Methicillin-resistant Staphylococcus aureus colonization in a long-term-care facility

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.

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.

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.

Outcomes after Stroke in Patients with Previous Pressure Ulcer: A Nationwide Matched Retrospective Cohort Study

BACKGROUND

Factors associated with poststroke adverse events were not completely understood. The purpose of this study was to investigate whether stroke patients with previous pressure ulcers had more adverse events after stroke.

METHODS

Using the claims data from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study matched by propensity score. Three thousand two first-ever stroke patients with previous pressure ulcer and 3002 first-ever stroke patients without pressure ulcer were investigated between 2002 and 2009. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of complications and 30-day mortality after stroke associated with previous pressure ulcer were calculated in the multivariate logistic regressions.

RESULTS

Patients with pressure ulcer had significantly higher risk than control for poststroke urinary tract infection (OR: 1.56, 95% CI: 1.38-1.78), pneumonia (OR: 1.35, 95% CI: 1.16-1.58), gastrointestinal bleeding (OR: 1.31, 95% CI: 1.04-1.66), and epilepsy (OR: 1.84, 95% CI: 1.83-1.85). Stroke patients with pressure ulcer had increased 30-day poststroke mortality (OR: 2.01, 95% CI: 1.55-2.61), particularly in those treated with debridement (OR: 2.87, 95% CI: 1.85-4.44) or high quantity of antibiotics (OR: 4.01, 95% CI: 2.10-7.66). Pressure ulcer was associated with poststroke mortality in both genders and patients aged 60 years or older.

CONCLUSIONS

This study showed increased poststroke complications and mortality in patients with previous pressure ulcer, which suggests the urgent need for monitoring stroke patients for pressure ulcer history.

Colonization with Multi-Drug Resistant Organisms in Nursing Homes: Scope, Importance, and Management

Bacterial infections are among the most common causes of morbidity and mortality in Nursing Homes (NH) and other long term care facilities. Multi-drug resistant organisms (MDROs) represent an ever-increasing share of causative agents of infection, and their prevalence in NHs is now just as high as in acute-care facilities, or even higher. Indeed, NHs are now considered a major reservoir of MDROs for the community at large. Asymptomatic colonization is usually a prerequisite to development of symptomatic infection. While progress has been made in defining epidemiology of MDROs in NHs, few studies have evaluated the role of changing healthcare delivery in introducing and further transmitting MDROs in this setting. Furthermore, the factors influencing the spread of colonization and the key prognostic indicators leading to symptomatic infections in the burgeoning short stay population need to be explored further. The difficulty of this task lies in the heterogeneity of NHs in terms of focus of care, organization and resources, and on the diversity among the many MDRO species encountered, which harbor different resistance genes and with a different prevalence depending on the geographic location, local antimicrobial pressure and residents risk factors such as use of indwelling devices, functional disability, wounds and other comorbidities. We present literature findings on the scope and importance of colonization as a pathway to infection with MDROs in NHs, underline important open questions that need further research, and discuss the strength of the evidence for current and proposed screening, prevention, and management interventions.

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.

Molecular Epidemiology of Methicillin–ResistantStaphylococcus Aureusin a Veterans Administration Medical Center

Objectives:

To determine whether patients who were colonized or infected with methicillin-resistantStaphylococcus aureus(MRSA) persistently carried the same strain and to identify the extent of strain variation within a population of patients.

Design:

Molecular typing by pulsed-field gel electrophoresis (PFGE) of stored MRSA isolates.

Setting:

A Veterans Administration Medical Center with 288 hospital, 45 intermediate-care, and 75 extended-care beds.

Isolates:

Between January 1991 and March 1993, 91 patients had MRSA identified in routine cultures. One hundred isolates from 57 patients (63%) were available for typing.

Results:

Before 1988, only occasional MRSA isolates were identified. By 1993, 50% ofS. aureusisolates from unique patients were resistant to methicillin. PFGE identified 7 MRSA strains, 3 of which were identified in specimens from 1 patient each. The most common strains were SD4 (20 patients), SD1 (12 patients), SD2 (12 patients), and SD5a (5 patients). Twenty patients had 2 or more isolates obtained at least 1 week apart (mean, 30.7 weeks; range, 1 to 102 weeks). Of these patients, 12 were colonized or infected with only one strain (mean time observed, 25.1 weeks; range, 1 to 82 weeks). Eight patients had at least 2 different strains (mean time observed, 39 weeks; range, 2 to 102 weeks).

Conclusion:

Numerous MRSA strains circulated in tiiis endemic setting; 40% of patients observed over time were colonized or infected witii more than one strain. Molecular typing was an essential tool for evaluating the epidemiology of MRSA in this setting.

Antibiotic use and resistance in long term care facilities

INTRODUCTION

The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance.

