A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices: A Randomized Clinical Trial

Justin Kyei-Frimpong, PharmD candidate 2015, Mercer University College of Pharmacy

According to the Centers of Medicare and Medicaid approximately 1.4 million Americans reside in 15 600 US nursing homes (NHs), and in 2010 there were 2.5 million short-stay admissions.1 Studies conducted by Kauffman et al. showed that multidrug-resistant organisms are 35% more prevalent in nursing homes than they are in hospitals.2 Data from Medicaid and Medicare services communicate that indwelling devices such as catheters and feeding tubes are used frequently in Nursing home residents.1 Evidence from studies by Kauffman et al. suggest nursing home residents with indwelling devices share many characteristics with hospitalized populations, and improper care of residents with these devices presents opportunities for pathogen acquisition.2 This study aims to gain more knowledge on how a multimodal targeted infection program can help lower infection rates in nursing homes.

Title: A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices3
Design Randomized; 418 participants
Objective

(Primary)

To test whether a multimodal targeted infection program (TIP) reduces the prevalence of multidrug-resistant organisms (MDROs) and incident device-related infections
Study Groups Two groups:

1) Intervention group

2) Control group

Methods Residents with indwelling catheter devices were enrolled from 12 nursing homes. The nursing homes were randomized into two equal control and intervention groups. The TIP intervention group received the following, preemptive barrier precautions, active surveillance for MDROs and infections, with data feedback; and NH staff education on key infection prevention practices and hand hygiene promotion. The control group NHs continued to practice according to their own infection prevention policies.
Duration May 2010 to April 2013
Primary outcome measure Prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident’s participation
Baseline Characteristics Intervention group (n= 203): Mean age 74, male 46%, white race 86%, urinary catheter 59.1%, feeding tube 27.6%, both urinary catheter and feeding tube 13.3%

Control group (n=215): Mean age 72, male 57%, white race 87%, urinary catheter 52.1%, feeding tube 32.6%, both urinary catheter and feeding tube 15.3%

Results Intervention group: All MDROs infections  1299, (MRSA 254, VRE 122, Ceftazidime-resistant GNB 185, Ciprofloxacin-resistant GNB 738)

Control group: All MDROs infections 1732 (MRSA 323. VRE 162, Ceftazidime-resistant GNB 295, Ciprofloxacin-resistant GNB 952)

New MDRO acquisition rate

MRSA: Intervention group 6.2, Control group 7.9, Hazard ratio 0.78 (0.65-0.95), P-value = 0.01

VRE: Intervention group 1.7, Control group 2.3, Hazard ratio 0.85 (0.45-1.60), P-value = 0.61

Ciprofloxacin-Resistant or Ceftazidime-Resistant GNB Acquisition: Intervention group 5.6, Control group 6.2, Hazard ratio 0.9 (0.60-1.33), P-value = 0.59

Adverse Events Common Adverse Events: not reported
Serious Adverse Events: not reported
Percentage that Discontinued due to Adverse Events: not reported
Study Author Conclusions 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.

This study suggests a multimodal targeted infection program reduces MDRO prevalence and infections. From a clinical standpoint the components of this study could be integrated into routine nursing home care to help enhance routine infection prevention and reduce antibiotic use in high risk populations. However before these results can be established into protocols or policy, further studies are desirable to confirm and expand the results.

References

  1. Centers for Medicare & Medicaid Services. Nursing Home Data Compendium. 2013. http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/nursinghomedatacompendium_508.pdf. Accessed March 19, 2015.
  2. Mody L, Kauffman CA, Donabedian S, Zervos M, Bradley SF. Epidemiology of Staphylococcus aureus colonization in nursing home residents. Clin Infect Dis. 2008;46(9):1368-1373
  3. Mody L, Krein SL, Saint SK, et al. A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices: A Randomized Clinical Trial. JAMA Intern Med. 2015
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