Impact of external female urinary catheter use on urine chemistry test results

BACKGROUND

We aimed to evaluate how urine chemistry tests are impacted by collection using a female external urinary catheter employing wicking and suction, to assess this catheter's potential as an alternative to transurethral catheters for collecting urine samples from incontinent patients.

METHODS

We obtained 50 random 40 mL refrigerated urine specimens from excess volume submitted to the Michigan Medicine Biochemical Laboratory. Specimens were split into a 10 mL "control" sample simulating voided urine, and a 30 mL paired "wicked" sample applied dropwise to and collected from a fresh PureWick system simulating collection from an incontinent patient. Each sample pair was tested for glucose, sodium, potassium, creatinine, urea, total protein, and derived ratios of sodium/creatinine, urea/creatinine, and protein/creatinine, then compared using Pearson correlation coefficients. Wicking materials were imaged via absorption contrast tomography on a laboratory X-ray microscope, to study the structure through which urine passes.

RESULTS

Control and wicked urine samples had very similar results for all chemical tests evaluated: strong Pearson correlation coefficients ranging from 0.955 (potassium) to 0.997 (glucose). Microscopic assessment of the amorphous wicking materials demonstrated an average pore spacing of 95.38 µm.

CONCLUSIONS

Common urine chemistry tests were unaltered by collection using the PureWick female external catheter system. This external device can be used to collect urine for chemistry tests as an alternative to transurethral catheters.

A reference standard for urinary tract infection research: a multidisciplinary Delphi consensus study

The absence of a consensus-based reference standard for urinary tract infection (UTI) research adversely affects the internal and external validity of diagnostic and therapeutic studies. This omission hinders the accumulation of evidence for a disease that imposes a substantial burden on patients and society, particularly in an era of increasing antimicrobial resistance. We did a three-round Delphi study involving an international, multidisciplinary panel of UTI experts (n=46) and achieved a high degree of consensus (94%) on the final reference standard. New-onset dysuria, urinary frequency, and urinary urgency were considered major symptoms, and non-specific symptoms in older patients were not deemed indicative of UTI. The reference standard distinguishes between UTI with and without systemic involvement, abandoning the term complicated UTI. Moreover, different levels of pyuria were incorporated in the reference standard, encouraging quantification of pyuria in studies done in all health-care settings. The traditional bacteriuria threshold (105 colony-forming units per mL) was lowered to 104 colony-forming units per mL. This new reference standard can be used for UTI research across many patient populations and has the potential to increase homogeneity between studies.

Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Importance

Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common.

Objectives

To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB.

Design, Setting, and Participants

This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia.

Results

Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.

Conclusions and Relevance

In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

Post-acute sequelae of SARS-CoV-2 (PASC) in nursing home residents: A retrospective cohort study

BACKGROUND

Post-acute sequelae of SARS-CoV-2 (PASC) describes a syndrome of physical and cognitive decline that persists after acute symptoms of infection resolve. Few studies have explored PASC among nursing home (NH) residents.

METHODS

A retrospective cohort study was conducted at two NHs in Michigan. COVID-positive patients were identified from March 21, 2020 to October 26, 2021. The comparison group were patients who lived at the same NH but who were never infected during the study period. Minimum Data Set was used to examine trajectories of functional dependence (Activity of Daily Living [ADL] composite score) and cognitive function (Brief Interview for Mental Status [BIMS]). Linear mixed-effects models were constructed to estimate short-term change in function and cognition immediately following diagnosis and over time for an additional 12 months, compared to pre-COVID and non-COVID trajectories and adjusting for sex, age, and dementia status.

RESULTS

We identified 171 residents (90 COVID-19 positive, 81 non-COVID) with 719 observations for our analyses. Cohort characteristics included: 108 (63%) ≥ 80 yrs.; 121 (71%) female; 160 (94%) non-Hispanic white; median of 3 comorbidities (IQR 2-4), with no significant differences in characteristics between groups. COVID-19 infection affected the trajectory of ADL recovery for the first 9 months following infection, characterized by an immediate post-infection decrease in functional status post-infection (-0.60 points, p = 0.002) followed by improvement toward the expected functional trajectory sans infection (0.04 points per month following infection, p = 0.271).

CONCLUSIONS

NH residents experienced a significant functional decline that persisted for 9 months following acute infection. Further research is needed to determine whether increased rehabilitation services after COVID-19 may help mitigate this decline.

