Association of Pressure injury with body care activities in nursing homes.

Frequent repositioning and skin examinations are the cornerstone of many pressure injury prevention programs. This study explores the hypothesis that frequent skin-exposing body care activities are protective against pressure injuries in residents of long-term care facilities. We designed a cross-sectional observational cohort study of 381 residents from 13 such facilities. Data were collected on resident characteristics and nursing care activities for each resident. We analyzed those data, looking for an association between skin-exposing body care and the presence of a pressure injury of stage 1 or greater. Body-exposing care activities were divided into high- and low-frequency groups. A logistic regression model was developed to include confounding variables. The odds ratio associated with body care and pressure injury was calculated. Fifteen percent of the residents in our study had pressure injuries. Confounders were activities of daily living score, heart failure, recent hospitalization, and stool incontinence. The adjusted odds ratio for body care as a risk factor was 4.9 (95% CI, 2.4, 10.4), indicating that residents with more than five body care needs are approximately five times more likely to have a pressure injury. Our results fail to support our hypothesis that frequent skin-exposing body care activities protect against pressure injury. Further exploration is needed to understand the resident characteristics and co-morbid conditions associated with the persistent risk for pressure injury despite frequent skin examinations.

The Effectiveness of Contact Precautions on Methicillin-Resistant Staphylococcus aureus in Long-term Care Across the United States.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of health care-associated infections in long-term care facilities (LTCFs). The Centers for Disease Control and Prevention recommends contact precautions for the prevention of MRSA within acute care facilities, which are being used within the United States Department of Veterans Affairs (VA) for LTCFs in a modified fashion. The impact of contact precautions in long-term care is unknown. METHODS: To evaluate whether contact precautions decreased MRSA acquisition in LTCFs, compared to standard precautions, we performed a retrospective effectiveness study (pre-post, with concurrent controls) using data from the VA health-care system from 1 January 2011 until 31 December 2015, 2 years before and after a 2013 policy recommending a more aggressive form of contact precautions. RESULTS: Across 75 414 patient admissions from 74 long-term care facilities in the United States, the overall unadjusted rate of MRSA acquisition was 2.6/1000 patient days. Patients were no more likely to acquire MRSA if they were cared for using standard precautions versus contact precautions in a multivariable, discrete time survival analysis, controlling for patient demographics, risk factors, and year of admission (odds ratio, 0.97; 95% confidence interval, .85-1.12; P = .71). CONCLUSIONS: MRSA acquisition and infections were not impacted by the use of active surveillance and contact precautions in LTCFs in the VA.

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.

Comparative Effectiveness of Cefazolin Versus Nafcillin or Oxacillin for Treatment of Methicillin-Susceptible Staphylococcus aureus Infections Complicated by Bacteremia: A Nationwide Cohort Study.

Background: To treat patients with methicillin-susceptible Staphylococcus aureus (MSSA) infections, ß-lactams are recommended for definitive therapy; however, the comparative effectiveness of individual ß-lactams is unknown. This study compared definitive therapy with cefazolin vs nafcillin or oxacillin among patients with MSSA infections complicated by bacteremia. Methods: This retrospective study included patients admitted to 119 Veterans Affairs hospitals from 2003 to 2010. Patients were included if they had a blood culture positive for MSSA and received definitive therapy with cefazolin, nafcillin, or oxacillin. Cox proportional hazards regression and ordinal logistic regression were used to identify associations between antibiotic therapy and mortality or recurrence. A recurrent infection was defined as a MSSA blood culture between 45 and 365 days after the first MSSA blood culture. Results: Of 3167 patients, 1163 (37%) patients received definitive therapy with cefazolin. Patients who received cefazolin had a 37% reduction in 30-day mortality (hazard ratio [HR], 0.63; 95% confidence interval [CI], .51-.78) and a 23% reduction in 90-day mortality (HR, 0.77; 95% CI, .66-.90) compared with patients receiving nafcillin or oxacillin, after controlling for other factors. The odds of recurrence (odds ratio, 1.13; 95% CI, .94-1.36) were similar among patients who received cefazolin compared with patients who received nafcillin or oxacillin, after controlling for other factors. Conclusions: In this large, multicenter study, patients who received cefazolin had a lower risk of mortality and similar odds of recurrent infections compared with nafcillin or oxacillin for MSSA infections complicated by bacteremia. Physicians might consider definitive therapy with cefazolin for these infections.

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.).

Factors Leading to Transmission Risk of Acinetobacter baumannii.

