Search

Background: Resistant gram-negative bacteria (R-GNB) colonization in nursing home patients can cause clinical infection and intrafacility transmission. Limited data exist on the roles of age and function on R-GNB colonization. Methods: A secondary data analysis was performed from a cohort study of 896 patients admitted to 6 Michigan nursing homes between November 2013 and May 2018. Swabs obtained upon enrollment, weekly for 1 month, then monthly until nursing home discharge from 5 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Patients with growth of the same R-GNB as the initial positive visit, from any anatomical site at any subsequent visit, 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 R-GNB colonization versus those without, and those with persistent R-GNB colonization versus those with spontaneous decolonization. Results: Of 169 patients with a positive R-GNB culture and ≥2 subsequent study visits, 89 (53%) were transiently colonized and 80 (47%) were persistently colonized. Compared to uncolonized patients, persistent and transient R-GNB colonization were associated with higher PSMS score: 1.14 (95% confidence interval or CI, 1.05–1.23; P = .002) and 1.10 (95% CI, 1.01–1.19; P = .023), respectively. Persistent colonization was independently associated with longer duration of nursing home stay (1.02; 95% CI, 1.01–1.02; P < .001). Higher readmission rate among persistently colonized patients was observed on unadjusted analysis. Conclusions: Persistent R-GNB colonization is associated with younger age, functional disability, and prolonged length of nursing home stay. In-depth longitudinal studies to understand new acquisition and transmission dynamics of R-GNB in nursing homes are needed.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

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.

Background: Postacute sequelae of SARS-CoV-2 (PASC) include fatigue, dyspnea, anxiety, and cognitive impairment. Few studies have explored the prevalence or presentation of PASC among nursing home (NH) residents. Method: A case–control study was conducted at 1 NH in Michigan in December 2021. Cases were defined as residents with SARS-CoV-2 infection between November 2, 2020, and October 8, 2021. Controls lived at the same NH during this interval and never tested positive for SARS CoV-2. Patient characteristics were compared between cases and controls using the Fisher exact test and Wilcoxon rank-sum test. Primary outcomes were functional decline, cognition, and adverse health outcomes. Outcomes were assessed by comparing measures on last observation to observations before COVID-19 diagnosis (cases) or to earliest observation (controls). Multivariable logistic regression assessed correlation between COVID-19 diagnosis and outcomes. Results: In total, 152 residents were identified for inclusion (147 included in final analyses, 76 cases, 71 controls); 5 were excluded due to insufficient data. We collected the following resident characteristics: 66% were aged ≥80 years; 73% were female; 95% were non-Hispanic white; 82% were long-stay residents; median of 3 comorbidities (IQR, 2–4). The mean number of follow-up observations was 2.60 (SD, 1.25). No significant differences in population characteristics were detected between cases and controls. Moreover, 106 patients (46 cases and 60 controls) had at least 1 follow-up visit and were thus included in the analyses to evaluate long-term outcomes. Among them, cases experienced significant declines in completing transfers (OR 5.65, p Conclusions: Nursing home residents with COVID-19 are more likely to enter hospice and have a higher mortality rate in the year following infection. Survivors experience significant functional decline in basic activities of daily living, specifically in the ability to transfer and dress. Larger studies are needed to further characterize our findings and to design interventions that can help overcome these long-term sequelae from COVID-19.Funding: NoneDisclosures: None

