Background: vSNFs are known reservoirs of MDROs. However, data are lacking on how MDRO carriage may differ between residents in ventilator-capable (vBed) and non-ventilator-capable (non-vBed) areas within vSNFs. Methods: We conducted two point-prevalence MDRO sweeps in two vSNFs (Facility A: 44 vBeds/55 non-vBeds; Facility B: 31 vBeds/167 non-vBeds) from May-June 2025. All occupied beds were sampled except for Facility B’s non-vBeds which randomly sampled 50 beds due to size. Sampling involved hands, axilla/groin and peri-rectal areas cultured for MRSA, ESBL, VRE, C. auris, CRAB, and CRE, plus bilateral nares swabs cultured for MRSA and C. auris. Descriptive statistics summarized overall and MDRO-specific prevalence across body sites, with differences between vBed and non-vBed residents evaluated using t-tests and chi-square tests. Results: Overall MDRO prevalence was higher in vBeds (83.9%, 115/137) than non-vBeds (73.2%, 145/198; p=0.029) although the rank order of carriage was similar: MRSA > ESBL > VRE > C. auris > CRAB > CRE. vBed residents had significantly higher prevalence for all pathogens except MRSA (Figure). Multi-MDRO burden was greater in vBeds (mean 2.3 MDROs/resident) than non-vBeds (1.3; p<0.001); vBeds had a substantially higher likelihood of carrying ≥3 (46.0% vs 13.6%; p<0.001), ≥4 (24.1% vs 4.0%; p<0.001), or ≥5 MDROs (10.9% vs 1.0%; p<0.001). Emerging MDROs (CRE, CRAB, C. auris) were more prevalent in vBeds (43.1% vs. 19.7%; p<0.001), and were highly associated with endemic MDRO co-carriage (98.3% [58/59] vBeds; 97.4% [38/39] non?vBeds). The mean number of positive body sites was higher in vBeds (2.4 vs 2.0; p=0.003), with a higher likelihood of being positive at ≥2 sites (73.0% vs 59.6%; p=0.009), ≥3 sites (51.1% vs 39.4%; p=0.017), or 4 sites (35.0% vs 23.7%; p=0.010). vBed residents were more likely to have axilla/groin carriage (79.6% vs 58.1%; p<0.001) with non-significantly higher carriage at other sites (Figure). Nasal carriage patterns differed by organism: MRSA prevalence was similar between vBed and non?vBed residents (29.2% vs 32.8%; p=0.559), whereas C. auris was markedly higher in vBeds (29.2% vs 4.0%; p<0.001). Conclusion: Carriage of both endemic and emerging MDROs is widespread in vSNFs, affecting ~75% of residents regardless of ventilator status. However, vBed occupants were more likely to harbor an MDRO, and more likely to harbor multiple MDROs at multiple body sites. Emerging pathogens were also more common in vBed occupants, and were almost always associated with co-carriage of endemic MDROs. Guidance is needed for comprehensive MDRO response in vSNFs.

Background: vSNFs are known reservoirs of MDROs. However, data are lacking on how MDRO carriage may differ between residents in ventilator-capable (vBed) and non-ventilator-capable (non-vBed) areas within vSNFs. Methods: We conducted two point-prevalence MDRO sweeps in two vSNFs (Facility A: 44 vBeds/55 non-vBeds; Facility B: 31 vBeds/167 non-vBeds) from May-June 2025. All occupied beds were sampled except for Facility B’s non-vBeds which randomly sampled 50 beds due to size. Sampling involved hands, axilla/groin and peri-rectal areas cultured for MRSA, ESBL, VRE, C. auris, CRAB, and CRE, plus bilateral nares swabs cultured for MRSA and C. auris. Descriptive statistics summarized overall and MDRO-specific prevalence across body sites, with differences between vBed and non-vBed residents evaluated using t-tests and chi-square tests. Results: Overall MDRO prevalence was higher in vBeds (83.9%, 115/137) than non-vBeds (73.2%, 145/198; p=0.029) although the rank order of carriage was similar: MRSA > ESBL > VRE > C. auris > CRAB > CRE. vBed residents had significantly higher prevalence for all pathogens except MRSA (Figure). Multi-MDRO burden was greater in vBeds (mean 2.3 MDROs/resident) than non-vBeds (1.3; p<0.001); vBeds had a substantially higher likelihood of carrying ≥3 (46.0% vs 13.6%; p<0.001), ≥4 (24.1% vs 4.0%; p<0.001), or ≥5 MDROs (10.9% vs 1.0%; p<0.001). Emerging MDROs (CRE, CRAB, C. auris) were more prevalent in vBeds (43.1% vs. 19.7%; p<0.001), and were highly associated with endemic MDRO co-carriage (98.3% [58/59] vBeds; 97.4% [38/39] non?vBeds). The mean number of positive body sites was higher in vBeds (2.4 vs 2.0; p=0.003), with a higher likelihood of being positive at ≥2 sites (73.0% vs 59.6%; p=0.009), ≥3 sites (51.1% vs 39.4%; p=0.017), or 4 sites (35.0% vs 23.7%; p=0.010). vBed residents were more likely to have axilla/groin carriage (79.6% vs 58.1%; p<0.001) with non-significantly higher carriage at other sites (Figure). Nasal carriage patterns differed by organism: MRSA prevalence was similar between vBed and non?vBed residents (29.2% vs 32.8%; p=0.559), whereas C. auris was markedly higher in vBeds (29.2% vs 4.0%; p<0.001). Conclusion: Carriage of both endemic and emerging MDROs is widespread in vSNFs, affecting ~75% of residents regardless of ventilator status. However, vBed occupants were more likely to harbor an MDRO, and more likely to harbor multiple MDROs at multiple body sites. Emerging pathogens were also more common in vBed occupants, and were almost always associated with co-carriage of endemic MDROs. Guidance is needed for comprehensive MDRO response in vSNFs.

