Development and Validation of a Clinical Prediction Rule to Predict Transmission of Methicillin-Resistant Staphylococcus aureus in Nursing Homes.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among nursing home residents is high. Health-care workers (HCWs) often serve as a vector in MRSA transmission. The ability to identify residents who are likely to transmit MRSA to HCWs' hands and clothing during clinical care is important so that infection control measures, such as Contact Precautions, can be employed. Using data on demographic and clinical characteristics collected from residents of community nursing homes in Maryland and Michigan between 2012 and 2014, we developed a clinical prediction rule predicting the probability of MRSA transmission to HCWs' gowns. We externally validated this model in a cohort of Department of Veterans Affairs nursing home residents from 7 states between 2012 and 2016. The prediction model, which included sex, race, resident dependency on HCWs for care, the presence of any medical device, diabetes mellitus, and chronic skin breakdown, showed good performance (C statistic = 0.70; sensitivity = 76%, specificity = 49%) in the development set. The decision curve analysis indicated that this model has greater clinical utility than use of a nares surveillance culture for MRSA colonization, which is current clinical practice for placing hospital inpatients on Contact Precautions. The prediction rule demonstrated less utility in the validation cohort, suggesting that a separate rule should be developed for residents of Veterans Affairs nursing homes.

Transmission of Resistant Gram-Negative Bacteria to Health Care Worker Gowns and Gloves during Care of Nursing Home Residents in Veterans Affairs Community Living Centers.

The objectives of the study were to estimate the risk of transmission of antibiotic-resistant Gram-negative bacteria (RGNB) to gowns and gloves (G&G) worn by health care workers (HCWs) when providing care to nursing home residents and to identify the types of care and resident characteristics associated with transmission. A multicenter, prospective observational study was conducted with residents and HCWs from Veterans Affairs (VA) nursing homes. Perianal swabs to detect RGNB were collected from residents. HCWs wore G&G during usual care activities, and the G&G were swabbed at the end of the interaction in a standardized manner. Transmission of RGNB from a colonized resident to G&G by type of care was measured. Odds ratios (ORs) associated with type of care or resident characteristics were estimated. Fifty-seven (31%) of 185 enrolled residents were colonized with ≥1 RGNB. RGNB transmission to HCW gloves or gowns occurred during 9% of the interactions (n = 905): 7% to only gloves and 2% to only gowns. Bathing the resident and providing hygiene and toilet assistance were associated with a high risk of transmission. Glucose monitoring and assistance with feeding or medication were associated with a low risk of transmission. In addition, antibiotic use by the resident was strongly associated with greater transmission (OR, 2.51; P < 0.01). RGNB were transferred to HCWs during ∼9% of visits. High-risk types of care were identified for which use of G&G may be prioritized. Antibiotic use was associated with 2.5 times greater risk of transmission, emphasizing the importance of antibiotic stewardship. (This study has been registered at ClinicalTrials.gov under registration no. NCT01350479.).

Racial differences in disease activity and quality of life in patients with Crohn's disease.

BACKGROUND: The existing literature on racial differences in Crohn's disease (CD) activity and quality of life (QOL) is limited and extrapolated from surrogate measures. AIM: The aim of our study was to compare objective markers of disease activity and QOL over time by race. STUDY: A clinical data repository of inflammatory bowel disease (IBD) patients at University of Maryland, Baltimore IBD Program, was used. CD patients from 2004 to 2009 were included if they had greater than or equal to two clinic visits with disease activity and QOL scores during the study period. Differences in disease activity and QOL were compared by race over time. RESULTS: A total of 296 patients with CD met inclusion criteria; of these, 19% (56/296) were African Americans (AA) and 81% (240/296) were Caucasian. Baseline disease activity and QOL scores did not differ by race (p > 0.05). Caucasians had a steady decline in disease activity and increase in QOL. AA experienced a similar pattern of change in disease activity and QOL scores over time; however, the declines were not statistically significant between groups. At each time point post-baseline, disease activity and QOL scores were similar between races. CONCLUSION: We found that Caucasian and AA patients with CD had similar disease activity and QOL scores at initial presentation and over time. Thus, AA do not represent a more severe subgroup of CD patients to treat. These findings have important implications for clinicians that care for patients with CD.