Background: SARS-CoV-2, the virus causing COVID-19 infection, can significantly contaminate environmental surfaces and can remain viable on surfaces for up to 9 days. Although respiratory route remains the most significant mode of transmission, fomites and environmental sources of infection remain a concern for healthcare personnel who are working in dedicated COVID-19 units. We investigated the extent of detectable SARS-CoV-2 contamination in the environment of COVID-19 patients at a single VA hospital, with the intent of identifying potential high-touch surfaces at risk for viral contamination, which could be used to inform the development of simple COVID-19 prevention strategies. Methods: We conducted a cohort study at 1 VA hospital in a unit housing adult veterans admitted with COVID-19 between October and December 2020. In total, 11 swab specimens were collected for PCR analysis (SARS-CoV-2 env gene) from environmental surfaces inside and just outside the rooms of COVID-19 patients one time. Retrospective chart reviews were conducted to provide the SARS-CoV-2 epidemiologic context for environmental detection. Results: In total, 297 swabs were collected from the unit and environmental areas surrounding 27 hospitalized patients: average age, 72.5 years (range, 34–94); 100% male; 92% non-Hispanic white; average comorbidities, 1.8 (SD, 1.1). Of 297 swabs, 80 (27%) were positive for SARS-CoV-2 and 19 (70%) of 27 patients had at least 1 positive site. The most contaminated site was the floor just outside the patient room (78% positive samples), followed by the patient’s bedrail (37%) and chair handle (37%) (Fig. 1). Traditionally high-touch surfaces, such as the door handle (outside patient room) and the light switch, did not have high positivity rates (Conclusions: The presence of environmental contamination by SARS-CoV-2 highlights the importance of transmission via direct or indirect contact. Studies targeting high-risk populations are needed to better understand the transmission of SARS-CoV-2 between infected patients and their environment. Our findings also suggest that handwashing and attention to using disinfecting wipes may mitigate the risk of transmission of virus from surfaces that one might consider safe to touch.Funding: NoneDisclosures: None

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.Funding: NoneDisclosures: None

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.Funding: NoneDisclosures: None

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the “AHRQ Safety Program for Long-Term Care,” which focused on practices to reduce CAUTI.METHODSChanges in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.RESULTSThere was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67–1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95–1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82–1.05).CONCLUSIONSNo changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA’s prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.Infect Control Hosp Epidemiol 2018;820–825

Background: Patient colonization and shedding of vancomycin-resistant enterococci (VRE) is a major source of environmental contamination leading to VRE transmission in nursing homes. We hypothesize that we can inform mitigation strategies by identifying patient clinical and microbiota features associated with environmental contamination with VRE. Methods: During a 6-month period of active surveillance in 6 Michigan nursing homes, 245 patients (with 806 follow-up visits) were enrolled. Patient clinical data and swabs for VRE were collected from multiple body sites and high-touch environmental surfaces. In total, 316 perirectal swabs were collected from 137 patients for gut microbiota analysis and community status type (CST) assignment based on taxonomic composition. The associations between VRE colonization pattern, gut microbial CST, and patient factors were examined using multivariable generalized estimating equations, adjusting for patient-and facility-level clustering. We used VRE colonization patterns to group study visits: “uncolonized” (patient−/environment−); “environment-only” (patient−/environment+); “patient-only” (patient+/environment−); “both” (patient+/environment+). Results: Across all study visits, VRE colonization on patient hand and groin/perirectal area was positively correlated with VRE contamination of high-touch environmental surfaces, suggesting direct transfer of VRE between patient and environment via patient hands (Figure 1A). We next set out to identify patient factors associated with patient colonization and environmental contamination. At baseline, while patients in the “both” group had anticipated risk factors such as longer prior hospitalization and more frequent broad-spectrum antibiotic use, they were unexpectedly younger than “uncolonized” patients and had similar functional status. This last feature contrasted with the “patient-only” group, characterized by higher urinary catheter use and higher functional dependence, suggestive of lower functional dependence facilitating patient contamination of their environment. No clinical features distinguished “uncolonized” and “environment-only” patients (Table 1). Lastly, in multivariable analyses, we determined the contribution of patient functional status and gut microbiota features to environmental contamination. Low-diversity CST, characterized by reduced anaerobic taxa, was weakly associated with “patient-only” and significantly associated with “both.” Notably, high functional dependence was significantly associated with “environment-only” and “patient-only” but not “both,” indicating high-functioning patients with disrupted gut microbiota as drivers of environmental contamination (Figure 1B). Conclusions: Our findings suggest that antimicrobial exposure disrupts patient gut microbiota, a significant mediator of colonization dynamics between patients and their environment, and that high-functioning patients may be more likely to spread VRE between their body sites and high-touch environmental surfaces (Figure 2). These findings highlight both antibiotic stewardship and patient hand hygiene as important targets for interrupting transmission mediated by environmental contamination.Funding: NoDisclosures: None

