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

We present a case report about a Moroccan 3-year-old girl, with an intermediate phenotype of muscular dystrophy-dystroglycanopathy (congenital with brain and eye anomalies), type A, 8 form. We performed clinical and instrumental evaluation, muscle biopsy, genetic screening of 59 genes for different cerebral malformations, follow-up and review of literature. After investigations, we identified an intermediate new phenotype between the severe and mild form, characterised by significant malformations of the cortex with myopatic symptoms, this increases the genotype–phenotype correlation knowledge about POMGNT2 gene mutations. New homozygous missense mutation on POMGNT2 (c.511 G>A, p.Asp171Asn, rs768063378) was detected.

Objective:Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity.Design:Observational pilot study.Setting:Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.Patients:Inpatients with MRSA colonization or infection.Methods:At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients’ hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.Results:In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.Conclusion:Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient’s MRSA body colonization pattern and the patient activity.

Nursing home (NH) patients often acquire colonization with antibiotic-resistant organisms (AROs). We show that patients exposed to broad-spectrum antibiotics during previous hospitalizations have elevated enterococcal relative abundances on NH admission and higher risk of subsequent ARO acquisition. Our findings suggest that interventions preventing ARO spread should extend beyond NH doors.

Objectives To quantify the multidrug-resistant organism (MDRO) burden of high-touch common area and rehabilitation gym surfaces, and to assess microorganism transfer potential during rehabilitation sessions. Design Prospective study of environmental contamination. Setting Nursing home (NH). Participants Six Michigan NHs. Measurements Monthly samples from common area surfaces (eg, living room), rehabilitation equipment, and rehabilitation personnel hands were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant gram-negative bacilli (R-GNB). To assess microorganism transfer potential, we conducted an in-depth assessment of microorganism transfer during 10 rehabilitation sessions. Microorganism transfer was defined as the identification of a microorganism on a destination surface that was uncontaminated before the rehabilitation session. Patient frequency of common area usage was also assessed qualitatively. Results We obtained 1338 common area specimens from 180 monthly facility visits, of which 13.4% (179/1338) were MDRO positive: MRSA, 3.8%; VRE, 5.8%; and R-GNB, 5.1%. A total of 64% (116/180) of sampling visits had at least one MDRO-positive common area specimen. Within rehabilitation gyms, we obtained 521 equipment and 190 personnel hand specimens during 60 monthly visits. Of the equipment specimens collected, 7.7% (40/521) were MDRO positive: MRSA, 2.5%; VRE, 4.0%; and R-GNB, 1.9%. Of the 190 rehabilitation personnel hand specimens collected, 3.7% (7/190) were MDRO positive. Overall, 55% (33/60) of rehabilitation gym visits had at least one MDRO-positive specimen. Microorganism transfer assessment during 10 rehabilitation sessions revealed 35 opportunities for transfer during which microorganism transfer occurred in 17.1% (6/35) of opportunities. Conclusion NH common areas and rehabilitation gyms are MDRO reservoirs that may contribute to the transmission of healthcare-associated pathogens. Because NHs accommodate the increasing short-stay patient population, developing effective interventions that reduce MDRO transmission in the common area and rehabilitation gym environment should be considered an infection prevention priority. J Am Geriatr Soc 68:478-485, 2020.

Little is known about the short-term dynamics of methicillin-resistantObservational pilot study.Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.Inpatients with MRSA colonization or infection.At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients' hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient's MRSA body colonization pattern and the patient activity.

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Multiple room occupancy is common in Nursing Homes (NHs), and its role in transmission of antibiotic-resistant pathogens is unclear. We investigated prevalence of patient colonization and environmental contamination with vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) in NH roommates, compared it with expected prevalence, and determined specific body and environmental sites that may act as sources of roommate colonization. Roommate contamination was associated with index patient’s colonization (relative risk (RR): 2.57 (95% CI 1.04–6.37)) for MRSA, and index patient’s immediate environment contamination for VRE (RR: 3.60 (95% CI 1.59–8.12)). When specific index patient sites associated with roommate colonization were investigated, the side table (Fisher’s p = 0.029 and 0.047 for VRE and MRSA, respectively) and the nurse call button (p = 0.001 and 0.052) stood out, together with patient hands in the case of VRE (p = 0.026). Future studies should be carried out to establish whether these sites should be a specific target of infection prevention campaigns in NHs with multiple occupancy rooms. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00972-1.

