQ, Chu AK. Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital. Infect Control Hosp Epidemiol 2024; 45:292-301. [PMID: 38196201 PMCID: PMC10933503 DOI: 10.1017/ice.2023.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A). METHODS We defined an incident case as the first detection of blaKPC or blaVIM from a patient's clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing. RESULTS From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates. CONCLUSIONS Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.
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Affiliation(s)
- Danielle A. Rankin
- Florida Department of Health in Orange County, Orlando, Florida
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maroya Spalding Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Luz Caicedo
- Florida Department of Health in Orange County, Orlando, Florida
| | - Paige Gable
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Allison Chan
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Albert Burks
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Kendra Edwards
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gillian McAllister
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alyssa Kent
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alison Laufer Halpin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina Moore
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Tracy McLemore
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Linda Thomas
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Nychie Q. Dotson
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- HCA Healthcare, Nashville, Tennessee
| | - Alvina K. Chu
- Florida Department of Health in Orange County, Orlando, Florida
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Martins DM, Cardoso EM, Capellari L, Botelho LAB, Ferreira FA. Detection of Staphylococcus aureus from nares of elderly living in a Brazilian nursing home. Diagn Microbiol Infect Dis 2024; 108:116089. [PMID: 37931385 DOI: 10.1016/j.diagmicrobio.2023.116089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/23/2023] [Accepted: 09/14/2023] [Indexed: 11/08/2023]
Abstract
Asymptomatically nasal colonization by Staphylococcus aureus is a well-established risk factor for S. aureus infections. The aimed of the study was to identify the prevalence and factors associated with nasal carriage of S. aureus and Methicillin-resistant S. aureus (MRSA) from individuals residing in one Brazilian nursing home (NH). Three time-separate nasal swab collections were obtained from the elderly enrolled. The S. aureus isolates identified were submitted to Antimicrobial Susceptibility test (AST). The study showed a high prevalence of S. aureus (n = 9; 60%) and MRSA (n = 4; 26.7%) among elderly. Resistance to erythromycin was the most detected. S. aureus or MRSA colonization could not be associated to the data collected on demographics, personal habits, and medical history of the participants. Despite the small number of individuals enrolled, our study can contribute to improve the control of S. aureus and MRSA dissemination within the community, especially among the most vulnerable like the elderly.
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Affiliation(s)
- Damaris Miriã Martins
- Laboratório de Genética Molecular Bacteriana (GeMBac), Departamento de Microbiologia, Imunologia e Parasitologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Emanuela Mendes Cardoso
- Laboratório de Genética Molecular Bacteriana (GeMBac), Departamento de Microbiologia, Imunologia e Parasitologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Lilian Capellari
- Laboratório de Genética Molecular Bacteriana (GeMBac), Departamento de Microbiologia, Imunologia e Parasitologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Larissa Alvarenga Batista Botelho
- Departamento de Microbiologia Medica, Instituto de Microbiologia Paulo de Goes, Centro de Ciencias da Saude, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Fabienne Antunes Ferreira
- Laboratório de Genética Molecular Bacteriana (GeMBac), Departamento de Microbiologia, Imunologia e Parasitologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil.
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Cole M. Impact of dry hydrogen peroxide on environmental bioburden reduction in a long-term care facility. Am J Infect Control 2023; 51:1344-1349. [PMID: 37295673 DOI: 10.1016/j.ajic.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/31/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Environmental infection transmission is a perennial problem in long-term care facilities (LTCFs), exacerbated by shared living arrangements, residents with cognitive deficits, staffing shortages, and suboptimal cleaning and disinfection. This study evaluates the impact of dry hydrogen peroxide (DHP), as a supplement to manual decontamination, on bioburden within an LTCF neurobehavioral unit. METHODS In this prospective environmental cohort study utilizing DHP in an LTCF's 15-bed neurobehavioral unit, 264 surface microbial samples (44 per time point) were collected in 8 patient rooms, 2 communal areas on 3 consecutive days pre-DHP deployment and on days 14, 28, and 55 post-DHP deployments. The microbial reduction was evaluated by characterizing bioburden as total colony-forming units in each sampling site pre- and post-DHP deployment. Volatile organic compound levels were also measured in each patient area on all sampling dates. Multivariate regression was used to analyze microbial reductions associated with DHP exposure, controlling for sample and treatment sites. RESULTS A statistically significant relationship was detected between exposure to DHP and surface microbial load (P ≤ .00001). Additionally, the average volatile organic compound level postintervention was significantly lower than baseline levels (P = .0031). CONCLUSIONS DHP can significantly reduce surface bioburden in occupied spaces, potentially enhancing infection prevention, and control efforts in LTCFs.
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Affiliation(s)
- Mary Cole
- The Highlands at Brighton part of UR Medicine, Rochester, NY.
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4
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Duraiswamy S, Agarwalla S, Lok KS, Tse YY, Wu R, Wang Z. A multiplex Taqman PCR assay for MRSA detection from whole blood. PLoS One 2023; 18:e0294782. [PMID: 38011181 PMCID: PMC10681265 DOI: 10.1371/journal.pone.0294782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) causes a wide range of hospital and community-acquired infections worldwide. MRSA is associated with worse clinical outcomes that can lead to multiple organ failure, septic shock, and death, making timely diagnosis of MRSA infections very crucial. In the present work, we develop a method that enables the positive enrichment of bacteria from spiked whole blood using protein coated magnetic beads, followed by their lysis, and detection by a real-time multiplex PCR directly. The assay targeted bacterial 16S rRNA, S. aureus (spa) and methicillin resistance (mecA). In addition, an internal control (lambda phage) was added to determine the assay's true negative. To validate this assay, staphylococcal and non-staphylococcal bacterial strains were used. The three-markers used in this study were detected as expected by monomicrobial and poly-microbial models of the S. aureus and coagulase-negative staphylococci (CoNS). The thermal cycling completed within 30 mins, delivering 100% specificity. The detection LoD of the pre-processing step was ∼ 1 CFU/mL from 2-5mL of whole blood and that of PCR was ∼ 1pg of NA. However, the combined protocol led to a lower detection limit of 100-1000 MRSA CFUs/mL. The main issue with the method developed is in the pre-processing of blood which will be the subject of our future study.
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Affiliation(s)
- Suhanya Duraiswamy
- Department of Chemical Engineering, Indian Institute of Technology Hyderabad, Telangana, India
| | - Sushama Agarwalla
- Department of Chemical Engineering, Indian Institute of Technology Hyderabad, Telangana, India
| | - Khoi Sheng Lok
- Singapore Institute of Manufacturing Technology (SIMTech), Agency for Science, Technology and Research (A*STAR), Singapore, Republic of Singapore
| | - Yee Yung Tse
- Singapore Institute of Manufacturing Technology (SIMTech), Agency for Science, Technology and Research (A*STAR), Singapore, Republic of Singapore
| | - Ruige Wu
- Singapore Institute of Manufacturing Technology (SIMTech), Agency for Science, Technology and Research (A*STAR), Singapore, Republic of Singapore
| | - Zhiping Wang
- Singapore Institute of Manufacturing Technology (SIMTech), Agency for Science, Technology and Research (A*STAR), Singapore, Republic of Singapore
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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The Impact of the COVID-19 Pandemic on the Prevalence of Multidrug-Resistant Organisms in Veterans Affairs Nursing Homes. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Crnich CJ. Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19. J Am Med Dir Assoc 2022; 23:1909-1915. [PMID: 36423677 PMCID: PMC9666375 DOI: 10.1016/j.jamda.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022]
Abstract
Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.
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Affiliation(s)
- Christopher J Crnich
- School of Medicine & Public Health, University of Wisconsin-Madison, Madison, WI, USA; William S. Middleton Veterans Hospital Geriatric Research Education and Clinical Center, Madison, WI, USA.
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Gussin GM, Singh RD, Nguyen KP, Huang SS. Value of a confidential COVID-19 helpline for nursing home staff. Am J Infect Control 2022:S0196-6553(22)00788-X. [PMID: 36403708 PMCID: PMC9671874 DOI: 10.1016/j.ajic.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
We hosted a confidential helpline to address concerns about COVID-19 prevention among staff in 12 nursing homes in Orange County, California. We fielded 301 inquiries from April 2021-April 2022, most commonly involving questions about vaccines (40%), nursing home COVID-19 prevention (28%), SARS-CoV-2 variants (18%), symptom reporting (10%), and home and community COVID-19 prevention (5%). During COVID-19 surges, staff dominantly expressed fear, anger, and exhaustion. During nadirs, sentiment shifted towards optimism and acceptance.
