RESUMO
BACKGROUND: Whole-genome sequencing (WGS) has emerged as an alternative genotyping tool for outbreak investigations in the healthcare setting. We describe the investigation and control of a New Delhi metallo-B-lactamase (NDM)-producing Escherichia coli cluster in Southeast Michigan. METHODS: Michigan Bureau of Laboratories identified several closely related NDM-producing E. coli isolates with WGS. An epidemiologic investigation, including case-control study, assessment of infection control practices, and endoscope culturing, was performed to identify source of transmission. Targeted screening of potentially exposed patients was performed following identification of probable source. RESULTS: Between July 2021 and February 2023, nine patients were identified. Phylogenetic analysis confirmed the isolates were closely related with less than 26 single nucleotide polymorphism (SNP) differences between isolates, suggesting an epidemiological link. Eight (89%) patients had a duodenoscope and/or gastroscope exposure. Cases were compared with 23 controls. Cases had significantly higher odds of exposure to duodenoscopes (odds ratio 15.0; 95% CI, 1.8-142.2; P = .015). The mean incubation period, estimated as date of procedure to positive index culture, was 86 days (range, 1-320 days). No lapses in endoscope reprocessing were identified; NDM-producing E. coli was not recovered from reprocessed endoscopes or during targeted screening. No additional cases were identified after removal of implicated gastroscopes and replacement of duodenoscope with disposable end caps. CONCLUSIONS: In this investigation, WGS was utilized to identify transmission of an NDM-producing E. coli outbreak associated with endoscope exposure. Coupled with epidemiologic data, WGS can facilitate outbreak investigations by rapidly identifying linked cases and potential sources to prevent further transmission.
RESUMO
Background: Most nursing facilities (NFs) lack methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) surveillance programs due to limited resources and high costs. We investigated the utility of environmental screening of high-touch surfaces in patient rooms as a way to circumvent these challenges. Methods: We compared MRSA and VRE culture data from high-touch surfaces in patients' rooms (14450 samples from 6 NFs) and ranked each site's performance in predicting patient colonization (7413 samples). The best-performing sites were included in a MRSA- and a VRE-specific panel that functioned as a proxy for patient colonization. Molecular typing was performed to confirm available concordant patient-environment pairs. Results: We identified and validated a MRSA panel that consisted of the bed controls, nurse call button, bed rail, and TV remote control. The VRE panel included the toilet seat, bed controls, bed rail, TV remote control, and top of the side table. Panel colonization data tracked patient colonization. Negative predictive values were 89%-92% for MRSA and 82%-84% for VRE. Molecular typing confirmed a strong clonal type relationship in available concordant patient-environment pairs (98% for MRSA, 91% for VRE), pointing to common epidemiological patterns for environmental and patient isolates. Conclusions: Environmental panels used as a proxy for patient colonization and incorporated into facility surveillance protocols can guide decolonization strategies, improve awareness of MRSA and VRE burden, and inform efforts to reduce transmission. Targeted environmental screening may be a viable surveillance strategy for MRSA and VRE detection in NFs.
