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Background: Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid., Purpose: Systematic literature review of strategies to reduce UTIs in nursing home residents., Data Sources: Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015., Study Selection: Interventional studies with a comparison group reporting at least 1 outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use., Data Extraction: Two authors abstracted study design, participant and intervention details, outcomes, and quality measures., Data Synthesis: Of 5794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Quality (range, 8-25; median, 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; 9 studies employed general infection prevention strategies (eg, improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The 19 studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); 9 studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly)., Limitations: Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes., Conclusions: Several practices, often implemented in bundles, such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions, appear to reduce UTI or CAUTI in nursing home residents. Journal of Hospital Medicine 2017;12:356-368., (© 2017 Society of Hospital Medicine)

Historically, the medical subspecialties have not focused on the needs of older adults. This has changed with the implementation of initiatives to integrate geriatrics and aging research into the medical and surgical subspecialties and with the establishment of a home for internal medicine specialists within the annual American Geriatrics Society (AGS) meeting. With the support of AGS, other professional societies, philanthropies, and federal agencies, efforts to integrate geriatrics into the medical and surgical subspecialties have focused largely on training the next generation of physicians and researchers. They have engaged several subspecialties, which have followed parallel paths in integrating geriatrics and aging research. As a result of these combined efforts, there has been enormous progress in the integration of geriatrics and aging research into the medical and surgical subspecialties, and topics once considered to be geriatric concerns are becoming mainstream in medicine, but this integration remains a work in progress and will need to adapt to changes associated with healthcare reform., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Background: Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD)., Objective: We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT), or both. Design/participants/measurements: A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. The ADs were divided as follows: (1) comfort oriented: comfort measures only, no hospital transfer; (2) palliative oriented: comfort focused, allowing hospital transfer (except intensive care unit), antibiotic use, but no cardiopulmonary resuscitation; (3) usual care: full code, no limitations to care. We calculated incidences for these outcomes., Results: Seventy-eight (87%) residents had ADs: 18 (23%) comfort oriented, 32 (41%) palliative oriented, and 28 (36%) usual care. The groups did not differ regarding demographics, comorbidity, function, device presence, or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (Incidence rate [IR] = 15.6/1000 follow-up days vs IR = 8.8/1000 follow-up days, Incident rate ratio [IRR] 0.6 [95% confidence interval, CI, 0.3 -1.1], P value .09) but received fewer antibiotics (IR = 18.9/1000 follow-up days vs IR = 7.5/1000 follow-up days, IRR 0.4 [95% CI, 0.2-0.8], P value .005)., Conclusion: Nursing home residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual-care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.

OBJECTIVE The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non-VA nursing homes. SETTING VA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative. METHODS Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire. RESULTS A total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; P<.001) and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs 66%; P<.001), sharing CAUTI data with leadership (94% vs 70%; P=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004). CONCLUSIONS Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems. Infect Control Hosp Epidemiol 2017;38:287-293.