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Affiliation(s)
- Gabrielle M Gussin
- Address correspondence to Gabrielle Gussin, MS, University of California Irvine School of Medicine, 100 Theory, Suite 120, Irvine, CA 92617
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Chahine EB, Cook RO, Carrion T, Sarkissian RJ. Impact of the Antimicrobial Stewardship Mandate on Multidrug-Resistant Organisms and Clostridioides difficile Infection Among Long-term Care Facility Residents. Sr Care Pharm 2022; 37:345-356. [PMID: 35879843 DOI: 10.4140/tcp.n.2022.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To determine whether the long-term care facility (LTCF) Centers for Medicare & Medicaid Services (CMS) Antimicrobial Stewardship (AMS) mandate was associated with a change in the combined rate of LTCF-acquired multidrug-resistant organism infection or colonization (MDRO-I/C) and Clostridioides difficile infection (CDI). Design Retrospective quasi-experimental study. Setting A 233-bed community hospital. Participants LTCF residents 75 years of age and older with MDRO-I/C or CDI admitted to the hospital before the AMS mandate in 2015 through 2016 or after the mandate in 2018 through 2019. Intervention LTCF CMS AMS mandate. Main Outcomes Measures Rates of LTCF-acquired MDRO-I/C and CDI. MDRO-I/C were defined by a culture positive for methicillin-resistant Staphylococcus aureus or extended-spectrum beta-lactamase-producing Enterobacterales. CDI was defined by a positive test for C. difficile using a multistep algorithm of toxin, glutamate dehydrogenase, and nucleic acid amplification tests. These specimens must have been collected within 48 hours of hospital admission. Results There were 33 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 205 hospitalized residents with MDRO-I/C or CDI in 2015 and 2016, resulting in a rate of 16.10%. In comparison, there were 38 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 253 hospitalized residents with MDRO-I/C or CDI in 2018 and 2019 resulting in a rate of 15.02%. The difference in the combined rate of LTCF-acquired MDRO-I/C and CDI was -1.08% (P = 0.75). Conclusion The AMS mandate was not associated with a significant change in the combined rate of LTCF-acquired MDRO-I/C and CDI, suggesting a need for more robust AMS programs in LTCFs.
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Affiliation(s)
- Elias B Chahine
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Ryan O Cook
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Tanya Carrion
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Robert J Sarkissian
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
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High frequency of extended-spectrum beta-lactamase-producing Enterobacteriaceae carriers at a Japanese long-term care hospital. J Infect Chemother 2022; 28:1578-1581. [DOI: 10.1016/j.jiac.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/01/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022]
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Sims S, Harris R, Hussein S, Rafferty AM, Desai A, Palmer S, Brearley S, Adams R, Rees L, Fitzpatrick JM. Social Distancing and Isolation Strategies to Prevent and Control the Transmission of COVID-19 and Other Infectious Diseases in Care Homes for Older People: An International Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063450. [PMID: 35329137 PMCID: PMC8955170 DOI: 10.3390/ijerph19063450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 12/18/2022]
Abstract
Older people living in care homes are at high risk of poor health outcomes and mortality if they contract COVID-19 or other infectious diseases. Measures used to protect residents include social distancing and isolation, although implementation is challenging. This review aimed to assess the social distancing and isolation strategies used by care homes to prevent and control the transmission of COVID-19 and other infectious diseases. Seven electronic databases were searched: Medline, CINAHL, Embase, PsycINFO, HMIC, Social Care Online, and Web of Science Core Collection. Grey literature was searched using MedRxiv, PDQ-Evidence, NICE Evidence Search, LTCCovid19.org and TRIP. Extracted data were synthesised using narrative synthesis and tabulation. 103 papers were included (10 empirical studies, seven literature reviews, and 86 policy documents). Strategies used to prevent and control the transmission of COVID-19 and other infectious diseases included social distancing and isolation of residents and staff, zoning and cohorting of residents, restriction of resident movement/activities, restriction of visitors and restriction of staff working patterns. This review demonstrates a lack of empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. Evaluative research on these interventions is needed urgently, focusing on the well-being of all residents, particularly those with hearing, vision or cognitive impairments.
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Affiliation(s)
- Sarah Sims
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK; (S.S.); (R.H.); (A.M.R.); (A.D.)
| | - Ruth Harris
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK; (S.S.); (R.H.); (A.M.R.); (A.D.)
| | - Shereen Hussein
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Anne Marie Rafferty
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK; (S.S.); (R.H.); (A.M.R.); (A.D.)
| | - Amit Desai
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK; (S.S.); (R.H.); (A.M.R.); (A.D.)
| | - Sinead Palmer
- Personal Social Services Research Unit, University of Kent, Canterbury CT2 7NZ, UK;
| | - Sally Brearley
- School of Nursing, Kingston University and St George’s University London, London SW17 0RE, UK;
| | | | - Lindsay Rees
- Encore Care Homes Management Ltd., Bournemouth BH8 9RL, UK;
| | - Joanne M. Fitzpatrick
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK; (S.S.); (R.H.); (A.M.R.); (A.D.)
- Correspondence:
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Resistência microbiana a medicamentos em uma Instituição de Longa Permanência para Idosos. ACTA PAUL ENFERM 2022. [DOI: 10.37689/acta-ape/2022ao03751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Iaboni A, Quirt H, Engell K, Kirkham J, Stewart S, Grigorovich A, Kontos P, McMurray J, Levy A, Bingham K, Rodrigues K, Astell A, Flint AJ, Maxwell C. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 2022; 22:74. [PMID: 35078424 PMCID: PMC8786624 DOI: 10.1186/s12877-022-02759-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/05/2022] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
People working in long-term care homes (LTCH) face difficult decisions balancing the risk of infection spread with the hardship imposed on residents by infection control and prevention (ICP) measures. The Dementia Isolation Toolkit (DIT) was developed to address the gap in ethical guidance on how to safely and effectively isolate people living with dementia while supporting their personhood. In this observational study, we report the results of a survey of LTCH staff on barriers and facilitators regarding isolating residents, and the impact of the DIT on staff moral distress.
Methods
We completed an online cross-sectional survey. Participants (n = 207) were staff working on-site in LTCH in Ontario, Canada since March 1, 2020, with direct or indirect experience with the isolation of residents. LTCH staff were recruited through provincial LTCH organizations, social media, and the DIT website. Survey results were summarized, and three groups compared, those: (1) unfamiliar with, (2) familiar with, and (3) users of the DIT.
Results
61% of respondents identified distress of LTCH staff about the harmful effects of isolation on residents as a major barrier to effective isolation. Facilitators for isolation included delivery of 1:1 activity in the resident’s room (81%) and designating essential caregivers to provide support (67%). Almost all respondents (84%) reported an increase in moral distress. DIT users were less likely to report an impact of moral distress on job satisfaction (odds ratio (OR) 0.41, 95% CI 0.19-0.87) with 48% of users reporting the DIT was helpful in reducing their level of moral distress.
Conclusions
Isolation as an ICP measure in LTCH environments creates moral distress among staff which is a barrier to its effectiveness. ICP guidance to LTCH would be strengthened by the inclusion of a dementia-specific ethical framework that addresses how to minimize the harms of isolation on both residents and staff.
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Wong VWY, Huang Y, Wei WI, Wong SYS, Kwok KO. Approaches to multidrug-resistant organism prevention and control in long-term care facilities for older people: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2022; 11:7. [PMID: 35033198 PMCID: PMC8761316 DOI: 10.1186/s13756-021-01044-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/23/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite clear evidence of benefits in acute-care hospitals, controversy over the effectiveness of IPC measures for MDROs is perceptible and evidence-based practice has not been established. OBJECTIVE To investigate the effects of IPC interventions on MDRO colonization and infections in LTCFs. DATA SOURCES Ovid MEDLINE, EMBASE, and CINAHL from inception to September 2020. ELIGIBILITY CRITERIA Original and peer-reviewed articles examining the post-intervention effects on MDRO colonization and infections in LTCFs. INTERVENTIONS (i) Horizontal interventions: administrative engagement, barrier precautions, education, environmental cleaning, hand hygiene, performance improvement, and source control; and (ii) vertical intervention: active surveillance plus decolonization. STUDY APPRAISAL AND SYNTHESIS We employed a random-effects meta-analysis to estimate the pooled risk ratios (pRRs) for methicillin-resistant Staphylococcus aureus (MRSA) colonization by intervention duration; and conducted subgroup analyses on different intervention components. Study quality was assessed using Cochrane risk of bias tools. RESULTS Of 3877 studies identified, 19 were eligible for inclusion (eight randomized controlled trials (RCTs)). Studies reported outcomes associated with MRSA (15 studies), vancomycin-resistant Enterococci (VRE) (four studies), Clostridium difficile (two studies), and Gram-negative bacteria (GNB) (two studies). Eleven studies were included in the meta-analysis. The pRRs were close to unity regardless of intervention duration (long: RR 0.81 [95% CI 0.60-1.10]; medium: RR 0.81 [95% CI 0.25-2.68]; short: RR 0.95 [95% CI 0.53-1.69]). Vertical interventions in studies with a small sample size showed significant reductions in MRSA colonization while horizontal interventions did not. All studies involving active administrative engagement reported reductions. The risk of bias was high in all but two studies. CONCLUSIONS Our meta-analysis did not show any beneficial effects from IPC interventions on MRSA reductions in LTCFs. Our findings highlight that the effectiveness of interventions in these facilities is likely conditional on resource availability-particularly decolonization and barrier precautions, due to their potential adverse events and uncertain effectiveness. Hence, administrative engagement is crucial for all effective IPC programmes. LTCFs should consider a pragmatic approach to reinforce standard precautions as routine practice and implement barrier precautions and decolonization to outbreak responses only.
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Affiliation(s)
- Valerie Wing Yu Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region, China
| | - Ying Huang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region, China
| | - Wan In Wei
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region, China
| | - Samuel Yeung Shan Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region, China
| | - Kin On Kwok
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region, China.