Assuntos
Fômites/microbiologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Enterococos Resistentes à Vancomicina/isolamento & purificação , Aparelho Sanitário/microbiologia , Leitos/microbiologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Infecção Hospitalar/transmissão , Monitoramento Ambiental , Contaminação de Equipamentos , Infecções por Bactérias Gram-Positivas/prevenção & controle , Infecções por Bactérias Gram-Positivas/transmissão , Humanos , Controle de Infecções , Decoração de Interiores e Mobiliário , Staphylococcus aureus Resistente à Meticilina/genética , Tipagem Molecular , Casas de Saúde , Quartos de Pacientes , Valor Preditivo dos Testes , Fatores de Risco , Infecções Estafilocócicas/prevenção & controle , Infecções Estafilocócicas/transmissão , Enterococos Resistentes à Vancomicina/genéticaRESUMO
Background: The spread of multidrug-resistant organisms (MDROs) is a global concern, and much about transmission in healthcare systems remains unknown. To reduce hospital stays, nursing facilities (NFs) have increasingly assumed care of post-acute populations. We estimate the prevalence of MDRO colonization in NF patients on enrollment and discharge to community settings, risk factors for colonization, and rates of acquiring MDROs during the stay. Methods: We conducted a prospective, longitudinal cohort study of newly admitted patients in 6 NFs in southeast Michigan using active microbial surveillance of multiple anatomic sites sampled at enrollment, days 14 and 30, and monthly thereafter for up to 6 months. Results: We enrolled 651 patients and collected 7526 samples over 1629 visits, with an average of 29 days of follow-up per participant. Nearly all participants were admitted for post-acute care (95%). More than half (56.8%) were colonized with MDROs at enrollment: methicillin-resistant Staphylococcus aureus (MRSA), 16.1%; vancomycin-resistant enterococci (VRE), 33.2%; and resistant gram-negative bacilli (R-GNB), 32.0%. Risk factors for colonization at enrollment included prolonged hospitalization (>14 days), functional disability, antibiotic use, or device use. Rates per 1000 patient-days of acquiring a new MDRO were MRSA, 3.4; VRE, 8.2; and R-GNB, 13.6. MDRO colonization at discharge was similar to that at enrollment (56.4%): MRSA, 18.4%; VRE, 30.3%; and R-GNB, 33.6%. Conclusions: Short-stay NF patients exhibit a high prevalence of MDROs near the time of admission, as well as at discharge, and may serve as a reservoir for spread in other healthcare settings. Future interventions to reduce MDROs should specifically target this population.
Assuntos
Infecções Bacterianas/transmissão , Docentes de Enfermagem , Bactérias Gram-Negativas/isolamento & purificação , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Enterococos Resistentes à Vancomicina/isolamento & purificação , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Farmacorresistência Bacteriana Múltipla , Feminino , Bactérias Gram-Negativas/efeitos dos fármacos , Infecções por Bactérias Gram-Negativas/transmissão , Hospitalização , Humanos , Tempo de Internação , Estudos Longitudinais , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Michigan , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Infecções Estafilocócicas/transmissão , Enterococos Resistentes à Vancomicina/efeitos dos fármacosRESUMO
OBJECTIVES: To identify facility- and individual-level predictors of nursing home safety culture. DESIGN: Cross-sectional survey of individuals within facilities. SETTING: Nursing homes participating in the national Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infections Project. PARTICIPANTS: Responding nursing home staff (N = 14,177) from 170 (81%) of 210 participating facilities. MEASUREMENTS: Staff responses to the Nursing Home Survey on Patient Safety Culture (NHSOPS), focused on five domains (teamwork, training and skills, communication openness, supervisor expectations, organizational learning) and individual respondent characteristics (occupation, tenure, hours worked), were merged with data on facility characteristics (from the Certification and Survey Provider Enhanced Reporting): ownership, chain membership, percentage residents on Medicare, bed size. Data were analyzed using multivariate hierarchical models. RESULTS: Nursing assistants rated all domains worse than administrators did (P < .001), with the largest differences for communication openness (24.3 points), teamwork (17.4 points), and supervisor expectations (16.1 points). Clinical staff rated all domains worse than administrators. Nonprofit ownership was associated with worse training and skills (by 6.0 points, P =.04) and communication openness (7.3 points, P =.004), and nonprofit and chain ownership were associated with worse supervisor expectations (5.2 points, P =.001 and 3.2 points, P =.03, respectively) and organizational learning (5.6 points, P =.009 and 4.2 points, P = .03). The percentage of variation in safety culture attributable to facility characteristics was less than 22%, with ownership having the strongest effect. CONCLUSION: Perceptions of safety culture vary widely among nursing home staff, with administrators consistently perceiving better safety culture than clinical staff who spend more time with residents. Reporting safety culture scores according to occupation may be more important than facility-level scores alone to describe and assess barriers, facilitators, and changes in safety culture.