Characterizing infection prevention programs and urinary tract infection prevention practices in nursing homes: A mixed-methods study

OBJECTIVE

US policies require robust nursing home (NH) infection prevention and control (IPC) programs to ensure safe care. We assessed IPC resources and practices related to catheter and non-catheter-associated urinary tract infection (CAUTI and UTI) prevention among NHs.

METHODS

We conducted a mixed-methods study from April 2018 through November 2019. Quantitative surveys assessed NH IPC program resources, practices, and communication during resident transfer. Semistructured qualitative interviews focused on IPC programs, CAUTI and UTI prevention practices, and resident transfer processes. Using a matrix as an analytic tool, findings from the quantitative survey data were combined with the qualitative data in the form of a joint display.

RESULTS

Representatives from 51 NHs completed surveys; interviews were conducted with 13 participants from 7 NHs. Infection preventionists (IPs) had limited experience and/or additional roles, and in 36.7% of NHs, IPs had no specific IPC training. IP turnover was often mentioned during interviews. Most facilities were aware of their CAUTI and UTI rates and reported using prevention practices, such as hydration (85.7%) or nurse-initiated catheter discontinuation (65.3%). Qualitative interviewees confirmed use of these practices and expressed additional concerns about overuse of urine testing and antibiotics. Although transfer sheets were used by 84% to communicate about infections, the information received was described as suboptimal.

CONCLUSIONS

NHs identified IP challenges related to turnover, limited education, and serving multiple roles. However, most NHs reported awareness of their CAUTI and UTI rates as well as their use of prevention practices. Importantly, we identified opportunities to enhance communication between NHs and hospitals to improve resident care and safety.

Association of patient clinical and gut microbiota features with vancomycin-resistant enterococci environmental contamination in nursing homes: a retrospective observational study

BACKGROUND

Preventing transmission is crucial for reducing infections with multidrug-resistant organisms (MDROs) in nursing homes. To identify resident characteristics associated with MDRO spread, we investigated associations between patient characteristics and contamination of their proximate room surfaces with vancomycin-resistant enterococci (VRE).

METHODS

In this retrospective observational study, we used demographic and clinical data (including data on comorbidities, physical independence, catheter use within the past 30 days, and antibiotic exposure within the past 30 days) and surveillance cultures of patient body sites and room surfaces at enrolment and during weekly follow-up visits within the first month, and monthly thereafter (up to 6 months), in six US nursing homes collected in a previous clinical trial (September, 2016, to August, 2018). We did 16S rRNA gene sequencing on perirectal surveillance swabs to investigate the association between the gut microbiota and the culture status of participants and their rooms.

FINDINGS

We included 245 participants (mean age 72·5 years [SD 13·6]; 111 [45%] were men, 134 [55%] were women, 132 [54%] were non-Hispanic white, and 112 [46%] were African American). We collected 2802 participant samples and 5592 environmental samples. At baseline, VRE colonisation was present in 49 (20%) participants, with environmental surfaces being contaminated in 36 (73%) of these patients. Hand contamination among VRE-colonised participants was more common in those with environmental contamination compared with those without (50 [51%] of 99 vs seven [13%] of 55; p<0·0001). We found a correlation between hand contamination and both groin and perirectal colonisation and contamination of various high-touch room surfaces (Cohen's κ 0·43). We found participant microbiota composition to be associated with antibiotic receipt within the past 30 days (high-risk antibiotics p=0·011 and low-risk antibiotics p=0·0004) and participant VRE colonisation status, but not environmental contamination among VRE-colonised participants (participant only vs uncolonised p=0·071, both participant and environment vs uncolonised p=0·025, and participant only vs participant and environment p=0·29). Multivariable analysis to identify independent factors associated with VRE-colonised participants contaminating their environment identified antibiotic exposure (adjusted odds ratio 2·75 [95% CI 1·22-6·16]) and male sex (2·75 [1·24-6·08]) as being associated with increased risk of environmental contamination, and physical dependence as being associated with a reduced risk of environmental contamination (0·91 [0·83-0·99]).

INTERPRETATION

Our data support antibiotic use and interaction with proximal surfaces by physically independent nursing home residents as under-appreciated drivers of environmental contamination among VRE-colonised residents. Integrating resident hand-hygiene education and antimicrobial stewardship will strengthen efforts to reduce MDROs in nursing homes.

