SHEA/APIC Guideline: Infection prevention and control in the long-term care facility

Mind the gap: knowledge, attitudes and perceptions on antimicrobial resistance, antimicrobial stewardship and infection prevention and control in long-term care facilities for people with disabilities in the Netherlands

BACKGROUND

Antimicrobial resistance (AMR) has become one of the major public health threats worldwide, emphasizing the necessity of preventing the development and transmission of drug resistant microorganisms. This is particularly important for people with vulnerable health conditions, such as people with intellectual disabilities (ID) and long-term care residents. This study aimed to assess the current status of AMR, antimicrobial stewardship (AMS) and infection prevention and control (IPC) in Dutch long-term care facilities for people with intellectual disabilities (ID-LTCFs).

METHODS

A web-based cross-sectional survey distributed between July and November 2023, targeting (both nonmedically and medically trained) healthcare professionals working in ID-LTCFs in The Netherlands, to study knowledge, attitudes and perceptions regarding AMR, AMS and IPC.

RESULTS

In total, 109 participants working in 37 long-term care organizations for people with intellectual disabilities throughout the Netherlands completed the questionnaire. The knowledge levels of AMR and IPC among nonmedically trained professionals (e.g., social care professionals) were lower than those among medically trained professionals (p = 0.026). In particular regarding the perceived protective value of glove use, insufficient knowledge levels were found. Furthermore, there was a lack of easy-read resources and useful information regarding IPC and AMR, for both healthcare professionals as well as people with disabilities. The majority of the participants (> 90%) reported that AMR and IPC need more attention within the disability care sector, but paradoxically, only 38.5% mentioned that they would like to receive additional information and training about IPC, and 72.5% would like to receive additional information and training about AMR.

CONCLUSION

Although the importance of AMR and IPC is acknowledged by professionals working in ID-LTCFs, there is room for improvement in regards to appropriate glove use and setting-specific IPC and hygiene policies. As nonmedically trained professionals comprise most of the workforce within ID-LTCFs, it is also important to evaluate their needs. This can have a substantial impact on developing and implementing AMR, AMS and/or IPC guidelines and policies in ID-LTCFs.

Evaluation of an Infection surveillance program in residential aged care facilities in Victoria, Australia

BACKGROUND

Infection surveillance is a key element of infection prevention and control activities in the aged care sector. In 2017, a standardised infection surveillance program was established for public residential aged care services in Victoria, Australia. This program will soon be expanded to a national level for all Australian residential aged care facilities. It has not been evaluated since its inception.

METHODS

The current study aimed to evaluate the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP), to understand its performance and functionality. A mixed methods evaluation was performed using the Updated Guidelines for Evaluating Public Health Surveillance Systems developed by the United States Centers for Disease Control and Prevention as a framework. VICNISS staff who coordinate and manage the ACIIP were invited to participate in interviews. Residential aged care staff who use the program were invited to participate in a survey. Document analysis was also performed.

RESULTS

Four VICNISS staff participated in the interviews and 38 aged care staff participated in the survey. The ACIIP is stable and able to be adapted quickly to changing definitions for infections. Users found the system relatively easy to use but have difficulties after the long intervals between data entry year on year. VICNISS staff provide expert guidance which benefits users. Users appreciated the benefit of participating and many use the data for improving local practice.

CONCLUSIONS

The ACIIP is a usessful state-wide infection surveillance program for aged care. Further development of data validation, IT system capacity and models for education and user support will be required to support future scalability.

Impact of dry hydrogen peroxide on environmental bioburden reduction in a long-term care facility

BACKGROUND

Environmental infection transmission is a perennial problem in long-term care facilities (LTCFs), exacerbated by shared living arrangements, residents with cognitive deficits, staffing shortages, and suboptimal cleaning and disinfection. This study evaluates the impact of dry hydrogen peroxide (DHP), as a supplement to manual decontamination, on bioburden within an LTCF neurobehavioral unit.

METHODS

In this prospective environmental cohort study utilizing DHP in an LTCF's 15-bed neurobehavioral unit, 264 surface microbial samples (44 per time point) were collected in 8 patient rooms, 2 communal areas on 3 consecutive days pre-DHP deployment and on days 14, 28, and 55 post-DHP deployments. The microbial reduction was evaluated by characterizing bioburden as total colony-forming units in each sampling site pre- and post-DHP deployment. Volatile organic compound levels were also measured in each patient area on all sampling dates. Multivariate regression was used to analyze microbial reductions associated with DHP exposure, controlling for sample and treatment sites.

RESULTS

A statistically significant relationship was detected between exposure to DHP and surface microbial load (P ≤ .00001). Additionally, the average volatile organic compound level postintervention was significantly lower than baseline levels (P = .0031).

CONCLUSIONS

DHP can significantly reduce surface bioburden in occupied spaces, potentially enhancing infection prevention, and control efforts in LTCFs.

The Effects of an Advanced Air Purification Technology on Environmental and Clinical Outcomes in a Long-Term Care Facility

BACKGROUND

Long-term care facilities (LTCFs) are constantly working to reduce sources of infectious pathogens to improve resident care. LTCF residents are particularly susceptible to health care-associated infections (HAIs), many of which originate from the air. An advanced air purification technology (AAPT) was designed to comprehensively remediate volatile organic compounds (VOCs) and all airborne pathogens including all airborne bacteria, fungi, and viruses. The AAPT contains a unique combination of proprietary filter media, high-dose ultraviolet germicidal irradiation, and high-efficiency particulate air (HEPA) filtration.

