Introduction
Privacy curtains are an understudied potential vector for pathogen transmission.1,2 They are ubiquitous in healthcare facilities, touched frequently by HCWs (often between hand hygiene and patient interaction),3–6 and infrequently changed or cleaned. Best practices in terms of the optimal materials and usage are not well established. In this study, we evaluate the microbial concordance and strain similarity between MDRO contamination of curtains and patient colonization.
Methods
A prospective cohort study was conducted in six NHs in southeast Michigan between November 2013 and May 2016.7 After obtaining informed consent, we obtained cultures from several patient body sites and high-touch surfaces in the patient’s room, including the privacy curtain, at admission, day 14, day 30 & monthly thereafter up to 6 months.8 Age, sex, race and risk factors for MDRO colonization (functional disability,9 indwelling devices, comorbidities, prior antibiotic use, hospitalization length), and data on facility curtain changing policies were collected. The University of Michigan institutional review board approved the study.
At each visit, swabs (Bacti-swabs, Remel, Lenexa, Kansas) were used to sample patient body sites (dominant hand, nares, oropharynx, groin, perianal area, wounds if present, enteral feeding tube insertion site, suprapubic catheter site) and high-touch surfaces (bed controls, bedside table, nurse call button, privacy curtain, toilet seat, door knob, TV remote control, bed rail, wheelchair handles) in the patient’s room as previously described.8 For privacy curtains, an area of approximately 43 cm2 was swabbed from the leading edge of the flame-retardant polyester curtain.
Swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and resistant Gram-negative bacilli (R-GNB).7 Pulsed-field gel electrophoresis (PFGE) was performed on a subset of MRSA and VRE isolates as previously described.8 Isolates were placed in the same pulsotype if their SmaI restriction patterns were ≥ 80% similar.
Baseline characteristics were compared between patients with an MDRO-contaminated curtain at any point in the study and those with no contamination. T-tests were used to compare continuous variables, Pearson’s chi-square and Fisher’s exact test for categorical variables. The relationship between curtain MDRO contamination and patient MDRO colonization were calculated using chi-squared tests.
Results
Of the 625 study patients, 250 (40.0%) had a MDRO-contaminated privacy curtain at some point during the study. Those patients were more likely to have: an indwelling device in place, multiple comorbidities, a higher PSMS score, a longer hospital stay prior to NH admission, and disabilities related to ambulation and toileting (Table 1).
Table 1.
Characteristics of nursing home patients on enrollment
| All patients N=625 |
Curtain contamination at any time, any MDRO N=250 |
No curtain contamination at any time, any MDRO N=375 |
p-value | |
|---|---|---|---|---|
| Age, mean (SD) | 74.7 (12.2) | 74.7 (12.1) | 75.8 (12.2) | 0.993a |
| Male sex, No. (%) | 262/625 (41.9) | 108/250 (43.2) | 154/375 (41.1) | 0.596b |
| Non-Hispanic white, No. (%) | 384/625 (61.4) | 143/250 (57.2) | 241/375 (64.3) | 0.075b |
| Device use, No. (%) | 65/625 (10.4) | 34/250 (13.6) | 31/375 (8.3) | 0.032 b |
| Antibiotic use in past 30d, No. (%) | 371/610 (60.8) | 157/246 (63.8) | 214/364 (58.8) | 0.212b |
| History of MRSA, No. (%) | 23/616 (3.7) | 12/244 (4.9) | 11/372 (3.0) | 0.209b |
| History of VRE, No. (%) | 12/613 (2.0) | 11/241 (4.6) | 1/372 (0.3) | 0.000 c |
| History of R-GNB, No. (%) | 34/601 (5.7) | 21/237 (8.9) | 13/364 (3.6) | 0.006 b |
| Charlson comorbidity score, mean (SD) | 2.5 (2.1) | 2.7 (2.0) | 2.4 (2.1) | 0.051a |
| Charlson score >2 | 278/625 (44.5) | 128/250 (51.2) | 150/375 (40.0) | 0.006 b |
| PSMS score | 14.5 (4.7) | 15.0 (4.8) | 14.2 (4.6) | 0.022 a |
| Open wounds | 273/624 (43.8) | 110/250 (44.0) | 163/374 (43.6) | 0.918b |
| Length of preadmission hospitalization, No (%) | ||||
| Length of preadmission hospitalization, mean (SD) | 7.1 (6.7) (N=621; range 0–75) |
8.0 (8.1) (N=248; range 0–75) |
6.5 (5.2) (N=373; range 0–44) |
0.005 a |
