SHEA/CDC/AMDA Sponsored Post-Acute and Long-Term Care Certificate Course

The SHEA/CDC/AMDA infection prevention in Post-Acute and Long-Term Care certificate course will take place during the first 2 days of the SHEA 2016 meeting.

Q: What will the SHEA/CDC/AMDA Post-Acute and Long-Term Care course cover?

     A: Starting with an overview of healthcare epidemiology, the course will go over surveillance definitions and how surveillance data can be put to good use (beyond satisfying checkboxes on surveyors’ clipboards). The speakers will also discuss aspects of infection prevention that are unique to skilled nursing facilities, where residents enjoy shared dining, recreation and rehabilitation experiences. Sessions will also address occupational health concerns in long-term care, including outbreaks that affect both staff and residents, such as influenza and norovirus. (Did you know that a box of chocolates is a great vector for norovirus? Poor Forrest Gump…..). The course will also emphasize opportunities to reduce unnecessary and inappropriate antimicrobial use. Speakers will specifically discuss communication at care transitions and ways to educate talking with concerned family members, who may have been taught myths and misinformation about antibiotic use for UTI management (e.g., bad dreams are an indication for treating a positive urine culture with antibiotics). Really.

Q: What does the SHEA/CDC/AMDA Post-Acute and Long-Term Care certificate look like?

     A:

Q: Where can I sign up for SHEA 2016 and the Certificate Course?

     A: At the SHEA 2016 meeting website: here

Q: Is there an early bird discount?

     A: Yes! Register before February 15, 2016

Lovin' Contact Precautions (this time in nursing homes)

Contact precautions get very little love on our humble blog. So little in fact, that I've taken it upon myself to be the resident contact precautions fanboy. Just today on rounds, I was waxing sentimental about the poor yellow gowns that protect us from horrible pathogens and how we unceremoniously toss them into the trash after wearing them - we never even say goodbye...but I digress

There is a new study in the September ICHE by Mary-Claire Roghmann and colleagues from the University of Maryland and University of Michigan that sought to estimate the transmission of MRSA from nursing home residents to healthcare workers' gowns and gloves based on clinical activity and resident characteristics (i.e. skin integrity or stool incontinence).  They aimed to determine if there were certain situations where wearing gowns/gloves would be most protective of HCW contamination (and thus reduce MRSA transmission).  The logic - if gowns and gloves are contaminated, the underlying hands would be contaminated if gloves/gowns weren't worn and since no one has ever gotten hand hygiene compliance near 90-100% anywhere, including nursing homes, then gowns/gloves result in cleaner hands and less MRSA transmission. I know, much more complicated than a cluster-RCT, but important data...but I digress again...

RESULTS! Overall, they enrolled 401 nursing home residents from 13 facilities including 113 (28%) who were MRSA colonized. 62% were nasally colonized, 9% were colonized at the perianal skin and 28% were colonized at both sites. There were 954 HCW interactions (median 7 per patient) with MRSA+ patients with a median duration of 6 minutes. Overall, gowns were contaminated after 14% of the interactions and gloves were contaminated 24% of the time. Gown/Glove isolates were identical (Spa type) to patient isolates 89% of the time. Overall, the contamination rate ranged from zero to 24% for gowns and 8 to 37% for gloves based on activity. So as far as hand contamination goes, there were no safe interactions and thus, we wouldn't expect activity-based precautions to be effective. (See figure below)  Significant predictors of glove/gown contamination included dressing, transferring, patient hygiene, changing linens and changing diapers.

As far as patient characteristics, stool incontinence did not modify gown/glove contamination with MRSA, but skin breakdown was associated with higher contamination when healthcare workers transferred the patient, changed their diapers and helped dress the patient.

My interpretation of the study is that if we want to limit the substantial transmission of MRSA in nursing homes, we better up our game. And that game should probably include gloves and perhaps gowns for most of the analyzed patient care activities. Unless we can get hand hygiene compliance up to 100%, we better just learn to love the glove.

SHEA 2015: *New* Post-Acute and Long-Term Care Track

 

This is a special guest post by Dr. Silvia Munoz-Price, Enterprise Epidemiologist at Froedtert & Medical College of Wisconsin Institute for Health and Society and the Department of Medicine. She is co-directing the new SHEA Certificate Track in Post-Acute and Long-Term Care at the 2015 SHEA Meeting in Orlando.

In healthcare, we are in the process of transforming our approach from caring of an isolated individual to caring for the population as a whole. Similarly, we are slowly migrating from paying attention to single hospital encounters to focusing on the continuum of care of individuals. These facts are important in the fields of Infection Control and Hospital Epidemiology, as in order to control the spread of highly resistant pathogens we need to internalize that our hospital systems are interconnected through patient transfers. This is particularly evident in the interactions between acute care hospitals, long term care acute care hospitals (LTACHs), and nursing homes within regions. A few years ago, this interrelatedness was elegantly described by Won and colleagues in the midst of a regional outbreak of KPC Klebsiella pneumoniae in the Chicago area (Won et al CID 53: 532-540, figure below). Furthermore, controlling the spreadwithin the LTACH changed the whole transmission dynamic in the region (Munoz-Price Infect Control Hosp Epidemiol. 2010 Apr;31(4):341-7).

