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SUMMARYTo examine the pathogenesis of USA300 MRSA infection in long-term care residents, we performed a retrospective cohort study of 1691 adult residents of two extended-care facilities from 2003 to 2007 to assess whether the risk of subsequent MRSA infection is higher in USA300 MRSA-colonized residents compared to non-colonized residents or non-USA300 MRSA colonized residents. Six per cent of residents were colonized with USA300 MRSA; 12% of residents were colonized with non-USA300 MRSA; and 101 residents developed MRSA infection. The risk of infection was twofold higher in residents colonized with USA300 MRSA compared to residents not colonized with MRSA [adjusted hazard ratio 2·3, 95% confidence interval (CI) 1·1-4·5]. The risk of infection in USA300 MRSA-colonized residents was similar to USA300 MRSA non-colonized residents (relative risk 1·1, 95% CI 0·5-2·3). Our findings show that colonization with USA300 MRSA increases the risk of MRSA infection suggesting a similar pathogenesis. [ABSTRACT FROM AUTHOR]

Roghmann M-C, Gorman PH, Wallin MT, Kreisel K, Shurland S, Johnson JA. Staphylococcus aureus colonization in community-dwelling people with spinal cord dysfunction. OBJECTIVES: To estimate the prevalence of and determine risk factors for Staphylococcus aureus colonization of the perineum. DESIGN: Cross-sectional study with follow-up of up to 1 year. SETTING: Multiple outpatient sites. PARTICIPANTS: Eighty-four community-dwelling adults with spinal cord dysfunction (SCD). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Colonization of perineum with S. aureus. RESULTS: Overall, 24% of the study cohort carried S. aureus on their perineal skin at enrollment, with 16% having methicillin-susceptible S. aureus and 10% having methicillin-resistant S. aureus (MRSA). Most perineal carriers were also colonized in the anterior nares. Participants with trauma as the cause of their SCD were more likely to be colonized with S. aureus than participants with SCD caused by multiple sclerosis or other causes (relative risk [RR], 2.8; 95% confidence interval [CI], 1.2-6.6; P=.01). Participants with pelvic decubiti were more likely to be colonized with S. aureus than participants without pelvic decubiti (RR=4.3; 95% CI, 2.4-7.7; P<.001). The recent use of any antibiotic was not associated with an increased risk of colonization with S. aureus (RR=1.5; 95% CI, 0.7-3.3; P=.31); however, recent fluoroquinolone use was significantly associated with perineal colonization (RR=2.8; 95% CI, 1.4-5.8; P=.02). Of the 8 participants with MRSA colonization, only 2 (25%) had a history of MRSA colonization. CONCLUSIONS: S. aureus colonization of the perineum is common in this outpatient population of people with SCD. The use of fluoroquinolones was associated with S. aureus colonization. Colonization with MRSA without a history of MRSA was common. Copyright © 2007 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation [ABSTRACT FROM AUTHOR]

Background: Enhanced Barrier Precautions (EBPs) recommend using gowns and gloves for certain nursing home residents during specific high-contact care activities associated with multidrug-resistant organism (MDRO) transmission. Though EBP is included in published guidance as an MDRO control strategy, optimal implementation approaches remain unclear., Methods: We implemented a quality improvement (QI) initiative using the 4E process model (engagement, education, execution, and evaluation) to optimize EBP implementation in 4 Maryland nursing homes. Semistructured interviews with health care personnel (HCP) occurred to understand EBP acceptability., Results: Glove use during high-contact care increased from 85% in the baseline to 97% during the intervention (P < .01). Gown use increased from 27% to 78% (P < .01). The accuracy of identifying residents eligible for EBP improved from 63% to 99% (P < .01). Of 780 residents observed, one third met EBP indications: MDRO colonization (21%), indwelling medical device (14%), and/or chronic wound (10%). The most noted facilitator to EBP implementation included HCP perception that EBP reduces MDRO transmission to other residents and staff. The most noted barrier was uncomfortable gowns., Conclusions: Implementation was complex and required assessments of barriers and facilitators within each facility. HCP interviews identified barriers and facilitators of EBP that can inform future EBP implementation projects., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.)

Background: Candida auris is an emerging fungal pathogen increasingly recognized as a cause of healthcare-associated infections including outbreaks., Methods: We performed a mixed-methods study to characterize the emergence of C. auris in the state of Maryland from 2019 to 2022, with a focus on socioeconomic vulnerability and infection prevention opportunities. We describe all case-patients of C. auris among Maryland residents from June 2019 to December 2021 detected by Maryland Department of Health. We compared neighborhood socioeconomic characteristics of skilled nursing facilities (SNFs) with and without C. auris transmission outbreaks using both the social vulnerability index (SVI) and the area deprivation index (ADI). The SVI and the ADI were obtained at the state level, with an SVI ≥ 75th percentile or an ADI ≥ 80th percentile considered severely disadvantaged. We summarized infection control assessments at SNFs with outbreaks using a qualitative analysis., Results: A total of 140 individuals tested positive for C. auris in the study period in Maryland; 46 (33%) had a positive clinical culture. Sixty (43%) were associated with a SNF, 37 (26%) were ventilated, and 87 (62%) had a documented wound. Separate facility-level neighborhood analysis showed SNFs with likely C. auris transmission were disproportionately located in neighborhoods in the top quartile of deprivation by the SVI, characterized by low socioeconomic status and high proportion of racial/ethnic minorities. Multiple infection control deficiencies were noted at these SNFs., Conclusion: Neighborhood socioeconomic vulnerability may contribute to the emergence and transmission of C. auris in a community.