Lower antibody levels to Staphylococcus aureus exotoxins are associated with sepsis in hospitalized adults with invasive S. aureus infections.

BACKGROUND: Staphylococcus aureus has numerous virulence factors, including exotoxins that may increase the severity of infection. This study was aimed at assessing whether preexisting antibodies to S. aureus toxins are associated with a lower risk of sepsis in adults with S. aureus infection complicated by bacteremia. METHODS: We prospectively identified adults with S. aureus infection from 4 hospitals in Baltimore, MD, in 2009­2011. We obtained serum samples from prior to or at presentation of S. aureus bacteremia to measure total immunoglobulin G (IgG) and IgG antibody levels to 11 S. aureus exotoxins. Bacterial isolates were tested for the genes encoding S. aureus exotoxins using polymerase chain reaction (PCR). RESULTS: One hundred eligible subjects were included and 27 of them developed sepsis. When adjusted for total IgG levels and stratified for the presence of toxin in the infecting isolate as appropriate, the risk of sepsis was significantly lower in those patients with higher levels of IgG against α-hemolysin (Hla), δ-hemolysin (Hld), Panton Valentine leukocidin (PVL), staphylococcal enterotoxin C-1 (SEC-1), and phenol-soluble modulin α3 (PSM-α3). CONCLUSIONS: Our results suggest that higher antibody levels against Hla, Hld, PVL, SEC-1, and PSM-α3 may protect against sepsis in patients with invasive S. aureus infections.

What did nursing home residents think about COVID-19 prevention practices in the era of vaccination and treatment?

We surveyed 57 nursing home residents to assess the subjective impact of COVID-19 prevention practices. Residents were mostly accepting of testing and symptom screening; however, many would like more choices. Sixty-nine percent want to have some say in when or where to mask. Most (87%) residents want to return to group activities. Residents on long-stay units (58%) are more likely than residents on short-stay units (27%) to accept additional risk of COVID-19 transmission to increase their quality of life.

Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria.

Importance: Antibiotic treatment for asymptomatic bacteriuria is not recommended in guidelines but is a major driver of inappropriate antibiotic use. Objective: To evaluate whether clinician culture and personality traits are associated with a predisposition toward inappropriate prescribing. Design, Setting, and Participants: This survey study involved secondary analysis of a previously completed survey. A total of 723 primary care clinicians in active practice in Texas, the Mid-Atlantic, and the Pacific Northwest, including physicians and advanced practice clinicians, were surveyed from June 1, 2018, to November 26, 2019, regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Clinician culture was represented by training background and region of practice. Attitudes and cognitive characteristics were represented using validated instruments to assess numeracy, risk-taking preferences, burnout, and tendency to maximize care. Data were analyzed from November 8, 2021, to March 29, 2022. Interventions: The survey described a male patient with asymptomatic bacteriuria and changes in urine character. Clinicians were asked to indicate whether they would prescribe antibiotics. Main Outcomes and Measures: The main outcome was self-reported willingness to prescribe antibiotics for asymptomatic bacteriuria. Willingness to prescribe antibiotics was hypothesized to be associated with clinician characteristics, background, and attitudes, including orientation on the Medical Maximizer-Minimizer Scale. Individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous. Results: Of the 723 enrolled clinicians, 551 (median age, 32 years [IQR, 29-44 years]; 292 [53%] female; 296 [54%] White) completed the survey (76% response rate), including 288 resident physicians, 202 attending physicians, and 61 advanced practice clinicians. A total of 303 respondents (55%) were from the Mid-Atlantic, 136 (25%) were from Texas, and 112 (20%) were from the Pacific Northwest. A total of 392 clinicians (71% of respondents) indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% CI, 1.53-5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38-3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38-0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33-0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria. Conclusions and Relevance: The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the US Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions.

Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing.

BACKGROUND: Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization. METHODS: We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins. RESULTS: Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty. CONCLUSIONS: Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.

Effect of mupirocin for Staphylococcus aureus decolonization on the microbiome of the nose and throat in community and nursing home dwelling adults.

