Colonization of skilled-care facility residents with antimicrobial-resistant pathogens

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19

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.

Prevalence and Risk Factors for Multidrug-Resistant Organisms Colonization in Long-Term Care Facilities Around the World: A Review

Elderly people confined to chronic care facilities face an increased risk of acquiring infections by multidrug-resistant organisms (MDROs). This review presents the current knowledge of the prevalence and risk factors for colonization by MDROs in long-term care facilities (LTCF), thereby providing a useful reference to establish objectives for implementing successful antimicrobial stewardship programs (ASPs). We searched in PubMed and Scopus for studies examining the prevalence of MDROs and/or risk factors for the acquisition of MDROs in LTCF. One hundred and thirty-four studies published from 1987 to 2020 were included. The prevalence of MDROs in LTCF varies between the different continents, where Asia reported the highest prevalence of extended-spectrum ß-lactamase (ESBL) Enterobacterales (71.6%), carbapenem resistant (CR) Enterobacterales (6.9%) and methicillin-resistant Staphylococcus aureus (MRSA) (25.6%) and North America the highest prevalence to MDR Pseudomonas aeruginosa (5.4%), MDR Acinetobacter baumannii (15.0%), vancomycin-resistant Enterococcus spp. (VRE) (4.0%), and Clostridioides difficile (26.1%). Furthermore, MDRO prevalence has experienced changes over time, with increases in MDR P. aeruginosa and extended spectrum ß-lactamase producing Enterobacterales observed starting in 2015 and decreases of CR Enterobacterales, MDR A. baumannii, VRE, MRSA and C. difficile. Several risk factors have been found, such as male sex, chronic wounds, the use of medical devices, and previous antibiotic use. The last of these aspects represents one of the most important modifiable factors for reducing colonization with MDROs through implementing ASPs in LTCF.

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration

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.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

Emergence of concurrent levofloxacin- and trimethoprim/sulfamethoxazole-resistant Stenotrophomonas maltophilia: Risk factors and antimicrobial sensitivity pattern analysis from a single medical center in Taiwan

BACKGROUND

The emergence of concurrent levofloxacin- and trimethoprim/sulfamethoxazole (TMP/SMX)-resistant Stenotrophomonas maltophilia (LTSRSM) in Taiwan is becoming a serious problem, but clinical data analysis on this has not been reported.

METHODS

A matched case-control-control study was conducted to investigate risk factors for LTSRSM occurrence in hospitalized patients. For patients with LTSRSM infection/colonization (the case group), two matched control groups were used: control group A with levofloxacin- and TMP/SMX-susceptible S. maltophilia (LTSSSM) and control group B without S. maltophilia. Besides, tigecycline, ceftazidime, cefepime, ciprofloxacin, gentamicin, amikacin, and colistin susceptibilities in collected LTSRSM and levofloxacin- and TMP/SMX-susceptible S. maltophilia (LTSSSM) isolates were compared.

RESULTS

From January 2014 to June 2016, 129 LTSRSM from cultured 1213 S. maltophilia isolates (10.6%) were identified. A total of 107 LTSRSM infected patients paired with 107 LTSSSM-, and 107 non-S. maltophilia-infected ones were included. When compared with control group A, previous fluoroquinolone and TMP/SMX use was found to be independently associated with LTSRSM occurrence. When compared with control group B, mechanical ventilation, cerebrovascular disease, and previous fluoroquinolone use were risk factors for LTSRSM occurrence. Eighty-five LTSRSM and 85 LTSSSM isolates were compared for antibiotic susceptibilities; the resistance rates and minimum inhibitory concentrations of tigecycline and ceftazidime were significantly higher for LTSRSM than for LTSSSM isolates.

CONCLUSION

The emergence of LTSRSM showing cross resistance to tigecycline and ceftazidime would further limit current therapeutic options. Cautious fluoroquinolone and TMP/SMX use may be helpful to limit such high-level resistant strains of S. maltophilia occurrence.

Aging, Frailty, and the Microbiome-How Dysbiosis Influences Human Aging and Disease

The human gut microbiome is a collection of bacteria, protozoa, fungi, and viruses that coexist in our bodies and are essential in protective, metabolic, and physiologic functions of human health. Gut dysbiosis has traditionally been linked to increased risk of infection, but imbalances within the intestinal microbial community structure that correlate with untoward inflammatory responses are increasingly recognized as being involved in disease processes that affect many organ systems in the body. Furthermore, it is becoming more apparent that the connection between gut dysbiosis and age-related diseases may lie in how the gut microbiome communicates with both the intestinal mucosa and the systemic immune system, given that these networks have a common interconnection to frailty. We therefore discuss recent advances in our understanding of the important role the microbiome plays in aging and how this knowledge opens the door for potential novel therapeutics aimed at shaping a less dysbiotic microbiome to prevent or treat age-related diseases.

High-dimensional Causal Mediation Analysis with a Large Number of Mediators Clumping at Zero to Assess the Contribution of the Microbiome to the Risk of Bacterial Pathogen Colonization in Older Adults

Background:

Causal mediation analysis is conducted in biomedical research with the goal of investigating causal mechanisms that consist of both direct causal pathways between the treatment and outcome variables and intermediate causal pathways through mediators. Recently, this type of analysis has been applied in the context of bioinformatics; however, it encounters the obstacle of high-dimensional and semi-continuous mediators with clumping at zero.

Methods:

In this article, we develop a methodology to conduct high-dimensional causal mediation analysis with a modeling framework that involves (i) a nonlinear model for the outcome variable, (ii) two-part models for semi-continuous mediators with clumping at zero, and (iii) sophisticated variable-selection techniques using machine learning. We conducted simulations and investigated the performance of the proposed method. It is shown that the proposed method can provide reliable statistical information on the causal effects with high-dimensional mediators. The method is adopted to assess the contribution of the intestinal microbiome to the risk of bacterial pathogen colonization in older adults from US nursing homes.

Conclusions:

The proposed high-dimensional causal mediation analysis with nonlinear models is an innovative and reliable approach to conduct causal inference with high-dimensional mediators.

Decolonization of Staphylococcus aureus

Staphylococcus aureus infections are associated with increased morbidity, mortality, hospital stay, and health care costs. S aureus colonization has been shown to increase risk for invasive and noninvasive infections. Decolonization of S aureus has been evaluated in multiple patient settings as a possible strategy to decrease the risk of S aureus transmission and infection. In this article, we review the recent literature on S aureus decolonization in surgical patients, patients with recurrent skin and soft tissue infections, critically ill patients, hospitalized non-critically ill patients, dialysis patients, and nursing home residents to inform clinical practice.

The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California

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.

High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect"

OBJECTIVE

Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).

DESIGN

Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.

SETTING

Twenty-eight NHs in Southern California from 2016 to 2017.

PARTICIPANTS

NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.

METHODS

Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).

RESULTS

A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.

