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The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Omicron variant has been hypothesized to exhibit faster clearance (time from peak viral concentration to clearance of acute infection), decreased sensitivity of antigen tests, and increased immune escape (the ability of the variant to evade immunity conferred by past infection or vaccination) compared to prior variants. These factors necessitate reevaluation of prevention and control strategies, particularly in high-risk, congregate settings like nursing homes that have been heavily impacted by other coronavirus disease 2019 (COVID-19) variants. We used a simple model representing individual-level viral shedding dynamics to estimate the optimal strategy for testing nursing home healthcare personnel and quantify potential reduction in transmission of COVID-19. This provides a framework for prospectively evaluating testing strategies in emerging variant scenarios when data are limited. We find that case-initiated testing prevents 38% of transmission within a facility if implemented within a day of an index case testing positive, and screening testing strategies could prevent 30% to 78% of transmission within a facility if implemented daily, depending on test sensitivity. [ABSTRACT FROM AUTHOR]

Background Identifying asymptomatic individuals early through serial testing is recommended to control coronavirus disease 2019 (COVID-19) in nursing homes, both in response to an outbreak ("outbreak testing" of residents and healthcare personnel) and in facilities without outbreaks ("nonoutbreak testing" of healthcare personnel). The effectiveness of outbreak testing and isolation with or without nonoutbreak testing was evaluated. Methods Using published SARS-CoV-2 transmission parameters, the fraction of SARS-CoV-2 transmissions prevented through serial testing (weekly, every 3 days, or daily) and isolation of asymptomatic persons compared with symptom-based testing and isolation was evaluated through mathematical modeling using a Reed-Frost model to estimate the percentage of cases prevented (ie, "effectiveness") through either outbreak testing alone or outbreak plus nonoutbreak testing. The potential effect of simultaneous decreases (by 10%) in the effectiveness of isolating infected individuals when instituting testing strategies was also evaluated. Results Modeling suggests that outbreak testing could prevent 54% (weekly testing with 48-hour test turnaround) to 92% (daily testing with immediate results and 50% relative sensitivity) of SARS-CoV-2 infections. Adding nonoutbreak testing could prevent up to an additional 8% of SARS-CoV-2 infections (depending on test frequency and turnaround time). However, added benefits of nonoutbreak testing were mostly negated if accompanied by decreases in infection control practice. Conclusions When combined with high-quality infection control practices, outbreak testing could be an effective approach to preventing COVID-19 in nursing homes, particularly if optimized through increased test frequency and use of tests with rapid turnaround. [ABSTRACT FROM AUTHOR]

A suspected outbreak of influenza A and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at a long-term care facility in Los Angeles County was, months later, determined to not involve influenza. To prevent inadvertent transmission of infections, facilities should use highly specific influenza diagnostics and follow Centers for Disease Control and Prevention (CDC) guidelines that specifically address infection control challenges. [ABSTRACT FROM AUTHOR]

We surveyed clinical staff and on-site teachers working at pediatric long-term care facilities regarding prevention and control of acute respiratory infections and influenza in staff and residents. We uncovered knowledge gaps, particularly among teachers and clinical staff working <5 years at sites, thereby elucidating areas for targeted staff education. [ABSTRACT FROM AUTHOR]

In 2016, 42% of nursing homes enrolled in the National Healthcare Safety Network reported meeting all 7 of the Centers for Disease Control and Prevention's Core Elements of Antibiotic Stewardship. Bivariate analyses suggested that implementation of all core elements differed by ownership type and amount of infection prevention staff hours. [ABSTRACT FROM AUTHOR]

Background Most nursing facilities (NFs) lack methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) surveillance programs due to limited resources and high costs. We investigated the utility of environmental screening of high-touch surfaces in patient rooms as a way to circumvent these challenges. Methods We compared MRSA and VRE culture data from high-touch surfaces in patients’ rooms (14450 samples from 6 NFs) and ranked each site’s performance in predicting patient colonization (7413 samples). The best-performing sites were included in a MRSA- and a VRE-specific panel that functioned as a proxy for patient colonization. Molecular typing was performed to confirm available concordant patient-environment pairs. Results We identified and validated a MRSA panel that consisted of the bed controls, nurse call button, bed rail, and TV remote control. The VRE panel included the toilet seat, bed controls, bed rail, TV remote control, and top of the side table. Panel colonization data tracked patient colonization. Negative predictive values were 89%–92% for MRSA and 82%–84% for VRE. Molecular typing confirmed a strong clonal type relationship in available concordant patient-environment pairs (98% for MRSA, 91% for VRE), pointing to common epidemiological patterns for environmental and patient isolates. Conclusions Environmental panels used as a proxy for patient colonization and incorporated into facility surveillance protocols can guide decolonization strategies, improve awareness of MRSA and VRE burden, and inform efforts to reduce transmission. Targeted environmental screening may be a viable surveillance strategy for MRSA and VRE detection in NFs. [ABSTRACT FROM AUTHOR]

