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Background: Pneumonia (PNA) is an important cause of morbidity and mortality among nursing home residents. The McGeer surveillance definitions were revised in 2012 to help NHs better monitor infections for quality improvement purposes. However, the concordance between surveillance definitions and clinically diagnosed PNA has not been well studied. Our objectives were to identify nursing home residents who met the revised McGeer PNA definition, to compare them with residents with clinician documented PNA, and determine whether modifications to the surveillance criteria could increase concordance. Methods: We analyzed respiratory tract infection (RTI) data from 161 nursing homes in 10 states that participated in a 1-day healthcare-associated infection point-prevalence survey in 2017. Trained surveillance officers from the CDC Emerging Infections Program collected data on residents with clinician documentation, signs, symptoms, and diagnostic testing potentially indicating an RTI. Clinician-documented pneumonia was defined as any resident with a diagnosis of pneumonia identified in the medical chart. We identified the proportion of residents with clinician documented PNA who met the revised McGeer PNA definition. We evaluated the criteria reported to develop 3 modified PNA surveillance definitions (Box), and we compared them to residents with clinician documented PNA.
Results: Among the 15,296 NH residents surveyed, 353 (2%) had >1 signs and/or symptoms potentially indicating RTI. Among the 353 residents, the average age was 76 years, 105 (30%) were admitted to postacute care or rehabilitation, and 108 (31%) had clinician-documented PNA. Among those with PNA, 28 (26%) met the Revised McGeer definition. Among 81 residents who did not meet the definition, 39 (48%) were missing the chest x-ray requirement, and among the remaining 42, only 3 (7%) met the constitutional criteria requirement (Fig. 1). Modification of the constitutional criteria requirement increased the detection of clinically documented PNA from 28 (26%) to 36 (33%) using modified definition 1; to 51 (47%) for modified definition 2; and to 55 (51%) for modified definition 3. Conclusions: Tracking PNA among nursing home residents using a standard definition is essential to improving detection and, therefore, informing prevention efforts. Modifying the PNA criteria increased the identification of clinically diagnosed PNA. Better concordance with clinically diagnosed PNA may improve provider acceptance and adoption of the surveillance definition, but additional research is needed to test its validity.
Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.
Background: With an aging population, increasingly complex care, and frequent re-admissions, prevention of healthcare-associated infections (HAIs) in nursing homes (NHs) is a federal priority. However, few contemporary sources of HAI data exist to inform surveillance, prevention, and policy. Prevalence surveys (PSs) are an efficient approach to generating data to measure the burden and describe the types of HAI. In 2017, the Centers for Disease Control and Prevention (CDC) performed its first large-scale HAI PS through the Emerging Infections Program (EIP) to measure the prevalence and describe the epidemiology of HAI in NH residents. Methods: NHs from several states (CA, CO, CT, GA, MD, MN, NM, NY, OR, & TN) were randomly selected and asked to participate in a 1-day HAI PS between April and October 2017; participation was voluntary. EIP staff reviewed available medical records for NH residents present on the survey date to collect demographic and basic clinical information and infection signs and symptoms. HAIs with onset on or after NH day 3 were identified using revised McGeer infection definitions applied to data collected by EIP staff and were reported to the CDC through a web-based system. Data were reviewed by CDC staff for potential errors and to validate HAI classifications prior to analysis. HAI prevalence, number of residents with >1 HAI per number of surveyed residents ×100, and 95% CIs were calculated overall (pooled mean) and for selected resident characteristics. Data were analyzed using SAS v9.4 software. Results: Among 15,296 residents in 161 NHs, 358 residents with 375 HAIs were identified. The most common HAI sites were skin (32%), respiratory tract (29%), and urinary tract (20%). Cellulitis, soft-tissue or wound infection, symptomatic UTI, and cold or pharyngitis were the most common individual HAIs (Fig. 1). Overall HAI prevalence was 2.3 per 100 residents (95% CI, 2.1–2.6); at the NH level, the median HAI prevalence was 1.8 and ranged from 0 to 14.3 (interquartile range, 0–3.1). At the resident level (Fig. 2), HAI prevalence was significantly higher in persons admitted for postacute care with diabetes, with a pressure ulcer, receiving wound care, or with a device. Conclusions: In this large-scale survey, 1 in 43 NH residents had an HAI on a given day. Three HAI types comprised >80% of infections. In addition to identifying characteristics that place residents at higher risk for HAIs, these findings provide important data on HAI epidemiology in NHs that can be used to expand HAI surveillance and inform prevention policies and practices.