OBJECTIVE: To characterize the microbial communities of the anterior nares (nose) and posterior pharynx (throat) of adults dwelling in the community and in nursing homes before and after treatment with intranasal mupirocin. METHODS: Staphylococcus aureus-colonized adults were recruited from the community (n = 25) and from nursing homes (n = 7). S. aureus colonization was confirmed using cultures. Participants had specimens taken from nose and throat for S. aureus quantitation using quantitative PCR for the nuc gene and bacterial profiling using 16S rRNA gene sequencing over 12 weeks. After two baseline study visits 4 weeks apart, participants received intranasal mupirocin for 5 days with 3 further visits over a 8 week follow-up period. RESULTS: We found a decrease in the absolute abundance of S. aureus in the nose for 8 weeks after mupirocin (1693 vs 141 fg/ul, p = 0.047). Mupirocin caused a statistically significant disruption in bacterial communities of the nose and throat after 1 week, which was no longer detected after 8 weeks. Bacterial community profiling demonstrated that there was a decrease in the relative abundance of S. aureus (8% vs 0.3%, p<0.01) 8 weeks after mupirocin and a transient decrease in the relative abundance of Staphylococcus epidermidis in the nose (21% vs 5%, p<0.01) 1 week after mupirocin. CONCLUSIONS: Decolonization with mupirocin leads to a sustained effect on absolute and relative abundance of S. aureus but not for other bacteria in the nose. This demonstrates that a short course of mupirocin selectively decreases S. aureus in the nose for up to 8 weeks.

Short-Stay Admissions Associated With Large COVID-19 Outbreaks in Maryland Nursing Homes.

At the beginning of the COVID-19 pandemic, some nursing homes (NHs) in Maryland suffered larger outbreaks than others. This study examined how facility characteristics influenced outbreak size. We conducted a retrospective analysis of secondary data from Maryland NHs to identify characteristics associated with large outbreaks, defined as when total resident cases exceeded 10% of licensed beds, from January 1, 2020, through July 1, 2020. Our dataset was unique in its inclusion of short-stay residents as a measure of resident type and family satisfaction as a measure of quality. Facility characteristics were collected prior to 2020. Like other studies, we found that large outbreaks were more likely to occur in counties with high cumulative incidence of COVID-19, and in NHs with more licensed beds or fewer daily certified nursing assistant (CNA) hours. We also found that NHs with a greater proportion of short-stay residents were more likely to have large outbreaks, even after adjustment for other facility characteristics. Lower family satisfaction was not significantly associated with large outbreaks after adjusting for CNA hours. Understanding the characteristics of NHs with large COVID-19 outbreaks can guide facility re-structuring to prevent the spread of respiratory infections in future pandemics.

Conditional reflex to urine culture: Evaluation of a diagnostic stewardship intervention within the Veterans' Affairs and Centers for Disease Control and Prevention Practice-Based Research Network.

OBJECTIVE: In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention. DESIGN: We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression. SETTING: The study included 6 acute-care hospitals within the Veterans' Health Administration across the United States. PARTICIPANTS: Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included. METHODS: At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days. RESULTS: The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49). CONCLUSIONS: Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

Targeted gown and glove use to prevent Staphylococcus aureus acquisition in community-based nursing homes: A pilot study.

OBJECTIVE: To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents. DESIGN: Uncontrolled clinical trial. SETTING: This study was conducted in 2 community-based nursing homes in Maryland. PARTICIPANTS: The study included 322 residents on mixed short- and long-stay units. METHODS: During a 2-month baseline period, all residents had nose and inguinal fold swabs taken to estimate S. aureus acquisition. The intervention was iteratively developed using a participatory human factors engineering approach. During a 2-month intervention period, healthcare personnel wore gowns and gloves for high-risk care activities while caring for residents with wounds or medical devices, and S. aureus acquisition was measured again. Whole-genome sequencing was used to assess whether the acquisition represented resident-to-resident transmission. RESULTS: Among short-stay residents, the methicillin-resistant S. aureus acquisition rate decreased from 11.9% during the baseline period to 3.6% during the intervention period (odds ratio [OR], 0.28; 95% CI, 0.08-0.92; P = .026). The methicillin-susceptible S. aureus acquisition rate went from 9.1% during the baseline period to 4.0% during the intervention period (OR, 0.41; 95% CI, 0.12-1.42; P = .15). The S. aureus resident-to-resident transmission rate decreased from 5.9% during the baseline period to 0.8% during the intervention period. CONCLUSIONS: Targeted gown and glove use by healthcare personnel for high-risk care activities while caring for residents with wounds or medical devices, regardless of their S. aureus colonization status, is feasible and potentially decreases S. aureus acquisition and transmission in short-stay community-based nursing-home residents.

