Background: A regional decolonization intervention (SHIELD-OC) involving universal chlorhexidine for routine bathing and 5 days of twice-daily nasal iodophor every other week in nursing homes (NHs) recently demonstrated marked reductions in multidrug-resistant organisms, all-cause hospitalizations, and infection-related hospitalizations in Orange County, California. Specific to methicillin-resistant Staphylococcus aureus (MRSA), NH prevalence (nares, skin, or perirectal) decreased from 43% to 29%. Methods: We conducted a retrospective cohort study evaluating the impact of decolonization on factors associated with MRSA carriage. The cohort included residents from 18 SHIELD-OC NHs who were sampled for MRSA using nares, axilla, groin, and perirectal cultures. A point-prevalence survey was conducted in 2016–2017 (before decolonization, 50 randomly sampled residents per NH) and in 2018–2019 (decolonization, all residents sampled). Resident characteristics were obtained from their most proximal admission, quarterly, and/or discharge assessment using data mandated for NH reporting (CMS minimum data set), and included demographics, medical devices, comorbidities (including Alzheimer’s disease and related dementias or ADRD), and mobility and hygiene needs. We used generalized-linear mixed models stratified by decolonization and clustered by NH to identify differences in factors associated with MRSA carriage. Results: Of the 2,351NH residents, 2,255 (96%) had characteristics available in the CMS data set. Of the 2,255 residents included, 774 (34%) were MRSA carriers. Before decolonization, medical devices (OR, 2.5), limited mobility (OR, 1.6), and diabetes (OR, 1.4) were significantly associated with MRSA carriage in an adjusted model (Table). During decolonization, these effects were mitigated (medical device OR, 2.5–1.1; diabetes OR, 1.4–0.9) and were no longer significantly associated with MRSA carriage. Male sex appeared to have more of an effect in the decolonization phase (OR, 1.3–1.6), but limited mobility remained stable (OR, 1.6–1.7). Several variables were collinear. Presence of a medical device was collinear with postacute stays (<100 days) and Medicaid insurance. Limited mobility was associated with limited ability for hygienic self-care. ADRD was collinear with age. Final adjusted models accounted for medical devices, limited mobility, diabetes, ADRD, cancer, sex, and ethnicity. Conclusions: In a large interventional cohort of 18 NHs, factors associated with MRSA carriage changed after adoption of universal decolonization. Specifically, the increased risk of MRSA associated with medical devices and diabetes were substantially mitigated by decolonization, suggesting that these risks are modifiable. These long-term care findings are consistent with clinical trials showing reductions in MRSA carriage after implementing chlorhexidine bathing in ICUs and in non-ICU patients with devices. The ability of decolonization to attenuate the risk of MRSA carriage among diabetics or other potential high-risk groups deserves further study.

Disclosures: None

The CLEAR Trial recently found that decolonization reduced infections and hospitalizations in MRSA carriers in the year following hospital discharge. In this secondary analysis, we explored whether decolonization had a similar benefit in the subgroup of trial participants who harbored USA300, using two different definitions for the USA300 strain-type.

In a prospective cohort study, we compared a 2-swabs-per-nostril 5% iodophor regimen with a 1-swab-per-nostril 10% iodophor regimen on methicillin-resistant Staphylococcus aureus carriage in nursing-home residents. Compared with baseline, both single-swab and double-swab regimens resulted in an identical 40% reduction in nasal carriage and 60% reduction in any carriage, skin or nasal.

We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that reduced MRSA infection and hospitalization by 30%. Hospitalized MRSA infection was associated with 7.9 days of non-MRSA antibiotics and CDI in 3.9%. Preventing MRSA infection and associated hospitalization may reduce antibiotic use and CDI incidence.