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region, China.
- Shenzhen Research Institute of The Chinese University of Hong Kong, Shenzhen, China.
- Hong Kong Institute of Asia-Pacific Studies, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region, China.
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Akine D, Sasahara T, Kiga K, Ae R, Kosami K, Yoshimura A, Kubota Y, Sasaki K, Kimura Y, Ogawa M, Watanabe S, Morisawa Y, Cui L. Distribution of Extended-Spectrum β-Lactamase Genes and Antimicrobial Susceptibility among Residents in Geriatric Long-Term Care Facilities in Japan. Antibiotics (Basel) 2021; 11:antibiotics11010036. [PMID: 35052913 PMCID: PMC8773109 DOI: 10.3390/antibiotics11010036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022] Open
Abstract
A high prevalence of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) may call for monitoring in geriatric long-term care facilities (g-LTCFs). We surveyed the distribution of ESBL-causative gene types and antimicrobial susceptibility in ESBL-PE strains from residents in g-LTCFs, and investigated the association between ESBL-causative gene types and antimicrobial susceptibility. First, we analyzed the types of ESBL-causative genes obtained from 141 ESBL-PE strains collected from the feces of residents in four Japanese g-LTCFs. Next, we determined the minimum inhibitory concentration values for alternative antimicrobial agents against ESBL-PE, including β-lactams and non-β-lactams. Escherichia coli accounted for 96% of the total ESBL-PE strains. Most strains (94%) contained blaCTX-M group genes. The genes most commonly underlying resistance were of the blaCTX-M-9 and blaCTX-M-1 groups. Little difference was found in the distribution of ESBL-causative genes among the facilities; however, antimicrobial susceptibility differed widely among the facilities. No specific difference was found between antimicrobial susceptibility and the number of ESBL-causative genes. Our data showed that ESBL-PEs were susceptible to some antimicrobial agents, but the susceptibility largely differed among facilities. These findings suggest that each g-LTCF may require specific treatment strategies based on their own antibiogram. Investigations into drug resistance should be performed in g-LTCFs as well as acute medical facilities.
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Affiliation(s)
- Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Teppei Sasahara
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
- Correspondence: (T.S.); (R.A.); Tel.: +81-285-58-7580 (T.S.)
| | - Kotaro Kiga
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
- Correspondence: (T.S.); (R.A.); Tel.: +81-285-58-7580 (T.S.)
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Hishimachi 3 chome, Kiryu 376-0001, Gunma, Japan;
| | - Yoshinari Kubota
- Nikko Citizen’s Hospital, Kiyotakiarasawamachi 1752-10, Nikko 321-1441, Tochigi, Japan;
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Shinya Watanabe
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Yuji Morisawa
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
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Ae R, Sasahara T, Yoshimura A, Kosami K, Hatakeyama S, Sasaki K, Kimura Y, Akine D, Ogawa M, Hamabata K, Cui L. Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities. Sci Rep 2021; 11:21607. [PMID: 34732819 PMCID: PMC8566574 DOI: 10.1038/s41598-021-01190-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 10/25/2021] [Indexed: 11/09/2022] Open
Abstract
Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.
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Affiliation(s)
- Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Teppei Sasahara
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Kiryu, Gunma, 376-0001, Japan
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shuji Hatakeyama
- Division of Infectious Diseases, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.,Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kenji Hamabata
- Gerontological Nursing, School of Nursing, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
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Insights into the epidemiology of community-associated methicillin-resistant Staphylococcus aureus in special populations and at the community-healthcare interface. Braz J Infect Dis 2021; 25:101636. [PMID: 34672988 PMCID: PMC9392173 DOI: 10.1016/j.bjid.2021.101636] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023] Open
Abstract
The current epidemic proportions of infections caused by Staphylococcus aureus strains and especially by methicillin-resistant S. aureus (MRSA) are one of today's many threats to global public health, particularly in underdeveloped countries where significant gaps on the subject exist. The rapid spread and diversification of pandemic clones that exhibit remarkably increasing virulence and antimicrobial resistance pose a risk to the effective prevention and treatment of a wide range of infections. Undoubtedly, the remarkable versatility involving the pathogenesis and resistance of these bacteria is perpetuated through geographic and temporal factors inherent to clonal evolution and is reflected in the dramatic epidemiological changes of MRSA which, after decades prevailing in healthcare settings, have emerged in the community. Denominated community-associated [CA]-MRSA, these strains are particularly prevalent in some population groups, facilitating the spread of successful clones that are potentially capable of triggering severe community-acquired infections. Therefore, a broad approach to local epidemiological aspects in less studied regions, but nonetheless at latent risk of endemic spread that may reach global proportions, is necessary. In Brazil, despite limited molecular epidemiology data, CA-MRSA strains predominantly characterized as SCCmec IV, often classified as CC30-ST30, CC5-ST5 and CC8-ST8, seem to be spreading across different population groups in different regions of the country. Another important fact addressed in this review is the identification of the ST398-MRSA-IV/V clone and methicillin-susceptible S. aureus (MSSA) in healthy individuals from the community. Although susceptible to methicillin, the ST398 clone is associated with severe infections in humans and animals, denominated livestock-associated MRSA. It is therefore important to encourage assertive actions by all government sectors and by society, with a reassessment of current public health measures in light of the new perspectives arising from the scientific and epidemiological data on MRSA.
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Martischang R, François P, Cherkaoui A, Gaïa N, Renzi G, Agostinho A, Perez M, Graf CE, Harbarth S. Epidemiology of ESBL-producing Escherichia coli from repeated prevalence studies over 11 years in a long-term-care facility. Antimicrob Resist Infect Control 2021; 10:148. [PMID: 34666836 PMCID: PMC8527759 DOI: 10.1186/s13756-021-01013-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/25/2021] [Indexed: 12/29/2022] Open
Abstract
Background Escherichia coli sequence type (ST) 131 H30 is an emerging multidrug resistant subclone, known to spread and cause outbreaks in long-term care facilities (LTCFs). Objectives and methods From 2010 through 2020, we performed 11 yearly surveillance studies for determining the prevalence of digestive carriage of ESBL-producing E. coli (ESBL-EC) among residents in a university-affiliated LCTF. Sequencing and genotyping of selected isolates were performed to characterize temporal trends in the prevalence and epidemic potential of ESBL-EC subclones, and for evaluating a potential rebound effect following discontinuation of contact precautions for ESBL-EC carriers in January 2019. Results This study included 2′403 LTCF residents, with 252 (10.5%) positive for ESBL-EC. Among the 236 ESBL-EC isolates available for typing, 58.0% belonged to the ST131 lineage, including 94/137 (68.6%) ST131 H30 isolates. An increasing yearly prevalence was observed for ESBL-EC (from 4.6 to 9.4%; p = 0.11), but not for the ST131 H30 subclone, which peaked in 2015 and declined thereafter. Multiple previously unnoticed ESBL-EC outbreaks occurred in the LTCF. Since 2018, we noted the clonal expansion of a rare ST131 H89 subclone (O16:H5) harboring CTX-M-14 and CTX-M-24. No rebound effect was observed in ESBL-EC prevalence nor in the different subclones following discontinuation of contact precautions for ESBL-EC carriers since 2019. Conclusion Clonal fluctuation was observed for ST131 H30 ESBL-EC with a current decline in prevalence. Surveillance should include the evolution of ST131 non-H30 subclones, which may spread in LTCFs. Our findings suggest that discontinuation of contact precautions for ESBL-EC carriers in LTCFs may be safely implemented, in support of European recommendations to limit ESBL-producing Enterobacteriaceae control measures in endemic settings to non-E. coli. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01013-7.
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Affiliation(s)
- Romain Martischang
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - Patrice François
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | | | - Nadia Gaïa
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Gesuele Renzi
- Bacteriology Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Americo Agostinho
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Monica Perez
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Christophe E Graf
- Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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He WP, Gu FF, Zhang J, Li XX, Xiao SZ, Zeng Q, Ni YX, Han LZ. Molecular characteristics and risk factor analysis of Staphylococcus aureus colonization put insight into CC1 colonization in three nursing homes in Shanghai. PLoS One 2021; 16:e0253858. [PMID: 34618818 PMCID: PMC8496869 DOI: 10.1371/journal.pone.0253858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/14/2021] [Indexed: 11/19/2022] Open
Abstract
Research indicates that Staphylococcus aureus colonization in the elderly with predisposing risks is associated with subsequent infection. However, the molecular epidemiology and risk factors for S. aureus colonization among residents and staff in nursing homes (NHs) in China remain unclear. A multicenter study was conducted in three NHs in Shanghai between September 2019 and October 2019. We explored the prevalence, molecular epidemiology, and risk factors for S. aureus colonization. All S. aureus isolates were characterized based on antimicrobial resistance, virulence genes, multilocus sequence typing (MLST), staphylococcus protein A (spa) typing, and staphylococcal cassette chromosome mec (SCCmec) typing. NH records were examined for potential risk factors for S. aureus colonization. S. aureus and methicillin-resistant S. aureus (MRSA) isolates were detected in 109 (100 residents and 9 staff, 19.8%, 109/551) and 28 (24 residents and 4 staff, 5.1%, 28/551) subjects among 496 residents and 55 staff screened, respectively. Compared to methicillin-susceptible S. aureus isolates, all 30 MRSA isolates had higher resistance rates to most antibiotics except minocycline, rifampicin, linezolid, vancomycin, and teicoplanin. Sequence type (ST) 1 (21.3%) was the most common sequence type, and t127 (20.5%) was the most common spa type among 122 S. aureus isolates. SCCmec type I (70%) was the dominant clone among all MRSA isolates. CC1 (26/122, 21.3%) was the predominant complex clone (CC), followed by CC398 (25/122, 20.5%), CC5 (20/122, 16.4%) and CC188 (18/122, 14.8%). Female sex (OR, 1.70; 95% CI, 1.04-2.79; P = 0.036) and invasive devices (OR, 2.19; 95% CI, 1.26-3.81; P = 0.006) were independently associated with S. aureus colonization.
