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Background: Nursing homes (NHs) have high prevalence of multi-drug resistant organisms (MDROs) with rates exceeding those in hospitals. This study proposes quantifying patients’ risk of MDRO colonization and creating a risk profile for the NH patient populations to assist in reducing MDRO burden in health care facilities. Methods: We assessed a risk classification model using data from a prospective cohort study (2018 Pathways study). Patient sample included 783 newly admitted patients followed for up to 180 days and 9,587 samples collected from patients during 2,089 visits. Individual risk factors of MDRO colonization were assessed using unadjusted logistic regression, and patients were risk classified based on number of risk factors. Multivariate regression was performed to obtain odds of MDRO colonization for patient risk groups adjusting for patient age, sex, race, and length of NH stay (LOS). The risk classification tool developed using Pathways data was also tested among a sample of NH residents from Veterans Administration (N=190). Results: The patient sample (Pathways data) was 43.2% male, 37.2% Black with a mean age 74 years. 69.3% were colonized with a MDRO during the study. In unadjusted regression, recent antibiotic use (p

Background: Methicillin-resistant S. aureus (MRSA) is known to cause frequent and severe infections in community living centers, potentially resulting in significant mortality for elderly patients. More research is needed to understand how to utilize genomic and epidemiological data to understand characteristics that may lead to increased transmission. We hypothesized that combining genomic and epidemiological information to sample patients and their environments during long-term stays, we will be able to capture a diverse set of MRSA strains. Method: This work included genome sequencing of patient and environmental samples from 11 patients within the VA Ann Arbor Healthcare System from May 4, 2021- November 16, 2022. All 11 patients tested positive for MRSA during their stay (mean days = 31). Patient and environmental samples were taken throughout their stays, screened for MRSA, and whole-genome sequenced. Single nucleotide variants (SNVs) were identified by mapping reads and calling variants against strain-specific reference genomes. We used ape v5.6-2 in R v4.2.2 to analyze and infer evolution, acquisition, and transmission events based on pairwise SNV distances. Genomic clusters were determined using stats v3.6.2, with a SNV distance threshold of 20. Result: Samples that were collected from patient bodily sites were able to reveal 20 distinct genomic clusters of MRSA (patient hands: n = 10, nares: n = 7, groin: n = 3). Environmental samples from patient environments also revealed distinct genomic MRSA clusters (tv remote: n = 9, toilet seat and bed rail: n = 6, table top, bed control, and call button: n = 5, bed curtain: n = 4, pulse ox = 2, cell phone, tray, pulse ox, mat, body hoist wrap, and bed: n = 1). Conclusion: The identification of various genomic clusters from patients and their environmental reservoirs suggests intrahost variation that can only be captured by using a more holistic approach of integrating epidemiology and genomic sequencing. Developing studies that incorporate genomic data, various environmental sources, and multiple isolates over time within community living centers can increase our understanding of strains that are more likely to transmit, survive on living and non-living surfaces and therefore lead to improved recommendation for infection prevention interventions and drivers of endemicity.

Background and objectives: Patients with functional disabilities are at higher risk of adverse outcomes, including infections. Although healthcare worker hand contamination has long been recognized as an important source of pathogen acquisition, the role of patient hands has been less clearly defined. We sought to determine whether the presence of functional disabilities is correlated with patient hand contamination by multidrug-resistant organisms (MDROs) and thus a potential target for patient hand hygiene (PHH) interventions. Methods: Case–control study of hand contamination with methicillin-resistant S. aureus, vancomycin-resistant enterococci, and gram-negative bacilli resistant to cephalosporins, fluoroquinolones, and/or carbapenems in 2 acute-care hospitals in southeastern Michigan. Cases (n = 40) and controls (n = 359) were defined as patients with or without hand contamination by MDROs, respectively. We assigned 3 exposure categories based on Katz activities of daily living scores: no functional disabilities (independent, reference group), 1–3 functional disabilities (partially dependent), and 4+ functional disabilities (dependent). We used stepwise logistic regression to identify confounding variables. Logistic regression was then used to establish the relationship between a patient’s functional dependence level and their hand contamination by MDROs. Results: The distribution of hand contamination of each target MDRO by level of patient dependence is shown in the Table. Overall, methicillin-resistant Staphylococcus aureus (MRSA) was the most represented, followed by resistant gram-negatives and vancomycin-resistant enterococci (VRE). Hospital site, sex, and history of MDROs were included in the model based on stepwise regression. The odds ratio (OR) of MRSA hand contamination in the dependent category was 3.19 (95% CI, 1.18–5.54) compared to the independent category, and for any MDRO the OR was 2.77 (95% CI, 1.22–6.32) (Fig. 1). The OR of MRSA hand contamination in the partially dependent category was 1.38 (95% CI, 0.27–7.07) compared to the independent group, and for any MDRO the OR was 0.86 (95% CI, 0.24–3.10) (Fig. 1). Feeding dependence had the highest single association with hand contamination (OR, 3.79, 95% CI, 1.26–11.43), with dressing dependence having the second highest association with hand contamination (OR, 2.82; 95% CI, 1.31–6.05) (Fig. 2). Conclusions: Patients with more functional dependencies were more likely to have MDRO hand contamination. This finding suggests a need for targeted PHH interventions in patients with functional disabilities to help prevent the spread of MDROs in the acute-care setting.

