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Background An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study. Methods Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia. Results We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak. Conclusions Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak.

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than “pay-for-performance” models.

The impact of variability in infection surveillance methodologies on publicly reported rates of surgical site infection (SSI) is not well defined.We performed a cross-sectional study to assess infection preventionists' surveillance practices across acute care US hospitals. We collected self-reported annual facility standardized infection ratios for colon surgery and abdominal hysterectomy as provided by the National Healthcare Safety Network. Trend analysis using Kendall's rank correlation evaluated the association between surveillance rigor and SSI rates.Among 492 participating hospitals, 63%, 15%, 13%, and 8% were community, university-affiliated, critical access, and ambulatory surgical centers, respectively. Most critical access hospitals (82%) and ambulatory surgical centers (98%) reported less than one full time infection preventionists (P ≤ .001). University-affiliated medical centers spent significantly more time and used more data sources for monthly SSI review compared with other hospitals. Critical access hospitals and ambulatory surgical centers were more likely to rely on manual surveillance only (P.001). The number of different data sources used for SSI surveillance was positively associated with higher SSI rates: (KRigorous SSI surveillance using more data sources for case-finding is more likely to be associated with higher facility SSI rates for colon surgery and abdominal hysterectomy.

Surgical site infection (SSI) prevention requires multiple interventions packaged into “bundles.” The implementation of all bundle elements is key to the bundle’s efficacy. A human-factors engineering approach can be used to identify key barriers and facilitators to implementing elements and develop recommendations for bundle implementation within the clinical work system.

Objective:Alternatives to skin preparation with conventional preoperative antiseptics are required because of adverse reactions and the potential emergence of resistance. Here, we present 2 phase 2 studies of ZuraGard (ZG), a novel formulation of isopropyl alcohol and functional excipients developed for preoperative skin antisepsis.Methods:Microbial skin flora on abdominal and inguinal sites in healthy volunteers were quantitatively assessed following application of ZG versus a negative control (ZV) and a chlorhexidine/alcohol preparation, Chloraprep (CP). In trial 1, ZG administered for both recommended and abbreviated application times was compared with CP and ZV via bacterial reductions at 10 minutes, and 6 hours, 12 hours, and 24 hours following application. In trial 2, the 10-minute postapplication responder rates (RRs) for ZG, participants with abdominal ≥2 log10 per cm2, and inguinal ≥3 log10 per cm2 reductions in colony-forming units (CFU) were compared to RRs of participants treated with CP.Results:In trial 1, ZG at the recommended application time reduced mean bacterial counts by ~3.18 log10 CFU/cm2 and ~2.98 log10 CFU/cm2 at abdominal and inguinal sites, respectively. Qualitatively similar reductions were observed for the abbreviated ZG application time and all CP applications. Application of ZV was ineffective. In trial 2, 10-minute RRs for ZG and CP exceeded 90% at abdominal sites. At inguinal sites, RRs were 83.3% for ZG and 86.7% for CP. No skin irritation or other adverse events were observed.Conclusions:ZG matched CP efficacy under these experimental conditions with immediate and persistent microbial reductions, including abbreviated application times. Further clinical studies of this novel preoperative antiseptic are merited.

To assess the clinical epidemiology and outcomes of patients hospitalized with COVID-19 who did not experience fever and cough during the early pandemic.Retrospective cohort of all patients admitted during March 13, 2020 through May 13, 2020 with laboratory-confirmed COVID-19 to 3 tertiary-care hospitals. Patient-level data (demographic, clinical manifestations, comorbid illnesses, inpatient treatment) were analyzed. The main outcome variable was atypical presentation, defined as any hospitalized patient with COVID-19 infection who did not experience both fever and cough. We identified risk factors for atypical presentation on univariate and multivariate analyses and assessed 30-day mortality differences via survival analysis.Of 163 patients in the study, 39 (24%) were atypical. On univariate analysis, atypical cases were significantly more likely to be older, reside in a long-term-care facility (LTCF), and have underlying diabetes mellitus, stroke, or cardiac disease; present without dyspnea or myalgia, have lower C-reactive proteins (CRP) and higher beta-natriuretic peptides. They were less likely to receive intensive care unit care or specific COVID-19 treatments (During the first pandemic surge, COVID-19 patients without inflammatory signs and symptoms were more likely to be LTCF residents and had higher mortality. Timely recognition of these atypical presentations may have prevented spread and improved clinical outcomes.

While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.

ObjectiveCurrent practice guidelines recommend cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam as first-line antibiotic prophylaxis in hysterectomy. We undertook this systematic review and meta-analysis of randomized controlled trials (RCTs) to determine whether cefazolin, with limited antianaerobic spectrum, is as effective in preventing surgical site-infection (SSI) as the other first-choice antimicrobials that have more extensive antianaerobic activity.MethodsWe searched PubMed, Scopus, Web of Science, Cochrane Central, and EMBASE for relevant randomized controlled trials (RCT) in any language up to January 23, 2018. We only included trials that measured SSI (our primary outcome) defined as superficial, deep, or organ space. We excluded trials of β-lactams no longer in clinical use.ResultsIn terms of SSI incidence, cefazolin use was not inferior to its comparator in 12 of 13 individual RCTs included in the analysis. The meta-analysis summary estimate showed a significantly higher SSI risk with cefazolin versus cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04–2.77; P = .03). However, most studies included nonstandardized dosing and duration of antimicrobial prophylaxis, had indeterminate or high risk of bias, did not include patients with gynecological malignancies, and/or were older RCTs not reflective of current clinical practices.ConclusionDue to inherent limitations associated with old RCTs with limited relevance to contemporary surgery, an RCT of cefazolin versus regimens with significant antianaerobic spectrum is needed to establish the optimal choice for SSI prevention in hysterectomy.