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Affiliation(s)
- Wei-Ping He
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei-Fei Gu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji Zhang
- Department of Clinical Laboratory, Shanghai People’s Hospital of Putuo District, Shanghai, China
| | - Xin-Xin Li
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu-Zhen Xiao
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qian Zeng
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Xing Ni
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-Zhong Han
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Dunne EM, Hylsky D, Peterson E, Voermans R, Ward A, Turner K, Hahn C, Arduino M, Ball C, Carter KK, Lee JR. A cluster of Achromobacter xylosoxidans led to identification of Pseudomonas aeruginosa and Serratia marcescens contamination at a long-term-care facility. Am J Infect Control 2021; 49:1331-1333. [PMID: 33887423 DOI: 10.1016/j.ajic.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Abstract
A cluster of Achromobacter xylosoxidans, an emerging multidrug-resistant aquaphilic bacterium, was identified in 3 long-term-care facility residents. As Pseudomonas aeruginosa and Serratia marcescens were also present in clinical specimens, we conducted an investigation of all 3 water-associated species and identified P. aerguniosa and S. marcescens contamination at the facility. Sequencing analysis linked P. aeruginosa to a clinical isolate. Findings highlight the need for precautionary measures to prevent transmission of water-associated multidrug-resistant bacteria in long-term-care facilities.
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Bartsch SM, Wong KF, Mueller LE, Gussin GM, McKinnell JA, Tjoa T, Wedlock PT, He J, Chang J, Gohil SK, Miller LG, Huang SS, Lee BY. Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region. JAMA Netw Open 2021; 4:e2119212. [PMID: 34347060 PMCID: PMC8339938 DOI: 10.1001/jamanetworkopen.2021.19212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement. OBJECTIVE To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California. DESIGN, SETTING, AND PARTICIPANTS An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses. EXPOSURES Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities. MAIN OUTCOMES AND MEASURES MRSA and CRE prevalence and number of new carriers (ie, transmission events). RESULTS Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events). CONCLUSIONS AND RELEVANCE The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.
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Affiliation(s)
- Sarah M. Bartsch
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Kim F. Wong
- Center for Simulation and Modeling, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie E. Mueller
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Gabrielle M. Gussin
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Torrance Memorial Medical Center, Torrance, California
| | - Thomas Tjoa
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Patrick T. Wedlock
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Jiayi He
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Justin Chang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Shruti K. Gohil
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | | | - Susan S. Huang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Bruce Y. Lee
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
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Factors associated with environmental service worker cleaning practices in health care settings: A systematic review of the literature. Am J Infect Control 2021; 49:919-927. [PMID: 33434592 DOI: 10.1016/j.ajic.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/31/2020] [Accepted: 01/02/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Health care-associated infections can be reduced through better environmental disinfection practices. Central to effective disinfection is the environmental service worker (ESW). The aim of this systematic literature review was to identify factors associated with the disinfection practices of ESWs in health care settings. METHODS A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles. Ten online databases and search engines were selected for the review of English-language studies published between 2000 and 2019. RESULTS Thirty-one (31) eligible studies were identified. Environmental disinfection was associated with many factors (eg, knowledge, perceptions) as well as ESW exposure to education/training sessions. When education/training was combined with performance evaluation/feedback, significant improvement in ESW disinfection practices was reported. CONCLUSIONS To sustain improvements in disinfection practices, education/training sessions need to be continuous. The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs. Future studies need to use a randomized controlled design with larger sample sizes to determine a true effect.
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Mody L, Gontjes KJ, Cassone M, Gibson KE, Lansing BJ, Mantey J, Kabeto M, Galecki A, Min L. Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116555. [PMID: 34269807 PMCID: PMC8285736 DOI: 10.1001/jamanetworkopen.2021.16555] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Multidrug-resistant organisms (MDROs) can cause significant morbidity and mortality. Preventing MDROs can reduce the risk of subsequent transmission and infection. OBJECTIVE To determine whether a multicomponent infection prevention intervention can reduce MDRO prevalence in nursing homes (NHs). DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial of a multicomponent intervention was conducted in 6 NHs in Michigan from September 2016 to August 2018. Three NHs adopted a multicomponent intervention, while 3 control NHs continued without investigator intervention. Study visits were conducted at baseline; days 7, 14, 21, and 30; and monthly thereafter for up to 6 months or discharge. Visits included clinical data collection and MDRO surveillance culturing of multiple body sites and high-touch surfaces in patient rooms. Any patients who provided informed consent within 14 days of admission to the NH were enrolled in this study. Non-English speakers and patients receiving hospice care were ineligible. Analysis was performed from November 2018 to February 2020. INTERVENTIONS Intervention NHs adopted a multicomponent intervention that included enhanced barrier precautions, chlorhexidine bathing, MDRO surveillance, environmental cleaning education and feedback, hand hygiene promotion, and health care worker education and feedback. Control nursing homes continued standard care practices. MAIN OUTCOMES AND MEASURES The primary outcome, presence of MDROs, was measured longitudinally in the patient and room environment and was evaluated using generalized mixed effect models. The secondary outcome, time to new MDRO acquisition, was assessed using Cox proportional hazard models. RESULTS A total of 6 NHs were included, with 245 patients (mean [SD] age, 72.5 [13.6] years; 134 [54.7%] women) enrolled; 3 NHs with 113 patients (46.1%) were randomized to the intervention group and 3 NHs with 132 patients (53.9%) were randomized to the control group. A total of 132 patients (53.9%) were White, and 235 patients (95.9%) were receiving postacute care. Over 808 study visits, 3654 patient cultures and 5606 environmental cultures were obtained. The intervention reduced the odds of MDRO prevalence in patients' environment by 43% (aOR, 0.57; 95% CI, 0.35-0.94), but there was no statistically significant difference on the patient level before or after adjustment (aOR, 0.57; 95% CI, 0.29-1.14). There were no significant reductions in time to new acquisition for methicillin-resistant Staphylococcus aureus (hazard ratio [HR], 0.20; 95% CI, 0.04-1.09), vancomycin-resistant enterococci (HR, 0.84; 95% CI, 0.46-1.53), or resistant gram-negative bacilli (HR, 1.14; 95% CI, 0.73-1.78). CONCLUSIONS AND RELEVANCE This cluster randomized clinical trial found that the multicomponent intervention reduced the prevalence of MDROs in the environment of NH patients. Our findings highlight the potential for multicomponent interventions to directly and indirectly reduce MDRO prevalence in NHs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02909946.
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Affiliation(s)
- Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Kyle J. Gontjes
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Marco Cassone
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Kristen E. Gibson
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Bonnie J. Lansing
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Julia Mantey
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Mohammed Kabeto
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Andrzej Galecki
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Lillian Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Healthcare personnel experiences implementing carbapenem-resistant Enterobacterales infection control measures at a ventilator-capable skilled nursing facility-A qualitative analysis. Infect Control Hosp Epidemiol 2021; 43:1010-1016. [PMID: 34154697 DOI: 10.1017/ice.2021.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ventilator-capable skilled nursing facilities (vSNFs) are critical to the epidemiology and control of antibiotic-resistant organisms. During an infection prevention intervention to control carbapenem-resistant Enterobacterales (CRE), we conducted a qualitative study to characterize vSNF healthcare personnel beliefs and experiences regarding infection control measures. DESIGN A qualitative study involving semistructured interviews. SETTING One vSNF in the Chicago, Illinois, metropolitan region. PARTICIPANTS The study included 17 healthcare personnel representing management, nursing, and nursing assistants. METHODS We used face-to-face, semistructured interviews to measure healthcare personnel experiences with infection control measures at the midpoint of a 2-year quality improvement project. RESULTS Healthcare personnel characterized their facility as a home-like environment, yet they recognized that it is a setting where germs were 'invisible' and potentially 'threatening.' Healthcare personnel described elaborate self-protection measures to avoid acquisition or transfer of germs to their own household. Healthcare personnel were motivated to implement infection control measures to protect residents, but many identified structural barriers such as understaffing and time constraints, and some reported persistent preference for soap and water. CONCLUSIONS Healthcare personnel in vSNFs, from management to frontline staff, understood germ theory and the significance of multidrug-resistant organism transmission. However, their ability to implement infection control measures was hampered by resource limitations and mixed beliefs regarding the effectiveness of infection control measures. Self-protection from acquiring multidrug-resistant organisms was a strong motivator for healthcare personnel both outside and inside the workplace, and it could explain variation in adherence to infection control measures such as a higher hand hygiene adherence after resident care than before resident care.