FUNDING

US Centers for Disease Control and Prevention, National Institute of Health, Canadian Institutes of Health Research, and University of Michigan.

Epidemiology of resistant gram-negative bacteria in nursing homes

BACKGROUND

Resistant gram-negative bacteria (R-GNB) colonization in nursing home patients can cause clinical infection and intrafacility transmission. Limited data exist on the roles of age and function on R-GNB colonization.

METHODS

A secondary data analysis was performed from a cohort study of 896 patients admitted to 6 Michigan nursing homes between November 2013 and May 2018. Swabs obtained upon enrollment, weekly for 1 month, then monthly until nursing home discharge from 5 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Patients with growth of the same R-GNB as the initial positive visit, from any anatomical site at any subsequent visit, were considered persistently colonized. Demographic data, antibiotic use, device use, and physical self-maintenance scales (PSMSs) were obtained upon enrollment. Characteristics were compared between patients with R-GNB colonization versus those without, and those with persistent R-GNB colonization versus those with spontaneous decolonization.

RESULTS

Of 169 patients with a positive R-GNB culture and ≥2 subsequent study visits, 89 (53%) were transiently colonized and 80 (47%) were persistently colonized. Compared to uncolonized patients, persistent and transient R-GNB colonization were associated with higher PSMS score: 1.14 (95% confidence interval or CI, 1.05-1.23; P = .002) and 1.10 (95% CI, 1.01-1.19; P = .023), respectively. Persistent colonization was independently associated with longer duration of nursing home stay (1.02; 95% CI, 1.01-1.02; P < .001). Higher readmission rate among persistently colonized patients was observed on unadjusted analysis.

CONCLUSIONS

Persistent R-GNB colonization is associated with younger age, functional disability, and prolonged length of nursing home stay. In-depth longitudinal studies to understand new acquisition and transmission dynamics of R-GNB in nursing homes are needed.

Definitions of Urinary Tract Infection in Current Research: A Systematic Review

Defining urinary tract infection (UTI) is complex, as numerous clinical and diagnostic parameters are involved. In this systematic review, we aimed to gain insight into how UTI is defined across current studies. We included 47 studies, published between January 2019 and May 2022, investigating therapeutic or prophylactic interventions in adult patients with UTI. Signs and symptoms, pyuria, and a positive urine culture were required in 85%, 28%, and 55% of study definitions, respectively. Five studies (11%) required all 3 categories for the diagnosis of UTI. Thresholds for significant bacteriuria varied from 103 to 105 colony-forming units/mL. None of the 12 studies including acute cystitis and 2 of 12 (17%) defining acute pyelonephritis used identical definitions. Complicated UTI was defined by both host factors and systemic involvement in 9 of 14 (64%) studies. In conclusion, UTI definitions are heterogeneous across recent studies, highlighting the need for a consensus-based, research reference standard for UTI.

Diversity and Persistence of MRSA and VRE in Skilled Nursing Facilities: Environmental Screening, Whole Genome Sequencing, Development of a Dispersion Index

BACKGROUND

Environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) in skilled nursing facilities (SNFs) may contribute to patient acquisition. We assessed diversity and association of MRSA and VRE isolates in a SNF wing and developed a mathematical index to define each strain's tendency to persist in rooms and spread horizontally.

METHODS

Longitudinal study of MRSA and VRE colonization and contamination among successive patient occupancies in a cluster of nine SNF private rooms during eight months characterized by microbiological testing and whole genome isolate typing. 'Dispersion index" of a strain is defined as the number of rooms it was found in (including the patient), divided by the average of times it was found consecutively in the same room.

FINDINGS

MRSA (ten strain types) and VRE (seven types) were recovered from room or patient in 16.4% and 35.6% of the occupancies, respectively. MRSA showed moderate horizontal spread and several episodes of same-room persistence (three distinct strain types) (overall dispersion index: 1.08). VRE showed high tendency towards horizontal spread /new introductions (overall dispersion index: 3.25), and only one confirmed persistence episode.

INTERPRETATION

The emerging picture of high diversity among contaminating strains and high likelihood of room persistence despite terminal cleaning (MRSA) and horizontal spread between rooms (VRE) in this setting calls for improved cleaning practices, heightened contact precautions, and most of all to establish individually tailored facility screening programs to enable informed choices based on local, measurable and actionable epidemiologic parameters.