METHODS

Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations.

RESULTS

A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship.

CONCLUSION

The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.

New acquisition of antibiotic-resistant organisms in skilled nursing facilities

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

The prevalence of meticillin-resistant Staphylococcus aureus in long-term care facilities: is there a need for tailored glycopeptide prophylaxis?

Prophylactic antibiotics are effective in reducing the rate of surgical site infection (SSI). Cephalosporin antibiotics are recommended except for patients colonised with meticillin resistant staphylococcus aureus (MRSA), where glycopeptide antibiotics are indicated. However, in the trauma setting, the MRSA status is unknown prior to surgery.

Aim: To determine if the incidence of MRSA colonisation in trauma patients from long term care (LTC) warrants the use of empirical glycopeptide antibiotics.

Methods: A retrospective analysis of patients admitted with hip fractures was performed. The MRSA status of patient from LTC facilities and home was determined.

Results: The prevalence of MRSA colonisation in patients admitted from LTC facilities was 33.6%, compared to 3.6% for patients admitted from home, P < 0.001.

Our results suggest that risk of patients carrying MRSA is significantly higher for patients being admitted form LTC. This group of patients may benefit from empirical glycopeptide antibiotic when the MRSA status is unknown.

Reduced Cellular Toxicity of a New Silver-Containing Antimicrobial Dressing and Clinical Performance in Non-Healing Wounds

Bacterial colonisation of wounds may delay wound healing. Modern silver-containing dressings are antimicrobial, yet cellular toxicity is a serious side-effect. We provide data for a newly formulated silver-containing ointment dressing, Atrauman Ag, for antimicrobial activity and cytotoxicity. Atrauman Ag effectively killed a panel of commensal skin as well as pathogenic bacterial strains while cytotoxicity for HaCaT keratinocytes was only around 10%. With these favourable in vitro tests, Atrauman Ag was analysed in 86 patients with traumatic and non-healing wounds of different aetiologies. The wound state was evaluated for 3 subsequent dressing changes. The slough score was reduced from 59.2 to 35.8%, granulation tissue increased from 27 to 40% and epithelialisation went up from 12.1 to 24%. We conclude that Atrauman Ag has a superior profile of antimicrobial activity over cellular toxicity and the low silver ion release rate may prevent interference with wound-healing mechanisms.

Risk factors for Staphylococcus aureus nasal carriage in residents of three nursing homes in Germany

The prevalence of Staphylococcus aureus nasal carriage in three nursing homes (N=500) was 36.6%. No meticillin-resistant S. aureus (MRSA) was detected. The following significant risk factors for S. aureus nasal carriage were identified: vascular cognitive impairment [odds ratio (OR)=0.31]; diabetes mellitus (OR=1.82); hypertension (OR=0.30); chronic obstructive pulmonary disease (OR=1.86); stroke (OR=3.31); antibiotic therapy within the previous three months (OR=2.10); and level 2 care (defined as highly dependent, needing help in activities of daily living for up to 4h/day) (OR=1.97). Compared with other countries, the prevalence of MRSA nasal carriage in residents of German nursing homes is low.

The point prevalence and associated factors of nasal methicillin-resistant Staphylococcus aureus colonisation in eight geriatric hospitals in Korea

The prevalence and associated factors of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonisation were investigated among patients in geriatric hospitals in Korea. S. aureus was isolated from 317 (50.2%) of 632 patients. The nasal MRSA colonisation prevalence was 36.1%. In bivariate analysis, stay in an intensive care unit, decreased functional status, recent use of antibiotics, use of urinary catheters and the existence of skin breaks were associated with nasal MRSA colonisation (p < 0.05). Of these factors, only decreased functional status and recent use of systemic antibiotics were associated independently with nasal MRSA colonisation following logistic regression analysis.

Evaluating the probability of previously unknown carriage of MRSA at hospital admission

PURPOSE

We determined the prevalence and risk profile of patients with previously unknown carriage of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission.

SUBJECTS AND METHODS

We conducted a 7-month, prospective case-controlled study in adult inpatients admitted to a university hospital with endemic MRSA. Multivariate conditional logistic regression for data sets matched 1:4 was performed to identify the risk profile of newly identified MRSA carriers.