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Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:1431-1438. [PMID: 34118423 DOI: 10.1016/j.cmi.2021.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/14/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Long-term care facilities (LTCFs) are health-care settings with high antimicrobial consumption and hence need to develop effective antimicrobial stewardship programmes (ASPs). OBJECTIVE To assess the effects of ASPs on care-related, clinical and ecological outcomes in LTCFs. METHODS Data sources were PubMed, EMBASE, CINAHL and SCOPUS. Study eligibility criteria were original research articles (controlled clinical trials or controlled before and after studies) published up to 1 October 2020. Participants were adult residents of LTCFs, residential aged-care facilities, nursing homes, veterans' homes, skilled nursing facilities and assisted living facilities for older people. Interventions included ASPs versus standard care. Outcomes assessed were antimicrobial consumption and appropriateness, infections, hospital admissions and mortality. Available data were pooled in a meta-analysis, and inconsistency between studies was evaluated using the I2 statistic. Certainty of evidence was assessed using the GRADE approach. RESULTS Of the 3111 papers identified, 12 studies met the inclusion criteria. All of them analysed the impact of interventions on antimicrobial use based on consumption-related variables (n = 8) and/or percentage of inappropriate prescriptions (n = 6). Pooled data showed a mean difference of -0.47 prescriptions per 1000 resident-days in favour of ASPs (95% CI -0.87 to -0.07, I2 = 71%). Five studies analysed the clinical effect of ASPs on the number of hospital admissions and/or resident mortality. The meta-analysis showed a mean difference of 0.17 hospital admissions per 1000 resident-days (95% CI -0.07 to 0.41, I2 = 17%) and a mean difference of -0.02 deaths per 1000 resident-days (95% CI -0.14 to 0.09, I2 = 0%). Only two studies included infections as a study outcome. CONCLUSIONS ASPs appear to improve antimicrobial use in this setting without increasing hospital admissions or deaths, indicating that these programmes do not lead to under-treatment of infections. Nonetheless, further higher-quality clinical trials are required to understand the effects of ASPs in LTCFs. PROSPERO REGISTRATION NUMBER CRD42021225127.
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Aliyu S, McGowan K, Hussain D, Kanawati L, Ruiz M, Yohannes S. Prevalence and Outcomes of Multi-Drug Resistant Blood Stream Infections Among Nursing Home Residents Admitted to an Acute Care Hospital. J Intensive Care Med 2021; 37:565-571. [PMID: 33938320 DOI: 10.1177/08850666211014450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The prevalence of multi-drug resistant organism (MDRO) colonization in nursing home residents has been well documented, but little is known about the impact of MDRO bloodstream infections (BSIs). The aim of this study was to assess the prevalence, cost, and outcomes of MDRO-BSI vs. non-MDRO-BSI among nursing home residents. DESIGN Retrospective cohort study. SETTING 960 bed tertiary academic medical center. PATIENTS Persons ≥18 years old admitted to an acute care tertiary hospital from Skilled Nursing Facilities with a diagnosis of sepsis between 2015 and 2018. INTERVENTIONS Retrospective analysis of prevalence and outcomes. MEASUREMENTS AND MAIN RESULTS Among patients admitted to the study hospital with a diagnosis of sepsis during the study period, 7% were from nursing homes. The prevalence of MDRO-BSI was 47%. We identified 54 (50%) gram positive BSIs, 48 (45%) gram negative BSI and 5 (5%) fungal BSI. Thirty-one (57%) of the gram-positive infections and 14 (30%) of the gram-negative infections were with MDROs. The prevalence of BSI organisms were Staphylococcus aureus in 24%, Escherichia coli in 14%, Proteus mirabilis in 13%, Staphylococcus epidermidis in 8%, Enterococcus faecalis in 7%, and Klebsiella pneumoniae in 6%. We found that intensive care unit length of stay (7 days vs 5 days, P = .009), direct cost ($13,639 vs $9,922, P = .027), and total cost ($23,752 vs $17,900 P = .032) were significantly higher in patients with MDRO-BSI vs. non-MDRO-BSI. Patients with MDRO-BSI were twice as likely to receive inappropriate empiric antiinfective therapy (31% vs 16%, P = .006) and were more likely to die (49.1% vs 29.6%, P = .049). CONCLUSION Nursing home residents have a high prevalence of MDRO-BSI, which is associated with higher risk of receiving inappropriate initial anti-infective therapy, higher cost, higher ICU LOS, and higher mortality. Our research adds new information about the prevalence of fungemia in this population.
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Affiliation(s)
- Sainfer Aliyu
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Kevin McGowan
- Georgetown University School of Medicine, Washington, DC, USA
| | - Dilbi Hussain
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Lama Kanawati
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Maria Ruiz
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Seife Yohannes
- 8405MedStar Washington Hospital Center, Washington, DC, USA
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Wang J, Foxman B, Pirani A, Lapp Z, Mody L, Snitkin ES. Application of Combined Genomic and Transfer Analyses to Identify Factors Mediating Regional Spread of Antibiotic-resistant Bacterial Lineages. Clin Infect Dis 2021; 71:e642-e649. [PMID: 32239131 DOI: 10.1093/cid/ciaa364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/31/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients entering nursing facilities (NFs) are frequently colonized with antibiotic-resistant organisms (AROs). To understand the determinants of ARO colonization on NF admission, we applied whole-genome sequencing to track the spread of 4 ARO species across regional NFs and evaluated patient-level characteristics and transfer acute care hospitals (ACHs) as risk factors for colonization. METHODS Patients from 6 NFs (n = 584) were surveyed for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis/faecium (VREfc/VREfm), and ciprofloxacin-resistant Escherichia coli (CipREc) colonization. Genomic analysis was performed to quantify ARO spread between NFs and compared to patient-transfer networks. The association between admission colonization and patient-level variables and recent ACH exposures was examined. RESULTS The majority of ARO isolates belonged to major healthcare-associated lineages: MRSA (sequence type [ST] 5); VREfc (ST6); CipREc (ST131), and VREfm (clade A). While the genomic similarity of strains between NF pairs was positively associated with overlap in their feeder ACHs (P < .05 for MRSA, VREfc, and CipREc), limited phylogenetic clustering by either ACH or NF supported regional endemicity. Significant predictors for ARO colonization on NF admission included lower functional status and recent exposure to glycopeptides (adjusted odds ratio [aOR], > 2 for MRSA and VREfc/VREfm) or third-/fourth-generation cephalosporins (aOR, > 2 for MRSA and VREfm). Transfer from specific ACHs was an independent risk factor for only 1 ARO/ACH pair (VREfm/ACH19: aOR, 2.48). CONCLUSIONS In this region, healthcare-associated ARO lineages are endemic among connected NFs and ACHs, making patient characteristics more informative of NF admission colonization risk than exposure to specific ACHs.
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Affiliation(s)
- Joyce Wang
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Betsy Foxman
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Ali Pirani
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zena Lapp
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Evan S Snitkin
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Thompson ND, Stone ND, Brown CJ, Penna AR, Eure TR, Bamberg WM, Barney GR, Barter D, Clogher P, DeSilva MB, Dumyati G, Frank L, Felsen CB, Godine D, Irizarry L, Kainer MA, Li L, Lynfield R, Mahoehney JP, Maloney M, Nadle J, Ocampo VLS, Pierce R, Ray SM, Davis SS, Sievers M, Srinivasan K, Wilson LE, Zhang AY, Magill SS. Antimicrobial Use in a Cohort of US Nursing Homes, 2017. JAMA 2021; 325:1286-1295. [PMID: 33821897 PMCID: PMC8025112 DOI: 10.1001/jama.2021.2900] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. OBJECTIVE To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. EXPOSURES Residence in one of the participating nursing homes at the time of the survey. MAIN OUTCOMES AND MEASURES Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. RESULTS Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. CONCLUSIONS AND RELEVANCE In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.
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Affiliation(s)
- Nicola D. Thompson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D. Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cedric J. Brown
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Austin R. Penna
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Taniece R. Eure
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Now with Medical Epidemiology Consulting, Denver, Colorado
| | - Grant R. Barney
- New York Emerging Infections Program, Rochester
- Now with New York State Department of Health, Albany
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver
| | - Paula Clogher
- Connecticut Emerging Infections Program, New Haven
- Yale School of Public Health, New Haven, Connecticut
| | - Malini B. DeSilva
- Minnesota Department of Health, St Paul
- Now with HealthPartners Institute, Minneapolis, Minnesota
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester, Rochester, New York
| | - Linda Frank
- California Emerging Infections Program, Oakland
| | - Christina B. Felsen
- New York Emerging Infections Program, Rochester
- University of Rochester, Rochester, New York
| | | | | | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Now with Western Health, Melbourne, Australia
| | - Linda Li
- Maryland Emerging Infections Program, Maryland Department of Health, Baltimore
| | | | | | | | | | | | | | - Susan M. Ray
- Georgia Emerging Infections Program, Atlanta
- Emory University, Atlanta, Georgia
| | | | | | | | - Lucy E. Wilson
- Maryland Emerging Infections Program, Maryland Department of Health, Baltimore
- Now with Maryland Emerging Infections Program, University of Maryland Baltimore County, Baltimore
| | | | - Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, Aydelotte ME, Karlic A, Nicholas NC, Petrone KK, Pine RD, Schabel SL, Medina-Walpole A, Dumyati GK. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. J Am Med Dir Assoc 2021; 21:55-61.e2. [PMID: 31888865 DOI: 10.1016/j.jamda.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS Six NHs in Monroe County, NY. METHODS A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.