Background: vSNFs are known for exceedingly high MDRO prevalence, raising questions about the role of environmental contamination and persistence in this healthcare setting. Methods: Environmental sampling was conducted May-June 2025 in two vSNFs. High-touch objects in common areas (mobile/shower equipment, staff breakrooms, dining rooms, rehabilitation gyms) and resident rooms were swabbed using spongesicles, homogenized in trypticase soy broth, incubated 18-24 hours, and cultured for MRSA, VRE, ESBL, C. auris, CRAB, and CRE. On the same day, resident carriage of the same organisms was assessed at nares, hands, axilla/groin, and peri?rectal sites. All ventilator-capable (vBed) and non-vBed occupied beds were sampled except for one facility’s non-vBeds, which randomly sampled 50 beds due to size. The proportion of positive common area objects was compared with MDRO carriage prevalence using two-sample tests of proportions. Within resident rooms, object contamination was compared among carriers and non-carriers for each pathogen, overall and stratified by vBed status, using Fisher’s exact tests. Results: Sampling included 96 common area objects and 245 objects from 39 resident rooms (20 vBed, 19 non-vBed). MDRO contamination of high-touch objects in common areas was extensive (73.9%), including 77.8% of mobile equipment and 58.3% of common area objects (37.5% staff breakroom, 87.5% rehabilitation gym, 50.0% dining objects). The most frequently detected MDROs on objects were MRSA>CRAB>VRE>ESBL>C. auris>CRE, which differed from the sequence of MDRO carriage among residents: MRSA>ESBL>VRE>C. auris>CRAB>CRE. Object contamination and resident carriage were similar for MRSA (65.6% vs. 60.5%, p=0.43), VRE (19.8% vs. 23.3%, p=0.54), and CRE (1.0% vs. 4.1%, p=0.27). In contrast, contamination was markedly lower than carriage for ESBL (8.3% vs. 43.6%, p<0.001) and C. auris (3.1% vs. 25.6%, p<0.001), while CRAB contamination far exceeded carriage (21.9% vs. 11.0%, p=0.02) (Figure 1). Among bedrooms, all sampled rooms had some MDRO contamination, including all rooms of non-carriers. MRSA contamination was similar in the rooms of carriers and non-carriers; all other pathogens, contamination was substantially greater in rooms of carriers (Figure 2). Conclusions: The relationship between MDRO contamination and resident carriage in vSNFs showed clear pathogen?specific patterns. MRSA and VRE contamination closely mirrored resident carriage, whereas ESBL and C. auris were less frequent on surfaces despite high carriage. Notably, CRAB was disproportionately common in the environment, suggesting environmental persistence. Bedrooms of carriers had higher contamination, yet MDROs were also present in non-carrier rooms, contributing to ongoing transmission risk. Effective containment likely requires universal strategies supplemented by targeted, pathogen-specific efforts.