CONCLUSIONS AND IMPLICATIONS

In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

Antimicrobial Resistance Gene Prevalence in a Population of Patients with Advanced Dementia Is Related to Specific Pathobionts

Long-term care facilities are significant reservoirs of antimicrobial-resistant organisms, and patients with advanced dementia are particularly vulnerable to multidrug-resistant organism (MDRO) acquisition and antimicrobial overuse. In this study, we longitudinally examined a group of patients with advanced dementia using metagenomic sequencing. We found significant inter- and intra-subject heterogeneity in microbiota composition, suggesting temporal instability. We also observed a link between the antimicrobial resistance gene density in a sample and the relative abundances of several pathobionts, particularly Escherichia coli, Proteus mirabilis, and Enterococcus faecalis, and used this relationship to predict resistance gene density in samples from additional subjects. Furthermore, we used metagenomic assembly to demonstrate that these pathobionts had higher resistance gene content than many gut commensals. Given the frequency and abundances at which these pathobionts were found in this population and the underlying vulnerability to MDRO of patients with advanced dementia, attention to microbial blooms of these species may be warranted.

Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why?

Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.

A 2-Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes

OBJECTIVES

To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group.

DESIGN

Two-year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group).

SETTING

A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate.

PARTICIPANTS

Nursing staff and medical care providers in the participating NHs.

INTERVENTION

Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit.

MEASUREMENTS

Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections.

RESULTS

Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69-0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65-0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92-0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2-year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653.

CONCLUSIONS

Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46-54, 2019.

Antimicrobial Stewardship Programs in Long-Term Care Settings: A Meta-Analysis and Systematic Review

BACKGROUND

Antimicrobial stewardship programs have been established in hospitals, but less studied in long‐term care facilities (LTCFs), a setting with unique challenges related to patient populations and available resources. This systematic review sought to provide a comprehensive assessment of antimicrobial stewardship interventions implemented in LTCFs, using meta‐analysis to examine their impact on overall antimicrobial use.

METHODS

Electronic searches of MEDLINE, Embase, and CINAHL (1990 to July 2018) identified any antimicrobial stewardship interventions in LTCFs, with no restriction on patient population, study design, or outcomes. Intervention components were categorized using the Cochrane Effective Practice and Organization of Care taxonomy on implementation strategies. Random‐effects meta‐analysis used ratio of means to facilitate pooling of different metrics of antimicrobial use.

RESULTS

Eighteen studies (one randomized controlled trial [RCT], four cluster RCTs, four controlled pre/post studies, and nine uncontrolled pre/post studies) met inclusion, using 13 different antimicrobial stewardship intervention strategies; 15 studies used multifaceted (maximum, seven; median, four) interventions. The three most commonly implemented strategies were educational materials, educational meetings, and guideline implementation. Intervention labor intensity and resource requirements varied considerably among interventions. Meta‐analysis of 11 studies demonstrated that antimicrobial stewardship strategies were associated with a 14% reduction in overall antimicrobial use (95% confidence interval = −8% to −20%; P < .0001), with similar results by study design but high heterogeneity (I² = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I² = 0%) for the cluster RCT and controlled pre/post study subgroups. Funnel plot analysis suggested publication bias, with a lack of publication of smaller studies showing increased antibiotic use.

CONCLUSION

Antimicrobial stewardship strategies implemented in long‐term care vary considerably in design and resource intensity, but collectively suggest potential to reduce antimicrobial use in this challenging setting. J Am Geriatr Soc 67:392–399, 2019.

Prevalence and molecular characterization of Staphylococcus aureus from human stool samples

Background

To determine the prevalence of intestinal S. aureus colonization of patients at a large teaching hospital and determine the molecular characteristics of the identified strains. The second objective of this research was to determine risk factors associated with S. aureus intestinal colonization.

Methods

A cross-sectional study of 781 specimens from inpatients and outpatients at the University of Iowa Hospitals and Clinics Clinical Microbiology Laboratory was conducted. S. aureus was identified using traditional culture methodologies. Methicillin-resistance was determined via PCR of the mecA gene. PVL PCR, spa typing, and antimicrobial sensitivity testing were also done. A nested case-control study was done on a subset of patients with all colonized patients defined as cases and non-colonized controls. Medical record abstractions were done to identify risk factors for intestinal colonization in the nested study.

Results

Out of 625 patients included in the final study, 58 were positive for S. aureus (9.3%). One isolate was positive for the PVL gene. A high number of isolates were resistant to multiple antibiotics including oxacillin (43.1%), erythromycin (51.7%), and levofloxacin (41.4%). All isolates were susceptible to vancomycin, daptomycin, linezolid, and quinupristin-dalfopristin. In the nested study, having a disease or condition of the gastrointestinal tract significantly increased the odds of intestinal colonization (OR: 1.96, 95% CI: 1.04–3.7; aOR: 13.9, 95% CI: 1.67–115.7). No other variables were significantly associated with increased odds of colonization.

Conclusions

S. aureus was identified from the stool of patients at the University of Iowa Hospitals and Clinics, with a large number of those isolates being resistant to antibiotics and may serve a reservoir for subsequent infections as well as asymptomatic transmission.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

Acquisition and persistence of strain-specific methicillin-resistant Staphylococcus aureus and their determinants in community nursing homes

Background

Nursing home residents are frequently colonized with various strains of methicillin-resistant Staphylococcus aureus (MRSA) but the intra-facility dynamics of strain-specific MRSA remains poorly understood. We aimed at identifying and quantifying the associations between acquisition and carriage of MRSA strains and their potential risk factors in community nursing homes using mathematical modeling.

Methods

The data was collected during a longitudinal MRSA surveillance study in six nursing homes in South Central Wisconsin. MRSA cultures were obtained from subjects every 3 months for up to one year. MRSA isolates were subsequently strain-typed by pulsed-field gel electrophoresis (PFGE), and their genetic similarity was established based on the Dice coefficients. Bayesian network analysis, logistic regression and elastic net were used to quantify the associations between acquisition and carriage of MRSA strains discriminated at 80% and 95% strain similarity thresholds and potentially modifiable resident characteristics including previous antibiotic exposure, comorbidity, medical devices, chronic wounds, functional and cognitive status and recent hospitalizations.

Results

Absence of severe cognitive impairment as well as presence of a wound, device and severe comorbidity was associated with elevated probability of USA100 carriage although there was a variation based on the combination of those risk factors. Residents with severe comorbidity and cognitive status and presence of device and wound were identified as certain carriers of USA100 in our sample. Residents with a chronic wound were more likely to carry USA100 MRSA (OR = 2.77, 95% CI = 1.37–5.87). Functional status was identified as an important determinant of carriage of USA100 and USA300 strains. Comorbidity and cognitive status were the two factors associated with carriage of all clonal groups in the study (USA100, USA300 and USA1200).