OBJECTIVETo describe the investigation and control of a cluster ofSerratia marcescensbacteremia in a 505-bed tertiary-care center.METHODSCluster cases were defined as all patients withS. marcescensbacteremia between March 2 and April 7, 2014, who were found to have identical or related blood isolates determined by molecular typing with pulsed-field gel electrophoresis. Cases were compared using bivariate analysis with controls admitted at the same time and to the same service as the cases, in a 4:1 ratio.RESULTSIn total, 6 patients developedS. marcescensbacteremia within 48 hours after admission within the above period. Of these, 5 patients had identicalSerratiaisolates determined by molecular typing, and were included in a case-control study. Exposure to the post-anesthesia care unit was a risk factor identified in bivariate analysis. Evidence of tampered opioid-containing syringes on several hospital units was discovered soon after the initial cluster case presented, and a full narcotic diversion investigation was conducted. A nurse working in the post-anesthesia care unit was identified as the employee responsible for the drug diversion and was epidemiologically linked to all 5 patients in the cluster. No further cases were identified once the implicated employee’s job was terminated.CONCLUSIONIllicit drug use by healthcare workers remains an important mechanism for the development of bloodstream infections in hospitalized patients. Active mechanisms and systems should remain in place to prevent, detect, and control narcotic drug diversions and associated patient harm in the healthcare setting.Infect Control Hosp Epidemiol2017;38:1027–1031

Background Fever and cough are frequently reported in COVID-19 infections, although little is known about the subgroup of symptomatic patients who do not manifest these classic symptoms. We aimed to compare clinical manifestations and outcomes for hospitalized COVID-19 patients with typical vs. atypical presentations and identify risk factors for atypical COVID-19 presentations. Methods We conducted a retrospective cohort of all patients hospitalized with laboratory-confirmed COVID-19 infections during 3/13- 5/13/2020 at UW Health, a network of 3 acute-care hospitals in Midwest. We defined atypical cases as patients hospitalized for COVID-19 related reasons presenting without fever and cough and compared them in univariate analysis with patients manifesting both symptoms (controls). We identified independent risk factors for atypical COVID-19 presentations by logistic regression. Results Among the 163 patients hospitalized during the 60-day study frame, 39 (24%) had atypical presentations. Table 1 shows demographic, clinical manifestations, and outcomes of atypical vs. typical cases. On univariate analysis, atypical cases were more likely to be older, reside in a long-term-care facility (LTCF), have underlying diabetes mellitus, stroke, cardiac disease, and deny myalgias or dyspnea, despite having no significant difference in the prevalence of hypoxia or radiological lung infiltrates. Atypical cases also had a significantly higher Beta-Natriuretic-Peptide and lower C-Reactive-Protein, although other inflammatory markers were not significantly different. They were less likely to be admitted to the ICU, and more likely to die within 30 days, as older patients with respiratory failure and multiple comorbidities opted for comfort measures and less aggressive care. On multivariate analysis, LTCF residence was the only independent predictor for atypical status (Table 2). Conclusion LTCF residents are more likely to experience COVID-19 respiratory illness (hypoxia, pneumonia) without classic symptoms (fever, cough, myalgias, dyspnea). Given the excessive pandemic burden in the LTCF setting, timely recognition and diagnosis of these atypical, more subtle presentations is critical. Disclosures All Authors: No reported disclosures

Background: Prior studies suggest that cefazolin, widely used for antibiotic prophylaxis in hysterectomy, might not prevent surgical site infections (SSIs) as well as antibiotics with a broader antianaerobic antimicrobial spectrum. We compared the effectiveness of cefazolin versus antibiotic regimens with a broader antimicrobial spectrum in a ≥500-bed regional referral center. Methods: Study design: retrospective cohort. Population and setting: patients ≥18 years old who underwent hysterectomy between 1998 and 2018 at the University of Wisconsin Hospital. Analysis: propensity score matching with a caliper of 0.2 to select controls for cefazolin treatment, matching on: age, body mass index (BMI), diabetes, length of stay, duration of surgery, and preoperative renal function. We conducted a crude SSI incidence analysis and adjusted for additional covariates (malignancy, intraoperative temperature, and preoperative glucose level) using a Cox proportional hazards model. All analyses were conducted using STATA SE v15 software. Results: We had 4,087 hysterectomy patients, with 123 SSIs (3%). Among these SSIs, 46%, 11%, and 42% were superficial, deep, and organ-space, respectively. Malignancies were present in 83% of SSI patients, with 30% being ovarian cancer. Risk factors for SSI in the unmatched sample multivariable analysis (MV) were length of stay (aHR, 1.1; 95% CI, 1.05–1.1; P < .001), duration of surgery (aHR, 1.2; 95% CI, 1.1–1.32; P < .001), and BMI (aHR, 1.04; 95% CI, 1.02–1.06; P < .001). After propensity matching, 2,282 hysterectomies remained. In the crude incidence analysis, cefazolin (IR, 6.0) had a protective SSI effect compared to cefoxitin (IR, 7.1), ciprofloxacin/metronidazole (IR, 27.2), clindamycin/gentamicin (IR, 14.1), any antianaerobic regimen (IR, 8.0), and regimens not guideline recommended (IR, 11.7). In our MV analyses of cefazolin versus comparator antibiotic regimens, we found that hypothermia was consistently associated with a higher SSI risk (P ≤ .03). Receipt of a β-lactam antibiotic regimen was associated with a significantly lower SSI risk (aHR, 0.31; 95% CI, 0.11–0.89, P = .03), but cefazolin’s protective SSI effect was no longer statistically significant. Conclusions: We found that cefazolin had a lower SSI risk compared to other antibiotic regimens, including those with better antianaerobic spectrum, in our tertiary-care hospital’s 11-year high-risk cohort. Our analysis suggests that maintaining intraoperative normothermia and administering β-lactam antibiotic prophylaxis are important modifiable risk factors for SSI prevention.Funding: NoneDisclosures: None

Although surgical hand antisepsis is paramount to surgical infection prevention, adherence to correct technique may be suboptimal. We conducted direct observations and semistructured interviews to identify barriers and facilitators to appropriate surgical hand antisepsis in a tertiary care hospital. Only 18% (9 out of 50) surgical hand antisepsis observations were fully compliant with the recommended application techniques. Most surgical staff members considered lack of organizational oversight, monitoring, and direct hands-on training as important barriers to adherence.