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Affiliation(s)
- Christina B Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC
| | - Grant R Barney
- Emerging Infections Program, New York State Department of Health, Albany, NY
| | - Dallas L Nelson
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Joseph A Nicholas
- Department of Medicine and Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Alexander Karlic
- Unity Living Center and Unity Hospital, Rochester Regional Health, Rochester, NY
| | - Nirmala C Nicholas
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | | | | | - Scott L Schabel
- Division of Long Term Care, Rochester Regional Health, Rochester, NY
| | - Annette Medina-Walpole
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Ghinwa K Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY; Department of Medicine, Division of Infectious Disease, University of Rochester Medical Center, Rochester, NY.
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Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee. J Am Med Dir Assoc 2021; 21:12-24.e2. [PMID: 31888862 DOI: 10.1016/j.jamda.2019.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 02/04/2023]
Abstract
The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.
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Lena P, Ishak A, Karageorgos SA, Tsioutis C. Presence of Methicillin-Resistant Staphylococcus aureus (MRSA) on Healthcare Workers' Attire: A Systematic Review. Trop Med Infect Dis 2021; 6:42. [PMID: 33807299 PMCID: PMC8103237 DOI: 10.3390/tropicalmed6020042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022] Open
Abstract
Contaminated healthcare workers' (HCW) clothing risk transferring methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. We performed a systematic review in Pubmed and Scopus for 2000-2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to analyze evidence of MRSA on HCW attire. The primary study outcome was MRSA isolation rates on HCW clothing in healthcare settings. Out of 4425 articles, 23 studies were included: 18 with 1760 HCWs, four with 9755 HCW-patient interactions and one with 512 samples. There was a notable variation in HCWs surveyed, HCW attires, sampling techniques, culture methods and laundering practices. HCW attire was frequently colonized with MRSA with the highest rates in long-sleeved white coats (up to 79%) and ties (up to 32%). Eight studies reported additional multidrug-resistant bacteria on the sampled attire. HCW attire, particularly long-sleeved white coats and ties, is frequently contaminated with MRSA. Banning certain types and giving preference to in-house laundering in combination with contact precautions can effectively decrease MRSA contamination and spread.
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Affiliation(s)
- Pavlina Lena
- School of Sciences, European University Cyprus, Nicosia 2404, Cyprus;
| | - Angela Ishak
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (A.I.); (S.A.K.)
| | - Spyridon A Karageorgos
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (A.I.); (S.A.K.)
- Department of Pediatrics, Limassol General Hospital, Limassol 3304, Cyprus
| | - Constantinos Tsioutis
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (A.I.); (S.A.K.)
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Association between level of care and colonization with resistant gram-negative bacteria among nursing-home residents. Infect Control Hosp Epidemiol 2021; 42:760-762. [PMID: 33749575 DOI: 10.1017/ice.2020.1274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In this cross-sectional study, we examined the relationship between resident level of care in the nursing home and colonization with resistant gram-negative bacteria. Residential-care residents were more likely to be colonized with resistant gram-negative bacteria than were postacute care residents (odds ratio, 2.3; 95% confidence interval, 1.40-3.80; P < .001).
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Risk adjustment for benchmarking nursing home infection surveillance data: A narrative review. Am J Infect Control 2021; 49:366-374. [PMID: 32791257 DOI: 10.1016/j.ajic.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/20/2022]
Abstract
Until recently, there was no national surveillance system for monitoring infection occurrence in long-term care facilities (LTCF) in the United States. As a result, there are no national benchmarks for LTCF infection rates that can be utilized for quality improvement at the facility level. One of the major challenges in the reporting of health care-related infection data is accounting for nonmodifiable facility and patient characteristics that influence benchmarks for infection. The objectives of this paper are to review: (a) published infection rates in LTCF in the United States to assess the level of variability; (b) studies describing facility- and resident-level risk factors for infection that can be used in risk adjustment models; (c) published attempts to risk-adjust LTCF infection rates; and (d) efforts to develop models specifically for risk adjustment of infection rates in LTCF for benchmarking. It is anticipated that this review will stimulate further study of methods to risk-adjust LTCF infection rates for benchmarking that will facilitate research and public reporting.
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Nelson RE, Lautenbach E, Chang N, Jones M, Willson T, David M, Linkin D, Glick H, Doshi JA, Stevens VW. Attributable Cost of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infection in a Long-term Care Center. Clin Infect Dis 2021; 72:S27-S33. [PMID: 33512522 DOI: 10.1093/cid/ciaa1582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies have shown that healthcare-associated infections (HAIs) due to methicillin-resistant Staphylococcus aureus (MRSA) can lead to substantial healthcare costs in acute care settings. However, little is known regarding the consequences of these infections on patients in long-term care centers (LTCCs). The purpose of this study was to estimate the attributable cost of MRSA HAIs in LTCCs within the Department of Veterans Affairs (VA). METHODS We performed a retrospective cohort study of patients admitted to VA LTCCs between 1 January 2009 and 30 September 2015. MRSA HAIs were defined as a positive clinical culture at least 48 hours after LTCC admission so as to exclude community-acquired infections. Positive cultures were further classified by site (sterile or nonsterile). We used multivariable generalized linear models and 2-part models to compare the LTCC and acute care costs between patients with and without an MRSA HAI. RESULTS In our primary analysis, there was no difference in LTCC costs between patients with and without a MRSA HAI. There was, however, a significant increase in the odds of being transferred to an acute care facility (odds ratio, 4.40 [95% confidence interval {CI}, 3.40-5.67]) and in acute care costs ($9711 [95% CI, $6961-$12 462]). CONCLUSIONS Our findings of high cost and increased risk of transfer from LTCC to acute care are important because they highlight the substantial clinical and economic impact of MRSA infections in this population.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ebbing Lautenbach
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nelson Chang
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Makoto Jones
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tina Willson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael David
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darren Linkin
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Henry Glick
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jalpa A Doshi
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa W Stevens
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Sasahara T, Kosami K, Yoshimura A, Ae R, Akine D, Ogawa M, Morisawa Y. Improvement of hand hygiene adherence among staff in long-term care facilities for elderly in Japan. J Infect Chemother 2020; 27:329-335. [PMID: 33341372 DOI: 10.1016/j.jiac.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hand hygiene is crucial for infection control in long-term care facilities for elderly (LTCFEs), because it can be easily implemented in the low-resource settings of LTCFEs. This study investigated the actual status of hand hygiene adherence in LTCFEs, identified the factors inhibiting its appropriate implementation, and evaluated the effectiveness of a hand hygiene promotion program. METHODS In this before-and-after study, participants were staff members (n = 142) at two LTCFEs in Gunma Prefecture, Japan. We modified the World Health Organization's "five moments for hand hygiene" and assessed participants' hand hygiene adherence rates in four situations: (1) Before touching around a resident's mucous membrane area; (2) Before medical practice or clean/aseptic procedures; (3) After body fluid exposure/risk or after touching around a resident's mucous membrane area; and (4) After touching a resident's contaminated environments. The study was divided into four phases. In Phase 1, participants self-assessed their hand hygiene adherence using a questionnaire. In Phase 2, we objectively assessed participants' pre-intervention adherence rates. In Phase 3, an intervention comprising various hand hygiene promotion measures, such as education and hands-on training on hand hygiene practices and timings, was implemented. In Phase 4, participants' post-intervention adherence rates were objectively measured. RESULTS Although most participants reported high hand hygiene adherence rate in the self-assessment (93.1%), the pre-intervention evaluation revealed otherwise (16.8%). Participants' post-intervention adherence rates increased for all four situations (77.3%). CONCLUSION The intervention program helped increase participants' hand hygiene adherence rates, indicating its effectiveness. Similar interventions in other LTCFEs may also improve adherence rates.
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Affiliation(s)
- Teppei Sasahara
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan; Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Kiryu, Gunma, 376-0001, Japan.
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan; Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Yuji Morisawa
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
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Sasahara T, Ae R, Yoshimura A, Kosami K, Sasaki K, Kimura Y, Akine D, Ogawa M, Hamabata K, Hatakeyama S, Cui L. Association between length of residence and prevalence of MRSA colonization among residents in geriatric long-term care facilities. BMC Geriatr 2020; 20:481. [PMID: 33208107 PMCID: PMC7672839 DOI: 10.1186/s12877-020-01885-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
Background A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization has been reported among residents in geriatric long-term care facilities (LTCFs). Some studies indicate that MRSA might be imported from hospitals into LTCFs via resident transfer; however, other studies report that high MRSA prevalence might be caused by cross-transmission inside LTCFs. We aimed to assess which factors have a large impact on the high MRSA prevalence among residents of geriatric LTCFs. Methods We conducted a cohort study among 260 residents of four geriatric LTCFs in Japan. Dividing participants into two cohorts, we separately analyzed (1) the association between prevalence of MRSA carriage and length of LTCF residence (Cohort 1: n = 204), and (2) proportion of residents identified as MRSA negative who were initially tested at admission but subsequently identified as positive in secondary testing performed at ≥2 months after their initial test (Cohort 2: n = 79). Results Among 204 residents in Cohort 1, 20 (9.8%) were identified as positive for MRSA. Compared with residents identified as MRSA negative, a larger proportion of MRSA-positive residents had shorter periods of residence from the initial admission (median length of residence: 5.5 vs. 2.8 months), although this difference was not statistically significant (p = 0.084). Among 79 residents in Cohort 2, 60 (75.9%) were identified as MRSA negative at the initial testing. Of these 60 residents, only one (1.7%) had subsequent positive conversion in secondary MRSA testing. In contrast, among 19 residents identified as MRSA positive in the initial testing, 10 (52.6%) were negative in secondary testing. Conclusions The prevalence of MRSA was lower among residents with longer periods of LTCF residence than among those with shorter periods. Furthermore, few residents were found to become MRSA carrier after their initial admission. These findings highlight that MRSA in LTCFs might be associated with resident transfer rather than spread via cross-transmission inside LTCFs.