Treatment of Depression after Traumatic Brain Injury Reduces Risk of Neuropsychiatric Outcomes.

The objectives of this study were to identify characteristics associated with receipt of antidepressants for treatment of incident depression diagnosed following traumatic brain injury (TBI) and to assess the impact of receipt of treatment for depression on risk of other neuropsychiatric outcomes associated with TBI. We conducted a retrospective cohort study of individuals with TBI who were subsequently diagnosed with incident depression between 2008 and 2014 using data from the OptumLabs® Data Warehouse. We identified factors associated with receipt of antidepressants and compared risk of new diagnosis of alcohol dependence disorder, anxiety, insomnia, and substance dependence disorder between those who received antidepressants and those who did not over a maximum 2-year follow-up, controlling for duration of use and clinical and demographic characteristics. Of 9581 individuals newly diagnosed with depression following TBI, 4103 (43%) received at least one antidepressant. Moderate-severe TBI (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.39, 1.50), female sex (OR 1.21; 95% CI: 1.19, 1.24), diagnosis of Alzheimer's disease (OR 1.39; 95% CI: 1.35, 1.44), and anxiety (OR 1.35; 95% CI: 1.31, 1.38) were associated with receipt of antidepressants. Longer duration of antidepressant use was associated with decreased risk of newly diagnosed anxiety (hazard ratio [HR] 0.92; 95% CI: 0.89, 0.96), insomnia (HR 0.94; 95% CI: 0.91, 0.98), and substance dependence disorder (HR 0.92; 95% CI: 0.88, 0.97). These results provide evidence of a beneficial effect of antidepressant use on incidence of outcomes associated with poorer recovery from TBI.

Diabetic Foot Infections: Local Prevalence of and Case-Control Study of Risk Factors for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa.

We identified deep diabetic foot infections by culture and conducted a case-control study examining the risk factors for moderate to severe methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PsA) diabetic foot infections. Our MRSA prevalence was lower than literature values; PsA was higher. Gangrene may be predictive of Pseudomonas infection.

Burden of perianal Staphylococcus aureus colonization in nursing home residents increases transmission to healthcare worker gowns and gloves.

OBJECTIVE: To evaluate the effect of the burden of Staphylococcus aureus colonization of nursing home residents on the risk of S. aureus transmission to healthcare worker (HCW) gowns and gloves. DESIGN: Multicenter prospective cohort study. SETTING AND PARTICIPANTS: Residents and HCWs from 13 community-based nursing homes in Maryland and Michigan. METHODS: Residents were cultured for S. aureus at the anterior nares and perianal skin. The S. aureus burden was estimated by quantitative polymerase chain reaction detecting the nuc gene. HCWs wore gowns and gloves during usual care activities; gowns and gloves were swabbed and then cultured for the presence of S. aureus. RESULTS: In total, 403 residents were enrolled; 169 were colonized with methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) and comprised the study population; 232 were not colonized and thus were excluded from this analysis; and 2 were withdrawn prior to being swabbed. After multivariable analysis, perianal colonization with S. aureus conferred the greatest odds for transmission to HCW gowns and gloves, and the odds increased with increasing burden of colonization: adjusted odds ratio (aOR), 2.1 (95% CI, 1.3-3.5) for low-level colonization and aOR 5.2 (95% CI, 3.1-8.7) for high level colonization. CONCLUSIONS: Among nursing home patients colonized with S. aureus, the risk of transmission to HCW gowns and gloves was greater from those colonized with greater quantities of S. aureus on the perianal skin. Our findings inform future infection control practices for both MRSA and MSSA in nursing homes.

Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease.