Background: Greater than 10% of hospitalized MRSA carriers experience serious MRSA infection in the year following discharge. Prevention opportunities have primarily focused on hospital stays; however postdischarge interventions have the potential to reduce morbidity, mortality and healthcare costs. The CLEAR trial found a 30% hazard reduction in postdischarge MRSA infections among patients who had inpatient MRSA cultures and were given postdischarge decolonization (5 days twice-a-month for 6 months) relative to hygiene education alone. We conducted a cost analysis of the CLEAR intervention to quantify the economic implications and understand the value of adopting this MRSA decolonization strategy. Methods: We constructed a decision model to estimate the one-year healthcare utilization and costs associated with postdischarge decolonization relative to hygiene education. Trial results for MRSA infection risk and downstream outcomes (including outpatient and emergency room visits, hospitalizations, related nursing home stays, and postdischarge antibiotics) were used to parameterize the model. Other medical care and prescription drug costs were based on Medicare Fee Schedules, Red Book and the literature. Patient out-of-pocket costs and time costs associated with subsequent infections were from a survey of trial participants experiencing infection (n=405). All costs were reported in 2019 US dollars. The analysis was conducted using healthcare system and societal perspectives. Sensitivity analyses were conducted on key parameters. Results: Among a hypothetical cohort of 1,000 hospitalized MRSA carriers, we estimated that a postdischarge decolonization intervention versus hygiene education would result in at least 36 fewer subsequent MRSA infections (130 vs 93 of 1,000, respectively) and >40 fewer MRSA-attributable healthcare events including 32 hospitalizations and 6 postdischarge nursing home visits over the course of a year. Assuming an intervention cost of $185 per individual, the program would result in an overall cost savings of $469,000 per 1,000 MRSA carriers undergoing decolonization. This translates to an overall savings of $13,200 per infection averted and $9,000 per infection averted from the healthcare system perspective. Even assuming a lower infection rate or a less effective intervention (15% reduction in infections vs 30% in the CLEAR trial), or a more expensive (up to $653 per patient) intervention, a decolonization program would still result in cost-savings for society, the healthcare system and patients. Conclusions: In addition to health benefits of preventing infections, postdischarge decolonization of MRSA carriers yields substantial savings to society and the healthcare system. Future recommendations for reducing postdischarge MRSA-related disease among MRSA carriers should consider routine decolonization at hospital discharge.

Funding: This study was supported by a grant from the AHRQ Healthcare-Associated Infections Program (R01HS019388) and by the University of California Irvine Institute for Clinical and Translational Science, which was funded by a grant from the NIH Clinical and Translational Sciences Award program (UL1 TR000153).

Disclosures: Dr. Huang reports conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), Mölnlycke, 3M, Clorox, Xttrium Laboratories, and Medline. Ms. Singh reports conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories, and Medline. Dr. Rashid, conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker(Sage Products), Clorox, and Medline. Dr. McKinnell reports receiving grant support to his institution from Melinta Therapeutics, and fees for serving as a research investigator from Lightship, conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories and Medline, and serving as cofounder of Expert Stewardship. Dr. Miller reports receiving grant support from Gilead Sciences, Merck, Abbott, Cepheid, Genentech, Atox Bio, and Paratek Pharmaceuticals, grant support and fees for serving on an advisory board from Achaogen and grant support, consulting fees, and fees for serving on an advisory board from Tetraphase and conducting clinical studies in which participating nursing homes and hospitals received donated products from Stryker (Sage Products), 3M, Clorox, Xttrium Laboratories, and Medline.

Background: More than half of nursing home (NH) residents harbor a multidrug-resistant organism (MDRO), and MDRO contamination of the environment is common. Whether NH decolonization of residents reduces MDRO contamination remains unclear. The PROTECT trial was a cluster-randomized trial of decolonization versus routine care in 28 California NHs from April 2017 through December 2018. Decolonization involved chlorhexidine bathing plus nasal iodophor (Monday–Friday, every other week), and it reduced resident nares and skin MDRO colonization by 36%. Methods: We swabbed high-touch objects in resident rooms and common areas for MDROs before and after the 3-month decolonization phase-in (April–July 2017). Five high-touch objects (bedrail, call button and TV remote, doorknob, light switch, and bathroom handles) were swabbed in 3 resident rooms per NH based on care needs (Alzheimer’s disease and related dementias (ADRD), ie, total care; ADRD, ambulatory care; and short stay). Five high-touch objects were also swabbed in the common area (nursing station, table, chair, railing, and drinking fountain). Swabs were processed for methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). We used generalized linear mixed models to assess the impact of decolonization on MDRO environmental contamination when clustering by NH and room and adjusting for room type and object because unclustered and unadjusted results are likely to be inaccurate. Results: A high proportion of rooms were contaminated with any MDRO in control NHs: 43 of 56 (77%) in the baseline period and 46 of 56 (82%) in the intervention period. In contrast, decolonization NHs had similar baseline contamination (45 of 56, 80%) but lower intervention MDRO contamination (29 of 48, 60%). When evaluating the intervention impact using multivariable models, decolonization was associated with significantly less room contamination for any MDRO (OR, 0.25; 95% CI, 0.06–0.96; P = .04) and MRSA (OR, 0.16; 95% CI, 0.05–0.55; P = .004) but nonsignificant reductions in VRE contamination (OR, 0.86; 95% CI, 0.23–3.13) and ESBL contamination (OR, 0.13; 95% CI, 0.01–1.62). CRE was not modeled due to rare counts (2 rooms total). In addition, room type was important, with common areas associated with 5-fold, 9-fold, and 3-fold higher contamination with any MDRO, MRSA, and VRE, respectively, compared with short-stay rooms. Conclusions: The high burden of MDROs in NHs calls for universal prevention strategies that can protect all residents. Although decolonization was associated with an 84% reduction in odds of MRSA contamination of inanimate room objects, significant reductions in VRE or ESBL contamination were not seen, possibly due to the lower proportion of baseline contamination due to these organisms. Multimodal strategies are needed to address high levels of MDRO contamination in NHs.