To identify the most common strategies currently used for S. aureus decolonization and surgical site infection (SSI) prevention. Pre-operative colonization with Staphylococcus aureus increases SSI risk. Screening and decolonization with intra-nasal mupirocin and pre-operative chlorhexidine bathing remains the most common and effective strategy, especially for orthopedic and cardiovascular surgery. Intra-nasal povidone-iodine immediately before surgery appears effective in preliminary studies, is less expensive, and may be easier to implement in the clinical setting. Future well-designed clinical research studies are needed to confirm its effectiveness in SSI prevention. Intra-nasal alcohol-based antisepsis and photodynamic therapy are promising strategies that deserve further study before they can be clinically applied to SSI prevention. Decolonization with intra-nasal mupirocin or povidone-iodine, in addition to pre-operative chlorhexidine bathing, is an important SSI prevention strategy. Future studies should address optimal dosing, timing, and number of applications for each regimen.

Background Preoperative antibiotic prophylaxis and surgical technological advances have greatly reduced, but not totally eliminated surgical site infection (SSI) posthysterectomy. We aimed to identify risk factors for SSI posthysterectomy among women with a high prevalence of gynecologic malignancies, in a tertiary care setting where compliance with the Joint Commission's Surgical Care Improvement Project core measures is excellent. Methods The study was a matched case–control, 2 controls per case, matched on date of surgery. Study time was January 2, 2012-December 31, 2015. Procedures included abdominal and vaginal hysterectomies (open, laparoscopic, and robotic). SSI (superficial incisional or deep/organ/space) was defined as within 30 days postoperatively, per Centers for Disease Control and Prevention criteria. Statistical analysis included bivariate analysis and conditional logistic regression controlling for demographic and clinical variables, both patient-related and surgery-related, including detailed prophylactic antibiotic exposure. Results Of the total 1,531 hysterectomies performed, we identified 52 SSIs (3%), with 60% being deep incisional or organ/space infections. All case patients received appropriate preoperative antibiotics (timing, choice, and weight-based dosing). Bivariate analysis showed that higher median weight, higher median Charlson comorbidity index, immune suppressed state, American Society of Anesthesiologists score ≥ 3, prior surgery within 60 days, clindamycin/gentamicin prophylaxis, surgery involving the omentum or gastrointestinal tract, longer surgery duration, ≥4 surgeons present in the operating room, higher median blood loss, ≥7 catheters or invasive devices in the operating room, and higher median length of hospital stay increased SSI risk ( P P P = .02). Conclusions In our population of women with multimorbidity and hysterectomies largely due to underlying gynecologic malignancies, duration of surgery, presumed a marker of surgical complexity, is a significant SSI risk factor. The choice of preoperative antibiotic did not alter SSI risk in our study.

Background: Intravitreal injection of vascular endothelial growth factor inhibitors with or without steroids is a well-established, effective therapy for several ocular disorders. The expected rate of complications from these injections is low, with meta-analyses reporting 5–6 occurrences of infectious endophthalmitis per 10,000 injections. Through October 2019, our health system observed 8 cases of endophthalmitis among 7,693 injections (10.4 per 10,000 injections), compared to 1 case in 2018. This unusually high rate prompted an infection control investigation and a case control study to examine risk factors for the development of postintravitreal injection endophthalmitis. Methods: Infection control providers performed direct observation of several ophthalmologists performing intravitreal injections on 3 separate occasions to determine points of intervention to prevent infection. To define risk factors for postintravitreal injection endophthalmitis, we conducted a retrospective case-control study of the 8 affected patients. Four control patients were selected per case, matched by clinic location, drug injected, and date of injection (total subjects, N = 40). We extracted patient-level risk factors from medical records; documentation was not sufficient to compare procedure-level factors. We conducted unadjusted univariate Poisson regression and Mantel–Cox method rate ratios to identify significant risk predictors of endophthalmitis. Results: Direct observation yielded variable practice in use of masks, gloves, sterile lid speculum, and the duration of povidone-iodine contact on the ocular surface prior to injection. The location of alcohol hand gel relative to the procedure field was suboptimal. Due to patient volume, there were significant delays between procedure and patient prep and injection time. The mean age was 76 years among cases and 74.1 years among controls; 35% of patients were men. Age-related macular degeneration was the most common indication for injection (55%). Only 10% of injections were bilateral. Although not statistically significant, patients with coronary artery disease had a higher rate of infection than those without coronary artery disease (165.3 vs 16.3 per 10,000 person years; IRR = 3.0; 95% CI, 0.60–14.8; P = .18); current smokers were also at higher risk (86.9 per 10,000; IRR, 3.2; 95% CI, 0.33–30.4; P = .32). Conclusions: Coronary artery disease and smoking were risk factors for the development of postintravitreal injection endophthalmitis in a 2019 cluster of cases in our organization. We are continuing to work with our ophthalmologists to optimize infection prevention in the injection environment, including strict use of gloves, appropriate use of povidone-iodine, and routinely wearing a mask and encouraging a no-talking policy during injections.Funding: NoneDisclosures: None

We conducted a cross-sectional survey of healthcare workers in two community teaching hospitals to better understand clinicians' beliefs and practices related to cleaning of their stethoscopes. The study was conducted from September 2015 to May 2016.Among the total 358 responses received, 45%, 40%, 10% and 5% were from attending physicians, medical students, nurses, and resident physicians, respectively.Although the majority of the respondents (76%) frequently used a stethoscope at work, and almost all (93%) believed that stethoscopes can be involved in pathogen transmission, only 29% of participants reported cleaning their stethoscopes after every use.Hospitals should include stethoscope cleaning into their overall infection prevention efforts.