The SHIELD Regional Collaborative (JAMA 2024, PMID: 38557703) was a quasi-experimental decolonization initiative that found a 27% reduction in infection-related hospitalizations among the 16 nursing homes that adopted universal decolonization— chlorhexidine bathing and nasal iodophor. We evaluated whether this intervention also reduced antibiotic use. This SHIELD secondary analysis compared 16 participating nursing homes vs 45 non-participants in Orange County, CA to evaluate the effect of universal decolonization on antibiotic use in residents, defined as the number of days of antibiotic administration during the 7 days reported for each Minimum Data Set (MDS) assessment (admission, quarterly, discharge). We conducted a difference-in-differences analysis using generalized linear mixed logistic regression models to account for clustering within facility, and to assess the relative change in the odds of antibiotic use using an interaction term between participation status and time period. Compared with the baseline period, decolonization nursing homes had a 48.1% reduction (OR=0.519, 95% CI: 0.512-0.527) in antibiotic use in the intervention period compared to a 41.2% reduction in routine care nursing homes (OR=0.588, 95% CI: 0.577-0.599), resulting in an 11.7% greater reduction in the odds of antibiotic use (relative OR=0.883; 95% CI 0.854-0.912; p< 0.0001) in decolonization nursing homes after the intervention, adjusting for age, gender, race, ethnicity, insurance, and coexisting conditions. Predicted probabilities showed antibiotic use decreased from 6.9% to 3.7% in the decolonization group compared to a decline from 7.0% to 4.2% in the routine care group. These findings support universal decolonization as an effective strategy to reduce antibiotic use in nursing homes. In addition to improved health outcomes, this reduction in antibiotic use plus the previously shown reduction in infection-related hospitalizations supports universal decolonization as a cost-saving strategy for nursing homes. Loren G. Miller, MD MPH, Armata: Grant/Research Support|GSK: Grant/Research Support|Merck: Grant/Research Support|Paratek: Grant/Research Support Susan Huang, MD, MPH, Xttrium: Conducting studies in which participating nursing homes and hospitalized patients receive contributed antiseptic products|Xttrium Laboratories: Conducting studies in which participating nursing homes and hospitalized patients receive contributed antiseptic product

Abstract Background Nursing homes are high-risk settings for multidrug-resistant organism (MDRO) prevalence and spread. We investigated whether nursing home roommates were more likely to carry the same MDRO compared to non-roommates. Methods We conducted a secondary analysis of 44 nursing homes in two studies (Protect Trial-Miller NEJM 2023; SHIELD-Gussin JAMA 2024) involving universal chlorhexidine bathing and nasal iodophor. We used MDRO status from baseline (2016-17) and end-intervention (2018-19) visits where 50 residents were sampled at random at each nursing home. Sampling included bilateral nares swabs processed for methicillin-resistant Staphylococcus aureus (MRSA), and axilla/groin swabs processed for MRSA, vancomycin-resistant Enterococci (VRE), and extended-spectrum beta-lactamase (ESBL) producers. We used generalized estimating equations with alternating logistic regressions to assess the odds ratio (OR) for each MDRO while clustering by nursing home. These ORs are the relative odds of one person being positive (outcome) given that the paired person is positive (exposure), divided by the odds of being positive if the paired person is negative. We estimated separate values when the two people are roommates and when they are non-roommates. Models adjusted for age, gender, post-acute status, need for full care assistance, presence of an indwelling device, MDRO history, and baseline vs. decolonization period. Shared room assignments (cohorting) due to known history of the specific MDRO being modeled were excluded. Results The 44 nursing home sample included 4851 residents who were roomed in 180 single rooms, 1945 doubles, 874 triples, 93 quads, four 5-bed rooms, and six 6-bed rooms. The Table shows significantly higher ORs of concordant MDRO carriage among roommates than among non-roommates for each MDRO. Conclusion Roommates in nursing homes are significantly more likely to carry the same MDRO versus non-roommates, indicating potential transmission within shared rooms. Disclosures Ken Kleinman, ScD, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Raveena D. Singh, MA, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Raheeb Saavedra, AS, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work

Abstract Background Candida auris is an emerging drug-resistant yeast that is spreading rapidly in U.S. healthcare facilities, particularly in nursing homes. Like MRSA, C. auris is commonly found in the nose, raising questions about whether nasal iodophor application can reduce carriage. Methods We evaluated the impact of iodophor on C. auris nasal carriage at two nursing homes. Nasal carriers were identified from point prevalence sampling of bilateral nares of residents for both C. auris and MRSA conducted at each nursing home. Nasal iodophor was given to carriers according to a 5-day twice-daily decolonization protocol. Nasal swabs for C. auris and MRSA culture were collected on Day 1 (pre-iodophor), Day 5 (last day of iodophor administration), and Day 9 (4 days after iodophor cessation). Bioburden was assessed on an ordinal scale (none = 0, few =1, 1+ = 2, 2+ = 3, 3+ = 4, and 4+ = 5). Paired t-tests compared C. auris and MRSA bioburden between timepoints. Results Twenty-two residents with C. auris nares carriage completed the evaluation. Seven (32%) also harbored MRSA. Between Days 1 and 5, mean nares bioburden decreased from 3.6 to 2.8 for C. auris (P=0.03) and from 4.3 to 2.3 for MRSA (P=0.02) (Figure). Comparing Day 9 to Day 1, mean C. auris bioburden at Day 9 was 2.8 (P=0.01) and mean MRSA bioburden at Day 9 was 3.1 (P=0.14). Conclusion Five days of nasal iodophor antisepsis appeared to suppress both C. auris and MRSA carriage. Rebound growth four days after iodophor discontinuation was seen for MRSA but not C. auris, although numbers were small. Nasal iodophor may be an effective strategy for reducing nasal carriage in high-risk settings. The value of repeated antisepsis for sustained bioburden reduction was not evaluated in this study. Disclosures Raveena D. Singh, MA, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Raheeb Saavedra, AS, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work