BACKGROUND & AIMS: There is a need for a reliable and inexpensive noninvasive marker of hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). We compared the performance of the FIB4 index (based on age, aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels, and platelet counts) with 6 other non-invasive markers of fibrosis in patients with NAFLD. METHODS: Using a nation-wide database of 541 adults with NAFLD, jackknife-validated areas under receiver operating characteristic curves (AUROC) of FIB4 and 7 other markers were compared. The sensitivity at 90% specificity, 80% positive predictive value, and 90% negative predictive values were determined along with cutoffs for advanced fibrosis. RESULTS: The median FIB4 score was 1.11 (interquartile range = 0.74-1.67). The jackknife-validated AUROC for FIB4 was 0.802 (95% confidence interval [CI], 0.758-0.847), which was higher than that of the NAFLD fibrosis score (0.768; 95% CI, 0.720-0.816; P = .09), Goteburg University Cirrhosis Index (0.743; 95% CI, 0.695-0.791; P < .01), AST:ALT ratio (0.742; 95% CI, 0.690-0.794; P < .015), AST:platelet ratio index (0.730; 95% CI, 0.681-0.779; P < .001), AST:platelet ratio (0.720; 95% CI, 0.669-0.770; P < .001), body mass index, AST:ALT, diabetes (BARD) score (0.70; P < .001), or cirrhosis discriminant score (0.666; 95% CI, 0.614-0.718; P < .001). For a fixed specificity of 90% (FIB4 = 1.93), the sensitivity in identifying advanced fibrosis was only 50% (95% CI, 46-55). A FIB4 > or = 2.67 had an 80% positive predictive value and a FIB4 index < or = 1.30 had a 90% negative predictive value. CONCLUSIONS: The FIB4 index is superior to 7 other noninvasive markers of fibrosis in patients with NAFLD; however its performance characteristics highlight the need for even better noninvasive markers.

Transmission of resistant Gram-negative bacteria to healthcare personnel gowns and gloves during care of residents in community-based nursing facilities.

OBJECTIVE: To estimate the risk of transmission of antibiotic-resistant Gram-negative bacteria (RGNB) to gowns and gloves worn by healthcare personnel (HCP) when providing care to residents of community-based nursing facilities to identify the types of care and resident characteristics associated with transmission. DESIGN: Prospective observational study.Settings and participantsResidents and HCP from 13 community-based nursing facilities in Maryland and Michigan. METHODS: Perianal swabs were collected from residents and cultured to detect RGNB. HCP wore gowns and gloves during usual care activities, and at the end of each interaction, these were swabbed in a standardized manner. Transmission of RGNB from a colonized resident to gowns and gloves was estimated. Odds ratios (ORs) of transmission associated with type of care or resident characteristic were calculated. RESULTS: We enrolled 403 residents and their HCP in this study. Overall, 19% of enrolled residents with a perianal swab (n=399) were colonized with at least 1 RGNB. RGNB transmission to either gloves or gowns occurred during 11% of the 584 interactions. Showering the resident, hygiene or toilet assistance, and wound dressing changes were associated with a high risk of transmission. Glucose monitoring and assistance with feeding or medication were associated with a low risk of transmission. Residents with a pressure ulcer were 3 times more likely to transmit RGNB than residents without one (OR, 3.3; 95% confidence interval [CI], 1.0-11.1). CONCLUSIONS: Gown and glove use in community nursing facilities should be prioritized for certain residents and care interactions that are deemed a high risk for transmission.

Microbiological effect of mupirocin and chlorhexidine for Staphylococcus aureus decolonization in community and nursing home based adults.

OBJECTIVE: To compare the presence of Staphylococcus aureus and pathogenic Gram-negative rods (GNR) in the anterior nares, posterior pharynx and three skin sites in community-based adults and nursing home-based adults before and after treatment with nasal mupirocin and topical chlorhexidine. METHODS: S. aureus-colonized adults were recruited from the community (n=26) and from nursing homes (n=8). Eligible participants were cultured for S. aureus and GNR during two study visits and then received intranasal mupirocin and topical chlorhexidine for 5days, with a 2-month follow-up period. RESULTS: After decolonization, we found sustained decreases of S. aureus colonization in nose, throat and skin sites over 4-8weeks in both populations. Intranasal mupirocin did not increase GNR colonization in nose or throat. Chlorhexidine did not decrease GNR colonization in skin sites. CONCLUSIONS: Decolonization with mupirocin and chlorhexidine leads to a sustained effect on S. aureus colonization without affecting GNR colonization.

Comparison of the Microbiota of Older Adults Living in Nursing Homes and the Community.