Background: Certain nursing home (NH) resident care tasks have a higher risk for multidrug-resistant organisms (MDRO) transfer to healthcare personnel (HCP), which can result in transmission to residents if HCPs fail to perform recommended infection prevention practices. However, data on HCP-resident interactions are limited and do not account for intrafacility practice variation. Understanding differences in interactions, by HCP role and unit, is important for informing MDRO prevention strategies in NHs. Methods: In 2019, we conducted serial intercept interviews; each HCP was interviewed 6–7 times for the duration of a unit’s dayshift at 20 NHs in 7 states. The next day, staff on a second unit within the facility were interviewed during the dayshift. HCP on 38 units were interviewed to identify healthcare personnel (HCP)–resident care patterns. All unit staff were eligible for interviews, including certified nursing assistants (CNAs), nurses, physical or occupational therapists, physicians, midlevel practitioners, and respiratory therapists. HCP were asked to list which residents they had cared for (within resident rooms or common areas) since the prior interview. Respondents selected from 14 care tasks. We classified units into 1 of 4 types: long-term, mixed, short stay or rehabilitation, or ventilator or skilled nursing. Interactions were classified based on the risk of HCP contamination after task performance. We compared proportions of interactions associated with each HCP role and performed clustered linear regression to determine the effect of unit type and HCP role on the number of unique task types performed per interaction. Results: Intercept-interviews described 7,050 interactions and 13,843 care tasks. Except in ventilator or skilled nursing units, CNAs have the greatest proportion of care interactions (interfacility range, 50%–60%) (Fig. 1). In ventilator and skilled nursing units, interactions are evenly shared between CNAs and nurses (43% and 47%, respectively). On average, CNAs in ventilator and skilled nursing units perform the most unique task types (2.5 task types per interaction, Fig. 2) compared to other unit types (P < .05). Compared to CNAs, most other HCP types had significantly fewer task types (0.6–1.4 task types per interaction, P < .001). Across all facilities, 45.6% of interactions included tasks that were higher-risk for HCP contamination (eg, transferring, wound and device care, Fig. 3). Conclusions: Focusing infection prevention education efforts on CNAs may be most efficient for preventing MDRO transmission within NH because CNAs have the most HCP–resident interactions and complete more tasks per visit. Studies of HCP-resident interactions are critical to improving understanding of transmission mechanisms as well as target MDRO prevention interventions.
Funding: Centers for Disease Control and Prevention (grant no. U01CK000555-01-00)
Disclosures: Scott Fridkin, consulting fee, vaccine industry (spouse)
Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.