Tests lack analytical and clinical validity, requiring more federal oversight to prevent consumer harm.

We surveyed 57 nursing home residents to assess the subjective impact of COVID-19 prevention practices. Residents were mostly accepting of testing and symptom screening; however, many would like more choices. Sixty-nine percent want to have some say in when or where to mask. Most (87%) residents want to return to group activities. Residents on long-stay units (58%) are more likely than residents on short-stay units (27%) to accept additional risk of COVID-19 transmission to increase their quality of life., (Copyright © 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: The Centers for Disease Control and Prevention (CDC) recommends implementing Enhanced Barrier Precautions (EBP) for all nursing home (NH) residents known to be colonized with targeted multidrug-resistant organisms (MDROs), wounds, or medical devices. Differences in health care personnel (HCP) and resident interactions between units may affect risk of acquiring and transmitting MDROs, affecting EBP implementation. We studied HCP-resident interactions across a variety of NHs to characterize MDRO transmission opportunities., Design: 2 cross-sectional visits., Setting and Participants: Four CDC Epicenter sites and CDC Emerging Infection Program sites in 7 states recruited NHs with a mix of unit care types (≥30 beds or ≥2 units). HCP were observed providing resident care., Methods: Room-based observations and HCP interviews assessed HCP-resident interactions, care type provided, and equipment use. Observations and interviews were conducted for 7-8 hours in 3-6-month intervals per unit. Chart reviews collected deidentified resident demographics and MDRO risk factors (eg, indwelling devices, pressure injuries, and antibiotic use)., Results: We recruited 25 NHs (49 units) with no loss to follow-up, conducted 2540 room-based observations (total duration: 405 hours), and 924 HCP interviews. HCP averaged 2.5 interactions per resident per hour (long-term care units) to 3.4 per resident per hour (ventilator care units). Nurses provided care to more residents (n = 12) than certified nursing assistants (CNAs) and respiratory therapists (RTs) (CNA: 9.8 and RT: 9) but nurses performed significantly fewer task types per interaction compared to CNAs (incidence rate ratio (IRR): 0.61, P < .05). Short-stay (IRR: 0.89) and ventilator-capable (IRR: 0.94) units had less varied care compared with long-term care units (P < .05), although HCP visited residents in these units at similar rates., Conclusions and Implications: Resident-HCP interaction rates are similar across NH unit types, differing primarily in types of care provided. Current and future interventions such as EBP, care bundling, or targeted infection prevention education should consider unit-specific HCP-resident interaction patterns., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Background: Diabetic foot infections are a common precursor to lower extremity amputations. The treatment of diabetic foot infections involves both medical and surgical management, of which limb-sparing surgeries are increasingly preferred over amputations at or above the ankle to preserve mobility and quality of life. The outcomes following these limb-sparing surgeries are not well described., Methods: This was a single-center, retrospective cohort study of 90 Veterans with moderate-to-severe diabetic foot infections between 2017 and 2019 from the Veterans Affairs Maryland Health Care System. The exposure was foot surgery with bone resection (ie, toe amputation, metatarsal resection, transmetatarsal amputation) vs debridement alone. The outcome was healing within 1 year. We used log-binomial regression to assess the association between foot surgery type and healing, stratify by infection location, and evaluate potential confounding variables., Results: The cumulative incidence of healing after foot surgery with bone resection was greater than that following debridement (risk ratio [RR], 1.80 [95% confidence interval {CI}, 1.17-2.77]). This association was modified by infection location and greater for toe infections (RR, 4.52 [95% CI, 1.30-15.7]) than other foot infections (RR, 1.19 [95% CI, .69-2.02]). We found no evidence of confounding by comorbidities or infection severity., Conclusions: For patients with toe infections, foot surgery with bone resection was associated with better healing than debridement alone. The multiple specialties caring for patients with diabetic foot infections need a stronger common knowledge base-from studies like this and future studies-to better counsel patients about their treatment and prognosis., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

At the beginning of the COVID-19 pandemic, some nursing homes (NHs) in Maryland suffered larger outbreaks than others. This study examined how facility characteristics influenced outbreak size. We conducted a retrospective analysis of secondary data from Maryland NHs to identify characteristics associated with large outbreaks, defined as when total resident cases exceeded 10% of licensed beds, from January 1, 2020, through July 1, 2020. Our dataset was unique in its inclusion of short-stay residents as a measure of resident type and family satisfaction as a measure of quality. Facility characteristics were collected prior to 2020. Like other studies, we found that large outbreaks were more likely to occur in counties with high cumulative incidence of COVID-19, and in NHs with more licensed beds or fewer daily certified nursing assistant (CNA) hours. We also found that NHs with a greater proportion of short-stay residents were more likely to have large outbreaks, even after adjustment for other facility characteristics. Lower family satisfaction was not significantly associated with large outbreaks after adjusting for CNA hours. Understanding the characteristics of NHs with large COVID-19 outbreaks can guide facility re-structuring to prevent the spread of respiratory infections in future pandemics., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objective: To characterize the microbial communities of the anterior nares (nose) and posterior pharynx (throat) of adults dwelling in the community and in nursing homes before and after treatment with intranasal mupirocin., Methods: Staphylococcus aureus-colonized adults were recruited from the community (n = 25) and from nursing homes (n = 7). S. aureus colonization was confirmed using cultures. Participants had specimens taken from nose and throat for S. aureus quantitation using quantitative PCR for the nuc gene and bacterial profiling using 16S rRNA gene sequencing over 12 weeks. After two baseline study visits 4 weeks apart, participants received intranasal mupirocin for 5 days with 3 further visits over a 8 week follow-up period., Results: We found a decrease in the absolute abundance of S. aureus in the nose for 8 weeks after mupirocin (1693 vs 141 fg/ul, p = 0.047). Mupirocin caused a statistically significant disruption in bacterial communities of the nose and throat after 1 week, which was no longer detected after 8 weeks. Bacterial community profiling demonstrated that there was a decrease in the relative abundance of S. aureus (8% vs 0.3%, p<0.01) 8 weeks after mupirocin and a transient decrease in the relative abundance of Staphylococcus epidermidis in the nose (21% vs 5%, p<0.01) 1 week after mupirocin., Conclusions: Decolonization with mupirocin leads to a sustained effect on absolute and relative abundance of S. aureus but not for other bacteria in the nose. This demonstrates that a short course of mupirocin selectively decreases S. aureus in the nose for up to 8 weeks., Competing Interests: The authors have declared that no competing interests exist.