FUNDING

University of Michigan OAIC REC Scholarship to M.C. National Institutes of Health K24 AG050685 to L.M.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Clin-Star corner: What's new at the interface of geriatrics, infectious diseases, and antimicrobial stewardship

Antibiotics are among the leading causes of adverse drug events in older adults. Short-course antibiotic therapy has been shown to work as well as the traditional longer durations for many types of infections. Antibiotic stewardship interventions including deprescribing strategies have shown a reduction in patient readmissions and mortality among older adults. We identified practice-changing clinical trials focusing on three major domains of overprescribing antibiotics in older adults - community-acquired pneumonia, urinary tract infections, and gram-negative bacteremia. The selected articles underscore the safety and effectiveness of shorter durations of antibiotic treatment for infections in older adults, thus highlighting an opportunity for deprescribing in the aging population. By optimizing antibiotic use, we stand to reduce adverse events and enhance overall health outcomes in older adults.

Advancing clinical trials in nursing homes: A proposed roadmap to success

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

Pragmatic trials in long-term care: Research challenges and potential solutions in relation to key areas of care

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Association of Exposure to High-risk Antibiotics in Acute Care Hospitals With Multidrug-Resistant Organism Burden in Nursing Homes

IMPORTANCE

Little is known about the contribution of hospital antibiotic prescribing to multidrug-resistant organism (MDRO) burden in nursing homes (NHs).

OBJECTIVES

To characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021.

EXPOSURES

Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories.

MAIN OUTCOMES AND MEASURES

The primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics.

RESULTS

A total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [OR], 1.70; 95% CI, 1.22-2.38) and MDRO environmental contamination (OR, 1.67; 95% CI, 1.17-2.39). Exploratory stratification by C diffogenic agent exposure increased the effect size (MDRO colonization: OR, 1.99; 95% CI, 1.33-2.96; MDRO environmental contamination: OR, 1.86; 95% CI, 1.24-2.79). Likewise, exploratory stratification by exposure to high-risk WHO AWARE antibiotics increased the effect size (MDRO colonization: OR, 2.32; 95% CI, 1.61-3.36; MDRO environmental contamination: OR, 1.86; 95% CI, 1.26-2.75).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce MDROs in postacute care NHs. This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology.

Functional and Cognitive Decline Among Older Adults After High-risk Surgery

OBJECTIVE

The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use.

SUMMARY BACKGROUND DATA

Patient-centered outcomes after surgery are poorly characterized.

METHODS

Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use.

RESULTS

The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001).

CONCLUSION

Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel’s recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

380. Environmental Contamination with SARS-CoV-2 in Nursing Homes

Background

The COVID-19 pandemic has disproportionately affected nursing home (NH) patients, accounting for 5% of all cases and 32% of all COVID-19 deaths nationwide. Little is known about the frequency and persistence of SARS-CoV-2 environmental contamination in NHs. We characterize SARS-CoV-2 contamination in the rooms of COVID-19 patients and common areas in and around COVID-19 units.

Methods

A prospective cohort study was conducted at four NHs in Michigan between October 2020 and January 2021. Clinical research personnel obtained swab specimens from high-touch room surfaces of COVID-19 infected patients, up to three times per patient. Weekly swab specimens from six high-touch surfaces in common areas were also obtained. Demographic and clinical data were collected from patient clinical records. Our primary outcome of interest was the probability of SARS-CoV-2 detection from specific environmental surfaces in COVID-19 patient rooms.

Results

One hundred four patients with COVID-19 were enrolled and followed for 241 visits. Patient characteristics included: 61.5% over the age of 80; 67.3% female; 89.4% non-Hispanic white; 50.1% short-stay. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities including dementia (55.8%), diabetes (40.4%) and heart failure (32.7) (Table 1). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient room surfaces, 191 common area swabs). Figure 1 shows contamination rates at sites proximate and distant to the patient bed. SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Over the course of follow-up, 89.4% (93/104) of patients had SARS-CoV-2 contamination in their room at least once (Figure 2). Environmental contamination detected on enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination.