Conclusions

The combination of Bayesian network analysis, logistic regression and elastic net can be used to identify associations between acquisition and carriage of MRSA strains and their potential risk factors in the face of scarce data. The revealed associations may be used to generate hypothesis for further study of determinants of acquisition and carriage of selected MRSA subtypes and to better inform infection control efforts in community nursing homes.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2837-3) contains supplementary material, which is available to authorized users.

Regional Supply of Nursing Home and Hospital Beds Determine Discharge Destination of Nursing Home Residents in Japan

OBJECTIVES

Japanese special nursing homes provide permanent residence to elderly people under the public long-term care insurance program. However, a quarter of discharges occur via death in hospital, and a fifth occur via admission to hospital. The objective was to identify factors associated with discharge destinations for residents of Japanese special nursing homes.

DESIGN

A retrospective design for data collected in 2007, 2010, and 2013.

SETTING

We used data from the Survey of Institutions and Establishments for Long-Term Care, which is a nationally representative cross-sectional survey that assessed discharge from special nursing homes in September every 3 years.

PARTICIPANTS

There were 2426 discharged residents included in the analysis.

MEASUREMENTS

Discharge destination was categorized as death at facility, death in hospital, hospital admission, and another care setting. Multivariate multinomial logistic regression analysis was conducted with discharge destination as the dependent variable.

RESULTS

Of the 2426 discharged residents included in the analysis, 874 (36.0%) were deceased at the facility, 773 (31.9%) were deceased in hospital, 652 (26.9%) were admitted to hospital, and 127 (5.2%) were admitted to another care setting. Residents of facilities in the regions with fewer nursing home beds or more hospital beds were more likely to be discharged via admittance to hospital or another care setting relative to being deceased at the facility.

CONCLUSION

The regional supply of nursing home and hospital beds could have affected end-of-life care locations for residents of special nursing homes. To promote end-of-life care in special nursing homes, regional supply of nursing home beds should be reinforced while controlling oversupply of hospital beds.

Antibacterial Prophylaxis for Surgical Site Infection in the Elderly: Practical Application

Surgical site infections are among the most common healthcare-associated infections and are linked with increased length of hospitalization, re-admission, mortality and significant financial burden. Risk factors for the occurrence of surgical site infections include variables related to the surgical procedure as well as host factors. Increasing age is associated with the occurrence of surgical site infections. The aim of this review is to give an update on the antibiotic prophylaxis for surgical site infection in elderly people. We focused on specific issues and practical applications, such as the importance of targeting the antimicrobial agent to the susceptibility pattern of colonizing flora in selected cases and the need for dosage modifications.

Transmission of Resistant Gram-Negative Bacteria to Health Care Worker Gowns and Gloves during Care of Nursing Home Residents in Veterans Affairs Community Living Centers

The objectives of the study were to estimate the risk of transmission of antibiotic-resistant Gram-negative bacteria (RGNB) to gowns and gloves (G&G) worn by health care workers (HCWs) when providing care to nursing home residents and to identify the types of care and resident characteristics associated with transmission. A multicenter, prospective observational study was conducted with residents and HCWs from Veterans Affairs (VA) nursing homes. Perianal swabs to detect RGNB were collected from residents. HCWs wore G&G during usual care activities, and the G&G were swabbed at the end of the interaction in a standardized manner. Transmission of RGNB from a colonized resident to G&G by type of care was measured. Odds ratios (ORs) associated with type of care or resident characteristics were estimated. Fifty-seven (31%) of 185 enrolled residents were colonized with ≥1 RGNB. RGNB transmission to HCW gloves or gowns occurred during 9% of the interactions (n = 905): 7% to only gloves and 2% to only gowns. Bathing the resident and providing hygiene and toilet assistance were associated with a high risk of transmission. Glucose monitoring and assistance with feeding or medication were associated with a low risk of transmission. In addition, antibiotic use by the resident was strongly associated with greater transmission (OR, 2.51; P < 0.01). RGNB were transferred to HCWs during ∼9% of visits. High-risk types of care were identified for which use of G&G may be prioritized. Antibiotic use was associated with 2.5 times greater risk of transmission, emphasizing the importance of antibiotic stewardship. (This study has been registered at ClinicalTrials.gov under registration no. NCT01350479.).

Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review

INTRODUCTION

Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH.

METHODS

PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines).

RESULTS

A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations.

DISCUSSION

The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization.

CONCLUSION

Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.

Extended-spectrum β-lactamase-producing Enterobacteriaceae colonisation in long-term care facilities: a systematic review and meta-analysis

The objectives of this study were to estimate the colonisation rate by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) among residents of long-term care facilities (LTCFs) and to identify pertinent risk factors. A systematic search of PubMed and EMBASE databases for studies published up to May 2016 that provided raw data for gastrointestinal colonisation by ESBL-PE among LTCF residents was performed. Twenty-three studies reporting data on 9775 screened subjects met the inclusion criteria. The pooled prevalence of ESBL-PE among LTCF residents was 18% [95% confidence interval (CI) 12-24%]. Risk factors for colonisation included recent antibiotic use (within 6 months) [odds ratio (OR) = 2.06, 95% CI 1.78-2.38], previous hospitalisation (within 2.5 years) (OR = 1.50, 95% CI 1.04-2.15), history of invasive procedures (within 2 years) (OR = 2.79, 95% CI 1.66-4.70), previous ESBL-PE colonisation or infection (OR = 6.77, 95% CI 1.33-34.62), history of urinary tract infection (OR = 2.66, 95% CI 1.76-4.01) and urinary catheter use (OR = 2.55, 95% CI 1.29-5.04). In conclusion, almost one in five LTCF residents is colonised with ESBL-PE, and colonised residents are more likely to have a history of recent antibiotic use or healthcare facility utilisation. Strict adherence to antimicrobial stewardship in LTCFs is needed to address these high resistance rates.

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department

OBJECTIVES

To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review.

DESIGN

Prospective, observational study.

SETTING

Urban, tertiary-care ED.

PARTICIPANTS

Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent.

MEASUREMENTS

Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines.

RESULTS

Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-).

CONCLUSION

Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.

Challenges and Strategies for Prevention of Multidrug-Resistant Organism Transmission in Nursing Homes

PURPOSE OF REVIEW

Nursing home residents are at high risk for colonization and infection with bacterial pathogens that are multidrug-resistant organisms (MDROs). We discuss challenges and potential solutions to support implementing effective infection prevention and control practices in nursing homes.

RECENT FINDINGS

Challenges include a paucity of evidence that addresses MDRO transmission during the care of nursing home residents, limited staff resources in nursing homes, insufficient infection prevention education in nursing homes, and perceptions by nursing home staff that isolation and contact precautions negatively influence the well being of their residents. A small number of studies provide evidence that specifically address these challenges. Their outcomes support a paradigm shift that moves infection prevention and control practices away from a pathogen-specific approach and toward one that focuses on resident risk factors.