Background: Candidemia is associated with high morbidity and mortality. Although risk factors for candidemia and other bloodstream infections (BSIs) overlap, little is known about patient characteristics and the outcomes of polymicrobial infections. We used data from the CDC Emerging Infections Program (EIP) candidemia surveillance to describe polymicrobial candidemia infections and to assess clinical differences compared with Candida-only BSIs. Methods: During January 2017–December 2017 active, population-based candidemia surveillance was conducted in 45 counties in 9 states covering ~6% of the US population through the CDC EIP. A case was defined as a blood culture with Candida spp in a surveillance-area resident; a blood culture >30 days from the initial culture was considered a second case. Demographic and clinical characteristics were abstracted from medical records by trained EIP staff. We examined characteristics of polymicrobial cases, in which Candida and ≥1 non-Candida organism were isolated from a blood specimen on the same day, and compared these to Candida-only cases using logistic regression or t tests using SAS v 9.4 software. Results: Of the 1,221 candidemia cases identified during 2017, 215 (10.2%) were polymicrobial. Among polymicrobial cases, 50 (23%) involved ≥3 organisms. The most common non-Candida organisms were Staphylococcus epidermidis (n = 30, 14%), Enterococcus faecalis (n = 26, 12%), Enterococcus faecium (n = 17, 8%), and Staphylococcus aureus, Klebsiella pneumoniae, and Stenotrophomonas maltophilia (n = 15 each, 7%). Patients with polymicrobial cases were significantly younger than those with Candida-only cases (54.3 vs 60.7 years; P < .0004). Healthcare exposures commonly associated with candidemia like total parenteral nutrition (relative risk [RR], 0.82; 95% CI, 0.60–1.13) and surgery (RR, 0.99; 95% CI, 0.77–1.29) were similar between the 2 groups. Polymicrobial cases had shorter median time from admission to positive culture (1 vs 4 days, P < .001), were more commonly associated with injection drug use (RR, 1.95; 95% CI, 1.46–2.61), and were more likely to be community onset-healthcare associated (RR, 1.91; 95% CI, 1.50–2.44). Polymicrobial cases were associated with shorter hospitalization (14 vs 17 days; P = .031), less ICU care (RR, 0.7; 95% CI, 0.51–0.83), and lower mortality (RR, 0.7; 95% CI, 0.50–0.92). Conclusions: One in 10 candidemia cases were polymicrobial, with nearly one-quarter of those involving ≥3 organisms. Lower mortality among polymicrobial cases is surprising but may reflect the younger age and lower severity of infection of this population. Greater injection drug use, central venous catheter use, and long-term care exposures among polymicrobial cases suggest that injection or catheter practices play a role in these infections and may guide prevention opportunities.
Background: Urinary tract infection (UTI) and Clostridioides difficile infection (CDI) both pose significant diagnostic challenges. Excess testing has implications for hospital-associated infection surveillance and may also lead to overtreatment and associated patient risk. Accurate diagnosis requires stewardship efforts to ensure that the correct patients are tested appropriately. In coordination with clinicians and microbiology labs, hospital infection prevention departments can aid diagnostic stewardship efforts by creating policies for order indications and proper test collection methods and by developing electronic medical record (EMR) support for diagnostic and treatment algorithms. The prevalence of these practices in Oregon, however, is unknown. Methods: We deployed a web-based survey to infection preventionists at all 61 acute-care hospitals in Oregon in January 2019. Responses were collected through April 2019, and a subset of applicable questions were analyzed. Results: Of 61 acute-care hospitals, 58 (95%) responded. A response from a single long-term acute-care hospital was excluded. For urinary tract infections (UTIs), a minority of hospitals reported having policies requiring annual sterile urine collection training for registered nurses (n = 7, 12%), annual observation of the RN sterile urine collection procedure (n = 1, 2%), or use of boric acid containers for urine collection (n = 10, 17%). UTI testing and treatment algorithms embedded in the electronic medical record (EMR) were more common (Fig. 1). Regarding urine culture reflex policies, 39 facilities (68%) reported reflexing abnormal urinalyses to culture only if ordered, whereas 14 respondents (25%) reported automatically reflexed all abnormal urinalyses to culture. For Clostridioides difficile infection (CDI), respondents reported using a variety of methods to discourage inappropriate testing (Fig. 2). Although almost all facilities (n = 53, 93%) reported having a policy to reject formed stool, less than half (n = 27, 47%) reported having a policy to reject stool in patients receiving laxatives. Furthermore, 74% of respondents (n = 42) had a published testing algorithm, more than twice the 18 (32%) hospitals that reported having a comparable UTI algorithm. Conclusions: Infection prevention departments in Oregon acute-care hospitals utilize a variety of tools to contribute to diagnostic and treatment stewardship for UTI and CDI. Our survey revealed many opportunities for improvement in UTI and C. difficile testing and treatment stewardship in Oregon hospitals. For example, although most hospitals reject formed stool for CDI testing, policies for other diagnosis and treatment stewardship techniques were much less commonly employed. Future work will compare the results of this survey to a set of similar questions on a statewide microbiology laboratory survey, assess best practices, and form consensus recommendations on stewardship practices for the state.
Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance.
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