Objectives: To determine the relationship between clinically diagnosed catheter-associated urinary tract infection (CAUTI) and standardized criteria and to assess microorganism-level differences in symptom burden in a cohort of catheterized nursing home (NH) residents., Design: Post hoc analysis of a prospective longitudinal study., Setting: Twelve NHs in southeast Michigan., Participants: NH residents with indwelling urinary catheters (n = 233; 90% white, 52% male, mean age 73.7)., Measurements: Clinical and demographic data, including CAUTI epidemiology and symptoms, were obtained at study enrollment, 14 days, and monthly thereafter for up to 1 year., Results: One hundred twenty participants with an indwelling catheter (51%) were prescribed systemic antibiotics for 182 clinically diagnosed CAUTIs. Common signs and symptoms were acute change in mental status (28%), fever (21%), and leukocytosis (13%). Forty percent of clinically diagnosed CAUTIs met Loeb's minimum criteria, 32% met National Health Safety Network (NHSN) criteria, and 50% met Loeb's minimum or NHSN criteria. CAUTIs involving Staphylococcus aureus and Enterococcus spp. were least likely to meet criteria. CAUTIs involving Klebsiella pneumoniae were most likely to meet Loeb's minimum criteria (odds ratio (OR) = 9.7, 95% confidence interval (CI) = 2.3-40.3), possibly because of an association with acute change in mental status (OR = 5.9, 95% CI = 1.8-19.4)., Conclusion: Fifty percent of clinically diagnosed CAUTIs met standardized criteria, which represents an improvement in antibiotic prescribing practices. At the microorganism level, exploratory data indicate that symptom burden may differ between microorganisms. Exploration of CAUTI signs and symptoms associated with specific microorganisms may yield beneficial information to refine existing tools to guide appropriate antibiotic treatment., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Urinary catheter use is prevalent in health care settings, and polymicrobial colonization by urease-positive organisms, such as Proteus mirabilis and Providencia stuartii, commonly occurs with long-term catheterization. We previously demonstrated that coinfection with P. mirabilis and P. stuartii increased overall urease activity in vitro and disease severity in a model of urinary tract infection (UTI). In this study, we expanded these findings to a murine model of catheter-associated UTI (CAUTI), delineated the contribution of enhanced urease activity to coinfection pathogenesis, and screened for enhanced urease activity with other common CAUTI pathogens. In the UTI model, mice coinfected with the two species exhibited higher urine pH values, urolithiasis, bacteremia, and more pronounced tissue damage and inflammation compared to the findings for mice infected with a single species, despite having a similar bacterial burden within the urinary tract. The presence of P. stuartii, regardless of urease production by this organism, was sufficient to enhance P. mirabilis urease activity and increase disease severity, and enhanced urease activity was the predominant factor driving tissue damage and the dissemination of both organisms to the bloodstream during coinfection. These findings were largely recapitulated in the CAUTI model. Other uropathogens also enhanced P. mirabilis urease activity in vitro, including recent clinical isolates of Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae, and Pseudomonas aeruginosa We therefore conclude that the underlying mechanism of enhanced urease activity may represent a widespread target for limiting the detrimental consequences of polymicrobial catheter colonization, particularly by P. mirabilis and other urease-positive bacteria., (Copyright © 2017 American Society for Microbiology.)

OBJECTIVE To assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative. DESIGN Baseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections. SETTING Nursing homes across 14 states participating in the national "Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection." PARTICIPANTS Licensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel. METHODS Each facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses. RESULTS A total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed). CONCLUSIONS This national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care. Infect. Control Hosp. Epidemiol. 2016;1-6.

Background: The purpose of this study was to assess effectiveness of an interactive educational program in increasing knowledge of key infection prevention and control (IPC) principles with emphasis on indwelling device care, hand hygiene, and multidrug-resistant organisms (MDROs) among nursing home (NH) health care personnel (HCP)., Methods: We conducted a multimodal randomized controlled study involving HCP at 12 NHs. Ten comprehensive and interactive modules covered common IPC topics. We compared intervention and control scores to assess differences in pretest scores as a result of field interventions, pre- and post-test scores to assess knowledge gain, and magnitude of knowledge gain based on job categories., Results: We conducted over 200 in-services across 10 topics at six intervention sites over 36 months. There were 4,962 tests returned over the course of the study, ranging from 389-633 per module. Participants were mostly female certified nursing assistants (CNAs). Score improvement was highest for modules emphasizing hand hygiene, urinary catheter care, and MDROs (15.6%, 15.9%, and 22.0%, respectively). After adjusting for cluster study design, knowledge scores were significantly higher after each educational module, suggesting the education delivery method was effective. When compared with CNAs, nursing and rehabilitation personnel scored significantly higher in their knowledge tests., Conclusions: Our intervention significantly improved IPC knowledge in HCP, especially for those involved in direct patient care. This increase in knowledge along with preemptive barrier precautions and active surveillance has enhanced resident safety by reducing MDROs and infections in high-risk NH residents., Competing Interests: We declare that we have no conflicts of interest., (Copyright © 2016. Published by Elsevier Inc.)

Objectives: To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia., Design: Prospective longitudinal study nested within a randomized trial, using data from control sites., Setting: Six NHs in southeast Michigan., Participants: NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection)., Measurements: Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year., Results: One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection., Conclusion: Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs., Design: Exploratory, qualitative pilot study., Setting: Two community based SNFs., Participants: Residents with PICCs, frontline nurses (RNs, LPNs), unit nurse managers, and SNF administrators., Methods: Over 36 weeks, 56 residents with PICCs and their nurses were observed and informally interviewed, focusing on PICC care practices and documentation. In addition, baseline PICC data were collected on placement indication (e.g., antimicrobial administration), placement setting (hospital vs SNF), and dwell time. Focus groups were then conducted with frontline nurses and unit nurse managers, and semistructured interviews were conducted with SNF administrators to evaluate perceived preparedness for PICC care. Data were analyzed using a descriptive analysis approach., Results: Variations in documentation were observed during weekly informal interviews and observations. Differences were noted between resident self-reported PICC concerns (quality of life) and those described by frontline nurses. Deficiencies in communication between hospitals and SNFs with respect to device care, date of last dressing change, and PICC removal time were also noted. During focus group sessions, perceived inadequacy of information at the time of care transitions, limited availability of resources to care for PICCs, and gaps in training and education were highlighted as barriers to improving practice and safety., Conclusion: Practices for PICC care in SNFs can be improved. Multimodal strategies that enhance staff education, improve information exchange during care transitions, and increase resource availability in SNFs appear necessary to enhance PICC care and safety., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

