Definitions of infection for surveillance in long-term care facilities

Trends in point-prevalence studies of healthcare associated infections in long-term care facilities: A nationwide surveillance program in Catalonia, Spain (2013-2022)

INTRODUCTION

From 2013 to 2022, annual point-prevalence studies (PPS) of healthcare-associated infections (HAIs) were conducted in 97 long-term care facilities (LTCF) within the VINCat Program in Catalonia, Spain. The objective was to analyze trends in HAIs and antibiotic use to evaluate the burden of HAIs in this setting.

METHODS

We compare PPS data from two 5-year periods. Period 1 (2013-2017) involving 50,378 residents and period 2 (2018-2022) involving 65,997 residents. Variables included demographic characteristics, patient conditions, medical devices on the day of PPS and recent surgery. Source of HAI, causative microorganisms, antibiotics and indication were recorded. HAIs were defined according to ECDC criteria.

RESULTS

A total of 116,375 residents were included, median age of 82 years (range: 73-88), 56.7% female. Although severe dependency was more common in period 1, the presence of vascular and urinary catheters increased in period 2. Overall, 9943 (8.5%) residents had one or more HAIs. The HAI prevalence rate significantly decreased from 9.3% in period 1 to 8% in period 2, being urinary tract infections the most prevalent HAI in both periods, followed by respiratory tract infections. Escherichia coli was the most frequently identified microorganism. No significant differences in the prevalence of antibiotic use between periods (11.8 vs 12.1 respectively) were found, although there was a shift toward more targeted prescriptions.

CONCLUSION

Despite a significant reduction over the study period, the prevalence of HAIs remains high in LTCFs of Catalonia, affecting 8% of residents. Implementation of infection prevention and control interventions are highly required.

Assessment of potentially unnecessary antibiotic use for suspected urinary tract infections in nursing homes using a simplified algorithm

BACKGROUND

Nursing home (NH) residents are frequently treated with antibiotics for urinary tract infections (UTIs), often due to overdiagnosis. The aim of this study was to evaluate the proportion of potentially unnecessary antibiotic use for suspected UTIs in NHs across eight European countries.

RESEARCH DESIGN AND METHODS

Over a three-month period (February to April 2024), NH professionals recorded information on all antibiotic treatments for UTIs using a specific registration chart. Based on medical literature and the expertise of the project consortium members, the authors developed and endorsed by consensus a simplified algorithm to assess unnecessary antibiotic use in residents without indwelling catheters.

RESULTS

The study, conducted across 110 NHs, included 2773 antibiotic-treated infections. Of these, 1158 (41.8%) were treated for UTIs. Among 975 UTI cases without catheters, 54.1% may have been unnecessarily treated. Over one-third involved nonspecific symptoms including poor general condition and changes in urine appearance, while specific urinary symptoms, such as incontinence (21.3%) and dysuria (20.8%), were less common. A trend toward greater, potentially unnecessary antibiotic use was observed when urine dipsticks were performed.

CONCLUSIONS

The findings reveal potentially unnecessary antibiotic use. Further algorithm validation is needed to enhance diagnostic criteria, reduce overuse, and improve UTI management in NHs.

Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: a narrative review

BACKGROUND

Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear reference standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations.

OBJECTIVES

This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research.

SOURCES

The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes.

CONTENT

The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities.

IMPLICATIONS

Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.

Flemish consensus statement on the prevention, diagnosis and treatment of urinary tract infections in older nursing home residents

BACKGROUND

Urinary tract infections (UTIs) are one of the most commonly reported infections in Belgian nursing home residents. In older adults, UTI diagnosis and management is complex, often leading to over-diagnosis and irrational antimicrobial use, stressing the need for a guideline approach.

OBJECTIVES AND METHODS

A consensus statement on the prevention, diagnosis and treatment of UTIs in older adults residing in nursing homes was developed in a collaborative effort between the Flemish Hospital Outbreak Support Teams, the Flemish Agency for Care and Health, the Association of the Flemish Coordinating and Advising General Practitioners, the Belgian Association of Urology, the Belgian Society for Gerontology and Geriatrics and PhD researchers based on a combination of clinical expertise, (inter)national guidelines and peer-reviewed studies.

RESULTS

Optimizing fluid intake, appropriate toilet behaviour and posture, mobilization and local estrogen therapy in women are of proven value in UTI prevention, whereas the use of cranberry and probiotics is not to be advocated. The importance of avoiding bladder catheterization is stressed. In older nursing home residents, the diagnosis of UTIs remains challenging, mostly due to atypical systemic symptoms. A consensus diagnostic algorithm for UTI among residents with and without a urinary catheter was developed, including the presence of suggestive clinical symptoms and a positive urine culture. Urine dipsticks have a high negative but a low positive predictive value. C-reactive protein point-of-care testing is not recommended. Asymptomatic bacteriuria should not be screened for, in order to avoid unnecessary triggers for treatment. In cystitis, nitrofurantoin is the primary choice for treatment, with fosfomycin as an alternative; in prostatitis and uncomplicated pyelonephritis a fluoroquinolone is the advocated empirical antimicrobial.

The clinical usefulness of guideline-based strategies with and without the role of nonspecific symptoms to predict urinary tract infections in nursing homes: a decision curve analysis

Objective

The aim of this study was to assess the clinical value of urinary tract infections (UTIs) guideline algorithms and the role of nonspecific symptoms to support clinical decision-making in nursing home residents.

Design

In a preplanned secondary analysis of a cross-sectional study including nursing home residents with a presumed UTI, 2 prediction models were used in a decision curve analysis (DCA): (1) guideline-based and (2) extended: nonspecific symptom(s) added to the guideline model. The stringent outcome definition for "true UTIs" included symptom improvement during adequate antimicrobial therapy, based on susceptibility test results. The outcome of a DCA is the Net Benefit to quantify the performance of the prediction models, visualized in a decision curve.

Setting

Dutch nursing homes (n = 13).

Patients

Nursing home residents with a presumed UTI.

