A targeted infection prevention intervention in nursing home residents with indwelling devices: A randomized clinical trial - Abstract

IMPORTANCE: Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs).

Inadequate care of residents with these devices contributes to high rates of multi-drug resistant organisms (MDROs) and device-related infections in NHs.

OBJECTIVE: To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections.

DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both.

INTERVENTIONS: Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education.

MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables.

RESULTS: In total, 418 NH residents with indwelling devices were enrolled, with 34 174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections.

CONCLUSIONS AND RELEVANCE: Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals.

Written by:
Mody L, Krein SL, Saint SK, Min LC, Montoya A, Lansing B, McNamara SE, Symons K, Fisch J, Koo E, Rye RA, Galecki A, Kabeto MU, Fitzgerald JT, Olmsted RN, Kauffman CA, Bradley SF.   Are you the author?
Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor; Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Division of General Medicine, University of Michigan Health System, Ann Arbor; Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Rosenstiel School of Marine and Atmospheric Science, University of Miami, Miami, Florida; Hemlock, Michigan; Department of Biostatistics, University of Michigan Medical School, Ann Arbor; Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Medical Education, University of Michigan Medical School, Ann Arbor; Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan; Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.

Reference: JAMA Intern Med. 2015 Mar 16. Epub ahead of print.
doi: 10.1001/jamainternmed.2015.132


PubMed Abstract
PMID: 25775048

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