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Affiliation(s)
- Teppei Sasahara
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Akio Yoshimura
- Medical corporation Sanikukai Nissin Hospital, Kiryu, Gunma, 376-0001, Japan
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.,Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kenji Hamabata
- Gerontological Nursing, School of Nursing, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shuji Hatakeyama
- Division of Infectious Diseases, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
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Targeted gown and glove use to prevent Staphylococcus aureus acquisition in community-based nursing homes: A pilot study. Infect Control Hosp Epidemiol 2020; 42:448-454. [PMID: 33077004 DOI: 10.1017/ice.2020.1219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents. DESIGN Uncontrolled clinical trial. SETTING This study was conducted in 2 community-based nursing homes in Maryland. PARTICIPANTS The study included 322 residents on mixed short- and long-stay units. METHODS During a 2-month baseline period, all residents had nose and inguinal fold swabs taken to estimate S. aureus acquisition. The intervention was iteratively developed using a participatory human factors engineering approach. During a 2-month intervention period, healthcare personnel wore gowns and gloves for high-risk care activities while caring for residents with wounds or medical devices, and S. aureus acquisition was measured again. Whole-genome sequencing was used to assess whether the acquisition represented resident-to-resident transmission. RESULTS Among short-stay residents, the methicillin-resistant S. aureus acquisition rate decreased from 11.9% during the baseline period to 3.6% during the intervention period (odds ratio [OR], 0.28; 95% CI, 0.08-0.92; P = .026). The methicillin-susceptible S. aureus acquisition rate went from 9.1% during the baseline period to 4.0% during the intervention period (OR, 0.41; 95% CI, 0.12-1.42; P = .15). The S. aureus resident-to-resident transmission rate decreased from 5.9% during the baseline period to 0.8% during the intervention period. CONCLUSIONS Targeted gown and glove use by healthcare personnel for high-risk care activities while caring for residents with wounds or medical devices, regardless of their S. aureus colonization status, is feasible and potentially decreases S. aureus acquisition and transmission in short-stay community-based nursing-home residents.
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McKinnell JA, Singh RD, Miller LG, Kleinman K, Gussin G, He J, Saavedra R, Dutciuc TD, Estevez M, Chang J, Heim L, Yamaguchi S, Custodio H, Gohil SK, Park S, Tam S, Robinson PA, Tjoa T, Nguyen J, Evans KD, Bittencourt CE, Lee BY, Mueller LE, Bartsch SM, Jernigan JA, Slayton RB, Stone ND, Zahn M, Mor V, McConeghy K, Baier RR, Janssen L, O'Donnell K, Weinstein RA, Hayden MK, Coady MH, Bhattarai M, Peterson EM, Huang SS. The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California. Clin Infect Dis 2020; 69:1566-1573. [PMID: 30753383 DOI: 10.1093/cid/ciz119] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs. METHODS A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility. RESULTS Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage. CONCLUSIONS The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.
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Affiliation(s)
- James A McKinnell
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Raveena D Singh
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Loren G Miller
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Ken Kleinman
- University of Massachusetts Amherst School of Public Health and Health Sciences, Orange
| | - Gabrielle Gussin
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jiayi He
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Raheeb Saavedra
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Tabitha D Dutciuc
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Marlene Estevez
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Justin Chang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Lauren Heim
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Stacey Yamaguchi
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Harold Custodio
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Shruti K Gohil
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Steven Park
- University of California Irvine Health, Orange
| | - Steven Tam
- Division of Geriatrics, Department of Medicine, University of California Irvine, Orange
| | | | - Thomas Tjoa
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jenny Nguyen
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | | | | | - Bruce Y Lee
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Leslie E Mueller
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Bartsch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Zahn
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kevin McConeghy
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Rosa R Baier
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Lynn Janssen
- Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Kathleen O'Donnell
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California.,Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Robert A Weinstein
- Cook County Health and Hospitals System, Chicago, Illinois.,Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mary K Hayden
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Micaela H Coady
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Megha Bhattarai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Susan S Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange.,Health Policy Research Institute, University of California Irvine School of Medicine
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Octaria R, Chan A, Wolford H, Devasia R, Moon TD, Zhu Y, Slayton RB, Kainer MA. Web-Based Interactive Tool to Identify Facilities at Risk of Receiving Patients with Multidrug-Resistant Organisms. Emerg Infect Dis 2020; 26:2046-2053. [PMID: 32818409 PMCID: PMC7454098 DOI: 10.3201/eid2609.191691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To identify facilities at risk of receiving patients colonized or infected with multidrug-resistant organisms (MDROs), we developed an interactive web-based interface for visualization of patient-sharing networks among healthcare facilities in Tennessee, USA. Using hospital discharge data and the Centers for Medicare and Medicaid Services' claims and Minimum Data Set, we constructed networks among hospitals and skilled nursing facilities. Networks included direct and indirect transfers, which accounted for <365 days in the community outside of facility admissions. Authorized users can visualize a facility of interest and tailor visualizations by year, network dataset, length of time in the community, and minimum number of transfers. The interface visualizes the facility of interest with its connected facilities that receive or send patients, the number of interfacility transfers, and facilities at risk of receiving transfers from the facility of interest. This tool will help other health departments enhance their MDRO outbreak responses.
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Sangeda RZ, Kibona J, Munishi C, Arabi F, Manyanga VP, Mwambete KD, Horumpende PG. Assessment of Implementation of Antimicrobial Resistance Surveillance and Antimicrobial Stewardship Programs in Tanzanian Health Facilities a Year After Launch of the National Action Plan. Front Public Health 2020; 8:454. [PMID: 32974264 PMCID: PMC7481440 DOI: 10.3389/fpubh.2020.00454] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 01/29/2023] Open
Abstract
Introduction: Antimicrobial resistance (AMR) is a current global health threat and a challenge to the treatment of infectious diseases. The WHO advocates a strategy of antibiotic stewardship programs (ASP) in optimizing antimicrobial use in hospitals. This study aimed at assessing the existence of AMR surveillance and ASP implementation in health facilities in Tanzania in the year following the launch of the National Action Plan (NAP). Methodology: From December 2017 through July 2018, a descriptive cross-sectional study was conducted using a structured questionnaire administered online. A total of 199 health facilities in Tanzania mainland whose contacts was obtained from the Ministry of Health Community Development Gender Elderly and Children (MoHCDGEC) were reached by phone and thereafter, a survey was sent via text or e-mail to focal persons in the corresponding facilities. Results: Only 39 (32.5%) responses from contacted facilities were received and analyzed. Thirty (76.9%) of the facilities were government-owned. Of the 39 respondents surveyed, 13 (35.9%) declared to have implemented some sort of coordinated ASP to promote the rational use of antimicrobials at their facilities. The respondents reported the presence of guidelines for the implementation of ASP at variable proportions, whereas the presence of a committee for Infection Prevention and Control was reported by 27 (69.2%). Twenty-four (61.5%) had a Medical and Therapeutic Committee. Although all 39 (100%) respondents were aware of the presence of AMR in Tanzania, only 26 (66.7%) were aware of the presence of the Tanzanian NAP for AMR. Hospital antibiotic policy document was present in 6 (15.4%) facilities. Only 7 (17.9%) facilities conducted prescription auditing; 9 (23.1%) had a hospital formulary; 14 (35.9%) had standard hospital prescription. 9 (23.1%) had software for data storage about AMR. Only 7 (17.9%) facilities conducted microorganisms' susceptibility tests and kept the record of the microorganism susceptibility testing. Conclusion: Our study found the existence of AMR surveillance activities and ASP implementation in Tanzania, albeit at a low level. The implementation was inconsistent across the surveyed facilities. These data have identified areas of improvement in addressing AMR in Tanzania through the NAP.
