Targeted Infection Prevention (TIP) Program in Nursing Homes

描述（由申请人提供）：本修订后的申请旨在支持一项旨在减少养老院（NH）居民多药耐药和感染的介入性研究。每年，NHs中发生的感染人数达到惊人的150万至200万。其中许多感染是由多重耐药生物（MDROs）引起的，包括耐甲氧西林金黄色葡萄球菌（MRSA）、耐万古霉素肠球菌（VRE）和多重耐药革兰氏阴性杆菌（R-GNB）。常见细菌的抗菌素耐药性对临床过程产生不利影响，并成倍增加医疗保健费用。认识到需要采取行动，立法者、决策者和消费者团体正在倡导对这些耐多药耐蚀药进行基于病原体的普遍预防性筛查，特别是在医院和NHs中进行MRSA筛查。然而，实施这一广泛的授权是有争议的、昂贵的、被动的，而且没有基于经验证据。它可能导致被隔离预防措施的NH居民人数增加10-20倍，并有可能减少卫生保健工作者的关注、隔离和功能下降。我们的建议评估了一种介于“什么都不做”和“搜索所有并摧毁”策略之间的新颖的重点方法，针对的是一组有留置装置的NH居民，他们具有获得mdro和感染的高风险。我们假设我们的目标感染控制程序（TIP）将减少MDRO定植和感染在NH居民留置装置。该集群随机试验将涉及12个NHs；6名患者将随机分配到TIP组，6名患者将随机分配到常规护理组。我们的多组件TIP干预将包括：组件1：为所有使用留置装置的NH居民加强屏障预防措施；积极筛查MDRO（每月），使用从多个身体部位收集的培养物，以确定这些居民中无症状的MDRO携带；并将结果传播给临床工作人员和管理层。第2部分：使用标准化定义对使用留置装置的居民进行感染的结构化、主动监测，并将结果传播给临床工作人员和管理部门。组成部分3：手卫生促进计划。组成部分4：与医疗保健工作者的留置设备护理有关的结构化教育计划。我们的研究将确定我们的多组分TIP干预是否减少了NH留置装置高风险亚组中mdro的无症状携带（主要结果）和症状性感染（次要结果）。提出的研究也将为耐药病原体的分子流行病学和传播机制提供新的见解。利用分子方法，我们将确定在不同设施内和设施之间使用留植装置的居民之间MDRO的遗传相关性，追踪任何新菌株的来源，并评估我们的干预对特定菌株的影响。我们的研究结果将允许感染控制从业人员、卫生保健工作者、临床医生、政策制定者、立法机构和消费者更好地解决NHs老年人的抗菌素耐药性和感染问题。公共卫生相关性：随机临床试验将支持有针对性的感染控制干预措施可以减少养老院体弱老年人的感染和抗微生物药物耐药性负担的观点。分子流行病学方法将追踪养老院耐药菌株的起源，并进一步描述在这一经常被忽视的环境中出现和传播的耐药耐药菌株的新菌株。

DESCRIPTION (provided by applicant): 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.