Infection Control & Hospital Epidemiology
Having an ostomy bag also had a strong association with transmission to HCP gowns (OR, 5.4; 95% CI, 1.8–16.1); however, this finding was driven by HCP interactions with a single nursing home resident with other risk factors (ie, hemiplegia, currently on antibiotics, feeding tube). Due to the selective pressure of antibiotics on MDRO colo-
nization,15 we analyzed the association between the resident’s antibiotic use and RGNB transmission risk. Overall, 15% of our colonized population was receiving systemic antibiotics at the time of enrollment. The residents received fluoroquinolones, cephalosporins, tetracyclines, sulfamethoxazole trimethoprim, amoxicillin, or glycopeptides. Residents using systemic antibiotics at enrollment did not have a significantly higher odds of gown or glove contamination than residents not on antibiotics at enroll- ment (OR, 1.5; P=.57 vs OR, 1.3; P=.66, respectively).
Discussion
Overall, 11% of the HCP interactions with an RGNB-colonized resident resulted in the transmission of RGNB to HCP glove or gowns in community nursing homes. Showering, bathing, and dressing the resident, as well as diaper change, providing hygiene, and transferring the resident were identified as high-risk types of care for HCP gown and glove contamination. Glucose monitoring and assistance with medications were also identified as low-risk activities. Having an unhealed pressure ulcer increased the risk of RGNB transmission from the resident to the HCP. The observed high-risk and low-risk types of care were con-
resistant gram-negative bacteria.16,17 Braga et al16 isolated 72 gram-negative isolates from infected or colonized pressure ulcers of 60 different patients. Also, 7% of the isolates were resistant to fluoroquinolones, 76% were resistant to cephalosporins, 14% were resistant to carbapenems, and 40% were multidrug resistant.16 Furthermore, the presence of pressure ulcers has been described as a risk factor associated with RGNB colonization.18 Given this finding and the high dependency of those with pressure ulcers on HCP for care, it is not surprising that interacting with a resident with a pressure ulcer was associated with a higher risk of RGNB transmission. This finding is consistent with previously published results by our group about MRSA transmission to HCP gowns and gloves from MRSA-colonized residents in this popu- lation.9 Additionally, we observed similar high-risk activities associated with transmission of RGNB and MRSA among this subpopulation.9 Although we observed a similar risk of transmission of RGNB
sistent with previously published results by our group about RGNB transmission to HCP’s gowns and gloves from RGNB colonized residents in VA nursing homes.10 These findings were also consistent with the high-risk and low-risk types of care associated with MRSA transmission in this same population.9 Pressure ulcers have been shown to be reservoirs of multidrug-
to gloves associated with systemic antibiotic use, we were unable to replicate the positive association between systemic antibiotic use and transmission to gowns previously described in VA community living centers.10 Although both colonized populations had similar antibiotic use at enrollment, the current population received mostly broad-spectrum antibiotics, which could have impacted both gram-negative and gram-positive bacteria coloni- zation and, as a result, their transmission to HCP gowns and gloves. Topical antibiotic use was not recorded for the current study, which could help explain this difference.
1429 As observed in our prior studies, we detected transmission of
RGNB to HCP gloves or gown from residents not detected to be colonized by RGNB in the perianal culture.9,10,19 Other potential sources of RGNB exist that could explain these findings, such as other body sites of RGNB colonization (eg, skin or wounds) or the envir- onment.20–24 Importantly, the definition of transmission of RGNB in residents not colonized at the study baseline is less strict than among colonized residents because there is no baseline isolate to match the HCP gown and glove isolate by antibiotic resistance and specific bacteria. All nursing homes should recognize the high prevalence of RGNB in their population and environment. Colonization of RGNB in nursing home residents has been described as high as 59%,1,3 highlighting the need for appropriate and effective guidelines for gown and glove use that protect their HCP and their other residents. This study is limited by the fact that our outcome, transmission to
HCP gowns and gloves, acts as a surrogate for RGNB transmission to other nursing home residents. We were unable to estimate how often contamination of gowns and gloves resulted in transmission to other HCP or residents.10,19 We did not perform molecular typing to compare the residents’ strains with the strains isolated from gowns and gloves. In earlier studies, we observed a high concordance (up to 89%) between antibiotic resistant strains from residents and those detected on gowns and gloves.9,21 Our study is strengthened by its design, a multisite prospective study, which is representative of community nursing facilities across the United States. In contrast to other healthcare settings, nursing homes call for
a balance between infection prevention and a home-like atmo- sphere. Nursing homes are also more limited in resources than acute-care hospitals. Therefore, evidence-based guidelines tailored to this setting are important. This study provides evidence sup- porting the potential benefit of a care-based or resident-specific approach to reduce the transmission of MDROs in community nursing homes.
Acknowledgments.
Financial support. This project was supported by the National Institutes of Health (NIH grant no. R03AI122223). Dr Sorkin and Dr Roghmann are supported by the Baltimore Veterans Affairs (VA) Medical Center Geriatrics Research, Education, and Clinical Center, the National Institute on Aging (grant no. 5 P30 AG028747), and the National Institute of Diabetes and Digestive and Kidney Diseases (grant no. 5 P30 DK072488). Dr Mody is supported by the Ann Arbor VA Geriatrics Research, Education, and Clinical Center, National Institute on Aging (grant nos. R01 AG032298, R01 AG41780, R18 HS019979) and by the University of Michigan Claude D. Pepper Older Americans Independence Center (grant no. P30 AG024824).
Conflicts of interest. L.M. reports receiving grants from the NIH and the AHRQ during the conduct of the study. All other authors report no conflicts of interest relevant to this article.
References
1. Mody L, Foxman B, Bradley S, et al. Longitudinal assessment of multidrug-resistant organisms in newly admitted nursing facility patients: implications for an evolving population. Clin Infect Dis. 2018;67:837–844.
2. Cassone M, Mody L. Colonization with multi-drug resistant organisms in nursing homes: scope, importance, and management. Curr Geriatr Rep. 2015;4:87–95.
3. Aliyu S, Smaldone A, Larson E. Prevalence of multidrug-resistant gram- negative bacteria among nursing home residents: a systematic review and meta-analysis. Am J Infect Control 2017;45:512–518.
4. Harris AD, Perencevich EN, Johnson JK, et al. Patient-to-patient transmission is important in extended-spectrum beta-lactamase-
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124