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Affiliation(s)
- Raphael Z Sangeda
- Department Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joel Kibona
- Department Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Castory Munishi
- Department Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Frank Arabi
- Department Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Vicky P Manyanga
- Department of Medicinal Chemistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kennedy D Mwambete
- Department Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Pius G Horumpende
- Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Department of Microbiology, Immunology and Molecular Biology, Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania.,Department of Preventive Medicine and Research, Lugalo General Military Hospital (GMH) and Military College of Medical Sciences (MCMS), Dar es Salaam, Tanzania
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Nace DA, Hanlon JT, Crnich CJ, Drinka PJ, Schweon SJ, Anderson G, Perera S. A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents. JAMA Intern Med 2020; 180:944-951. [PMID: 32391862 PMCID: PMC7215632 DOI: 10.1001/jamainternmed.2020.1256] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections. OBJECTIVE To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents. DESIGN, SETTING, AND PARTICIPANTS A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018. INTERVENTIONS Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death. RESULTS Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]). CONCLUSIONS AND RELEVANCE This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Christopher J Crnich
- Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison.,Medical Service, William S. Middleton Veterans Affairs Hospital, Madison, Wisconsin
| | - Paul J Drinka
- Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison
| | | | - Gulsum Anderson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mayer J, Stone ND, Leecaster M, Hu N, Pettey W, Samore M, Pacheco SM, Sambol S, Donskey C, Jencson A, Gupta K, Strymish J, Johnson D, Woods C, Young E, McDonald LC, Gerding D. Reinforcement of an infection control bundle targeting prevention practices for Clostridioides difficile in Veterans Health Administration nursing homes. Am J Infect Control 2020; 48:626-632. [PMID: 31812271 DOI: 10.1016/j.ajic.2019.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. METHODS A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. RESULTS All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87-197 vs. post 84-245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. DISCUSSION Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. CONCLUSIONS Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.
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Determining the ideal prevention strategy for multidrug-resistance organisms in resource-limited countries: a cost-effectiveness analysis study. Epidemiol Infect 2020; 148:e176. [PMID: 32430090 PMCID: PMC7439291 DOI: 10.1017/s0950268820001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The aim of this study was to determine the most cost-effective strategy for the prevention and control of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) in areas with limited health resources. The study was conducted in 12 ICUs of four hospitals. The total cost for the prevention of MDROs and the secondary attack rate (SAR) of MDROs for each strategy were collected retrospectively from 2046 subjects from January to December 2017. The average cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were calculated. Hand hygiene (HH) had the lowest total cost (2149.6 RMB) and SAR of MDROs (8.8%) while single-room isolation showed the highest cost (33 700.2 RMB) and contact isolation had the highest SAR of MDROs (31.8%). The average cost per unit infection prevention was 24 427.8 RMB, with the HH strategy followed by the environment disinfection strategy (CER = 21 314.67). HH had the highest iterative cost effect under willingness to pay less than 2000 RMB. Due to the low cost for repeatability and obvious effectiveness, we conclude that HH is the optimal strategy for MDROs infections in ICUs in developing countries. The cost-effectiveness of the four prevention strategies provides some reference for developing countries but multiple strategies remain to be examined.
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Sluggett JK, Lalic S, Hosking SM, Ritchie B, McLoughlin J, Shortt T, Robson L, Cooper T, Cairns KA, Ilomäki J, Visvanathan R, Bell JS. Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093282. [PMID: 32397193 PMCID: PMC7246482 DOI: 10.3390/ijerph17093282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 12/16/2022]
Abstract
Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.
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Affiliation(s)
- Janet K. Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (S.L.); (S.M.H.); (J.I.); (J.S.B.)
- University of South Australia, Adelaide 5001, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby 2077, Australia
- Correspondence: ; Tel.: +61-8812-849-99
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (S.L.); (S.M.H.); (J.I.); (J.S.B.)
- Pharmacy Department, Monash Health, Melbourne 3168, Australia
| | - Sarah M. Hosking
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (S.L.); (S.M.H.); (J.I.); (J.S.B.)
- National Health and Medical Research Council of Australia Centre of Research Excellence in Frailty and Healthy Aging, Adelaide 5005, Australia;
| | - Brett Ritchie
- Infectious Diseases Department, Women’s and Children’s Hospital, Adelaide 5006, Australia;
| | - Jennifer McLoughlin
- Resthaven Incorporated, Adelaide 5034, Australia; (J.M.); (T.S.); (L.R.); (T.C.)
| | - Terry Shortt
- Resthaven Incorporated, Adelaide 5034, Australia; (J.M.); (T.S.); (L.R.); (T.C.)
| | - Leonie Robson
- Resthaven Incorporated, Adelaide 5034, Australia; (J.M.); (T.S.); (L.R.); (T.C.)
| | - Tina Cooper
- Resthaven Incorporated, Adelaide 5034, Australia; (J.M.); (T.S.); (L.R.); (T.C.)
| | - Kelly A. Cairns
- Pharmacy Department, The Alfred, Alfred Health, Melbourne, VIC 3181, Australia;
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (S.L.); (S.M.H.); (J.I.); (J.S.B.)
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Renuka Visvanathan
- National Health and Medical Research Council of Australia Centre of Research Excellence in Frailty and Healthy Aging, Adelaide 5005, Australia;
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5005, Australia
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, SA Health, Adelaide 5011, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (S.L.); (S.M.H.); (J.I.); (J.S.B.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby 2077, Australia
- National Health and Medical Research Council of Australia Centre of Research Excellence in Frailty and Healthy Aging, Adelaide 5005, Australia;
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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Challenges of infection prevention and control in Scottish long-term care facilities. Infect Control Hosp Epidemiol 2020; 41:943-945. [PMID: 32317037 DOI: 10.1017/ice.2020.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Residents living in long-term care facilities (LTCFs) are at high risk of contracting healthcare-associated infections (HAIs). The unique operational and cultural characteristics of LTCFs and the currently evolving models of healthcare delivery in Scotland create great challenges for infection prevention and control (IPC). Existing literature that discusses the challenges of infection control in LTCFs focuses on operational factors within a facility and does not explore the challenges associated with higher levels of management and the lack of evidence to support IPC practices in this setting.1-7 Here, we provide a broader view of challenges faced by LTCFs in the context of the current health and social care models in Scotland. Many of these challenges are also faced in the rest of the United Kingdom and internationally.
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Environmental service workers as potential designers of infection control policy in long-term care settings. Am J Infect Control 2020; 48:398-402. [PMID: 32087975 DOI: 10.1016/j.ajic.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Long-term care facility residents are at higher risk of methicillin-resistant Staphylococcus aureus infection and colonization than the general population. In 2009, the Department of Veterans Affairs (VA) implemented the "methicillin-resistant S. aureus prevention initiative" in long-term care facilities (ie, Community Living Centers or "CLCs"). METHODS Over 4 months, 40 semistructured interviews were conducted with staff in medicine, nursing, and environmental services at 5 geographically dispersed CLCs. Interviews addressed knowledge, attitudes, and beliefs concerning infection prevention and resident-centered care. A modified constant comparative approach was used for data analysis. RESULTS In CLCs, staff work to prevent and control infections in spaces where residents live. Nurses and Environmental Service Workers daily balance infection prevention conventions with the CLC setting. Infection control team members, who are accustomed to working in acute care settings, struggle to reconcile the CLC context with infection prevention. DISCUSSION The focus on the resident's room as the locus of care, and thus the main target of infection control, misses opportunities for addressing infection prevention in the spaces beyond the residents' rooms. CONCLUSIONS Environmental Service Workers' daily work inside the rooms and within the wider facility produces a unique perspective that might help in the design of workable infection control policies in CLCs.
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Lee MH, Lee GA, Lee SH, Park YH. A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control. PLoS One 2020; 15:e0229911. [PMID: 32155208 PMCID: PMC7064182 DOI: 10.1371/journal.pone.0229911] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 02/17/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively. AIM The aim of this systematic review was to verify the causes and problems contributing to transmission and to identify control measures during outbreaks in LTCFs. METHODS Four electronic databases were searched for articles published from 2007 to 2018. Articles written in English reporting outbreaks in LTCFs were included. The quality of the studies was assessed using the risk-of-bias assessment tool for nonrandomized studies. FINDINGS A total of 37 studies were included in the qualitative synthesis. The most commonly reported single pathogen was influenza virus, followed by group A streptococcus (GAS). Of the studies that identified the cause, about half of them noted outbreaks transmitted via person-to-person. Suboptimal infection control practice including inadequate decontamination and poor hand hygiene was the most frequently raised issue propagating transmission. Especially, lapses in specific care procedures were linked with outbreaks of GAS and hepatitis B and C viruses. About 60% of the included studies reported affected cases among staff, but only a few studies implemented work restriction during outbreaks. CONCLUSIONS This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs.
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Affiliation(s)
- Min Hye Lee
- The Research Institute of Nursing Science, College of Nursing, Seoul National University, Seoul, South Korea
| | - Gyeoung Ah Lee
- College of Nursing, Seoul National University, Seoul, South Korea
| | - Seong Hyeon Lee
- College of Nursing, Seoul National University, Seoul, South Korea
| | - Yeon-Hwan Park
- The Research Institute of Nursing Science, College of Nursing, Seoul National University, Seoul, South Korea
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Nace DA, Fridkin SK. Are Antibiograms Ready for Prime Time in the Nursing Home? J Am Med Dir Assoc 2020; 21:8-11. [PMID: 31888866 PMCID: PMC11040279 DOI: 10.1016/j.jamda.2019.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Scott K Fridkin
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA
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Sloane PD, Zimmerman S, Nace DA. Progress and Challenges in the Management of Nursing Home Infections. J Am Med Dir Assoc 2020; 21:1-4. [DOI: 10.1016/j.jamda.2019.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 01/08/2023]
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