Perianal screening can be intrusive. The sensitivities of multianatomical, nonperianal surveillance were 92.3% for methicillin-resistant Staphylococcus aureus (MRSA), 58.7% for vancomycin-resistant enterococci (VRE), and 54.9% for resistant Gram-negative bacilli (R-GNB). Sensitivities improved upon adding environmental surveillance (95.5%, 82.9%, and 67.9%, respectively). Multianatomical, nonperianal screening and room environment surveillance may replace perianal screening and reduce healthy participant bias in nursing homes.

Background The COVID-19 pandemic has disproportionately affected nursing home (NH) patients, accounting for 5% of all cases and 32% of all COVID-19 deaths nationwide. Little is known about the frequency and persistence of SARS-CoV-2 environmental contamination in NHs. We characterize SARS-CoV-2 contamination in the rooms of COVID-19 patients and common areas in and around COVID-19 units. Methods A prospective cohort study was conducted at four NHs in Michigan between October 2020 and January 2021. Clinical research personnel obtained swab specimens from high-touch room surfaces of COVID-19 infected patients, up to three times per patient. Weekly swab specimens from six high-touch surfaces in common areas were also obtained. Demographic and clinical data were collected from patient clinical records. Our primary outcome of interest was the probability of SARS-CoV-2 detection from specific environmental surfaces in COVID-19 patient rooms. Results One hundred four patients with COVID-19 were enrolled and followed for 241 visits. Patient characteristics included: 61.5% over the age of 80; 67.3% female; 89.4% non-Hispanic white; 50.1% short-stay. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities including dementia (55.8%), diabetes (40.4%) and heart failure (32.7) (Table 1). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient room surfaces, 191 common area swabs). Figure 1 shows contamination rates at sites proximate and distant to the patient bed. SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Over the course of follow-up, 89.4% (93/104) of patients had SARS-CoV-2 contamination in their room at least once (Figure 2). Environmental contamination detected on enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination. Table 1. Clinical and Demographic Characteristics of the Study Population Including Short- and Long-stay Patients Figure 1. Contamination of Environmental Surfaces Relative to Distance from Patient Bed Figure 2. SARS-CoV-2 on Swab Specimens Collected – Patient-level, Visit-level, and Swab-level Conclusion We conclude that environmental contamination of surfaces in the rooms of COVID-19 patients is nearly universal and persistent. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment. Disclosures All Authors: No reported disclosures

Little is known about the contribution of hospital antibiotic prescribing to multidrug-resistant organism (MDRO) burden in nursing homes (NHs).To characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment.This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021.Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories.The primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics.A total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [OR], 1.70; 95% CI, 1.22-2.38) and MDRO environmental contamination (OR, 1.67; 95% CI, 1.17-2.39). Exploratory stratification by C diffogenic agent exposure increased the effect size (MDRO colonization: OR, 1.99; 95% CI, 1.33-2.96; MDRO environmental contamination: OR, 1.86; 95% CI, 1.24-2.79). Likewise, exploratory stratification by exposure to high-risk WHO AWARE antibiotics increased the effect size (MDRO colonization: OR, 2.32; 95% CI, 1.61-3.36; MDRO environmental contamination: OR, 1.86; 95% CI, 1.26-2.75).The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce MDROs in postacute care NHs. This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology.

Nursing home (NH) patients often acquire colonization with antibiotic-resistant organisms (AROs). We show that patients exposed to broad-spectrum antibiotics during previous hospitalizations have elevated enterococcal relative abundances on NH admission and higher risk of subsequent ARO acquisition. Our findings suggest that interventions preventing ARO spread should extend beyond NH doors.