OBJECTIVE To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes. DESIGN Cost analysis of data collected from a prospective, observational study. SETTING AND PARTICIPANTS Care activity data from 401 residents from 13 nursing homes in 2 states. METHODS Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups. RESULTS The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127). CONCLUSIONS The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities. Infect Control Hosp Epidemiol 2016;37:962-966.

This review summarizes current literature pertaining to infection prevention in nursing home population including post-acute care patients and long-term care residents. Approximately 2 million infections occur each year and more than one-third of older adults harbor multidrug-resistant organisms in this setting. Surveillance, hand hygiene, isolation precautions, resident and employee health programs, education, and antibiotic stewardship are essential elements of infection prevention and control programs in nursing homes. This article discusses emerging evidence suggesting the usefulness of interactive multimodal bundles in reducing infections and antimicrobial resistance, thereby enhancing safety and quality of care for older adults in nursing homes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

BACKGROUND Rates of multidrug-resistant gram-negative organisms are surpassing those of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in nursing homes (NHs). OBJECTIVE To characterize the incidence and duration of carriage of ciprofloxacin-resistant Escherichia coli (CipREc) in NHs and identify those in the O25b-ST131 lineage. METHODS We collected 227 CipREc isolates obtained by routine and regular surveillance of high-risk NH residents with indwelling devices. Repetitive element palindromic (REP)-polymerase chain reaction assay and multiplex polymerase chain reaction amplification for O25b-ST131 E. coli detection were performed using (GTG)5-primers and O25pabBspe and trpA2 primer pairs, respectively. RESULTS We found a high period prevalence of CipREc colonization (21.5%), high rates of recolonization with the same strain following clearing (0.46 recolonizations/ person/ year), and an acquisition incidence of 1.05 cases/1,000 person-days. Almost three-quarters of colonized residents carried strains in the O25b-ST131 E. coli lineage. Compared with isolates not in the lineage, O25b-ST131 isolates were carried significantly longer (10 vs 3 months). We identified 18 different REP-types; 2 occurred in 55% of the residents colonized with CipREc, and in more than 1 NH. Duration of CipREc carriage varied by REP-type and averaged 6 months. CONCLUSION CipREc occurred frequently in NH residents and is carried for long durations, and reacquisition following clearance is common Trial registration. ClinicalTrials.gov identifier: NCT01062841.

Objective: To characterize the epidemiology of multidrug-resistant (MDR) Acinetobacter baumannii colonization in high-risk nursing home (NH) residents., Design: Nested case-control study within a multicenter prospective intervention trial., Setting: Four NHs in Southeast Michigan. PARTICIPANTS Case patients and control subjects were NH residents with an indwelling device (urinary catheter and/or feeding tube) selected from the control arm of the Targeted Infection Prevention study. Cases were residents colonized with MDR (resistant to ≥3 classes of antibiotics) A. baumannii; controls were never colonized with MDR A. baumannii., Methods: For active surveillance cultures, specimens from the nares, oropharynx, groin, perianal area, wounds, and device insertion site(s) were collected upon study enrollment, day 14, and monthly thereafter. A. baumannii strains and their susceptibilities were identified using standard microbiologic methods., Results: Of 168 NH residents, 25 (15%) were colonized with MDR A. baumannii. Compared with the 143 controls, cases were more functionally disabled (Physical Self-Maintenance Score >24; odds ratio, 5.1 [95% CI, 1.8-14.9]; P<.004), colonized with Proteus mirabilis (5.8 [1.9-17.9]; P<.003), and diabetic (3.4 [1.2-9.9]; P<.03). Most cases (22 [88%]) were colonized with multiple antibiotic-resistant organisms and 16 (64%) exhibited co-colonization with at least one other resistant gram-negative bacteria., Conclusion: Functional disability, P. mirabilis colonization, and diabetes mellitus are important risk factors for colonization with MDR A. baumannii in high-risk NH residents. A. baumannii exhibits widespread antibiotic resistance and a preference to colonize with other antibiotic-resistant organisms, meriting enhanced attention and improved infection control practices in these residents.

