Targeted Infection-control Program (TIP) to reduce Resistant Pathogens and Infect

描述(申请人提供)：这项修改后的申请寻求支持一项旨在减少养老院(NH)居民的多重耐药和感染的干预性研究。每年，英国国民健康保险制度中发生的感染人数达到惊人的150-200万人。其中许多感染是由多重耐药菌(MDRO)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)和多药耐药革兰氏阴性杆菌(R-GNB)。常见细菌中的抗菌素耐药性正在对临床病程产生不利影响，并指数级增加医疗成本。认识到采取行动的必要性，立法者、政策制定者和消费者团体正在倡导对这些MDRO，特别是医院和NHS中的MRSA进行基于病原体的普遍先发制人筛查。然而，执行这一全面授权是有争议的、代价高昂的、被动的，而且不是基于经验证据。它可能导致被置于隔离预防措施中的NH居民的数量增加10-20倍，可能会减少医护人员的关注、隔离和功能下降。我们的提案评估了一种介于“无所作为”和“搜索所有并销毁”策略之间的新的重点方法，通过将目标对准具有留置装置的NH居民子群，他们具有感染MDRO和感染的高风险。我们假设我们的有针对性的感染控制计划(TIP)将减少MDRO在NH居民中的定植和使用留置装置的感染。这项整群随机试验将涉及12个NHS；6个将随机分配到TIP组，6个随机分配到常规护理组。我们的多成分TIP干预措施将包括：第一部分：为所有使用留置设备的NH居民制定加强的屏障预防措施；使用从多个身体部位收集的培养物积极筛查MDRO(每月)，以确定这些居民是否携带无症状的MDRO；以及向临床工作人员和管理人员传播结果。组成部分2：使用标准化定义对使用留置装置的居民进行结构化、积极的感染监测，并将结果传播给临床工作人员和管理人员。第三部分：手部卫生促进方案。构成部分4：有关医护人员留置设备护理的结构化教育方案。我们的研究将确定我们的多成分TIP干预是否减少了使用留置装置的NH高危人群中无症状的MDRO携带者(主要结果)和症状性感染(次要结果)。这项拟议的研究还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。使用分子方法，我们将确定在不同设施内和不同设施之间使用留置装置的居民之间的MDRO的遗传联系，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。我们的结果将使感染控制从业者、医护人员、临床医生、政策制定者、立法机构和消费者能够更好地解决NHS老年人中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这样的概念，即有针对性的感染控制干预可以减少虚弱的养老院居民的感染和抗菌素耐药性负担。分子流行病学方法将追踪养老院耐药菌株的来源，并进一步表征在这个经常被忽视的环境中出现和传播的新的MDRO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.