| Functional disabilities on enrollment, No (%) | ||||
| Ambulation | 400/625 (64.0) | 175/250 (70.0) | 225/375 (60.0) | 0.011 b |
| Dressing | 379/625 (60.6) | 162/250 (64.8) | 217/375 (57.9) | 0.082b |
| Bathing | 332/625 (53.1) | 144/250 (57.6) | 188/375 (50.1) | 0.067b |
| Toileting | 210/625 (33.6) | 97/250 (38.8) | 113/375 (30.1) | 0.025 b |
| Grooming | 177/625 (28.3) | 78/250 (31.2) | 99/375 (26.4) | 0.192b |
| Feeding | 43/625 (6.9) | 19/250 (7.6) | 24/375 (6.4) | 0.561b |
p-value calculated using two-sided t test
p-value calculated using Pearson’s chi-square
p-value calculated using Fisher’s Exact
Of 1,521 total curtain samples, 334 (22.0%) were contaminated with an MDRO, including: 210 (13.8%) with VRE, 94 (6.2%) with R-GNB, and 74 (4.9%) with MRSA (Supplemental Table 1). The most commonly isolated R-GNB were Pantoea spp. (47 isolates), A. baumannii (21 isolates), and Enterobacter cloacae (10 isolates). MDRO prevalence varied among facilities, ranging from 11.9% to 28.5% (VRE 7.1% to 17.6%; R-GNB 2.0% to 11.6%; MRSA 2.8% to 8.8%). There were 36 cases (8.8% of at-risk patients) of new MRSA curtain contamination and 56 cases (15.8% of at-risk patients) of new VRE contamination. In 47 (51.0%) instances, MRSA or VRE patient colonization preceded the positive curtain sample. Among instances where isolates from the curtain as well as the patient and/or the environment were available, identical PFGE patterns were found in 15 of 19 visits (78.9%) for MRSA and 14 of 25 visits (56.0%) for VRE (Supplemental Table 2).
Discussion
We found high rates of MDRO contamination among privacy curtains in occupied rooms at six nursing facilities; 40% of patients (250/625) had an MDRO isolated from his or her privacy curtain at some point (334/1521 samples, 22% of sampling visits), VRE being the most common (13.8% of samples). New MDRO curtain contamination occurred predominantly in rooms with preexisting patient colonization, often with matching isolates.
Privacy curtains serve an important role in healthcare settings but are a potential pathogen reservoir.1–4,6 due to large surface area and frequent contact by HCWs and patients. Prior studies in intensive care units reported rapid MRSA or VRE contamination, within one week of new curtain placement.4,5 Transmission of bacteria to HCW hands occurs after 50% of curtain contacts.10 Our study showed the more common sequence of events to be patient colonization followed by curtain contamination; however, there were some cases where curtain contamination preceded the patient colonization, making it a plausible source of transmission to patients.
In this hypothesis-generating study, we did not assess the directionality of MDRO contamination, nor did we quantify the level of curtain contamination, assess curtain cleaning practices at individual sites, nor determine effect on MDRO colonization status of roommates. To our knowledge, this is the first investigation of curtain contamination in NH settings, where the prevalence of MDRO patient colonization is particularly high. Widespread curtain contamination has been linked to lack of regular disinfection or replacement.6 Antimicrobial curtains, including antimicrobial textile technology, have been studied as a potential solution.5
Action can and should be taken to decrease curtain contamination, including standard practice guidelines for cleaning or replacing curtains, and implementation of simple strategies, such as better handwashing by medical staff, patients, and visitors, while also considering alternative designs, such as removable handles, retractable partitions, and argon glass doors.
Supplementary Material
Acknowledgements
Financial support.
This work was supported by the National Institutes of Health [RO1 AG041780 and K24 AG050685].
Thank you notes.
We thank all nursing home patients and healthcare workers who participated in this research study.
Footnotes
This research was presented at the 2019 European Congress of Clinical Microbiology and Infectious Diseases in Amsterdam and the 2019 American Geriatrics Society annual meeting.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
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