Background Vancomycin-resistant Enterococcus faecium and Enterococcus faecalis frequently colonize nursing facility (NF) residents, creating opportunities for vancomycin-resistant Enterococcus (VRE) transmission and dissemination of mobile genetic elements conferring antimicrobial resistance. Most VRE studies do not speciate; our study addresses this lack and compares the epidemiology of E faecium and E faecalis. Methods We enrolled 651 newly admitted patients from 6 different NFs and collected swabs from several body sites at enrollment, 14 days, 30 days, and monthly thereafter for up to 6 months. The VRE were speciated using a duplex polymerase chain reaction. We used multinomial logistic regression models to compare risk factors associated with colonization of E faecium and E faecalis. Results Overall, 40.7% were colonized with E faecium, E faecalis, or both. At enrollment, more participants were colonized with E faecium (17.8%) than E faecalis (8.4%); 3.2% carried both species. Enterococcus faecium was carried twice as long as E faecalis (69 days and 32 days, respectively), but incidence rates were similar (E faecium, 3.9/1000 person-days vs E faecalis, 4.1/1000 person-days). Length of stay did not differ by species among incident cases. Residents who used antibiotics within the past 30 days had a greater incidence of both E faecium (odds ratio [OR] = 2.89; 95% confidence interval [CI], 1.82–4.60) and E faecalis (OR = 1.80; 95% CI, 1.16–2.80); device use was most strongly associated with the incidence of E faecium colonization (OR = 2.01; 95% CI, 1.15–3.50). Conclusions Recent increases in vancomycin-resistant E faecium prevalence may reflect increased device use and longer duration of carriage.

Background Vancomycin-resistant Enterococcus faecium and Enterococcus faecalis frequently colonize nursing facility (NF) residents, creating opportunities for vancomycin-resistant Enterococcus (VRE) transmission and dissemination of mobile genetic elements conferring antimicrobial resistance. Most VRE studies do not speciate; our study addresses this lack and compares the epidemiology of E faecium and E faecalis. Methods We enrolled 651 newly admitted patients from 6 different NFs and collected swabs from several body sites at enrollment, 14 days, 30 days, and monthly thereafter for up to 6 months. The VRE were speciated using a duplex polymerase chain reaction. We used multinomial logistic regression models to compare risk factors associated with colonization of E faecium and E faecalis. Results Overall, 40.7% were colonized with E faecium, E faecalis, or both. At enrollment, more participants were colonized with E faecium (17.8%) than E faecalis (8.4%); 3.2% carried both species. Enterococcus faecium was carried twice as long as E faecalis (69 days and 32 days, respectively), but incidence rates were similar (E faecium, 3.9/1000 person-days vs E faecalis, 4.1/1000 person-days). Length of stay did not differ by species among incident cases. Residents who used antibiotics within the past 30 days had a greater incidence of both E faecium (odds ratio [OR] = 2.89; 95% confidence interval [CI], 1.82–4.60) and E faecalis (OR = 1.80; 95% CI, 1.16–2.80); device use was most strongly associated with the incidence of E faecium colonization (OR = 2.01; 95% CI, 1.15–3.50). Conclusions Recent increases in vancomycin-resistant E faecium prevalence may reflect increased device use and longer duration of carriage.

Background:Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP).Methods:HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence.Results:We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44–4.54) and after patient care (OR, 3.11; 95% CI, 1.77–5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15–0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11–0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%).Conclusions:Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

Background The spread of multidrug-resistant organisms (MDROs) is a global concern, and much about transmission in healthcare systems remains unknown. To reduce hospital stays, nursing facilities (NFs) have increasingly assumed care of post-acute populations. We estimate the prevalence of MDRO colonization in NF patients on enrollment and discharge to community settings, risk factors for colonization, and rates of acquiring MDROs during the stay. Methods We conducted a prospective, longitudinal cohort study of newly admitted patients in 6 NFs in southeast Michigan using active microbial surveillance of multiple anatomic sites sampled at enrollment, days 14 and 30, and monthly thereafter for up to 6 months. Results We enrolled 651 patients and collected 7526 samples over 1629 visits, with an average of 29 days of follow-up per participant. Nearly all participants were admitted for post-acute care (95%). More than half (56.8%) were colonized with MDROs at enrollment: methicillin-resistant Staphylococcus aureus (MRSA), 16.1%; vancomycin-resistant enterococci (VRE), 33.2%; and resistant gram-negative bacilli (R-GNB), 32.0%. Risk factors for colonization at enrollment included prolonged hospitalization (>14 days), functional disability, antibiotic use, or device use. Rates per 1000 patient-days of acquiring a new MDRO were MRSA, 3.4; VRE, 8.2; and R-GNB, 13.6. MDRO colonization at discharge was similar to that at enrollment (56.4%): MRSA, 18.4%; VRE, 30.3%; and R-GNB, 33.6%. Conclusions Short-stay NF patients exhibit a high prevalence of MDROs near the time of admission, as well as at discharge, and may serve as a reservoir for spread in other healthcare settings. Future interventions to reduce MDROs should specifically target this population.