Objective: To estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) transmission to gowns and gloves worn by healthcare workers (HCWs) interacting with nursing home residents to better inform infection prevention policies in this setting, Design: Observational study, Setting: Participants were recruited from 13 community-based nursing homes in Maryland and Michigan, Participants: Residents and HCWs from these nursing homes, Methods: Residents were cultured for MRSA at the anterior nares and perianal or perineal skin. HCWs wore gowns and gloves during usual care activities. At the end of each activity, a research coordinator swabbed the HCW's gown and gloves., Results: A total of 403 residents were enrolled; 113 were MRSA colonized. Glove contamination was higher than gown contamination (24% vs 14% of 954 interactions; P1.0; P<.05). We also identified low-risk care activities: giving medications and performing glucose monitoring (OR<1.0; P<.05). Residents with chronic skin breakdown had significantly higher rates of gown and glove contamination., Conclusions: MRSA transmission from MRSA-positive residents to HCW gown and gloves is substantial; high-contact activities of daily living confer the highest risk. These activities do not involve overt contact with body fluids, skin breakdown, or mucous membranes, which suggests the need to modify current standards of care involving the use of gowns and gloves in the nursing home setting.

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

Objectives: To describe patterns of use, care practices, and outcomes related to peripherally inserted central catheter (PICC) use in skilled nursing facilities (SNFs)., Design: Prospective cohort study., Setting: Two community SNFs., Participants: Adult SNF residents with PICCs (N = 56)., Measurements: Information on indication for PICC use, device characteristics (e.g., lumens, gauge), and participant data (comorbidities, medications) were obtained from medical records. Care practices (e.g., frequency of flushing, dressing care) and problems related to PICCs were recorded. Major (central line-associated bloodstream infection, venous thromboembolism, catheter dislodgement) and minor (migration, dressing disruption, lumen occlusion, exit site infection) complications and process measures (flushing of PICC, assessment of necessity) were recorded. Bivariate analyses with t-tests, chi-square tests, or Fischer exact tests were used for continuous and categorical data., Results: Participants were enrolled from two SNFs. The most common indication for PICC use was intravenous antibiotic delivery. The average PICC dwell time was 43 days, and most devices were single-lumen PICCs. Major and minor complications were common and occurred in 11 (20%) and 18 (32%) participants, respectively. Occlusion (23%, n = 13), accidental dislodgement (12%, n = 7), and dressing disruption (11%, n = 6) were the commonest complications observed. Documentation regarding catheter care practices occurred in 41% of cases., Conclusion: Quality improvement efforts that seek to benchmark practice, identify gaps, and institute efforts to improve PICC care and practice in SNFs appear necessary., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Importance: Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs., Objective: To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections., Design, Setting, and Participants: Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both., Interventions: Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education., Main Outcomes and Measures: The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables., Results: In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections., Conclusions and Relevance: Our 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. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals., Trial Registration: clinicaltrials.gov Identifier: NCT01062841.

Objectives: To use a simple measure of activities of daily living, wounds, and indwelling devices (urinary catheter, feeding tube) to predict prevalent, new, and intermittent multidrug-resistant organism (MDRO) acquisition in nursing home (NH) residents., Design: Secondary analysis, prospective cohort study., Setting: Southeast Michigan NHs (n = 15)., Participants: NH residents (N = 111, mean age 81) with two or more monthly visits (729 total)., Measurements: Monthly microbiological surveillance for MDROs from multiple anatomic sites from enrollment until discharge or 1 year. The Arling scale, previously developed as a measure of NH residents' need (time-intensity) for nursing resources, was used to predict prevalent and time to new or intermittent acquisition (months) of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and antibiotic-resistant gram-negative bacteria (R-GNB) colonization using multiple-failure accelerated time-factor survival analysis, controlling for comorbidity, hospitalization, and antibiotic use in the prior month., Results: One-fifth of participants had a wound, and one-third had a device. There were 60 acquisitions of MRSA, 56 of R-GNB, and 15 of VRE. Expected time to acquisition was less than 1 year for MRSA (median 6.7 months) and R-GNB (median 4.5 months) and more than 1 year for VRE (median 40 months). Arling score was associated with earlier new MRSA and VRE acquisition. A resident with only mild functional impairment and no device or wound would be expected to acquire MRSA in 20 months, versus 5 months for someone needing the most-intense nursing contact., Conclusion: MDRO acquisition is common in community NHs. Need for nursing care predicts new MDRO acquisition in NHs, suggesting potential mechanisms for MDRO acquisition and strategies for future interventions for high-risk individuals (e.g., enhanced barrier precautions)., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