Table 1. Clinical and Demographic Characteristics of the Study Population Including Short- and Long-stay Patients

Conclusion

We conclude that environmental contamination of surfaces in the rooms of COVID-19 patients is nearly universal and persistent. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

Disclosures

All Authors: No reported disclosures

When planning meets reality: COVID-19 interpandemic survey of Michigan Nursing Homes

BACKGROUND

Nursing home (NH) populations have borne the brunt of morbidity and mortality of COVID-19. We surveyed Michigan NHs to evaluate preparedness, staffing, testing, and adaptations to these challenges.

METHODS

Interpandemic survey responses were collected May 1-12, 2020. We used Pearson's Chi-squared test, Fisher's exact test, and logistic regression to evaluate relationships.

RESULTS

Of 452 Michigan NHs contacted via e-mail, 145 (32.1%) opened the survey and of these, 143 (98.6%) responded. Sixty-eight percent of respondents indicated their response plan addressed most issues. NHs reported receiving rapidly changing guidance from many sources. Two-thirds reported shortages of personal protective equipment and other supplies. Half (50%) lacked sufficient testing resources with only 36% able to test residents and staff with suspected COVID-19. A majority (55%) experienced staffing shortages. Sixty-three percent experienced resignations, with front-line clinical staff more likely to resign, particularly in facilities caring for COVID-19 patients (P < .001). Facilities adapted quickly, creating COVID-19 units (78%) to care for patients on site. To reduce isolation, NHs facilitated communication via phone calls (98%), videoconferencing (96%), and window visits (81%). A majority continued to provide requisite therapies (90%).

CONCLUSIONS

NHs experienced shortages of resources, testing supplies, and staffing challenges. COVID-19 in the facility was a key predictor of staff resignations. Facilities relied on rapidly changing, often conflicting advice from multiple sources, suggesting high-yield areas of improvement.

Environmental contamination with SARS-CoV-2 in nursing homes

BACKGROUND

SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied.

METHODS

A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up.

RESULTS

One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination.

CONCLUSIONS

Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Seasonal Patterns in Incidence and Antimicrobial Resistance of Common Bacterial Pathogens in Nursing Home Patients and Their Rooms

Background: Colonization is the main precursor to infection, which may lead to adverse clinical outcomes among older adults in nursing homes (NHs). Understanding seasonal changes in the local burden of common bacterial pathogens is key to implementing appropriate and cost-effective infection prevention measures in this resource-constrained healthcare environment. It is thus surprising that seasonal trends in patient and environmental colonization with major bacterial pathogens are presently unknown in the expanding NH setting.

Methods: We examined the seasonal incidence of four major pathogens among 640 nursing home patients and high-touch surfaces within their rooms over 2 years. In cases where a significant number of antimicrobial-resistant strains was found, incidence in antimicrobial-susceptible and antimicrobial-resistant isolates was compared, along with antibiotic use trends.

Results: We observed spring peaks in the incidence of vancomycin-resistant enterococci (1.70 peak to trough ratio for both patient and environmental isolates) and methicillin-resistant Staphylococcus aureus (1.95 peak to trough ratio for patient isolates, 1.50 for environmental isolates). We also observed summer peaks in Klebsiella pneumoniae (1.83 and 1.82 peak to trough ratio for patient and environmental isolates, respectively), and ciprofloxacin-resistant Escherichia coli. Susceptible S. aureus and E. coli did not follow seasonal patterns.

Conclusions: A meaningful seasonal pattern may be present in the NH setting for several significant pathogens, and especially antimicrobial-resistant ones. Whether such patterns are consistent across geographic areas and over longer periods of time should be a key focus of investigation, in order to better inform timing of surveillance and infection prevention efforts in this setting.

Not too close! impact of roommate status on MRSA and VRE colonization and contamination in Nursing Homes

Multiple room occupancy is common in Nursing Homes (NHs), and its role in transmission of antibiotic-resistant pathogens is unclear. We investigated prevalence of patient colonization and environmental contamination with vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) in NH roommates, compared it with expected prevalence, and determined specific body and environmental sites that may act as sources of roommate colonization. Roommate contamination was associated with index patient's colonization (relative risk (RR): 2.57 (95% CI 1.04-6.37)) for MRSA, and index patient's immediate environment contamination for VRE (RR: 3.60 (95% CI 1.59-8.12)). When specific index patient sites associated with roommate colonization were investigated, the side table (Fisher's p = 0.029 and 0.047 for VRE and MRSA, respectively) and the nurse call button (p = 0.001 and 0.052) stood out, together with patient hands in the case of VRE (p = 0.026). Future studies should be carried out to establish whether these sites should be a specific target of infection prevention campaigns in NHs with multiple occupancy rooms.

Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial

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.

Gut Microbiota Features on Nursing Home Admission Are Associated With Subsequent Acquisition of Antibiotic-resistant Organism Colonization

Nursing home (NH) patients often acquire colonization with antibiotic-resistant organisms (AROs). We show that patients exposed to broad-spectrum antibiotics during previous hospitalizations have elevated enterococcal relative abundances on NH admission and higher risk of subsequent ARO acquisition. Our findings suggest that interventions preventing ARO spread should extend beyond NH doors.

Application of Combined Genomic and Transfer Analyses to Identify Factors Mediating Regional Spread of Antibiotic-resistant Bacterial Lineages

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.

917. Persistence of Multidrug-Resistant Organisms during Occupancy Changes in the Nursing Home Setting, and Impact of Patient Hand Hygiene Assistance

Background

We investigated the effect of changes in room occupancy, and patient hand hygiene, on the burden of multidrug-resistant organisms (MDRO) in nursing homes. We assessed: 1/ persistence of MDRO after patients are discharged; and 2/ impact of hand hygiene assistance on colonization and room contamination.

Methods

Prospective cohort study of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and ceftazidime, ciprofloxacin or meropenem-resistant gram-negative bacilli (rGNB) in 9 single rooms screened three times a week for 34 weeks (five environmental surfaces, plus nares, groin, and hands of enrolled patients). Relative risk (RR) for patient colonization and room contamination were calculated in patient visits based on: 1/ performance of hand hygiene, and 2/ receiving assistance to perform it.

Results

We collected 4670 swabs over a total of 723 visits. Of 143 patient discharges, 31 times the room was swabbed before another patient was admitted (41 total visits), 48 times the next admitted patient was enrolled and available to be swabbed (295 visits), and 64 times the patient was not enrolled but the environment was sampled (387 total visits) (Figure).

Twenty-four (50%) patients were colonized at least once with an MDRO. Rooms were contaminated at least once with MDRO in 72 cases (64%). MDRO persistence during occupancy changes involving at least one screened patient was observed in 21 of 73 cases (29%). In addition, we detected 2 cases of contamination of unoccupied, terminally cleaned rooms with MDRO recovered also in the previous (MRSA) or the following occupancy (VRE).

In 40 occasions, patients performed hand hygiene with assistance from healthcare personnel, while in 169 occasions they performed hand hygiene by themselves. Requiring assistance was a risk factor for patient colonization (27.5% vs. 12.4% not requiring assistance (RR 2.20, 95% CI 1.16-4.18), and for room contamination (37.5% vs. 18.9%, RR 1.97, 95% CI 1.18-3.27) (Table).

Figure. Example of successive changes in room occupancy.

Conclusion

MDRO can persist during changes in patient occupancy. Patients requiring assistance with hand hygiene experienced a higher MDRO burden. These observations call for further investigation of improved cleaning practices and patient assistance.

Disclosures

All Authors: No reported disclosures

156. How Does Exposure to C. Diffogenic Antibiotics Impact Multidrug-resistant Organism Colonization and Environment Contamination in Nursing Homes?

Background

Antimicrobial stewardship program (ASP) outcomes are often measured in the acute care setting, less is known about the effect of acute care antibiotic exposures on multidrug-resistant organism (MDROs) colonization of nursing home (NH) patients. We assessed exposure to antibiotics commonly associated with Clostridioides difficile (C. diffogenic agents) on post-acute care patient colonization and room environment contamination (Figure 1).

Figure 1. Conceptual Diagram of Hospital Antibiotic Exposure’s Influence on Patient Colonization and Room Environment Contamination with Multidrug-Resistant Organisms

Methods

MDRO surveillance of post-acute care patients in 6 NHs between 2013–16. We screened patient hands, nares, oropharynx, groin, perianal area, and high-touch room environment surfaces for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant Gram-negative bacilli (rGNB). C. diffogenic agents were defined as fluoroquinolones, 3^rd/4^th generation cephalosporins, penicillin combinations, lincosamides, and carbapenems. Multivariable logistic regression was used to assess whether hospital antibiotic exposure is an independent risk factor for MDRO colonization and room environment contamination on study enrollment.