Comparison of stool versus rectal swab samples and storage conditions on bacterial community profiles

BACKGROUND

Sample collection for gut microbiota analysis from in-patients can be challenging. Collection method and storage conditions are potential sources of variability. In this study, we compared the bacterial microbiota from stool stored under different conditions, as well as stool and swab samples, to assess differences due to sample storage conditions and collection method.

METHODS

Using bacterial 16S rRNA gene sequence analysis, we compared the microbiota profiles of stool samples stored and collected under various conditions. Stool samples (2 liquid, 1 formed) from three different patients at two hospitals were each evaluated under the following conditions: immediately frozen at -80°C, stored at 4°C for 12-48 hours before freezing at -80°C and stored at -20°C with 1-2 thaw cycles before storage at -80°C. Additionally, 8 stool and 30 rectal swab samples were collected from 8 in-patients at one hospital. Microbiota differences were assessed using the Yue and Clayton dissimilarity index (θYC distance) and analysis of molecular variance (AMOVA).

RESULTS

Regardless of the storage conditions, the bacterial communities of aliquots from the same stool samples were very similar based on θYC distances (median intra-sample θYC distance: 0.035, IQR: 0.015-0.061) compared to aliquots from different stool samples (median inter-sample θYC distance: 0.93, IQR: 0.85-0.97) (Wilcoxon test p-value: <0.0001). For the stool and rectal swab comparison, samples from different patients, regardless of sample collection method, were significantly different (AMOVA p-values: <0.001-0.029) compared to no significant difference between all stool and swab samples (AMOVA p-value: 0.976). The θYC dissimilarity index between swab and stool samples was significantly lower within individuals (median 0.17, IQR: 0.10-0.27) than between individuals (median 0.93, IQR: 0.85-0.97) (Wilcoxon test p-value: <0.0001), indicating minimal differences between stool and swab samples collected from the same individual over the sampling period.

CONCLUSION

For gastrointestinal microbiota studies based on bacterial 16S rRNA gene sequence analysis, interim stool sample storage at 4 °C or -20 °C, rather than immediate storage at -80 °C, does not significantly alter results. Additionally, stool and rectal swab microbiotas from the same subject were highly similar, indicating that these sampling methods could be used interchangeably to assess the community structure of the distal GI tract.

Current Prescribing Practices for Skin and Soft Tissue Infections in Nursing Homes

OBJECTIVES

Antibiotic stewardship has been called for across all sites of health care, including nursing homes (NHs). Skin and soft tissue infections (SSTIs) are the third most common indication for antibiotics in the NH, and so should be a focus of stewardship. This study audited medical records to identify signs and symptoms of SSTIs treated with antibiotics in relation to the McGeer criteria for surveillance, the Loeb minimum criteria for antibiotic initiation, and prescribing recommendations of the Infectious Disease Society of America.

DESIGN

Cross-sectional study.

SETTING

Thirty-one NHs in Southeastern United States.

MEASUREMENTS

Chart data from a random sample of 161 antibiotic prescriptions for SSTIs were abstracted. To meet the McGeer criteria, pus was present at a suspected SSTI site, or at least four of the following findings were documented as present at the site: new or worsening warmth, redness, swelling, tenderness, serous drainage, or a constitutional finding. The Loeb minimum criteria for initiating antibiotics included findings of new or increasing purulent drainage at a suspected SSTI site or at least two of the following findings: fever or new or worsening redness, tenderness, warmth, or swelling at the suspected site. Audits also collected the name, route, and duration of the associated antibiotic. Analyses calculated the types of diagnoses and evaluated associations between published criteria and prescribing.

RESULTS

Cellulitis, skin/soft tissue injury with infection, and abscess were diagnosed in 37% (N = 59), 18% (N = 29), and 16% (N = 26) of cases, respectively; 27% (N = 43) had less specific diagnoses. The McGeer criteria were met in 25% (N = 40), and the Loeb minimum criteria were met in 48% (N = 77) of cases. Doxycycline was the most frequently prescribed antibiotic. The mean treatment length was 9.6 days (standard deviation, 5.6), and the median length of treatment was 8.5 days (range, 3-45).

CONCLUSION

SSTIs are not routinely diagnosed or treated according to recommended standards of care, and prescriptions for systemic antibiotics appear to be frequently initiated without regard to recommended definitions of infection or therapies for the associated diagnoses. These findings indicate that SSTIs present various opportunities to improve antibiotic stewardship.

Profiling the fecal carriage of β-lactamase genes in long-term care facility residents: A longitudinal study

BACKGROUND

The fecal carriage of β-lactamase (BL)-producing bacteria may play a major role in the spread of these organisms in long-term care facilities (LTCFs). The aims of this study were (1) to describe the gene profiles of fecal BL in 3 LCTFs in Taiwan and (2) to analyze the fecal carriage burden of BL genes between the residents (patient group) and staff (staff group) of LTCFs.

METHODS

Thirty fecal samples were collected during June 2013 and July 2015: 20 were obtained from 10 residents both during hospitalization (T1) and 1 month after discharge (T2), and 10 were obtained from 10 staff members.

RESULTS

In total, 80%, 70%, and 50% of the samples in the patient group at T1, staff group at T2, and patient group at T2, respectively, contained >2 BL genes. In the patient group, the predominant genes belonged to extended-spectrum BL genes (90%-100%) and AmpC BL genes (90%-100%). Furthermore, carbapenemase genes were approximately 20% during T1 and T2. The relative levels of SHV-type BLs were significantly higher (P < .05) in the patient group at T2 compared with the staff group.

CONCLUSIONS

In this study, we found a high carriage of fecal BLs among LTCF residents and staff. The monitoring of fecal BL carriage in LTCFs is needed for infection control measures and antibiotic choice for health care-associated infections.

Correlations between quality ratings of skilled nursing facilities and multidrug-resistant urinary tract infections

BACKGROUND

The purpose of this study was to determine risk factors for the acquisition of urinary tract infections (UTIs) and multidrug-resistant organisms (MDROs) in residents of skilled nursing facilities (SNFs).

METHODS

Using the informational database provided by the Centers for Medicare and Medicaid Services (CMS), a retrospective logistic regression was performed on 1,523 urine cultures from 12 SNFs located in Long Island, New York.

RESULTS

Of the 1,142 positive urine cultures, Escherichia coli was most prevalent. Additionally, 164 (14.4%) of the UTIs were attributed to an MDRO. In multivariate logistic regression, sex and overall quality rating predicted the occurrence of UTIs, whereas identification of MDROs was dependent on the level of nursing care received. The mean predicted probability of UTIs and receipt of contaminated samples was inversely dependent on the facility's rating, where the likelihood increased as overall quality ratings decreased.

CONCLUSIONS

The CMS's quality rating system may provide some insight into the status of infection control practices in SNFs. The results of this study suggest that potential consumers should focus on the overall star ratings and the competency of the nursing staff in these facilities rather than on individual quality measures.

Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications

Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.

Infection control policies and procedures for meticillin-resistant Staphylococcus aureus in care homes for older people in Northern Ireland: a questionnaire study

ackground: Limited information is available regarding the role of infection control in the prevention of infection in nursing and residential care homes.

Objectives: To determine what infection control policies and procedures are in place in care homes for older people in Northern Ireland.

Methods: Anonymous postal questionnaire survey of all 410 nursing and residential homes in Northern Ireland that provide care to residents over the age of 65.

Results: A total of 318 (78%) questionnaires were returned. Visits from infection control nurses from health boards or community trusts were infrequent, with only 23% of homes receiving such a visit. Nearly all homes (99.7%) had a policy on infection control, with 72.4% and 84.3% of homes having a policy on the admission and care of residents with meticillin-resistant Staphylococcus aureus (MRSA) respectively. Of those respondents that had a policy on admission of persons with MRSA, only a small percentage (9.2%) would not admit residents with MRSA. Only 11% of respondents believed that MRSA was a problem in their particular home, but at least 30% agreed that there was a problem with MRSA in care homes. A desire was expressed for more information and support, with 75% of respondents agreeing that more information should be provided to homes on MRSA.

Conclusions: There is a clear need for additional infection control advice to be available to care homes and for the development of uniform policies and an infection control audit tool. The audit tool could then be used to ensure that the appropriate policies and standards are in place within care homes and that these standards are met on an ongoing basis.

Descriptive Epidemiology and Case-Control Study of Patients Colonized With Vancomycin-Resistant Enterococcus and Methicillin-ResistantStaphylococcus aureus

Background.

Patients colonized or infected with vancomycin-resistant enterococcus and methicillin-resistantStaphylococcus aureusmay be at risk of acquiring vancomycin-resistantS. aureusif the vanA gene is transferred from vancomycin-resistant enterococcus to methicillin-resistantS. aureus..

Objective.

Our goal was to identify risk factors for cocolonization or coinfection (CC/CI) with vancomycin-resistant enterococcus and methicillin-resistantS. aureus.

Design.

We conducted a descriptive, epidemiologic study of all patients with CC/CI identified from January 1998 to May 2003 and a nested case-control study of a cohort of patients hospitalized in the burn and wound unit.

Setting.

We conducted our study in a 813-bed tertiary care university teaching hospital.

Population.

The study population consisted of patients found to have CC/CI during the study period.

Methods.

Descriptive epidemiologic data were collected from hospital records of all patients identified as having CC/CI. A subset of patients hospitalized in the burn and wound unit were included in a case-control study.

Results.

CC/CI was detected in 71% of the patients during a single hospital stay. The burn and wound unit, which does active surveillance for both organisms, and the general medicine unit, which does not do active surveillance for either organism, cared for more than one-half of these patients. Among patients being cared for in the burn and wound unit, having exposure to 2 or more invasive devices (central venous catheters, indwelling urinary catheters, and enteral feeding tubes) and renal insufficiency were independent risk factors for CC/CI.

Conclusions.

Patients with CC/CI are the population at greatest risk for vancomycin-resistantS. aureuscolonization or infection. The number of invasive devices to which patients are exposed and, thus, possibly the patients' underlying severity of illness, as well as renal insufficiency, appear to be risk factors for CC/CI.

Fecal Carriage of Staphylococcus aureus in the Hospital and Community Setting: A Systematic Review

BACKGROUND AND RATIONALE

Staphylococcus aureus fecal carriage has been identified as a potential source for nosocomial transmission and a risk factor for disease development. This systematic review determined the overall S. aureus [including methicillin susceptible and resistant S. aureus (MSSA and MRSA)] fecal carriage rates within the community and healthcare settings.

METHODOLOGY

Peer-reviewed articles indexed in Medline, Scopus, Academic Search Premier, Africa-Wide Information, CINAHL, and Web of Science were identified using applicable and controlled vocabulary through to 11 November 2015. Eligible studies were ascertained by three independent reviewers. Random-effects meta-analyses of proportions were performed to determine S. aureus, MSSA and MRSA fecal carriage rates reported by eligible studies.

RESULTS

Twenty six studies were included in this review. The pooled estimates for S. aureus, MSSA and MRSA fecal carriage were 26% (95% confidence interval (CI): 16.8-36.3%), 86% (95% confidence interval (CI): 65.9-97.9%) and 10% (95% CI: 0.7-27.0%), respectively. Fecal S. aureus carriage rates increased on average from 10 to 65% during the first 8 weeks of life, followed by an average carriage rate of 64% at 6 months and 46% at 1 year of life. Genotyping techniques were employed mainly in studies conducted in developed countries and comprised largely of gel-based techniques. Six studies reported on the role of S. aureus fecal strains in diarrhea (n = 2) and the risk for acquiring infections (n = 4). Eight of the 26 studies included in this review performed antibiotic susceptibility testing of S. aureus fecal isolates.

CONCLUSION

This study provides evidence that screening for S. aureus fecal carriage, at least in populations at high risk, could be an effective measure for the prevention of S. aureus transmission and infection in the healthcare and community setting. More well-structured studies need to be conducted and sequence-based genotyping techniques should be employed for the comparison of isolates on a global scale in both developing and developed countries.

Methicillin-Resistant Staphylococcus aureus in Saarland, Germany: The Long-Term Care Facility Study

Background

Multiresistant organisms pose a threat for patients and care recipients. Control interventions need to be tailored to region, the type of institution considered, and risk factors. The German state of Saarland is ideally suited to study colonisation epidemiology throughout its various health and care institutions. After conclusion of a large admission prevalence study in acute care hospitals, we now performed a methicillin-resistant Staphylococcus aureus (MRSA) point prevalence study in Saarland long term care facilities (LTCF), allowing for a direct comparison with respect of MRSA prevalence and associated risk factors between these two institutional types located within a confined region.

Methodology and Principal Findings

Of all LTCF of the region, 65/136 participated in the study performed between 09/2013 and 07/2014. Overall, complete microbiological specimen and questionnaires of 2,858 of 4,275 (66.8%) LTCF residents were obtained. 136/2,858 (4.8%) screened residents revealed MRSA carrier status. Multivariate risk factor analysis yielded ulcer/deep soft tissue infection, urinary tract catheter, and MRSA history with multiple MRSA decolonisation cycles to be independently associated with MRSA carrier status.

Conclusion

As already known from previous studies, colonisation with MRSA is common in LTCF residents even in an area with relatively low MRSA prevalence. This found prevalence can now be related to the acute care admission prevalence (2.2%) as well as to the admission prevalence in acute care geriatric departments (7.6%). The common clonal attribution (spa type) of MRSA isolates prevalent in the LTCF population as well as in the acute care admission population points towards a close relationship between both types of institutions. However, the ostensible absence of risk factors such as “previous hospitalisation” in conjunction with newly identified factors such as “multiple decolonisation cycles” refers to MRSA colonisation risks independent of contact with acute care facilities. Overall, this large LTCF point prevalence study allows data-based, region-tailored decisions on MRSA screening policies and provides a basis for additional preventative measures.

Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study

Background

Antibiotic resistance is a problem in nursing homes. Presumed urinary tract infections (UTI) are the most common infection. This study examines urine culture results from elderly patients to see if specific guidelines based on gender or whether the patient resides in a nursing home (NH) are warranted.

Methods

This is a cross sectional observation study comparing urine cultures from NH patients with urine cultures from patients in the same age group living in the community.

Results

There were 232 positive urine cultures in the NH group and 3554 in the community group. Escherichia coli was isolated in 145 urines in the NH group (64 %) and 2275 (64 %) in the community group. There were no clinically significant differences in resistance.

Combined, there were 3016 positive urine cultures from females and 770 from males. Escherichia coli was significantly more common in females 2120 (70 %) than in males 303 (39 %)(p < 0.05). Enterococcus faecalis was significantly less common in females 223(7 %) than males 137 (18 %) (p < 0.05). For females, there were lower resistance rates to ciprofloxacin among Escherichia coli (7 % vs 12 %; p < 0.05) and to mecillinam among Proteus mirabilis (3 % vs 12 %; p < 0.05).

Conclusions

Differences in resistance rates for patients in the nursing home do not warrant separate recommendations for empiric antibiotic therapy, but recommendations based on gender seem warranted.

Current prevalence of multidrug-resistant organisms in long-term care facilities in the Rhine-Main district, Germany, 2013

Multidrug-resistant organisms (MDRO) and in particular multidrug-resistant Gram-negative organisms (MRGN) are an increasing problem in hospital care. However, data on the current prevalence of MDRO in long-term care facilities (LTCFs) are rare. To assess carriage rates of MDRO in LTCF residents in the German Rhine-Main region, we performed a point prevalence survey in 2013. Swabs from nose, throat and perineum were analysed for meticillin-resistant Staphylococcus aureus (MRSA), perianal swabs were analysed for extended-spectrum beta-lactamase (ESBL)-producing organisms, MRGN and vancomycin-resistant enterococci (VRE). In 26 LTCFs, 690 residents were enrolled for analysis of MRSA colonisation and 455 for analysis of rectal carriage of ESBL/MRGN and VRE. Prevalences for MRSA, ESBL/MRGN and VRE were 6.5%, 17.8%, and 0.4%, respectively. MRSA carriage was significantly associated with MRSA history, the presence of urinary catheters, percutaneous endoscopic gastrostomy tubes and previous antibiotic therapy, whereas ESBL/MRGN carriage was exclusively associated with urinary catheters. In conclusion, this study revealed no increase in MRSA prevalence in LTCFs since 2007. In contrast, the rate of ESBL/MRGN carriage in German LTCFs was remarkably high. In nearly all positive residents, MDRO carriage had not been known before, indicating a lack of screening efforts and/or a lack of information on hospital discharge.

Daptomycin in the Clinical Setting: 8-Year Experience with Gram-positive Bacterial Infections from the EU-CORE(SM) Registry

INTRODUCTION

The aim of this study was to evaluate the clinical outcomes and safety of daptomycin therapy in patients with serious Gram-positive infections.

METHODS

Patients were enrolled in the European Cubicin(®) Outcomes Registry and Experience (EU-CORE(SM)), a non-interventional, multicenter, observational registry. The real-world data were collected across 18 countries (Europe, Latin America, and Asia) for patients who had received at least one dose of daptomycin between January 2006 and April 2012. Two-year follow-up data were collected until 2014 for patients with endocarditis, intracardiac/intravascular device infection, osteomyelitis, or orthopedic device infection.

RESULTS

A total of 6075 patients were enrolled. The most common primary infections were complicated skin and soft tissue infection (31.7%) and bacteremia (20.7%). Staphylococcus aureus was the most frequently reported pathogen (42.9%; methicillin-resistant S. aureus [MRSA], 23.2%), followed by Staphylococcus epidermidis and other coagulase-negative staphylococci (CoNS, 28.5%). The most commonly prescribed dose of daptomycin was 6 mg/kg/day (43.6%), and the median duration of therapy was 11 (range 1-300) days. Overall clinical success rate was 80.5%, and was similar whether daptomycin was used as first-line (82.9%) or second-line (79.2%) therapy. Clinical success rates were high in patients with S. aureus (83.9%; MRSA 83.0%) and CoNS (including S. epidermidis, 82.5%) infections. The majority of patients with endocarditis or intracardiac/intravascular device infection (86.7%) or osteomyelitis/orthopedic device infection (85.9%) had a sustained response during the 2-year follow-up period. There were no new or unexpected safety findings.

CONCLUSION

Results from real-world clinical experience showed that daptomycin is a valuable therapeutic option in the management of various difficult-to-treat Gram-positive infections.

FUNDING

This study was funded by Novartis Pharma AG.

[Healthcare associated infections (HAI), antibiotic use and prevalence of multidrug-resistant bacteria (MDRO) in residents of long-term care facilities: the Frankfurt HALT plus MDRO project 2012]

BACKGROUND

Residents of long-term care facilities (LTCF) are at risk of healthcare associated infections (HAI) and are often treated with antibiotics. In Germany a current HAI prevalence of 1.6 % and antibiotic use in 1.15% have been reported. However, data published on the current prevalence of multidrug-resistant organisms (MRDO) in LTCFs in Germany are scarce. Therefore, the prevalence of HAI, antibiotic use and presence of MDROs were investigated in LTCF residents in Frankfurt am Main, Germany.

METHODS

A point prevalence study of HAI and antibiotic use according to the European HALT protocol (health care associated infections in long-term care facilities) was carried out; swabs from the nose, throat and perineum were analyzed for methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamase producing enterobacteria (ESBL) and vancomycin-resistant enterococci (VRE).

RESULTS

A total of 880 residents in 8 LTCFs were enrolled in the study in 2012. The study participants were 30% male, 46.7%  were more than 85 years old, 70% exhibitied urinary or fecal incontinence, 11.4% had an indwelling urinary catheter and 0.1% a vascular catheter. Prevalence rates of HAI and of antibiotic use were 2.5 % and 1.5%, respectively. The prevalence of MDROs in 184 residents who agreed to being tested for MDROs was 9.2% MRSA, 26.7% ESBL and 2.7% VRE.

CONCLUSION

The HAIs and antibiotic use were comparable to the German HALT data from 2010. Compared to other German studies there is a steadily increasing MRSA problem in German LTCFs. High and increasing ESBL rates have been detected in German LTCFs. Further studies are needed to confirm this trend, preferably encompassing molecular methods to study epidemiology.

