Risk factors for infection with Escherichia coli in nursing home residents colonized with fluoroquinolone-resistant E. coli

Assessing a National Collaborative Program To Prevent Catheter-Associated Urinary Tract Infection in a Veterans Health Administration Nursing Home Cohort

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the "AHRQ Safety Program for Long-Term Care," which focused on practices to reduce CAUTI.METHODSChanges in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.RESULTSThere was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67-1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95-1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82-1.05).CONCLUSIONSNo changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA's prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.Infect Control Hosp Epidemiol 2018;820-825.

Risk factors of fecal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae in special nursing homes in Japan

OBJECTIVE

Japanese welfare facilities for the elderly are called as special nursing home (SNH), providing conventional-type with group care or unit-type with individual care. We investigated the risk factors of fecal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) of elderly who required care at SNH in Japan.

METHODS

The feces discharged on diaper were obtained from the total of 100 residents with fecal incontinence in 9 SNHs located in Tokyo, Japan. The samples were cultured on ESBL selection agar, and ESBL-E were determined by the antimicrobial susceptibility test and genetic analysis. The status of the residents and the characteristics of facilities, especially about the incontinence care, were obtained by questionnaire methods. Statistical analysis was performed to determine the factors related to carriage of ESBL-E.

RESULTS

Extended-spectrum β-lactamase-producing Enterobacteriaceae was isolated from 53 of 100 SNH residents. Risk factors of colonization among the individual residents were not found. The prevalence of ESBL-E carriage was significantly higher in the 6 conventional-type facilities than in the 3 unit-type facilities (P = .015). The cart for diaper exchange was used in 5 of 6 conventional-type facilities in 9 SNHs, and their residents tended to show high of ESBL-E colonization rate. The residents living in unit-type facilities which do not use gloves for changing diaper tended to show high ESBL-E colonization rate than other 2 facilities using gloves.

CONCLUSIONS

It is suggested that using the cart for changing diaper has relation to carry ESBL-E. In the facilities using cart, revision of their methods of excretion care will be needed.

Risk Factors for Community-Onset Pneumonia Caused by Levofloxacin-Nonsusceptible Streptococcus pneumoniae

BACKGROUND

Fluoroquinolones are antibiotics commonly used in the treatment of infections caused by Streptococcus pneumoniae. However, rates of fluoroquinolone resistance are increasing with their frequent use. We designed this study to verify current fluoroquinolone resistance rates and risk factors for community-onset pneumococcal pneumonia.

METHODS

A retrospective case-control study was conducted in a tertiary referral hospital. The study population comprised patients admitted for pneumococcal pneumonia between January 2011 and May 2017. The case group included community-onset pneumonia caused by levofloxacin-nonsusceptible S. pneumoniae. The control group consisted of two patients with levofloxacin-susceptible S. pneumoniae who were admitted around the same time as each case.

RESULTS

A total of 198 pneumococcal pneumonia cases were identified during the study period. Twenty-five levofloxacin-resistant S. pneumoniae cases and 3 levofloxacin-intermediate S. pneumoniae cases were included in the case group (nonsusceptibility rate = 14.1%). Multivariate analysis showed that healthcare-associated factors (odds ratio [OR] 4.78, 95% confidence interval [CI] 1.39-16.43, p = 0.013), bronchopulmonary disease (OR 3.79, 95% CI 1.07-13.40, p = 0.039), cerebrovascular disease (OR 6.08, 95% CI 1.24-29.75, p = 0.026), and exposure to fluoroquinolones within the previous 3 months (OR 5.89, 95% CI 1.21-28.68, p = 0.028) were associated with nonsusceptibility to levofloxacin.

CONCLUSION

Independent risk factors for levofloxacin-nonsusceptible pneumococcal pneumonia were recent hospitalization, bronchopulmonary disease, cerebrovascular disease, and prior antibiotic use within 3 months. Careful selection of empirical antibiotics is thus needed in at-risk patients. Similarly, efforts to prevent the interpersonal spread of drug-resistant pathogens in long-term care facilities and to restrict unnecessary fluoroquinolone prescriptions are important.

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

IMPORTANCE

Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms.

OBJECTIVE

To develop, implement, and evaluate an intervention to reduce catheter-associated UTI.

DESIGN, SETTING, AND PARTICIPANTS

A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016.

INTERVENTIONS

The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication.

MAIN OUTCOMES AND MEASURES

Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist.

RESULTS

In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001).

CONCLUSIONS AND RELEVANCE

In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.