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.

Abstract Objectives: Since the beginning of the COVID-19 pandemic, face masks have been worn by many in public areas and for prolonged periods by healthcare workers (HCWs). This may facilitate bacterial contamination and transmission to and from patients in nursing homes where clinical care areas with strict precautions and residential and activity areas are interconnected. We assessed and compared bacterial mask colonization in HCWs belonging to different demographic categories and professions (clinical and nonclinical) and among HCWs who had worn the mask for different periods of time. Design, setting and participants: We conducted a point-prevalence study of 69 HCW masks at the end of a typical work shift in a 105-bed nursing home serving postacute care and rehabilitation patients. Information collected about the mask user included profession, age, sex, length of time the mask was worn, and known exposure to patients with colonization. Results: In total, 123 distinct bacterial isolates were recovered (1–5 isolates per mask), including Staphylococcus aureus from 11 masks (15.9%) and gram-negative bacteria of clinical importance from 22 masks (31.9%). Antibiotic resistance rates were low. There were no significant differences in the number of clinically important bacteria among masks worn more or less than 6 hours, and there were no significant differences among HCWs with different job functions or exposure to colonized patients. Conclusions: Bacterial mask contamination was not associated with HCW profession or exposure and did not increase after 6 hours of mask wearing in our nursing home setting. Bacteria contaminating HCW masks may differ from those colonizing patients.

Background: Face masks have been worn universally and for long periods of time by healthcare personnel during the COVID-19 pandemic. They are frequently touched or adjusted with the hands and may come in contact with various surfaces and high-touch sites when taken off and on even briefly. These activities present opportunities for face masks to become contaminated with microorganisms. Nursing homes have high rates of multidrug-resistant bacteria and low PPE compliance; therefore, contamination of face masks in this setting may be of great interest. We investigated bacterial colonization status on used face masks in healthcare personnel, including assessing the presence of clinically important and multidrug-resistant bacteria. Methods: At a nursing home serving mostly post–acute-care patients, we collected 69 face masks from personnel at the end of the user’s work shift. Information about the mask and the user was also collected via a self-reported survey. Face masks were incubated in BHI broth overnight at 36°C and 10 μL was then plated on selective and differential plates. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and gram-negative bacteria (GNB) resistant to several antibiotic classes were identified using standard microbiological methods. Resistance testing for cefoxitin (S. aureus), ciprofloxacin, meropenem, tetracycline, erythromycin, gentamicin, trimethoprim–sulfamethoxazole, and ceftazidime with and without clavulanic acid (gram-negative bacteria) was performed using the disc diffusion technique on Mueller-Hinton plates (Kirby Bauer). Results: The job categories of face mask users were competency-evaluated nursing assistant or nursing assistant (22.73%), nurse (12.12%), and other or administrative (37.88%). Overall face mask contamination rates for MRSA (0%) and VRE (3.3%) were low; however, methicillin-susceptible S. aureus was found on 11 masks (15.9%). High contamination and resistance rates were found for gram-negative bacteria, with 113 isolates. Among them, 69 (60.9%) were resistant to at least 1 antibiotic, most commonly was erythromycin (59.4%). Additionally, higher rates of clinically important pathogenic gram-negative bacteria were identified: 14.3% of masks were contaminated with Klebsiella pneumoniae, 13.0% were contaminated with Enterobacter spp, and 4.2% were contaminated with Escherichia coli. Importantly, there were no significant differences in the total number of isolates of potential clinical significance recovered from masks worn >6 hours versus those worn

Background: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) is of special concern among frail patients in nursing homes. To understand environmental contamination patterns in this setting, we screened a suitable section of a nursing home over time and assessed MRSA and VRE prevalence in patients and their rooms. We were especially interested in assessing whether MRSA and VRE strains persist in rooms during changes of occupancy after patient discharge. Methods: We conducted a prospective cohort study of MRSA and VRE colonization and contamination among successive patients in a cluster of 9 single-occupancy rooms. Using flocked swabs, 5 high-touch surfaces were screened 3 times a week for 34 weeks. Patients were also screened (ie, nares, groin, and hands), if they agreed to participate. Whole-genome sequencing was performed on 67 nonredundant MRSA and VRE strains. Single-nucleotide polymorphism heatmaps and similarity trees were generated to evaluate strain diversity and persistence the facility. Results: Overall, 146 distinct occupancy events were captured during the study (16.5 average per room; range, 11–22), with 387 study visits and 4,670 total swabs collected. All rooms were contaminated with VRE, and 8 of 9 were contaminated with MRSA at least once during the study period. New contamination of a room with MRSA or VRE was observed in 43 (23%) of 185 opportunities, with potential persistence during occupancy changes in 25 (32.9%) of 76 opportunities. Sequencing of 67 nonredundant isolates identified at least 6 enterococcal clades and 10 MRSA clades (6 USA100 and 4 USA300), indicating a high degree of diversity and probably multiple introductions in the facility during the study time. In 3 separate cases, whole-genome sequencing confirmed persistence of a specific MRSA strain during a change of room occupancy, including 1 case of a MRSA strain persisting in a clean room before admission of the next patient. For VRE, 2 cases of persistence during room occupancy changes were confirmed, along with 6 cases of possible persistence (contamination across noncontiguous room occupancy events). Conclusions: Active surveillance screening and a recurring evaluation of terminal cleaning procedures should be considered due to high levels of circulation and persistence of MRSA and VRE in the nursing home setting.