Assuntos
Instituição de Longa Permanência para Idosos/organização & administração , Papel do Profissional de Enfermagem/psicologia , Casas de Saúde/organização & administração , Recursos Humanos de Enfermagem/psicologia , Cultura Organizacional , Propriedade/organização & administração , Segurança do Paciente , Gestão da Segurança/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid. PURPOSE: Systematic literature review of strategies to reduce UTIs in nursing home residents. DATA SOURCES: Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015. STUDY SELECTION: Interventional studies with a comparison group reporting at least 1 outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use. DATA EXTRACTION: Two authors abstracted study design, participant and intervention details, outcomes, and quality measures. DATA SYNTHESIS: Of 5794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Quality (range, 8-25; median, 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; 9 studies employed general infection prevention strategies (eg, improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The 19 studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); 9 studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly). LIMITATIONS: Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes. CONCLUSIONS: Several practices, often implemented in bundles, such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions, appear to reduce UTI or CAUTI in nursing home residents. Journal of Hospital Medicine 2017;12:356-368.
Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Instituição de Longa Permanência para Idosos , Controle de Infecções/métodos , Casas de Saúde , Cateterismo Urinário/efeitos adversos , Infecções Urinárias/prevenção & controle , Antibacterianos/uso terapêutico , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/epidemiologia , Cateteres de Demora/efeitos adversos , Cateteres de Demora/microbiologia , Instituição de Longa Permanência para Idosos/normas , Humanos , Controle de Infecções/normas , Casas de Saúde/normas , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Cateterismo Urinário/normas , Infecções Urinárias/diagnóstico , Infecções Urinárias/epidemiologiaRESUMO
Importance: Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective: To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants: A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions: The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures: Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results: In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance: In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.
Assuntos
Antibacterianos/uso terapêutico , Infecções Relacionadas a Cateter , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Cateterismo Urinário , Cateteres Urinários , Infecções Urinárias , Idoso , Técnicas Bacteriológicas/estatística & dados numéricos , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/etiologia , Infecções Relacionadas a Cateter/prevenção & controle , Feminino , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Assistência de Longa Duração/métodos , Assistência de Longa Duração/normas , Masculino , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/organização & administração , Estados Unidos/epidemiologia , Urinálise/métodos , Cateterismo Urinário/efeitos adversos , Cateterismo Urinário/métodos , Cateterismo Urinário/normas , Cateteres Urinários/efeitos adversos , Cateteres Urinários/estatística & dados numéricos , Infecções Urinárias/diagnóstico , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Infecções Urinárias/prevenção & controleRESUMO
BACKGROUND: Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD). OBJECTIVE: We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT), or both. Design/participants/measurements: A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. The ADs were divided as follows: (1) comfort oriented: comfort measures only, no hospital transfer; (2) palliative oriented: comfort focused, allowing hospital transfer (except intensive care unit), antibiotic use, but no cardiopulmonary resuscitation; (3) usual care: full code, no limitations to care. We calculated incidences for these outcomes. RESULTS: Seventy-eight (87%) residents had ADs: 18 (23%) comfort oriented, 32 (41%) palliative oriented, and 28 (36%) usual care. The groups did not differ regarding demographics, comorbidity, function, device presence, or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (Incidence rate [IR] = 15.6/1000 follow-up days vs IR = 8.8/1000 follow-up days, Incident rate ratio [IRR] 0.6 [95% confidence interval, CI, 0.3 -1.1], P value .09) but received fewer antibiotics (IR = 18.9/1000 follow-up days vs IR = 7.5/1000 follow-up days, IRR 0.4 [95% CI, 0.2-0.8], P value .005). CONCLUSION: Nursing home residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual-care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.
Assuntos
Adesão a Diretivas Antecipadas/estatística & dados numéricos , Diretivas Antecipadas/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Reanimação Cardiopulmonar/estatística & dados numéricos , Nutrição Enteral/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Michigan , Cuidados Paliativos/estatística & dados numéricos , Estudos Prospectivos , Cateterismo Urinário/estatística & dados numéricosRESUMO
OBJECTIVE The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non-VA nursing homes. SETTING VA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative. METHODS Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire. RESULTS A total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; P<.001) and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs 66%; P<.001), sharing CAUTI data with leadership (94% vs 70%; P=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004). CONCLUSIONS Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems. Infect Control Hosp Epidemiol 2017;38:287-293.
Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Casas de Saúde/normas , Infecções Urinárias/prevenção & controle , Humanos , Liderança , Modelos Logísticos , Análise Multivariada , Casas de Saúde/estatística & dados numéricos , Recursos Humanos de Enfermagem , Guias de Prática Clínica como Assunto , Administração da Prática Médica , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans AffairsRESUMO
OBJECTIVE To assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative. DESIGN Baseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections. SETTING Nursing homes across 14 states participating in the national "Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection." PARTICIPANTS Licensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel. METHODS Each facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses. RESULTS A total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed). CONCLUSIONS This national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care. Infect. Control Hosp. Epidemiol. 2016;1-6.
Assuntos
Gestão de Antimicrobianos , Infecção Hospitalar/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/educação , Casas de Saúde/normas , Bacteriúria/prevenção & controle , Infecções Relacionadas a Cateter/prevenção & controle , Humanos , Melhoria de Qualidade , Estados Unidos , Infecções Urinárias/prevenção & controleRESUMO
BACKGROUND: The purpose of this study was to assess effectiveness of an interactive educational program in increasing knowledge of key infection prevention and control (IPC) principles with emphasis on indwelling device care, hand hygiene, and multidrug-resistant organisms (MDROs) among nursing home (NH) health care personnel (HCP). METHODS: We conducted a multimodal randomized controlled study involving HCP at 12 NHs. Ten comprehensive and interactive modules covered common IPC topics. We compared intervention and control scores to assess differences in pretest scores as a result of field interventions, pre- and post-test scores to assess knowledge gain, and magnitude of knowledge gain based on job categories. RESULTS: We conducted over 200 in-services across 10 topics at six intervention sites over 36 months. There were 4,962 tests returned over the course of the study, ranging from 389-633 per module. Participants were mostly female certified nursing assistants (CNAs). Score improvement was highest for modules emphasizing hand hygiene, urinary catheter care, and MDROs (15.6%, 15.9%, and 22.0%, respectively). After adjusting for cluster study design, knowledge scores were significantly higher after each educational module, suggesting the education delivery method was effective. When compared with CNAs, nursing and rehabilitation personnel scored significantly higher in their knowledge tests. CONCLUSIONS: Our intervention significantly improved IPC knowledge in HCP, especially for those involved in direct patient care. This increase in knowledge along with preemptive barrier precautions and active surveillance has enhanced resident safety by reducing MDROs and infections in high-risk NH residents.
Assuntos
Infecção Hospitalar/prevenção & controle , Educação Médica/métodos , Pessoal de Saúde , Controle de Infecções/métodos , Competência Profissional , Estudos Controlados Antes e Depois , Feminino , Humanos , Masculino , Casas de Saúde , Distribuição AleatóriaRESUMO
BACKGROUND Rates of multidrug-resistant gram-negative organisms are surpassing those of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in nursing homes (NHs). OBJECTIVE To characterize the incidence and duration of carriage of ciprofloxacin-resistant Escherichia coli (CipREc) in NHs and identify those in the O25b-ST131 lineage. METHODS We collected 227 CipREc isolates obtained by routine and regular surveillance of high-risk NH residents with indwelling devices. Repetitive element palindromic (REP)-polymerase chain reaction assay and multiplex polymerase chain reaction amplification for O25b-ST131 E. coli detection were performed using (GTG)5-primers and O25pabBspe and trpA2 primer pairs, respectively. RESULTS We found a high period prevalence of CipREc colonization (21.5%), high rates of recolonization with the same strain following clearing (0.46 recolonizations/ person/ year), and an acquisition incidence of 1.05 cases/1,000 person-days. Almost three-quarters of colonized residents carried strains in the O25b-ST131 E. coli lineage. Compared with isolates not in the lineage, O25b-ST131 isolates were carried significantly longer (10 vs 3 months). We identified 18 different REP-types; 2 occurred in 55% of the residents colonized with CipREc, and in more than 1 NH. Duration of CipREc carriage varied by REP-type and averaged 6 months. CONCLUSION CipREc occurred frequently in NH residents and is carried for long durations, and reacquisition following clearance is common Trial registration. ClinicalTrials.gov identifier: NCT01062841.