In this cross-sectional study, we examined the relationship between resident level of care in the nursing home and colonization with resistant gram-negative bacteria. Residential-care residents were more likely to be colonized with resistant gram-negative bacteria than were postacute care residents (odds ratio, 2.3; 95% confidence interval, 1.40-3.80; P < .001).

Objective: To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents., Design: Uncontrolled clinical trial., Setting: This study was conducted in 2 community-based nursing homes in Maryland., Participants: The study included 322 residents on mixed short- and long-stay units., Methods: During a 2-month baseline period, all residents had nose and inguinal fold swabs taken to estimate S. aureus acquisition. The intervention was iteratively developed using a participatory human factors engineering approach. During a 2-month intervention period, healthcare personnel wore gowns and gloves for high-risk care activities while caring for residents with wounds or medical devices, and S. aureus acquisition was measured again. Whole-genome sequencing was used to assess whether the acquisition represented resident-to-resident transmission., Results: Among short-stay residents, the methicillin-resistant S. aureus acquisition rate decreased from 11.9% during the baseline period to 3.6% during the intervention period (odds ratio [OR], 0.28; 95% CI, 0.08-0.92; P = .026). The methicillin-susceptible S. aureus acquisition rate went from 9.1% during the baseline period to 4.0% during the intervention period (OR, 0.41; 95% CI, 0.12-1.42; P = .15). The S. aureus resident-to-resident transmission rate decreased from 5.9% during the baseline period to 0.8% during the intervention period., Conclusions: Targeted gown and glove use by healthcare personnel for high-risk care activities while caring for residents with wounds or medical devices, regardless of their S. aureus colonization status, is feasible and potentially decreases S. aureus acquisition and transmission in short-stay community-based nursing-home residents.

Frequent repositioning and skin examinations are the cornerstone of many pressure injury prevention programs. This study explores the hypothesis that frequent skin-exposing body care activities are protective against pressure injuries in residents of long-term care facilities. We designed a cross-sectional observational cohort study of 381 residents from 13 such facilities. Data were collected on resident characteristics and nursing care activities for each resident. We analyzed those data, looking for an association between skin-exposing body care and the presence of a pressure injury of stage 1 or greater. Body-exposing care activities were divided into high- and low-frequency groups. A logistic regression model was developed to include confounding variables. The odds ratio associated with body care and pressure injury was calculated. Fifteen percent of the residents in our study had pressure injuries. Confounders were activities of daily living score, heart failure, recent hospitalization, and stool incontinence. The adjusted odds ratio for body care as a risk factor was 4.9 (95% CI, 2.4, 10.4), indicating that residents with more than five body care needs are approximately five times more likely to have a pressure injury. Our results fail to support our hypothesis that frequent skin-exposing body care activities protect against pressure injury. Further exploration is needed to understand the resident characteristics and co-morbid conditions associated with the persistent risk for pressure injury despite frequent skin examinations., (© 2020 by the Wound Healing Society.)

Objective: To evaluate the effect of the burden of Staphylococcus aureus colonization of nursing home residents on the risk of S. aureus transmission to healthcare worker (HCW) gowns and gloves., Design: Multicenter prospective cohort study., Setting and Participants: Residents and HCWs from 13 community-based nursing homes in Maryland and Michigan., Methods: Residents were cultured for S. aureus at the anterior nares and perianal skin. The S. aureus burden was estimated by quantitative polymerase chain reaction detecting the nuc gene. HCWs wore gowns and gloves during usual care activities; gowns and gloves were swabbed and then cultured for the presence of S. aureus., Results: In total, 403 residents were enrolled; 169 were colonized with methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) and comprised the study population; 232 were not colonized and thus were excluded from this analysis; and 2 were withdrawn prior to being swabbed. After multivariable analysis, perianal colonization with S. aureus conferred the greatest odds for transmission to HCW gowns and gloves, and the odds increased with increasing burden of colonization: adjusted odds ratio (aOR), 2.1 (95% CI, 1.3-3.5) for low-level colonization and aOR 5.2 (95% CI, 3.1-8.7) for high level colonization., Conclusions: Among nursing home patients colonized with S. aureus, the risk of transmission to HCW gowns and gloves was greater from those colonized with greater quantities of S. aureus on the perianal skin. Our findings inform future infection control practices for both MRSA and MSSA in nursing homes.

