Could simple measures tip the balance against antimicrobial resistance in nursing homes?

Multi-center study led by U-M researchers shows reductions in MDROs and infections in high-risk nursing home residents

ANN ARBOR, Mich. -- Simple measures might be all it takes to push back at the spread of ‘superbugs’ in nursing homes, and reduce infections. That’s the finding of a new study that focused on multi-drug resistant organisms, or MDROs, among nursing home residents who relied on devices that carry a high risk of infection.

The study, by researchers at the University of Michigan and VA Ann Arbor Healthcare System, is important to the health of the more than 1.5 million residents living in 15,600 nursing homes in the United States.

The level of illness in this population has increased substantially in the last decade, as has the risk of acquiring new infections. As many as 35 percent of nursing home residents are infected with MDROs, surpassing the level seen in hospitals.

Nursing homes historically have had fewer infection prevention resources than hospitals, which contributes to these high rates. Patients with devices that stay in their bodies, such as urinary catheters and feeding tubes, present an attractive habitat for ‘superbugs,’ setting the stage for device-related infections.

In the new study of patients with these indwelling devices, as they are called, MDROs were reduced by 23 percent among 418 residents in six southeast Michigan nursing homes who participated over the course of the three-year study.

The numbers of catheter-associated urinary tract infections and MRSA acquisitions also decreased, by 46 percent and 22 percent respectively. Their paper is published online in JAMA Internal Medicine.

The authors examined the effect of a targeted infection program, or TIP, to reduce the prevalence of MDROs and of new infections associated with catheters or feeding tubes. The TIP intervention was three-fold:

a)    surveillance for infections and MDRO colonization with regular feedback to the nursing home;

b)    extensive and interactive staff education using adult learning theory about key infection prevention practices and hand hygiene; and

c)    use of gloves and gowns when providing assistance to patients for high-risk activities such as bathing and grooming.

“We presumed that all patients in the study were colonized with MDROs from the beginning, so we encouraged staff to wear gowns and gloves when providing patient care,” says Lona Mody, M.D., an associate professor of Internal Medicine at the U-M Medical School, Research Scientist at the VA Ann Arbor Geriatrics Research Education and Clinical Center (GRECC) and research associate professor at the U-M Institute of Gerontology.

Facilities were updated regularly on the number of MDROs and infections that the researchers detected. Staff education emphasized precautionary measures against the spread of infection and included mock game shows, songs and dances. Outcomes were measured by results of the cultures taken for each patient and monitoring infection rates.

The trial adapted new methodological approaches and study design to study infection prevention interventions including the use of cluster-randomized study design, adopting adult learning practices to engage frontline healthcare personnel and using multi-anatomic site sampling to demonstrate effectiveness of the program.  

“This research program engages community-based nursing homes with little experience in conducting prospective research,” says Mody. “They have few infection prevention resources, but these do not have to be barriers to implementing best practices and enhancing patient safety. The strategies we demonstrate in this study can successfully be adopted in traditionally resource-poor settings, and applied as narrowly or as broadly as desired.”

With the move towards integrated healthcare systems and reducing hospital length of stay, 40 percent of Medicare beneficiaries who have a hospital stay now head to a nursing home first.

As a result, today’s nursing home population is sicker, making it increasingly important to adjust and enhance evidence-based infection prevention practices accordingly. Many nursing home residents will need hospitalization again, raising the possibility that MDROs could travel with them and spread to others. 

“Reduction in MDROs among the high risk short-stay and long-stay nursing home population will decrease transmission of these superbugs between institutions,” says Mody. “This study provides a strong argument to reconsider MDRO management in nursing homes.”

Co-authors are Sarah L. Krein, Ph.D., Sanjay Saint, M.D., Lillian C. Min., M.D., Ana Montoya, M.D., Bonnie Lansing, LPN, Sara E. McNamara, MPH, Kathleen Symons, BA, Jay Fisch, BS, Evonne Koo, MPH, Ruth Anne Rye, BS, Andrzej Galecki, M.D., Ph.D., Mohammed U. Kabeto, MS, James T. Fitzgerald, Ph.D., Russell N. Olmsted, MPH, Carol A. Kauffman, M.D., Suzanne F. Bradley, M.D.

Saint and Krein are members of the U-M Institute for Healthcare Policy and Innovation.

Funding: National Institute on Aging (RO1AG032298, RO1AG041780), National Institutes of Health (K23AGO28943) and by the Claude D. Pepper Older American Independence Centers funding from the National Institute on Aging.

Disclosure: None

Reference: JAMA Intern Med. doi:10.1001/jamainternmed.201.132 Published online March 16, 2015.

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