Assuntos
Antibacterianos/uso terapêutico , Portador Sadio/epidemiologia , Ciprofloxacina/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Infecções por Escherichia coli/epidemiologia , Casas de Saúde , Idoso , Idoso de 80 Anos ou mais , Eletroforese em Gel de Campo Pulsado , Escherichia coli/classificação , Escherichia coli/efeitos dos fármacos , Infecções por Escherichia coli/tratamento farmacológico , Infecções por Escherichia coli/microbiologia , Feminino , Humanos , Masculino , Michigan , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Análise de Regressão , Método Simples-CegoRESUMO
OBJECTIVE: To characterize the epidemiology of multidrug-resistant (MDR) Acinetobacter baumannii colonization in high-risk nursing home (NH) residents. DESIGN: Nested case-control study within a multicenter prospective intervention trial. SETTING: Four NHs in Southeast Michigan. PARTICIPANTS Case patients and control subjects were NH residents with an indwelling device (urinary catheter and/or feeding tube) selected from the control arm of the Targeted Infection Prevention study. Cases were residents colonized with MDR (resistant to ≥3 classes of antibiotics) A. baumannii; controls were never colonized with MDR A. baumannii. METHODS: For active surveillance cultures, specimens from the nares, oropharynx, groin, perianal area, wounds, and device insertion site(s) were collected upon study enrollment, day 14, and monthly thereafter. A. baumannii strains and their susceptibilities were identified using standard microbiologic methods. RESULTS: Of 168 NH residents, 25 (15%) were colonized with MDR A. baumannii. Compared with the 143 controls, cases were more functionally disabled (Physical Self-Maintenance Score >24; odds ratio, 5.1 [95% CI, 1.8-14.9]; P<.004), colonized with Proteus mirabilis (5.8 [1.9-17.9]; P<.003), and diabetic (3.4 [1.2-9.9]; P<.03). Most cases (22 [88%]) were colonized with multiple antibiotic-resistant organisms and 16 (64%) exhibited co-colonization with at least one other resistant gram-negative bacteria. CONCLUSION: Functional disability, P. mirabilis colonization, and diabetes mellitus are important risk factors for colonization with MDR A. baumannii in high-risk NH residents. A. baumannii exhibits widespread antibiotic resistance and a preference to colonize with other antibiotic-resistant organisms, meriting enhanced attention and improved infection control practices in these residents.
Assuntos
Infecções por Acinetobacter/epidemiologia , Acinetobacter baumannii , Farmacorresistência Bacteriana Múltipla , Infecções por Acinetobacter/diagnóstico , Infecções por Acinetobacter/etiologia , Acinetobacter baumannii/isolamento & purificação , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Instituição de Longa Permanência para Idosos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Casas de Saúde , Prevalência , Estudos Prospectivos , Fatores de RiscoRESUMO
Preventing healthcare-associated infection (HAI) is a key contributor to enhancing resident safety in nursing homes. In 2013, the U.S. Department of Health and Human Services approved a plan to enhance resident safety by reducing HAIs in nursing homes, with particular emphasis on reducing indwelling catheter use and catheter-associated urinary tract infection (CAUTI). Lessons learned from a recent multimodal Targeted Infection Prevention program in a group of nursing homes as well as a national initiative to prevent CAUTI in over 950 acute care hospitals called "On the CUSP: STOP CAUTI" will now be implemented in nearly 500 nursing homes in all 50 states through a project funded by the Agency for Healthcare Research and Quality (AHRQ). This "AHRQ Safety Program in Long-Term Care: HAIs/CAUTI" will emphasize professional development in catheter utilization, catheter care and maintenance, and antimicrobial stewardship as well as promoting patient safety culture, team building, and leadership engagement. We anticipate that an approach integrating technical and socio-adaptive principles will serve as a model for future initiatives to reduce other infections, multidrug resistant organisms, and noninfectious adverse events among nursing home residents.