We identified deep diabetic foot infections by culture and conducted a case-control study examining the risk factors for moderate to severe methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PsA) diabetic foot infections. Our MRSA prevalence was lower than literature values; PsA was higher. Gangrene may be predictive of Pseudomonas infection., (© The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of health care-associated infections in long-term care facilities (LTCFs). The Centers for Disease Control and Prevention recommends contact precautions for the prevention of MRSA within acute care facilities, which are being used within the United States Department of Veterans Affairs (VA) for LTCFs in a modified fashion. The impact of contact precautions in long-term care is unknown., Methods: To evaluate whether contact precautions decreased MRSA acquisition in LTCFs, compared to standard precautions, we performed a retrospective effectiveness study (pre-post, with concurrent controls) using data from the VA health-care system from 1 January 2011 until 31 December 2015, 2 years before and after a 2013 policy recommending a more aggressive form of contact precautions., Results: Across 75 414 patient admissions from 74 long-term care facilities in the United States, the overall unadjusted rate of MRSA acquisition was 2.6/1000 patient days. Patients were no more likely to acquire MRSA if they were cared for using standard precautions versus contact precautions in a multivariable, discrete time survival analysis, controlling for patient demographics, risk factors, and year of admission (odds ratio, 0.97; 95% confidence interval, .85-1.12; P = .71)., Conclusions: MRSA acquisition and infections were not impacted by the use of active surveillance and contact precautions in LTCFs in the VA., (Published by Oxford University Press for the Infectious Diseases Society of America 2019.)

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among nursing home residents is high. Health-care workers (HCWs) often serve as a vector in MRSA transmission. The ability to identify residents who are likely to transmit MRSA to HCWs' hands and clothing during clinical care is important so that infection control measures, such as Contact Precautions, can be employed. Using data on demographic and clinical characteristics collected from residents of community nursing homes in Maryland and Michigan between 2012 and 2014, we developed a clinical prediction rule predicting the probability of MRSA transmission to HCWs' gowns. We externally validated this model in a cohort of Department of Veterans Affairs nursing home residents from 7 states between 2012 and 2016. The prediction model, which included sex, race, resident dependency on HCWs for care, the presence of any medical device, diabetes mellitus, and chronic skin breakdown, showed good performance (C statistic = 0.70; sensitivity = 76%, specificity = 49%) in the development set. The decision curve analysis indicated that this model has greater clinical utility than use of a nares surveillance culture for MRSA colonization, which is current clinical practice for placing hospital inpatients on Contact Precautions. The prediction rule demonstrated less utility in the validation cohort, suggesting that a separate rule should be developed for residents of Veterans Affairs nursing homes.

Objective: To estimate the risk of transmission of antibiotic-resistant Gram-negative bacteria (RGNB) to gowns and gloves worn by healthcare personnel (HCP) when providing care to residents of community-based nursing facilities to identify the types of care and resident characteristics associated with transmission., Design: Prospective observational study.Settings and participantsResidents and HCP from 13 community-based nursing facilities in Maryland and Michigan., Methods: Perianal swabs were collected from residents and cultured to detect RGNB. HCP wore gowns and gloves during usual care activities, and at the end of each interaction, these were swabbed in a standardized manner. Transmission of RGNB from a colonized resident to gowns and gloves was estimated. Odds ratios (ORs) of transmission associated with type of care or resident characteristic were calculated., Results: We enrolled 403 residents and their HCP in this study. Overall, 19% of enrolled residents with a perianal swab (n=399) were colonized with at least 1 RGNB. RGNB transmission to either gloves or gowns occurred during 11% of the 584 interactions. Showering the resident, hygiene or toilet assistance, and wound dressing changes were associated with a high risk of transmission. Glucose monitoring and assistance with feeding or medication were associated with a low risk of transmission. Residents with a pressure ulcer were 3 times more likely to transmit RGNB than residents without one (OR, 3.3; 95% confidence interval [CI], 1.0-11.1)., Conclusions: Gown and glove use in community nursing facilities should be prioritized for certain residents and care interactions that are deemed a high risk for transmission.

OBJECTIVETo directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practiceDESIGNObservational studySETTING AND PARTICIPANTSHealthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and TexasMETHODSOver a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15-30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.RESULTSA total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.CONCLUSIONSHealthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.Infect Control Hosp Epidemiol 2018;39:683-687.

The objectives of the study were to estimate the risk of transmission of antibiotic-resistant Gram-negative bacteria (RGNB) to gowns and gloves (G&G) worn by health care workers (HCWs) when providing care to nursing home residents and to identify the types of care and resident characteristics associated with transmission. A multicenter, prospective observational study was conducted with residents and HCWs from Veterans Affairs (VA) nursing homes. Perianal swabs to detect RGNB were collected from residents. HCWs wore G&G during usual care activities, and the G&G were swabbed at the end of the interaction in a standardized manner. Transmission of RGNB from a colonized resident to G&G by type of care was measured. Odds ratios (ORs) associated with type of care or resident characteristics were estimated. Fifty-seven (31%) of 185 enrolled residents were colonized with ≥1 RGNB. RGNB transmission to HCW gloves or gowns occurred during 9% of the interactions ( n = 905): 7% to only gloves and 2% to only gowns. Bathing the resident and providing hygiene and toilet assistance were associated with a high risk of transmission. Glucose monitoring and assistance with feeding or medication were associated with a low risk of transmission. In addition, antibiotic use by the resident was strongly associated with greater transmission (OR, 2.51; P < 0.01). RGNB were transferred to HCWs during ∼9% of visits. High-risk types of care were identified for which use of G&G may be prioritized. Antibiotic use was associated with 2.5 times greater risk of transmission, emphasizing the importance of antibiotic stewardship. (This study has been registered at ClinicalTrials.gov under registration no. NCT01350479.)., (Copyright © 2017 American Society for Microbiology.)