Carbapenem-ResistantKlebsiella pneumoniaein Post-Acute-Care Facilities in Israel

Objective.

To assess the prevalence of and risk factors for carbapenem-resistantKlebsiella pneumoniae(CRKP) carriage among patients in post-acute-care facilities (PACFs) in Israel.

Design, Setting, and Patients.

A cross-sectional prevalence survey was conducted in 12 PACFs. Rectal swab samples were obtained from 1,144 patients in 33 wards. Risk factors for CRKP carriage were assessed among the cohort. Next, a nested, matched case-control study was conducted to define individual risk factors for colonization. Finally, the cohort of patients with a history of CRKP carriage was characterized to determine risk factors for continuous carriage.

Results.

The prevalence of rectal carriage of CRKP among 1,004 patients without a history of CRKP carriage was 12.0%. Independent risk factors for CRKP carriage were prolonged length of stay (odds ratio [OR], 1.001;P< .001), sharing a room with a known carrier (OR, 3.09;P= .02), and increased prevalence of known carriers on the ward (OR, 1.02;P= .013). A policy of screening for carriage on admission was protective (OR, 0.41;P= .03). Risk factors identified in the nested case-control study were antibiotic exposure during the prior 3 months (OR, 1.66;P= .03) and colonization with other resistant pathogens (OR, 1.64;P= .03). Among 140 patients with a history of CRKP carriage, 47% were colonized. Independent risk factors for continued CRKP carriage were antibiotic exposure during the prior 3 months (OR, 3.05;P= .04), receipt of amoxicillin-clavulanate (OR, 4.18;P= .007), and screening within 90 days of the first culture growing CRKP (OR, 2.9;P= .012).

Conclusions.

We found a large reservoir of CRKP in PACFs. Infection-control polices and antibiotic exposure were associated with patient colonization.

Risk Factors for Methicillin-Resistant Staphylococcus Aureus Carriage in Residents of German Nursing Homes

Objectives:

To determine the prevalence of and the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage in nursing home residents in the Rhine-Neckar region of southern Germany.

Design:

Point-prevalence survey.

Setting:

Forty-seven nursing homes in the region.

Participants:

All residents of the approached nursing homes who agreed to participate.

Methods:

After informed consent was obtained, all participants had their nares swabbed, some personal data collected, or both. All swabs were examined for growth of MRSA All S. aureus isolates underwent oxacillin susceptibility testing and polymerase chain reaction for demonstration of the meek gene. All MRSA isolates were typed using pulsed-field gel electrophoresis after digestion with SmaI.

Results:

Swabs from 3,236 nursing home residents yielded 36 MRSA strains, contributing to a prevalence rate of 1.1%. Significant risk factors for MRSA carriage in the multivariate analysis were the presence of wounds or urinary catheters, limited mobility, admission to a hospital during the preceding 3 months, or stay in a medium-size nursing home. One predominant MRSA strain could be detected in 30 of the 36 MRSA carriers.

Conclusions:

The prevalence of MRSA in German nursing homes is still low. These residents seemed to acquire their MRSA in the hospital and transfer it to their nursing home. Apart from well-known risk factors for the acquisition of MRSA we identified the size of the nursing home as an independent risk factor. This might be due to an increased use of antimicrobials in nursing homes of a certain size.

Occurrence of Co-colonization or Co-Infection with Vancomycin-Resistant Enterococci and Methicillin-ResistantStaphylococcus aureusin a Medical Intensive Care Unit

Objective:

To determine the occurrence of co-colonization or co-infection with VRE and MRSA among medical patients requiring intensive care.

Design:

Prospective, single-center, observational study.

Setting:

A 19-bed medical ICU in an urban teaching hospital.

Patients:

Adult patients requiring at least 48 hours of intensive care and having at least one culture performed for microbiologie evaluation.

Results:

Eight hundred seventy-eight consecutive patients were evaluated. Of these patients, 402 (45.8%) did not have microbiologie evidence of colonization or infection with either VRE or MRSA 355 (40.4%) were colonized or infected with VRE, 38 (4.3%) were colonized or infected with MRSA, and 83 (9.5%) had co-colonization or co-infection with VRE and MRSA. Multiple logistic regression analysis demonstrated that increasing age, hospitalization during the preceding 6 months, and admission to a long-term-care facility were independently associated with colonization or infection due to VRE and co-colonization or co-infection with VRE and MRSA. The distributions of positive culture sites for VRE (stool, 86.7%; blood, 6.5%; urine, 4.8%; soft tissue or wound, 2.0%) and for MRSA (respiratory secretions, 34.1%; blood, 32.6%; urine, 17.1%; soft tissue or wound, 16.2%) were statistically different (P< .001).

Conclusions:

Co-colonization or co-infection with VRE and MRSA is common among medical patients requiring intensive care. The recent emergence of vancomycin-resistantStaphylococcus aureusand the presence of a patient population co-colonized or co-infected with VRE and MRSA support the need for aggressive infection control measures in the ICU.

Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia

IMPORTANCE

Infection management in advanced dementia has important implications for (1) providing high-quality care to patients near the end of life and (2) minimizing the public health threat posed by the emergence of multidrug-resistant organisms (MDROs).

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 362 residents with advanced dementia and their health care proxies in 35 Boston area nursing homes for up to 12 months.

MAIN OUTCOMES AND MEASURES

Data were collected to characterize suspected infections, use of antimicrobial agents (antimicrobials), clinician counseling of proxies about antimicrobials, proxy preference for the goals of care, and colonization with MDROs (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant gram-negative bacteria). Main outcomes were (1) proportion of suspected infections treated with antimicrobials that met minimum clinical criteria to initiate antimicrobial treatment based on consensus guidelines and (2) cumulative incidence of MDRO acquisition among noncolonized residents at baseline.

RESULTS

The cohort experienced 496 suspected infections; 72.4% were treated with antimicrobials, most commonly quinolones (39.8%) and third- or fourth-generation cephalosporins (20.6%). At baseline, 94.8% of proxies stated that comfort was the primary goal of care, and 37.8% received counseling from clinicians about antimicrobial use. Minimum clinical criteria supporting antimicrobial treatment initiation were present for 44.0% of treated episodes and were more likely when proxies were counseled about antimicrobial use (adjusted odds ratio, 1.42; 95% CI, 1.08-1.86) and when the infection source was not the urinary tract (referent). Among noncolonized residents at baseline, the cumulative incidence of MDRO acquisition at 1 year was 48%. Acquisition was associated with exposure (>1 day) to quinolones (adjusted hazard ratio [AHR], 1.89; 95% CI, 1.28-2.81) and third- or fourth-generation cephalosporins (AHR, 1.57; 95% CI, 1.04-2.40).

