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Decolonization in Nursing Homes to Prevent Infection and Hospitalization
Loren G Miller1, James A McKinnell1, Raveena D Singh1
1From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.).
Background:
Nursing home residents are at high risk for infection, hospitalization, and colonization with multidrug-resistant organisms.
Methods:
We performed a cluster-randomized trial of universal decolonization as compared with routine-care bathing in nursing homes. The trial included an 18-month baseline period and an 18-month intervention period. Decolonization entailed the use of chlorhexidine for all routine bathing and showering and administration of nasal povidone-iodine twice daily for the first 5 days after admission and then twice daily for 5 days every other week. The primary outcome was transfer to a hospital due to infection. The secondary outcome was transfer to a hospital for any reason. An intention-to-treat (as-assigned) difference-in-differences analysis was performed for each outcome with the use of generalized linear mixed models to compare the intervention period with the baseline period across trial groups.
Results:
Data were obtained from 28 nursing homes with a total of 28,956 residents. Among the transfers to a hospital in the routine-care group, 62.2% (the mean across facilities) were due to infection during the baseline period and 62.6% were due to infection during the intervention period (risk ratio, 1.00; 95% confidence interval [CI], 0.96 to 1.04). The corresponding values in the decolonization group were 62.9% and 52.2% (risk ratio, 0.83; 95% CI, 0.79 to 0.88), for a difference in risk ratio, as compared with routine care, of 16.6% (95% CI, 11.0 to 21.8; P<0.001). Among the discharges from the nursing home in the routine-care group, transfer to a hospital for any reason accounted for 36.6% during the baseline period and for 39.2% during the intervention period (risk ratio, 1.08; 95% CI, 1.04 to 1.12). The corresponding values in the decolonization group were 35.5% and 32.4% (risk ratio, 0.92; 95% CI, 0.88 to 0.96), for a difference in risk ratio, as compared with routine care, of 14.6% (95% CI, 9.7 to 19.2). The number needed to treat was 9.7 to prevent one infection-related hospitalization and 8.9 to prevent one hospitalization for any reason.
Conclusions:
In nursing homes, universal decolonization with chlorhexidine and nasal iodophor led to a significantly lower risk of transfer to a hospital due to infection than routine care. (Funded by the Agency for Healthcare Research and Quality; Protect ClinicalTrials.gov number, NCT03118232.).
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