RESULTS

Overall, 399 of 12072 screened admissions (prevalence, 3.3%) were found colonized (n = 368, 92%) or infected (n = 31, 8%) with MRSA. In 204 cases (prevalence, 1.7%), MRSA carriage was newly identified. Without screening on admission, 49% (196/399) of MRSA carriers would have been missed. We identified nine independent risk factors for newly identified MRSA carriage at admission (adjusted odds ratio): male sex (1.9); age greater than 75 years (2.0); receipt of fluoroquinolones (2.7), cephalosporins (2.1), and carbapenems (3.2) in the last 6 months; previous hospitalization (1.9) or intravenous therapy (1.7) during the last 12 months; urinary catheter at admission (2.0); and intrahospital transfer (2.4). A risk score (range, 0-13) was calculated by adding points assigned to these variables. On the basis of analysis of 1006 patients included in the case-controlled study, the probability of MRSA carriage was 8% (28/342) in patients with a low score (< or =1), 19% (92/482) in patients with an intermediate score (2-4), and 46% (84/182) in patients with a high score (> or =5). The risk score had good discrimination (c-statistic, 0.73) and showed excellent calibration (P = .88).

CONCLUSIONS

On-admission prevalence of previously unknown MRSA carriers was high. Applying the risk score to newly admitted patients with an intermediate or high probability of MRSA carriage could allow a more effective MRSA control strategy.

Survey of long-term-care facilities in Iowa for policies and practices regarding residents with methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci

OBJECTIVES

To identify infection control policies and practices used by long-term-care facilities (LTCFs) in Iowa for residents with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), and to estimate the prevalence of residents known to have these organisms.

DESIGN

Survey.

SETTING

LTCFs in Iowa from December 2002 through March 2003.

RESULTS

Of the 429 LTCFs in Iowa, 331 (77%) responded to the survey. The estimated prevalence of residents known to have MRSA was 13.4 per 1,000 and that of residents known to have VRE was 2.3 per 1,000. Facilities owned by the government or those with an average of more than 86 occupied beds were more likely to have residents known to have MRSA and VRE (P = .002 and .007, respectively). Of the responding facilities, 7.3% acknowledged that they refused to accept individuals known to have MRSA and 16.9% acknowledged that they refused to accept those known to have VRE. Facilities in large communities (population, > 100,000) were least likely to deny admission to an individual known to have either MRSA or VRE (P = .05). Most facilities reported adhering to the national guidelines, but fewer than half (44.7%) of the respondents had heard of the Iowa Antibiotic Resistance Task Force's guidelines regarding residents with MRSA or VRE.

CONCLUSIONS

Many LTCFs in Iowa care for residents known to have MRSA or VRE, but some refuse to admit these individuals. Infection control personnel and public health officials should work together to educate LTCF staff so that residents receive proper care and resistant organisms do not spread within this setting.

Clinical and epidemiologic features of methicillin-resistant Staphylococcus aureus in elderly hospitalized patients

We describe characteristics of elderly patients with MRSA identified in 37 Canadian hospitals between 1995 and 2002. Of these inpatients, 6,613 (66%) were older than 65 years. They were more likely than younger patients to have been colonized without infection and to have had MRSA isolated from urine or the perineum. The epidemiology and clinical features of these patients is distinct from that of younger patients.

Prevalence and nosocomial spread of methicillin-resistant Staphylococcus aureus in a long-term-care facility in Slovenia

OBJECTIVES

To determine the prevalence and incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among residents and healthcare workers (HCWs) of a long-term-care facility (LTCF), to assess possible routes of nosocomial spread, and to determine genetic relatedness of the isolates.

SETTING

A 351-bed community LTCF for the elderly.

DESIGN AND PARTICIPANTS

Study investigators made two visits, approximately 3 months apart, to the facility. Samples for cultures were obtained from 107 residents during the first visit, 91 residents during the second visit, and 38 HCWs.

RESULTS

The prevalence of MRSA colonization among residents was 9.3% during the first visit and 8.8% during the second visit. During the first visit, two HCWs were colonized. During the second visit, no HCWs were colonized. The colonization of HCWs suggested a potential role in the transmission of MRSA. Molecular typing showed that two of three roommates in one room had the same strain, whereas two in another room differed from one another. All isolates, except one, belonged to two related clonal groups. It seems that the clonal group to which most isolates belonged had the greatest potential for spreading among both residents and HCWs.

CONCLUSIONS

Similar prevalence rates of MRSA colonization have been found in other European countries, but such studies have usually involved residents with better functional status than that of the participants in this study. Nosocomial spread of MRSA occurred in the facility examined, but not frequently. More attention should be focused on the hand hygiene of HCWs.

Risk factors for colonization with methicillin-resistant Staphylococcus aureus in a long-term-care facility in Slovenia

OBJECTIVE

To evaluate risk factors associated with methicillin-resistant Staphylococcus aureus (MRSA) colonization in a long-term-care facility (LTCF) for the elderly in Slovenia.

SETTING

A 351-bed community LTCF for the elderly.

DESIGN AND PARTICIPANTS

This was a case-control study. MRSA carriage was identified in 102 of 127 residents of the facility's nursing unit. Two swabs were taken: one from the anterior nares and one from the largest skin lesion. If no skin lesions were present, the axillae and the groin area were swabbed. Data were collected regarding gender, age, length of stay in the facility, underlying conditions, functional status, presence of wounds or pressure sores, presence of catheters, antibiotic treatments, and hospital admissions.