Research dealing with Infection Control practices in post-acute care settings is progressing, as recently described in this blog here, here and here. Given our interdependence, it is fundamental that providers in post-acute care --who deal directly with these infection control issues-- are knowledgeable and up to date. This year, SHEA’s Spring meeting will have a 2-day post-acute care track specifically designed to provide a general infection control overview to infection control personnel in post-acute care and LTACHs. The co-Director of this track, Dr. Nimalie Stone, is the Medical Epidemiologist for Long-term Care in the Division of Healthcare Quality Promotion (DHQP) at CDC. Additionally, we will have top notch speakers such as David Nace, Lona Mody, Curtis Donskey, among others. Upon completion, attendees will receive a certificate from SHEA.

A full description of the track can be found here. Participation and engagement of our post-acute care/LTACH colleagues is fundamental to succeed in our fight against hospital acquired infections.

We hope to meet you in Orlando!

Discounted registration ends April 17th (save $100), so register now!

Screening, Decolonization and Environmental Decontamination for MRSA in Nursing Homes Doesn't Work

Just in the past couple of weeks, we've written about pneumonia prevention bundles, MDRO prevention bundles, and spread of S. aureus - all in nursing homes.  It's like no one cares about acute care facilities any more! (humor) There is now more great data for those charged with managing infection control in nursing homes.

Cristina Bellini and colleagues from Lausanne University Hospital in Switzerland just published the results of cluster-randomized trial of an MRSA prevention bundle in 104 nursing homes (53 intervention, 51 control) in the April ICHE. All residents in intervention and control nursing homes (NH), who gave consent, were screened for MRSA carriage at study entry and 12 months thereafter on a single day in each NH. Newly admitted or readmitted residents were screened when admitted to the NH. Screening included nasal, groin and ulcer swabs along with urine cultures if residents had an indwelling catheter. In the intervention NHs MRSA colonized residents underwent decolonization along with environmental decontamination.

The primary decolonization bundle included 5 days of nasal mupirocin, 5 days of CHG oral rinse twice per day, 5 days of CHG showers including CHG shampoo on day 1 and 5. Environmental disinfection included daily clothing changes for 5 days, new linens on day 1 and day 5, and daily bed/table/phone/remote/wheelchair/walker disinfection with 70% alcohol. A lot of steps.

Unfortunately, the MRSA decolonization and decontamination bundle was not successful. The baseline prevalence of MRSA was 8.9% in both groups. The rate declined in intervention units to 5.8% in the intervention unit and 6.6% on the control units after 12 months (p=0.66) Full stratified results are in Table 3 below, and as you can see, no matter how they analyzed the intervention, the MRSA bundle intervention did not reduce MRSA prevalence compared to controls. This was despite the fact that the participation rate was 87%.

A limitation of this study was that they only measured prevalence and not individual level acquisition of MRSA. It is possible that by measuring prevalence they missed detecting benefits of the intervention related to reduced patient-to-patient transmission of MRSA. In any case, as I said last week about the study in CID, congratulations to the authors and journal (this time ICHE) for publishing this important negative study.

Pneumonia Prevention Bundle in Nursing Homes: A Cluster-randomized Trail

If you're looking for another infection prevention bundle in long-term care, look no further than the March 15th issue of CID that included a cluster-randomized trial of a pneumonia prevention bundle in 36 Connecticut nursing homes by Juthani-Mehta and colleagues at Yale. (full text free)  Residents in the intervention nursing homes with at least one risk factor (impaired oral hygiene or swallowing difficulty) received a bundle that included manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding.

The primary outcome was development of first pneumonia defined as "presence of (1) a compatible infiltrate on chest radiograph (CXR) (if previous CXR was available, the infiltrate had to be new or worsened) and (2) at least 2 of the following clinical features within 72 hours of the CXR-documented infiltrate: fever, pleuritic chest pain, respiratory rate over 25 breaths/minute, worsening functional status (ie, decline in level of consciousness or activities of daily living), or new or increased cough, sputum production, shortness of breath, or chest examination findings."  The secondary outcome was first lower respiratory tract infection (LRTI).

After enrolling 834 participants (434 to the intervention arm and 400 to the control arm), the DSMB terminated the study for futility. Results showed no significant differences for cumulative incidence of first pneumonia (Figure 2A, below) or first LRTI between intervention and control arms. In fact, you can see that the intervention arm appears to have higher incidence of first pneumonia, which is concerning. Of note, adherence was 87.9% to chlorhexidine, 75.0% to toothpaste and 100% for upright feeding position in the intervention facilities. The authors offer several explanations for the study's failure, none of which are entirely convincing. For example, adherence at these levels should have still shown some benefit and not a trend toward harm, so it's unlikely that compliance explains the results. For those interested in reading more, there is an excellent commentary by Lona Mody, who we also mentioned last week. And congratulations to the authors and journal for publishing this important negative study.

USA300 invades a nursing home

A study in this month's Emerging Infectious Diseases analyzes the molecular epidemiology of MRSA infections over a 10 year period (1997-2006) at a 1,000 bed long-term care facility in San Francisco. Of the nearly 1,300 patients with S. aureus clinical isolates, 58% were methicillin resistant, with an increase to 72% methicillin resistance in 2006. Most notably, in 2002 11% of MRSA isolates were the USA300 clone with a sharp rise to 64% in 2006. The majority of USA300 strains were associated with skin/soft tissue infections. Given the high rates of transfer of patients between LTCFs and acute care hospitals, the implications of this study are very important, and we must be concerned with how widespread this problem is beyond the LTCF studied.