Funding: None

Disclosures: Gabrielle 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.

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: None

Disclosures: 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.

Distinguished Oral

Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll.

Funding: None

Disclosures: Gabrielle M. Gussin, University of California, Irvine, 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.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for the largest number of invasive infections due to a multidrug-resistant pathogen. Approximately 10% of hospitalized carriers will experience invasive MRSA disease in the year following discharge incurring antibiotic therapy beyond focused treatment of MRSA. Objective: We aimed to quantify the extent of non-MRSA empiric antibiotics incurred by MRSA infections and further assess the risk of Clostridioides difficile Infection (CDI) as a result of treatment of MRSA infection. Methods: The CLEAR Trial was a postdischarge randomized controlled trial of 2,121 MRSA carriers comparing MRSA education alone to education plus repeated decolonization that demonstrated a 30% reduction in MRSA infection and a 17% reduction in all-cause infection attributable to decolonization in the year following hospital discharge (Huang SS, NEJM 2019). We included all hospitalization outcomes due to MRSA infection in the CLEAR Trial with detailed medication administration records to quantify unintended consequences of MRSA infection related to empiric non-MRSA antibiotic use and resultant CDI. Full-text medical records were reviewed with a standardized abstraction form to collect inpatient administered antibiotics and hospital-associated CDI. Results: In total,154 hospitalizations due to MRSA infection with a mean length-of-stay of 10.6 days were identified. During 25 hospitalizations (16.2%), patients received only anti-MRSA antibiotics. During the remaining 129 (83.8%) hospitalizations, patients received a mean of 1.6 distinct non-MRSA antibiotics totaling a mean of 6.6 days of therapy (DOT). Empiric non-MRSA therapy was given for 3.2 DOT before MRSA culture results became available and was continued for an additional 3.4 DOT afterward. Among all 849 non-MRSA DOT, the most common were due to piperacillin-tazobactam (293 DOT, 34.5%), levofloxacin (105 DOT, 12.4%), and metronidazole (93 DOT, 11.0%). Across all 154 hospitalizations, a mean of 5.5 non-MRSA DOT was calculated per MRSA hospitalization, with 6 CDI cases (3.9%) as a direct sequelae of empiric non-MRSA antibiotics provided for MRSA infection. Conclusions: Hospitalization for MRSA infection results in extensive non-MRSA empiric antibiotic therapy both before and after MRSA culture results are known. This antibiotic use is associated with a 3.9% risk of CDI that exceeds the national risk of acquiring CDI (3.2 per 1,000 admissions) by 12-fold during any hospital stay (Barrett ML, AHRQ 2018). The CLEAR Trial findings that postdischarge decolonization reduces MRSA infection and hospitalization by 30% suggests that decolonization may also reduce non-MRSA antibiotic use and CDI in this population.

Funding: None

Disclosures: None

Nursing home residents are at risk for acquiring and transmitting MDROs. A serial point-prevalence study of 605 residents in 3 facilities using random sampling found MDRO colonization in 45% of residents: methicillin-resistant Staphylococcus aureus (MRSA, 26%); extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL, 17%); vancomycin-resistant Enterococcus spp. (VRE, 16%); carbapenem-resistant Enterobacteriaceae (CRE, 1%). MDRO colonization was associated with history of MDRO, care needs, incontinence, and catheters.

Infect Control Hosp Epidemiol 2016;1485–1488