RESULTS

We detected MRSA in 12 participants. Risk factors independently and significantly associated with MRSA colonization on the multivariate analysis were antibiotic treatments within 1 month before the investigation (odds ratio, 5.087; 95% confidence interval, 1.02 to 25.48; P = .048) and multiple hospital admissions in the 3 months before the investigation (odds ratio, 6.277; 95% confidence interval, 1.31 to 30.05; P = .022).

CONCLUSIONS

This is the first assessment of risk factors for colonization with MRSA in an LTCF in Slovenia. MRSA poses a problem in this LTCE Our observations may be valuable in implementing active surveillance cultures in infection control programs in Slovenian LTCFs.

Choix d’une stratégie de dépistage du Staphylococcus aureus résistant à la méticilline à l’admission en service de soins de suite et de réadaptation

OBJECTIVE

To identify a strategy of MRSA screening (methicillin-resistant Staphylococcus aureus) on admission to geriatric rehabilitation units, which would lead to acceptable efficacy and cost compared with a reference maximaliste strategy combining all six sampling sites. Method MRSA screening was conducted prospectively for 3 months in all the patients admitted to a geriatric follow-up and rehabilitation unit, using samples from the nostrils, armpits, urine scars cutaneous ulcers and sores. Six strategies were defined combing different sampling sites. Their efficacy and cost were compared with those of a maximaliste strategy combining the 6 sampling sites.

RESULTS

Combined screening of all six sites was the most effective but also the most expensive strategy. The least expensive strategy used only samples from ulcers and sores, but its efficacy was of only 45%. The strategy with the lowest loss of efficacy compared to the reference strategy combined the sampling of ulcers and sores and sampling from the nostrils: it was efficient in 91% and its cost was 2.5 fold lower than the cost of the reference strategy.

DISCUSSION

A preliminary, short term study established an MRSA screening strategy adapted to the specificities of a geriatric rehabilitation unit and its recruitment. The ability to define the optimal strategy for MRSA screening in a geriatric rehabilitation and follow-up unit may be an important factor in controlling the diffusion of MRSA.

Intérêt du dépistage actif des bactéries multirésistantes dans les services de médecine physique et réadaptation

OBJECTIVES

The objective of this study was to evaluate the epidemiology of antibiotic-resistant bacteria among motor impaired patients admitted to an acute rehabilitation unit.

METHODS

From January 2000 to December 2002, the acute rehabilitation units of R. Poincare Hospital have screened patients for methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase enterobacteria (ESBL-EB) carriage by nasal and rectal swab at admission, every month and exit.

RESULTS

Finally, MRSA was isolated form screening or diagnosis samples of 360 patients and ESBL-EB from screening or diagnosis samples of 170 patients, corresponding respectively to an incidence of 3.6 for 1000 days of hospitalization (DH) and 1.7 for 1000 DH. 66% (236/360) of MRSA carriers and 58% of ESBL-EB carriers were identified only by screening samples. Carriage origin was identified for year 2002: Cases were imported for 40% (26/65) of MRSA carriers and 43% (18/42) of ESBL-EB carriers. The median acquisition delays were of 31 days [3-154] for MRSA and 19 days [3-317] for ESBL-EB.

CONCLUSION

This allowed to set up contact precautions for more than 2 fold patients that would have allowed diagnosis samples alone.

Wound-related osteomyelitis: a case of containment not cure

Community nurses need to be aware that some patients with osteomyelitis are treated with antibiotics alone. Such patients often have co-morbidities and quality of life issues that directly impact on the decision to treat osteomyelitis surgically. However, adopting a conservative approach to osteomyelitis management is associated with an increased risk of osteomyelitis recurrence. The rationale for managing chronic wound-related osteomyelitis with antibiotics is discussed. Community nurses caring for patients that have received antibiotics alone to treat osteomyelitis need to be aware of the potential for osteomyelitis recurrence and how to make the diagnosis.

Tratamento e prevenção das infecções e da colonização por Staphylococcus aureus

The number of Staphylococcus aureus (S. aureus) community and nosocomial acquired infections have increased in the last twenty years. Between 1990 and 1992, this pathogen has become the most frequent source of nosocomial infections 1,2. On the other hand, as result of antibiotherapy selection pressure, we observe a dramatic increase in the methicillin-resistant S. aureus (MRSA) infections 3,4. With the recent emergence of multiresistant strains, including glycopeptides resistance, the treatment of these infections became still more difficult 2,4-6. It's important to prevent resistant strains emergence. To prevent further emergence of resistant strains, the use of antibiotherapy must be optimised, laboratory methods for the detection of resistant pathogens must be enhanced and strict precautions should be taken following of the infection or colonization of patients 6-10. In this paper, we review anti-staphylococci history evolution and point out the present recommendations for the treatment and prevention of Staphylococcus aureus infections and colonization.