Bacterial infections are among the most common causes of morbidity and mortality in Nursing Homes (NH) and other long term care facilities. Multi-drug resistant organisms (MDROs) represent an ever-increasing share of causative agents of infection, and their prevalence in NHs is now just as high as in acute-care facilities, or even higher. Indeed, NHs are now considered a major reservoir of MDROs for the community at large. Asymptomatic colonization is usually a prerequisite to development of symptomatic infection. While progress has been made in defining epidemiology of MDROs in NHs, few studies have evaluated the role of changing healthcare delivery in introducing and further transmitting MDROs in this setting. Furthermore, the factors influencing the spread of colonization and the key prognostic indicators leading to symptomatic infections in the burgeoning short stay population need to be explored further. The difficulty of this task lies in the heterogeneity of NHs in terms of focus of care, organization and resources, and on the diversity among the many MDRO species encountered, which harbor different resistance genes and with a different prevalence depending on the geographic location, local antimicrobial pressure and residents risk factors such as use of indwelling devices, functional disability, wounds and other comorbidities. We present literature findings on the scope and importance of colonization as a pathway to infection with MDROs in NHs, underline important open questions that need further research, and discuss the strength of the evidence for current and proposed screening, prevention, and management interventions.

Objective: Characterize the clinical and molecular epidemiology of new methicillin-resistant Staphylococcus aureus (MRSA) acquisitions at nasal and extranasal sites among high-risk nursing home (NH) residents., Design: Multicenter prospective observational study., Setting: Six NHs in southeast Michigan., Participants: A total of 120 NH residents with an indwelling device (feeding tube and/or urinary catheter)., Methods: Active surveillance cultures from the nares, oropharynx, groin, perianal area, wounds (if present), and device insertion site(s) were collected upon enrollment, at day 14, and monthly thereafter. Pulsed-field gel electrophoresis and polymerase chain reaction for SCCmec, agr, and Panton-Valentine leukocidin were performed., Results: Of 120 participants observed for 16,290 device-days, 50 acquired MRSA (78% transiently, 22% persistently). New MRSA acquisitions were common in extranasal sites, particularly at device insertion, groin, and perianal areas (27%, 23%, and 17.6% of all acquisitions, respectively). Screening extranasal sites greatly increases the detection of MRSA colonization (100% of persistent carriers and 97.4% of transient carriers detected with nares, groin, perianal, and device site sampling vs 54.5% and 25.6%, respectively, for nares samples alone). Colonization at suprapubic urinary catheter sites generally persisted. Healthcare-associated MRSA (USA100 and USA100 variants) were the dominant strains (79.3% of all new acquisition isolates). Strain diversity was more common in transient carriers, including acquisition of USA500 and USA300 strains., Conclusion: Indwelling device insertion sites as well as the groin and perianal area are important sites of new MRSA acquisitions in NH residents and play a role in the persistency of MRSA carriage. Clonal types differ among persistent and transient colonizers.

Twenty-four-hour reports are filled out by nurses daily to monitor nursing home residents and document any changes in resident status. Semistructured interviews conducted with ICPs from 12 southeast Michigan nursing homes showed that although 24-hour reports were used, they were not standardized for infection prevention activities. Our results indicate 24-hour reports can be an effective communication tool and potentially aid in early recognition of infections and outbreaks., (Published by Elsevier Inc.)

