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Since the beginning of the COVID-19 pandemic, face masks have been worn by many in public areas and for prolonged periods by healthcare workers (HCWs). This may facilitate bacterial contamination and transmission to and from patients in nursing homes where clinical care areas with strict precautions and residential and activity areas are interconnected. We assessed and compared bacterial mask colonization in HCWs belonging to different demographic categories and professions (clinical and nonclinical) and among HCWs who had worn the mask for different periods of time.
Design, setting and participants:
We conducted a point-prevalence study of 69 HCW masks at the end of a typical work shift in a 105-bed nursing home serving postacute care and rehabilitation patients. Information collected about the mask user included profession, age, sex, length of time the mask was worn, and known exposure to patients with colonization.
In total, 123 distinct bacterial isolates were recovered (1–5 isolates per mask), including Staphylococcus aureus from 11 masks (15.9%) and gram-negative bacteria of clinical importance from 22 masks (31.9%). Antibiotic resistance rates were low. There were no significant differences in the number of clinically important bacteria among masks worn more or less than 6 hours, and there were no significant differences among HCWs with different job functions or exposure to colonized patients.
Bacterial mask contamination was not associated with HCW profession or exposure and did not increase after 6 hours of mask wearing in our nursing home setting. Bacteria contaminating HCW masks may differ from those colonizing patients.
Resistant gram-negative bacteria (R-GNB) colonization in nursing home patients can cause clinical infection and intrafacility transmission. Limited data exist on the roles of age and function on R-GNB colonization.
A secondary data analysis was performed from a cohort study of 896 patients admitted to 6 Michigan nursing homes between November 2013 and May 2018. Swabs obtained upon enrollment, weekly for 1 month, then monthly until nursing home discharge from 5 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Patients with growth of the same R-GNB as the initial positive visit, from any anatomical site at any subsequent visit, were considered persistently colonized. Demographic data, antibiotic use, device use, and physical self-maintenance scales (PSMSs) were obtained upon enrollment. Characteristics were compared between patients with R-GNB colonization versus those without, and those with persistent R-GNB colonization versus those with spontaneous decolonization.
Of 169 patients with a positive R-GNB culture and ≥2 subsequent study visits, 89 (53%) were transiently colonized and 80 (47%) were persistently colonized. Compared to uncolonized patients, persistent and transient R-GNB colonization were associated with higher PSMS score: 1.14 (95% confidence interval or CI, 1.05–1.23; P = .002) and 1.10 (95% CI, 1.01–1.19; P = .023), respectively. Persistent colonization was independently associated with longer duration of nursing home stay (1.02; 95% CI, 1.01–1.02; P < .001). Higher readmission rate among persistently colonized patients was observed on unadjusted analysis.
Persistent R-GNB colonization is associated with younger age, functional disability, and prolonged length of nursing home stay. In-depth longitudinal studies to understand new acquisition and transmission dynamics of R-GNB in nursing homes are needed.