OBJECTIVES: To identify patient and healthcare worker factors associated with transmission risk of Acinetobacter baumannii during patient care. DESIGN: Prospective cohort study. SETTING: ICUs at a tertiary care medical center. PATIENTS: Adult ICU patients known to be infected or colonized with A. baumannii. MEASUREMENTS AND MAIN RESULTS: Cultures of skin, respiratory tract, and the perianal area were obtained from participants and evaluated for the presence of A. baumannii. Healthcare worker-patient interactions were observed (up to five interactions/patient) and activities were recorded. Healthcare worker hands/gloves were sampled at room exit (prior to hand hygiene or glove removal) and then evaluated for the presence of A. baumannii. Two hundred fifty-four healthcare worker-patient interactions were observed among 52 patients; A. baumannii was identified from healthcare worker hands or gloves in 77 (30%) interactions. In multivariate analysis, multidrug-resistant A. baumannii (odds ratio, 4.78; 95% CI, 2.14-18.45) and specific healthcare worker activities (touching the bed rail [odds ratio, 2.19; 95% CI, 1.00-4.82], performing a wound dressing [odds ratio, 8.35; 95% CI, 2.07-33.63] and interacting with the endotracheal tube or tracheotomy site [odds ratio, 5.15; 95% CI, 2.10-12.60]), were associated with hand/glove contamination. CONCLUSIONS: Healthcare worker hands/gloves are frequently contaminated with A. baumannii after patient care. Patient-level factors were not associated with an increased transmission risk; however, having multidrug-resistant-A. baumannii and specific healthcare worker activities led to an increased contamination risk. Our findings reveal a potential selective advantage possessed by multidrug-resistant-A. baumannii in this environment and suggest possible areas for future research.

Healthcare-associated infections in the elderly: what's new.

PURPOSE OF REVIEW: The high-risk population and current lack of knowledge regarding appropriate infection prevention in the long-term care (LTC) setting has contributed to substantial rates of resistance and healthcare-associated infections in this arena. More evidence-based research on LTC is necessary, particularly now that the elderly population is increasing. RECENT FINDINGS: Proposed government mandates highlight the urgent need to combat antimicrobial resistance in the LTC setting. Recent studies focusing on unique strategies for the prevention of transmission and infection with multidrug-resistant organisms in nursing homes are discussed, as well as attempts to formulate clear antimicrobial stewardship programs. SUMMARY: The long-term setting has unique challenges to instituting effective infection control precautions, therefore current accepted methods used in acute-care facilities need to be modified. Recent data suggest that prevention of transmission in LTC may be achieved with focus on high-risk patients or specific care-based activities rather than colonization status. Antimicrobial stewardship and consultation with specialized physicians may be important measures to combat resistance and adverse events in LTC. The prevention of unnecessary antibiotic use in palliative care may reduce rates of resistance as well as discomfort for terminal patients.

An Analysis of Curricular Structures in MD-PhD Programs in the United States.

PURPOSE: This study describes the structure and timing of the clinical education components of MD-PhD programs to illustrate how variations in preclerkship curriculum correlate with the opportunity for early clinical exposure and other key program characteristics. METHOD: A survey was disseminated to U.S. MD-PhD programs on May 25, 2022, asking about the preclerkship curriculum length (long [> 18 months], medium [13-18 months], or short [12 months]), United States Medical Licensing Examination Step 1 timing (relative to the PhD training and clerkships), and opportunity for clerkships before the PhD phase. This survey was supplemented with data from publicly available sources to include 92 MD-PhD programs. RESULTS: This study found a wide range of MD-PhD clinical curricula. A strong association was found between shorter preclerkship curriculum length and the opportunity for clerkships before the PhD (10 of 50 programs [20%] with long preclerkship curriculum, 19 of 35 programs [54%] with medium preclerkship curriculum, and 7 of 7 programs [100%] with short preclerkship curriculum, P < .001). Variations in United States Medical Licensing Examination Step 1 timing also exist based on preclerkship curriculum length and the opportunity for clerkships before the PhD. Shorter preclerkship curriculum length was associated with National Institutes of Health funding of the MD-PhD program (20 [40%] of long, 25 [69%] of medium, and 6 [86%] of short preclerkship curricula, P = .006) and larger MD-PhD program size (35 students with long, 70 with medium, and 86 with short preclerkship curricula, P < .001). Preclerkship curriculum length was not associated with public vs private medical schools, although the West had shorter preclerkship curricula. CONCLUSIONS: This study underscores the need for collaborative efforts to gain insights into the effectiveness and implications of educational interventions in MD-PhD programs, ultimately informing future training strategies and policies.