Background: Candida auris and methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in nursing homes, and both are known to shed profusely from the skin. We evaluated the degree of differential shedding during caregiving activities versus at rest in nursing home residents. Methods: Residents at two nursing homes were screened for C. auris and MRSA using nares, axilla/groin, and peri-rectal swabs. Carriers of C. auris, some of whom also carried MRSA, were evaluated for proximal shed around their bed during rest and caregiving activities using chromogenic settle plates. Morning caregiving activities (e.g. hygiene care, linen/clothing change) were noted to generally take 12 minutes. For rest, settle plates were placed for a 12-minute period prior to the resident awakening in the morning. For caregiving, settle plates were placed for the 12-minute period of morning activity shortly after awakening. Twin rest-caregiving measurements were taken on three separate days per C. auris carrier. In addition, prior to caregiving, bilateral nares, hands, axilla, groin, and perirectal swabs were taken for C. auris and MRSA culture, along with an axilla/groin swab for measuring chlorhexidine concentration (CHG used for routine bathing). Logistic regression with person-level clustering analyzed associations between positive settle plates (“shedding”) and activity (caregiving versus rest), along with other adjusters. Results: The study included 23 C. auris carriers, 15 of whom carried MRSA. 65% were male, 91% had an indwelling device, 39% had wounds. Mean number of positive body sites was 2.3 for C. auris and 1.2 for MRSA. Median CHG concentration was 156 µg/mL (IQR=39-1250). Shedding occurred more frequently during caregiving versus rest for both C. auris (8/69 vs 1/69, P=0.02) and MRSA (15/69 vs 3/69, p=0.002). In multivariable models (Table), caregiving was associated with increased odds of shedding for both C. auris (OR: 9.25 (95% CI: 1.07-80.35), P=0.04) and MRSA (OR: 6.52 (95% CI: 1.72-24.78), P =0.01). Higher CHG concentrations were non-significantly associated with reduced shedding of both pathogens. Conclusion: C. auris and MRSA shedding increased significantly during caregiving activities, supporting CDC’s current recommendations for enhanced barrier precautions in nursing homes, which involve gown and glove use during high-contact care for carriers of multidrug-resistant organisms. Remarkably, shedding was readily detected within 12 minutes of morning caregiving, highlighting a rapid “plume effect” during resident care.

Importance Current guidance to furlough health care staff with mild COVID-19 illness may prevent the spread of COVID-19 but may worsen nursing home staffing shortages as well as health outcomes that are unrelated to COVID-19. Objective To compare COVID-19-related with non-COVID-19-related harms associated with allowing staff who are mildly ill with COVID-19 to work while masked. Design, Setting, and Participants This modeling study, conducted from November 2023 to June 2024, used an agent-based model representing a 100-bed nursing home and its residents, staff, and their interactions; care tasks; and resident and staff health outcomes to simulate the impact of different COVID-19 furlough policies over 1 postpandemic year. Exposures Simulating increasing proportions of staff who are mildly ill and are allowed to work while wearing N95 respirators under various vaccination coverage, SARS-CoV-2 transmissibility and severity, and masking adherence. Main Outcomes and Measures The main outcomes were staff and resident COVID-19 cases, staff furlough days, missed care tasks, nursing home resident hospitalizations (related and unrelated to COVID-19), deaths, and costs. Results In the absence of SARS-CoV-2 infection in the study's 100-bed agent-based model, nursing home understaffing resulted in an annual mean (SD) 93.7 (0.7) missed care tasks daily (22.1%), 38.0 (7.6) resident hospitalizations (5.2%), 4.6 (2.2) deaths (0.6%), and 39.7 (19.8) quality-adjusted life years lost from non-COVID-19-related harms, costing $1 071 950 ($217 200) from the Centers for Medicare & Medicaid Services (CMS) perspective and $1 112 800 ($225 450) from the societal perspective. Under the SARS-CoV-2 Omicron variant conditions from 2023 to 2024, furloughing all staff who tested positive for SARS-CoV-2 was associated with a mean (SD) 326.5 (69.1) annual furlough days and 649.5 (95% CI, 593.4-705.6) additional missed care tasks, resulting in 4.3 (95% CI, 2.9-5.9) non-COVID-19-related resident hospitalizations and 0.7 (95% CI, 0.2-1.1) deaths, costing an additional $247 090 (95% CI, $203 160-$291 020) from the CMS perspective and $405 250 (95% CI, $358 550-$451 950) from the societal perspective. Allowing 75% of staff who were mildly ill to work while masked was associated with 5 additional staff and 5 additional resident COVID-19 cases without added COVID-19-related hospitalizations but mitigated staffing shortages, with 475.9 additional care tasks being performed annually, 3.5 fewer non-COVID-19-related hospitalizations, and 0.4 fewer non-COVID-19-related deaths. Allowing staff who were mildly ill to work ultimately saved an annual mean $85 470 (95% CI, $41 210-$129 730) from the CMS perspective and $134 450 (95% CI, $86 370-$182 540) from the societal perspective. These results were robust to increased vaccination coverage, increased nursing home transmission, increased importation of COVID-19 from the community, and failure to mask while working ill. Conclusion and Relevance In this modeling study of staff COVID-19 furlough policies, allowing nursing home staff to work with mild COVID-19 illness was associated with fewer resident harms from staffing shortages and missed care tasks than harms from increased COVID-19 transmission, ultimately saving substantial direct medical and societal costs.