Results

We enrolled 618 patients: average age was 74.4 years; 57.4% female; 62.3% white; 9.9% had indwelling devices (Table 1). Three hundred-fifty patients (56.6%) were MDRO colonized on enrollment: 98 (15.9%), MRSA; 208 (33.7%); VRE; 196 (31.7%), rGNB. Sixty-eight percent of patient rooms were MDRO contaminated: 166 (26.9%), MRSA; 293, (47.4%). VRE; 182 (29.5%), rGNB.

A majority (59.4%) of patients were exposed to an antibiotic before admission. Of which, 239 (65.1%) were exposed to a C. diffogenic antibiotic. In multivariable analysis, C. diffogenic antibiotic exposure was an independent risk factor for MDRO colonization (OR, 1.94; 95% CI, 1.35–2.79), MDRO room environment contamination (OR, 1.94; 95% CI, 1.43–2.63), VRE colonization (OR, 4.23; 95% CI, 2.59–6.90), and VRE room environment contamination (OR, 2.58; 95% CI, 2.00–3.33).

Table 1. Clinical Characteristics and MDRO Burden on Study Enrollment, Stratified by Hospital Antibiotic Exposure Status

Multivariable Analysis of Hospital Antibiotic Exposure Status as Risk Factor for Proximal and Distal MDRO Outcomes

Conclusion

Hospital exposure to antibiotics is associated with an increased risk of VRE colonization and room environment contamination on NH study enrollment. These observations highlight the potential influence of hospital-based ASPs on MDRO prevalence and transmission in NHs.

Disclosures

All Authors: No reported disclosures

66. What Worked (And Didn’t Work): A Survey of COVID-19 Response in Michigan Nursing Homes in the Midst of the Pandemic

Background

Nursing home (NH) populations are at higher risk for morbidity and mortality due to COVID-19. A March 2020 NH survey indicated improvements in pandemic planning when compared to a similar survey in 2007. We surveyed NHs to evaluate how well pandemic preparedness plans and infection prevention strategies met the reality of COVID-19.

Methods

The first COVID-19 case in Michigan was reported March 10, 2020. In the setting of 46,088 cases and 4,327 deaths statewide as of May 1, we disseminated an online survey to state department-registered NHs to describe their experience of the initial pandemic wave. Responses were collected May 1–12, during which the state averaged 585 cases/day. We were particularly interested in NH preparedness, challenges, testing capacity, and adaptations made.

Results

Of 452 NHs contacted, 145 opened the survey and 143 (32%) responded. A majority (68%) indicated that their facility’s pandemic response plan addressed > 90% of issues they experienced; 29% reported their plan addressed most but not all anticipated concerns (Table 1). As the pandemic evolved, all facilities (100%) provided additional staff education on proper personal protective equipment (PPE) use. 66% reported experiencing shortages of PPE and other supplies. Half of all facilities (50%) lacked sufficient resources to test asymptomatic residents or staff; only 36% were able to test all residents and staff with suspected COVID-19 infection. Half (52%) considered their communication regarding COVID-19 with nearby hospitals “very good.” The majority of facilities (55%) experienced staffing shortages, often relying on remaining staff to work additional hours and/or contracted staff to fill deficits (Table 2). NH staff resignations increased, with 63% of NHs experiencing resignations; staff with greater bedside contact were more likely to leave, including nurses and nurse assistants.

Conclusion

While most NHs had a plan to respond to COVID-19 pandemic in March 2020, many facilities experienced a lack of available resources, less than ideal communication lines with local hospitals, lack of testing capacity and insufficient staff. These shortcomings indicate potential high-yield areas of improvement in pandemic preparedness in the NH setting.

