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

描述（由申请人提供）：本修订申请寻求对一项旨在减少疗养院（NH）居民多药耐药性和感染的干预性研究的支持。每年，在NHS中发生惊人的150 - 200万感染。这些感染中的许多是由多重耐药生物体（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）和多重耐药革兰氏阴性杆菌（R-GNB）。常见细菌中的抗菌素耐药性对临床进程产生不利影响，并呈指数级增加医疗保健成本。认识到需要采取行动，立法者，政策制定者和消费者团体正在倡导对这些MDRO进行基于病原体的普遍先发制人的筛查，特别是医院和NH中的MRSA。然而，执行这一广泛的任务是有争议的，昂贵的，被动的，而不是基于经验证据。它可能导致被隔离预防措施的NH居民数量增加10-20倍，有可能减少医护人员的注意力，隔离和功能下降。我们的建议评估了一种新的集中方法之间的“什么都不做”和“搜索所有和销毁”的战略，针对一个亚组的NH居民与留置装置谁是在获得MDRO和感染的高风险。我们假设我们的目标感染控制计划（TIP）将减少使用留置器械的NH居民的MDRO定植和感染。这项随机分组试验将涉及12名NH; 6名将被随机分配到TIP组，6名分配到常规护理组。我们的多组分TIP干预将包括：组分1：为所有使用留置器械的NH居民制定增强的屏障预防措施;使用从多个身体部位收集的培养物进行MDRO主动筛查（每月一次），以确定这些居民中无症状的MDRO携带情况;并将结果分发给临床工作人员和行政部门。构成部分2：在使用留置器械的居民中使用标准化定义对感染进行结构化的主动监测，并将结果传播给临床工作人员和管理部门。组成部分3：手部卫生促进方案。组成部分4：一个结构化的教育计划有关的留置器械护理的医护人员。我们的研究将确定我们的多组分TIP干预是否减少了使用留置器械的NH居民高风险亚组中MDRO（主要结局）和症状性感染（次要结局）的无症状携带。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，我们将确定不同设施内和不同设施之间留置器械的居民之间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。我们的研究结果将使感染控制从业人员，医疗保健工作者，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中老年人的抗菌素耐药性和感染问题。公共卫生相关性：这项随机临床试验将支持这样一种观点，即有针对性的感染控制干预措施可以减少年老体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MDRO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.