Background: A robust infection prevention infrastructure is critical for creating a safe resident environment in nursing homes. The CDC NHSN provides a standardized approach to infection surveillance and analysis, which can drive internal quality improvement efforts in nursing homes and could serve as an indicator of facilities’ infection prevention aptitude. The purpose of this study was to compare the characteristics of nursing homes enrolled to those not enrolled in the NHSN, including interfacility communication methods, as an essential part of reducing resident infection-related risks. Methods: Over a 2-year period, 50 nursing homes participated in a 12-month program designed to reduce healthcare-associated infections (HAIs) by enhancing relationships between nursing homes and hospitals. Overall, 11 demographic surveys were administered to nursing homes prior to the start of the phase 1 pilot year between January and March 2018, and another 39 were administered prior to beginning phase 2 in January–February 2019. The survey consisted of 36 questions on facility characteristics, including NHSN enrollment, infection prevention and control (IPC) program and infection preventionist characteristics, and communication methods related to interfacility transfer of care. We compared facility, IPC program characteristics, and communication methods between nursing homes stratified based on NHSN enrollment. These were compared using the Fisher exact test. Results: In total, 50 nursing homes, varying in size and services provided, completed the demographic survey (Table 1). Of these 50 nursing homes, 11 (22%) were enrolled in the NHSN. Nursing homes enrolled in the NHSN were more likely to use a telephone report prior to resident transfer in and out of the facility (P = .04) and to disseminate infection data to all facility nursing staff (P = .02). Overall, less than half of nursing homes included a telephone report as part of their routine hand-off communication, and most nursing homes relied only on written transfer forms or discharge documentation. Moreover, 65% of the nursing homes reported use of a standardized method to accept new residents with history of multidrug-resistant organism (MDRO), including a review of infection or MDRO type, antibiotic orders, and ambulation status. NHSN-enrolled nursing homes were also more likely to have an antibiotic stewardship program and to use the electronic health record (EHR) to facilitate infection surveillance, though these differences were not statistically significant. Conclusions: A higher percentage of nursing homes enrolled in the NHSN engaged in activities connected with resident safety including verbal report prior to interfacility transfer and antimicrobial stewardship programs. Dedicating resources for nursing homes to enhance their IPC program including NHSN enrollment should be encouraged.Funding: This study was supported by a grant from the AHRQ (grant no. RO1HS25451).Disclosures: None

Background: Upon admission, 56.8% of patients entering 6 Michigan nursing facilities from regional acute-care hospitals (ACHs) were colonized with 1 or more antibiotic-resistant organisms (AROs) (Mody 2018, CID). This observation raises 2 questions critical to regional infection control strategies: (1) Is the high ARO burden entering nursing facilities driven by dominant epidemic lineages or diverse circulating strains? and (2) What are the relative roles of patient characteristics (eg, high-risk patients) and exposure to specific ACHs (eg, high-risk facilities) in determining whether patients are colonized with AROs upon nursing facility admission? Here, we integrated whole-genome sequencing, patient transfer, and clinical data to answer these questions for the 4 most prevalent ARO species in the region: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis (VREfc), Enterococcus faecium (VREfm), and ciprofloxacin-resistant Escherichia coli (CipREc). Methods: We studied colonizing isolates collected via active surveillance of 584 patients in 6 Michigan nursing facilities between 2013 and 2016. The whole genome of the first isolate of each ARO species collected from each patient was sequenced and analyzed to identify sequence types (STs) and to infer the transmission network by species. We determined the connectedness between nursing facilities based on the number of patients received from the same ACHs and assigned each ARO to the most recent ACH using curated transfer information. The associations between patient characteristics and recent ACH exposures with colonization by ARO were examined using multivariable models. Results: Most of the sequenced ARO isolates belonged to major healthcare-associated lineages: MRSA (ST5, N = 78 of 117); VREfc (ST6, N = 68 of 75); CipREc (ST131, N = 50 of 64); and closely related VREfm isolates (N = 129). Phylogenetically closely related isolates were found across study facilities, indicating that endemic ARO lineages have permeated local healthcare networks (Fig. 1). Patient characteristics played a dominant role in determining patient risk of ARO colonization on admission to a nursing facility. Only in the case of VREfm was a hospital significantly associated with colonization after adjustment for covariates (Table 1). Conclusions: ARO lineages were widely disseminated and colonization of specific ARO lineages at nursing facility entry could not be attributed to recent exposure to a specific ACH. Thus, for the ARO lineages studied here, a broader transmission system crosses ACHs, nursing facilities and probably the community. Therefore, the best indicators of ARO colonization were patient clinical characteristics, particularly poor functional status and antibiotic exposure. These findings suggest that intervention efforts targeting patients with characteristics associated with ARO colonization may help limit further spread among regional facilities.Funding: NoneDisclosures: None