Our objective for this study was to characterize the microbial communities of the anterior nares (nose), posterior pharynx (throat), and skin of the femoral and subclavian areas in older adults from nursing homes and the community. Older adults (≥65 years) without antibiotic use for the past 3 months were recruited from nursing homes (NH; n = 16) and from the community (CB; n = 51). Specimens were taken from nose, throat, and skin sites for culture and bacterial profiling using 16S rRNA gene sequencing. We found that pathogenic Gram-negative rod (GNR) colonization on the femoral skin was higher in NH participants than CB participants; otherwise, there were no differences in GNR colonization at other body sites or in Staphylococcus aureus colonization at any body site. Bacterial community profiling demonstrated that the operational taxonomic unit compositions of the different body sites were similar between NH and CB participants, but the analysis identified differences in relative abundance levels. Streptococcus spp. were more abundant and Prevotella spp. were less abundant in the throats of NH participants than in throats of CB participants. Proteus, Escherichia coli, and Enterococcus were more abundant in NH participants on the femoral skin. We found a pattern of decreased abundance of specific Proteobacteria in NH participants at the anterior nares and at both skin sites. We concluded that bacterial communities were largely similar in diversity and composition within body sites between older adults without recent antibiotic use from NH compared to those from the community. Our findings support the rationale for improved hygiene in NH residents to reduce the transmission risk of antibiotic-resistant bacteria, such as Enterococcus spp. or Enterobacteriaceae. IMPORTANCE The nose, throat, and skin over the subclavian and femoral veins are the body sites which harbor the bacteria which most commonly cause health care-associated infection. We assessed the effect of nursing home residence on the microbiota of these body sites in older adults. We found that the microbiota composition of the different body sites was similar between nursing home and community participants, but we identified differences in relative abundance levels. We found remarkable similarities in the bacterial communities of different body sites in older adults who lived in nursing homes compared to those in the community among people who had not been on antibiotics for the past 3 months. We also found that the femoral skin microbiota had evidence of stool contamination in the nursing home residents, providing a rationale for improved skin hygiene. Taken together, it appears that the health care environment does not alter the microbiota to the extent that antibiotics do.

Transmission of methicillin-resistant Staphylococcus aureus to health care worker gowns and gloves during care of residents in Veterans Affairs nursing homes.

BACKGROUND: This was an observational study designed to estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) transmission to gowns and gloves worn by health care workers (HCWs) interacting with Veterans Affairs Community Living Center (VA nursing home) residents to inform MRSA prevention policies. METHODS: Participants included residents and HCWs from 7 VA nursing homes in 4 states and Washington, DC. Residents were cultured for MRSA at the anterior nares, perianal skin, and wound (if present). HCWs wore gowns and gloves during usual care activities. After each activity, a research coordinator swabbed the HCW's gown and gloves. Swabs were cultured for MRSA. RESULTS: There were 200 residents enrolled; 94 (46%) were MRSA colonized. Glove contamination was higher than gown contamination (20% vs 11%, respectively; P < .01). Transmission varied greatly by type of care from 0%-19% for gowns and 7%-37% for gloves. High-risk care activities (odds ratio [OR] > 1.0, P < .05) for gown contamination included changing dressings (eg, wound), dressing, providing hygiene (eg, brushing teeth), and bathing. Low-risk care activities (OR < 1.0, P < .05 or no transmission) for gown contamination included glucose monitoring, giving medications, and feeding. CONCLUSIONS: MRSA transmission from colonized residents to gloves was higher than transmission to gowns. Transmission to gloves varies by type of care, but all care had a risk of contamination, demonstrating the importance of hand hygiene after all care. Transmission to gowns was significantly higher with certain types of care. Optimizing gown and glove use by targeting high-risk care activities could improve resident-centered care for MRSA-colonized residents by promoting a home-like environment.

Strategies to Prevent MRSA Transmission in Community-Based Nursing Homes: A Cost Analysis.

OBJECTIVE To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes. DESIGN Cost analysis of data collected from a prospective, observational study. SETTING AND PARTICIPANTS Care activity data from 401 residents from 13 nursing homes in 2 states. METHODS Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups. RESULTS The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127). CONCLUSIONS The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities. Infect Control Hosp Epidemiol 2016;37:962-966.