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BackgroundEnvironmental contamination is suspected to play an important role in Candida auris transmission. Understanding speed and risks of contamination after room disinfection could inform environmental cleaning recommendations.MethodsWe conducted a prospective multicenter study of environmental contamination associated with C. auris colonization at six ventilator-capable skilled nursing facilities and one acute-care hospital in Illinois and California. Known C. auris carriers were sampled at five body-sites followed by sampling of nearby room surfaces before disinfection and at 0, 4, 8, and 12-hours post-disinfection. Samples were cultured for C. auris and bacterial multidrug-resistant organisms (MDROs). Odds of surface contamination after disinfection were analyzed using multilevel generalized estimating equations.ResultsAmong 41 known C. auris carriers, colonization was detected most frequently on palms/fingertips (76%) and nares (71%). C. auris contamination was detected on 32.2% (66/205) of room surfaces pre-disinfection and 20.5% (39/190) of room surfaces by 4-hours post-disinfection. A higher number of C. auris-colonized body sites was associated with higher odds of environmental contamination at every time point following disinfection, adjusting for facility of residence. In the rooms of 38 (93%) C. auris carriers co-colonized with a bacterial MDRO, 2%-24% of surfaces were additionally contaminated with the same MDRO by 4-hours post-disinfection.ConclusionsC. auris can contaminate the healthcare environment rapidly after disinfection, highlighting the challenges associated with environmental disinfection. Future research should investigate long-acting disinfectants, antimicrobial surfaces, and more effective patient skin antisepsis to reduce the environmental reservoir of C. auris and bacterial MDROs in healthcare settings.

ObjectiveQuantify the frequency and drivers of unreported coronavirus disease 2019 (COVID-19) symptoms among nursing home (NH) staff.DesignConfidential telephone survey.SettingThe study was conducted in 70 NHs in Orange County, California, December 2020-February 2022.ParticipantsThe study included 120 NH staff with COVID-19.MethodsWe designed a 40-item telephone survey of NH staff to assess COVID-19 symptom reporting behavior and types of barriers [monetary, logistic, and emotional (fear or stigma)] and facilitators of symptom reporting using 5-point Likert scales. Summary statistics, reliability of survey constructs, and construct and discriminant validity were assessed.ResultsOverall, 49% of surveys were completed during the 2020-2021 COVID-19 winter wave and 51% were completed during severe acute respiratory coronavirus virus 2 (SARS-CoV-2) δ (delta)/ (omicron) waves, with a relatively even distribution of certified nursing assistants, licensed vocational or registered nurses, and nonfrontline staff. Most COVID-19 cases (71%) were detected during mandated weekly NH surveillance testing and most staff (67%) had ≥1 symptom prior to their test. Only 34% of those with symptoms disclosed their symptom to a supervisor. Responses were consistent across 8 discrete survey constructs with Cronbach α > 0.70. In the first wave of the pandemic, fear and lack of knowledge were drivers of symptom reporting. In later waves, adequate staffing and sick days were drivers of symptom reporting. COVID-19 help lines and encouragement from supervisors facilitated symptom reporting and testing.ConclusionsMandatory COVID-19 testing for NH staff is key to identifying staff COVID-19 cases due to reluctance to speak up about existing symptoms. Active encouragement from supervisors to report symptoms and stay home when ill was a major driver of symptom reporting and resultant infection prevention and worker safety measures.

BackgroundNursing home residents are at high risk for infection, hospitalization, and colonization with multidrug-resistant organisms.MethodsWe performed a cluster-randomized trial of universal decolonization as compared with routine-care bathing in nursing homes. The trial included an 18-month baseline period and an 18-month intervention period. Decolonization entailed the use of chlorhexidine for all routine bathing and showering and administration of nasal povidone-iodine twice daily for the first 5 days after admission and then twice daily for 5 days every other week. The primary outcome was transfer to a hospital due to infection. The secondary outcome was transfer to a hospital for any reason. An intention-to-treat (as-assigned) difference-in-differences analysis was performed for each outcome with the use of generalized linear mixed models to compare the intervention period with the baseline period across trial groups.ResultsData were obtained from 28 nursing homes with a total of 28,956 residents. Among the transfers to a hospital in the routine-care group, 62.2% (the mean across facilities) were due to infection during the baseline period and 62.6% were due to infection during the intervention period (risk ratio, 1.00; 95% confidence interval [CI], 0.96 to 1.04). The corresponding values in the decolonization group were 62.9% and 52.2% (risk ratio, 0.83; 95% CI, 0.79 to 0.88), for a difference in risk ratio, as compared with routine care, of 16.6% (95% CI, 11.0 to 21.8; P

We hosted a confidential helpline to address concerns about COVID-19 prevention among staff in 12 nursing homes in Orange County, California. We fielded 301 inquiries from April 2021-April 2022, most commonly involving questions about vaccines (40%), nursing home COVID-19 prevention (28%), SARS-CoV-2 variants (18%), symptom reporting (10%), and home and community COVID-19 prevention (5%). During COVID-19 surges, staff dominantly expressed fear, anger, and exhaustion. During nadirs, sentiment shifted towards optimism and acceptance.

BackgroundThe CLEAR Trial demonstrated that a multisite body decolonization regimen reduced post-discharge infection and hospitalization in methicillin-resistant Staphylococcus aureus (MRSA) carriers. Here, we describe decolonization efficacy.MethodsWe performed a large, multicenter, randomized clinical trial of MRSA decolonization among adult patients after hospital discharge with MRSA infection or colonization. Participants were randomized 1:1 to either MRSA prevention education or education plus decolonization with topical chlorhexidine, oral chlorhexidine, and nasal mupirocin. Participants were swabbed in the nares, throat, axilla/groin, and wound (if applicable) at baseline and 1, 3, 6, and 9 months after randomization. The primary outcomes of this study are follow-up colonization differences between groups.ResultsAmong 2121 participants, 1058 were randomized to decolonization. By 1 month, MRSA colonization was lower in the decolonization group compared with the education-only group (odds ration [OR] = 0.44; 95% confidence interval [CI], .36-.54; P ≤ .001). A similar magnitude of reduction was seen in the nares (OR = 0.34; 95% CI, .27-.42; P < .001), throat (OR = 0.55; 95% CI, .42-.73; P < .001), and axilla/groin (OR = 0.57; 95% CI, .43-.75; P < .001). These differences persisted through month 9 except at the wound site, which had a relatively small sample size. Higher regimen adherence was associated with lower MRSA colonization (P ≤ .01).ConclusionsIn a randomized, clinical trial, a repeated post-discharge decolonization regimen for MRSA carriers reduced MRSA colonization overall and at multiple body sites. Higher treatment adherence was associated with greater reductions in MRSA colonization.

Abstract Background Outpatient peripherally inserted central catheters (PICC) use has grown without standardized protocols for their management. We assessed the impact of a mobile app strategy for outpatient CLABSI prevention using photo-monitoring, assessment, and response to lines with local inflammation/infection in a cohort of cancer clinic patients. Methods This prospective cohort study evaluated adults with PICCs at an academic cancer clinic at baseline (7/2015–12/2016) and after implementing the SAFER (Standardizing Assessment For Effective Response) Lines program (intervention 5/2017–11/2018). This included a mobile app enabling (1) clinic assessment of localized inflammation or infection defined as Central Line Insertion Site Assessment (CLISA) score 2 or 3, respectively (Table 1), (2) photo-documentation, and (3) score-based automated physician alerts for remote response. We assessed demographics, malignancy type, and line characteristics. Generalized linear mixed effects model assessed program impact on frequency of CLISA 2 or 3 lines, clustered by patient. Cox proportional hazards and Kaplan Meier models assessed days to line removal after CLISA 2 or 3 were identified. Results Among 4,894 assessments of 528 PICCs in 380 outpatients, there were 272 lines (199 patients) at baseline and 256 lines (181 patients) after SAFER program implementation. Mean age, gender, PICC dwell time, and history of prior PICC were similar at baseline and intervention. The proportion of inflamed (CLISA 2) and infected (CLISA 3) lines decreased 40% (from 26% to 16%, and 19% to 11%, respectively) during intervention compared to baseline. Lines with peeling dressings decreased 80% (from 46% to 9%). Mean days to removal of inflamed lines decreased 59% (from 19 to 8 days); removal of infected lines decreased 85% (from 11 to < 2 days). Intervention was associated with 46% lower risk of local inflammation/infection (OR 0.46, CI=0.26–0.83, p< 0.01, Table 2) and faster line removal when such lines were identified (HR 0.18, CI=0.12–0.27, p< 0.01). Conclusion The SAFER Lines mobile app and program decreased the frequency of locally inflamed or infected PICC insertion sites and increased the speed of removal when local inflammation/infection was found in cancer clinic patients. Disclosures Raheeb Saavedra, AS, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Raveena D. Singh, MA, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Susan S. Huang, MD, MPH, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Molnlyke: Conducted clinical studies in which hospitals received contributed antiseptic product|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic product.

Abstract Background OC is the 6th largest U.S. county with 70 NHs. Universal decolonization (chlorhexidine for routine bathing, and twice daily nasal iodophor Mon-Fri every other week) was adopted in 24 NHs prior to the COVID-19 pandemic, and 12 NHs (11 of those adopting decolonization) participated in a COVID prevention training program with a rolling launch from July-Sept 2020. We evaluated the impact of these initiatives on staff and resident COVID cases. Methods We conducted a quasi-experimental study of the impact of decolonization and COVID prevention training on staff and resident COVID cases during the CA winter surge (11/16/20-1/31/21), when compared to non-participating NHs. Decolonization NHs received weekly visits for encouraging adherence during the pandemic, and NHs in the COVID training program received 3 in-person training sessions for all work shifts plus weekly feedback about adherence to hand hygiene, masking, and breakroom safety using video monitoring. We calculated incident 1) staff COVID cases, 2) resident COVID cases, and 3) resident COVID deaths adjusting for NH average daily census. We assessed impact of initiatives on these outcomes using linear mixed effects models testing the interaction between any training participation and calendar date when clustering by NH. Because of the overlap of the two initiatives, we evaluated ‘any training’ vs ‘no training.’ Results 63 NHs had available data. 24 adopted universal decolonization, 12 received COVID training (11 of which participated in decolonization), and 38 were not enrolled in either. During the winter surge, the 63 NHs experienced 1867 staff COVID cases, 2186 resident COVID cases, and 251 resident deaths due to COVID, corresponding to 29.6, 34.7, and 4.0 events per NH, respectively. In NHs participating in either initiative, staff COVID cases were reduced by 31% (OR=0.69 (0.52, 0.92), P=0.01), resident COVID cases were reduced by 43% (OR=0.57 (0.39, 0.82), P=0.003), and resident deaths were reduced (non-significantly) by 26% (OR=0.74 (0.46, 1.21), P=0.23). The grey box represents the California COVID-19 winter surge (11/16/20-1/31/21). Incident and cumulative COVID-19 cases and deaths for each nursing home were divided by the nursing home’s average daily census and multiplied by 100, representing events per 100 beds, which were aggregated across groups. Conclusion NHs are vulnerable to COVID-19 outbreaks. A universal decolonization and COVID prevention training initiative in OC, CA significantly reduced staff and resident COVID cases in this high-risk care setting. Disclosures Gabrielle Gussin, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Raveena Singh, MA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Raheeb Saavedra, AS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Robert Pedroza, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Chase Berman, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)

We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that reduced MRSA infection and hospitalization by 30%. Hospitalized MRSA infection was associated with 7.9 days of non-MRSA antibiotics and CDI in 3.9%. Preventing MRSA infection and associated hospitalization may reduce antibiotic use and CDI incidence.

ObjectiveDetermine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).DesignPoint prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.SettingTwenty-eight NHs in Southern California from 2016 to 2017.ParticipantsNH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.MethodsFifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).ResultsA total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.Conclusions and implicationsIn more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for the largest number of invasive infections due to a multidrug-resistant pathogen. Approximately 10% of hospitalized carriers will experience invasive MRSA disease in the year following discharge incurring antibiotic therapy beyond focused treatment of MRSA. Objective: We aimed to quantify the extent of non-MRSA empiric antibiotics incurred by MRSA infections and further assess the risk of Clostridioides difficile Infection (CDI) as a result of treatment of MRSA infection. Methods: The CLEAR Trial was a postdischarge randomized controlled trial of 2,121 MRSA carriers comparing MRSA education alone to education plus repeated decolonization that demonstrated a 30% reduction in MRSA infection and a 17% reduction in all-cause infection attributable to decolonization in the year following hospital discharge (Huang SS, NEJM 2019). We included all hospitalization outcomes due to MRSA infection in the CLEAR Trial with detailed medication administration records to quantify unintended consequences of MRSA infection related to empiric non-MRSA antibiotic use and resultant CDI. Full-text medical records were reviewed with a standardized abstraction form to collect inpatient administered antibiotics and hospital-associated CDI. Results: In total,154 hospitalizations due to MRSA infection with a mean length-of-stay of 10.6 days were identified. During 25 hospitalizations (16.2%), patients received only anti-MRSA antibiotics. During the remaining 129 (83.8%) hospitalizations, patients received a mean of 1.6 distinct non-MRSA antibiotics totaling a mean of 6.6 days of therapy (DOT). Empiric non-MRSA therapy was given for 3.2 DOT before MRSA culture results became available and was continued for an additional 3.4 DOT afterward. Among all 849 non-MRSA DOT, the most common were due to piperacillin-tazobactam (293 DOT, 34.5%), levofloxacin (105 DOT, 12.4%), and metronidazole (93 DOT, 11.0%). Across all 154 hospitalizations, a mean of 5.5 non-MRSA DOT was calculated per MRSA hospitalization, with 6 CDI cases (3.9%) as a direct sequelae of empiric non-MRSA antibiotics provided for MRSA infection. Conclusions: Hospitalization for MRSA infection results in extensive non-MRSA empiric antibiotic therapy both before and after MRSA culture results are known. This antibiotic use is associated with a 3.9% risk of CDI that exceeds the national risk of acquiring CDI (3.2 per 1,000 admissions) by 12-fold during any hospital stay (Barrett ML, AHRQ 2018). The CLEAR Trial findings that postdischarge decolonization reduces MRSA infection and hospitalization by 30% suggests that decolonization may also reduce non-MRSA antibiotic use and CDI in this population. Funding: None Disclosures: None

Background: Addressing the high burden of multidrug-resistant organisms (MDROs) in nursing homes is a public health priority. High interfacility transmission may be attributed to inadequate infection prevention practices, shared living spaces, and frequent care needs. We assessed the contribution of roommates to the likelihood of MDRO carriage in nursing homes. Methods: We performed a secondary analysis of the SHIELD OC (Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, CA) Project, a CDC-funded regional decolonization intervention to reduce MDROs among 38 regional facilities (18 nursing homes, 3 long-term acute-care hospitals, and 17 hospitals). Decolonization in participating nursing homes involved routine chlorhexidine bathing plus nasal iodophor (Monday through Friday, twice daily every other week) from April 2017 through July 2019. MDRO point-prevalence assessments involving all residents at 16 nursing homes conducted at the end of the intervention period were used to determine whether having a roommate was associated with MDRO carriage. Nares, bilateral axilla/groin, and perirectal swabs were processed for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear mixed models assessed the impact of maximum room occupancy on MDRO prevalence when clustering by room and hallway, and adjusting for the following factors: nursing home facility, age, gender, length-of-stay at time of swabbing, bedbound status, known MDRO history, and presence of urinary or gastrointestinal devices. CRE models were not run due to low counts. Results: During the intervention phase, 1,451 residents were sampled across 16 nursing homes. Overall MDRO prevalence was 49%. In multivariable models, we detected a significant increasing association of maximum room occupants and MDRO carriage for MRSA but not other MDROs. For MRSA, the adjusted odds ratios for quadruple-, triple-, and double-occupancy rooms were 3.5, 3.6, and 2.8, respectively, compared to residents in single rooms (P = .013). For VRE, these adjusted odds ratios were 0.3, 0.3, and 0.4, respectively, compared to residents in single rooms (P = NS). For ESBL, the adjusted odds ratios were 0.9, 1.1, and 1.5, respectively, compared to residents in single rooms (P = nonsignificant). Conclusions: Nursing home residents in shared rooms were more likely to harbor MRSA, suggesting MRSA transmission between roommates. Although decolonization was previously shown to reduce MDRO prevalence by 22% in SHIELD nursing homes, this strategy did not appear to prevent all MRSA transmission between roommates. Additional efforts involving high adherence hand hygiene, environmental cleaning, and judicious use of contact precautions are likely needed to reduce transmission between roommates in nursing homes. Funding: None Disclosures: Gabrielle M. Gussin, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

Background: More than half of nursing home (NH) residents harbor a multidrug-resistant organism (MDRO), and MDRO contamination of the environment is common. Whether NH decolonization of residents reduces MDRO contamination remains unclear. The PROTECT trial was a cluster-randomized trial of decolonization versus routine care in 28 California NHs from April 2017 through December 2018. Decolonization involved chlorhexidine bathing plus nasal iodophor (Monday–Friday, every other week), and it reduced resident nares and skin MDRO colonization by 36%. Methods: We swabbed high-touch objects in resident rooms and common areas for MDROs before and after the 3-month decolonization phase-in (April–July 2017). Five high-touch objects (bedrail, call button and TV remote, doorknob, light switch, and bathroom handles) were swabbed in 3 resident rooms per NH based on care needs (Alzheimer’s disease and related dementias (ADRD), ie, total care; ADRD, ambulatory care; and short stay). Five high-touch objects were also swabbed in the common area (nursing station, table, chair, railing, and drinking fountain). Swabs were processed for methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). We used generalized linear mixed models to assess the impact of decolonization on MDRO environmental contamination when clustering by NH and room and adjusting for room type and object because unclustered and unadjusted results are likely to be inaccurate. Results: A high proportion of rooms were contaminated with any MDRO in control NHs: 43 of 56 (77%) in the baseline period and 46 of 56 (82%) in the intervention period. In contrast, decolonization NHs had similar baseline contamination (45 of 56, 80%) but lower intervention MDRO contamination (29 of 48, 60%). When evaluating the intervention impact using multivariable models, decolonization was associated with significantly less room contamination for any MDRO (OR, 0.25; 95% CI, 0.06–0.96; P = .04) and MRSA (OR, 0.16; 95% CI, 0.05–0.55; P = .004) but nonsignificant reductions in VRE contamination (OR, 0.86; 95% CI, 0.23–3.13) and ESBL contamination (OR, 0.13; 95% CI, 0.01–1.62). CRE was not modeled due to rare counts (2 rooms total). In addition, room type was important, with common areas associated with 5-fold, 9-fold, and 3-fold higher contamination with any MDRO, MRSA, and VRE, respectively, compared with short-stay rooms. Conclusions: The high burden of MDROs in NHs calls for universal prevention strategies that can protect all residents. Although decolonization was associated with an 84% reduction in odds of MRSA contamination of inanimate room objects, significant reductions in VRE or ESBL contamination were not seen, possibly due to the lower proportion of baseline contamination due to these organisms. Multimodal strategies are needed to address high levels of MDRO contamination in NHs.Funding: NoneDisclosures: Gabrielle Gussin: Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

BackgroundMultidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs.MethodsA random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility.ResultsPrevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs

BackgroundHospitalized patients who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at high risk for infection after discharge.MethodsWe conducted a multicenter, randomized, controlled trial of postdischarge hygiene education, as compared with education plus decolonization, in patients colonized with MRSA (carriers). Decolonization involved chlorhexidine mouthwash, baths or showers with chlorhexidine, and nasal mupirocin for 5 days twice per month for 6 months. Participants were followed for 1 year. The primary outcome was MRSA infection as defined according to Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included MRSA infection determined on the basis of clinical judgment, infection from any cause, and infection-related hospitalization. All analyses were performed with the use of proportional-hazards models in the per-protocol population (all participants who underwent randomization, met the inclusion criteria, and survived beyond the recruitment hospitalization) and as-treated population (participants stratified according to adherence).ResultsIn the per-protocol population, MRSA infection occurred in 98 of 1063 participants (9.2%) in the education group and in 67 of 1058 (6.3%) in the decolonization group; 84.8% of the MRSA infections led to hospitalization. Infection from any cause occurred in 23.7% of the participants in the education group and 19.6% of those in the decolonization group; 85.8% of the infections led to hospitalization. The hazard of MRSA infection was significantly lower in the decolonization group than in the education group (hazard ratio, 0.70; 95% confidence interval [CI], 0.52 to 0.96; P=0.03; number needed to treat to prevent one infection, 30; 95% CI, 18 to 230); this lower hazard led to a lower risk of hospitalization due to MRSA infection (hazard ratio, 0.71; 95% CI, 0.51 to 0.99). The decolonization group had lower likelihoods of clinically judged infection from any cause (hazard ratio, 0.83; 95% CI, 0.70 to 0.99) and infection-related hospitalization (hazard ratio, 0.76; 95% CI, 0.62 to 0.93); treatment effects for secondary outcomes should be interpreted with caution owing to a lack of prespecified adjustment for multiple comparisons. In as-treated analyses, participants in the decolonization group who adhered fully to the regimen had 44% fewer MRSA infections than the education group (hazard ratio, 0.56; 95% CI, 0.36 to 0.86) and had 40% fewer infections from any cause (hazard ratio, 0.60; 95% CI, 0.46 to 0.78). Side effects (all mild) occurred in 4.2% of the participants.ConclusionsPostdischarge MRSA decolonization with chlorhexidine and mupirocin led to a 30% lower risk of MRSA infection than education alone. (Funded by the AHRQ Healthcare-Associated Infections Program and others; ClinicalTrials.gov number, NCT01209234 .).

BackgroundThe east-to-west spread of carbapenem-resistant Enterobacteriaceae (CRE) represents an opportunity to explore strategies to limit spread in nonendemic areas. We evaluated CRE emergence and regional support for containment strategies.MethodsA 17-question cross-sectional survey was administered to infection prevention programs in Orange County, CA (31 hospitals serving 3 million residents), between January and September 2014. Questions addressed newly detected hospital- and community-onset CRE cultures (2008-2013), current CRE control strategies, and support for prevention strategies for a hypothetical regional intervention.ResultsAmong 31 hospitals, 21 (68%, representing 17 infection prevention programs) completed the survey. CRE was scarcely detected between 2009-2010; within 4 years, 90% of hospitals reported CRE, with 2.5-fold higher community-onset than hospital-onset CRE. Between 2011 and 2013, annual CRE incidence increased 4.7-fold (1.4-6.3 cases/10,000 admissions). Support for a regional CRE prevention bundle was unanimous. Although 22% bathed patients positive for CRE with chlorhexidine gluconate and 11% actively screened for CRE, 86% and 57%, respectively, would consider these strategies in a regional intervention.ConclusionsCRE epidemiology in Orange County parallels early progression previously seen in now-endemic areas, representing an opportunity to consider interventions to prevent endemic spread. Many facilities would consider proactive strategies, such as chlorhexidine bathing, in the setting of a regional collaborative.

Nursing home residents are at risk for acquiring and transmitting MDROs. A serial point-prevalence study of 605 residents in 3 facilities using random sampling found MDRO colonization in 45% of residents: methicillin-resistant Staphylococcus aureus (MRSA, 26%); extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL, 17%); vancomycin-resistant Enterococcus spp. (VRE, 16%); carbapenem-resistant Enterobacteriaceae (CRE, 1%). MDRO colonization was associated with history of MDRO, care needs, incontinence, and catheters. Infect Control Hosp Epidemiol 2016;1485-1488.