Correlations between quality ratings of skilled nursing facilities and multidrug-resistant urinary tract infections


      • Risk factors associated with urinary tract infections caused by multidrug-resistant organisms in skilled nursing facilities were investigated.
      • The mean predicted probability of urinary tract infections and improper collection of specimens was inversely dependent on the facility's overall star rating.
      • The presence of multidrug-resistant organisms highly correlated with the type of nursing care received.


      The purpose of this study was to determine risk factors for the acquisition of urinary tract infections (UTIs) and multidrug-resistant organisms (MDROs) in residents of skilled nursing facilities (SNFs).


      Using the informational database provided by the Centers for Medicare and Medicaid Services (CMS), a retrospective logistic regression was performed on 1,523 urine cultures from 12 SNFs located in Long Island, New York.


      Of the 1,142 positive urine cultures, Escherichia coli was most prevalent. Additionally, 164 (14.4%) of the UTIs were attributed to an MDRO. In multivariate logistic regression, sex and overall quality rating predicted the occurrence of UTIs, whereas identification of MDROs was dependent on the level of nursing care received. The mean predicted probability of UTIs and receipt of contaminated samples was inversely dependent on the facility's rating, where the likelihood increased as overall quality ratings decreased.


      The CMS's quality rating system may provide some insight into the status of infection control practices in SNFs. The results of this study suggest that potential consumers should focus on the overall star ratings and the competency of the nursing staff in these facilities rather than on individual quality measures.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ortman J.
        • Velkoff V.
        • Hogan J.
        An aging nation: the older population in the United States.
        (Current Population Reports; Suitland, MD: US Census Bureau; Available from:) (Accessed April 11, 2016)
        • Knickman J.R.
        • Snell E.K.
        The 2030 problem: caring for aging baby boomers.
        Health Serv Res. 2002; 37: 849-884
        • Fermazin M.
        • Canady M.
        • Bauer K.
        • Cooper L.
        Nursing home compare: web site offers critical information to consumers, professionals.
        Lippincotts Case Manag. 2003; 8: 175-183
        • Bostick J.E.
        • Rantz M.J.
        • Flesner M.K.
        • Riggs C.J.
        Systematic review of studies of staffing and quality in nursing homes.
        J Am Med Dir Assoc. 2006; 7: 366-376
        • Collier E.
        • Harrington C.
        Staffing characteristics, turnover rates, and quality of resident care in nursing facilities.
        Res Gerontol Nurs. 2008; 1: 157-170
        • Williams A.
        • Straker J.K.
        • Applebaum R.
        The nursing home five star rating: how does it compare to resident and family views of care?.
        Gerontologist. 2016; 56: 234-242
        • Weissert W.G.
        • Cready C.M.
        • Pawelak J.E.
        The past and future of home- and community-based long-term care.
        Milbank Q. 1988; 66: 309-388
        • Benoit S.R.
        • Nsa W.
        • Richards C.L.
        • Bratzler D.W.
        • Shefer A.M.
        • Steele L.M.
        • et al.
        Factors associated with antimicrobial use in nursing homes: a multilevel model.
        J Am Geriatr Soc. 2008; 56: 2039-2044
        • Nicolle L.E.
        Urinary tract pathogens in complicated infection and in elderly individuals.
        J Infect Dis. 2001; 183: S5-8
        • Fisch J.
        • Lansing B.
        • Wang L.
        • Symons K.
        • Cherian K.
        • McNamara S.
        • et al.
        New acquisition of antibiotic-resistant organisms in skilled nursing facilities.
        J Clin Microbiol. 2012; 50: 1698-1703
        • Centers for Disease Control and Prevention
        Antibiotic resistance threats in the United States, 2013.
        (Available from:) (Accessed July 1, 2015)
        • Flores-Mireles A.L.
        • Walker J.N.
        • Caparon M.
        • Hultgren S.J.
        Urinary tract infections: epidemiology, mechanisms of infection and treatment options.
        Nat Rev Microbiol. 2015; 13: 269-284
        • Strausbaugh L.J.
        • Joseph C.L.
        The burden of infection in long-term care.
        Infect Control Hosp Epidemiol. 2000; 21: 674-679
        • Warren J.W.
        • Tenney J.H.
        • Hoopes J.M.
        • Muncie H.L.
        • Anthony W.C.
        A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters.
        J Infect Dis. 1982; 146: 719-723
        • van Houten M.A.
        • Luinge K.
        • Laseur M.
        • Kimpen J.L.
        Antibiotic utilisation for hospitalised paediatric patients.
        Int J Antimicrob Agents. 1998; 10: 161-164
        • Montoya A.
        • Mody L.
        Common infections in nursing homes: a review of current issues and challenges.
        Aging Health. 2011; 7: 889-899
        • Bonomo R.A.
        • Rice L.B.
        Emerging issues in antibiotic resistant infections in long-term care facilities.
        J Gerontol A Biol Sci Med Sci. 1999; 54: B260-7
        • Trick W.E.
        • Weinstein R.A.
        • DeMarais P.L.
        • Kuehnert M.J.
        • Tomaska W.
        • Nathan C.
        • et al.
        Colonization of skilled-care facility residents with antimicrobial-resistant pathogens.
        J Am Geriatr Soc. 2001; 49: 270-276
        • Mody L.
        • Bradley S.F.
        • Strausbaugh L.J.
        • Muder R.R.
        Prevalence of ceftriaxone- and ceftazidime-resistant Gram-negative bacteria in long-term-care facilities.
        Infect Control Hosp Epidemiol. 2001; 22: 193-194
        • Hughes C.
        • Tunney M.
        • Bradley M.C.
        Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people.
        Cochrane Database Syst Rev. 2013; (CD006354)
        • Rogers M.A.
        • Mody L.
        • Chenoweth C.
        • Kaufman S.R.
        • Saint S.
        Incidence of antibiotic-resistant infection in long-term residents of skilled nursing facilities.
        Am J Infect Control. 2008; 36: 472-475
        • Rawat D.
        • Nair D.
        Extended-spectrum beta-lactamases in Gram negative bacteria.
        J Glob Infect Dis. 2010; 2: 263-274
        • Rooney P.J.
        • O'Leary M.C.
        • Loughrey A.C.
        • McCalmont M.
        • Smyth B.
        • Donaghy P.
        • et al.
        Nursing homes as a reservoir of extended-spectrum beta-lactamase (ESBL)-producing ciprofloxacin-resistant Escherichia coli.
        J Antimicrob Chemother. 2009; 64: 635-641
        • MacVane S.H.
        • Tuttle L.O.
        • Nicolau D.P.
        Impact of extended-spectrum beta-lactamase-producing organisms on clinical and economic outcomes in patients with urinary tract infection.
        J Hosp Med. 2014; 9: 232-238
        • Cardwell S.M.
        • Crandon J.L.
        • Nicolau D.P.
        • McClure M.H.
        • Nailor M.D.
        Epidemiology and economics of adult patients hospitalized with urinary tract infections.
        Hosp Pract. 1995; 2016: 1-8
        • Kunin C.M.
        Detection, prevention and management of urinary tract infections.
        4th ed. Lea & Febiger, Philadelphia (PA)1987
        • Muder R.R.
        • Brennen C.
        • Wagener M.M.
        • Vickers R.M.
        • Rihs J.D.
        • Hancock G.A.
        • et al.
        Methicillin-resistant staphylococcal colonization and infection in a long-term care facility.
        Ann Intern Med. 1991; 114: 107-112
        • Murphy S.
        • Denman S.
        • Bennett R.G.
        • Greenough III, W.B.
        • Lindsay J.
        • Zelesnick L.B.
        Methicillin-resistant staphylococcus aureus colonization in a long-term-care facility.
        J Am Geriatr Soc. 1992; 40: 213-217