Infection Control
Loren Bonner
An estimated 1.6 million to 3.8 million nursing home residents acquire a health care–associated infection each year. It’s one of the most common reasons for hospitalization and even death in this patient population. Decolonization, a type of pathogen reduction that eliminates colonizing pathogens specifically on the skin and mucosal surfaces, has already been shown to reduce infections for patients in hospital ICUs or before surgical procedures. But what about nursing home residents—a vulnerable group at high risk for serious illness?
For the first time, researchers conducted a large scale prevention study in residents of nursing homes where soap and water were swapped out during bathing with chlorhexidine for the decolonization process.
Results showed that for a typical 100-bed nursing home, the decolonization process would prevent 1.9 infection-related hospitalizations per month.
“This is a dramatic drop for such a relatively straightforward and inexpensive intervention,” said lead author Loren Miller, MD, MPH, a professor of medicine at the David Geffen School of Medicine at UCLA and chief of the division of infectious diseases at Harbor-UCLA Medical Center.
Chlorhexidine is a topical skin disinfectant, relatively inexpensive and available over the counter. “Most of the nursing homes randomized to switch to chlorhexidine could implement the decolonization protocol since basically they weren’t bathing residents any more or less frequently than they were already doing. They were just swapping the skin cleanser,” said Miller.
The decolonization process also involved the administration of nasal povidone-iodine twice daily for the first 5 days after admission and then twice daily for 5 days every other week.
“Implementing the nasal iodophor decolonization was trickier since this adds a process that staff weren’t already doing,” said Miller. In the big picture, however, it’s not a huge commitment.
“Our results really argue that nursing homes can do decolonization,” said Miller.
Adherence to chlorhexidine use was 85% to 95% from the participating nursing homes, according to the findings.
“Implementing this intervention takes training, takes initiative from nursing home leadership, but it can be done and incorporated into daily workflow with minimal disruption,” Miller said.
Trial details
Given that the study was a cluster randomized trial in which the research team randomized nursing homes—not residents or patients—Miller said the effect of decolonization was striking: decolonizing 10 residents prevented one infection-related hospitalization, according to the findings.
Researchers obtained their data from 28 nursing homes, all in Southern California, with a total of 28,956 residents participating. The trial took place from September 2015 through December 2018. All the nursing homes provided skilled nursing care.
At the time of trial randomization, none of the sites routinely used topical chlorhexidine or performed nasal decolonization. The nursing homes that were assigned to the routine-care group continued their usual bathing practices. Those in the decolonization group put the decolonization protocol into practice with 10% nasal povidone-iodine and chlorhexidine for bathing.
The findings showed that transfers to hospitals for infections in the intervention nursing homes decreased compared to those nursing homes that continued their standard of care bathing routine.
What’s next?
Miller noted that without the nursing home leadership support they had for this study, rolling this out would have been impossible. “Even in our trial in which we provided logistical support for the nursing homes, 4 of the 28 nursing homes withdrew from the study,” he said. He attributes some of that to leadership transitions. Nursing home administration leadership turnover is common.
“Based on the trial’s results, I’m really hoping that local and state health departments now start to advocate that decolonization should be the standard for nursing home residents,” Miller said. “Again, nursing home residents are our loved ones, and advocating for their safety through such a simple intervention, in my mind, is a no-brainer.” ■