Key Points Question What is the effect of a multicomponent infection prevention intervention on multidrug-resistant organisms in nursing homes? Findings In this cluster randomized clinical trial of 6 nursing homes, including 245 patients, a multicomponent intervention consisting of enhanced barrier precautions, chlorhexidine bathing, microbial surveillance, and staff engagement statistically significantly reduced the odds of multidrug-resistant organism contamination in patients’ environments. Meaning These findings suggest that multicomponent interventions can be tailored to reduce multidrug-resistant organisms burden and transmission potential in nursing homes., This cluster randomized clinical trial examines the effectiveness of a multicomponent infection prevention intervention for multidrug resistant organisms in nursing homes., Importance Multidrug-resistant organisms (MDROs) can cause significant morbidity and mortality. Preventing MDROs can reduce the risk of subsequent transmission and infection. Objective To determine whether a multicomponent infection prevention intervention can reduce MDRO prevalence in nursing homes (NHs). Design, Setting, and Participants This cluster randomized clinical trial of a multicomponent intervention was conducted in 6 NHs in Michigan from September 2016 to August 2018. Three NHs adopted a multicomponent intervention, while 3 control NHs continued without investigator intervention. Study visits were conducted at baseline; days 7, 14, 21, and 30; and monthly thereafter for up to 6 months or discharge. Visits included clinical data collection and MDRO surveillance culturing of multiple body sites and high-touch surfaces in patient rooms. Any patients who provided informed consent within 14 days of admission to the NH were enrolled in this study. Non-English speakers and patients receiving hospice care were ineligible. Analysis was performed from November 2018 to February 2020. Interventions Intervention NHs adopted a multicomponent intervention that included enhanced barrier precautions, chlorhexidine bathing, MDRO surveillance, environmental cleaning education and feedback, hand hygiene promotion, and health care worker education and feedback. Control nursing homes continued standard care practices. Main Outcomes and Measures The primary outcome, presence of MDROs, was measured longitudinally in the patient and room environment and was evaluated using generalized mixed effect models. The secondary outcome, time to new MDRO acquisition, was assessed using Cox proportional hazard models. Results A total of 6 NHs were included, with 245 patients (mean [SD] age, 72.5 [13.6] years; 134 [54.7%] women) enrolled; 3 NHs with 113 patients (46.1%) were randomized to the intervention group and 3 NHs with 132 patients (53.9%) were randomized to the control group. A total of 132 patients (53.9%) were White, and 235 patients (95.9%) were receiving postacute care. Over 808 study visits, 3654 patient cultures and 5606 environmental cultures were obtained. The intervention reduced the odds of MDRO prevalence in patients’ environment by 43% (aOR, 0.57; 95% CI, 0.35-0.94), but there was no statistically significant difference on the patient level before or after adjustment (aOR, 0.57; 95% CI, 0.29-1.14). There were no significant reductions in time to new acquisition for methicillin-resistant Staphylococcus aureus (hazard ratio [HR], 0.20; 95% CI, 0.04-1.09), vancomycin-resistant enterococci (HR, 0.84; 95% CI, 0.46-1.53), or resistant gram-negative bacilli (HR, 1.14; 95% CI, 0.73-1.78). Conclusions and Relevance This cluster randomized clinical trial found that the multicomponent intervention reduced the prevalence of MDROs in the environment of NH patients. Our findings highlight the potential for multicomponent interventions to directly and indirectly reduce MDRO prevalence in NHs. Trial Registration ClinicalTrials.gov Identifier: NCT02909946

