Conceptual Model for Reducing Infections and Antimicrobial Resistance in Skilled Nursing Facilities: Focusing on Residents with Indwelling Devices

Abstract

Infections in skilled nursing facilities (SNFs) are common and result in frequent hospital transfers, functional decline, and death. Colonization with multidrug-resistant organisms (MDROs) – including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacilli (R-GNB) – is also increasingly prevalent in SNFs. Antimicrobial resistance among common bacteria can adversely affect clinical outcomes and increase health care costs. Recognizing a need for action, legislators, policy-makers, and consumer groups are advocating for surveillance cultures to identify asymptomatic patients with MDROs, particularly MRSA in hospitals and SNFs. Implementing this policy for all SNF residents may be costly, impractical, and ineffective. Such a policy may result in a large increase in the number of SNF residents placed in isolation precautions with the potential for reduced attention by health care workers, isolation, and functional decline. Detection of colonization and subsequent attempts to eradicate selected MDROs can also lead to more strains with drug resistance. We propose an alternative strategy that uses a focused multicomponent bundle approach that targets residents at a higher risk of colonization and infection with MDROs, specifically those who have an indwelling device. If this strategy is effective, similar strategies can be studied and implemented for other high-risk groups.

Wounds, Functional Disability, and Indwelling Devices Are Associated With Cocolonization by Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in Southeast Michigan

“…Indwelling devices are a well-known risk factor for colonization with antibiotic-resistant organisms [20]. We show that the risk of MRSA/VRE cocolonization is higher in individuals with indwelling devices, as is cocolonization at more anatomic sites than individuals without an indwelling device.…”

“…Nevertheless, we present important risk factors for cocolonization among SNF residents with indwelling devices, a high-risk cohort common in these facilities. Increasing awareness for the role functional status plays in colonization with multiple drugresistant pathogens has led to clinical studies that specifically investigate this association [20,23]. Additional studies are needed to confirm these findings, as well as identify additional risk factors responsible for cocolonization.…”

The 24-hour report as an effective monitoring and communication tool in infection prevention and control in nursing homes

“…6 The study was approved by the University of Michigan and the Ann Arbor VA Health System Institutional Review Boards. At the start of this study (2010) and at its conclusion (2013), a semi-structured interview, designed to follow the SHEA/APIC guideline for infection prevention and control in long-term care facilities, 7 was conducted (Authors: LM, SM, BL) with the IP at each facility.…”

Antibiotic stewardship challenges in the management of community-acquired infections for prevention of escalating antibiotic resistance

“…However, the threat of escalating antibiotic resistance is now also recognised in community settings, particularly for those who are the most vulnerable to infections owing to lower degrees of immunity (e.g. children and the elderly) [45][46][47], yet the risk remains underrated. There is therefore a high medical and societal need for antibiotic stewardship in community settings.…”

“…Overuse or inappropriate use of currently available antibiotics in clinical practice has led to the development of highly resistant MRSA, P. aeruginosa, A. baumannii, enterococci, ESBL-producing E. coli, and MDR or extensively drug-resistant (XDR) Mycobacterium tuberculosis in the hospital environment and in some community settings [30,45].…”