Our objective for this study was to characterize the microbial communities of the anterior nares (nose), posterior pharynx (throat), and skin of the femoral and subclavian areas in older adults from nursing homes and the community. Older adults (≥65 years) without antibiotic use for the past 3 months were recruited from nursing homes (NH; n = 16) and from the community (CB; n = 51). Specimens were taken from nose, throat, and skin sites for culture and bacterial profiling using 16S rRNA gene sequencing. We found that pathogenic Gram-negative rod (GNR) colonization on the femoral skin was higher in NH participants than CB participants; otherwise, there were no differences in GNR colonization at other body sites or in Staphylococcus aureus colonization at any body site. Bacterial community profiling demonstrated that the operational taxonomic unit compositions of the different body sites were similar between NH and CB participants, but the analysis identified differences in relative abundance levels. Streptococcus spp. were more abundant and Prevotella spp. were less abundant in the throats of NH participants than in throats of CB participants. Proteus , Escherichia coli , and Enterococcus were more abundant in NH participants on the femoral skin. We found a pattern of decreased abundance of specific Proteobacteria in NH participants at the anterior nares and at both skin sites. We concluded that bacterial communities were largely similar in diversity and composition within body sites between older adults without recent antibiotic use from NH compared to those from the community. Our findings support the rationale for improved hygiene in NH residents to reduce the transmission risk of antibiotic-resistant bacteria, such as Enterococcus spp. or Enterobacteriaceae . IMPORTANCE The nose, throat, and skin over the subclavian and femoral veins are the body sites which harbor the bacteria which most commonly cause health care-associated infection. We assessed the effect of nursing home residence on the microbiota of these body sites in older adults. We found that the microbiota composition of the different body sites was similar between nursing home and community participants, but we identified differences in relative abundance levels. We found remarkable similarities in the bacterial communities of different body sites in older adults who lived in nursing homes compared to those in the community among people who had not been on antibiotics for the past 3 months. We also found that the femoral skin microbiota had evidence of stool contamination in the nursing home residents, providing a rationale for improved skin hygiene. Taken together, it appears that the health care environment does not alter the microbiota to the extent that antibiotics do.

Background: This was an observational study designed to estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) transmission to gowns and gloves worn by health care workers (HCWs) interacting with Veterans Affairs Community Living Center (VA nursing home) residents to inform MRSA prevention policies., Methods: Participants included residents and HCWs from 7 VA nursing homes in 4 states and Washington, DC. Residents were cultured for MRSA at the anterior nares, perianal skin, and wound (if present). HCWs wore gowns and gloves during usual care activities. After each activity, a research coordinator swabbed the HCW's gown and gloves. Swabs were cultured for MRSA., Results: There were 200 residents enrolled; 94 (46%) were MRSA colonized. Glove contamination was higher than gown contamination (20% vs 11%, respectively; P < .01). Transmission varied greatly by type of care from 0%-19% for gowns and 7%-37% for gloves. High-risk care activities (odds ratio [OR] > 1.0, P < .05) for gown contamination included changing dressings (eg, wound), dressing, providing hygiene (eg, brushing teeth), and bathing. Low-risk care activities (OR < 1.0, P < .05 or no transmission) for gown contamination included glucose monitoring, giving medications, and feeding., Conclusions: MRSA transmission from colonized residents to gloves was higher than transmission to gowns. Transmission to gloves varies by type of care, but all care had a risk of contamination, demonstrating the importance of hand hygiene after all care. Transmission to gowns was significantly higher with certain types of care. Optimizing gown and glove use by targeting high-risk care activities could improve resident-centered care for MRSA-colonized residents by promoting a home-like environment., (Published by Elsevier Inc.)

Objectives: To identify patient and healthcare worker factors associated with transmission risk of Acinetobacter baumannii during patient care., Design: Prospective cohort study., Setting: ICUs at a tertiary care medical center., Patients: Adult ICU patients known to be infected or colonized with A. baumannii., Measurements and Main Results: Cultures of skin, respiratory tract, and the perianal area were obtained from participants and evaluated for the presence of A. baumannii. Healthcare worker-patient interactions were observed (up to five interactions/patient) and activities were recorded. Healthcare worker hands/gloves were sampled at room exit (prior to hand hygiene or glove removal) and then evaluated for the presence of A. baumannii. Two hundred fifty-four healthcare worker-patient interactions were observed among 52 patients; A. baumannii was identified from healthcare worker hands or gloves in 77 (30%) interactions. In multivariate analysis, multidrug-resistant A. baumannii (odds ratio, 4.78; 95% CI, 2.14-18.45) and specific healthcare worker activities (touching the bed rail [odds ratio, 2.19; 95% CI, 1.00-4.82], performing a wound dressing [odds ratio, 8.35; 95% CI, 2.07-33.63] and interacting with the endotracheal tube or tracheotomy site [odds ratio, 5.15; 95% CI, 2.10-12.60]), were associated with hand/glove contamination., Conclusions: Healthcare worker hands/gloves are frequently contaminated with A. baumannii after patient care. Patient-level factors were not associated with an increased transmission risk; however, having multidrug-resistant-A. baumannii and specific healthcare worker activities led to an increased contamination risk. Our findings reveal a potential selective advantage possessed by multidrug-resistant-A. baumannii in this environment and suggest possible areas for future research.