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

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

Background Most research examining the association between gut microbiota disruption and MDRO acquisition has been done in acute care settings. Obtaining stool samples in older NF adults is challenging. We hypothesized that perirectal samples can be used as a proxy of the gut microbiota. This prospective cohort study investigated the association between perirectal swab-derived gut microbiota features in newly admitted NF patients and the acquisition of vancomycin-resistant Enterococcus and/or resistant Gram-negative bacteria (rGNB) within 14 days. Methods Patients were recruited at 6 MI NFs from September 2016 to October 2018 as part of a larger NIH-funded trial. Colonization status was determined by culture swabs collected from multiple body sites at enrollment, d7, and d14. Our analysis focused on patients with no MDRO at baseline, a perirectal swab collected at baseline, and at least one follow-up visit. The V4 region of the 16S rRNA gene was sequenced from samples and processed with the mothur bioinformatics pipeline. Sequences typically associated with the skin microbiota were removed. The primary outcome was any MDRO acquisition. Exposures of interest included patient and microbiota characteristics. The Microbiome Health Index (MHI) was used to assess microbiota health. An MHI of 0 indicates a balanced abundance between taxa associated with protection and dysbiosis; an MHI above/below 0 suggests better/poorer health, respectively (Figure 1). Results Among 60 eligible patients (Table 1), 18 (30%) acquired MDROs within 14 days of enrollment (3 VRE, 13 rGNB, 2 both). The baseline microbiota features differed significantly in those who acquired a new MDRO. Of the major 8 phyla found across samples, patients who acquired an MDRO were depleted in the number of phyla present (4.4 ± 1.1 vs. 5 ± 1.1; P = 0.08) (Figure 2). The log-transformed relative abundance of Enterococcus was enriched in patients who acquired an MDRO (−0.7 ± 3.41) compared with those who did not (−4.2 ± 4.8; P < 0.01) (Figure 3). An MHI below 0 was predictive of MDRO acquisition after adjusting for catheter use within 30 days before baseline (adjusted OR 4.9; 95% CI 1.1–21.1). Conclusion Microbiota metrics calculated from perirectal samples are predictive of MDRO acquisition. The clinical utility of perirectal samples warrants further assessment. Disclosures All Authors: No reported Disclosures.

Background The clinical utility of patient and environmental surveillance screening for vancomycin-resistant enterococci (VRE) in the postacute care setting has not been definitively clarified. We assessed the longitudinal relationship between patient colonization and room contamination, and we established their association with unfavorable health outcomes. Methods Four hundred sixty-three postacute care patients were followed longitudinally from enrollment to discharge for up to 6 months. Multiple body and environmental sites were sampled at regular intervals to establish correlation between environmental contamination and patient colonization and with longer than expected stay, unplanned hospitalization, and infections adjusting for sex, age, race, Charlson’s comorbidity index, and physical self-maintenance score. Results New VRE acquisition was more likely in patients residing in contaminated rooms (multivariable odds ratio [OR] = 3.75; 95% confidence interval [CI], 1.98–7.11) and vice versa (OR = 3.99; 95% CI, 2.16–7.51). New acquisition and new contamination were associated with increased length of stay (OR = 4.36, 95% CI = 1.86–10.2 and OR = 4.61, 95% CI = 1.92–11.0, respectively) and hospitalization (OR = 2.42, 95% CI = 1.39–4.22 and OR = 2.80, 95% CI = 1.52–5.12). New-onset infections were more common with higher VRE burdens (15% in the absence of VRE, 20% when after VRE isolation only on the patient or only in the room, and 29% after VRE isolation in both the patient and the room). Conclusions Room contamination with VRE is a risk factor for patient colonization, and both are associated with future adverse health outcomes in our postacute care patients. Further research is warranted to establish whether VRE screening may contribute to better understanding of risk assessment and adverse outcome prevention in postacute care.

Nursing home residents are at a greater risk of developing pressure injuries that develop into an open wound. Open wounds can be colonized with bacteria from multiple sources. Emerging evidence suggests the specific composition of the open wound microbial community can result in delayed wound healing and increased infection risk. Understanding the factors that influence microbial colonization of open wounds, can lead to the prevention of infections. The relationship between bacteria found in urine and that of open wounds, is currently unknown. Recent studies have shown that nursing home residents can harbor a urinary microbiota independent of symptoms and frequently experience urinary incontinence. To determine if the colonization of open wounds mirrors urinary colonization, we conducted a pilot study with nursing home residents, comparing bacteria present in open pressure injuries below the umbilicus and urine. To identify microbial species that were present in both urine and open wound at one timepoint, standard bacteriologic culture techniques followed by MALDI-TOF was used as well as16S rRNA-encoding gene amplicon sequencing. In this study we found that some bacteria detected in urine were also detected in open wounds in one individual at one timepoint, using both culture dependent and independent techniques. Bacterial species that were more often detected at both sites included Enterococcus faecalis, Proteus mirabilis, Escherichia coli, and Providencia stuartii. This pilot study provides evidence that urinary colonization can mirror open wound colonization. Further studies are needed to investigate if parallel colonization of these anatomical sites affect infection outcomes.