Nursing informatics. Applications for long-term care

Long-term care (LTC) settings, specifically nursing homes, have found it difficult to manage the regulatory process and provide quality resident care without computerization. Clinical information systems in the current health care environment, including LTC, need to provide five functions. These five functions are providing the legal record of care; supporting clinical decision-making; capturing costs for financial purposes; accumulating a database for administrative queries, quality assurance, and research; and supporting data exchange between systems. While computerization may have occurred in LTC, the application of the informatics concepts with nursing standardized languages and financial and database usage may not have occurred. To succeed in the current health care environment, nursing informatics concepts need to be implemented in LTC. As a result, the quality of care for older adults in nursing homes will be improved. The purpose of this article is to identify application for nursing informatics use in the LTC setting.

Risk factors for colonization with methicillin-resistant Staphylococcus aureus among nursing home residents

Risk factors predictive of methicillin-resistant Staphylococcus aureus (MRSA) colonization in 786 of 910 nursing home residents were evaluated. A customized questionnaire was completed by theresidents, who were screened for MRSA. The risk factors significantly associated with MRSA colonization were male sex, age >80 years, residence in the nursing home for <six months, hospitalization during the previous 6 months, peripheral vascular disease, pressure sores, steroid therapy, poor general skin condition, antibiotic therapy during the previous three months and a mental test score of O14. Multivariate analysis identified male sex and pressure sores as independent variables.

The population impact of MRSA in a country: the national survey of MRSA in Wales, 1997

Continuous data collection on all new isolates of MRSA via CoSurv has taken place in Wales since January 1996. In order to audit this data collection, and to address some of the issues that it does not include, a survey of MRSA was carried out. Questionnaires were completed by infection control teams. Rates were calculated using hospital throughput denominators. Results from the one-day prevalence survey, the two-week incidence survey, and the follow-up survey carried out on new MRSA patients identified in the incidence survey, are presented. Results were found to be broadly similar to those collected via routine surveillance. MRSA was found frequently and disproportionately in the elderly, with higher rates in male than female patients. The highest incidence of total and invasive MRSA was in males aged 75 and over (total: 12.5/1000 finished consultant episodes; invasive: 2.8/1000). Although there was a large community reservoir of MRSA, most appeared to have been acquired in hospital, since most patients had a history of hospitalization, often with multiple hospital admissions. Community-based isolates from cases with no hospital history tended to have been from ulcers. Prevalence and incidence of MRSA was relatively low compared with hospital throughput (mean prevalence: 2.4/100 occupied beds; mean incidence: 3.6/1000 finished consultant episodes), there was also quite large variation between sites, even when screening samples were removed. Patients with MRSA had strikingly long stays before isolation of the organism (prevalence survey: 39 days; incidence survey: 31 days) and highest incidence occurred in elderly care wards. The outcome survey showed that approximately half of the patients were treated with some type of antimicrobial therapy for MRSA. Decontamination therapy was associated with clearance of MRSA only when controlling for sex of the patient. The majority of patients were discharged still with MRSA, mostly to their own homes. The survey emphasizes the need to continue surveillance to detect any changes, to allow guidelines based on evidence to be developed and to monitor the effectiveness of such guidelines.

Methicillin-resistant Staphylococcus aureus: long-term care concerns

Colonization of residents of long-term care facilities with methicillin-resistant Staphylococcus aureus (MRSA) is an important healthcare concern. MRSA colonization is prevalent; in two of the most common sites of colonization, nares and wounds, colonization rates range from 8% to 53%, and 30% to 82%, respectively. With such a large number of patients harboring the organism, it is imperative that long-term care facilities are knowledgeable regarding the overall significance of MRSA, are aware of MRSA infection rates at their facilities, and have established a threshold above which outbreak precautions will be instituted. More importantly, facilities must ensure that appropriate precautions (e.g., hand washing, glove changes, gowns) are utilized to prevent transmission of MRSA to noncolonized residents. If these basic measures are taken, MRSA-colonized residents of long-term facilities should be able to be fully integrated into the everyday activities within the long-term care environment. In the event of an outbreak of MRSA infection, stricter isolation of colonized and infected residents is warranted, and such isolation should be discontinued as soon as the chain of transmission has been disrupted. Systemic antibiotics should be avoided in asymptomatic colonized patients; topical antibiotics like mupirocin should be reserved for short-term administration in outbreak situations.

