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Randomized Controlled Trial
. 2015 May;175(5):714-23.
doi: 10.1001/jamainternmed.2015.132.

A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial

Lona Mody  1 , Sarah L Krein  2 , Sanjay Saint  2 , Lillian C Min  1 , Ana Montoya  3 , Bonnie Lansing  3 , Sara E McNamara  3 , Kathleen Symons  4 , Jay Fisch  5 , Evonne Koo  3 , Ruth Anne Rye  6 , Andrzej Galecki  7 , Mohammed U Kabeto  3 , James T Fitzgerald  8 , Russell N Olmsted  9 , Carol A Kauffman  10 , Suzanne F Bradley  10
Affiliations
Randomized Controlled Trial

A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial

Lona Mody et al. JAMA Intern Med. 2015 May.

Erratum in

Abstract

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.

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CONSORT Diagram
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References

    1. Centers for Medicare & Medicaid Services [Accessed December 3, 2014];Nursing Home Data Compendium. 2013 http: //www.cms.gov/Medicare/Provider-Enrollment -and-Certification/Cert....
    1. Medicare Payment Advisory Commission [Accessed November 26, 2014];Report to the Congress: Medicare and the health care delivery system. Statement of Mark E. Miller, Ph.D. 2014 Jun 18; http://www.medpac.gov/documents/congressional-testimony/testimony-report....
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