Background: To treat patients with methicillin-susceptible Staphylococcus aureus (MSSA) infections, β-lactams are recommended for definitive therapy; however, the comparative effectiveness of individual β-lactams is unknown. This study compared definitive therapy with cefazolin vs nafcillin or oxacillin among patients with MSSA infections complicated by bacteremia., Methods: This retrospective study included patients admitted to 119 Veterans Affairs hospitals from 2003 to 2010. Patients were included if they had a blood culture positive for MSSA and received definitive therapy with cefazolin, nafcillin, or oxacillin. Cox proportional hazards regression and ordinal logistic regression were used to identify associations between antibiotic therapy and mortality or recurrence. A recurrent infection was defined as a MSSA blood culture between 45 and 365 days after the first MSSA blood culture., Results: Of 3167 patients, 1163 (37%) patients received definitive therapy with cefazolin. Patients who received cefazolin had a 37% reduction in 30-day mortality (hazard ratio [HR], 0.63; 95% confidence interval [CI], .51-.78) and a 23% reduction in 90-day mortality (HR, 0.77; 95% CI, .66-.90) compared with patients receiving nafcillin or oxacillin, after controlling for other factors. The odds of recurrence (odds ratio, 1.13; 95% CI, .94-1.36) were similar among patients who received cefazolin compared with patients who received nafcillin or oxacillin, after controlling for other factors., Conclusions: In this large, multicenter study, patients who received cefazolin had a lower risk of mortality and similar odds of recurrent infections compared with nafcillin or oxacillin for MSSA infections complicated by bacteremia. Physicians might consider definitive therapy with cefazolin for these infections., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Objective: To compare the presence of Staphylococcus aureus and pathogenic Gram-negative rods (GNR) in the anterior nares, posterior pharynx and three skin sites in community-based adults and nursing home-based adults before and after treatment with nasal mupirocin and topical chlorhexidine., Methods: S. aureus-colonized adults were recruited from the community (n=26) and from nursing homes (n=8). Eligible participants were cultured for S. aureus and GNR during two study visits and then received intranasal mupirocin and topical chlorhexidine for 5days, with a 2-month follow-up period., Results: After decolonization, we found sustained decreases of S. aureus colonization in nose, throat and skin sites over 4-8weeks in both populations. Intranasal mupirocin did not increase GNR colonization in nose or throat. Chlorhexidine did not decrease GNR colonization in skin sites., Conclusions: Decolonization with mupirocin and chlorhexidine leads to a sustained effect on S. aureus colonization without affecting GNR colonization., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To explore current use and perceptions of glove and gown use in nursing homes., Design: Qualitative study using focus groups and semi-structured interviews., Setting: Three community-based nursing homes in Maryland., Participants: Direct care staff, administrators, and residents., Methods: We conducted three focus groups among nursing home staff, one focus group among nursing home administrators, and five interviews with residents. Topic guides were created based on our recent study results and a review of the literature. Two investigators separately analyzed the transcribed recordings and identified recurrent themes., Results: Direct care staff reported using gowns and gloves primarily as self-protection against contact with bodily fluids, not to prevent MRSA transmission. Glove use was described as common and more acceptable to staff and residents than gown use. Administrators were surprised that MRSA transmission to health care worker hands and clothing occurred during activities when direct care staff perceives no contact with bodily fluids. Staff and administrators expressed willingness to use gowns and gloves for high-risk care activities, particularly if use is targeted toward specific types of residents such as those with pressure ulcers. There was a knowledge deficit about MRSA transmission and infection among direct care staff and residents., Conclusions: Results from this study will inform a strategy to reduce MRSA transmission in long-term care., Competing Interests: The authors have no conflicts of interest to report., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

OBJECTIVE To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes. DESIGN Cost analysis of data collected from a prospective, observational study. SETTING AND PARTICIPANTS Care activity data from 401 residents from 13 nursing homes in 2 states. METHODS Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups. RESULTS The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127). CONCLUSIONS The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities. Infect Control Hosp Epidemiol 2016;37:962-966.

Purpose of Review: The high-risk population and current lack of knowledge regarding appropriate infection prevention in the long-term care (LTC) setting has contributed to substantial rates of resistance and healthcare-associated infections in this arena. More evidence-based research on LTC is necessary, particularly now that the elderly population is increasing., Recent Findings: Proposed government mandates highlight the urgent need to combat antimicrobial resistance in the LTC setting. Recent studies focusing on unique strategies for the prevention of transmission and infection with multidrug-resistant organisms in nursing homes are discussed, as well as attempts to formulate clear antimicrobial stewardship programs., Summary: The long-term setting has unique challenges to instituting effective infection control precautions, therefore current accepted methods used in acute-care facilities need to be modified. Recent data suggest that prevention of transmission in LTC may be achieved with focus on high-risk patients or specific care-based activities rather than colonization status. Antimicrobial stewardship and consultation with specialized physicians may be important measures to combat resistance and adverse events in LTC. The prevention of unnecessary antibiotic use in palliative care may reduce rates of resistance as well as discomfort for terminal patients.

OBJECTIVE To define how often methicillin-resistant Staphylococcus aureus (MRSA) is spread from resident to resident in long-term care facilities using whole-genome sequencing DESIGN Prospective cohort study SETTING A long-term care facility PARTICIPANTS Elderly residents in a long-term care facility METHODS Cultures for MRSA were obtained weekly from multiple body sites from residents with known MRSA colonization over 12-week study periods. Simultaneously, cultures to detect MRSA acquisition were obtained weekly from 2 body sites in residents without known MRSA colonization. During the first 12-week cycle on a single unit, we sequenced 8 MRSA isolates per swab for 2 body sites from each of 6 residents. During the second 12-week cycle, we sequenced 30 MRSA isolates from 13 residents with known MRSA colonization and 3 residents who had acquired MRSA colonization. RESULTS MRSA isolates from the same swab showed little genetic variation between isolates with the exception of isolates from wounds. The genetic variation of isolates between body sites on an individual was greater than that within a single body site with the exception of 1 sample, which had 2 unrelated strains among the 8 isolates. In the second cycle, 10 of 16 residents colonized with MRSA (63%) shared 1 of 3 closely related strains. Of the 3 residents with newly acquired MRSA, 2 residents harbored isolates that were members of these clusters. CONCLUSIONS Point prevalence surveys with whole-genome sequencing of MRSA isolates may detect resident-to-resident transmission more accurately than routine surveillance cultures for MRSA in long-term care facilities. Infect Control Hosp Epidemiol 2016;37:685-691.