Background. Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods. We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or <3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results. A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400-131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500-37 300), 20 900 (19%) recurred within 14-60 days (95% CI, 14 600-27 100), and 8700 (8%) died within 30 days (95% CI, 6600-10 700). Conclusions. Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI. [ABSTRACT FROM AUTHOR]

Preventing healthcare-associated infection (HAI) is a key contributor to enhancing resident safety in nursing homes. In 2013, the U.S. Department of Health and Human Services approved a plan to enhance resident safety by reducing HAIs in nursing homes, with particular emphasis on reducing indwelling catheter use and catheterassociated urinary tract infection (CAUTI). Lessons learned from a recent multimodal Targeted Infection Prevention program in a group of nursing homes as well as a national initiative to prevent CAUTI in over 950 acute care hospitals called "On the CUSP: STOP CAUTI" will now be implemented in nearly 500 nursing homes in all 50 states through a project funded by the Agency for Healthcare Research and Quality (AHRQ). This "AHRQ Safety Program in Long-Term Care: HAIs/CAUTI" will emphasize professional development in catheter utilization, catheter care and maintenance, and antimicrobial stewardship as well as promoting patient safety culture, team building, and leadership engagement. We anticipate that an approach integrating technical and socio-adaptive principles will serve as a model for future initiatives to reduce other infections, multidrug resistant organisms, and noninfectious adverse events among nursing home residents. [ABSTRACT FROM AUTHOR]

In this skilled nursing facility, 24 Group A Streptococcus infections occurred in 19 residents over 36 months. All invasive isolates were subtype emm 11.0. Infection risk factors included nonintact skin and living in wing A. Cases ceased following facility-wide chemoprophylaxis.Background. Group A Streptococcus (GAS) is an important bacterial cause of life-threatening illness among the elderly. Public health officials investigated a protracted GAS outbreak in a skilled nursing facility in Georgia housing patients requiring 24-hour nursing or rehabilitation, to prevent additional cases.Methods. We defined a case as illness in a skilled nursing facility resident with onset after January 2009 with GAS isolated from a usually sterile (invasive) or nonsterile site (noninvasive). Cases were “recurrent” if >1 month elapsed between episodes. We evaluated infection control practices, performed a GAS carriage study, emm-typed available GAS isolates, and conducted a case-control study of risk factors for infection.Results. Three investigations, spanning 36 months, identified 19 residents with a total of 24 GAS infections: 15 invasive (3 recurrent) and 9 noninvasive (2 recurrent) episodes. All invasive cases required hospitalization; 4 patients died. Seven residents were GAS carriers. All invasive cases and resident carrier isolates were type emm 11.0. We observed hand hygiene lapses, inadequate infection documentation, and more frequent wound care staff turnover on wing A versus wing B. Risk factors associated with infection in multivariable analysis included living on wing A (odds ratio [OR], 3.4; 95% confidence interval [CI], .9–16.4) and having an indwelling line (OR, 5.6; 95% CI, 1.2–36.4). Cases ceased following facility-wide chemoprophylaxis in July 2012.Conclusions. Staff turnover, compromised skin integrity in residents, a suboptimal infection control program, and lack of awareness of infections likely contributed to continued GAS transmission. In widespread, prolonged GAS outbreaks in skilled nursing facilities, facility-wide chemoprophylaxis may be necessary to prevent sustained person-to-person transmission. [ABSTRACT FROM AUTHOR]

Background Older adults residing in nursing homes (NH) are at increased risk for invasive group A Streptococcus (GAS) infections due to advanced age, presence of wounds, and comorbidities; approximately one-third of infected patients die. Beginning in 2015, increasing numbers of GAS infections in NH residents and several NH clusters were reported from the Denver metropolitan area. Colorado Department of Public Health and Environment (CDPHE) and CDC investigated to characterize cases and assess if outbreaks resulted from interfacility transmission. Methods We reviewed data from Active Bacterial Core surveillance (ABCs) in the 5-county Denver area from January 2017 to June 2018. We defined a case as isolation of GAS from a normally sterile site in an NH resident. GAS isolates underwent whole-genome sequencing (WGS) at CDC's Streptococcus Laboratory to determine emm types for genotyping. Among isolates with the same emm type, pairwise single-nucleotide polymorphism (SNP) distances were calculated using Nucmer software. In October 2018, a CDPHE-CDC team assessed infection control at NHs with cases of the most common emm type. Results Over 18 months, among >100 NHs in the Denver area, ≥1 GAS case was identified in 29 NHs, with 6 having ≥3 cases. During this period, 68 cases in NH residents were identified. WGS identified 17 emm types among isolates from these cases; most common was emm11.10 (34%, n = 22), a rare subtype in ABCs. All emm11.10 isolates had nearly identical genomes (average pairwise SNP distance: 3.2), and were isolated from 10 NHs, with 2 NHs having ≥ 4 cases. Multiple infection control lapses were noted during site visits to 8 NHs. Conclusion Multiple outbreaks due to GAS were noted in 5-county Denver area NHs in 2017–2018. WGS of surveillance isolates identified a rarely seen emm subtype 11.10 from multiple facilities with temporal and genomic clustering suggesting interfacility GAS transmission. Disclosures All Authors: No reported Disclosures. [ABSTRACT FROM AUTHOR]

