{"id":24974,"date":"2023-11-24T04:13:00","date_gmt":"2023-11-23T20:13:00","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=24974"},"modified":"2023-11-24T05:57:13","modified_gmt":"2023-11-23T21:57:13","slug":"nejm%e5%8f%91%e8%a1%a8%e8%bf%b0%e8%af%84%ef%bc%9a%e5%ae%89%e5%85%bb%e9%99%a2%e6%99%ae%e9%81%8d%e5%ae%9e%e6%96%bd%e5%8e%bb%e5%ae%9a%e6%a4%8d%ef%bc%9a%e6%98%8e%e6%98%be%e6%9c%89%e7%9b%8a%e4%bd%86","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=24974","title":{"rendered":"[NEJM\u53d1\u8868\u8ff0\u8bc4]\uff1a\u5b89\u517b\u9662\u666e\u904d\u5b9e\u65bd\u53bb\u5b9a\u690d\uff1a\u660e\u663e\u6709\u76ca\u4f46\u662f\u5426\u53ef\u884c\uff1f"},"content":{"rendered":"\n

EDITORIAL<\/a><\/p>\n\n\n\n

Universal Decolonization in Nursing Homes \u2014 Apparent Benefits but Feasible?<\/h1>\n\n\n\n

Morgan J. Katz, Sara E. Cosgrove<\/h3>\n\n\n\n

N Engl J Med 2023; 389:1815-1816
DOI: 10.1056\/NEJMe2311215<\/h3>\n\n\n\n

Nursing homes house a population most at risk for prolonged colonization with multidrug resistant organisms (MDROs) owing to the residents\u2019 older age, repeat health care and antibiotic exposures, and ongoing contact with other persons with colonization.1<\/a><\/sup> Although nursing homes pose a perfect opportunity for the cultivation and continued transmission of MDROs, decolonization efforts in this setting have been minimal, probably because of the real challenges of implementing decolonization in nursing homes. On account of limited resources, few nursing homes perform active surveillance for MDROs2<\/a><\/sup>; rather, they rely on often incomplete reports from the transferring hospital, which makes targeted decolonization based on positive cultures impractical. Furthermore, identifying an end point for decolonization poses a challenge because nursing home residents are living in a health care setting, are continuously transferring to and from other health care facilities, and are regularly exposed to newly admitted persons who have MDRO colonization.<\/p>\n\n\n\n

In this issue of the\u00a0Journal<\/em>, Miller et al.3<\/a><\/sup>\u00a0address these concerns in the Protect trial, a cluster-randomized trial involving 28 California nursing homes evaluating universal decolonization. Universal decolonization, which does not require active surveillance or different approaches to implementation based on colonization status, is less complicated than targeted decolonization, a feature that is needed as long-term care personnel continue to struggle with staffing and the implementation of new requirements in the wake of the coronavirus disease 2019 pandemic.4<\/a><\/sup>After an 18-month baseline survey and a 4-month phase-in period, 14 randomly selected facilities underwent the 18-month decolonization intervention, which entailed administration of nasal povidone\u2013iodine (iodophor) to all residents twice daily for 5 days on admission and every other week and the use of chlorhexidine wipes or antiseptic wash for all routine bathing or showering. The nursing home residents in the facilities in the routine-care group continued bathing according to usual site procedures without any intervention or oversight.<\/p>\n\n\n\n

The trial showed benefits in the decolonization group. The incidence of transfer to a hospital due to infection, the primary outcome that was assessed and recorded by nursing home staff in a hospital transfer log, decreased significantly in the decolonization group, dropping from 62.9% during the baseline period to 52.2% during the intervention period (risk ratio, 0.83; 95% confidence interval, 0.79 to 0.88); no change was observed in the routine-care group. The results were more modest for incidence of transfer to a hospital for any reason (the secondary outcome) in the decolonization group, dropping from 35.5% during the baseline period to 32.4% during the intervention period (risk ratio, 0.92; 95% CI, 0.88 to 0.96). The number needed to treat was 9.7 to prevent one infection-related hospitalization. On the basis of these results, implementing the decolonization intervention in a typical 100-bed nursing home could prevent 1.9 infection-related hospitalizations per month. Given the disruption and morbidity associated with transfer to a hospital among nursing home residents, these results offer an important potential way to mitigate these risks.5<\/a><\/sup><\/p>\n\n\n\n

Although the trial results pointed toward the benefits of implementing this decolonization protocol in nursing homes, the intervention does not appear to be as \u201crelatively simple\u201d as the authors describe. First, the trial was funded by the Agency for Healthcare Research and Quality and included support for all materials used for decolonization, which are more expensive than the products used by most facilities today and thus would require dedicated funds for their purchase. Second, the facilities in the decolonization group had intensive training and support from the trial personnel, who emphasized proper and regular bathing, wound care, care of indwelling devices, and skin care. The routine-care group facilities, in contrast, were given no oversight on bathing practices and were advised to follow their routine protocols and avoid any quality-improvement initiatives around bathing during the intervention period. It is very possible that the emphasis on bathing and skin care alone may have been a substantial driver of the lower incidence of infection among the facilities in the decolonization group. Third, nursing home staff were aware of the trial group that their nursing home was assigned to, which could have influenced their assessment of the infection status of the patient at the time of transfer to a hospital.<\/p>\n\n\n\n

Of the 14 facilities in the decolonization group, 3 dropped out of the trial before completion despite being provided decolonization resources, citing administrative turnover and difficulty devoting time to the project \u2014 a common theme in research in the nursing home setting. This dropout may have affected the results, because the facilities that remained in the trial may have been better resourced to facilitate high adherence to the protocol or other unmeasured safety strategies that could affect the quality of care.<\/p>\n\n\n\n

When we envision the widespread implementation of this decolonization protocol across nursing homes, perhaps the most glaring concern is the indefinite continuation of chlorhexidine in residents who will remain in the nursing home for the rest of their lives. Data are lacking with regard to the risk or benefit of prolonged bathing with chlorhexidine products, and although there were few adverse events in this cohort (most of which were skin irritation), ongoing assessment of the effect of chlorhexidine on residents\u2019 skin and the emergence of resistance that could render chlorhexidine ineffective with continued use over the ensuing years will be essential. In addition, although adherence to chlorhexidine bathing was relatively high in the facilities in the decolonization group (87.4% for routine bathing), adherence to nasal iodophor was considerably lower (67.4% for routine administration); thus, the additive effect of the nasal iodophor portion of the decolonization intervention remains uncertain.<\/p>\n\n\n\n

The results of the Protect trial show promise for universal decolonization as an approach to preventing infection-related transfers to a hospital. However, the intervention requires resources \u2014 something many nursing homes are currently lacking. To generate real change in this setting, facilities must be encouraged to take steps such as enhanced bathing or decolonization to improve the health of residents, and the forward-thinking facilities that do take such steps should be rewarded through reimbursement incentives for high-quality care.<\/p>\n","protected":false},"excerpt":{"rendered":"

EDITORIAL Universal Decolonization in Nursing Homes \u2014 A […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24974"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=24974"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24974\/revisions"}],"predecessor-version":[{"id":24976,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24974\/revisions\/24976"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=24974"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=24974"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=24974"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}