High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect"

Abstract

Objective: Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).

Design: Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.

Setting: Twenty-eight NHs in Southern California from 2016 to 2017.

Participants: NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.

Methods: Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).

Results: A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.

Conclusions and implications: In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

Keywords: CRE; ESBL; Infectious disease; MDRO colonization; MRSA; epidemiology; infection control.

Fig. 1.

The iceberg of MDRO colonization in skilled nursing facilities. (1) Nearly half (48%) of nursing home residents are colonized with MDRO. The top “exposed” portion of the iceberg represents the (4%) of patients for whom point prevalence survey confirmed previously known colonization status (n = 53 residents). (2) Most of the MDRO colonization is unknown to the facility, with 45% of residents representing the unknown submerged iceberg population of previously unknown MDRO colonization. Of the NH population, 39% (n = 552 residents) had no history of MDRO, but point prevalence survey identi_fied MDRO Carriage. In addition, 5% of the NH population (n = 75 residents) had a history of an MDRO, but point prevalence survey identified an additional MDRO unknown to the facility.