title: A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education.
  
  
  METHODS
  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
  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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01062841.
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor2Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
authors.forename: Lona
authors.initials: L
authors.lastname: Mody
authors.affiliation: Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Division of General Medicine, University of Michigan Health System, Ann Arbor.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Krein
authors.affiliation: Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan4Division of General Medicine, University of Michigan Health System, Ann Arbor.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Saint
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor2Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
authors.forename: Lillian C
authors.initials: LC
authors.lastname: Min
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Ana
authors.initials: A
authors.lastname: Montoya
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Lansing
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Sara E
authors.initials: SE
authors.lastname: McNamara
authors.affiliation: Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Symons
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor6currently with the Rosenstiel School of Marine and Atmospheric Science, University of Miami, Miami, Florida.
authors.forename: Jay
authors.initials: J
authors.lastname: Fisch
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Evonne
authors.initials: E
authors.lastname: Koo
authors.affiliation: currently a long-term care infection prevention and control consultant in Hemlock, Michigan.
authors.forename: Ruth Anne
authors.initials: RA
authors.lastname: Rye
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor8Department of Biostatistics, University of Michigan Medical School, Ann Arbor.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Galecki
authors.affiliation: Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Mohammed U
authors.initials: MU
authors.lastname: Kabeto
authors.affiliation: Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan9Department of Medical Education, University of Michigan Medical School, Ann Arbor.
authors.forename: James T
authors.initials: JT
authors.lastname: Fitzgerald
authors.affiliation: Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan.
authors.forename: Russell N
authors.initials: RN
authors.lastname: Olmsted
authors.affiliation: Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Kauffman
authors.affiliation: Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
authors.forename: Suzanne F
authors.initials: SF
authors.lastname: Bradley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects* / Q000379:methods; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000187:drug effects / Q000302:isolation & purification*; D008875:Middle Aged; D009735:Nursing Homes; D010043:Outcome and Process Assessment, Health Care; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000517:prevention & control; D013192:Staff Development / Q000379:methods*; D013203:Staphylococcal Infections / Q000209:etiology / Q000517:prevention & control*; D016635:Universal Precautions / Q000379:methods*; D014546:Urinary Catheterization / Q000009:adverse effects* / Q000379:methods; D014552:Urinary Tract Infections / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000900:Anti-Bacterial Agents