All In: If You Share Patients, Collaborate
MDROs fall when facilities join across the continuum
May 1, 2024
A regional decolonization collaborative among hospitals and long-term care facilities that commonly share patients led to decreased infections, hospitalizations, costs, and deaths caused by multidrug-resistant organisms (MDROs), researchers reported.1
“Over the course of about 25 months, we prevented what was estimated to be 800 hospitalizations and 60 deaths. [That is just] from the nursing homes,” says lead investigator Susan Huang, MD, MPH, medical director of epidemiology and infection prevention at the University of California, Irvine.
Whereas the protocol was universal in the long-term care settings, hospital patients included in the study already were under contact precautions for MDROs and, of course, had shorter lengths of stay. “They have shorter stays, so we’re lucky if we could finish the decolonization protocol before they were discharged,” she says. “The benefit is probably gained elsewhere.”
Since all facilities shared patients, a benefit anywhere may move across the continuum to help another facility. The 35 participating facilities included 16 hospitals, 16 nursing homes, and three long-term acute care hospitals (LTACHs) in Orange County, CA.
The protocol used chlorhexidine bathing and nasal iodophor antisepsis (10% povidone-iodine) for residents in long-term care and hospitalized patients in contact precautions.
“The intervention involved universal decolonization in nursing homes and LTACHs using 2% leave-on chlorhexidine-impregnated cloths for bed bathing, and 4% rinse-off chlorhexidine liquid for showering on admission and routinely thereafter,” the authors reported.1 “Additionally, all nursing home residents and LTACH patients received twice-daily nasal iodophor for five days on admission and then Monday through Friday, every other week.”
Hospitals received refresher training for ongoing universal chlorhexidine bathing in intensive care units (ICUs) and adopted targeted decolonization for all non-ICU patients in contact precautions.
“Targeted decolonization involved five days of chlorhexidine baths and twice daily nasal iodophor,” the authors noted. “Residents in nursing homes generally received a bath or shower three times per week, while patients in LTACHs or hospitals were generally offered a daily bath or shower.”
Prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and extended spectrum beta-lactamase (ESBLs) significantly decreased in nursing homes and LTACHs. Decolonization was associated with a 27% reduction in infection-related hospitalization costs. That study was conducted from July 1, 2017, to July 31, 2019.
Q & A
Hospital Infection Control & Prevention (HIC) spoke with Huang in the following interview, which has been edited for length and clarity.
HIC: Your group has published a series of papers, sometimes recommending chlorhexidine bathing and mupirocin for nasal decolonization. This study looked at chlorhexidine bathing and nasal iodophor antisepsis. Can you speak to how this paper reflects on your previous work?
Huang: Each of the prior cluster randomized trials that we’ve done has been focused on one particular setting. This one really looks at a regional effect of trying to reduce MDROs across an entire region. The idea is that, since MDROs are contagious, why don’t we all work together? This particular study really looks at the value of doing [decolonization protocols] simultaneously.
We invited these individual hospitals, nursing homes and LTACHs based on their network of sharing a lot of patients with each other. They were not part of a singular system, but they had high interactivity on patient-sharing metrics, they had high interactivity. They had some interest in working together toward a common goal.
I think that’s one of the major values of thinking about doing regional approaches where we know something’s contagious and there’s some greater value [to be gained]. If you decolonize patients, even if they’re leaving the hospital in three days, the benefit will ultimately come back to you.
HIC: Why did you use the 10% povidone-iodine for nasal decolonization instead of mupirocin?
Huang: That particular question is interesting. We published a paper last fall showing that in ICUs mupirocin is superior.2 It’s 18% better. But when we started this particular project, we didn’t know that mupirocin was superior, but it is. But more importantly, for the nursing homes, there are a couple advantages of iodophor when you need to do a prescription. Mupirocin is great in the ICU where you can have a standing order, doctors are on-site at all times, it’s easy to have pharmacy dispense it because it’s 24/7.