The DTC microbiome testing industry needs more regulation.

Tests lack analytical and clinical validity, requiring more federal oversight to prevent consumer harm.

Optimizing the implementation of Enhanced Barrier Precautions in community-based nursing homes.

BACKGROUND: Enhanced Barrier Precautions (EBPs) recommend using gowns and gloves for certain nursing home residents during specific high-contact care activities associated with multidrug-resistant organism (MDRO) transmission. Though EBP is included in published guidance as an MDRO control strategy, optimal implementation approaches remain unclear. METHODS: We implemented a quality improvement (QI) initiative using the 4E process model (engagement, education, execution, and evaluation) to optimize EBP implementation in 4 Maryland nursing homes. Semistructured interviews with health care personnel (HCP) occurred to understand EBP acceptability. RESULTS: Glove use during high-contact care increased from 85% in the baseline to 97% during the intervention (P < .01). Gown use increased from 27% to 78% (P < .01). The accuracy of identifying residents eligible for EBP improved from 63% to 99% (P < .01). Of 780 residents observed, one third met EBP indications: MDRO colonization (21%), indwelling medical device (14%), and/or chronic wound (10%). The most noted facilitator to EBP implementation included HCP perception that EBP reduces MDRO transmission to other residents and staff. The most noted barrier was uncomfortable gowns. CONCLUSIONS: Implementation was complex and required assessments of barriers and facilitators within each facility. HCP interviews identified barriers and facilitators of EBP that can inform future EBP implementation projects.

C. auris and neighborhood socioeconomic vulnerability in the state of Maryland from 2019 to 2022.

BACKGROUND: Candida auris is an emerging fungal pathogen increasingly recognized as a cause of healthcare-associated infections including outbreaks. METHODS: We performed a mixed-methods study to characterize the emergence of C. auris in the state of Maryland from 2019 to 2022, with a focus on socioeconomic vulnerability and infection prevention opportunities. We describe all case-patients of C. auris among Maryland residents from June 2019 to December 2021 detected by Maryland Department of Health. We compared neighborhood socioeconomic characteristics of skilled nursing facilities (SNFs) with and without C. auris transmission outbreaks using both the social vulnerability index (SVI) and the area deprivation index (ADI). The SVI and the ADI were obtained at the state level, with an SVI ≥ 75th percentile or an ADI ≥ 80th percentile considered severely disadvantaged. We summarized infection control assessments at SNFs with outbreaks using a qualitative analysis. RESULTS: A total of 140 individuals tested positive for C. auris in the study period in Maryland; 46 (33%) had a positive clinical culture. Sixty (43%) were associated with a SNF, 37 (26%) were ventilated, and 87 (62%) had a documented wound. Separate facility-level neighborhood analysis showed SNFs with likely C. auris transmission were disproportionately located in neighborhoods in the top quartile of deprivation by the SVI, characterized by low socioeconomic status and high proportion of racial/ethnic minorities. Multiple infection control deficiencies were noted at these SNFs. CONCLUSION: Neighborhood socioeconomic vulnerability may contribute to the emergence and transmission of C. auris in a community.

Infection prevention in the cancer center.

Cancer patients are frequently immunosuppressed and at risk for a wide range of opportunistic and healthcare-associated infections. A good infection prevention program is extremely important to reduce risk of infection. This review focuses on infection prevention measures specific to patients, healthcare personnel, and visitors in the cancer center.

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.

Assessing Pathogen Transmission Opportunities: Variation in Nursing Home Staff-Resident Interactions.