Background An outbreak of hospital-acquired Legionella pneumonia, associated with potable water contamination, occurred at our university hospital in November of 2018, despite a longstanding copper-silver ionization system. We conducted a case–control study to examine risk factors for Legionella pneumonia. Methods We matched controls to cases by dates of admission, hospital ward, and admitting service, in a 4:1 ratio. We reviewed patient charts for potential risk factors and exposures, and summarized demographic information using descriptive analyses. Univariate and multiple logistic regression analyses were also performed. We used pulsed-field gel electrophoresis for molecular typing of isolates from patient respiratory samples and hospital water samples. Results We identified 13 cases of nosocomial legionella pneumonia over a one-month period (Figure 1), with 8 males, 5 females, and a mean age of 63 years. The average time to diagnosis was 19 days following admission. Six patients were transplant recipients – two had solid organ, and six had bone marrow transplant. Urinary Legionella antigen was positive in all cases. Table 1 shows predictors for Legionella pneumonia in univariate analyses. Current smoking (OR = 7.5, 95% CI [1.11 – 50.84], p = 0.03], pre-admission steroid prescription (OR = 6.5, 95% CI [1.65 – 26.20], p = 0.008], documentation of shower (OR = 6.2, 95% CI [1.54 – 25.82], p = 0.01], and number of showers prior to hyper-chlorination (OR = 1.45, 95% CI [1.03 – 2.04], p = 0.03] were significant risk factors on univariate analysis. The multiple regression model was also significant (P < 0.001) with all of the above-identified predictors (Table 2). Molecular typing found Legionella strains from patient respiratory samples and water samples to be identical. Multiple interventions, including restriction of showering, hyper-chlorination, and optimization of water flow through the copper-silver ionization system were implemented, and were successful in mitigating the outbreak. Conclusion We found showering to be a modifiable risk factor for Legionella pneumonia in this outbreak. Interventions to reduce this risk might include point of use filters in showers in high-risk populations. Disclosures All authors: No reported disclosures.

Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.

The prevalence of colonization with toxigenic Clostridium difficile among patients with hematological malignancies and/or bone marrow transplant at admission to a 566-bed academic medical care center was 9.3%, and 13.3% of colonized patients developed symptomatic disease during hospitalization. This population may benefit from targeted C. difficile infection control interventions. Infect Control Hosp Epidemiol 2017;38:718–720

Background Current US hospital reimbursement models rely on self-reported SSI rates. The impact of variability in SSI surveillance on publicly reported SSI rates is unknown. Methods Cross-sectional survey to US hospitals administered during November 18 – 2/19 through the Association for Professionals in Infection Control. We assessed SSI surveillance practices, and asked for self-reported facility standardized infection ratios (SIR) for hysterectomy and colon surgeries. We performed bivariate analysis and used Kendall’s ranks correlation for trend analysis. Results Of the 2,851 hospitals surveyed, 491 (17.2%) responded. Table 1 shows facility descriptors. Critical Access Hospitals (OR 6.11 [3.12 – 11.750, P < 0.005) and Ambulatory Surgical Centers (OR 3.92 [1.68 – 8.64], P < 0.001) were more likely to have less than one full-time ICP. University Hospitals were more likely to have ≥4 ICPs (OR 12.15 [6.73 – 22.04, P < 0.001). The majority (83%) of the 477 respondents reported electronic software for SSI surveillance, with Epic (23%), Theradoc (22%), and Cerner (11%) as the most common packages used. Manual surveillance was more likely for Critical Access Hospitals (OR 2.80 [1.47 – 5.19], P < 0.001). University Hospitals were more likely to have higher rates in 2016 for colon surgery (P = 0.02) and hysterectomy (P = 0.002). Table 2 shows characteristics of SSI surveillance practices reported by study participants. Ambulatory Surgical Center ICPs were more likely to use reports from surgeons and/or surgical staff as the initial trigger for SSI surveillance. University Hospital ICPs were significantly more likely to spend increased time (mean hours/month 69.77 vs. 28.99, P < 0.001), and to use more data sources for SSI review (mean 4.58 vs. 3.99, P = 0.001). In our trend analyses, we found the number of data sources used for SSI surveillance to be positively associated with higher SSI rates: (KT =0.14, P = 0.028 for colon SIR in 2017; KT = 0.20, P = 0.009; KT = 0.25, P = 0.001 for hysterectomy SIR in 2016 and 2017, respectively). Conclusion SSI surveillance practices across US hospitals vary significantly, and rigorous surveillance methods are associated with higher SSI rates. Standardizing SSI surveillance is necessary to accurately capture SSI burden of disease. Disclosures All authors: No reported disclosures.

Background Surgical site infection (SSI) prevention bundles in colorectal surgery are common. The optimal bundle composition and impact of increasingly complex and resource-intensive bundled interventions on SSI remain unclear. Methods (1) A systematic review and meta-analysis of randomized and observational trials with pre-post implementation data for colorectal SSI prevention bundles to study their effect on superficial, deep, and organ-space SSI. (2) A meta-regression to determine whether the bundle size (number of different bundle elements) affects SSI. (3) A correlation analysis to identify individual bundle elements with greatest SSI reduction. We used the METAN, METAEFF, and METAREG packages in STATA SE 15 for analysis. Results We included 38 studies in the systematic review, and 29 studies (49,589 patients) in the meta-analysis. Bundle composition was highly variable, ranging from 3 – 13 guideline-recommended elements per bundle. Meta-analyses showed bundles to be associated with relative risk reductions of 43% for any SSI (RR 0.57 [95% CI 0.48–0.67]; 44% for superficial SSI (RR 0.56 [95% CI 0.42–0.75]; 33% for deep SSI (RR 0.67 [95% CI 0.45–0.98], and 37% for organ/space SSI (RR 0.63 [95% CI 0.49 – 0.81]). On meta-regression, bundle size, especially ≥10 elements, was significantly associated with SSI reduction for any SSI (P = 0.04) and for superficial SSI (P = 0.005). Individual bundle elements correlated with strongest SSI reductions were mechanical bowel prep combined with oral antibiotics (R = −0.68, P = 0.0028) and pre-operative chlorhexidine showers (R = −0.49, P = 0.04) for organ/space SSI. Protocols including separate instrument trays and glove ± gown change prior to surgical wound closure (R = −0.55, P = 0.009), and standardized postoperative wound dressing change at 48 hours (R = −30.59, P = 0.005) correlated with highest superficial SSI reductions. Conclusion Complex colorectal bundles with ≥10 clinical guideline-recommended prevention elements are associated with higher reductions in any SSI and in superficial SSI. Further research should evaluate how complex SSI prevention colorectal bundles can be implemented and sustained with high fidelity in the clinical setting in a cost-effective manner. Disclosures All authors: No reported disclosures.

To examine the relationship between influenza and activity of daily living (ADL) decline and other clinical indicators in nursing home (NH) residents.Retrospective NH-aggregated longitudinal study.Two thousand three hundred fifty-one NHs in 122 U.S. cities from 1999 to 2005.Long-stay (90 days) NH residents.Quarterly city-level influenza mortality and state-level influenza severity. Quarterly incidence of Minimum Data Set-derived ADL decline (≥ 4 points), weight loss, new or worsening pressure ulcers (PUs), and infections. Outcome variables chosen as clinical controls were antipsychotic use, restraint use, and persistent pain.City-level influenza mortality and state-level influenza severity were associated with higher rates of large (≥ 4 points) ADL decline (mortality β = 0.20, P.001; severity β = 0.18, P.001), weight loss (β = 0.19, P.001; β = 0.24, P.001), worsening PUs (β = 0.04, P = .08; β = 0.12, P.001), and infections (β = 0.41, P.001; β = 0.47, P.001) but not with restraint use, antipsychotic use, or persistent pain. NH influenza vaccination rates were weakly associated with the outcomes (e.g., β = -0.009, P = .03 for ADL decline, β = 0.008, P = .07 for infections). Compared with the summer quarter of lowest influenza activity, the results for the other quarters translate to an additional 12,284 NH residents experiencing large ADL decline annually, 15,168 experiencing significant weight loss, 6,284 new or worsening PUs, and 29,753 experiencing infections due to influenza.The results suggest a substantial and potentially costly effect of influenza on NH residents. The effect of influenza vaccination on preventing further ADL decline and other clinical outcomes in NH residents should be studied further.

Background Surgical site infections (SSI) following arthroscopy are associated with considerable morbidity. Whether antibiotic prophylaxis can reduce the risk of SSI following knee arthroscopy is unclear. Methods We undertook a meta-analysis of studies comparing incidence of SSI in patients receiving antibiotic prophylaxis vs. no antibiotics before undergoing knee arthroscopy. We searched multiple computerized databases; data were pooled using a random effects model. We excluded knee arthroscopy studies for which the distribution of patients receiving antibiotics vs. no antibiotics was unavailable. CDC definitions for SSI were used to determine incidence of infection. Results Five retrospective studies including 47,548 patients met inclusion criteria; none were randomized trials. The risk of SSI in the prophylactic antibiotic group was 0.38% and in the no antibiotic group was 0.37% (pooled OR 0.99, 95% CI 0.69–1.42). There was no statistical heterogeneity. Conclusion The evidence to date, which is limited to retrospective studies, suggests no difference in SSI incidence with and without antibiotic prophylaxis for knee arthroscopies. Prospective studies are required to further evaluate this finding. Future research should evaluate whether antibiotic prophylaxis prevents SSI in other joint arthroscopy procedures, such as shoulder arthroscopy. Disclosures All authors: No reported disclosures.

Background Cutibacterium (formerly Propionibacterium) acne, residing on skin, hair follicles, and sebaceous glands, can persist in the dermal layer despite standard surgical skin preparations. Traditionally considered a colonizer, it’s been increasingly recognized as a cause of surgical site infections (SSI). We aimed to gain further clinical insight into C. acne’s role in SSI. Methods Study design: retrospective chart review. Study Time: January 1, 2013–December 31, 2017. Study Setting: three hospitals within University of Wisconsin Health network. Case identification: all patients with ≥1 postoperative culture positive for C. acne. We defined SSI by CDC criteria, and collected basic demographic and relevant clinical variables. Results We identified 77 patients with C. acne postoperative cultures: neurosurgical (61%), orthopedic (17%), cardiothoracic (9%), general surgery (8%), and other surgical departments (5%). Forty-six (60%) of the patients were male. Time from surgery to positive culture was median 24 days (range: 1–670), with > 30 days in 36% patients. Infection and colonization were present in 77 and 23% of the patients, respectively. Infected patients were more likely to have wound infection on examination (OR 5.8 [1.4–27.9, P = 0.004), but had no significant difference in temperature, leukocytosis, or C-reactive protein compared with colonized patients. Additional surgeries for debridement, implant revision, or device re-implantation were needed in 62% of the patients. Length of hospital stay due to SSI was prolonged by median 6 days (range 0–33). Median antibiotic duration was 2 weeks, with 25% patients receiving antibiotics for ≥6 weeks. Infection outcomes included cure (86%), chronic infection (3%), transition to hospice (3%), and recurrence (8%). All six patients with recurrences had neurosurgeries and did not receive antibiotics after the initial positive culture (infection not recognized). Conclusion SSI caused by C. acne are associated with significant morbidity, especially in patients undergoing implant-related neurosurgical or orthopedic procedures. Due to low virulence and slow-growing properties, time to infection may be prolonged, and traditional inflammatory markers may be lacking. Early recognition of infection, while challenging, is crucial to improving postoperative patient outcomes. Disclosures All authors: No reported disclosures.

Influenza is an important cause of morbidity and mortality in the elderly population each year. The often subtle clinical manifestations in the frail geriatric patients may not be recognized initially, impeding timely administration of antiviral treatment. The effectiveness of current influenza vaccines in the elderly population is often diminished by immune senescence. Increasing immunization rates among health-care workers and elderly caregivers, and finding more effective vaccines for the elderly people are likely to significantly improve disease prevention in this population at risk.

