Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia

Abstract Background Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in ‘real-world’ practice. Methods This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer’s disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents’ charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive. Discussion TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the ‘real-world’. Trial registration ClinicalTrials.gov, NCT03244917. Registered on 10 August 2017.

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Multidrug-Resistant Gram-Negative Bacteria: Inter- and Intradissemination Among Nursing Homes of Residents With Advanced Dementia

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2015.97 ◽

2015 ◽

Vol 36 (8) ◽

pp. 930-935 ◽

Cited By ~ 17

Author(s):

Erika M. C. D’Agata ◽

Daniel Habtemariam ◽

Susan Mitchell

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Risk Group ◽

Nursing Home Residents ◽

Multidrug Resistant ◽

High Risk Group ◽

Pulsed Field Gel Electrophoresis ◽

Gram Negative Bacteria ◽

Advanced Dementia ◽

Gram Negative

OBJECTIVETo quantify the extent of inter– and intra–nursing home transmission of multidrug-resistant gram-negative bacteria (MDRGN) among residents with advanced dementia and characterize MDRGN colonization among these residents.DESIGNProspective cohort study.SETTINGTwenty-two nursing homes in the greater Boston, Massachusetts, area.PATIENTSResidents with advanced dementia.METHODSSerial rectal surveillance cultures for MDRGN and resident characteristics were obtained every 3 months for 12 months or until death. Molecular typing of MDRGN isolates was performed by pulsed-field gel electrophoresis.RESULTSA total of 190 MDRGN isolates from 152 residents with advanced dementia were included in the analyses. Both intra– and inter–nursing home transmission were identified. Genetically related MDRGN strains, recovered from different residents, were detected in 18 (82%) of the 22 nursing homes. The percent of clonally related strains in these nursing homes ranged from 0% to 86% (average, 35%). More than 50% of strains were clonally related in 3 nursing homes. Co-colonization with more than 1 different MDRGN species occurred among 28 residents (18.4%). A total of 168 (88.4%), 20 (10.5%), and 2 (1.0%) of MDRGN isolates were resistant to 3, 4, and 5 different antimicrobials or antimicrobial classes, respectively.CONCLUSIONSMDRGN are spread both within and between nursing homes among residents with advanced dementia. Infection control interventions should begin to target this high-risk group of nursing home residents.Infect Control Hosp Epidemiol2015;36(8):930–935

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Satisfaction with End-of-Life Care for Nursing Home Residents with Advanced Dementia

Yearbook of Neurology and Neurosurgery ◽

10.1016/s0513-5117(08)79065-3 ◽

2008 ◽

Vol 2008 ◽

pp. 118-119

Author(s):

J.P. Blass

Keyword(s):

Nursing Home ◽

End Of Life ◽

End Of Life Care ◽

Nursing Home Residents ◽

Life Care ◽

Advanced Dementia

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'Waiting for Resident Number 4': Experiences of Recruiting Nursing Home Residents Living with Advanced Dementia to a Cluster Feasibility Trial of the Namaste Care Intervention

10.26226/morressier.5c76c8b7e2ea5a7237612295 ◽

2019 ◽

Author(s):

Lesley Dunleavy

Keyword(s):

Nursing Home ◽

Nursing Home Residents ◽

Feasibility Trial ◽

Advanced Dementia ◽

Care Intervention

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Impact of Roommates on MDRO Spread in Nursing Homes

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.553 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s66-s67

Author(s):

Gabrielle M. Gussin ◽

Ken Kleinman ◽

Raveena D. Singh ◽

Raheeb Saavedra ◽

Lauren Heim ◽

...

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Secondary Analysis ◽

Nursing Home Residents ◽

Multidrug Resistant ◽

Healthcare Intervention ◽

Odds Ratios ◽

Care Needs ◽

Environmental Cleaning ◽

The Impact

Background: Addressing the high burden of multidrug-resistant organisms (MDROs) in nursing homes is a public health priority. High interfacility transmission may be attributed to inadequate infection prevention practices, shared living spaces, and frequent care needs. We assessed the contribution of roommates to the likelihood of MDRO carriage in nursing homes. Methods: We performed a secondary analysis of the SHIELD OC (Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, CA) Project, a CDC-funded regional decolonization intervention to reduce MDROs among 38 regional facilities (18 nursing homes, 3 long-term acute-care hospitals, and 17 hospitals). Decolonization in participating nursing homes involved routine chlorhexidine bathing plus nasal iodophor (Monday through Friday, twice daily every other week) from April 2017 through July 2019. MDRO point-prevalence assessments involving all residents at 16 nursing homes conducted at the end of the intervention period were used to determine whether having a roommate was associated with MDRO carriage. Nares, bilateral axilla/groin, and perirectal swabs were processed for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear mixed models assessed the impact of maximum room occupancy on MDRO prevalence when clustering by room and hallway, and adjusting for the following factors: nursing home facility, age, gender, length-of-stay at time of swabbing, bedbound status, known MDRO history, and presence of urinary or gastrointestinal devices. CRE models were not run due to low counts. Results: During the intervention phase, 1,451 residents were sampled across 16 nursing homes. Overall MDRO prevalence was 49%. In multivariable models, we detected a significant increasing association of maximum room occupants and MDRO carriage for MRSA but not other MDROs. For MRSA, the adjusted odds ratios for quadruple-, triple-, and double-occupancy rooms were 3.5, 3.6, and 2.8, respectively, compared to residents in single rooms (P = .013). For VRE, these adjusted odds ratios were 0.3, 0.3, and 0.4, respectively, compared to residents in single rooms (P = NS). For ESBL, the adjusted odds ratios were 0.9, 1.1, and 1.5, respectively, compared to residents in single rooms (P = nonsignificant). Conclusions: Nursing home residents in shared rooms were more likely to harbor MRSA, suggesting MRSA transmission between roommates. Although decolonization was previously shown to reduce MDRO prevalence by 22% in SHIELD nursing homes, this strategy did not appear to prevent all MRSA transmission between roommates. Additional efforts involving high adherence hand hygiene, environmental cleaning, and judicious use of contact precautions are likely needed to reduce transmission between roommates in nursing homes.Funding: NoneDisclosures: Gabrielle M. Gussin, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

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