You wait for ages, and then two come at once..


Sometimes waiting for research highlighting an issue that you know is a problem is like waiting for a bus..  Following on from my colleague @jonotter who last week posted about MRSA spread in nursing home settings, I was interested to read this new paper from the USA, published in the Journal of the American Geriatric Society. The study notes the high prevalence of Multi-Drug Resistant Organism (MDRO) carriage in nursing homes that was in excess of that in hospital settings and sought to determine any associations. The findings are interesting, if not surprising.

The two most significant risk factors for acquisition of an MDRO were functional disability and intensive nursing contact. Residents with only a mild disability, no medical device or wounds would acquire MRSA after 20 months, whereas someone with intensive nursing contacts would become MRSA-positive at around 5 months. Similar findings were reported for Vancomycin-resistant Enterococci (VRE).

Surprising? No, but significant given the paucity of literature in this field. Infection prevention activities in community settings in terms of education, motivation and practice assessment should be strengthened of we are to attempt to combat the problems that allowing high prevalence of MDROs in nursing homes to build will bring. In a nursing home, although colonisation rates may be high, infection may be rare due to less opportunity for these pathogens to access areas where they can do damage. However residents are often admitted to acute care, where the risks of infection multiply and more opportunities for transmission due to the intensity of patient contact are present.

This study strengthens the argument for strengthening IPC activity in non-acute hospital settings (not that there should be one). Need for intensive nursing support for a nursing home resident is a predictor of acquisition of MDROs. Even something as simple as walking ability could be a predictor. Time to acquisition of MDR gram-negative bacteria for a resident with complete dependence in walking was amost twice as fast as residents with moderate dependence in walking. Hospitals may even consider building this into assessments on admission. MDRO screens may take a few days and isolating a resident who has been in receipt of significant nursing input in terms of devices and wound management may prove to be a wise precaution.

As for the future? Passive surveillance will only detect the infections. The rest of the iceberg is unseen. Whether there is any appetite for real support and resource for more active programmes before the stable door is bolted with the horse heading over the horizon remains to be seen.

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