Leptin, a pluripotent adipokine, has been discovered as a hormone controlling energy balance in hypothalamic neuroendocrine centers. In addition, recent studies provided ample evidence that leptin can be produced by cells other than adipocytes, and that the hormone can regulate many physiological processes other than energy balance and appetite. In this context, it is not surprising that both leptin excess as well as leptin insufficiency have been implicated in various pathologies. Consequently, despite initially disappointing results with recombinant leptin as the drug for obesity management, new leptin receptor modifiers have been developed and emerged as potential treatment modalities for numerous metabolic, immunological and neoplastic diseases. The major focus of this paper is a systematic review of current experimental leptin-based therapies, including pharmacological advantages and limitations of each prodrug category.

Background The impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further. Methods Patients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients’ hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing. Results A total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces. Conclusions Our data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections., In a prospective study of 399 hospital patients, we show that multidrug-resistant organisms (MDROs) on patient hands are common on admission and correlate with room contamination. New MDRO acquisition is frequent, suggesting a need to develop patient hand hygiene protocols in hospitals.

Background Antimicrobial stewardship program (ASP) outcomes are often measured in the acute care setting, less is known about the effect of acute care antibiotic exposures on multidrug-resistant organism (MDROs) colonization of nursing home (NH) patients. We assessed exposure to antibiotics commonly associated with Clostridioides difficile (C. diffogenic agents) on post-acute care patient colonization and room environment contamination (Figure 1). Figure 1. Conceptual Diagram of Hospital Antibiotic Exposure’s Influence on Patient Colonization and Room Environment Contamination with Multidrug-Resistant Organisms Methods MDRO surveillance of post-acute care patients in 6 NHs between 2013–16. We screened patient hands, nares, oropharynx, groin, perianal area, and high-touch room environment surfaces for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant Gram-negative bacilli (rGNB). C. diffogenic agents were defined as fluoroquinolones, 3rd/4th generation cephalosporins, penicillin combinations, lincosamides, and carbapenems. Multivariable logistic regression was used to assess whether hospital antibiotic exposure is an independent risk factor for MDRO colonization and room environment contamination on study enrollment. Results We enrolled 618 patients: average age was 74.4 years; 57.4% female; 62.3% white; 9.9% had indwelling devices (Table 1). Three hundred-fifty patients (56.6%) were MDRO colonized on enrollment: 98 (15.9%), MRSA; 208 (33.7%); VRE; 196 (31.7%), rGNB. Sixty-eight percent of patient rooms were MDRO contaminated: 166 (26.9%), MRSA; 293, (47.4%). VRE; 182 (29.5%), rGNB. A majority (59.4%) of patients were exposed to an antibiotic before admission. Of which, 239 (65.1%) were exposed to a C. diffogenic antibiotic. In multivariable analysis, C. diffogenic antibiotic exposure was an independent risk factor for MDRO colonization (OR, 1.94; 95% CI, 1.35–2.79), MDRO room environment contamination (OR, 1.94; 95% CI, 1.43–2.63), VRE colonization (OR, 4.23; 95% CI, 2.59–6.90), and VRE room environment contamination (OR, 2.58; 95% CI, 2.00–3.33). Table 1. Clinical Characteristics and MDRO Burden on Study Enrollment, Stratified by Hospital Antibiotic Exposure Status Multivariable Analysis of Hospital Antibiotic Exposure Status as Risk Factor for Proximal and Distal MDRO Outcomes Conclusion Hospital exposure to antibiotics is associated with an increased risk of VRE colonization and room environment contamination on NH study enrollment. These observations highlight the potential influence of hospital-based ASPs on MDRO prevalence and transmission in NHs. Disclosures All Authors: No reported disclosures

