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High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect"
James A McKinnell1, Loren G Miller2, Raveena D Singh3
1Department of Medicine, Infectious Disease Clinical Outcomes Research (ID-CORE), LA Biomed at Harbor-UCLA Medical Center, Torrance, CA, USA; Los Angeles County Department of Public Health, Healthcare Outreach Unit, Los Angeles, CA, USA; Expert Stewardship, Newport, CA, USA.
Objective:
Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).
Design:
Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.
Setting:
Twenty-eight NHs in Southern California from 2016 to 2017.
Participants:
NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.
Methods:
Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).
Results:
A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.
Conclusions And Implications:
In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.
Insights
Multidrug-resistant organisms (MDROs) like MRSA and ESBL are highly prevalent in nursing home residents and environments. Over half of residents carried MDROs, with widespread contamination found in rooms and common areas, necessitating enhanced infection control.
Area of Science:
- Infectious Diseases
- Public Health
- Epidemiology
Background:
- Nursing homes (NHs) are high-risk settings for the spread of multidrug-resistant organisms (MDROs).
- Prevalence data on key MDROs among NH residents and their environment are crucial for effective infection control.
- Understanding colonization rates and environmental contamination is vital for preventing outbreaks.
Purpose of the Study:
- To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) in NH residents and their environment.
- To assess the extent of MDRO carriage among NH residents, including those without a known history of colonization.
- To evaluate the level of environmental contamination with MDROs in resident rooms and common areas.
Main Methods:
- Point prevalence sampling of 1400 residents across 28 NHs in Southern California (2016-2017).
- Environmental sampling of 20 high-touch objects per NH, including common areas and resident rooms (ambulatory, total care, dementia care).
- Analysis of 2797 swabs to determine the prevalence of specific MDROs (MRSA, VRE, ESBL, CRE) and overall MDRO carriage.
Main Results:
- Median MDRO carriage prevalence per NH was 50% (range: 24%-70%).
- Specific MDRO prevalence: MRSA 36%, ESBL 16%, VRE 5%, CRE 0%.
- A median of 45% of residents harbored MDROs without a known history; 74% of rooms and 93% of common areas showed environmental contamination.
Conclusions:
- More than 50% of residents in over half of the NHs were colonized with clinically significant MDROs, primarily MRSA and ESBL.
- Widespread environmental contamination with MDROs was observed in both resident rooms and common areas.
- Findings suggest a significant 'hidden' reservoir of MDRO carriers in NHs, underscoring the need for universal infection prevention strategies like hand hygiene, environmental cleaning, and decolonization.
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