Background: Although active surveillance for multidrug-resistant organism (MDRO) colonization permits timely intervention, obtaining cultures can be time-consuming, costly, and uncomfortable for patients. We evaluated clinical differences between patients with and without attainable perianal cultures, and we sought to determine whether environmental surveillance could replace perianal screening. Methods: We collected active surveillance cultures from patient hands, nares, groin, and perianal area upon enrollment, at day 14, and monthly thereafter in 6 Michigan nursing homes. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant gram-negative bacilli (RGNB) were identified using standard methods. Patient characteristics were collected by trained research professionals. This substudy focused on visits during which all body sites were sampled. To determine the contribution of perianal screening to MDRO detection, site of colonization was categorized into 2 groups: perianal and non-perianal. We evaluated the utility of multisite surveillance (eg, type 1 and type 2 error) using nonperianal sites and environment surveillance. To evaluate characteristics associated with the acquisition of perianal cultures (eg, selection bias), we compared clinical characteristics, overall patient colonization, and room environment contamination of patients in whom all body sites were sampled during a study visit (533 patients; 1,026 visits) to patients with all body sites except the perianal culture sampled during a study visit (108 patients; 168 visits). Results: Of 651 patients, 533 met the inclusion criteria; average age was 74.5 years, 42.6% were male, and 60.8% were white. Of 1,026 eligible visits, 620 visits detected MDRO colonized patients; 155 MRSA, 363 VRE, and 386 RGNB (Table 1). If perianal cultures were not collected, nonperianal surveillance misses 7.7%, 41.3%, and 45.1% of MRSA, VRE, and RGNB colonized visits, respectively. The addition of environmental surveillance to non-perianal screening detected 95.5%, 82.9%, and 67.9% of MRSA, VRE, and RGNB colonized visits, respectively. The specificity of environmental screening was 85.3%, 72.7%, and 73.4% for MRSA, VRE, and RGNB, respectively. Patients without attainable perianal cultures had significantly more comorbidities, worse functional status, shorter length of stay, and higher baseline presence of wounds than patients with attainable perianal cultures; introducing potential selection bias to surveillance efforts (Table 2). No significant differences in overall patient colonization and room contamination were noted between patients with and without attainable perianal cultures. Conclusion: Perianal screening is important for the detection of VRE and RGNB colonization. Infection prevention must be cognizant of the tradeoff between reducing type 2 error and the selection bias that occurs with required attainment of perianal cultures. In the absence of perianal cultures, environmental surveillance improves MDRO detection while introducing type 1 error.Funding: NoneDisclosures: None

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.

OBJECTIVEThe impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non–VA nursing homes.SETTINGVA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative.METHODSNursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire.RESULTSA total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; PPP=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004).CONCLUSIONSAmong nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems.Infect Control Hosp Epidemiol 2017;38:287–293

OBJECTIVETo assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative.DESIGNBaseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections.SETTINGNursing homes across 14 states participating in the national “Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection.”PARTICIPANTSLicensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel.METHODSEach facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses.RESULTSA total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed).CONCLUSIONSThis national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care.Infect. Control Hosp. Epidemiol. 2016;1–6

OBJECTIVETo estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes.DESIGNCost analysis of data collected from a prospective, observational study.SETTING AND PARTICIPANTSCare activity data from 401 residents from 13 nursing homes in 2 states.METHODSCost 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.RESULTSThe 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).CONCLUSIONSThe 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