Unlabelled: Although Staphylococcus aureus is a prominent cause of infections, no vaccine is currently available. Active vaccination relies on immune memory, a core competence of the adaptive immune system. To elucidate whether adaptive immunity can provide protection from serious complications of S. aureus infection, a prospective observational study of 44 patients with S. aureus infection complicated by bacteremia was conducted. At diagnosis, serum IgG binding to S. aureus extracellular proteins was quantified on immunoblots and with Luminex-based FLEXMAP 3D™ assays comprising 64 recombinant S. aureus proteins. Results were correlated with the course of the infection with sepsis as the main outcome variable. S. aureus-specific serum IgG levels at diagnosis of S. aureus infection were lower in patients developing sepsis than in patients without sepsis (P<0.05). The pattern of IgG binding to eight selected S. aureus proteins correctly predicted the disease course in 75% of patients. Robust immune memory of S. aureus was associated with protection from serious complications of bacterial invasion. Serum IgG binding to eight conserved S. aureus proteins enabled stratification of patients with high and low risk of sepsis early in the course of S. aureus infections complicated by bacteremia., Significance: S. aureus is a dangerous pathogen of ever increasing importance both in hospitals and in the community. Due to the crisis of antibiotic resistance, an urgent need exists for new strategies to combat S. aureus infections, such as vaccination. To date, however, all vaccine trials have failed in clinical studies. It is therefore unclear whether the adaptive immune system is at all able to control S. aureus in humans. The paper demonstrates the use of proteomics for providing an answer to this crucial question. It describes novel results of a prospective study in patients with S. aureus infection complicated by bloodstream invasion. Immune proteomic analysis shows that robust immune memory of S. aureus - reflected by strong serum IgG antibody binding to S. aureus antigens - is associated with clinical protection from sepsis. This lends support to the notion of a vaccine to protect against the most serious complications of S. aureus infection. Hence, the data encourage further efforts in vaccine development., (Copyright © 2015. Published by Elsevier B.V.)

S. aureus vaccine development has proven particularly difficult. The conventional approach to achieve sterile immunity through opsonophagocytic killing has been largely unsuccessful. S. aureus is highly toxigenic and a great body of evidence suggests that a successful future vaccine for this organism should target extracellular toxins which are responsible for host tissue destruction and immunosuppression. Major staphylococcal toxins are alpha toxin (a single subunit hemolysin) along with a group of bicomponent pore-forming toxins (BCPFT), namely Panton-Valentine leukocidin (PVL), gamma hemolysins (HlgCB and AB), LukAB and LukED. In our previous report, an attenuated mutant of LukS-PV (PVL- S subunit) named as "LukS-mut9" elicited high immunogenic response as well as provided a significant protection in a mouse sepsis model. Recent discovery of PVL receptors shows that mice lack receptors for this toxin, thus the reported protection of mice with the PVL vaccine may relate to cross protective responses against other homologous toxins. This manuscript addresses this issue by demonstrating that polyclonal antibody generated by LukS-mut9 can neutralize other canonical and non-canonical leukotoxin pairs. In this report, we also demonstrated that several potent toxins can be created by non-canonical pairing of subunits. Out of 5 pairs of canonical and 8 pairs of non-canonical toxins tested, anti-LukS-mut9 polyclonal antibodies neutralized all except for LukAB. We also studied the potential hemolytic activities of canonical and noncanonical pairs among biocomponent toxins and discovered that a novel non-canonical pair consisting of HlgA and LukD is a highly toxic combination. This pair can lyse RBC from different species including human blood far better than alpha hemolysin. Moreover, to follow-up our last report, we explored the correlation between the levels of pre-existing antibodies to new sets of leukotoxins subunits and clinical outcomes in adult patients with S. aureus bacteremia. We found that there is an inversed correlation between the antibody titer to sepsis for leukotoxins LukS-mut9, LukF-PV, HlgC, LukE and LukAB, suggesting the risk of sepsis was significantly lower in the patients with higher antibody titer against those toxins.

Objective: To estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) transmission to gowns and gloves worn by healthcare workers (HCWs) interacting with nursing home residents to better inform infection prevention policies in this setting, Design: Observational study, Setting: Participants were recruited from 13 community-based nursing homes in Maryland and Michigan, Participants: Residents and HCWs from these nursing homes, Methods: Residents were cultured for MRSA at the anterior nares and perianal or perineal skin. HCWs wore gowns and gloves during usual care activities. At the end of each activity, a research coordinator swabbed the HCW's gown and gloves., Results: A total of 403 residents were enrolled; 113 were MRSA colonized. Glove contamination was higher than gown contamination (24% vs 14% of 954 interactions; P1.0; P<.05). We also identified low-risk care activities: giving medications and performing glucose monitoring (OR<1.0; P<.05). Residents with chronic skin breakdown had significantly higher rates of gown and glove contamination., Conclusions: MRSA transmission from MRSA-positive residents to HCW gown and gloves is substantial; high-contact activities of daily living confer the highest risk. These activities do not involve overt contact with body fluids, skin breakdown, or mucous membranes, which suggests the need to modify current standards of care involving the use of gowns and gloves in the nursing home setting.

