Vancomycin-resistant enterococci (VRE) are an important cause of nosocomial infections in acute-care hospitals (ACHs), intermediate-care facilities (ITCFs), and long-term care facilities (LTCFs). This study contemporaneously compared the epidemiology and risk factors for VRE colonization in different care settings in a health care network. We conducted a serial cross-sectional study in a 1,700-bed ACH and its six closely affiliated ITCFs and LTCFs in June and July of 2014 to 2016. Rectal swab or stool specimens were cultured for VRE. Multivariable logistic regression was used to assess for independent risk factors associated with VRE colonization. Of 5,357 participants, 523 (9.8%) were VRE colonized. VRE prevalence was higher in ACHs (14.2%) than in ITCFs (7.6%) and LTCFs (0.8%). Common risk factors between ACHs and ITCFs included prior VRE carriage, a longer duration of antibiotic therapy, surgery in the preceding 90 days, and the presence of a skin ulcer. Independent risk factors specific to ACH-admitted patients were prior methicillin-resistant carriage, a higher number of beds per room, prior proton pump inhibitor use, and a length of stay of>14 days. For ITCFs, a length of stay of >14 days was inversely associated with VRE colonization. Similarities and differences in risk factors for VRE colonization were observed between health care settings. VRE prevention efforts should target the respective high-risk patients.

MRSA transmission dynamics between the ACH and ILTCFs were complex. The greater diversity of STs in ILTCFs suggests that the ecosystem in such settings might be more conducive for intrafacility transmission events. ST22 and ST45 have successfully established themselves in ILTCFs. The importance of interconnected infection prevention and control measures and strategies cannot be overemphasized.

BACKGROUND Movement of patients in a healthcare network poses challenges for the control of carbapenemase-producing Enterobacteriaceae (CPE). We aimed to identify intra- and inter-facility transmission events and facility type-specific risk factors of CPE in an acute care hospital (ACH) and its intermediate-term and long-term care facilities (ILTCFs). METHODS Serial cross-sectional studies were conducted in June-July of 2014-2016 to screen for CPE. Whole genome sequencing was done to identify strain relatedness and CPE genes (blaIMI; blaIMP-1; blaKPC-2; blaNDM-1; blaOXA-48). Multivariable logistic regression models, stratified by facility type were used to determine independent risk factors. RESULTS Of 5357 patients, half (55%) were from the ACH. CPE prevalence was 1.3% in the ACH and 0.7% in ILTCFs (p=0.029). After adjusting for socio-demographics, screening year, and facility type, the odds of CPE colonization increased significantly with hospital stay ≥ 3 weeks (aOR 2.67, 95%CI 1.17-6.05), penicillins use (aOR 3.00, 95%CI 1.05–8.56), proton pump inhibitors use (aOR 3.20, 95%CI 1.05–9.80), dementia (aOR 3.42, 95%CI 1.38–8.49), connective tissue disease (aOR 5.10, 95%CI 1.19-21.81), and prior carbapenem-resistant Enterobacteriaceae (CRE) carriage (aOR 109.02, 95%CI 28.47–417.44) in the ACH. For ILTCFs, presence of wound (aOR 5.30, 95%CI 1.01–27.72), respiratory procedures (aOR 4.97, 95%CI 1.09-22.71), vancomycin-resistant Enterococci carriage (aOR 16.42, 95%CI 1.52–177.48), and CRE carriage (aOR 758.30, 95%CI 33.86-16982.52) showed significant association. Genomic analysis revealed only possible intra-ACH transmission, and no evidence for ACH-to-ILTCFs transmission. CONCLUSIONS Although CPE colonization was predominantly in the ACH, risk factors varied between facilities. Targeted screening and precautionary measures are warranted.

Objectives: Methicillin resistant Staphylococcus aureus (MRSA) has spread across countries and health care settings, with different clones occupying different ecological niches. It is crucial to understand the comparative epidemiology of MRSA clones between healthcare settings and independent factors asso ciated with colonization of specific clones. Methods: We conducted annual cross sectional surveillance studies in a network comprising an acute care hospital and six closely affiliated intermediate and long term care facilities in Singapore be tween June and July, 2014 2016; 5394 patients contributed 16 045 nasal, axillary and groin samples for culture and MRSA isolates for whole genome sequencing. Multivariable multilevel multinomial regres sion models were constructed to assess independent factors associated with MRSA colonization. Results: MRSA clonal complex (CC) 22 was more prevalent in the acute care hospital (n ¼ 256/493; 51.9%) and intermediate care facilities (n ¼ 348/634; 54.9%) than in long term care (n ¼ 88/351; 25.1%) facilities, with clones other than CC22 and CC45 being more prevalent in long term care facilities (n ¼ 144/351; 41.0%) (p < 0.001). Groin colonization with CC45 was six times that of nasal colonization (aOR 6.21, 95%CI 4.26 9.01). Prior MRSA carriage was associated with increased odds of current MRSA colonization in all settings, with a stronger association with CC22 (aOR 6.45, 95%CI 3.85 10.87) than CC45 (aOR 4.15, 95%CI 2.26 7.58). Conclusions: Colonization by MRSA clones differed between anatomical sites and across healthcare settings. With CC22 having a predilection for the nares and CC45 the groin, MRSA screening should include both sites. Prior MRSA carriage is a risk factor for colonization with predominant MRSA clones in the acute care hospital and intermediate and long term care facilities. Contact precautions for prior MRSA carriers on admission to any healthcare facility could prevent intra and inter institutional MRSA transmission.

treat MDRGNB infections. This finding pointed that strict antibiotic policies were required to work out the issue of emerging MDR-GNB infections.

Introduction: There are limited studies exploring functional improvement in relation to characteristics of patients who, following acute hospital care, receive inpatient rehabilitation in community hospitals. We evaluated the association of acute hospital admission-related factors with functional improvement on community hospital discharge. Methods: We conducted a retrospective cohort study among patients who were transferred to community hospitals within 14-day post-discharge from acute hospital between 2016 and 2018. Modified Barthel Index (MBI) on a 100-point ordinal scale was used to assess functional status on admission to and discharge from the community hospital. We categorised MBI into 6 bands: 0–24, 25–49, 50–74, 75–90, 91–99 and 100. Multivariable logistic regression models were constructed to determine factors associated with categorical improvement in functional status, defined as an increase in at least one MBI band between admission and discharge. Results: A total of 5,641 patients (median age 77 years, interquartile range 69–84; 44.2% men) were included for analysis. After adjusting for potential confounders, factors associated with functional improvement were younger age, a higher MBI on admission, and musculoskeletal diagnosis for the acute hospital admission episode. In contrast, a history of dementia or stroke; lower estimated glomerular filtration rate; abnormal serum albumin or anaemia measured during the acute hospital episode; and diagnoses of stroke, cardiac disease, malignancy, falls or pneumonia; and other chronic respiratory diseases were associated with lower odds of functional improvement. Conclusion: Clinicians may want to take into account the presence of these high-risk factors in their patients when planning rehabilitation programmes, in order to maximise the likelihood of functional improvement. Keywords: Barthel Index, community hospitals, functional status, inpatients, rehabilitation, risk factors

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