Background: Methicillin-resistant Staphylococcus aureus (MRSA) colonization of patients and contamination of their immediate environmental surfaces is common in the acute care setting, but there is much to be learned about the dynamics of MRSA transmission over a short period of time. Methods: A prospective, observational time-motion qualitative study was conducted at 2 hospitals: 1 in Michigan (hospital 1) and 1 in Zurich, Switzerland (hospital 2)—between November 2018 and July 2019. Hospitalized patients with a MRSA infection or colonization were enrolled. Microbiologic cultures for MRSA were collected from patient nares, axilla, groin and hands and several high-touch surfaces in their room (bed controls, call button, tray table, etc) at the first visit, and patient hands and high-touch surfaces continued to be swabbed every 90 minutes over the course of 5 hours. Patient hands and environment were disinfected after each swabbing. Clinical data were collected from patient’s medical chart. Results: We recruited 10 MRSA colonized or infected patients for the study with 50 hours of observation and obtained 360 patient and environmental swabs. Most were women (7 of 10); the average age was 52.8 years (Table 1). At the first visit, 8 (80%) patients were MRSA-colonized (at 1 or more body sites) and 5 (50%) rooms were MRSA-contaminated (at 1 or more surfaces). Also, 6 patients (60%) had an active MRSA infection and were actively receiving an anti-MRSA agent (eg, Vancomycin). Among those 6 patients receiving an anti-MRSA agent, 4 patients (67%) and 2 rooms (33%) were contaminated at the first visit. Among those 4 patients not receiving an anti-MRSA agent, all 4 patients (100%) and 3 rooms (75%) were contaminated at the baseline visit. Acquisitions (ie, MRSA recovered from a site it was not previously recovered from) occurred on 3 of 7 patient hands (43%) and on 6 occasions in the room (among 5 patients), most commonly at the toilet seat (2 of 6 times). MRSA prevalence on patient and room surfaces for the 5 patients enrolled at hospital 2 are illustrated in Figure 1, which shows colonization of patient and contamination of environment as well as activities performed by the patient in between culturing. Conclusions: We evaluated transmission of MRSA over brief periods of time; our results show that transmission of MRSA depended on patient activity in the room. Furthermore, degree of patient colonization is reflected by environmental contamination and supports the notion of constant transmission of MRSA from patients to environment.Funding: NoneDisclosures: None

OBJECTIVETo characterize the epidemiology of multidrug-resistant (MDR)Acinetobacter baumanniicolonization in high-risk nursing home (NH) residents.DESIGNNested case-control study within a multicenter prospective intervention trial.SETTINGFour NHs in Southeast Michigan.PARTICIPANTSCase patients and control subjects were NH residents with an indwelling device (urinary catheter and/or feeding tube) selected from the control arm of the Targeted Infection Prevention study. Cases were residents colonized with MDR (resistant to ≥3 classes of antibiotics)A. baumannii; controls were never colonized with MDRA. baumannii.METHODSFor active surveillance cultures, specimens from the nares, oropharynx, groin, perianal area, wounds, and device insertion site(s) were collected upon study enrollment, day 14, and monthly thereafter.A. baumanniistrains and their susceptibilities were identified using standard microbiologic methods.RESULTSOf 168 NH residents, 25 (15%) were colonized with MDRA. baumannii. Compared with the 143 controls, cases were more functionally disabled (Physical Self-Maintenance Score >24; odds ratio, 5.1 [95% CI, 1.8–14.9];PProteus mirabilis(5.8 [1.9–17.9];PPCONCLUSIONFunctional disability,P. mirabiliscolonization, and diabetes mellitus are important risk factors for colonization with MDRA. baumanniiin high-risk NH residents.A. baumanniiexhibits widespread antibiotic resistance and a preference to colonize with other antibiotic-resistant organisms, meriting enhanced attention and improved infection control practices in these residents.Infect Control Hosp Epidemiol 2015;36(10):1155–1162