Results

Of the 180 residents with a presumed UTI, 43 fulfilled the definition of "true UTI" (23.9%). The Net Benefit of the guideline-based model was low and the corresponding threshold range was small (21%-28%). The extended model improved the prediction of UTIs. However, the clinical usefulness of the extended model was still limited to a small threshold range (10%-28%).

Conclusions

The clinical usefulness of the current guideline-based algorithm to diagnose UTI in nursing home residents seems limited, and adding nonspecific symptoms does not further improve decision-making due to the small threshold probability. Given the poor performance of the guideline-based model, refinement of the guidelines may be required.

Trial registry

Dutch trial registry: NTR6467; date of first registration, 25/05/2017.

Healthcare-associated infections in long-term care facilities: a systematic review and meta-analysis of point prevalence studies

Objectives

Residents of long-term care facilities (LTCFs) are especially vulnerable to acquiring healthcare-associated infections (HAIs). Our systematic review and meta-analysis estimated the burden of HAIs, identified the most frequent HAIs and explored the impact of facility-level and surveillance methodological differences on HAI burden in LTCFs, as determined by point prevalence studies (PPS).

Design

Systematic review and meta-analysis.

Data sources

Bibliographic databases MEDLINE (Ovid), Embase (Ovid) and CINAHL (EBSCOhost) were searched for potentially eligible English-language original research publications. References of short-listed full-text publications, the European Centre for Disease Control and Prevention website and an unpublished 2016-2022 Australian Aged Care PPS report were also checked.

Eligibility criteria

PPS monitoring HAIs, published and undertaken between January 1991 and June 2023 in LTCFs.

Data extraction and synthesis

Two reviewers independently screened for eligible PPS and if included, assessed risk of bias for each PPS using the Joanna Briggs Institute (JBI) critical appraisal tool for prevalence studies. Meta-analysis was performed using a generalised linear mixed model.

Results

31 publications (including 123 PPS from 33 countries encompassing 709 860 residents) were included. Nine PPS (7.3%) were allocated a JBI quality score greater than 80% while 30 PPS (24.4%) were allocated a score between 70% and 80%. The overall pooled HAI point prevalence was 3.5% (95% CI 3.1% to 4.0%); 3.9% (95% CI 3.2% to 4.7%) when higher bias-risk PPS (<70% quality score) were excluded. Of 120 PPS, the most frequently reported HAIs were urinary tract (UTIs; 38.9%), respiratory tract (RTIs; 33.6%) and skin or soft tissue (SSTIs; 23.7%) infections. HAI point prevalence varied by geographical region (p<0.001), study decade (p<0.001) and HAI surveillance definitions used (p<0.001). There was no difference across facility types (p=0.57) or season (p=0.46).

Conclusions

HAIs remain a global public health problem and threat to the safety of LTCF residents; effective infection prevention and control strategies to reduce HAIs in LTCFs are still required. Guidance specifically about the prevention and management of UTIs, RTIs and SSTIs should be prioritised.

PROSPERO registration number

CRD42023406844.

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Healthcare-Associated Infections and Prevention Programs in General Nursing versus Residential Homes-Results of the Point Prevalence Survey in Polish Long-Term Care Facilities

Background and Objectives: The number of residents of long-term care facilities (LTCFs) is expected to increase. Determining the epidemiological situation in the context of organizational conditions is therefore extremely important for planning the necessary future activities in the field of infection prevention. The aim of this study was to analyze the prevalence rates in Polish nursing vs. residential homes, in the context of the medical and functional burdens of residents and the organizational conditions of both types of units. Material and Methods: the data that were analyzed came from a point prevalence survey of infections and antibiotic consumption in LTCFs, conducted in accordance with the HALT-3 protocol in Poland in 2017, between April and June. Results: This study included a total of 2313 residents in 24 LTCFs. The most common risk factors for infections in the study population were urinary and fecal incontinence (77.0%), impaired mobility (the patient was in a wheelchair or lying down) (68.7%), and impaired spatial and temporal orientation (52.5%). The median prevalence in nursing homes (NHs) was 3.2% and that in residential homes (RHs) was 0.7%, but without statistical significance. The median for the entire group was 2.6%. A total of 93 healthcare-related infections were detected in 91 residents. The most frequently reported forms of infections were urinary tract infections, lower respiratory tract infections, and skin infections. A statistically significant positive correlation was found only between the percentage of residents with pressure ulcers and other wounds and the incidence of gastrointestinal infections (correlation coefficient = 0.413, p < 0.05). Infection prevention and control measures were implemented mainly in nursing homes, and in residential homes, only hand hygiene procedures were commonly available. Conclusions: For the two types of LTCFs, the epidemiological situation in terms of nosocomial infections is diverse. Consequently, both types of facilities require different approaches to infection control and prevention and outcomes analysis.

Prevalence of healthcare-associated infections in Dutch long-term care facilities from 2009 to 2019

OBJECTIVE

We assessed trends in the prevalence of healthcare-associated infections (HCAIs) and associated resident and facility characteristics in a national network of long-term care facilities (LTCFs) in the Netherlands from 2009 to 2019.

METHODS

Participating LTCFs registered the prevalence of urinary tract infection (UTI), lower respiratory tract infection (LRTI), gastrointestinal infection (GI), bacterial conjunctivitis, sepsis and skin infection, using standardized definitions, in biannual point-prevalence surveys (PPSs). In addition, resident and LTCF characteristics were collected. Multi-level analyses were performed to study changes in the HCAI prevalence over time and to identify resident and LTCF-related risk factors. Analyses were performed for HCAIs overall and for UTI, LRTI and GI combined as these were recorded throughout the period.

RESULTS

Overall, 1353 HCAIs were registered in 44,551 residents with a prevalence of 3.0% (95% confidence interval: 2.8-3.1; range between years 2.3-5.1%). When including only UTI, LRTI and GI the prevalence decreased from 5.0% in 2009 to 2.1% in 2019. Multi-variable regression analyses for UTI, LRTI and GI combined indicated that both prolonged participation and calendar time were independently associated with HCAI prevalence; in LTCFs that participated ≥4 years, the HCAI risk was decreased (OR 0.72 (0.57-0.92)) compared with the first year, and the OR per calendar year was 0.93 (0.88-0.97).