We evaluated whether universal chlorhexidine bathing (decolonization) with or without COVID-19 intensive training impacted COVID-19 rates in 63 nursing homes (NHs) during the 2020-2021 Fall/Winter surge. Decolonization was associated with a 43% lesser rise in staff case-rates (P < .001) and a 52% lesser rise in resident case-rates (P < .001) versus control.

OBJECTIVE:Nursing home residents may be particularly vulnerable to coronavirus disease 2019 (COVID-19). Therefore, a question is when and how often nursing homes should test staff for COVID-19 and how this may change as severe acute respiratory coronavirus virus 2 (SARS-CoV-2) evolves. DESIGN:We developed an agent-based model representing a typical nursing home, COVID-19 spread, and its health and economic outcomes to determine the clinical and economic value of various screening and isolation strategies and how it may change under various circumstances. RESULTS:Under winter 2023-2024 SARS-CoV-2 omicron variant conditions, symptom-based antigen testing averted 4.5 COVID-19 cases compared to no testing, saving $191 in direct medical costs. Testing implementation costs far outweighed these savings, resulting in net costs of $990 from the Centers for Medicare & Medicaid Services perspective, $1,545 from the third-party payer perspective, and $57,155 from the societal perspective. Testing did not return sufficient positive health effects to make it cost-effective [$50,000 per quality-adjusted life-year (QALY) threshold], but it exceeded this threshold in ≥59% of simulation trials. Testing remained cost-ineffective when routinely testing staff and varying face mask compliance, vaccine efficacy, and booster coverage. However, all antigen testing strategies became cost-effective (≤$31,906 per QALY) or cost saving (saving ≤$18,372) when the severe outcome risk was ≥3 times higher than that of current omicron variants. CONCLUSIONS:SARS-CoV-2 testing costs outweighed benefits under winter 2023-2024 conditions; however, testing became cost-effective with increasingly severe clinical outcomes. Cost-effectiveness can change as the epidemic evolves because it depends on clinical severity and other intervention use. Thus, nursing home administrators and policy makers should monitor and evaluate viral virulence and other interventions over time.

BACKGROUND:Environmental contamination is suspected to play an important role in Candida auris transmission. Understanding speed and risks of contamination after room disinfection could inform environmental cleaning recommendations. METHODS:We conducted a prospective multicenter study of environmental contamination associated with C. auris colonization at 6 ventilator-capable skilled nursing facilities and 1 acute care hospital in Illinois and California. Known C. auris carriers were sampled at 5 body sites followed by sampling of nearby room surfaces before disinfection and at 0, 4, 8, and 12 hours after disinfection. Samples were cultured for C. auris and bacterial multidrug-resistant organisms (MDROs). Odds of surface contamination after disinfection were analyzed using multilevel generalized estimating equations. RESULTS:Among 41 known C. auris carriers, colonization was detected most frequently on palms/fingertips (76%) and nares (71%). C. auris contamination was detected on 32.2% (66/205) of room surfaces before disinfection and 20.5% (39/190) of room surfaces by 4 hours after disinfection. A higher number of C. auris-colonized body sites was associated with higher odds of environmental contamination at every time point following disinfection, adjusting for facility of residence. In the rooms of 38 (93%) C. auris carriers co-colonized with a bacterial MDRO, 2%-24% of surfaces were additionally contaminated with the same MDRO by 4 hours after disinfection. CONCLUSIONS:C. auris can contaminate the healthcare environment rapidly after disinfection, highlighting the challenges associated with environmental disinfection. Future research should investigate long-acting disinfectants, antimicrobial surfaces, and more effective patient skin antisepsis to reduce the environmental reservoir of C. auris and bacterial MDROs in healthcare settings.