Background: Persistent colonization with resistant gram-negative bacteria (R-GNB) increases risk of clinical infection and intra-facility transmission among nursing home (NH) patients. Limited data exist on the roles of age and function on duration of R-GNB colonization. Methods: Secondary data analysis was performed from a cohort study of patients admitted to 6 Michigan NHs between November 2013 and May 2018. Swabs obtained upon enrollment, day 14, day 30, then monthly until NH discharge from 6 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Positive R-GNB culture from a single visit followed by negative cultures for the same organism from ≥2 subsequent visits were defined as transient R-GNB colonization. All other patients with positive R-GNB cultures from multiple visits were considered persistently colonized. Demographic data, antibiotic use, device use, and physical self-maintenance scales (PSMSs) were obtained upon enrollment. Characteristics were compared between patients with transient versus persistent R-GNB and uncolonized patients using multinomial logistic regression. Results: We recruited 896 patients (median age, 75 years; 41% male; 46% nonwhite) and followed them for 2,437 total visits. Of 896 patients, 407 (45.4%) were colonized with ≥1 R-GNB during their stay. Of 171 patients with ≥ 2 follow-up visits after R-GNB detection, 94 (55%) remained persistently colonized with the same R-GNB (Table 1). Escherichia coli (30%) and Proteus mirabilis (22%) were the most frequently identified R-GNB. The most common anatomical colonization sites were perirectal (368 [24.3%] of 1,147) groin (340 [14.3%] of 2,046), and hands (115 [4.8%] of 2283). Compared to uncolonized patients, patients with persistent (1.09; 95% CI, 1.00–1.19, P = .048) and transient R-GNB colonization (1.13; 95% CI, 1.04–1.23; P = .003) had lower PSMS (Tables 2 and 3). Compared to uncolonized and transiently colonized patients, patients with persistent R-GNB colonization had prolonged lengths of NH stay (1.01; 95% CI, 1.00–1.01; P = .003). Conclusions: R-GNB colonization in vulnerable NH patients is common (407 [45.5%] of 896 and often persistent (94 [55%] of 171 patients with sufficient follow-up to assess persistence). Patients with persistent R-GNB had lower functional status, longer LOS, and higher readmission rates than those without. R-GNB decolonization should be investigated as a strategy to potentially improve outcomes among NH patients.

OBJECTIVES/GOALS: We investigated the association between gut microbiota features in newly admitted nursing facility (NF) patients and the acquisition of vancomycin-resistant Enterococcus (VRE) and/or resistant Gram-negative bacteria (rGNB) within 14 days. METHODS/STUDY POPULATION: Patients were recruited at 6 Michigan NFs from 09/16-08/18. VRE or rGNB colonization status was determined by culture swabs collected from multiple body sites at enrolment, day 7, and day 14. Our analysis focused on patients with no colonization at baseline, a perirectal swab collected at baseline, and at least one follow-up visit. The V4 hypervariable region of the 16S rRNA gene from bacterial DNA in each sample was PCR-amplified and sequenced on the MiSeq platform. Sequencing results were then processed with the mothur bioinformatics pipeline to classify bacterial taxa present in each sample. Taxa typically associated with the skin microbiota were removed. The primary outcome was acquisition of VRE and/or rGNB within 14 days. Exposures of interest included patient and microbiota characteristics. RESULTS/ANTICIPATED RESULTS: Among 61 patients, 18 (30%) acquired AROs within 14 days of enrolment (3 VRE, 13 rGNB, 2 both) (Table 1). The baseline microbiota features differed significantly in those who acquired a new ARO. Of the major 8 phyla found across samples, patients who acquired an ARO were depleted in the number of phyla present (5.74 ± 1.20 vs 5.06 ± 1.43; p = 0.037) (Fig. 1). The log10-transformed relative abundance of Enterococcus was enriched in patients who acquired an ARO (−0.32 ± 1.47) compared to those who did not (−1.68 ± 1.76; p = 0.021) (Fig. 2). Patients who did not acquire an ARO tended to harbour more butyrate-producing bacterial taxa and strict anaerobes, although the differences were not statistically significant (relative abundance of butyrate producer: 29.49 ± 22.09 vs 22.05 ± 17.76; anaerobes: 64.78 ± 23.54 vs 53.68 ± 27.61). DISCUSSION/SIGNIFICANCE OF IMPACT: Microbiota metrics calculated from perirectal samples are predictive of ARO acquisition. The clinical utility of perirectal samples thus warrants further assessment.