You go into a nursing home where the pharmacy isn’t open 24/7 or even on-site — it becomes really important to be able to use something that may not be perfect but is better than not using it. And that’s what iodophor provides. It provides easy access because it’s over the counter, and it is incredibly inexpensive. It’s pennies for a swab when you use the generic version. And that really fits into the lower-resource settings like nursing homes.
HIC: There’s more interest and research on this whole question of transferring MDROs across health systems via patients. Yes, all facilities benefit, but why was this approach particularly effective in nursing homes?
Huang: In the long-term care settings, the nursing homes and the long term acute care hospitals, we did it for everybody — it was a universal approach. That has greater benefit because MDROs are contagious, so everybody around you is protecting you, and you are protecting the entire setting.
In the hospitals, we’ve tailored it so it was only those that were in contact precautions that got it. It’s about 10% of the hospital population, not including the ICUs, which were already doing it by then. I think it’s not surprising that long-term care facilities derived a much more measurable benefit because residents stay longer. Before decolonizing them, we do a point prevalence sample and then, later, you can see big reductions — 20%, 30% reductions in their MDROs [and that] reduces hospitalizations.
HIC: Did you see that effect in the LTACHs? They’re known to harbor a lot of MDROs.
Huang: We had to combine their information a lot of times. There are only three long-term acute care facilities that serve adults in Orange County, and all of them participated. We didn’t have the same control group that we had for everybody else, where we could look at those that didn’t participate vs. those that did. But we saw even greater reductions in their clinical cultures for MDROs. They start at about 80% positivity. I mean, that’s a pretty remarkable level of MDRO prevalence. If there’s any place that could really use a universal approach, the LTACHs really [could benefit]. But the numbers were not enough for us to [determine] whether their hospitalizations were reduced. I think in a larger study that had more LTACHs that would be the likely goal.
HIC: Can you put the reductions in colonization in context for the three settings?
Huang: I would say that the reduction in colonization pretty much mirrors the reduction in infection for long-term care. It’s about 20% to 30%, depending on which one you’re measuring. The hospital [is] much less, about 15%, because of the short turnaround time. And I think the nice thing about the long-term care effect is that colonization mirrors the infection, the clinical culture reduction. It’s very, very similar. And then, ultimately, the big drop in hospitalizations and deaths are very much linked to the nursing home decolonization.
HIC: You note in the paper that the benefits of regional decolonization may accumulate with sustained adoption. Do you see this approach being more widely adopted by other groups of facilities?
Huang: Yes, here in Orange County after the intervention occurred, we still have about 20-something nursing homes that are actively doing this on their own accord. I think the uptake — especially in lower-resourced settings — is really going to be [dependent on] insurers, the Centers for Medicare and Medicaid Services (CMS), to really help incentivize this.
The iodophor is really quite inexpensive. Chlorhexidine is a little more expensive, but it does require an upfront investment and that investment is really hard to do in lower-resource settings. What we find is that if we can engage the health insurers — which are the ones who stand to benefit the most from cost reduction for hospitalizations — this could be a really wise way to implement a quality improvement strategy. Central California Medicaid is doing just that. They’re incentivizing the nursing homes in their region to adopt this and reduce their Medicaid expenditures for members. It’s that type of vision, I think, that’s going to make a really big difference in whether this will be adopted for those that have a hard time putting up the upfront costs. We think the camaraderie is really powerful [between settings], so our hope is that there’ll be other counties and regions that take this up.
REFERENCES
- Huang SS, Septimus EJ, Kleinman K, et al. Nasal iodophor antiseptic vs nasal mupirocin antibiotic in the setting of chlorhexidine bathing to prevent infections in adult ICUs: A randomized clinical trial. JAMA 2023;10;330:1337-1347.
- Gussin GM, McKinnell JA, Singh RD, et al. Reducing hospitalizations and multidrug-resistant organisms via regional decolonization in hospitals and nursing homes. JAMA 2024; Apr 1. doi:10.1001/jama.2024.2759. [Online ahead of print].
A regional decolonization collaborative among hospitals and long-term care facilities that commonly share patients led to decreased infections, hospitalizations, costs, and deaths caused by multidrug-resistant organisms, researchers reported.
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