All Wales surveillance of methicillin-resistant Staphylococcus aureus (MRSA): the first year's results

Over the last five years, hospitals in Wales have experienced difficulties with increasing numbers of isolates of methicillin-resistant Staphylococcus aureus (MRSA). Continuous total population surveillance of MRSA was introduced with the objectives of gaining an understanding of the extent and variation in time and place of its occurrence, the burden of disease and possible risk factors associated with its isolation and resistance to other antibiotics. All first isolates of MRSA from both hospital and community settings and all isolates of methicillin-sensitive Staphylococcus aureus (MSSA) associated with bacteraemia and cerebrospinal fluid (CSF) isolates detected in medical microbiology laboratories in Wales were collected via CoSurv, a set of interconnected data-base modules for communicable disease control. A data set was collected on each isolate and the patient associated with that isolate and compiled centrally at CDSC (Wales) for all-Wales analysis of the MRSA situation. Surveillance started in January 1996 and at the end of the first year, 2700 new isolates of MRSA had been reported from hospital and community settings, giving a rate of 92.43/100,000 population. The incidence of MRSA from bacteraemias and CSF was 5.20/100,000 compared with 12.70/100,000 for MSSA. MRSA from bacteraemia and CSF was significantly more commonly associated with male patients than MSSA. MRSA patients were significantly older. For all MRSA isolates, the highest reporting rate was in men aged 75+ (647.21/100,000). The highest incidence of invasive disease was also in men aged 75+ (45.69/100,000). Isolates from post-surgical patients were more likely to be involved in invasive disease (OR = 2.59), P < 0.001) than strains from other sources. The majority of isolates were resistant to at least two antibiotics in addition to methicillin, most frequently erythromycin and the fluoroquinolones. Very little resistance to fusidic acid, mupirocin or rifampicin was reported. Continuous total population surveillance has provided a minimum incidence of MRSA in Wales and has allowed a simple and intelligible picture of the problem to be determined, which has been fed back to hospitals to assist decisions on control.

Hospital-acquired infection in elderly patients

Increasing numbers of elderly people are being treated in hospitals and are at particular risk of acquiring infections. The incidence, risk factors and types of hospital-acquired infection (HAI) in the elderly are reviewed. Special reference is made to urinary tract infections, respiratory tract infections, gastrointestinal infections including Clostridium difficile, bacteraemia, skin and soft tissue infections and infections with antibiotic-resistant organisms.

Pressure ulcers

Pressure ulcers are localized areas of tissue necrosis that result from unrelieved pressure. They are graded or staged according to the degree of tissue damage observed. The main etiologic factors include pressure, shearing forces, friction, and moisture. The clinical course may be complicated by several conditions including infection, sepsis, osteomyelitis, fistulas, and carcinoma. Preventive measures in persons at risk can significantly reduce the incidence of pressure ulcers. Successful management should address the four etiologic factors as well as the general condition of the patient.

New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage

BACKGROUND

Nosocomial infections cause significant patient morbidity and mortality. The 2.5 million nosocomial infections that occur each year cost the US healthcare system $5 million to $10 million. Staphylococcus aureus has long been recognized as an important pathogen in human disease and is the most common cause of nosocomial infections.

OBJECTIVE

To describe the epidemiology of S. aureus nosocomial infections that are attributable to patients' endogenous colonization.

DATA SOURCES

Review of the English-language literature and a MEDLINE search (as of September 1997).

DATA SYNTHESIS

The ecologic niche of S. aureus is the anterior nares. The prevalence of S. aureus nasal carriage is approximately 20-25%, but varies among different populations, and is influenced by age, underlying illness, race, certain behaviors, and the environment in which the person lives or works. The link between S. aureus nasal carriage and development of subsequent S. aureus infections has been established in patients on hemodialysis, on continuous ambulatory peritoneal dialysis, and those undergoing surgery. S. aureus nasal carriers have a two-to tenfold increased risk of developing S. aureus surgical site or intravenous catheter infections. Thirty percent of 100% of S. aureus infections are due to endogenous flora and infecting strains were genetically identical to nasal strains. Three treatment strategies may eliminate nasal carriage: locally applied antibiotics or disinfectants, systemic antibiotics, and bacterial interference. Among these strategies, locally applied or systemic antibiotics are most commonly used. Nasal ointments or sprays and oral antibiotics have variable efficacy and their use frequently results in antimicrobial resistance among S. aureus strains. Of the commonly used agents, mupirocin (pseudomonic acid) ointment has been shown to be 97% effective in reducing S. aureus nasal carriage. However, resistance occurs when the ointment has been applied for a prolonged period over large surface areas.

CONCLUSIONS

Given the importance of S. aureus nosocomial infections and the increased risk of S. aureus nasal carriage in patients with nosocomial infections, investigators need to study cost-effective strategies to prevent certain types of nosocomial infections or nosocomial infections that occur in specific settings. One potential strategy is to decrease S. aureus nasal carriage among certain patient populations.

Surveillance of colonization and infection with Staphylococcus aureus susceptible or resistant to methicillin in a community skilled-nursing facility

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen in acute care hospitals and long-term care facilities. Few studies have been reported in private skilled nursing facilities (SNFs) not experiencing outbreaks of infections caused by MRSA.

METHODS

From a 149-bed SNF with no outbreaks, we report a 1-year prospective surveillance study of S. aureus colonization and infection, with focus on S. aureus phenotypes, both methicillin susceptible (MS) and methicillin resistant (MR). Nasal and stool or rectal screening cultures were done on admission, and all patients underwent screening on at least a quarterly basis for 1 year.

RESULTS

Overall, 35% of patients were colonized at least once with S. aureus, (72% MS, 25% MR, and 3% mixed phenotypes), 94% of the MRSA were ciprofloxacin resistant. Nasal colonization with any S. aureus was more frequent, but 13% of patients had positive results only in rectal specimens. Twenty-one percent of the newly admitted and 15% of continuing patients acquired colonization during their stay in the SNE Colonization was transient or persistent, persisted longer in the nares compared with colonization in rectal specimens, and was more stable for methicillin-susceptible S. aureus. Nine percent of patients had development of infection with S. aureus. There was no indication that MRSA colonization led to more infections than methicillin-susceptible S. aureus. Of the 13 infected patients in whom cultures had previously been obtained, seven (54%) had been colonized by the same phenotype strains.

CONCLUSIONS

In this private SNF, endemic S. aureus infections occur at a low frequency, reflecting a moderate level of colonization with S. aureus. However, a trend showing gradual increases in frequencies of colonization and infection is of concern and suggests that in this SNF, future intervention could become warranted.

National survey of MRSA: Ireland, 1995

The objective of this survey was to obtain an indication of the size of the methicillin-resistant Staphylococcus aureus (MRSA) problem in Ireland prior to introducing national MRSA control guidelines. A survey of all microbiology laboratories in Ireland was carried out over two weeks in Spring 1995. For patients from whom MRSA was isolated during the study period standard demographic and clinical data were requested and period prevalence/1000 discharges was calculated. All 45 microbiology laboratories surveyed responded. MRSA was isolated from 448 patients during the two-week period. The period prevalence of MRSA was 16.5/1000 discharges. Males aged > or = 65 had the highest rate (50/1000 discharges). Half of all isolates were from patients in surgical or medical wards, but 4% were from community-based sources such as GPs, nursing homes and hospices. Thirty-two percent of MRSA patients were infected rather than colonized. MRSA is clearly a significant problem in Ireland. While it is largely a hospital problem at present, the increasing trend towards day procedures and shorter hospital stay means that infection will increase in the community.

Carriage of Staphylococcus aureus in the elderly

The point prevalence and incidence of Staphylococcus aureus (methicillin-sensitive and -resistant) carriage by inpatients on acute elderly care wards was estimated. The relationship to body site and to previous admissions to hospital or other institutions was determined. Fifty-five patients were included in the point prevalence study and 136 in the incidence study, which was performed over a two-month period. One in three patients carried S. aureus and 1 in 20 was infected. The incidence rate for MRSA was 2.9%. No endemic strain was found. Nostrils were significantly associated with carriage, and skin break isolates were significant in the point prevalence survey. Screening these sites alone would be most cost effective.

Infection surveillance and antibiotic utilization in a community-based skilled nursing facility

To survey the types of suspect infections, the antibiotic utilization and the patterns of antibiotic resistance among bacterial pathogens in a community Skilled Nursing Facility (SNF), we conducted a 20-month prospective observational surveillance program comprising all 585 patients admitted to a 149-bed private community SNF. Data were collected form medical charts, laboratory reports and nurses reports. Overall, 41% of the patients developed at least one presumptive nosocomial infection, and 54% of the patients received one or more antibiotic treatments. The overall presumptive nosocomial infection rate was 7.2 per 1000 patient days. The most common sites of presumptive nosocomial infection were the urinary tract (38%) and the respiratory tract (28%). The most common pathogens overall were E. coli (25%). Antibiotic groups used most frequently were the quinolones (22% of prescriptions). Thirty-nine percent of the Staphylococcus aureus isolates associated with suspected infections were resistant to methicillin, and of these 94% were also resistant to ciprofloxacin. Most of the resistant S. aureus isolates were from indwelling catheter-associated with UTIs. Infections associated with quinolone resistant strains of gram-negative bacilli were infrequent. No epidemiologic evidence of nosocomial clustering was apparent.