OBJECTIVES: The Centers for Disease Control and Prevention (CDC) recommends implementing Enhanced Barrier Precautions (EBP) for all nursing home (NH) residents known to be colonized with targeted multidrug-resistant organisms (MDROs), wounds, or medical devices. Differences in health care personnel (HCP) and resident interactions between units may affect risk of acquiring and transmitting MDROs, affecting EBP implementation. We studied HCP-resident interactions across a variety of NHs to characterize MDRO transmission opportunities. DESIGN: 2 cross-sectional visits. SETTING AND PARTICIPANTS: Four CDC Epicenter sites and CDC Emerging Infection Program sites in 7 states recruited NHs with a mix of unit care types (≥30 beds or ≥2 units). HCP were observed providing resident care. METHODS: Room-based observations and HCP interviews assessed HCP-resident interactions, care type provided, and equipment use. Observations and interviews were conducted for 7-8 hours in 3-6-month intervals per unit. Chart reviews collected deidentified resident demographics and MDRO risk factors (eg, indwelling devices, pressure injuries, and antibiotic use). RESULTS: We recruited 25 NHs (49 units) with no loss to follow-up, conducted 2540 room-based observations (total duration: 405 hours), and 924 HCP interviews. HCP averaged 2.5 interactions per resident per hour (long-term care units) to 3.4 per resident per hour (ventilator care units). Nurses provided care to more residents (n = 12) than certified nursing assistants (CNAs) and respiratory therapists (RTs) (CNA: 9.8 and RT: 9) but nurses performed significantly fewer task types per interaction compared to CNAs (incidence rate ratio (IRR): 0.61, P < .05). Short-stay (IRR: 0.89) and ventilator-capable (IRR: 0.94) units had less varied care compared with long-term care units (P < .05), although HCP visited residents in these units at similar rates. CONCLUSIONS AND IMPLICATIONS: Resident-HCP interaction rates are similar across NH unit types, differing primarily in types of care provided. Current and future interventions such as EBP, care bundling, or targeted infection prevention education should consider unit-specific HCP-resident interaction patterns.

Association Between Foot Surgery Type and Subsequent Healing in Veterans With Moderate-to-Severe Diabetic Foot Infections.

BACKGROUND: Diabetic foot infections are a common precursor to lower extremity amputations. The treatment of diabetic foot infections involves both medical and surgical management, of which limb-sparing surgeries are increasingly preferred over amputations at or above the ankle to preserve mobility and quality of life. The outcomes following these limb-sparing surgeries are not well described. METHODS: This was a single-center, retrospective cohort study of 90 Veterans with moderate-to-severe diabetic foot infections between 2017 and 2019 from the Veterans Affairs Maryland Health Care System. The exposure was foot surgery with bone resection (ie, toe amputation, metatarsal resection, transmetatarsal amputation) vs debridement alone. The outcome was healing within 1 year. We used log-binomial regression to assess the association between foot surgery type and healing, stratify by infection location, and evaluate potential confounding variables. RESULTS: The cumulative incidence of healing after foot surgery with bone resection was greater than that following debridement (risk ratio [RR], 1.80 [95% confidence interval {CI}, 1.17-2.77]). This association was modified by infection location and greater for toe infections (RR, 4.52 [95% CI, 1.30-15.7]) than other foot infections (RR, 1.19 [95% CI, .69-2.02]). We found no evidence of confounding by comorbidities or infection severity. CONCLUSIONS: For patients with toe infections, foot surgery with bone resection was associated with better healing than debridement alone. The multiple specialties caring for patients with diabetic foot infections need a stronger common knowledge base-from studies like this and future studies-to better counsel patients about their treatment and prognosis.

Staphylococcus aureus infections in US veterans, Maryland, USA, 1999-2008.

Trends in Staphylococcus aureus infections are not well described. To calculate incidence in overall S. aureus infection and invasive and noninvasive infections according to methicillin susceptibility and location, we conducted a 10-year population-based retrospective cohort study (1999-2008) using patient-level data in the Veterans Affairs Maryland Health Care System. We found 3,674 S. aureus infections: 2,816 (77%) were noninvasive; 2,256 (61%) were methicillin-resistant S. aureus (MRSA); 2,517 (69%) were community onset, and 1,157 (31%) were hospital onset. Sixty-one percent of noninvasive infections were skin and soft tissue infections; 1,112 (65%) of these were MRSA. Ten-year averaged incidence per 100,000 veterans was 749 (± 132 SD, range 549-954) overall, 178 (± 41 SD, range 114-259) invasive, and 571 (± 152 SD, range 364-801) noninvasive S. aureus infections. Incidence of all S. aureus infections significantly increased (p<0.001), driven by noninvasive, MRSA, and community-onset infections (p<0.001); incidence of invasive S. aureus infection significantly decreased (p<0.001).

Association between level of care and colonization with resistant gram-negative bacteria among nursing-home residents.

In this cross-sectional study, we examined the relationship between resident level of care in the nursing home and colonization with resistant gram-negative bacteria. Residential-care residents were more likely to be colonized with resistant gram-negative bacteria than were postacute care residents (odds ratio, 2.3; 95% confidence interval, 1.40-3.80; P < .001).

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.