Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial

Lona Mody, Kyle J Gontjes, Marco Cassone, Kristen E Gibson, Bonnie J Lansing, Julia Mantey, Mohammed Kabeto, Andrzej Galecki, Lillian Min, Lona Mody, Kyle J Gontjes, Marco Cassone, Kristen E Gibson, Bonnie J Lansing, Julia Mantey, Mohammed Kabeto, Andrzej Galecki, Lillian Min

Abstract

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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mody reported receiving grants from the Agency for Healthcare Research and Quality and serving as a consultant for UpToDate. No other disclosures were reported.

Figures

Figure.. Participant Enrollment Flowchart
Figure.. Participant Enrollment Flowchart
Patients were enrolled within 14 days of arrival at the nursing home.

References

    1. Cassone M, Mody L. Colonization with multi-drug resistant organisms in nursing homes: scope, importance, and management. Curr Geriatr Rep. 2015;4(1):87-95. doi:10.1007/s13670-015-0120-2
    1. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, Enterococcus, gram-negative bacilli, Clostridium difficile, and Candida. Ann Intern Med. 2002;136(11):834-844. doi:10.7326/0003-4819-136-11-200206040-00013
    1. Cassone M, Zhu Z, Mantey J, et al. . Interplay between patient colonization and environmental contamination with vancomycin-resistant Enterococci and their association with patient health outcomes in postacute care. Open Forum Infect Dis. 2019;7(1):ofz519. doi:10.1093/ofid/ofz519
    1. Dumyati G, Stone ND, Nace DA, Crnich CJ, Jump RL. Challenges and strategies for prevention of multidrug-resistant organism transmission in nursing homes. Curr Infect Dis Rep. 2017;19(4):18. doi:10.1007/s11908-017-0576-7
    1. Davis KA, Stewart JJ, Crouch HK, Florez CE, Hospenthal DR. Methicillin-resistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA infection. Clin Infect Dis. 2004;39(6):776-782. doi:10.1086/422997
    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(6):837-844. doi:10.1093/cid/ciy194
    1. McKinnell JA, Miller LG, Singh RD, et al. . High prevalence of multidrug-resistant organism colonization in 28 nursing homes: an “iceberg effect.” J Am Med Dir Assoc. 2020;21(12):1937-1943.e2. doi:10.1016/j.jamda.2020.04.007
    1. Suleyman G, Alangaden G, Bardossy AC. The role of environmental contamination in the transmission of nosocomial pathogens and healthcare-associated infections. Curr Infect Dis Rep. 2018;20(6):12. doi:10.1007/s11908-018-0620-2
    1. Ludden C, Cormican M, Austin B, Morris D. Rapid environmental contamination of a new nursing home with antimicrobial-resistant organisms preceding occupation by residents. J Hosp Infect. 2013;83(4):327-329. doi:10.1016/j.jhin.2012.11.023
    1. Murphy CR, Eells SJ, Quan V, et al. . Methicillin-resistant Staphylococcus aureus burden in nursing homes associated with environmental contamination of common areas. J Am Geriatr Soc. 2012;60(6):1012-1018. doi:10.1111/j.1532-5415.2012.03978.x
    1. Gontjes KJ, Gibson KE, Lansing B, Cassone M, Mody L. Contamination of common area and rehabilitation gym environment with multidrug-resistant organisms. J Am Geriatr Soc. 2020;68(3):478-485. doi:10.1111/jgs.16284
    1. Cassone M, Mantey J, Perri MB, et al. . Environmental panels as a proxy for nursing facility patients with methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus colonization. Clin Infect Dis. 2018;67(6):861-868. doi:10.1093/cid/ciy115
    1. Patel PK, Mantey J, Mody L. Patient hand colonization with MDROs is associated with environmental contamination in post-acute care. Infect Control Hosp Epidemiol. 2017;38(9):1110-1113. doi:10.1017/ice.2017.133
    1. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73(4):305-315. doi:10.1016/j.jhin.2009.04.019
    1. Chen W, Li S, Li L, Wu X, Zhang W. Effects of daily bathing with chlorhexidine and acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a meta-analysis. J Thorac Dis. 2013;5(4):518-524.
    1. Septimus EJ, Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016;29(2):201-222. doi:10.1128/CMR.00049-15
    1. Hayden MK, Lin MY, Lolans K, et al. ; Centers for Disease Control and Prevention Epicenters Program . Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae in long-term acute-care hospitals. Clin Infect Dis. 2015;60(8):1153-1161. doi:10.1093/cid/ciu1173
    1. Torgerson DJ. Contamination in trials: is cluster randomisation the answer? BMJ. 2001;322(7282):355-357. doi:10.1136/bmj.322.7282.355
    1. Donner A, Klar NS. Design and Analysis of Cluster Randomisation Trials in Health Research. Arnold; 2000:64-69.
    1. Mantey J, Min L, Cassone M, Gibson KE, Mody L. Changing dynamics of colonization in nursing facility patients over time: reduction in methicillin-resistant Staphylococcus aureus (MRSA) offset by increase in vancomycin-resistant Enterococcus (VRE) prevalence. Infect Control Hosp Epidemiol. 2019;40(9):1069-1070. doi:10.1017/ice.2019.169
