Regional Approach Effective in Reducing Multi-Drug Resistant Bacteria

A county-wide decolonization intervention in nursing homes and among selected hospital patients led to fewer multidrug-resistant organism (MDRO) infections, hospitalizations, and deaths across the region, according to the SHIELD-OC (Orange County) study in California.

From baseline, the antiseptic measures resulted in the following decreases in MDRO prevalence among participating facilities:

• 13.6% (P=0.03) among hospitalized patients undergoing contact precautions
• 21.9% (P<0.001) among nursing home residents
• 33.4% (P=0.01) among residents of long-term acute care hospitals

Decolonization also decreased infection-related hospitalization among participating nursing homes by an adjusted 26.7% (95% CI 19.0%-34.5%) compared with nonparticipating nursing homes, Susan Huang MD, MPH, of the University of California Irvine School of Medicine, and colleagues reported in JAMA.

That reduction was similar to the 31% seen in the PROTECT trial that evaluated universal chlorhexidine and nasal iodophor intervention in nursing homes, Huang and co-authors noted.

Decolonization was also associated with an adjusted 23.7% (95% CI 4.5%-43%, P<0.001) reduction in deaths from infection-related hospitalizations among participating nursing homes when compared with nonparticipating nursing homes.

“We were incredibly gratified to see the large size of those reductions across the county, especially in long-term care,” Huang told MedPage Today in an email. “Even more exciting and unanticipated were the drops in hospitalizations and deaths from nursing home residents.”

Interventions in the current study included chlorhexidine bathing and nasal iodophor antisepsis.

“It is always better to prevent infection than to have to treat it, and it’s best to avoid having an antibiotic-resistant bacteria,” Huang pointed out. “This can be achieved by switching out routine soap with chlorhexidine antiseptic soap for patient baths and showers in hospitals and nursing homes and by providing nasal ointments to remove bacteria in the nose.”

Incident MDRO clinical cultures (i.e., non-screening cultures) were also decreased by an adjusted 30.4% (95% CI 16.4%-42.1%) in nursing homes, 12.9% (95% CI 3.3%-21.5%) in hospitals, and 22.5% (95% CI 4.4%-37.1%) in long-term acute care hospitals, when compared with nonparticipating facilities.

In addition, hospitalization costs associated with MDRO infections were reduced by 26.8% (95% CI 26.7%-26.9%) among participating nursing homes compared with nonparticipating nursing homes.

“Health insurers should examine the cost-effectiveness of incentivizing hospitals and nursing homes to adopt this quality improvement strategy,” Huang said. “The cost savings from hospitalizations is likely to far outweigh the costs of inexpensive antiseptic soap and nasal ointment.”

In an accompanying editorial, Christopher Crnich, MD, PhD, of the University of Wisconsin School of Medicine and Public Health in Madison, wrote that most efforts to prevent the emergence and spread of MDROs have focused on acute care facilities, but that long-term care facilities (LTCFs) often have higher colonization rates than tertiary care referral facilities and those providing post-acute care have repeatedly been a source of regional outbreaks of MDROs. “These findings point to a critical need to expand MDRO efforts beyond the hospital setting,” he emphasized.

Crnich also pointed out that universal application of the intervention appeared to have been a more effective strategy than targeting specific high-risk individuals, which may explain the high levels of adherence to the interventions. Among nursing home residents, mean adherence was 86.3% to chlorhexidine and 69.5% to povidone-iodine. Adherence was also high among hospitalized patients in contact precautions with a mean adherence of 79.3% to chlorhexidine and 69.6% to povidone-iodine.

“It’s hard to predict the impact of a prevention strategy because it depends on how well it’s performed,” Huang said. “Having a regional collaborative with strong and enthusiastic hospital, nursing home, and long-term acute care hospital partners enabled us to achieve this win together for better health across our region.”

Crnich noted that the relative contributions of intranasal iodophor application and bathing using chlorhexidine to the success of the decolonization intervention aren’t clear. “It can be argued that simply routinizing bathing practices in LTCFs can decrease a resident’s risk of MDRO colonization and the lack of detail on bathing practices in control facilities is a missed opportunity,” he wrote.

The SHIELD-OC quality improvement study, conducted from July 2017 through July 2019, included a total of 35 facilities in Orange County — 16 nursing homes, 16 hospitals, and three long-term acute care hospitals — that adopted the decolonization intervention.

The intervention for nursing homes and long-term acute care hospitals involved using 2% chlorhexidine-impregnated cloths for bed bathing, 4% rinse-off chlorhexidine liquid for routine showering, and application of twice-daily nasal iodophor (10% povidone-iodine) for 5 days on admission, and then Monday through Friday every other week. Residents of nursing homes typically received a bath or shower three times a week whereas patients in long-term acute care hospitals could bathe or shower daily. Targeted decolonization among hospitalized patients in control precautions included 5 days of chlorhexidine baths and twice daily nasal iodophor.

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