Objective.Characterize the clinical and molecular epidemiology of new methicillin-resistantStaphylococcus aureus(MRSA) acquisitions at nasal and extranasal sites among high-risk nursing home (NH) residents.Design.Multicenter prospective observational study.Setting.Six NHs in southeast Michigan.Participants.A total of 120 NH residents with an indwelling device (feeding tube and/or urinary catheter).Methods.Active surveillance cultures from the nares, oropharynx, groin, perianal area, wounds (if present), and device insertion site(s) were collected upon enrollment, at day 14, and monthly thereafter. Pulsed-field gel electrophoresis and polymerase chain reaction for SCCmec, agr, and Panton-Valentine leukocidin were performed.Results.Of 120 participants observed for 16,290 device-days, 50 acquired MRSA (78% transiently, 22% persistently). New MRSA acquisitions were common in extranasal sites, particularly at device insertion, groin, and perianal areas (27%, 23%, and 17.6% of all acquisitions, respectively). Screening extranasal sites greatly increases the detection of MRSA colonization (100% of persistent carriers and 97.4% of transient carriers detected with nares, groin, perianal, and device site sampling vs 54.5% and 25.6%, respectively, for nares samples alone). Colonization at suprapubic urinary catheter sites generally persisted. Healthcare-associated MRSA (USA100 and USA100 variants) were the dominant strains (79.3% of all new acquisition isolates). Strain diversity was more common in transient carriers, including acquisition of USA500 and USA300 strains.Conclusion.Indwelling device insertion sites as well as the groin and perianal area are important sites of new MRSA acquisitions in NH residents and play a role in the persistency of MRSA carriage. Clonal types differ among persistent and transient colonizers.

Objective.To assess the response of long-term care facilities (LTCFs) to the 2004-2005 influenza vaccine shortage and the impact on resident and healthcare worker (HCW) immunization rates.Methods.A 12-item questionnaire was sent to 824 randomly selected LTCFs in December 2004. The following 2 open-ended questions were also asked: “How did you cope with the vaccine shortage?” and “Who helped you get your supply?” Immunization rates reported by LTCF administrators for 2003-2003 and 2003-2004 were compared with those for 2004-2005. Immunization rates were defined as the proportion of all eligible residents and HCWs who received influenza vaccine.Results.Responses were received from 380 LTCFs (46.3%), which had a total of 38,447 beds. Resident mean influenza immunization rates (±SD) decreased from 85% ± 15.3% in 2002-2003 and 85.1% ± 15.3% in 2003-2004 to 81.9% ± 19.4% in the 2004-2005 influenza season (P = .025). The immunization rates among HCWs also decreased from 51% in 2002-2003 and 2003-2004 to 38.4% in 2004-2005 (PConclusions.The influenza vaccine shortage in 2004-2005 impacted immunization practices of LTCFs across the United States, leading to decreases in both resident and HCW vaccination rates. The significant decrease in vaccination rates in LTCFs is of concern and has broad implications for policy makers working on emergency preparedness for a possible pandemic of influenza.

Objective:To examine the impact of introduction of an alcohol-based hand rub on hand hygiene knowledge and compliance and hand colonization of healthcare workers (HCWs) in a long-term-care facility (LTCF).Methods:Two floors of an LTCF participated. Ward A used the hand rub as an adjunct to soap and water; ward B was the control. HCWs' hands were cultured using the bag-broth technique forStaphylococcus aureus,gram-negative bacilli (GNB),Candida,and vancomycin-resistant enterococci (VRE). HCWs completed a questionnaire at baseline and after an educational intervention and introduction of rub.Results:Hand hygiene practices, knowledge, and opinions did not change after the educational or rub intervention. Ward A HCWs thought that the rub was faster (P= .002) and less drying (P= .04) than soap. Hand hygiene frequency did not differ at baseline between the two floors, but increased on ward A by the end of the study (P= .04). HCWs were colonized frequently with GNB (66%),Candida(41%), S.aureus(20%), and VRE (9%). Although colonization did not change from baseline on either ward, the rub was more effective in clearing GNB (P= .03) and S.aureus(P= .003). Nosocomial infection rates did not change.Conclusion:The alcohol-based hand rub was a faster, more convenient, less drying method of hand hygiene for HCWs in an LTCF, and it improved compliance. Although microbial colonization did not change, the rub was more efficacious in removing pathogens already present on the hands of HCWs.

A case-control study of patients with stools assayed forClostridium difficiletoxin over a 24-month period at a Veterans Affairs hospital found that the majority of cases (70.6%) occurred in temporal clusters. Clustering was particularly evident on a designated human immunodeficiency virus (RW) unit. Thirty-four (75.5%) of 45 HIV-infected patients withC difficile-associated diarrhea (CDAD) died during their hospitalization. Third-generation cephalosporins were the antibiotics most strongly associated with CDAD.