Objectives: To identify characteristics of residential care facilities (RCFs) associated with having a pandemic influenza plan., Design: Nationally representative, cross-sectional survey., Setting: RCFs in the United States., Participants: Participating facilities in the 2010 National Survey of RCFs (N = 2,294), representing 31,030 assisted living facilities and personal care homes., Measurements: Facility-level characteristics associated with a pandemic influenza plan, including general organization descriptors, staffing, resident services, and immunization practices., Results: Forty-five percent (95% confidence interval (CI) = 43-47%) had a pandemic plan, 14% (95% CI = 13-16%) had a plan in preparation, and 41% (95% CI = 38-43%) had no plan. In the multivariable model, organization characteristics, staffing, and immunization practices were independently associated with the presence of a pandemic preparedness plan. Organization characteristics were larger size (extra large, OR = 3.27, 95% CI = 1.96-5.46; large, OR = 2.60, 95% CI = 1.81-3.75; medium, OR = 1.66, 95% CI = 1.21-2.27 vs small), not-for-profit status (OR = 1.65, 95% CI = 1.31-2.09 vs for profit), and chain affiliation (OR = 1.65, 95% CI = 1.31-2.09 vs nonaffiliated). Staffing characteristics included number of registered nurse hours (<15 minutes, OR = 1.36, 95% CI = 1.07-1.74 vs no hours), any licensed practical nurse hours (OR = 1.47, 95% CI = 1.08-1.99 vs no hours), and at least 75 hours of required training for aides (OR = 1.34, 95% CI = 1.05-1.71 vs <75 hours). RCFs with high staff influenza vaccination rates (81-100%, OR = 2.12, 95% CI = 1.27-3.53 vs 0% vaccinated) were also more likely to have a pandemic plan., Conclusion: A majority of RCFs lacked a pandemic influenza plan. These facilities were smaller, for-profit, non-chain-affiliated RCFs and had lower staff vaccination rates. These characteristics may help target facilities that need to develop plans to handle a pandemic, or other disasters., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Tigecycline is one of the few remaining therapeutic options for extensively drug-resistant (XDR) Gram-negative bacilli (GNB). MICs of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by the Etest compared to determinations by the broth microdilution (BMD) method. The study aim was to compare the susceptibility of GNB to tigecycline by four different testing methods. GNB were collected from six health care systems (25 hospitals) in southeast Michigan from January 2010 to September 2011. Tigecycline MICs among A. baumannii, carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, and susceptible Enterobacteriaceae isolates were determined by Etest, BMD, Vitek-2, and MicroScan. Nonsusceptibility was categorized as a tigecycline MIC of ≥4 μg/ml for both A. baumannii and Enterobacteriaceae. The study included 4,427 isolates: 2,065 ESBL-producing Enterobacteriaceae, 1,105 A. baumannii, 888 susceptible Enterobacteriaceae, and 369 CRE isolates. Tigecycline nonsusceptibility among A. baumannii isolates was significantly more common as determined by Etest compared to that determined by BMD (odds ratio [OR], 10.3; P<0.001), MicroScan (OR, 12.4; P<0.001), or Vitek-2 (OR, 9.4; P<0.001). These differences were not evident with the other pathogens. Tigecycline MICs varied greatly according to the in vitro testing methods among A. baumannii isolates. Etest should probably not be used by laboratories for tigecycline MIC testing of A. baumannii isolates, since MICs are significantly elevated with Etest compared to those determined by the three other methods.

The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.

Importance: Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice., Objective: To review management of asymptomatic bacteriuria and symptomatic UTI and review prevention of recurrent UTIs in older community-dwelling women., Evidence Review: A search of Ovid (Medline, PsycINFO, Embase) for English-language human studies conducted among adults aged 65 years and older and published in peer-reviewed journals from 1946 to November 20, 2013., Results: The clinical spectrum of UTIs ranges from asymptomatic bacteriuria, to symptomatic and recurrent UTIs, to sepsis associated with UTI requiring hospitalization. Recent evidence helps differentiate asymptomatic bacteriuria from symptomatic UTI. Asymptomatic bacteriuria is transient in older women, often resolves without any treatment, and is not associated with morbidity or mortality. The diagnosis of symptomatic UTI is made when a patient has both clinical features and laboratory evidence of a urinary infection. Absent other causes, patients presenting with any 2 of the following meet the clinical diagnostic criteria for symptomatic UTI: fever, worsened urinary urgency or frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A positive urine culture (≥105 CFU/mL) with no more than 2 uropathogens and pyuria confirms the diagnosis of UTI. Risk factors for recurrent symptomatic UTI include diabetes, functional disability, recent sexual intercourse, prior history of urogynecologic surgery, urinary retention, and urinary incontinence. Testing for UTI is easily performed in the clinic using dipstick tests. When there is a low pretest probability of UTI, a negative dipstick result for leukocyte esterase and nitrites excludes infection. Antibiotics are selected by identifying the uropathogen, knowing local resistance rates, and considering adverse effect profiles. Chronic suppressive antibiotics for 6 to 12 months and vaginal estrogen therapy effectively reduce symptomatic UTI episodes and should be considered in patients with recurrent UTIs., Conclusions and Relevance: Establishing a diagnosis of symptomatic UTI in older women requires careful clinical evaluation with possible laboratory assessment using urinalysis and urine culture. Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Asymptomatic bacteriuria in older women should not be treated.