ObjectivesTo evaluate the epidemiologic, clinical, and economic value of an annual nursing home (NH) COVID-19 vaccine campaign and the impact of when vaccination starts.DesignAgent-based model representing a typical NH.Setting and ParticipantsNH residents and staff.MethodsWe used the model representing an NH with 100 residents, its staff, their interactions, COVID-19 spread, and its health and economic outcomes to evaluate the epidemiologic, clinical, and economic value of varying schedules of annual COVID-19 vaccine campaigns.ResultsAcross a range of scenarios with a 60% vaccine efficacy that wanes starting 4 months after protection onset, vaccination was cost saving or cost-effective when initiated in the late summer or early fall. Annual vaccination averted 102 to 105 COVID-19 cases when 30-day vaccination campaigns began between July and October (varying with vaccination start), decreasing to 97 and 85 cases when starting in November and December, respectively. Starting vaccination between July and December saved $3340 to $4363 and $64,375 to $77,548 from the Centers for Medicare & Medicaid Services and societal perspectives, respectively (varying with vaccination start). Vaccination's value did not change when varying the COVID-19 peak between December and February. The ideal vaccine campaign timing was not affected by reducing COVID-19 levels in the community, or varying transmission probability, preexisting immunity, or COVID-19 severity. However, if vaccine efficacy wanes more quickly (over 1 month), earlier vaccination in July resulted in more cases compared with vaccinating later in October.Conclusions and ImplicationsAnnual vaccination of NH staff and residents averted the most cases when initiated in the late summer through early fall, at least 2 months before the COVID-19 winter peak but remained cost saving or cost-effective when it starts in the same month as the peak. This supports tethering COVID vaccination to seasonal influenza campaigns (typically in September-October) for providing protection against SARS-CoV-2 winter surges in NHs.

ImportanceInfections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalization, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections.ObjectiveTo evaluate whether implementation of a decolonization collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalizations, costs, and deaths.Design, Setting, and ParticipantsThis quality improvement study was conducted from July 1, 2017, to July 31, 2019, across 35 health care facilities in Orange County, California.ExposuresChlorhexidine bathing and nasal iodophor antisepsis for residents in long-term care and hospitalized patients in contact precautions (CP).Main Outcomes and MeasuresBaseline and end of intervention MDRO point prevalence among participating facilities; incident MDRO (nonscreening) clinical cultures among participating and nonparticipating facilities; and infection-related hospitalizations and associated costs and deaths among residents in participating and nonparticipating nursing homes (NHs).ResultsThirty-five facilities (16 hospitals, 16 NHs, 3 long-term acute care hospitals [LTACHs]) adopted the intervention. Comparing decolonization with baseline periods among participating facilities, the mean (SD) MDRO prevalence decreased from 63.9% (12.2%) to 49.9% (11.3%) among NHs, from 80.0% (7.2%) to 53.3% (13.3%) among LTACHs (odds ratio [OR] for NHs and LTACHs, 0.48; 95% CI, 0.40-0.57), and from 64.1% (8.5%) to 55.4% (13.8%) (OR, 0.75; 95% CI, 0.60-0.93) among hospitalized patients in CP. When comparing decolonization with baseline among NHs, the mean (SD) monthly incident MDRO clinical cultures changed from 2.7 (1.9) to 1.7 (1.1) among participating NHs, from 1.7 (1.4) to 1.5 (1.1) among nonparticipating NHs (group × period interaction reduction, 30.4%; 95% CI, 16.4%-42.1%), from 25.5 (18.6) to 25.0 (15.9) among participating hospitals, from 12.5 (10.1) to 14.3 (10.2) among nonparticipating hospitals (group × period interaction reduction, 12.9%; 95% CI, 3.3%-21.5%), and from 14.8 (8.6) to 8.2 (6.1) among LTACHs (all facilities participating; 22.5% reduction; 95% CI, 4.4%-37.1%). For NHs, the rate of infection-related hospitalizations per 1000 resident-days changed from 2.31 during baseline to 1.94 during intervention among participating NHs, and from 1.90 to 2.03 among nonparticipating NHs (group × period interaction reduction, 26.7%; 95% CI, 19.0%-34.5%). Associated hospitalization costs per 1000 resident-days changed from $64 651 to $55 149 among participating NHs and from $55 151 to $59 327 among nonparticipating NHs (group × period interaction reduction, 26.8%; 95% CI, 26.7%-26.9%). Associated hospitalization deaths per 1000 resident-days changed from 0.29 to 0.25 among participating NHs and from 0.23 to 0.24 among nonparticipating NHs (group × period interaction reduction, 23.7%; 95% CI, 4.5%-43.0%).Conclusions and RelevanceA regional collaborative involving universal decolonization in long-term care facilities and targeted decolonization among hospital patients in CP was associated with lower MDRO carriage, infections, hospitalizations, costs, and deaths.

Persons with Alzheimer's disease and related dementias (ADRD) are prone to receiving reduced quality of care. We compared the quality of room cleaning of rooms with ADRD residents and rooms with non-ADRD residents in nursing homes using an ultraviolet (UV) marker. ADRD status was associated with greater failure of UV marker removal (odds ratio, 1.68; 95% confidence interval, 1.04-2.71; P = .03).