Background: Persistent colonization with resistant gram-negative bacteria (R-GNB) increases risk of clinical infection and intra-facility transmission among nursing home (NH) patients. Limited data exist on the roles of age and function on duration of R-GNB colonization. Methods: Secondary data analysis was performed from a cohort study of patients admitted to 6 Michigan NHs between November 2013 and May 2018. Swabs obtained upon enrollment, day 14, day 30, then monthly until NH discharge from 6 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Positive R-GNB culture from a single visit followed by negative cultures for the same organism from ≥2 subsequent visits were defined as transient R-GNB colonization. All other patients with positive R-GNB cultures from multiple visits were considered persistently colonized. Demographic data, antibiotic use, device use, and physical self-maintenance scales (PSMSs) were obtained upon enrollment. Characteristics were compared between patients with transient versus persistent R-GNB and uncolonized patients using multinomial logistic regression. Results: We recruited 896 patients (median age, 75 years; 41% male; 46% nonwhite) and followed them for 2,437 total visits. Of 896 patients, 407 (45.4%) were colonized with ≥1 R-GNB during their stay. Of 171 patients with ≥ 2 follow-up visits after R-GNB detection, 94 (55%) remained persistently colonized with the same R-GNB (Table 1). Escherichia coli (30%) and Proteus mirabilis (22%) were the most frequently identified R-GNB. The most common anatomical colonization sites were perirectal (368 [24.3%] of 1,147) groin (340 [14.3%] of 2,046), and hands (115 [4.8%] of 2283). Compared to uncolonized patients, patients with persistent (1.09; 95% CI, 1.00–1.19, P = .048) and transient R-GNB colonization (1.13; 95% CI, 1.04–1.23; P = .003) had lower PSMS (Tables 2 and 3). Compared to uncolonized and transiently colonized patients, patients with persistent R-GNB colonization had prolonged lengths of NH stay (1.01; 95% CI, 1.00–1.01; P = .003). Conclusions: R-GNB colonization in vulnerable NH patients is common (407 [45.5%] of 896 and often persistent (94 [55%] of 171 patients with sufficient follow-up to assess persistence). Patients with persistent R-GNB had lower functional status, longer LOS, and higher readmission rates than those without. R-GNB decolonization should be investigated as a strategy to potentially improve outcomes among NH patients.
Background: Face masks have been worn universally and for long periods of time by healthcare personnel during the COVID-19 pandemic. They are frequently touched or adjusted with the hands and may come in contact with various surfaces and high-touch sites when taken off and on even briefly. These activities present opportunities for face masks to become contaminated with microorganisms. Nursing homes have high rates of multidrug-resistant bacteria and low PPE compliance; therefore, contamination of face masks in this setting may be of great interest. We investigated bacterial colonization status on used face masks in healthcare personnel, including assessing the presence of clinically important and multidrug-resistant bacteria. Methods: At a nursing home serving mostly post–acute-care patients, we collected 69 face masks from personnel at the end of the user’s work shift. Information about the mask and the user was also collected via a self-reported survey. Face masks were incubated in BHI broth overnight at 36°C and 10 μL was then plated on selective and differential plates. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and gram-negative bacteria (GNB) resistant to several antibiotic classes were identified using standard microbiological methods. Resistance testing for cefoxitin (S. aureus), ciprofloxacin, meropenem, tetracycline, erythromycin, gentamicin, trimethoprim–sulfamethoxazole, and ceftazidime with and without clavulanic acid (gram-negative bacteria) was performed using the disc diffusion technique on Mueller-Hinton plates (Kirby Bauer). Results: The job categories of face mask users were competency-evaluated nursing assistant or nursing assistant (22.73%), nurse (12.12%), and other or administrative (37.88%). Overall face mask contamination rates for MRSA (0%) and VRE (3.3%) were low; however, methicillin-susceptible S. aureus was found on 11 masks (15.9%). High contamination and resistance rates were found for gram-negative bacteria, with 113 isolates. Among them, 69 (60.9%) were resistant to at least 1 antibiotic, most commonly was erythromycin (59.4%). Additionally, higher rates of clinically important pathogenic gram-negative bacteria were identified: 14.3% of masks were contaminated with Klebsiella pneumoniae, 13.0% were contaminated with Enterobacter spp, and 4.2% were contaminated with Escherichia coli. Importantly, there were no significant differences in the total number of isolates of potential clinical significance recovered from masks worn >6 hours versus those worn <6 hours. Conclusions: Among nursing-home healthcare workers, face masks were often contaminated with multiple organisms, including potentially pathogenic bacteria and antibiotic-resistant gram-negative organisms. This contamination may pose a risk for transmission if face masks are not properly used and/or disposed of after wearing. Prolonged duration of face-mask wearing, however, was not associated with increased contamination rates.