Utilizing a self-administered questionnaire in 440 health care workers (81% response rate), we evaluated the impact of health care workers policy awareness on hand hygiene and urinary catheter care in nursing homes. We show that health care workers aware of their nursing home policies are more likely to report wearing gloves and practicing hand hygiene as per evidence-based recommendations during urinary catheter care compared with those who are unaware of their facility policies., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Objectives: Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers., Design: Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008., Participants: The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size., Results: Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P < .001), Chronic obstructive pulmonary disease (z = 3.9; P < .001), and cancer (z = 8.5; P < .001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease., Conclusion: With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes., (Copyright © 2013. Published by Elsevier Inc.)

Background: This study aimed to (1) identify inpatient complications associated with the greatest differential mortality risk between young and old patients with traumatic injury and (2) identify older patients at elevated risk for mortality-associated complications., Methods: Secondary analysis of more than 280,000 patients hospitalized for traumatic injury in 2001 to 2005 collected by the National Trauma Data Bank was performed. Predictor variables include 21 hospital complications. We used each complication to predict odds of hospital mortality, stratified by old (65+ years) versus young (18-64 years) age, controlling for age, sex, and preexisting condition count. We defined mortality-associated geriatric complications (MGCs) as complications associated with more than two times risk of mortality in older patients compared with younger patients. We then used age, comorbidity, and sex to predict development of MGCs or death., Results: We defined seven infectious and six noninfectious complications as MGCs (adjusted relative risk reduction for death associated with old age [aRRR] with 95% confidence interval [CI]): abscess (aRRR, 4.1; 95% CI, 3.6-4.5), wound infection (aRRR, 3.5; 95% CI, 3.2-3.9), empyema (aRRR, 3.4; 95% CI, 3.1, 3.8), urinary tract infection (aRRR, 3.3; 95% 3.0-3.6), pneumonia (aRRR, 3.1; 95% CI, 2.8-3.5), bacteremia (aRRR, 2.8; 95% CI, 2.6-3.0), aspiration pneumonia (aRRR, 2.6; 95% CI, 2.2-3.0), reduction/fixation failure (aRRR, 3.6; 95% CI, 3.3-3.9), pressure ulcer (aRRR, 3.3; 95% CI, 3.1-3.6), deep venous thrombosis (aRRR, 3.2; 95% CI, 2.9-3.6), pneumothorax (aRRR, 3.1; 95% CI, 2.5-3.7), and compartment syndrome (aRRR, 2.2; 95% CI, 1.5-2.9). We developed a graphical nomogram based on sex, age, and number of preexisting conditions to predict risk of MGCs (c statistic, 0.74)., Conclusion: Older patients at risk for MGC development should be considered for targeted interventions to improve quality of care., Level of Evidence: Prognostic/epidemiologic study, level III.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

The epidemiology of new acquisition of antibiotic-resistant organisms (AROs) in community-based skilled nursing facilities (SNFs) is not well studied. To define the incidence, persistence of, and time to new colonization with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CAZ(r)) and ciprofloxacin-resistant (CIP(r)) Gram-negative bacteria (GNB) in SNFs, SNF residents were enrolled and specimens from the nares, oropharynx, groin, perianal area, and wounds were prospectively cultured monthly. Standard microbiological tests were used to identify MRSA, VRE, and CAZ(r) and CIP(r) GNB. Residents with at least 3 months of follow-up were included in the analysis. Colonized residents were categorized as having either preexisting or new acquisition. The time to colonization for new acquisition of AROs was calculated. Eighty-two residents met the eligibility criteria. New acquisition of AROs was common. For example, of the 59 residents colonized with CIP(r) GNB, 28 (47%) were colonized with CIP(r) GNB at the start of the study (96% persistent and 4% intermittent), and 31 (53%) acquired CIP(r) GNB at the facility (61% persistent). The time to new acquisition was shortest for CIP(r) GNB, at a mean of 75.5 days; the time to new acquisition for MRSA was 126.6 days (P = 0.007 versus CIP(r) GNB), that for CAZ(r) was 176.0 days (P = 0.0001 versus CIP(r) GNB), and that for VRE was 186.0 days (P = 0.0004 versus CIP(r) GNB). Functional status was significantly associated with new acquisition of AROs (odds ratio [OR], 1.24; P = 0.01). New acquisition of AROs, in particular CIP(r) GNB and MRSA, is common in SNFs. CIP(r) GNB are acquired rapidly. Additional longitudinal studies to investigate risk factors for ARO acquisition are required.

To address controversies surrounding contact isolation precautions in skilled nursing facilities (SNF), we surveyed 356 nurses and nurses' aides from 7 SNFs on their opinions regarding benefits and harms of contact isolation precautions. Whereas a majority of health care workers believed that contact isolation reduces transmission of antibiotic-resistant organisms, they were also concerned about potentially harmful consequences to the SNF residents including depression and isolation., (Published by Mosby, Inc.)