Background Infections caused by antimicrobial-resistant bacteria are associated with substantial morbidity and mortality. Residents of long-term care facilities (LTCF) are among the main reservoirs of antimicrobial-resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Multidrug-resistant gram-negative organisms (MDRGN) are emerging as important pathogens among LTCF residents. Data on the clinical epidemiology of MDRGN, especially in comparison to VRE and MRSA, are limited. Methods All clinical cultures collected from residents of a 750-bed LTCF for a period of 2 years were analyzed for the presence of MDRGN, VRE, and MRSA. Multidrug resistance among gram-negative bacteria was defined as resistance to three or more antimicrobials or antimicrobial groups including extended-spectrum penicillins (ampicillin/sulbactam or piperacillin/tazobactam), cephalosporins (cefazolin or ceftriaxone), gentamicin, ciprofloxacin, and trimethoprim-sulfamethoxazole (TMP/SMX). Results A total of 1,661 clinical cultures were included in the analysis. MDRGN were recovered from 180 (10.8%) cultures, MRSA from 104 (6.3%), and VRE from 11 (0.6%). MDRGN were isolated more frequently than MRSA or VRE throughout the study period. The prevalence of MDRGN increased significantly from 7% in 2003 to 13% in 2005 (p = .001). More than 80% of MDRGN isolates were resistant to ciprofloxacin, TMP/SMX, and ampicillin/sulbactam. Resistance to three, four, and five or more antimicrobials were identified among 122 (67.8%), 47 (26.1%), and 11 (6.1%) MDRGN isolates, respectively. Conclusions Rates of MDRGN exceeded those of MRSA and VRE and increased throughout the study period. Resistance to multiple, commonly prescribed antimicrobials among MDRGN raises concerns about therapeutic options available to treat MDRGN infections among LTCF residents.

OBJECTIVES: To quantify the prevalence, risk factors, and mode of transmission associated with colonization by multidrug-resistant gram-negative bacteria (MDRGN) in the long-term care (LTC) setting. DESIGN: Cross-sectional. SETTING: Four nursing units in a 648-bed LTC facility in Boston, Massachusetts. PARTICIPANTS: Eighty-four long-term care residents. MEASUREMENTS: Nasal and rectal swabs were obtained to determine colonization with MDRGN; if present, molecular typing was performed. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) was also determined. Demographic and clinical characteristics were obtained from the medical record. Multivariable analysis was used to identify factors independently associated with MDRGN colonization. RESULTS: A total of 51%, 28%, and 4% subjects were colonized with MDRGN, MRSA, and VRE, respectively. After multivariable adjustment, advanced dementia (adjusted odds ratio (AOR)=2.9, 95% confidence interval (CI)=1.2–7.35, P=.02) and nonambulatory status (AOR=5.7, 95% CI=1.1–28.9, P=.04) were the only independent risk factors for harboring MDRGN. Molecular typing indicated person-to-person transmission. CONCLUSION: Colonization with MDRGN is common in the LTC setting. A diagnosis of advanced dementia is a major risk factor for harboring MDRGN.

Objectives To estimate the effect of influenza vaccination on hospitalization and mortality in nursing home (NH) residents. Design Retrospective cohort study. Setting Medicare claims data linked to NH Minimum Data Set assessments and Centers for Disease Control and Prevention (CDC) surveillance data from 122 U.S. cities. Participants More than 1 million Medicare fee-for-service, long-stay NH residents between 2000 and 2009. Measurements Weekly facility outcome aggregates of NH resident pneumonia and influenza (P&I) hospitalizations and all-cause mortality and city-level P&I mortality as reported by the CDC were created. The seasonal vaccine match rate for influenza A/H1N1, A/H3N2, and B strains was calculated, and each outcome was compared in seasons of high and low match rates using facility fixed-effects regression models separately for full-year and nonsummer months. Results Average weekly all-cause mortality varied across seasons from 3.74 to 4.13 per 1,000 NH residents per week, and hospitalization for P&I varied from 2.05 to 2.43. Vaccine match rates were invariably high for H1N1 but variable across seasons for the other two types. The association between vaccine match and reduction in overall mortality and P&I hospitalizations was strongest for A/H3N2, the influenza strain typically responsible for the most-severe influenza cases. Given the approximately 130,000 deaths and 77,000 P&I hospitalizations of long-stay NH residents during the 32 nonsummer weeks, the model estimated that a 50-percentage-point increase in the A/H3N2 match rate (from 75%) reduced long-stay NH resident deaths by 2.0% and P&I hospitalizations by 4.2%. Conclusion Well-matched influenza vaccine prevents P&I hospitalizations and mortality in NH residents.

In our study, 50% of 42 hospitalized patients with 2009 H1N1 pandemic influenza experienced symptoms longer than 1 week. Older age and delay in oseltamivir initiation were associated with prolonged illness. Patients with pneumonia and fever ≥7 days were more likely to have polymerase chain reaction-positive nasopharyngeal swabs beyond 1 week.

Background Guidelines for prevention of surgical site infection (SSI) recommend using pre-surgical chlorhexidine bathing or shower to reduce bioburden on the skin. However, there is considerable variation in how and to what extent this intervention is implemented. Understanding barriers to implementation are essential for effective implementation. We undertook a systems approach to examining challenges to implementation of pre-surgical chlorhexidine bathing or shower at an academic medical center. Methods Barriers and facilitators to implementation were assessed using direct observations and interviews of front line providers. Results were categorized with deductive coding using the Systems Engineering Initiative for Patient Safety Model (SEIPS), which has five major components - tools/technology, tasks, person, environment and organization. Results Major barriers to implementation of pre-surgical showering or bathing in the five SEIPS categories were: Person—lack of ownership and role ambiguity regarding who should be responsible for dispensing the product, limited ability to measure compliance with the intervention and workflow changes to pre-operative visits to accommodate education about pre-surgical chlorhexidine bathing; Task—uncertainty about duration of chlorhexidine on the skin and number of showers required pre-operatively; Tools/Technology—pros and cons of product selection (liquid vs. wipes), and lack of documentation in the electronic medical record; Environment—the pre-operative surgical visit not being conducive to education regarding the use of chlorhexidine because of time constraints; Organization—cost of the product and lack of policy governing the use of chlorhexidine were noted. Conclusion Although seemingly simple, pre-surgical showering or bathing is a complex behavioral intervention. A systems engineering approach may be useful in assessing barriers and facilitators to devise effective interventions for high fidelity compliance with the goal of preventing SSI. Disclosures All authors: No reported disclosures.

Influenza is a common RNA virus that causes yearly epidemics with an illness typically presenting with fever, myalgias, constitutional symptoms, and upper and/or lower respiratory tract symptoms. Patients with malignancies receiving chemotherapy are at increased risk for influenza-related illness1,2 and have been shown to have higher complication and mortality rates.3–5 The Centers for Disease Control (CDC) recommends annual influenza vaccination for all persons older than 6 months.6 The CDC endorses the practice of influenza vaccination for patients with malignancies, although little concrete evidence exists to suggest that patients with malignancies and/or those undergoing active chemotherapy mount a sufficient immunologic response to achieve clinical protection. In the general population, influenza vaccination results in prevention of infection in ∼70%–90% of healthy young adults.7,8 Serologic response is high, with seroconversion rates of 75%–80% and seroprotection rates of around 95% based on hemagglutinin inhibition (HI) titer assessment.9,10 Studies have demonstrated reduced immunogenicity in elderly populations, with seroconversion rates of 23%–51% and seroprotection rates of 68%–97%,11 as well as other groups including patients with end-stage renal disease,12 renal transplants,13,14 liver transplants,15 and lung transplants,16 HIV populations,17 and others. Investigation of influenza vaccine efficacy in patients with malignancies has been limited. Cancer patients are vaccinated at rates well below 50%. Lack of awareness of the current recommendations, fear of side effects, and concerns about vaccine efficacy have been cited as the primary reasons for not offering vaccination.18 Studies have demonstrated seroconversion and seroprotection rates similar to healthy adults following vaccination of patients with lung cancer19 as well as those with a variety of solid tumors.20 In patients with hematologic malignancies, seroconversion rates have been reported to be lower (21%).21 Some studies have evaluated the efficacy of single vaccination, while others have suggested additional efficacy using a multidose regimen.22 The efficacy of influenza vaccination has not been evaluated in patients with central nervous system (CNS) malignancies. Nevertheless, this is a potentially robust population for study given the immunosuppressive effects of gliomas and its associated treatment,23 variable degrees of therapy-induced lymphopenia and neutropenia, and the inclusion of glucocorticoids into pharmocotherapeutic regimens. The current study pilots an investigation into influenza vaccine immunogenicity in a group of patients with CNS malignancy.

Affiliations: 1. Division of Infectious Diseases, Memorial Hospital of Rhode Island, Warren Alpert Medical School at Brown University, Pawtucket, Rhode Island; 2. Healthcentric Advisors, Providence, Rhode Island; and Department of Health Services, Policy, and Practice, Warren Alpert Medical School at Brown University, Providence, Rhode Island. Received October 1, 2013; accepted October 2, 2013; electronically published November 26, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3501-0004$15.00. DOI: 10.1086/674397 A decade into the new Clostridium difficile epidemic, the excessive morbidity, mortality, and healthcare costs associated with C. difficile infection (CDI) are now well recognized. The updated 2010 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) guidelines for CDI prevention and treatment are incorporated into clinical practice, and multifaceted infection control bundles aimed at CDI prevention are adopted in most healthcare settings. Diagnosis using the more sensitive nucleic acid–based modalities is increasingly becoming the new standard. Reporting laboratory-identified CDI to the National Healthcare Safety Network is mandatory for all hospitals receiving payments from the Centers for Medicare and Medicaid Services, and comparisons between hospitals’ CDI rates will soon become publicly available. Similar approaches to preventing healthcare-acquired infections—such as central line–associated bloodstream infections, for example—met with considerable success, with sustained zero rates in many intensive care units across the United States. Unfortunately, this has not been the case with CDI. The number of patients hospitalized with a primary CDI diagnosis in the United States more than tripled during the period 2000–2009. The steady increase in CDI diagnoses over the last decade across acute care settings appears to have stabilized only recently. The study by Landelle et al in this issue offers a vivid insight into why C. difficile might be so stubbornly persistent in our hospitals. The authors set out to quantify healthcare worker (HCW) hand contamination with C. difficile spores during patient care in a French university-affiliated hospital not affected by the hypervirulent NAP1/BI strain. They sampled HCWs’ hands after glove removal at the end of patient care but before performance of hand hygiene and recovered the spores by treatment with 95% ethanol and filtration. Almost a quarter (24%) of HCWs caring for patients with CDI had hand contamination with spores. As expected, the risk of spore contamination was higher when there was contact with infected body fluids through direct contact with patients, their medical equipment, or their adjacent environment (high-risk contact) or when there was a failure to use gloves. Interestingly, 44% of the HCWs with contaminated hands provided at least 1 episode of direct patient care without use of gloves, despite the fact that they were fully aware that they were being observed for study purposes. The amount of hand contamination in a hospital where the hypersporulating NAP1/BI strain is endemic and the degree of noncompliance with contact precautions in unmonitored healthcare settings remain open to speculation. The study by Landelle and colleagues is timely and reenforces basic infection control principles that have become generally accepted: (1) HCWs’ hands become contaminated with C. difficile spores during patient care; (2) glove use, while effective in reducing the incidence of CDI in the hospital setting, does not fully protect against contamination and remains largely underutilized by the exact HCWs who are most exposed during patient care; (3) C. difficile spores are exceptionally resistant to disinfectants such as alcohol; and (4) contaminated HCWs’ hands likely provide an effective vehicle for in-hospital transmission of C. difficile spores. Cognizant of these principles, therefore, HCWs involved in direct care of patients with CDI would presumably seek to remove C. difficile spores from their contaminated hands immediately upon glove removal at the completion of each patient care task. Ironically, 166 years after Semmelweis signaled the importance of antisepsis in medical practice, the appropriate type of hand hygiene in the CDI setting is still a matter of debate. Landelle and colleagues favor the Centers for Disease Control and Prevention’s recommendation of hand hygiene with soap and water for all instances of CDI care. Additional support for this recommendation comes from previous stud

Objective.To determine, among patients withClostridium difficileinfection (CDI) at hospital admission, the impact of concurrent use of systemic, non-CDI-related antimicrobials on clinical outcomes and the risk factors associated with unnecessary antimicrobial prescribing.Design.Retrospective cohort study.Setting.University-affiliated community hospital.Methods.We reviewed computerized medical records for all patients with CDI at hospital admission during a 24-month period (January 1, 2008, through December 31, 2009). Colectomy, discharge to hospice, and in-hospital mortality were considered to be adverse outcomes. Antimicrobial use was considered unnecessary in the absence of physical signs and laboratory or radiological findings suggestive of an infection other than CDI or in the absence of antimicrobial activity against the organism(s) recovered from clinical cultures.Results.Among the 94 patients with CDI at hospital admission, 62% received at least one non-CDI-related antimicrobial during their hospitalization for CDI. Severe complicated CDI (odds ratio [OR], 7.1 [95% confidence interval {CI}, 1.8–28.5];P= .005), duration of non-CDI-related antimicrobial exposure (OR, 1.2 [95% CI, 1.03–1.36];P= .016), and age (OR, 1.1 [95% CI, 1.0–1.1];P= .043) were independent risk factors for adverse clinical outcomes. One-third of the patients received unnecessary antimicrobial therapy. Sepsis at hospital admission (OR, 5.3 [95% CI, 1.8–15.8];P= .003) and clinical suspicion of urinary tract infection (OR, 9.7 [95% CI, 2.9–32.3];P< .001) were independently associated with unnecessary antimicrobial prescriptions.Conclusions.Empirical use of non-CDI-related antimicrobials was common. Prolonged exposure to non-CDI-related antimicrobials was associated with adverse clinical outcomes, including increased in-hospital mortality. Minimizing non-CDI-related antimicrobial exposure in patients with CDI seems warranted.

Seasonal and pandemic influenza clinically remain remarkably similar in long-term care populations. Clinicians cannot distinguish clinical influenza, whether seasonal or pandemic H1N1, from other respiratory viral infections in individual patients. Part of the difficulty in the clinical diagnosis relates to fewer clinical features that might help with diagnostic differentiation, such as fever. However, the nursing home provides an epidemiologic context that can prove helpful to clinicians who inquire--by considering illness patterns among others in the facility, both staff and residents. This can lead to more timely diagnosis and treatment in the resident, and prophylaxis--an opportunity to protect the remaining residents and staff. Check out the treatment guidelines posted on the CDC website to be sure to select the best agents, because antiviral resistance patterns have been rapidly changing.

Background.Multidrug-resistant (MDR) gram-negative bacteria are reported increasingly frequently among isolates recovered from elderly patients. The clinical epidemiology of bloodstream infection (BSI) due to MDR gram-negative bacteria among elderly patients is unknown.Objective.To characterize the clinical epidemiology of BSI due to MDR gram-negative bacteria among elderly patients at hospital admission in an effort to provide a greater understanding of these serious infections and ultimately to improve patient outcomes.Design.Case-control study.Setting.Tertiary care hospital in Boston, Massachusetts.Patients.Patients 65 years of age and older.Methods.From 1999 to 2007, computerized medical records were reviewed for BSI due to MDR gram-negative bacteria within 48 hours of hospital admission. Risk factors for BSI due to these bacteria were identified.Results.MDR gram-negative bacteria were recovered from 61 (8%) of 724 elderly patients with BSI caused by gram-negative bacteria. Over the -year study period, the percentage of MDR gram-negative bacteria among bloodstream isolates increased from 2 (1%) of 199 to 34 (16%) of 216. Empiric therapy was ineffective for 38 (63%) of 60 patients with BSI caused by MDR gram-negative bacteria. The variables independently associated with BSI due to these bacteria were as follows: residency in a long-term care facility (odds ratio [OR], 4.9 [95% confidence interval {CI} 1.6–14.9]; P = .006), presence of an invasive device (OR, 6.0 [95% CI, 1.5–23.5]; P = .01), severe sepsis (OR, 7.9 [95% CI, 1.7–37.1]; P = .009), and delayed initiation of effective therapy (OR, 12.8 [95% CI, 3.9–41.1]; PConclusion.The 16-fold increase in BSI due to MDR gram-negative bacteria at hospital admission among elderly patients, especially among those who resided in long-term care facilities prior to admission, contributes further to the expanding body of evidence that these patients are the main reservoirs of MDR gram-negative bacteria. Given their contribution to the influx of antimicrobial-resistant bacteria in the hospital setting, infection control interventions that target this high-risk group need to be considered.

To quantify the prevalence, risk factors, and mode of transmission associated with colonization by multidrug-resistant gram-negative bacteria (MDRGN) in the long-term care (LTC) setting.Cross-sectional.Four nursing units in a 648-bed LTC facility in Boston, Massachusetts.Eighty-four long-term care residents.Nasal and rectal swabs were obtained to determine colonization with MDRGN; if present, molecular typing was performed. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) was also determined. Demographic and clinical characteristics were obtained from the medical record. Multivariable analysis was used to identify factors independently associated with MDRGN colonization.A total of 51%, 28%, and 4% subjects were colonized with MDRGN, MRSA, and VRE, respectively. After multivariable adjustment, advanced dementia (adjusted odds ratio (AOR)=2.9, 95% confidence interval (CI)=1.2-7.35, P=.02) and nonambulatory status (AOR=5.7, 95% CI=1.1-28.9, P=.04) were the only independent risk factors for harboring MDRGN. Molecular typing indicated person-to-person transmission.Colonization with MDRGN is common in the LTC setting. A diagnosis of advanced dementia is a major risk factor for harboring MDRGN.