Assuntos
Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Controle de Infecções/métodos , Casas de Saúde , Segurança do Paciente , Infecções Urinárias/epidemiologia , Infecções Urinárias/prevenção & controle , Política de Saúde , Humanos , Estados Unidos/epidemiologiaRESUMO
IMPORTANCE: Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. OBJECTIVE: To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. INTERVENTIONS: Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. RESULTS: In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. CONCLUSIONS AND RELEVANCE: Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01062841.
Assuntos
Antibacterianos/uso terapêutico , Instituição de Longa Permanência para Idosos , Intubação Gastrointestinal/efeitos adversos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Casas de Saúde , Infecções Relacionadas à Prótese , Desenvolvimento de Pessoal/métodos , Infecções Estafilocócicas/prevenção & controle , Precauções Universais/métodos , Cateterismo Urinário/efeitos adversos , Infecções Urinárias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Farmacorresistência Bacteriana Múltipla , Feminino , Humanos , Intubação Gastrointestinal/métodos , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/prevenção & controle , Infecções Estafilocócicas/etiologia , Cateterismo Urinário/métodos , Infecções Urinárias/etiologiaRESUMO
OBJECTIVE: Characterize the clinical and molecular epidemiology of new methicillin-resistant Staphylococcus aureus (MRSA) acquisitions at nasal and extranasal sites among high-risk nursing home (NH) residents. DESIGN: Multicenter prospective observational study. SETTING: Six NHs in southeast Michigan. PARTICIPANTS: A total of 120 NH residents with an indwelling device (feeding tube and/or urinary catheter). METHODS: Active surveillance cultures from the nares, oropharynx, groin, perianal area, wounds (if present), and device insertion site(s) were collected upon enrollment, at day 14, and monthly thereafter. Pulsed-field gel electrophoresis and polymerase chain reaction for SCCmec, agr, and Panton-Valentine leukocidin were performed. RESULTS: Of 120 participants observed for 16,290 device-days, 50 acquired MRSA (78% transiently, 22% persistently). New MRSA acquisitions were common in extranasal sites, particularly at device insertion, groin, and perianal areas (27%, 23%, and 17.6% of all acquisitions, respectively). Screening extranasal sites greatly increases the detection of MRSA colonization (100% of persistent carriers and 97.4% of transient carriers detected with nares, groin, perianal, and device site sampling vs 54.5% and 25.6%, respectively, for nares samples alone). Colonization at suprapubic urinary catheter sites generally persisted. Healthcare-associated MRSA (USA100 and USA100 variants) were the dominant strains (79.3% of all new acquisition isolates). Strain diversity was more common in transient carriers, including acquisition of USA500 and USA300 strains. CONCLUSION: Indwelling device insertion sites as well as the groin and perianal area are important sites of new MRSA acquisitions in NH residents and play a role in the persistency of MRSA carriage. Clonal types differ among persistent and transient colonizers.
Assuntos
Cateteres de Demora/microbiologia , Virilha/microbiologia , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Staphylococcus aureus Resistente à Meticilina , Cavidade Nasal/microbiologia , Casas de Saúde/estatística & dados numéricos , Infecções Estafilocócicas , Idoso , Toxinas Bacterianas/análise , Técnicas de Tipagem Bacteriana/métodos , Técnicas de Tipagem Bacteriana/estatística & dados numéricos , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/etiologia , Infecção Hospitalar/prevenção & controle , Eletroforese em Gel de Campo Pulsado , Exotoxinas/análise , Feminino , Humanos , Leucocidinas/análise , Masculino , Staphylococcus aureus Resistente à Meticilina/classificação , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Staphylococcus aureus Resistente à Meticilina/fisiologia , Michigan/epidemiologia , Estudos Prospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/etiologia , Infecções Estafilocócicas/prevenção & controleRESUMO
Twenty-four-hour reports are filled out by nurses daily to monitor nursing home residents and document any changes in resident status. Semistructured interviews conducted with ICPs from 12 southeast Michigan nursing homes showed that although 24-hour reports were used, they were not standardized for infection prevention activities. Our results indicate 24-hour reports can be an effective communication tool and potentially aid in early recognition of infections and outbreaks.