Background We investigated the effect of changes in room occupancy, and patient hand hygiene, on the burden of multidrug-resistant organisms (MDRO) in nursing homes. We assessed: 1/ persistence of MDRO after patients are discharged; and 2/ impact of hand hygiene assistance on colonization and room contamination. Methods Prospective cohort study of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and ceftazidime, ciprofloxacin or meropenem-resistant gram-negative bacilli (rGNB) in 9 single rooms screened three times a week for 34 weeks (five environmental surfaces, plus nares, groin, and hands of enrolled patients). Relative risk (RR) for patient colonization and room contamination were calculated in patient visits based on: 1/ performance of hand hygiene, and 2/ receiving assistance to perform it. Results We collected 4670 swabs over a total of 723 visits. Of 143 patient discharges, 31 times the room was swabbed before another patient was admitted (41 total visits), 48 times the next admitted patient was enrolled and available to be swabbed (295 visits), and 64 times the patient was not enrolled but the environment was sampled (387 total visits) (Figure). Twenty-four (50%) patients were colonized at least once with an MDRO. Rooms were contaminated at least once with MDRO in 72 cases (64%). MDRO persistence during occupancy changes involving at least one screened patient was observed in 21 of 73 cases (29%). In addition, we detected 2 cases of contamination of unoccupied, terminally cleaned rooms with MDRO recovered also in the previous (MRSA) or the following occupancy (VRE). In 40 occasions, patients performed hand hygiene with assistance from healthcare personnel, while in 169 occasions they performed hand hygiene by themselves. Requiring assistance was a risk factor for patient colonization (27.5% vs. 12.4% not requiring assistance (RR 2.20, 95% CI 1.16-4.18), and for room contamination (37.5% vs. 18.9%, RR 1.97, 95% CI 1.18-3.27) (Table). Figure. Example of successive changes in room occupancy. Table. Breakdown of colonization and contamination at each visit according to hand hygiene performance and need for assistance. Conclusion MDRO can persist during changes in patient occupancy. Patients requiring assistance with hand hygiene experienced a higher MDRO burden. These observations call for further investigation of improved cleaning practices and patient assistance. Disclosures All Authors: No reported disclosures

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

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

This review summarizes current literature pertaining to infection prevention in nursing home population including post-acute care patients and long-term care residents. Approximately 2 million infections occur each year and more than one-third of older adults harbor multidrug-resistant organisms in this setting. Surveillance, hand hygiene, isolation precautions, resident and employee health programs, education, and antibiotic stewardship are essential elements of infection prevention and control programs in nursing homes. This article discusses emerging evidence suggesting the usefulness of interactive multimodal bundles in reducing infections and antimicrobial resistance, thereby enhancing safety and quality of care for older adults in nursing homes.

The mef(A) gene was originally identified as the resistance determinant responsible for type M resistance to macrolides, a phenotype frequently found in clinical isolates of Streptococcus pneumoniae and Streptococcus pyogenes. MefA was defined as a secondary transporter of the major facilitator superfamily driven by proton-motive force. However, when characterizing the mef(A)-carrying elements Tn1207.1 and Φ1207.3, another macrolide resistance gene, msr(D), was found adjacent to mef(A). To define the respective contribution of mef(A) and msr(D) to macrolide resistance, three isogenic deletion mutants were constructed by transformation of a S. pneumoniae strain carrying Φ1207.3: (i) Δmef(A)–Δmsr(D); (ii) Δmef(A)–msr(D); and (iii) mef(A)–Δmsr(D). Susceptibility testing of mutants clearly showed that msr(D) is required for macrolide resistance, while deletion of mef(A) produced only a twofold reduction in the minimal inhibitory concentration (MIC) for erythromycin. The contribution of msr(D) to macrolide resistance was also studied in S. pyogenes, which is the original host of Φ1207.3. Two isogenic strains of S. pyogenes were constructed: (i) FR156, carrying Φ1207.3, and (ii) FR155, carrying Φ1207.3/Δmsr(D). FR155 was susceptible to erythromycin, whereas FR156 was resistant, with an MIC value of 8 μg/ml. Complementation experiments showed that reintroduction of the msr(D) gene could restore macrolide resistance in Δmsr(D) mutants. Radiolabeled erythromycin was retained by strains lacking msr(D), while msr(D)-carrying strains showed erythromycin efflux. Deletion of mef(A) did not affect erythromycin efflux. This data suggest that type M resistance to macrolides in streptococci is due to an efflux transport system of the ATP-binding cassette (ABC) superfamily, in which mef(A) encodes the transmembrane channel, and msr(D) the two ATP-binding domains.