Over 1.5 million people live in 16,000 nursing homes in the USA and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Emerging infections and antibiotic-resistant organisms in an institutional environment where there is substantial antimicrobial overuse and the population is older, frailer and sicker, create unique challenges for infection control. This review discusses the common infections, challenges, and a framework for a practical infection prevention program.

With the changing health care delivery, patients receive care at various settings, including acute care hospitals, skilled nursing facilities (SNFs), and ambulatory clinics, thus becoming exposed to pathogens. Various health care settings face unique challenges requiring individualized infection control programs. The programs in SNFs should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs. In ambulatory clinics, the program should address triage and standard transmission-based precautions; cleaning, disinfection, and sterilization principles; surveillance in surgical clinics; safe injection practices; and bioterrorism and disaster planning., (Published by Elsevier Inc.)

We evaluated the prevalence of colonization with all gram-negative bacilli (GNB) and with ciprofloxacin-resistant GNB among nursing home residents with and without indwelling devices. We found that device presence increases the risk of colonization with all GNB and with ciprofloxacin-resistant GNB. Colonization with ciprofloxacin-resistant GNB increases with decreasing functional status.

Objectives: To assess the knowledge of recommended urinary catheter care practices among nursing home (NH) healthcare workers (HCWs) in southeast Michigan., Design: Self-administered survey., Setting: Seven NHs in southeast Michigan., Participants: HCWs., Measurements: The survey included questions about respondent characteristics and knowledge about indications, care, and personal hygiene pertaining to urinary catheters. The association between knowledge measures and occupation (nurses vs aides) was assessed using generalized estimating equations., Results: Three hundred fifty-six of 440 HCWs (81%) responded. More than 90% of HCWs were aware of measures such as cleaning around the catheter daily, glove use, and hand hygiene with catheter manipulation. They were less aware of research-proven recommendations of not disconnecting the catheter from its bag (59% nurses, 30% aides, P<.001), not routinely irrigating the catheter (48% nurses, 8% aides, P<.001), and hand hygiene after casual contact (60% nurses, 69% aides, P=.07). HCWs were also unaware of recommendations regarding alcohol-based hand rub (27% nurses and 32% aides with correct responses, P=.38). HCWs reported informal (e.g., nurse supervisors) and formal (in-services) sources of knowledge about catheter care., Conclusion: Significant discrepancies remain between research-proven recommendations pertaining to urinary catheter care and HCWs' knowledge. Nurses and aides differ in their knowledge of recommendations against harmful practices, such as disconnecting the catheter from the bag and routinely irrigating catheters. Further research should focus on strategies to enhance dissemination of proven infection control practices in NHs., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Background: Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels)., Methods: A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded., Results: Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, beta2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16)., Conclusion: Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.

Pathogenicity islands (PAIs) are a specific group of genomic islands that contribute to genomic variability and virulence of bacterial pathogens. Using a strain-specific comparative genomic hybridization array, we report the identification of a 94-kb PAI, designated ICEPm1, that is common to Proteus mirabilis, Providencia stuartii, and Morganella morganii. These organisms are highly prevalent etiologic agents of catheter-associated urinary tract infections (caUTI), the most common hospital acquired infection. ICEPm1 carries virulence factors that are important for colonization of the urinary tract, including a known toxin (Proteus toxic agglutinin) and the high pathogenicity island of Yersinia spp. In addition, this PAI shares homology and gene organization similar to the PAIs of other bacterial pathogens, several of which have been classified as mobile integrative and conjugative elements (ICEs). Isolates from this study were cultured from patients with caUTI and show identical sequence similarity at three loci within ICEPm1, suggesting its transfer between bacterial genera. Screening for the presence of ICEPm1 among P. mirabilis colonizing isolates showed that ICEPm1 is more prevalent in urine isolates compared to P. mirabilis strains isolated from other body sites (P<0.0001), further suggesting that it contributes to niche specificity and is positively selected for in the urinary tract.

There are few studies that have assessed factors influencing infection control practices among health care workers (HCW) in nursing homes. We conducted a cross-sectional survey of HCWs (N = 392) in 4 nursing homes to assess whether knowledge, beliefs, and perceptions influence reported hand hygiene habits. Positive perceptions and beliefs regarding effectiveness of infection control in nursing homes were associated with reported appropriate glove use and fingernail characteristics, respectively, among HCWs. Further research on hand hygiene interventions, including targeted educational in-services should be conducted in the nursing home setting.

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption.