Could Simple Measures Tip the Balance Against Antimicrobial Resistance in Nursing Homes?

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 multidrug resistant organisms (MDROs) among nursing home residents who relied on devices that carry a high risk of infection. The paper is published in JAMA Internal Medicine.

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% 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% 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% and 22%, respectively.

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

1. surveillance for infections and MDRO colonization with regular feedback to the nursing home;
2. extensive and interactive staff education using adult learning theory about key infection prevention practices and hand hygiene; and
3. 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, MD, an associate professor of internal medicine at the University of Michigan Medical School, research scientist at the VA Ann Arbor Geriatrics Research Education and Clinical Center, and research associate professor at the University of Michigan 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 health care personnel and using multianatomic 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 health care systems and reducing hospital length of stay, 40% 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."

Source: University of Michigan Health System