This amended application seeks support for an interventional study aimed at reducing multi-drug resistance and infections in nursing home (NH) residents. Each year, a staggering 1.5-2.0 million infections occur in NHs. Many of these infections are caused by multiple drug resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug resistant Gram-negative bacilli (R-GNB). Antimicrobial resistance among common bacteria are adversely affecting the clinical course and exponentially increasing healthcare costs. Recognizing a need for action, legislators, policy makers, and consumer groups are advocating for pathogen-based universal preemptive screening for these MDROs, particularly MRSA in hospitals and NHs. However, implementing this sweeping mandate is controversial, costly, reactive, and not based on empirical evidence. It can result in a 10-20-fold increase in the number of NH residents placed in isolation precautions with the potential for reduced attention by healthcare workers, isolation and functional decline. Our proposal evaluates a novel focused approach between 'do nothing'and 'search all and destroy'strategies by targeting a subgroup of NH residents with indwelling devices who are at a high risk of acquiring MDROs and infections. We hypothesize that our targeted infection control program (TIP) will reduce MDRO colonization and infections in NH residents with indwelling devices. This cluster randomized trial will involve 12 NHs;6 will be randomized to the TIP arm and 6 to the routine care arm. Our multicomponent TIP intervention will include: Component 1: Institute enhanced barrier precautions for all NH residents with indwelling devices;active screening for MDROs (monthly) using cultures collected from multiple body sites to identify asymptomatic MDRO carriage in these residents;and dissemination of results to clinical staff and administration. Component 2: Structured, active surveillance for infections using standardized definitions in residents with indwelling devices and dissemination of results to clinical staff and administration. Component 3: A hand hygiene promotion program. Component 4: A structured educational program pertaining to indwelling device care for healthcare workers. Our research will determine if our multi-component TIP intervention reduces asymptomatic carriage of MDROs (primary outcome) and symptomatic infections (secondary outcome) in a high-risk sub-group of NH residents with indwelling devices. The proposed research will also provide novel insight into the molecular epidemiology and mechanisms of transmission of resistant pathogens. Using molecular methods, we will determine the genetic relatedness of MDRO between residents with indwelling devices within and between different facilities, trace the source of any new strain, and evaluate the impact of our intervention on specific strains. Our results will allow infection control practitioners, healthcare workers, clinicians, policy makers, legislatures, and consumers to better address antimicrobial resistance and infections in older adults in NHs.

Public Health Relevance

The randomized clinical trial will support the notion that targeted infection control interventions can lead to reduced infections and burden of antimicrobial resistance in frail elderly nursing home residents. Molecular epidemiologic methods will trace the origin of resistant strains in nursing homes and further characterize newer strains of MDROs emerging and spreading in this often neglected setting.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Project (R01)
Project #
5R01AG032298-05
Application #
8510538
Study Section
Aging Systems and Geriatrics Study Section (ASG)
Program Officer
Hannah, Judy S
Project Start
2009-09-15
Project End
2014-07-31
Budget Start
2013-08-01
Budget End
2014-07-31
Support Year
5
Fiscal Year
2013
Total Cost
$311,248
Indirect Cost
$64,226
Name
University of Michigan Ann Arbor
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
073133571
City
Ann Arbor
State
MI
Country
United States
Zip Code
48109
Harrod, Molly; Montoya, Ana; Mody, Lona et al. (2016) Challenges for Nurses Caring for Individuals with Peripherally Inserted Central Catheters in Skilled Nursing Facilities. J Am Geriatr Soc 64:2059-2064
Eke-Usim, Angela C; Rogers, Mary A M; Gibson, Kristen E et al. (2016) Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High-Risk Nursing Home Residents. J Am Geriatr Soc 64:1975-1980
Ismail, Miriam D; Luo, Ting; McNamara, Sara et al. (2016) Long-Term Carriage of Ciprofloxacin-Resistant Escherichia coli Isolates in High-Risk Nursing Home Residents. Infect Control Hosp Epidemiol 37:440-7
Koo, Evonne; McNamara, Sara; Lansing, Bonnie et al. (2016) Making infection prevention education interactive can enhance knowledge and improve outcomes: Results from the Targeted Infection Prevention (TIP) Study. Am J Infect Control 44:1241-1246
Mody, Lona; Crnich, Christopher (2015) Effects of Excessive Antibiotic Use in Nursing Homes. JAMA Intern Med 175:1339-41
Chopra, Vineet; Montoya, Ana; Joshi, Darius et al. (2015) Peripherally Inserted Central Catheter Use in Skilled Nursing Facilities: A Pilot Study. J Am Geriatr Soc 63:1894-9
Crnich, Christopher J; Jump, Robin; Trautner, Barbara et al. (2015) Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs Aging 32:699-716
Cassone, Marco; Mody, Lona (2015) Colonization with Multi-Drug Resistant Organisms in Nursing Homes: Scope, Importance, and Management. Curr Geriatr Rep 4:87-95
Mody, Lona; Gibson, Kristen E; Horcher, Amanda et al. (2015) Prevalence of and risk factors for multidrug-resistant Acinetobacter baumannii colonization among high-risk nursing home residents. Infect Control Hosp Epidemiol 36:1155-62
Mody, Lona (2015) Editorial commentary: Preventing aspiration pneumonia in high-risk nursing home residents: role of chlorhexidine-based oral care questioned again. Clin Infect Dis 60:858-9

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