Asymptomatic SARS-CoV-2 Infection and COVID-19 Mortality During an Outbreak Investigation in a Skilled Nursing Facility.

BACKGROUND: Outbreaks of coronavirus disease 2019 (COVID-19) have been reported in nursing homes and assisted living facilities; however, the extent of asymptomatic and presymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in this high-risk population remains unclear. METHODS: We conducted an investigation of the first known outbreak of SARS-CoV-2 at a skilled nursing facility (SNF) in Illinois on 15 March 2020 and followed residents for 30 days. We tested 126/127 residents for SARS-CoV-2 via reverse-transcription polymerase chain reaction and performed symptom assessments. We calculated the point prevalence of SARS-CoV-2 and assessed symptom onset over 30-day follow-up to determine: (1) the proportion of cases who were symptomatic, presymptomatic, and asymptomatic and (2) incidence of symptoms among those who tested negative. We used the Kaplan-Meier method to determine the 30-day probability of death for cases. RESULTS: Of 126 residents tested, 33 had confirmed SARS-CoV-2 on 15 March. Nineteen (58%) had symptoms at the time of testing, 1 (3%) developed symptoms over follow-up, and 13 (39%) remained asymptomatic. Thirty-five residents who tested negative on 15 March developed symptoms over follow-up; of these, 3 were re-tested and 2 were positive. The 30-day probability of death among cases was 29%. CONCLUSIONS: SNFs are particularly vulnerable to SARS-CoV-2, and residents are at risk of severe outcomes. Attention must be paid to preventing outbreaks in these and other congregate care settings. Widespread testing and infection control are key to help prevent COVID-19 morbidity and mortality in these high-risk populations.

Non-ventilator health care-associated pneumonia (NV-HAP): Long-term care.

Nonventilator health care-associated pneumonia (NV-HAP) is costly and preventable with significant impact on patient morbidity and mortality. This chapter outlines the increased risk of NV-HAP among individuals residing in long-term care facilities and the incidence of pneumonia in this health care setting which accounts for up to 18% of all persons admitted to acute care hospital for pneumonia. A description of prevention strategies with detail on modifiable and Nonmodifiable risk factors for acquiring pneumonia are presented along with the need for a robust interdisciplinary team and approach for this vulnerable population. In addition, the lack of active surveillance and infection prevention expertise may result in the spread of pathogens that can cause NVHAP outbreaks.

First known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in China in December, 2019. In January, 2020, state, local, and federal public health agencies investigated the first case of COVID-19 in Illinois, USA. METHODS: Patients with confirmed COVID-19 were defined as those with a positive SARS-CoV-2 test. Contacts were people with exposure to a patient with COVID-19 on or after the patient's symptom onset date. Contacts underwent active symptom monitoring for 14 days following their last exposure. Contacts who developed fever, cough, or shortness of breath became persons under investigation and were tested for SARS-CoV-2. A convenience sample of 32 asymptomatic health-care personnel contacts were also tested. FINDINGS: Patient 1-a woman in her 60s-returned from China in mid-January, 2020. One week later, she was hospitalised with pneumonia and tested positive for SARS-CoV-2. Her husband (Patient 2) did not travel but had frequent close contact with his wife. He was admitted 8 days later and tested positive for SARS-CoV-2. Overall, 372 contacts of both cases were identified; 347 underwent active symptom monitoring, including 152 community contacts and 195 health-care personnel. Of monitored contacts, 43 became persons under investigation, in addition to Patient 2. These 43 persons under investigation and all 32 asymptomatic health-care personnel tested negative for SARS-CoV-2. INTERPRETATION: Person-to-person transmission of SARS-CoV-2 occurred between two people with prolonged, unprotected exposure while Patient 1 was symptomatic. Despite active symptom monitoring and testing of symptomatic and some asymptomatic contacts, no further transmission was detected. FUNDING: None.

Exploring inappropriate certified nursing assistant glove use in long-term care.

BACKGROUND: Certified Nursing Assistants (CNAs) frequently wear gloves when they care for patients in standard precautions. If CNAs use gloves inappropriately, they may spread pathogens to patients and the environment, potentially leading to health care-associated infections (HAIs). METHODS: Using a descriptive structured observational design, we examined the degree of inappropriate health care personnel glove use in a random sample of 74 CNAs performing toileting and perineal care at 1 long-term care facility. RESULTS: During the 74 patient care events, CNAs wore gloves for 80.2% (1,774/2,213) of the touch points, failing to change gloves at 66.4% (225/339) of glove change points. CNAs changed gloves a median of 2.0 times per patient care event. A median of 1.0 change occurred at a change point. CNAs failed to change their gloves at a glove change point a median of 2.5 times per patient care event. Most (61/74; 82.4%) patient care events had >1 contaminated touch point. Over 44% (782/1,774) of the gloved touch points were defined as contaminated for a median of 8.0 contaminated glove touch points per patient care event. All contaminated touches were with gloved hands (P <.001). CONCLUSIONS: Inappropriate glove use was frequently observed in this study. Contaminated gloves may be a significant cause of cross-contamination of pathogens in health care environments. Future research studies should evaluate strategies to improve glove use to reduce HAIs.

Reduction of methicillin-resistant Staphylococcus aureus infection in long-term care is possible while maintaining patient socialization: A prospective randomized clinical trial.