Disclosures

All Authors: No reported disclosures

A Survey of Patient Perspectives on Approach to Health Care: Focus on Physician Competency and Compassion

We conducted a cross-sectional, survey study of 764 volunteers to gain insight into patients’ perceptions of physician qualities of compassion and competence. Among 651 (85% response rate) survey participants, mean age was 52.4 (SD 21.4) years, 70.8% (n = 458) were female, and 84% (n = 539) identified as white. Predictors of compassion over competence included female gender (adjusted odds ratio [aOR] = 1.4, 95% CI: 1.04-1.89) and whether the respondent had a personal connection to the vignette (aOR = 1.24, 95% CI: 1.0-1.53). Thematic analysis demonstrated that preferences were influenced by: (a) explicit beliefs regarding the value of physician compassion and physician competence; (b) impact of emotional and mental health on medical experiences; (c) the type and frequency of health care exposure; and (d) perceived role of the physician in various clinical vignettes. Patients had wide-ranging, complex opinions on the qualities they valued in their physicians. These findings suggest that patients are engaged and can provide critical thoughtful feedback on the practice and delivery of health care.

Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes

BACKGROUND/OBJECTIVES

Almost half of deaths related to COVID‐19 in the United States are linked to nursing homes (NHs). We describe among short‐term and long‐term residents at three NHs in Michigan the outbreak identification process, universal testing, point prevalence of COVID‐19, and subsequent containment efforts, outcomes, and challenges.

DESIGN

Outbreak investigation.

SETTING

Three NHs in southeast Michigan.

PARTICIPANTS

All residents (N = 215) at three NHs (total beds = 356) affiliated with a large academic healthcare system.

METHODS

Upon detection of confirmed cases within the facility, each NH in collaboration and consultation with local hospital, public health officials, and parent corporation implemented immediate facility‐wide testing and the following intervention measures: cohorting of COVID‐19 positive residents; communication regarding testing and results with residents, healthcare professionals, and families; personal protective equipment reeducation and use throughout facilities; and dedicated staffing for infected patients cohorted in a dedicated COVID‐19 wing. We collected patient data regarding demographics, symptoms, comorbidities, hospitalization, and 14‐day outcomes.

RESULTS

A total of 29 cases of COVID‐19 were identified at three participating NHs. Nineteen cases of COVID‐19 were identified through symptom‐triggered testing from March 23 to April 23, 2020; 10 (4.7%) additional cases were identified through universal testing of 215 residents conducted from April 7 to 15, 2020. The hospitalization rate was 37.9%. The case fatality rate was 20.7% (6/29); these patients had multiple comorbidities. No residents who tested positive through the point‐prevalence survey required hospitalization, and five were discharged home within 14 days.

CONCLUSION

Proactive and coordinated steps between NH medical directors and administrators, referral hospitals including their laboratories, and local public health officials are necessary to rapidly respond to an outbreak and limit the transmission of COVID‐19. This coordinated public health approach may save lives, minimize the burden to the healthcare system, and reduce healthcare costs.

See related editorial by Kathleen Unroe

Epidemiology of Vancomycin-Resistant Enterococcus faecium and Enterococcus faecalis Colonization in Nursing Facilities

BACKGROUND

Vancomycin-resistant Enterococcus faecium and Enterococcus faecalis frequently colonize nursing facility (NF) residents, creating opportunities for vancomycin-resistant Enterococcus (VRE) transmission and dissemination of mobile genetic elements conferring antimicrobial resistance. Most VRE studies do not speciate; our study addresses this lack and compares the epidemiology of E faecium and E faecalis.

METHODS

We enrolled 651 newly admitted patients from 6 different NFs and collected swabs from several body sites at enrollment, 14 days, 30 days, and monthly thereafter for up to 6 months. The VRE were speciated using a duplex polymerase chain reaction. We used multinomial logistic regression models to compare risk factors associated with colonization of E faecium and E faecalis.

RESULTS

Overall, 40.7% were colonized with E faecium, E faecalis, or both. At enrollment, more participants were colonized with E faecium (17.8%) than E faecalis (8.4%); 3.2% carried both species. Enterococcus faecium was carried twice as long as E faecalis (69 days and 32 days, respectively), but incidence rates were similar (E faecium, 3.9/1000 person-days vs E faecalis, 4.1/1000 person-days). Length of stay did not differ by species among incident cases. Residents who used antibiotics within the past 30 days had a greater incidence of both E faecium (odds ratio [OR] = 2.89; 95% confidence interval [CI], 1.82-4.60) and E faecalis (OR = 1.80; 95% CI, 1.16-2.80); device use was most strongly associated with the incidence of E faecium colonization (OR = 2.01; 95% CI, 1.15-3.50).

CONCLUSIONS

Recent increases in vancomycin-resistant E faecium prevalence may reflect increased device use and longer duration of carriage.