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 MEASURESThe 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. RESULTSIn 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

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. T he prevalence of antibiotic-resistant organisms (AROs), such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), and resistant Gram-negative bacteria (GNB) has been well studied (4,11,18,28,30). It is estimated that one-third of the 1.6 million skilled nursing facility (SNF) residents in the United States are colonized with at least one ARO. MRSA is the most common ARO studied, and cross-sectional point prevalence studies in SNFs show a wide range of colonization rates, with 10 to 50% of residents being colonized with MRSA (20,22,26,31,33). Multidrug-resistant (MDR) Gramnegative bacteria have been found to colonize over 20% of residents of long-term care facilities (23), while prevalence rates for VRE are found to be lower at 4 to 9.6% (2, 3, 26). The presence of indwelling devices, functional impairment, prior hospitalization, and antimicrobial usage are all considered to increase the risk of multiple ARO colonization (7,12,20,32,35,36).In contrast to the large quantity of cross-sectional data available, there are limited prospective studies that document new acquisition rates in SNFs. In one prospective study by Bradley et al. (5), specimens from multiple body sites were cultured monthly for a year, and it was found that 25% of SNF veterans were colonized with MRSA upon initial culturing. Over the course of the year of study, 10% of admitted residents newly acquired MRSA at the facility. Another study by Stone et al. (29) found a 48% prevalence of MRSA on weekly cultures obtained over an 8-week period in a long-term care facility. Only 29% of newly admitted residents were colonized on their initial culture, indicating a relatively large number of new acquisitions at the facility. A recent prospective study documented that 39% of long-term care residents acquired at least 1 MDR Gram-negative organism during a 1-year sampling period (24). Other short-term prospective studies documented new acquisition of ceftazidime-resistant (CAZ r )GNB in 22 of 86 (25.6%) colonized surgical intensive care unit patients during their stay over the 5-month s...

The objective of this prospective surveillance study was to quantify colonization with antimicrobial-resistant organisms (AROs) and infections attributable to indwelling devices in skilled nursing facility (SNF) residents. The study was conducted in 15 SNFs in Southeast Michigan. Residents with (n = 90) and without (n = 88) an indwelling device were enrolled and followed for 907 resident-months. Residents were cultured monthly from multiple anatomic sites and data on infections were obtained. The device-attributable rate was calculated by subtracting the infection rate in the device group from the infection rate in the non-device group. A total of 197 new infections occurred during the study period; 87 in the device group (incidence rate [IR] = 331/1,000 resident-months) and 110 infections in the non-device group (IR = 171/1,000 resident-months), with a relative risk of 1.9 (95% confidence interval [CI]: 1.4–2.6). The attributable rate of excess infections among residents in the device group was 160/1,000 resident-months, with an attributable fraction of 48% (95% CI: 31–61%). Prevalence rates for all AROs were higher in the device group compared with the no-device group. The prevalence of the number of AROs per 1,000 residents cultured increased from no-device to those with only feeding tubes, followed by those with only urinary catheters and both these devices. In conclusion, the presence of indwelling devices is associated with higher incidence rates for infections and prevalence rates for AROs. Our study quantifies this risk and shows that approximately half of all infections in SNF residents with indwelling devices can be eliminated with device removal. Effective strategies to reduce infections and AROs in these residents are warranted.

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