Background Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) are often multidrug-resistant, and the KPC resistance determinant can be transmitted between bacteria. KPCOs are associated with healthcare facility exposures; identification in community-based, residential care settings is uncommon. In September 2018, the Washoe County Health District was notified of a KPC-producing Escherichia coli from a group home (GH) resident. We investigated the source of this KPCO and evaluated transmission in the GH. Methods A case was defined as detection of KPCO from a GH resident or staff from June 1 to November 30, 2018. Staff included caregivers who provided daily care (including toileting, bathing, feeding) and visiting healthcare workers. Residents and staff were offered KPCO screening to assess colonization status. Exposures were assessed by medical record review and interviews. Genetic relatedness of KPCOs was evaluated by whole-genome sequencing (WGS). Infection prevention and control (IPC) practices were reviewed. Results Overall, six cases were identified, including the index, two of seven staff screened and three of six residents screened. Three residents with KPCOs had recent hospitalizations and shared a bathroom in the GH; one overlapped on the same hospital unit as a patient with KPC-producing Klebsiella oxytoca. Staff with KPCOs were caregivers who had extensive contact with residents and their environment and no IPC training. Gaps in hand hygiene and environmental cleaning were observed. Organism was recovered from 4 positive screening tests as well as from blood cultures from the index case; all were KPC-producing E. coli. WGS showed that the five E. coli isolates were closely related, consistent with transmission, and harbored the same KPC variant as the K. oxytoca. No new cases occurred after IPC was improved. Conclusion A GH resident likely acquired KPCOs during a recent hospitalization, and extensive transmission among GH residents and staff occurred. Factors contributing to transmission included resident dependence on caregivers for daily care and minimal IPC knowledge among caregivers. Facilities with similar populations should increase IPC training to prevent transmission of resistant pathogens. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Antibiotics are frequently prescribed in nursing homes (NH). National data describing facility-level antibiotic use (AU) in NH are lacking. The objectives of this analysis were to use NH electronic health records (EHR) to describe AU in NH and variability in AU rates across NH. Methods We analyzed antibiotic orders for 309,884 residents in 1,664 US NHs using one EHR company in 2016. We calculated AU rates as antibiotic days-of-therapy (DOT) per 1,000 resident-days and compared by the type of stay (short-stay (SS) ≤ 100 days vs. long-stay (LS) >100 days). We also examined prescribing indications and the duration of nursing home-initiated antibiotic orders. We assessed facility-level correlates of AU using resident health and NH facility characteristics publically available through NH Compare and LTCfocus using a univariate linear regression. Results In 2016, 57% of NH residents received at least one systemic antibiotic; overall rate of AU was 90 DOT/1,000 resident-days. The median facility-level AU rate was 64 DOT/1,000 resident-days (IQR 36–104). The median proportion of SS residents at a facility was 74% (IQR 60–84%). The SS and LS AU rates were 241 DOT/1,000 resident-days (IQR 173–342) and 24 DOT/1,000 resident-days (IQR 14–37), respectively. Overall, the three most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and extended-spectrum β-lactams (10%). Antibiotics were most frequently prescribed for urinary tract infections, and the mean duration of an antibiotic order was 9 days (range 1–365). Higher facility AU rate correlated positively with the following facility characteristics; proportion of SS residents, urban location, proportion of residents with mild cognitive impairment and lower activities of daily living scores, presence of ventilator beds, proportion of LS residents with urinary catheters or pressure ulcers, facility case-mix index, and not-for-profit ownership and multiorganization facilities. Conclusion Significant variability in NH AU rates exist, and SS residents have higher AU rates. Identifying NH with high rates of AU after adjusting for facility-level predictors of AU may identify opportunities for targeting efforts to improve prescribing practices. Disclosures All Authors: No reported Disclosures. [ABSTRACT FROM AUTHOR]

Two consecutive outbreaks of group A Streptococcus (GAS) infections occurred from 2015–2016 among residents of a Chicago skilled nursing facility. Evaluation of wound care practices proved crucial for identifying transmission factors and implementing prevention measures. We demonstrated shedding of GAS on settle plates during care of a colonized wound. [ABSTRACT FROM AUTHOR]