Abstract Background Widespread CHG bathing to prevent infection has raised concerns about potential skin microbiome perturbations and depletion of commensal microbiota. Methods A prospective repeated measures cross-over study in NH residents/hospital patients evaluated the impact of CHG vs routine soap bathing on the nose/skin microbiome. Participants underwent serial visits during distinct CHG and routine soap phases (Figure) involving nares, axilla, groin, and finger/hand swabs processed for MDROs, CHG concentration (skin sites only), and bacterial 16S rRNA V1-3 gene sequencing (Illumina MiSeq). Sequences were processed with DADA2 and analyzed with PhyloSeq and Vegan packages in R to calculate microbial diversity and composition. Results We enrolled 30 participants (20 NH, 10 hospital). Mean age was 62y, 52% female. Mean CHG concentration was 1736 µg/mL (range: 0-20000) during CHG visits vs 17.5 µg/mL (range: 0-1250) during routine soap visits. MDRO prevalence was lower during CHG visits (NH: 19%, hospital: 9%) vs routine soap visits (NH: 47%, hospital: 23%). 555 samples from 30 participants were adequate for microbiome analyses. CHG did not affect overall alpha diversity of microbial communities on skin (Figure), but proteobacteria were notably higher in NH vs hospital participants (P< 0.001). Because gram-negative bacteria often exhibit higher MICs to CHG than gram-positive bacteria, we assessed whether CHG concentration in NHs was associated with greater relative abundance of proteobacteria using generalized linear mixed models clustered by person. In NHs, CHG concentration was not associated with relative abundance of skin proteobacteria, although body mass index ≥30 (14% higher abundance, P=0.01) and stool/urine incontinence were (13% higher, P=0.01). Compared to the axilla, the groin had 35% higher relative abundance of proteobacteria (P< 0.001); fingers/hand samples had 9% lower (P=0.01). Nose/Skin Taxonomic Diversity Not Impacted by CHG Bathing Timeline and alpha diversity using the Shannon Diversity Index of axilla, groin, finger/hand, and nares samples during CHG versus routine soap bathing phases. Each dot represents a sample. There were no significant differences in alpha diversity between CHG and routine soap phases. Conclusion CHG bathing reduced MDRO prevalence but did not impact skin or nasal microbial alpha diversity in hospital or NH participants. Overall, NH residents had notably higher relative abundance of skin proteobacteria vs hospital patients. This finding was not associated with CHG concentration. Rather, proteobacteria appeared enriched in NH residents with obesity or incontinence. Disclosures Gabrielle Gussin, MS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Raveena D. Singh, MA, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Raheeb Saavedra, AS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Connie Nguyen, n/a, Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Robert Pedroza, BS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product Chase Berman, BS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product Susan S. Huang, MD MPH, Medline Industries, Inc: Conducted studies whereby participating nursing homes and hospital patients received cleaning & antiseptic products|Xttrium Laboratories: Conducted studies where participating nursing homes and hospital patients received antiseptic products

We hosted a confidential helpline to address concerns about COVID-19 prevention among staff in 12 nursing homes in Orange County, California. We fielded 301 inquiries from April 2021-April 2022, most commonly involving questions about vaccines (40%), nursing home COVID-19 prevention (28%), SARS-CoV-2 variants (18%), symptom reporting (10%), and home and community COVID-19 prevention (5%). During COVID-19 surges, staff dominantly expressed fear, anger, and exhaustion. During nadirs, sentiment shifted towards optimism and acceptance.

AbstractObjective:Quantify the frequency and drivers of unreported coronavirus disease 2019 (COVID-19) symptoms among nursing home (NH) staff.Design:Confidential telephone survey.Setting:The study was conducted in 70 NHs in Orange County, California, December 2020–February 2022.Participants:The study included 120 NH staff with COVID-19.Methods:We designed a 40-item telephone survey of NH staff to assess COVID-19 symptom reporting behavior and types of barriers [monetary, logistic, and emotional (fear or stigma)] and facilitators of symptom reporting using 5-point Likert scales. Summary statistics, reliability of survey constructs, and construct and discriminant validity were assessed.Results:Overall, 49% of surveys were completed during the 2020–2021 COVID-19 winter wave and 51% were completed during severe acute respiratory coronavirus virus 2 (SARS-CoV-2) δ (delta)/ (omicron) waves, with a relatively even distribution of certified nursing assistants, licensed vocational or registered nurses, and nonfrontline staff. Most COVID-19 cases (71%) were detected during mandated weekly NH surveillance testing and most staff (67%) had ≥1 symptom prior to their test. Only 34% of those with symptoms disclosed their symptom to a supervisor. Responses were consistent across 8 discrete survey constructs with Cronbach α > 0.70. In the first wave of the pandemic, fear and lack of knowledge were drivers of symptom reporting. In later waves, adequate staffing and sick days were drivers of symptom reporting. COVID-19 help lines and encouragement from supervisors facilitated symptom reporting and testing.Conclusions:Mandatory COVID-19 testing for NH staff is key to identifying staff COVID-19 cases due to reluctance to speak up about existing symptoms. Active encouragement from supervisors to report symptoms and stay home when ill was a major driver of symptom reporting and resultant infection prevention and worker safety measures.