BACKGROUND: Antibiotic resistance is a challenge in long-term care facilities (LTCFs). The objective of this study was to demonstrate that a novel, minimally invasive program not interfering with activities of daily living or socialization could lower methicillin-resistant Staphylococcus aureus (MRSA) disease. METHODS: This was a prospective, cluster-randomized, nonblinded trial initiated at 3 LTCFs. During year 1, units were stratified by type of care and randomized to intervention or control. In year 2, all units were converted to intervention consisting of universal decolonization using intranasal mupirocin and a chlorhexidine bath performed twice (2 decolonization-bathing cycles 1 month apart) at the start of the intervention period. Subsequently, after initial decolonization, all admissions were screened on site using real-time polymerase chain reaction, and those MRSA positive were decolonized, but not isolated. Units received annual instruction on hand hygiene. Enhanced bleach wipe cleaning of flat surfaces was done every 4 months. RESULTS: There were 16,773 tests performed. The MRSA infection rate decreased 65% between baseline (44 infections during 365,809 patient days) and year 2 (12 infections during 287,847 patient days; P <.001); a significant reduction was observed at each of the LTCFs (P <.03). CONCLUSIONS: On-site MRSA surveillance with targeted decolonization resulted in a significant decrease in clinical MRSA infection among LTCF residents.

Impact of Detection, Education, Research and Decolonization without Isolation in Long-term care (DERAIL) on methicillin-resistant Staphylococcus aureus colonization and transmission at 3 long-term care facilities.

We tested infection prevention strategies to limit exposure of long-term care facility residents to drug-resistant pathogens in a prospective, cluster randomized 2-year trial involving 3 long-term care facilities (LTCFs) using methicillin-resistant Staphylococcus aureus (MRSA) as a model. We hypothesized that nasal MRSA surveillance using rapid quantitative polymerase chain reaction and decolonization of carriers would successfully lower overall MRSA colonization. In year 1, randomly assigned intervention units received decolonization with nasal mupirocin and chlorhexidine bathing and enhanced environmental cleaning with bleach every 4 months. Newly admitted MRSA nares-positive residents were decolonized on admission. Control units were screened but not decolonized. All units received periodic bleach environmental cleaning and instruction on hand hygiene. In year 2, all units followed intervention protocol caused by failure of the cluster randomized approach to sufficiently segregate patients. MRSA colonization was monitored using point prevalence testing every 4-6 months. Colonization status at admission and discharge was performed 1 quarter per year to determine acquisition. Fisher exact test was used for statistical analysis. Baseline MRSA colonization rate was 16.64%. In year 1, the colonization rate of intervention units was 11.61% (P = .028) and 17.85% in control units (P = .613) compared with baseline. Intervention unit rate difference compared with the controls was significant (P = .001). In year 2, the colonization rate was 10.55% (P < .001) compared with baseline. The transmission rates were 1.66% and 3.52% in years 1 and 2, respectively (P = .034). The planned interventions of screening and decolonization were successful at lowering MRSA colonization.

Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities.

OBJECTIVES: The primary objective of this study was to identify proton pump inhibitor (PPI) prescribing patterns in a population of older adults admitted to 22 Midwestern skilled long term care facilities (LTCF) with medical coverage provided by the US Medicare Part A program. The relationship between PPI prescribing patterns and specific ICD-9 diagnostic codes and symptoms management was examined. The long-term objective is appropriate PPI prescription guidance through the development of evidence- and regulation-based pharmacy formulary and policy practices, as well as practical prescribing guidance for practitioners who are supported by this pharmacy. DESIGN: An observational cohort study was conducted, using prospectively collected and de-identified prescribing and diagnostic data from a convenience sample of all Medicare A skilled nursing patients admitted between January 1, 2010, and May 31, 2011, to 22 urban, suburban, and rural Midwestern US LTCFs. SETTING AND PARTICIPANTS: A common pharmacy service de-identified and aggregated PPI prescribing data and patient diagnostic information. These secondary data were analyzed for trends and patterns related to PPI use for all Medicare A patients admitted to these 22 facilities during a 17-month period in 2010 and 2011. MEASUREMENT AND RESULTS: Rates of PPI use were determined and were compared with diagnostic codes. Of 1381 total admissions, 1100 patients (79.7%) were prescribed PPI. There was no appropriate diagnosis for PPI use in 718 patients (65.3%). Gastroesophageal reflux disease (GERD) tended to be the blanket diagnosis that was used most frequently for PPIs, but there was usually no follow-up or symptomatic evidence documented of active GERD. When long-term (current) use of nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin) and/or anticoagulant therapy (warfarin) was considered as appropriate indications for 382 patients, 336 (24%) of all Medicare patients were still receiving PPIs with no relevant gastrointestinal ICD-9 diagnostic code. Total cost of PPIs prescribed from January 2010 to June 2011 was $348,414. CONCLUSIONS: The examined PPI prescribing patterns show discordance between ICD-9 diagnostic code and prescribed use of PPIs in the study population. More than half (52%) of the total number of Medicare A patients were taking the medication without an indicated diagnosis. Even when NSAIDs and anticoagulant therapy were taken into consideration as valid reasons for PPI use, 24% of all patients admitted were still prescribed PPIs without a diagnosis that indicated the need for a PPI. Considering the economic cost, potential side effects, and CMS F329 regulations, which require that an LTCF resident's drug regimen be free from unnecessary medication, it is important that prescribers in LTCFs carefully consider use of PPIs in older adults in LTCFs and monitor the continued use of PPIs to prevent both the personal cost of physical side effects and drug-drug interactions, as well as the economic cost of unnecessary medication use.