    1. Mills JP, Zhu Z, Mantey J, et al. . The devil is in the details: factors influencing hand hygiene adherence and contamination with antibiotic-resistant organisms among healthcare providers in nursing facilities. Infect Control Hosp Epidemiol. 2019;40(12):1394-1399. doi:10.1017/ice.2019.292
    1. Mody L, Krein SL, Saint S, et al. . A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial. JAMA Intern Med. 2015;175(5):714-723. doi:10.1001/jamainternmed.2015.132
    1. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186. doi:10.1093/geront/9.3_Part_1.179
    1. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245-1251. doi:10.1016/0895-4356(94)90129-5
    1. Saliba D, Buchanan J. Development and Validation of a Revised Nursing Home Assessment Tool: MDS 3.0. RAND Health; 2008.
    1. Huang SS. Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why? J Hosp Infect. 2019;103(3):235-243. doi:10.1016/j.jhin.2019.08.025
    1. Donskey CJ, Deshpande A. Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: a review of the literature. Am J Infect Control. 2016;44(5)(suppl):e17-e21. doi:10.1016/j.ajic.2016.02.024
    1. Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: expanding the armamentarium for infection control and prevention. Clin Infect Dis. 2008;46(2):274-281. doi:10.1086/524736
    1. Roghmann M-C, Lydecker AD, Langenberg P, Mongodin EF, Johnson JK. Microbiological effect of mupirocin and chlorhexidine for Staphylococcus aureus decolonization in community and nursing home based adults. Diagn Microbiol Infect Dis. 2017;88(1):53-57. doi:10.1016/j.diagmicrobio.2017.02.005
    1. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073-2079. doi:10.1001/archinte.167.19.2073
    1. Kampf G. Acquired resistance to chlorhexidine—is it time to establish an ‘antiseptic stewardship’ initiative? J Hosp Infect. 2016;94(3):213-227. doi:10.1016/j.jhin.2016.08.018
    1. Climo MW, Yokoe DS, Warren DK, et al. . Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-542. doi:10.1056/NEJMoa1113849
    1. Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infect Control Hosp Epidemiol. 2009;30(10):959-963. doi:10.1086/605925
    1. Vernon MO, Hayden MK, Trick WE, Hayes RA, Blom DW, Weinstein RA; Chicago Antimicrobial Resistance Project (CARP) . Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med. 2006;166(3):306-312. doi:10.1001/archinte.166.3.306
    1. Miller L, Mckinnell JA, Singh R, et al. . Reduction of MDRO colonization in nursing home residents with routine use of chlorhexidine bathing and nasal iodophor (Project PROTECT). Open Forum Infect Dis. 2016;3(suppl 1):1386. doi:10.1093/ofid/ofw172.1089
    1. Roghmann M-C, Johnson JK, Sorkin JD, et al. . Transmission of methicillin-resistant Staphylococcus aureus (MRSA) to healthcare worker gowns and gloves during care of nursing home residents. Infect Control Hosp Epidemiol. 2015;36(9):1050-1057. doi:10.1017/ice.2015.119
    1. Min L, Galecki A, Mody L. Functional disability and nursing resource use are predictive of antimicrobial resistance in nursing homes. J Am Geriatr Soc. 2015;63(4):659-666. doi:10.1111/jgs.13353
    1. Lydecker AD, Osei PA, Pineles L, et al. . Targeted gown and glove use to prevent Staphylococcus aureus acquisition in community-based nursing homes: a pilot study. Infect Control Hosp Epidemiol. 2021;42(4):448-454. doi:10.1017/ice.2020.1219
    1. Mody L, McNeil SA, Sun R, Bradley SE, Kauffman CA. Introduction of a waterless alcohol-based hand rub in a long-term-care facility. Infect Control Hosp Epidemiol. 2003;24(3):165-171. doi:10.1086/502185
    1. Schweon SJ, Edmonds SL, Kirk J, Rowland DY, Acosta C. Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility. Am J Infect Control. 2013;41(1):39-44. doi:10.1016/j.ajic.2012.02.010
    1. Huang GKL, Stewardson AJ, Grayson ML. Back to basics: hand hygiene and isolation. Curr Opin Infect Dis. 2014;27(4):379-389. doi:10.1097/QCO.0000000000000080
    1. Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands: a missed opportunity. JAMA Intern Med. 2016;176(5):705-706. doi:10.1001/jamainternmed.2016.0142
    1. Mody L, Washer LL, Kaye KS, et al. . Multidrug-resistant organisms in hospitals: what is on patient hands and in their rooms? Clin Infect Dis. 2019;69(11):1837-1844. doi:10.1093/cid/ciz092
    1. Lee MH, Lee GA, Lee SH, Park YH. Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review. J Hosp Infect. 2019;102(4):377-393. doi:10.1016/j.jhin.2019.02.008
    1. Uchida M, Pogorzelska-Maziarz M, Smith PW, Larson E. Infection prevention in long-term care: a systematic review of randomized and nonrandomized trials. J Am Geriatr Soc. 2013;61(4):602-614. doi:10.1111/jgs.12175

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