CONCLUSIONS

Over 11 years of PPS in LTCFs the HCAI prevalence decreased over time. Prolonged participation further reduced the HCAI prevalence, in particular UTIs, despite the increasing age and associated frailty of the LTCF population, illustrating the potential value of surveillance.

Urinary tract infections: a review of the current diagnostics landscape

Urinary tract infections are the most common bacterial infections worldwide. Infections can range from mild, recurrent (rUTI) to complicated (cUTIs), and are predominantly caused by uropathogenic Escherichia coli (UPEC). Antibiotic therapy is important to tackle infection; however, with the continued emergence of antibiotic resistance there is an urgent need to monitor the use of effective antibiotics through better stewardship measures. Currently, clinical diagnosis of UTIs relies on empiric methods supported by laboratory testing including cellular analysis (of both human and bacterial cells), dipstick analysis and phenotypic culture. Therefore, development of novel, sensitive and specific diagnostics is an important means to rationalise antibiotic therapy in patients. This review discusses the current diagnostic landscape and highlights promising novel diagnostic technologies in development that could aid in treatment and management of antibiotic-resistant UTIs.

Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents

One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.

Associated Factors of Functional Ability in Older Persons Undergoing Hip Surgery Immediately Post-Hospital Discharge: A Prospective Study

BACKGROUND

hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery.

METHODS

a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data.

RESULTS

most participants were female, with a mean age of 78.10 years (range = 60-93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049).

Prevalence of indwelling urinary catheters in nursing home residents: Systematic review

BACKGROUND

This systematic review examines the prevalence of indwelling urinary catheters in nursing home residents.

METHODS

MEDLINE via PubMed, CINAHL, and EMBASE were searched from inception to 9 August 2022. Cross-sectional studies and longitudinal studies with cross-sectional analyses reporting catheter prevalence in nursing home residents were identified and summarized descriptively. Study quality was assessed using the Joanna Briggs Institute's tool.

RESULTS

Sixty-seven studies (92.5 % cross-sectional) were included. The reported number of included residents ranged from 73 to 110,656. The median catheter prevalence was 7.3 % (interquartile range 4.3-10.1 %; n = 65 studies). It was higher in Germany (10.2 % [9.7-12.8 %]; n = 15) than in the United States of America (9.3 % [6.3-11.9 %]; n = 9), United Kingdom (6.9 % [4.8-8.5 %]; n = 7), and Sweden (7.3 % [6.4-7.9 %]; n = 6). Furthermore, it was higher among men (17.0 % [16.0-26.0 %]) than among women (5.3 % [4.0-9.5 %]) (n = 9). Only one study investigated differences by age. The prevalence was higher for transurethral (5.7 % [5.6-7.2 %]; n = 12) than for suprapubic (1.2 % [0.6-2.5 %]; n = 13) catheters. Most catheterized residents were long-term catheterized (n = 6) and had their catheter changed within 3 months (n = 2). Symptomatic urinary tract infections were more common among catheterized than among non-catheterized residents (n = 4).

DISCUSSION

Catheter prevalence in nursing home residents varies between studies and countries. Prevalence differences by sex, age, and catheter type as well as duration of catheterization, catheter change intervals, and catheter-associated urinary tract infections are rarely reported because most studies do not primarily focus on catheters. Future studies should focus on the circumstances of urinary catheter use and care in nursing home residents.

REGISTRATION AND FUNDING

PROSPERO (29 August 2022; CRD42022354358); no funding.

An Increasing Threat in Intensive Care Units, Evaluation of Multi-Drug-Resistant Myroides spp. Infections and Risk Factors

BACKGROUND

Myroides species are gram-negative bacilli that are commonly found in soil and water, acting as low-level opportunistic pathogens and causing a variety of infections.

AIM

The purpose of this study is to assess the risk factors for multidrug-resistant Myroides infections, their association with comorbid illnesses, patient care, and their susceptibility to antibiotics.

METHODS

This retrospective analytical study was conducted in Istanbul Başakşehir Çam and Sakura City Hospital by including patients with Myroides spp isolation in their culture samples. The total hospitalization days, first isolation days, and 30-day mortality values of the patients were analysed statistically, and the significance level was accepted as p < 0.05.

RESULTS

Myroides spp. were isolated from 228 patients' 437 culture samples. Of these cases, 210 (92.1%) were classified as having asymptomatic bacteriuria, and 18 (7.9%) as having an infection caused by Myroides spp. 174 (76.3%) of these patients were followed up in the intensive care unit, and the total hospitalization days (median = 24.50) and the first isolation day (median = 9.50) of infected patients were shorter than colonized patients (p = 0.023, p = 0.030), no difference was found between 30-day mortality (p = 0.312).

CONCLUSIONS

It was observed that Myroides infections could be seen more frequently in patients who were hospitalized for a long time, used broad-spectrum antimicrobials, had invasive procedures, and had co-factors such as diabetes and cerebrovascular disease. In addition, it was observed that the resistance rates of M. odoratus strains were higher than M. odoratimimus strains and the use of quinolone antimicrobials in the treatment of patients with M. odoratimimus infection provided more cure.

Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis

BACKGROUND

Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization.

METHODS

MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year.

RESULTS

In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia.

CONCLUSION

The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

[Healthcare-associated infections and antimicrobial use in long-term care facilities. German results of the third European point prevalence survey HALT-3]

BACKGROUND AND OBJECTIVE

The essential role of infection prevention in long-term care facilities has become evident during the current SARS-CoV‑2 pandemic. In order to obtain a reliable database on nosocomial infections and antibiotic use, the European Centre for Disease Prevention and Control (ECDC) initiated the third point prevalence survey in European long-term care facilities from 2016 to 2017 (HALT-3).

MATERIAL AND METHODS

In Germany, 131 facilities with 10,565 residents participated voluntarily. On a single day in 2016, the number of nosocomial infections and/or uses of antibiotics as well as care characteristics and risk factors of the residents were recorded. Infections were documented based on symptoms using an algorithm in accordance with the McGeer surveillance criteria for long-term care facilities.

RESULTS

A nosocomial infection was documented in 177 residents, which corresponds to a prevalence of 1.7% (95% CI: 1.3-2.1), still low in comparison with the European prevalence (mean value 3.9%). Urinary tract infections were the most common infections at almost 50%, followed by respiratory, skin, and soft-tissue infections. The type of infection was consistent with the most common indications for antibiotic use. Antibiotic use was documented in 143 residents (prevalence of 1.4%, 95% CI: 1.1-1.7). The frequent use of fluoroquinolones with over 20% of all prescriptions was noticeable.

CONCLUSIONS

The establishment of facility-based surveillance of the most common infections and antibiotic consumption, together with the creation of guidelines specifically tailored to the geriatric population, could contribute to improving infection prevention and control as well as a more rational use of antibiotics, thus increasing the quality and safety of care.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

Healthcare-associated infections and antimicrobial use in Belgian nursing homes: results of three point prevalence surveys between 2010 and 2016

Background

Belgium monitors the burden of healthcare-associated infections (HAIs) and antimicrobial use in nursing homes (NHs) by participating in the European point prevalence surveys (PPSs) organised in long-term care facilities (HALT surveys). We present the main findings of the three national PPSs conducted in NHs participating in at least one of these surveys, and in a cohort that participated in all three consecutive surveys.

Methods

All NHs were invited to voluntarily participate and conduct the survey on one single day in May-September 2010 (HALT-1), in April-May 2013 (HALT-2) or in September-November 2016 (HALT-3). Data were collected at institutional, ward and resident level. A detailed questionnaire had to be completed for all eligible (i.e. living full time in the facility since at least 24 h, present at 8:00 am and willing to participate) residents receiving at least one systemic antimicrobial agent and/or presenting at least one active HAI on the PPS day. The onset of signs/symptoms had to occur more than 48 h after the resident was (re-)admitted to the NH.

Results

A total of 107, 87 and 158 NHs conducted the HALT-1, HALT-2 and HALT-3 survey, respectively. The median prevalence of residents with antimicrobial agent(s) increased from 4.3% (95% confidence interval (CI): 3.5-4.8%) in HALT-1 to 4.7% (95% CI: 3.5-6.5%) in HALT-2 and 5.0% (95% CI: 4.2-5.9%) in HALT-3. The median prevalence of residents with HAI(s) varied from 1.8% (95% CI: 1.4-2.7%) in HALT-1 to 3.2% (95% CI: 2.2-4.2%) in HALT-2 and 2.7% (95% CI: 2.1-3.4%) in HALT-3. Our post-hoc analysis on the cohort (n = 25 NHs) found similar trends. In all three surveys, respiratory tract infections were most frequently reported, followed by skin/wound infections in HALT-1 and urinary tract infections in HALT-2 and HALT-3. Antimicrobials were most commonly prescribed for the therapeutic treatment of an infection: 66.4% in HALT-1, 60.9% in HALT-2 and 64.1% in HALT-3. Uroprophylaxis accounted for 28.7%, 35.6% and 28.4% of all prescriptions, respectively.

Conclusions

None withstanding the limitations peculiar to the study design, the PPSs enabled us to assess the occurrence of and to increase awareness for HAIs and rational antimicrobial use in NHs at both local and national level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00818-1.

Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns

BACKGROUND

The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation.

METHODS

A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment.

RESULTS

64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively).

CONCLUSION

Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.

Intrauterine devices as an exposure risk for urinary tract infections: A scoping review

BACKGROUND

The intrauterine device (IUD) as a potential source of uro-gynecologic infection has raised concern for decades. While a causal link between IUD and pelvic inflammatory disease has been refuted, the relationship between IUDs and urinary tract infections (UTIs) remains incompletely understood.

METHODS

We used a PubMed, CINAHL, and Cochrane Library search strategy to identify studies evaluating UTI occurrence and microbial signatures among women exposed to IUD. We evaluated the question, "what is currently known about the IUD as an exposure risk for UTIs?"

RESULTS

Nine studies met inclusion criteria and were summarized in this structured, scoping review. Studies to date have not reported a significant association between IUD exposue and UTI occurence. While all nine studies acknowledged the breadth of contraceptive methods, none evaluated the impact of different IUD types (i.e., copper vs. hormone-eluting) on UTI incidence.

CONCLUSION

Small sample sizes and inconsistent UTI definitions limit the current literature. Future studies should rigorously define the UTI phenotype and evaluate the association of UTI with IUD exposure accounting for known covariates.

A retrospective comparison of guidelines to assess hospital-diagnosed urinary tract infection in nursing home residents

BACKGROUND

Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment.

METHODS

A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness.

RESULTS

Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The 2 criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity.

CONCLUSIONS

Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.

Antibiotic consumption in long-term care facilities in Poland and other European countries in 2017

Introduction

The aim of this research study was to compare the situation concerning the use of microbiology testing, the epidemiology of healthcare-associated infection (HAI) and antimicrobial consumption (AMC) in Polish long-term care facilities (LTCFs) with other European countries, using the most recent findings available in the European databases. Furthermore, this study aimed to highlight several basic factors that contribute to the observable differences in AMC between countries participating in the HALT-3 study, especially the relationship with demographic indicators, as well as the health care resources utilization rates.

Patients and methods

The most recent HAIs in Long-Term care facilities Point Prevalence Survey (HALT PPS) was carried out in EU/EEA countries in 2016–2017, and in Poland it was carried out in April–June 2017 in 24 LTCFs. AMC data was collected with use of methodology of the Anatomical Therapeutic Chemical (ATC) classification system of the WHO.

Results

In total total in HALT-3 study on the day of the PPS, 5035 out of the 102,301 eligible residents received at least one antimicrobial agent, with prevalence of 4.9%, and in Poland 3.2%. The most common HAIs in the countries included into the study was urinary tract infection with relative frequency of 32%, in Poland it was skin infection, 30.4%. The respiratory tract infections, excluding pneumonia (PNU) were observed in 29.5% of residents in total, in Poland 17.4%, the prevalence rate of PNU were 1.4% and 5.4%, respectively. The lack of microbiological results of HAIs testing concerned the vast majority of all HAIs, 75.8% in total and 81.5% in Poland. The most frequently used antibacterial for systemic use were beta-lactams and the most frequently prescribed antimicrobial agent was ‘amoxicillin and enzyme inhibitor’. AMC was closely correlated with the age of the general population (65 years of age and more) and the availability of doctors in general population.

Conclusions

A significant problem observed in LTCFs was the empirical use of antibiotics and the scarcity of microbiological testing. In the studied Polish LTCFs, where the age of residents was low, also the AMC was found to be lower.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01019-1.

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Quality Indicators for the Diagnosis and Management of Menière's Disease

OBJECTIVE

Menière's disease (MD) is a clinical disorder that often provides challenges in diagnosis and management. High-quality evidence to guide care providers is sparse, which can result in significant practice variations. Quality indicators (QIs) are one method that can be used to standardize and measure accepted care practices to improve healthcare quality and patient outcomes. Here, we developed practical, high-yield QIs that serve to measure and inform the quality of care provided to patients with MD.

STUDY DESIGN

Modified RAND Corporation University of California, Los Angeles appropriateness methodology for QI development.

SETTING

Multicenter nine-member expert panel.

PATIENTS

NA.

INTERVENTIONS

NA.

MAIN OUTCOME MEASURE

Final QIs deemed appropriate measures of quality care with agreement by the expert panel.

RESULTS

Twenty-seven candidate indicators were identified after literature review. After the first round of evaluations, the panel agreed on three candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss disagreements. Two agreed-upon QIs were revised during this discussion before final evaluations. The expert panel ultimately agreed upon five QIs as appropriate measures of high-quality care after completing final evaluations and reviewing updated literature. The five quality indicators measure audiometric documentation, minimization of electrocochleography, use of intratympanic dexamethasone, use of intratympanic gentamycin, and rate of labyrinthectomy/vestibular neurectomy in refractory MD patient.

CONCLUSIONS

This study proposes five QIs that cover key aspects of care for MD, such as accurate diagnosis and management options including initial destructive therapies. These QIs can serve multiple purposes, the most important of which is to galvanize quality improvement initiatives.

Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988-2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran's Q = 166,837.8, p < .001, I² = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss

OBJECTIVE

Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level.

METHODS

Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology.

RESULTS

Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL.

CONCLUSION

The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.

The effect of a hand hygiene intervention on infections in residents of nursing homes: a cluster randomized controlled trial

BACKGROUND

The primary goal of hand hygiene is to reduce infectious disease rates. We examined if a nursing home's participation in a hand hygiene intervention resulted in residents having fewer healthcare associated infections (HAIs) when compared to nursing homes without the hand hygiene intervention.

METHODS

This study is a part of a cluster randomized controlled trial (RCT) in 33 nursing homes to improve hand hygiene (HANDSOME). The incidence of five illnesses was followed over 13 months: gastroenteritis, influenza-like illness, pneumonia, urinary tract infections and infections from methicillin-resistant Staphylococcus aureus (MRSA). Incidence rates per study arm were reported for baseline (October-December 2016) and two follow-up periods (January-April 2017, May-October 2017). HAI rates were compared in a Poisson multilevel analysis, correcting for baseline differences (the baseline infection incidence and the size of the nursing home), clustering of observations within nursing homes, and period in the study.

RESULTS

There was statistically significantly more gastroenteritis (p < 0.001) and statistically significantly less influenza-like illness (p < 0.01) in the intervention arm when compared to the control arm. There were no statistically significant differences or pneumonia, urinary tract infections, and MRSA infections in the intervention arm when compared to the control arm. In a sensitivity analysis, gastroenteritis was no longer statistically significantly higher in the intervention arm (p = 0.92).

CONCLUSIONS

As in comparable studies, we could not conclusively demonstrate the effectiveness of an HH intervention in reducing HAIs among residents of nursing homes, despite the use of clearly defined outcome measures, a standardized reporting instrument, and directly observed HH in a multicenter cluster RCT. Trial registration Netherlands Trial Register, trial NL6049 (NTR6188). Registered October 25, 2016, https://www.trialregister.nl/trial/6049 .

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact

In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14–0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13–0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.

Development of a core outcome set for clinical trials aimed at improving antimicrobial stewardship in care homes

Background

Diverse outcomes reported in clinical trials of antimicrobial stewardship (AMS) interventions in care homes have hindered evidence synthesis. Our main objective was to develop a core outcome set (COS) for use in trials aimed at improving AMS in care homes.

Methods

A refined inventory of outcomes for AMS interventions in care homes, compiled from a previous study, was rated in a three-round international Delphi survey with 82 participants, using a nine-point Likert scale (from 1, unimportant, to 9, critical). This was followed by an online consensus exercise with 12 participants from Northern Ireland to finalise the COS content. Subsequently, a suitable outcome measurement instrument (OMI) was selected for each outcome in the COS by: identifying existing OMIs through a literature search and experts’ suggestions, assessing the quality of OMIs, and selecting one OMI for each core outcome via a two-round international Delphi survey with 59 participants.

Results

Of 14 outcomes initially presented, consensus was reached for inclusion of five outcomes in the COS after the three-round Delphi survey and the online consensus exercise, comprising the total number of antimicrobial courses prescribed, appropriateness of antimicrobial prescribing, days of therapy per 1000 resident-days, rate of antimicrobial resistance, and mortality related to infection. Of 17 potential OMIs identified, three were selected for the two-round Delphi exercise after the quality assessment. Consensus was reached for selection of two OMIs for the COS.

Conclusion

This COS is recommended to be used in clinical trials aimed at improving AMS in care homes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00925-8.

Risk adjustment for benchmarking nursing home infection surveillance data: A narrative review

Until recently, there was no national surveillance system for monitoring infection occurrence in long-term care facilities (LTCF) in the United States. As a result, there are no national benchmarks for LTCF infection rates that can be utilized for quality improvement at the facility level. One of the major challenges in the reporting of health care-related infection data is accounting for nonmodifiable facility and patient characteristics that influence benchmarks for infection. The objectives of this paper are to review: (a) published infection rates in LTCF in the United States to assess the level of variability; (b) studies describing facility- and resident-level risk factors for infection that can be used in risk adjustment models; (c) published attempts to risk-adjust LTCF infection rates; and (d) efforts to develop models specifically for risk adjustment of infection rates in LTCF for benchmarking. It is anticipated that this review will stimulate further study of methods to risk-adjust LTCF infection rates for benchmarking that will facilitate research and public reporting.

Association of environmental surface contamination with hand hygiene and infections in nursing homes: a prospective cohort study

Background

Little is known about the presence of infections in nursing home residents, the causative micro-organisms, how hand hygiene (HH) influences the presence of infections in residents, and the extent to which environmental contamination is associated with the incidence of infection among residents.

Aims

To establish if environmental contamination can be used as an indicator for HH compliance, and if environmental contamination is associated with the incidence of infection.

Methods

Environmental surface samples (ESS) were collected in an exploratory study as part of a HH intervention in 60 nursing homes. ESS results from three distinct surfaces (nurses' station, communal toilet and residents' shared living area) were compared with nurses' HH compliance and the incidence of infection among residents. Real-time polymerase chain reaction assays were used to detect norovirus genogroup I and II, rhinovirus and Escherichia coli. HH compliance was measured by direct observation. The incidence of infection was registered weekly.

Findings

Rhinovirus (nurses' station: 41%; toilet: 14%; living area: 29%), norovirus (nurses' station: 18%; toilet: 12%; living area: 16%) and E. coli (nurses' station: 14%; toilet: 58%; living area: 54%) were detected. No significant (P<0.05) associations were found between HH compliance and the presence of micro-organisms. An association was found between E. coli contamination and the incidence of disease in general (P=0.04). No other associations were found between micro-organisms and the incidence of disease.

Conclusion

Rhinovirus, norovirus and E. coli were detected on surfaces in nursing homes. No convincing associations were found between environmental contamination and HH compliance or the incidence of disease. This study provides reference data about surface contamination.

Development and Application of a Surveillance Method for Healthcare-Associated Infections in Long-Term Care Hospitals in Korea

Background

This study developed a surveillance method for healthcare-associated infections (HAIs) in long-term care hospitals (LTCHs) and investigated the current status of HAIs in LTCHs in Korea.

Methods

We applied the HAI-related surveillance criteria for long-term care facilities developed by McGeer in six LTCHs.

Results

The 197 confirmed HAIs corresponded to incidence rates of 30.38/100 inpatients and 1.57/1,000 days of hospitalization and included 84 cases of respiratory tract infection (43.8%), 78 cases of systemic infection (40.6%), 24 cases of gastrointestinal tract infection (12.5%), and 6 cases of skin and soft tissue mucosal infection (2.1%). The subtypes included 78 cases of unexplained febrile illness (40.6%); 40 cases of pneumonia (20.8%); 27 cases of lower respiratory tract infection (14.1%); 21 cases of gastroenteritis (10.9%); 9 cases of influenza-like illness (4.7%); 8 cases of common cold or pharyngitis (4.2%); 4 cases of cellulitis, soft tissue, or wound infection (2.1%); 3 cases of Clostridium difficile infection (1.6%); 1 case of conjunctivitis (0.5%); and 1 case of fungal oral/perioral and skin infection (0.5%).

Conclusion

Establishing an HAI surveillance method for LTCHs and identifying HAI rates and risk factors among LTCH patients may help prevent HAIs in LTCHs in Korea.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Diagnosis, prevention and control of urinary tract infections: a survey of routine practices in Belgian nursing homes

Background

Urinary tract infections (UTIs) are one of the most frequently reported infections in older adults and the most common reason for antimicrobial prescribing in nursing homes (NHs). In this vulnerable population, both a good diagnosis and prevention of these infections are crucial as overuse of antibiotics can lead to a variety of negative consequences including the development of multidrug-resistant organisms.

Objective

To determine infection prevention and control (IPC) and diagnostic practices for UTIs in Belgian NHs.

Methods

Local staff members had to complete an institution-level questionnaire exploring the availability of IPC practices and resources and procedures for UTI surveillance, diagnosis, and urinary catheter and incontinence care.

Results

UTIs were the second most common infections in the 87 participating NHs (prevalence: 1.0%). Dipstick tests and urine cultures were routinely performed in 30.2% and 44.6% of the facilities, respectively. In non-catheterised residents, voided or midstream urine sampling was most frequently applied. Protocols/guidelines for urine sampling, urinary catheter care and incontinence care were available in 43.7%, 45.9% and 31.0% of the NHs, respectively. Indwelling catheters were uncommon (2.3% of the residents) and urinary retention (84.9%) and wound management (48.8%) were the most commonly reported indications. Only surveillance was found to significantly impact the UTI prevalence: 2.2% versus 0.8% in NHs with or without surveillance, respectively (P < 0.001).

Discussion

This survey identified key areas for improving the diagnosis and prevention of UTIs, such as education and training regarding the basics of urine collection and catheter care.

Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review

The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.

The situation of infection in the elderly in Spain: a multidisciplinary opinion document

Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.

Registered Nurses' Decisions Around Referral of Residents With Urinary Tract Infections: A Retrospective Cohort Study

Background

Referral of residents with urinary tract infections (UTIs) in residential aged care facilities (RACFs) to hospital are common. However, there is limited information on what influences Registered Nurses’ (RN) decision-making process.

Aim

To investigate resident factors that influence RN’s decisions to escalate care.

Design

A retrospective cohort approach audited electronic clinical records of residents with UTIs.

Methods

Data were extracted from the electronic database and analyzed using descriptive and regression analysis. Approval was obtained from both the RACFs and University Human Research Ethics Committee.

Results

There was a higher likelihood of being referred to hospital if residents were female, had had a past fall, had related comorbidity, or had abnormal vital signs. However, being older and having a urinary catheter were protective factors for referral by the RN.

Conclusion

Referral of residents with UTIs by RNs to hospital is common in RACFs. Resident characteristics such as abnormal vital signs, past falls, and presence of comorbidity influence referrals by RNs. Nurse Practitioners dedicated to the RACFs could complement the role of a general practitioner. UTI-specific escalation protocols can assist RNs to make decisions about referrals. RNs’ related risk factors also need to be examined to understand other influencing factors.

Exploring barriers to and enablers of antimicrobial stewardship in rural health services

BACKGROUND

World-wide antimicrobial resistance is increasing, and antimicrobial stewardship (AMS) interventions aimed at increasing compliance with optimal antimicrobial prescribing are essential in tackling this issue. Local level research about antimicrobial use is important to tailor interventions in a place-based approach to solve local level problems.

METHODS

As part of a broader mixed methods study, Medical Practitioners and Senior Nurses at three rural health services were invited by email to participate in interviews to explore opinions and practices of antimicrobial prescribing.

RESULTS

Seven Medical Practitioners and thirteen Senior Nurses from three small rural health services participated in the study. The major findings were that nurses were perceived as the 'gatekeepers' to antimicrobial initiatives by all participants. Senior Nurses perceived AMS activities as being a link in a world-wide program to eradicate antimicrobial resistance, while Medical Practitioners perceived it as a local level program, aimed at educating individual prescribers. There was consensus that an intervention aimed at improved documentation at the point of prescribing and increased accessibility to antimicrobial prescribing guidelines had a high potential for increased compliance with optimal prescribing of antimicrobials.

CONCLUSION

The research enabled identification of interventions aimed at increasing optimal compliance with antimicrobial prescribing that are acceptable to and appropriate for Medical Practitioners and nursing staff at three rural health services.

A comparative analysis of prophylactic antimicrobial use in long-term care facilities in Ireland, 2013 and 2016

Background

Long-term care facilities (LTCFs) are important locations of antimicrobial consumption. Of particular concern is inappropriate prescribing of prophylactic antimicrobials.

Aim

We aimed to explore factors related to antimicrobial prophylaxis in LTCFs in Ireland.

Methods

The point prevalence surveys of Healthcare-Associated Infections in Long-Term Care Facilities (HALT) were performed in Ireland in May 2013 and 2016. Data were collected on facility (type and stewardship initiatives) and resident characteristics (age, sex, antimicrobial and indication) for those meeting the surveillance definition for a HAI and/or prescribed an antimicrobial.

Results

In 2013, 9,318 residents (in 190 LTCFs) and in 2016, 10,044 residents (in 224 LTCFs) were included. Of the 10% of residents prescribed antimicrobials, 40% were on prophylaxis, most of which was to prevent urinary tract infection. The main prophylactic agents were: nitrofurantoin (39%) and trimethoprim (41%) for urinary tract (UT); macrolides (47%) for respiratory tract and macrolides and tetracycline (56%) for skin or wounds. More than 50% of the prophylaxis was prescribed in intellectual disability facilities and around 40% in nursing homes. Prophylaxis was recorded more often for females, residents living in LTCFs for more than 1 year and residents with a urinary catheter. No difference in prophylactic prescribing was observed when comparing LTCFs participating and not participating in both years.

Conclusions

Forty per cent of antimicrobial prescriptions in Irish LTCFs were prophylactic. This practice is not consistent with national antimicrobial prescribing guidelines. Addressing inappropriate prophylaxis prescribing in Irish LTCFs should be a key objective of antimicrobial stewardship initiatives.

Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.

Improving Hand Hygiene Compliance in Nursing Homes: Protocol for a Cluster Randomized Controlled Trial (HANDSOME Study)

BACKGROUND

Hand hygiene compliance is considered the most (cost-)effective measure for preventing health care-associated infections. While hand hygiene interventions have frequently been implemented and assessed in hospitals, there is limited knowledge about hand hygiene compliance in other health care settings and which interventions and implementation methods are effective.

OBJECTIVE

This study aims to evaluate the effect of a multimodal intervention to increase hand hygiene compliance of nurses in nursing homes through a cluster randomized controlled trial (HANDSOME study).

METHODS

Nursing homes were randomly allocated to 1 of 3 trial arms: receiving the intervention at a predetermined date, receiving the identical intervention after an infectious disease outbreak, or serving as a control arm. Hand hygiene was evaluated in nursing homes by direct observation at 4 timepoints. We documented compliance with the World Health Organization's 5 moments of hand hygiene, specifically before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. The primary outcome is hand hygiene compliance of the nurses to the standards of the World Health Organization. The secondary outcome is infectious disease incidence among residents. Infectious disease incidence was documented by a staff member at each nursing home unit. Outcomes will be compared with the presence of norovirus, rhinovirus, and Escherichia coli on surfaces in the nursing homes, as measured using quantitative polymerase chain reaction.

RESULTS

The study was funded in September 2015. Data collection started in October 2016 and was completed in October 2017. Data analysis will be completed in 2020.

CONCLUSIONS

HANDSOME studies the effectiveness of a hand hygiene intervention specifically for the nursing home environment. Nurses were taught the World Health Organization's 5 moments of hand hygiene guidelines using the slogan "Room In, Room Out, Before Clean, After Dirty," which was developed for nursing staff to better understand and remember the hygiene guidelines. HANDSOME should contribute to improved hand hygiene practice and a reduction in infectious disease rates and related mortality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6188) NL6049; https://www.trialregister.nl/trial/6049.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17419.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Creation and implementation of a urinary tract infection diagnostic and treatment algorithm for psychiatric inpatients with a communication barrier

Background

Urinary tract infection (UTI) is considered a common cause of mental status changes, particularly in elderly patients and patients with a psychiatric condition. Genitourinary symptoms are essential to confirm UTI diagnosis but may be unobtainable in patients with a communication barrier. Sparse guidance suggests assessing specific symptoms that do not rely on patient report. The primary objective of this project was to provide assistance in diagnosis and treatment of UTIs in noncommunicative patients through the creation of an algorithm.

Algorithm Creation and Implementation

Through extensive interdisciplinary collaboration, the authors developed criteria to identify UTI symptoms that do not require communication. In order to make the algorithm comprehensive, we chose to include general information related to UTI diagnosis and treatment. The algorithm was implemented within the psychiatric emergency department as this is where patients are evaluated to determine need for psychiatric admission. Providers in the psychiatric emergency department were provided with detailed education on the algorithm as well as information about UTI diagnosis and treatment.