Infections and antibiotic resistance in nursing homes

Infections occur frequently in nursing home residents. The most common infections are pneumonia, urinary tract infection, and skin and soft tissue infection. Aging-associated physiologic and pathologic changes, functional disability, institutionalization, and invasive devices all contribute to the high occurrence of infection. Antimicrobial agent use in nursing homes is intense and usually empiric. All of these factors contribute to the increasing frequency of antimicrobial agent-resistant organisms in nursing homes. Programs that will limit the emergence and impact of antimicrobial resistance and infections in nursing homes need to be developed.

Contrasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes

PURPOSE

To compare the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, the patterns of MRSA acquisition, and the risk for subsequent MRSA infection between a hospital-based, Department of Veterans Affairs (VA) nursing home care unit (NHCU) and community-based nursing homes.

PATIENTS AND METHODS

In this prospective study, 148 residents of three community nursing homes and 55 residents of a VA NHCU had their anterior nares swabbed; repeat cultures were obtained from hospitalized patients and/or individuals colonized with MRSA. Subjects were followed up prospectively for 1 year to note hospitalizations and the development of MRSA infections.

RESULTS

The prevalence of MRSA colonization was significantly higher in the VA NHCU than in the community nursing homes (mean +/- SD 30.3% +/- 11% versus 9.9% +/- 4%). The rate of MRSA nares colonization was similar in the two settings. Acquisition of MRSA took place in both the long-term care facilities and hospitals, with 23.8% of incident cases occurring during a hospitalization. Only 3 of the 27 individuals colonized at baseline developed an MRSA infection. A trend toward an increased rate of infection was seen in colonized individuals residing in the community nursing homes versus those in the VA NHCU (relative risk 4.67; 95% Cl 0.55 to 39.9). Forty-seven percent of the 55 subjects hospitalized were colonized at some point during the study. In contrast to residents of the VA NHCU, MRSA colonization in the community facilities was a marker for high mortality.

CONCLUSIONS

Outcomes from colonization may be different in the VA NHCU population and the community nursing home population.

Methicillin-resistant Staphylococcus aureus colonization in a new nursing home

Methicillin-resistant Staphylococcus aureus (MRSA) has been detected in nursing homes and long-term care facilities. Studies disagree about the risk of infection with MRSA in colonized patients. MRSA colonization and infection were tracked for one year in all admissions to a 60-bed ward at the Philadelphia VA Nursing Home Care Unit (NHCU) from the time of its opening in June, 1990. Patients and staff were blinded to culture results, and the NHCU followed universal precautions for all patients. Of the first 72 patients, 7 were found to be colonized with MRSA; only one of them was known to have had MRSA prior to NHCU transfer. Three patients died (2 had negative cultures prior to death), and 1 was discharged home. Three patients spontaneously cleared MRSA colonization and lived to the end of the study. Three patients appeared to be colonized by MRSA after admission; subsequent cultures were negative. No patients were infected by MRSA in the NHCU. At the close of the study, one year after the nursing home opened, no patient in the nursing home had a culture positive for MRSA. In conclusion, colonization with MRSA at the time of admission to the nursing home is not uncommon, but patients can spontaneously clear it. Besides, nursing homes that pre-screen only those patients with classic risk factors may be admitting many MRSA-colonized patients. Nonetheless, universal precautions appear to be effective in limiting transmission of MRSA in the nursing home; in this study, MRSA acquisition was sporadic and brief.

Prevalence of oral methicillin-resistant Staphylococcus aureus in an institutionalized veterans population

Methicillin-resistant Staphylococcus aureus (MRSA) is a nosocomial pathogen now of great concern in nursing homes and other institutional settings. MRSA has been well-documented to inhabit the nares, skin wounds, and respiratory tract, but little is known about its presence in the oral cavity. In this study, all patients admitted to an 80-bed VA extended care facility were cultured weekly for 12 weeks to detect the presence of MRSA in the nares, wounds, in-dwelling devices, and the oral cavity. Of a total of 107 participating subjects, 20 cultured positive for oral MRSA, yielding a prevalence of 18.7%, compared with 19.6% prevalence in the nares--the traditionally accepted screening site for MRSA. There was a 91.6% agreement between oral and nasal carriage in subjects, but four of 107 subjects (3.7%) cultured positive for oral MRSA without evidence of nasal carriage. These results suggest that oral MRSA may be more common than previously thought in high-risk settings, with a prevalence comparable with that of nasal infection. Further investigation is necessary to characterize the factors associated with the presence of MRSA in the oral cavity.

Enhancing infection control for elderly and medically compromised patients

Some patients may be at risk for complications from relatively common infectious diseases. Influenza, tuberculosis and methicillin-resistant Staphylococcus aureus infection can lead to illness and even death in elderly, medically compromised and institutionalized individuals. Dental personnel caring for these individuals should adopt preventive strategies that are simple and inexpensive in addition to standard infection control guidelines.