CONCLUSIONS AND RELEVANCE

Antimicrobials are prescribed for most suspected infections in advanced dementia but often in the absence of minimum clinical criteria to support their use. Colonization with MDROs is extensive in nursing homes and is associated with exposure to quinolones and third- and fourth-generation cephalosporins. A more judicious approach to infection management may reduce unnecessary treatment in these frail patients, who most often have comfort as their primary goal of care, and the public health threat of MDRO emergence.

Role of body temperature in diagnosing bacterial infection in nursing home residents

OBJECTIVES

To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home (NH) residents.

DESIGN

Retrospective.

SETTING

Twelve North Carolina NHs.

PARTICIPANTS

NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes.

MEASUREMENTS

Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations (SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America (IDSA) criteria to determine how often each prescribing episode was associated with a "fever" according to each definition.

RESULTS

Mean population nonillness temperature was 97.7 ± 0.5 ºF. If "normal" were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7 ºF, and the previously published fever cutpoints and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions.

CONCLUSION

Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection.

Protective effect of methicillin-susceptible Staphylococcus aureus carriage against methicillin-resistant S. aureus acquisition in nursing homes: a prospective cross-sectional study

OBJECTIVE

To evaluate whether an ecologic inverse association exists between methicillin-susceptible Staphylococcus aureus (MSSA) prevalence and methicillin-resistant S. aureus (MRSA) prevalence in nursing homes.

METHODS

We conducted a secondary analysis of a prospective cross-sectional study of S. aureus prevalence in 26 nursing homes across Orange County, California, from 2008-2011. Admission prevalence was assessed using bilateral nares swabs collected from all new residents within 3 days of admission until 100 swabs were obtained. Point prevalence was assessed from a representative sample of 100 residents. Swab samples were plated on 5% sheep blood agar and Spectra MRSA chromogenic agar. If MRSA was detected, no further tests were performed. If MRSA was not detected, blood agar was evaluated for MSSA growth. We evaluated the association between MRSA and MSSA admission and point prevalence using correlation and linear regression testing.

RESULTS

We collected 3,806 total swabs. MRSA and MSSA admission prevalence were not correlated (r = -0.40, P = .09). However, MRSA and MSSA point prevalence were negatively correlated regardless of whether MSSA prevalence was measured among all residents sampled (r = -0.67, P = .0002) or among those who did not harbor MRSA (r = -0.41, P = .04). This effect persisted in regression models adjusted for the percentage of residents with diabetes (β = -0.73, P = .04), skin lesions (β = -1.17, P = .002), or invasive devices (β = -1.4, P = .0006).

CONCLUSIONS

The inverse association between MRSA and MSSA point prevalence and minimal association on admission prevalence suggest MSSA carriage may protect against MRSA acquisition in nursing homes. The minimal association on admission prevalence further suggests competition may occur during nursing home stays.

Inguinal skin colonization with multidrug-resistant bacteria among residents of elderly care facilities: frequency, persistence, molecular analysis and clinical impact

Frequency, persistence and molecular characteristics of multidrug resistant bacteria colonizing inhabitants of long term care facilities are topics of current concern. We performed a point-prevalence survey of 402 residents in 7 elderly care facilities in Berlin, Germany. Inguinal swabs were analyzed for the presence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and multidrug-resistant gram-negative bacteria. Three and six months following the initial investigation, all colonized residents were sampled again and the occurrence of intercurrent infections, hospital admissions and use of antimicrobials were registered. Genetic relatedness of the bacteria was investigated using multi-locus sequence typing (MLST), spa-typing and SmaI/XbaI-macrorestriction analysis. 33 (8.2%) residents were skin-colonized with multidrug-resistant bacteria. MRSA were found in 19 (4.7%) and ESBL-producing Enterobacteriaceae in 16 residents (3.98%). Independent risk factors for colonization with multidrug-resistant bacteria were a high level of care and the presence of chronic wounds. A large proportion of the observed bacteria persisted up to six months and showed a high degree of inter-individual diversity. Outcome analysis revealed that infections tend to occur slightly more often in residents colonized by multiresistant pathogens. We assume that a perceptible population of residents in nursing homes is at risk for individual colonization with multidrug-resistant bacteria as well as healthcare associated infections.

The role of Staphylococcus aureus carriage in the pathogenesis of bloodstream infection

Background

Staphylococcus aureus (SA) colonisation is associated with development of bloodstream infection (BSI), with the majority of colonising and infecting strains identical by pulsed-field gel electrophoresis (PFGE). We examined SA colonisation in patients with SABSI to delineate better the relationship between the two.

Methods

Patients with SABSI were swabbed in the nose, throat, groin, axilla and rectum. Isolates were typed using PFGE. Logistic regression was performed to determine factors associated with positive swabs.

Results

79 patients with SABSI had swabs taken. 46 (58%) had ≥ 1 screening swab positive for S. aureus; of these 37 (80%) were in the nose, 11 (24%) in the throat, 12 (26%) in the groin, 11 (24%) in the axilla and 8 (17%) in the rectum. On multivariate analysis, days from blood culture to screening swabs (OR 0.5, 95% CI 0.32-0.78, P = 0.003) and methicillin resistance (OR 9.5, 95% CI 1.07-84.73, P = 0.04) were associated with having positive swabs. Of 46 participants who had a blood sample and 1 other sample subtyped, 33 (72%, 95% CI 57-84%) had all identical subtypes, 1 (2%) had subtypes varying by 1–3 bands and 12 (26%) had subtypes ≥ 3 bands different. 30/36 (83%) blood-nose pairs were identical.

Conclusion

Overall, 58% of patients with SABSI had positive screening swabs. Of these, only 80% had a positive nose swab ie less than half (37/79, 47%) of all SABSI patients were nasally colonised. This may explain why nasal mupirocin alone has not been effective in preventing SA infection. Measures to eradicate non-nasal carriage should also be included.

Secure surveillance of antimicrobial resistant organism colonization or infection in Ontario long term care homes

Background

There is stigma attached to the identification of residents carrying antimicrobial resistant organisms (ARO) in long term care homes, yet there is a need to collect data about their prevalence for public health surveillance and intervention purposes.

Objective

We conducted a point prevalence study to assess ARO rates in long term care homes in Ontario using a secure data collection system.

Methods

All long term care homes in the province were asked to provide colonization or infection counts for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum beta-lactamase (ESBL) as recorded in their electronic medical records, and the number of current residents. Data was collected online during the October-November 2011 period using a Paillier cryptosystem that allows computation on encrypted data.

Results

A provably secure data collection system was implemented. Overall, 82% of the homes in the province responded. MRSA was the most frequent ARO identified at 3 cases per 100 residents, followed by ESBL at 0.83 per 100 residents, and VRE at 0.56 per 100 residents. The microbiological findings and their distribution were consistent with available provincial laboratory data reporting test results for AROs in hospitals.

Conclusions

We describe an ARO point prevalence study which demonstrated the feasibility of collecting data from long term care homes securely across the province and providing strong privacy and confidentiality assurances, while obtaining high response rates.