A new front opens up in germ warfare — the nursing home

Underneath the tranquil exterior of the nursing home lies a thriving community of new-found members whose presence poses an imminent threat to our elderly: i.e., multi-drug resistant organisms (MDROs) — aka “superbugs,” bad bugs, germs, or pathogens. Those invisible creatures that, in gangs of tens of millions or more, are in us, on us, and around us, and drive those nasty infections that antibiotics increasingly have no control over. So much so that:

“Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 30,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.”

The stunning quotation is from James A. McKinnell, MD, (email correspondence, 6/22), an Infectious Disease specialist at the Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute. He is also the co-lead author of an eye-opening new study that says there’s significantly more of these drug-resistant pathogens in our nursing homes than we knew. For example:

1) Almost half (47.5%) of the people in nursing homes are colonized with at least one superbug.

2) Nursing homes themselves are awash with superbugs: 88% of the rooms are contaminated with at least one. And watch out for the bedside table/bedrails as 86% of them are contaminated with at least one superbug.

3) The big dog is Methicillin-resistant staphylococcus aureus (MRSA). They were found in almost 2/3 of the rooms (65.2%); followed by VRE (46.4%), ESBL (26.4%), and CRE (5.1%).

4) We also know that these 4 bugs aren’t the only ones living in nursing homes. The Centers for Disease Control tells us there are 18 superbugs whose threat to our health is either “urgent” (such as CRE), “serious” (MRSA, ESBL, and CRE), or “concerning.” In other words, Mckinnell’s team, looking for less than ¼ of the known threats (a demanding task in itself) found almost 9 in 10 rooms colonized with these disease-causing drug-resistant pathogens.

5) Interestingly, the bugs in the room don’t always match the bugs on you. For example, among MRSA carriers, almost 2/3 of them (64.1%) had their rooms contaminated with non-MRSA bugs, thus exposing them to new and different superbug acquisition.

elderly 2

Dr. Mckinnell’s study matters because his group did something different: they looked harder. Investigators typically check for pathogens in just the nose — but why stop there? Using the so-called Zorro technique (the search mimics the motion the fictional character Zorro makes with his sword) his team checked the left armpit, right armpit, left groin, and right groin.

And voila, detection increased by 20%. In an interview with Medscape, Mckinnell reports that “We found 160 patients with MRSA. If we had only done nares, we would have only found 121; we would have missed 39 carriers.” Thus, he says, “When a facility tells me their rates are 6%, I usually add 30% to account for all the missed and untested multidrug-resistant organisms.”

The upshot is that “Nursing homes are the perfect storm of patients carrying pathogens and at the same time at [an increased] risk of getting sick if they are exposed to them.” The elderly have weaker immune systems, are more likely to have a history of MDRO carriage, be bed-bound, or be in need of a catheter, each one a risk factor for infection.

And the risk spreads. As others have pointed out, in the revolving door between the nursing home and the hospital, if colonized individuals are admitted to the hospital without having been screened, a silent transmission of pathogens can emanate throughout the healthcare system.

Estimates vary, but there seems to be at least twice as many people in nursing homes as there in hospitals in the US. The point of intervention, then, is clear: you want to debug — decolonize — people at the nursing home.

But there’s a trick to it. Targeted prevention becomes difficult when nearly half the patients in a nursing home are colonized with a MDRO, says Dr. McKinnell. Therefore, “We need universal interventions that protect everyone, and enhanced ones for those who need more protection.”

There’s one more consideration, captured in the dictum attached to Dr. Mckinnell’s emails, which reads: “Pick your travel partners wisely. You walk this road only once.” Sage words indeed; which assume, of course, that we have the ability to pick our partners in the first place — and thankfully, most of us do.

But not everyone. When you’re in a nursing home a great many of your partners are picked for you. We can’t see them, but we know they’re there — in the tens of millions — because they’re killing us. That’s not hyperbole. Look again at the number of nursing home infections, hospital admissions, and deaths, in the block quotation of Dr. Mckinnell, above. Now look at the three ladies in the picture and let’s ask ourselves a question: If we don’t engage in the universal interventions that Jamie Mckinnell is asking for, are we fulfilling our duty of care to the elderly?

 

 

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