Background: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) is of special concern among frail patients in nursing homes. To understand environmental contamination patterns in this setting, we screened a suitable section of a nursing home over time and assessed MRSA and VRE prevalence in patients and their rooms. We were especially interested in assessing whether MRSA and VRE strains persist in rooms during changes of occupancy after patient discharge. Methods: We conducted a prospective cohort study of MRSA and VRE colonization and contamination among successive patients in a cluster of 9 single-occupancy rooms. Using flocked swabs, 5 high-touch surfaces were screened 3 times a week for 34 weeks. Patients were also screened (ie, nares, groin, and hands), if they agreed to participate. Whole-genome sequencing was performed on 67 nonredundant MRSA and VRE strains. Single-nucleotide polymorphism heatmaps and similarity trees were generated to evaluate strain diversity and persistence the facility. Results: Overall, 146 distinct occupancy events were captured during the study (16.5 average per room; range, 11–22), with 387 study visits and 4,670 total swabs collected. All rooms were contaminated with VRE, and 8 of 9 were contaminated with MRSA at least once during the study period. New contamination of a room with MRSA or VRE was observed in 43 (23%) of 185 opportunities, with potential persistence during occupancy changes in 25 (32.9%) of 76 opportunities. Sequencing of 67 nonredundant isolates identified at least 6 enterococcal clades and 10 MRSA clades (6 USA100 and 4 USA300), indicating a high degree of diversity and probably multiple introductions in the facility during the study time. In 3 separate cases, whole-genome sequencing confirmed persistence of a specific MRSA strain during a change of room occupancy, including 1 case of a MRSA strain persisting in a clean room before admission of the next patient. For VRE, 2 cases of persistence during room occupancy changes were confirmed, along with 6 cases of possible persistence (contamination across noncontiguous room occupancy events). Conclusions: Active surveillance screening and a recurring evaluation of terminal cleaning procedures should be considered due to high levels of circulation and persistence of MRSA and VRE in the nursing home setting.
Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity.
Observational pilot study.
Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.
Inpatients with MRSA colonization or infection.
At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients’ hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.
In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.
Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient’s MRSA body colonization pattern and the patient activity.
Perianal screening can be intrusive. The sensitivities of multianatomical, nonperianal surveillance were 92.3% for methicillin-resistant Staphylococcus aureus (MRSA), 58.7% for vancomycin-resistant enterococci (VRE), and 54.9% for resistant Gram-negative bacilli (R-GNB). Sensitivities improved upon adding environmental surveillance (95.5%, 82.9%, and 67.9%, respectively). Multianatomical, nonperianal screening and room environment surveillance may replace perianal screening and reduce healthy participant bias in nursing homes.
Background: Although active surveillance for multidrug-resistant organism (MDRO) colonization permits timely intervention, obtaining cultures can be time-consuming, costly, and uncomfortable for patients. We evaluated clinical differences between patients with and without attainable perianal cultures, and we sought to determine whether environmental surveillance could replace perianal screening. Methods: We collected active surveillance cultures from patient hands, nares, groin, and perianal area upon enrollment, at day 14, and monthly thereafter in 6 Michigan nursing homes. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant gram-negative bacilli (RGNB) were identified using standard methods. Patient characteristics were collected by trained research professionals. This substudy focused on visits during which all body sites were sampled. To determine the contribution of perianal screening to MDRO detection, site of colonization was categorized into 2 groups: perianal and non-perianal. We evaluated the utility of multisite surveillance (eg, type 1 and type 2 error) using nonperianal sites and environment surveillance. To evaluate characteristics associated with the acquisition of perianal cultures (eg, selection bias), we compared clinical characteristics, overall patient colonization, and room environment contamination of patients in whom all body sites were sampled during a study visit (533 patients; 1,026 visits) to patients with all body sites except the perianal culture sampled during a study visit (108 patients; 168 visits). Results: Of 651 patients, 533 met the inclusion criteria; average age was 74.5 years, 42.6% were male, and 60.8% were white. Of 1,026 eligible visits, 620 visits detected MDRO colonized patients; 155 MRSA, 363 VRE, and 386 RGNB (Table 1). If perianal cultures were not collected, nonperianal surveillance misses 7.7%, 41.3%, and 45.1% of MRSA, VRE, and RGNB colonized visits, respectively. The addition of environmental surveillance to non-perianal screening detected 95.5%, 82.9%, and 67.9% of MRSA, VRE, and RGNB colonized visits, respectively. The specificity of environmental screening was 85.3%, 72.7%, and 73.4% for MRSA, VRE, and RGNB, respectively. Patients without attainable perianal cultures had significantly more comorbidities, worse functional status, shorter length of stay, and higher baseline presence of wounds than patients with attainable perianal cultures; introducing potential selection bias to surveillance efforts (Table 2). No significant differences in overall patient colonization and room contamination were noted between patients with and without attainable perianal cultures. Conclusion: Perianal screening is important for the detection of VRE and RGNB colonization. Infection prevention must be cognizant of the tradeoff between reducing type 2 error and the selection bias that occurs with required attainment of perianal cultures. In the absence of perianal cultures, environmental surveillance improves MDRO detection while introducing type 1 error.
Methicillin-resistant Staphylococcus aureus (MRSA) colonization of patients and contamination of their immediate environmental surfaces is common in the acute care setting, but there is much to be learned about the dynamics of MRSA transmission over a short period of time. Methods: A prospective, observational time-motion qualitative study was conducted at 2 hospitals: 1 in Michigan (hospital 1) and 1 in Zurich, Switzerland (hospital 2)—between November 2018 and July 2019. Hospitalized patients with a MRSA infection or colonization were enrolled. Microbiologic cultures for MRSA were collected from patient nares, axilla, groin and hands and several high-touch surfaces in their room (bed controls, call button, tray table, etc) at the first visit, and patient hands and high-touch surfaces continued to be swabbed every 90 minutes over the course of 5 hours. Patient hands and environment were disinfected after each swabbing. Clinical data were collected from patient’s medical chart. Results: We recruited 10 MRSA colonized or infected patients for the study with 50 hours of observation and obtained 360 patient and environmental swabs. Most were women (7 of 10); the average age was 52.8 years (Table 1). At the first visit, 8 (80%) patients were MRSA-colonized (at 1 or more body sites) and 5 (50%) rooms were MRSA-contaminated (at 1 or more surfaces). Also, 6 patients (60%) had an active MRSA infection and were actively receiving an anti-MRSA agent (eg, Vancomycin). Among those 6 patients receiving an anti-MRSA agent, 4 patients (67%) and 2 rooms (33%) were contaminated at the first visit. Among those 4 patients not receiving an anti-MRSA agent, all 4 patients (100%) and 3 rooms (75%) were contaminated at the baseline visit. Acquisitions (ie, MRSA recovered from a site it was not previously recovered from) occurred on 3 of 7 patient hands (43%) and on 6 occasions in the room (among 5 patients), most commonly at the toilet seat (2 of 6 times). MRSA prevalence on patient and room surfaces for the 5 patients enrolled at hospital 2 are illustrated in Figure 1, which shows colonization of patient and contamination of environment as well as activities performed by the patient in between culturing. Conclusions: We evaluated transmission of MRSA over brief periods of time; our results show that transmission of MRSA depended on patient activity in the room. Furthermore, degree of patient colonization is reflected by environmental contamination and supports the notion of constant transmission of MRSA from patients to environment.