Assuntos
Infecção Hospitalar/prevenção & controle , Notificação de Doenças/métodos , Controle de Infecções/métodos , Casas de Saúde , Notificação de Doenças/normas , Pesquisa sobre Serviços de Saúde , Humanos , Controle de Infecções/normas , Michigan , Estudos ProspectivosRESUMO
Utilizing a self-administered questionnaire in 440 health care workers (81% response rate), we evaluated the impact of health care workers policy awareness on hand hygiene and urinary catheter care in nursing homes. We show that health care workers aware of their nursing home policies are more likely to report wearing gloves and practicing hand hygiene as per evidence-based recommendations during urinary catheter care compared with those who are unaware of their facility policies.
Assuntos
Infecções Relacionadas a Cateter/enfermagem , Infecções Relacionadas a Cateter/prevenção & controle , Higiene das Mãos , Conhecimentos, Atitudes e Prática em Saúde , Controle de Infecções/métodos , Casas de Saúde , Cateterismo Urinário/enfermagem , Atitude do Pessoal de Saúde , Luvas Protetoras , Política de Saúde , Instituição de Longa Permanência para Idosos , Humanos , Michigan , Enfermeiras e Enfermeiros , Assistentes de Enfermagem , Autorrelato , Inquéritos e QuestionáriosRESUMO
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.
Assuntos
Antibacterianos/farmacologia , Infecções Bacterianas/epidemiologia , Farmacorresistência Bacteriana , Enterococcus/isolamento & purificação , Bactérias Gram-Negativas/isolamento & purificação , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/microbiologia , Enterococcus/efeitos dos fármacos , Feminino , Bactérias Gram-Negativas/efeitos dos fármacos , Virilha/microbiologia , Humanos , Incidência , Masculino , Nariz/microbiologia , Orofaringe/microbiologia , Períneo/microbiologia , Estudos Prospectivos , Fatores de Tempo , Ferimentos e Lesões/microbiologiaRESUMO
BACKGROUND: While Group B Streptococcus (GBS) human colonization and infection has long been suspected as originating from cows, several investigators have suggested that ongoing interspecies GBS transmission is unlikely due to genotyping data demonstrating that human and bovine-derived GBS strains represent mostly distinct populations. The possibility of ongoing transmission between humans and their livestock has not been systematically examined. METHODOLOGY/PRINCIPAL FINDINGS: To examine ongoing interspecies transmission, we conducted a prospective cross-sectional cohort study of 68 families and their livestock. Stool specimens were collected from 154 people and 115 livestock; GBS was detected in 19 (12.3%) humans and 2 (1.7%) animals (bovine and sheep). Application of multilocus sequence typing (MLST) identified 8 sequence types (STs or clones), with STs 1 and 23 predominating. There were 11 families in which two members submitted stools and at least one had GBS colonization. In 3 of these families, both members (consisting of couples) were colonized, yielding a co-colonization rate of 27% (95% CI: 7%-61%). Two of these couples had strains with identical MLST, capsule (cps) genotype, susceptibility, and RAPD profiles. One couple co-colonized with ST-1 (cps5) strains also had a bovine colonized with the identical strain type. On multivariate analysis of questionnaire data, cattle exposure was a predictor of GBS colonization, with each unit increase in days of cattle exposure increasing the odds of colonization by 20% (P = 0.02). These results support interspecies transmission with additional evidence for transmission provided by the epidemiological association with cattle exposure. CONCLUSIONS/SIGNIFICANCE: Although GBS uncommonly colonizes livestock stools, increased frequency of cattle exposure was significantly associated with human colonization and one couple shared the same GBS strains as their bovine suggesting intraspecies transmission. These results set the framework for GBS as a possible zoonotic infection, which has significant public health implications.