This study highlights the pragmatic considerations surrounding SARS-CoV-2 sample pooling beyond accuracy and costs. We performed a cost analysis to determine the percent positivity at which pooling would reduce costs versus single testing.

Abstract Background NHs are high-risk settings for MDRO spread. Methods We evaluated NH MDRO prevalence and co-carriage patterns in 22 NHs in Orange County, CA from Fall 2022-Spring 2023. 25 MDRO sweeps each involved 50 randomly-sampled occupied beds. Residents had swabs collected from bilateral axilla/groin and peri-rectal areas (MRSA, VRE, ESBL, CRE, CRAB, C. auris), and from bilateral nares (MRSA, C. auris). We assessed overall MDRO prevalence, as well as MDRO co-carriage patterns across organisms and MDRO body site carriage for each pathogen. Results Of 1250 residents, 57.5% (719) had MDRO carriage at any body site. Prevalence was highest for MRSA (36.7%), followed by ESBL (24.9%), VRE (14.2%), C. auris (7.1%), CRAB (2.1%), and CRE (1.0%). Of the 719 MDRO carriers, 62.2% (447) carried 1 MDRO and 37.8% (272) carried ≥2 MDROs. Carriers of one MDRO were likely to carry another (Table 1). For example, MRSA carriers had 48.1% likelihood of carrying another MDRO. Conversely, carriers of any other MDRO had a 45.9% (range: 44.9%-69.2%) likelihood of carrying MRSA. Notably, all CRE carriers and 92.3% of CRAB carriers carried another MDRO. Table 2 shows common body sites for carriage of each MDRO. Nares was the most common site of MRSA carriage; axilla/groin, for CRE and C. auris; peri-rectal areas, for VRE and ESBL; and axilla/groin and peri-rectal carriage, for CRAB. This table represents patterns of multidrug-resistant organism (MDRO) co-carriage among nursing home (NH) residents, for MDROs including Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), Extended Spectrum beta-lactamase (ESBL) producers, Carbapenem-resistant Enterobacterales (CRE), Carbapenem-resistant Acinetobacter baumannii (CRAB), and Candida auris. Each row shows the prevalence of MDRO co-carriage for a specific pathogen. For example, the first row shows MDRO co-carriage patterns among 459 MRSA carriers. MRSA carriers had 48.1% likelihood of carrying any other MDRO. Conversely, the last row shows that carriers of any MDRO other than MRSA had a 45.9% likelihood of carrying MRSA whereas carriers of any MDRO other than C. auris had a 9.2% likelihood of carrying C. auris. This table shows body site carriage of multidrug-resistant organisms (MDROs) among nursing home residents, for MDROs including Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), Extended Spectrum beta-lactamase (ESBL) producers, Carbapenem-resistant Enterobacterales (CRE), Carbapenem-resistant Acinetobacter baumannii (CRAB), and Candida auris. For each pathogen, the number and percent of carriers are shown per body site (axilla/groin, peri-rectal, nares). The dominant site of carriage for each MDRO is as follows: nares for MRSA (76.0%), peri-rectal for VRE (88.1%) and ESBL (84.6%), axilla/groin for CRE (76.9%) and C. auris (88.8%). Axilla/groin and peri-rectal sites had equal carriage for CRAB (63.2% each). By necessity, all dominant sites were the most common body site for solo carriage. For example, among nursing home residents with MRSA nares carriage, (42.1%) had MRSA only in the nares and 57.9% had MRSA at another body site. Conclusion Multi-MDRO carriage is common among NH residents with MDROs harbored at multiple body sites. Co-carriage was especially high among those harboring a carbapenem-resistant organism, likely reflecting accrued MDROs from extensive and repeated antibiotic exposure. Understanding MDRO co-carriage patterns can identify strategies that may be effective across MDROs. For example, nearly half of residents colonized with a non-MRSA MDRO also carried MRSA, suggesting that nasal decolonization of any MDRO carrier may benefit outcomes for MRSA, the most common MDRO in NHs. Disclosures Gabrielle Gussin, MS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Raveena D. Singh, MA, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Raheeb Saavedra, AS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning & antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Connie Nguyen, n/a, Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Alice Lee, n/a, Xttrium Laboratories: Conducted studies where participating hospitals & nursing homes received antiseptic bathing product Susan S. Huang, MD, MPH, Medline: Conducted studies in which participating nursing homes received contributed antiseptic bathing and cleaning products|Xttrium: Conducted studies in which participating nursing homes and hospital patients received contributed antiseptic soap

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.