OBJECTIVES/GOALS: We investigated the association between gut microbiota features in newly admitted nursing facility (NF) patients and the acquisition of vancomycin-resistant Enterococcus (VRE) and/or resistant Gram-negative bacteria (rGNB) within 14 days. METHODS/STUDY POPULATION: Patients were recruited at 6 Michigan NFs from 09/16-08/18. VRE or rGNB colonization status was determined by culture swabs collected from multiple body sites at enrolment, day 7, and day 14. Our analysis focused on patients with no colonization at baseline, a perirectal swab collected at baseline, and at least one follow-up visit. The V4 hypervariable region of the 16S rRNA gene from bacterial DNA in each sample was PCR-amplified and sequenced on the MiSeq platform. Sequencing results were then processed with the mothur bioinformatics pipeline to classify bacterial taxa present in each sample. Taxa typically associated with the skin microbiota were removed. The primary outcome was acquisition of VRE and/or rGNB within 14 days. Exposures of interest included patient and microbiota characteristics. RESULTS/ANTICIPATED RESULTS: Among 61 patients, 18 (30%) acquired AROs within 14 days of enrolment (3 VRE, 13 rGNB, 2 both) (Table 1). The baseline microbiota features differed significantly in those who acquired a new ARO. Of the major 8 phyla found across samples, patients who acquired an ARO were depleted in the number of phyla present (5.74 ± 1.20 vs 5.06 ± 1.43; p = 0.037) (Fig. 1). The log10-transformed relative abundance of Enterococcus was enriched in patients who acquired an ARO (−0.32 ± 1.47) compared to those who did not (−1.68 ± 1.76; p = 0.021) (Fig. 2). Patients who did not acquire an ARO tended to harbour more butyrate-producing bacterial taxa and strict anaerobes, although the differences were not statistically significant (relative abundance of butyrate producer: 29.49 ± 22.09 vs 22.05 ± 17.76; anaerobes: 64.78 ± 23.54 vs 53.68 ± 27.61). DISCUSSION/SIGNIFICANCE OF IMPACT: Microbiota metrics calculated from perirectal samples are predictive of ARO acquisition. The clinical utility of perirectal samples thus warrants further assessment.
The role of demographic characteristics, such as sex and race, as risk factors for colonization with multidrug-resistant organisms, has not been established in the nursing home setting. We demonstrate significantly higher prevalence overall in male patients, and sex differences are dependent on organism of interest and body site.
Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP).
HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence.
We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44–4.54) and after patient care (OR, 3.11; 95% CI, 1.77–5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15–0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11–0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%).
Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.
Characterize the clinical and molecular epidemiology of new methicillin-resistant Staphylococcus aureus (MRSA) acquisitions at nasal and extranasal sites among high-risk nursing home (NH) residents.
Multicenter prospective observational study.
Six NHs in southeast Michigan.
A total of 120 NH residents with an indwelling device (feeding tube and/or urinary catheter).
Active surveillance cultures from the nares, oropharynx, groin, perianal area, wounds (if present), and device insertion site(s) were collected upon enrollment, at day 14, and monthly thereafter. Pulsed-field gel electrophoresis and polymerase chain reaction for SCCmec, agr, and Panton-Valentine leukocidin were performed.
Of 120 participants observed for 16,290 device-days, 50 acquired MRSA (78% transiently, 22% persistently). New MRSA acquisitions were common in extranasal sites, particularly at device insertion, groin, and perianal areas (27%, 23%, and 17.6% of all acquisitions, respectively). Screening extranasal sites greatly increases the detection of MRSA colonization (100% of persistent carriers and 97.4% of transient carriers detected with nares, groin, perianal, and device site sampling vs 54.5% and 25.6%, respectively, for nares samples alone). Colonization at suprapubic urinary catheter sites generally persisted. Healthcare-associated MRSA (USA100 and USA100 variants) were the dominant strains (79.3% of all new acquisition isolates). Strain diversity was more common in transient carriers, including acquisition of USA500 and USA300 strains.
Indwelling device insertion sites as well as the groin and perianal area are important sites of new MRSA acquisitions in NH residents and play a role in the persistency of MRSA carriage. Clonal types differ among persistent and transient colonizers.
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