Discussion

Creating an algorithm within our institution required significant interdisciplinary collaboration. Providers were receptive to and appreciative of a comprehensive resource to assist in this difficult clinical situation. The authors plan to study the effects of algorithm implementation, specifically assessing changes in symptom documentation and antibiotic use.

A multifaceted intervention to reduce antimicrobial prescribing in care homes: a non-randomised feasibility study and process evaluation

Background

The most frequent acute health-care intervention that care home residents receive is the prescribing of medications. There are serious concerns about prescribing generally, and about antimicrobial prescribing in particular, with facilities such as care homes being described as an important ‘reservoir’ of antimicrobial resistance.

Objectives

To evaluate the feasibility and acceptability of a multifaceted intervention on the prescribing of antimicrobials for the treatment of infections.

Design

This was a non-randomised feasibility study, using a mixed-methods design with normalization process theory as the underpinning theoretical framework and consisting of a number of interlinked strands: (1) recruitment of care homes; (2) adaptation of a Canadian intervention (a decision-making algorithm and an associated training programme) for implementation in UK care homes through rapid reviews of the literature, focus groups/interviews with care home staff, family members of residents and general practitioners (GPs), a consensus group with health-care professionals and development of a training programme; (3) implementation of the intervention; (4) a process evaluation consisting of observations of practice and focus groups with staff post implementation; and (5) a survey of a sample of care homes to ascertain interest in a larger study.

Setting

Six care homes – three in Northern Ireland and three in the West Midlands.

Participants

Care home staff, GPs associated with the care homes and family members of residents.

Interventions

A training programme for care home staff in the use of the decision-making algorithm, and implementation of the decision-making algorithm over a 6-month period in the six participating care homes. REACH (REduce Antimicrobial prescribing in Care Homes) Champions were appointed in each care home to support intervention implementation and the training of staff.

Main outcome measures

The acceptability of the intervention in terms of recruitment, delivery of training, feasibility of data collection from a variety of sources, implementation, practicality of use and the feasibility of measuring the appropriateness of prescribing.

Results

Six care homes from two jurisdictions were recruited, and the intervention was adapted and implemented. The intervention appeared to be broadly acceptable and was implemented largely as intended, although staff were concerned about the workload associated with study documentation. It was feasible to collect data from community pharmacies and care homes, but hospitalisation data from administrative sources could not be obtained. The survey indicated that there was interest in participating in a larger study.

Conclusions

The adapted and implemented intervention was largely acceptable to care home staff. Approaches to minimising the data-collection burden on staff will be examined, together with access to a range of data sources, with a view to conducting a larger randomised study.

Trial registration

Current Controlled Trials ISRCTN10441831.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information. Queen’s University Belfast acted as sponsor.

Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017

Background

The 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis.

Aim

Our aim was to identify institutional and resident risk factors of AMU and HAI.

Methods

HALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data.

Results

Of 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2–0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1–0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9–1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1–0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7–1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3–1.0) with less HAI. AMU and HAI varied significantly between LTCF.

Conclusions

Multilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.

Culture-Negative Septic Shock Compared With Culture-Positive Septic Shock: A Retrospective Cohort Study

OBJECTIVES

To determine the clinical characteristics and outcomes of culture-negative septic shock in comparison with culture-positive septic shock.

DESIGN

Retrospective nested cohort study.

SETTING

ICUs of 28 academic and community hospitals in three countries between 1997 and 2010.

SUBJECTS

Patients with culture-negative septic shock and culture-positive septic shock derived from a trinational (n = 8,670) database of patients with septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients with culture-negative septic shock (n = 2,651; 30.6%) and culture-positive septic shock (n = 6,019; 69.4%) were identified. Culture-negative septic shock compared with culture-positive septic shock patients experienced similar ICU survival (58.3% vs 59.5%; p = 0.276) and overall hospital survival (47.3% vs 47.1%; p = 0.976). Severity of illness was similar between culture-negative septic shock and culture-positive septic shock groups ([mean and SD Acute Physiology and Chronic Health Evaluation II, 25.7 ± 8.3 vs 25.7 ± 8.1]; p = 0.723) as were serum lactate levels (3.0 [interquartile range, 1.7-6.1] vs 3.2 mmol/L [interquartile range, 1.8-5.9 mmol/L]; p = 0.366). As delays in the administration of appropriate antimicrobial therapy after the onset of hypotension increased, patients in both groups experienced congruent increases in overall hospital mortality: culture-negative septic shock (odds ratio, 1.56; 95% CI [1.47-1.66]; p < 0.0001) and culture-positive septic shock (odds ratio, 1.65; 95% CI [1.59-1.71]; p < 0.0001).

CONCLUSIONS

Patients with culture-negative septic shock behave similarly to those with culture-positive septic shock in nearly all respects; early appropriate antimicrobial therapy appears to improve mortality. Early recognition and eradication of infection is the most obvious effective strategy to improve hospital survival.

Advances and Challenges in the Diagnosis and Treatment of Urinary Tract Infections: the Need for Diagnostic Stewardship

PURPOSE OF REVIEW

Urinary tract infections (UTIs), including catheter-associated UTIs, are among the most common bacterial infections in both inpatient and outpatient settings. Diagnosis of true UTI remains a clinical challenge, and excessive antimicrobial treatment of asymptomatic bacteriuria (ASB) or contaminated urine cultures is common.

RECENT FINDINGS

Challenges with the appropriate diagnosis of UTIs include the lack of specific signs and symptoms, no definitive diagnostic criteria, high incidence of ASB, contamination of samples, and frequent lack of indications for ordering urine cultures. Promising interventions include education and feedback, indication requirements when ordering cultures, and use of reflex culture policies that limit urine cultures. Antimicrobial and diagnostic stewardship interventions can work synergistically to decrease ordering of urine cultures without clear indication and prevent excessive antimicrobial administration in patients without clearly defined UTI.

The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review

Background

Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.

Methods

A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.

Results

One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0–1.7, p = 0.034).

Conclusions

Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.