Transmission of Staphylococcus aureus colonization in community-based populations is not well understood. We sought to describe the molecular epidemiology of S. aureus colonization in the Old Order Amish. The study was a prospective, observational study of healthy adults and their same-sex siblings who were cultured from the anterior nares twice. S. aureus isolates were characterized using spa typing. Overall, 40% (159/398) of the study population was colonized with S. aureus. There were 84 spa types with the most abundant spa types being t012 (13%) and t021 (7%). There was no clustering of spa types within sibling groups; however, there was clustering within households. There were 111 S. aureus-colonized participant pairs living within the same household. Of these, 47% had concordant spa types. The diversity of spa types across a relatively isolated, genetically homogenous population with a similar lifestyle is striking. Taken together this suggests that S. aureus transmission is a local phenomenon limited to very close contact.

We hypothesized that prior colonization with antibiotic-resistant Gram-negative bacteria is associated with increased risk of subsequent antibiotic-resistant Gram-negative bacteremia among cancer patients. We performed a matched case-control study. Cases were cancer patients with a blood culture positive for antibiotic-resistant Gram-negative bacteria. Controls were cancer patients with a blood culture not positive for antibiotic-resistant Gram-negative bacteria. Prior colonization was defined as any antibiotic-resistant Gram-negative bacteria in surveillance or non-sterile-site cultures obtained 2-365 days before the bacteremia. Thirty-two (37%) of 86 cases and 27 (8%) of 323 matched controls were previously colonized by any antibiotic-resistant Gram-negative bacteria. Prior colonization was strongly associated with antibiotic-resistant Gram-negative bacteremia (odds ratio [OR] 7.2, 95% confidence interval [CI] 3.5-14.7) after controlling for recent treatment with piperacillin-tazobactam (OR 2.5, 95% CI 1.3-4.8). In these patients with suspected bacteremia, prior cultures may predict increased risk of antibiotic-resistant Gram-negative bacteremia., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Cancer patients are frequently immunosuppressed and at risk for a wide range of opportunistic and healthcare-associated infections. A good infection prevention program is extremely important to reduce risk of infection. This review focuses on infection prevention measures specific to patients, healthcare personnel, and visitors in the cancer center.

OBJECTIVE. To determine whether enhanced daily cleaning would reduce contamination of healthcare worker (HCW) gowns and gloves with methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Acinetobacter baumannii (MDRAB). DESIGN. A cluster-randomized controlled trial. SETTING. Four intensive care units (ICUs) in an urban tertiary care hospital. PARTICIPANTs. ICU rooms occupied by patients colonized with MRSA or MDRAB. INTERVENTION. Extra enhanced daily cleaning of ICU room surfaces frequently touched by HCWs. RESULTS. A total of 4,444 cultures were collected from 132 rooms over 10 months. Using fluorescent dot markers at 2,199 surfaces, we found that 26% of surfaces in control rooms were cleaned and that 100% of surfaces in experimental rooms were cleaned (P < .001). The mean proportion of contaminated HCW gowns and gloves following routine care provision and before leaving the rooms of patients with MDRAB was 16% among control rooms and 12% among experimental rooms (relative risk, 0.77 [95% confidence interval, 0.28-2.11]; P = .23). For MRSA, the mean proportions were 22% and 19%, respectively (relative risk, 0.89 [95% confidence interval, 0.50-1.53]; P = .16). DISCUSSION. Intense enhanced daily cleaning of ICU rooms occupied by patients colonized with MRSA or MDRAB was associated with a nonsignificant reduction in contamination of HCW gowns and gloves after routine patient care activities. Further research is needed to determine whether intense environmental cleaning will lead to significant reductions and fewer infections.

We assessed whether age modified the association between methicillin-resistant Staphylococcus aureus (MRSA) anterior nares colonization and subsequent infection. Among 7,405 patients (9,511 admissions), MRSA colonization was significantly associated with infection (adjusted odds ratio, 13.7 [95% confidence interval, 7.3-25.7]) but did not differ significantly by age group.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

Background: Staphylococcus aureus has numerous virulence factors, including exotoxins that may increase the severity of infection. This study was aimed at assessing whether preexisting antibodies to S. aureus toxins are associated with a lower risk of sepsis in adults with S. aureus infection complicated by bacteremia., Methods: We prospectively identified adults with S. aureus infection from 4 hospitals in Baltimore, MD, in 2009–2011. We obtained serum samples from prior to or at presentation of S. aureus bacteremia to measure total immunoglobulin G (IgG) and IgG antibody levels to 11 S. aureus exotoxins. Bacterial isolates were tested for the genes encoding S. aureus exotoxins using polymerase chain reaction (PCR)., Results: One hundred eligible subjects were included and 27 of them developed sepsis. When adjusted for total IgG levels and stratified for the presence of toxin in the infecting isolate as appropriate, the risk of sepsis was significantly lower in those patients with higher levels of IgG against α-hemolysin (Hla), δ-hemolysin (Hld), Panton Valentine leukocidin (PVL), staphylococcal enterotoxin C-1 (SEC-1), and phenol-soluble modulin α3 (PSM-α3)., Conclusions: Our results suggest that higher antibody levels against Hla, Hld, PVL, SEC-1, and PSM-α3 may protect against sepsis in patients with invasive S. aureus infections.