METHODS

The AAPT was installed in an LTCF's heating, ventilation, and air-conditioning ductwork and 2 floors were studied: the study floor with comprehensive AAPT remediation and HEPA filtration and the control floor with only HEPA filtration. VOC loading and airborne and surface pathogen loading were measured in 5 locations on both floors. Clinical metrics such as HAI rates were also studied.

RESULTS

There was a statistically significant 98.83% reduction in airborne pathogens, which are responsible for illness and infection, an 89.88% reduction in VOCs, and a 39.6% reduction in HAIs. Surface pathogen loading was reduced in all locations except 1 resident room where the detected pathogens were linked to direct touch.

CONCLUSIONS

The removal of airborne and surface pathogens by the AAPT led to a dramatic reduction in HAIs. The comprehensive removal of airborne contaminants has a direct positive impact on resident wellness and quality of life. It is critical that LTCFs incorporate aggressive airborne purification methods with their current infection control protocols.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities

BACKGROUND

Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia.

METHODS

This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework.

RESULTS

Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice.

CONCLUSION

Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

Colonization of Residents and Staff of an Italian Long-Term Care Facility and an Adjacent Acute Care Hospital Geriatrics Unit by Multidrug-Resistant Bacteria

In 2022, we undertook a point prevalence screening study for Enterobacterales with extended-spectrum β-lactamases (ESBLs), high-level AmpC cephalosporinases and carbapenemases, and also methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) in a long-term care facility (LTCF) and the associated acute-care hospital Geriatrics unit in Bolzano, Northern Italy. Urine samples and rectal, inguinal, oropharyngeal, and nasal swabs were plated on selective agar plates. Metadata of the patients, including demographic data, were collected, and risk factors for colonization were determined. ESBL, AmpC, carbapenemase, and quinolone resistance genes were investigated by the HybriSpot 12 PCR AUTO System. The following colonization percentages by multidrug-resistant (MDR) bacteria have been found in LTCF residents: all MDR organisms, 59.5%; ESBL producers, 46.0% (mainly CTX-M-type enzymes); carbapenemase producers, 1.1% (one Klebsiella pneumoniae with KPC-type); MRSA, 4.5%; VRE, 6.7%. Colonization by MDR bacteria was 18.9% for LTCF staff and 45.0% for Geriatrics unit patients. Peripheral vascular disease, the presence of any medical device, cancer, and a Katz Index of 0 were significant risk factors for colonization of LTCF residents by MDR bacteria in univariate and/or multivariate regression analysis. To conclude, the ongoing widespread diffusion of MDR bacteria in the LTCF suggests that efforts should be strengthened on MDR screening, implementation of infection control strategies, and antibiotic stewardship programs targeting the unique aspects of LTCFs. ClinicalTrials.gov ID: 0530250-BZ Reg01 30/08/2022.

Memory-efficient low-compute segmentation algorithms for bladder-monitoring smart ultrasound devices

Post-operative urinary retention is a medical condition where patients cannot urinate despite having a full bladder. Ultrasound imaging of the bladder is used to estimate urine volume for early diagnosis and management of urine retention. Moreover, the use of bladder ultrasound can reduce the need for an indwelling urinary catheter and the risk of catheter-associated urinary tract infection. Wearable ultrasound devices combined with machine-learning based bladder volume estimation algorithms reduce the burdens of nurses in hospital settings and improve outpatient care. However, existing algorithms are memory and computation intensive, thereby demanding the use of expensive GPUs. In this paper, we develop and validate a low-compute memory-efficient deep learning model for accurate bladder region segmentation and urine volume calculation. B-mode ultrasound bladder images of 360 patients were divided into training and validation sets; another 74 patients were used as the test dataset. Our 1-bit quantized models with 4-bits and 6-bits skip connections achieved an accuracy within [Formula: see text] and [Formula: see text], respectively, of a full precision state-of-the-art neural network (NN) without any floating-point operations and with an [Formula: see text] and [Formula: see text] reduction in memory requirements to fit under 150 kB. The means and standard deviations of the volume estimation errors, relative to estimates from ground-truth clinician annotations, were [Formula: see text] ml and [Formula: see text] ml, respectively. This lightweight NN can be easily integrated on the wearable ultrasound device for automated and continuous monitoring of urine volume. Our approach can potentially be extended to other clinical applications, such as monitoring blood pressure and fetal heart rate.

Comparison of antibiotic resistance rates and outcomes among older adult patients with urinary tract infections living in long- term care hospitals and the community

OBJECTIVE

In this study, we compared the proportion of antibiotic resistance between patients who visited the emergency department (ED) with urinary tract infection (UTI) from long-term care hospitals (LTCH), which is a type of long-term care facilities (LTCF) and the community. We assessed the resulting difference in prognosis.

METHOD

Older adults who visited the ED between January and December 2019 and were diagnosed with UTI were divided into community residents and LTCH residents. We investigated the antibiotics sensitivity rates, end of therapy (EOT), and the patient's outcomes were evaluated.

RESULTS

The antibiotic resistance rate was higher in LTCH residents. LTCH residents had a higher in hospital mortality rate compared to community residents. EOT was found to be longer, and admission rate and in-hospital mortality rate were also higher in LTCH residents.

CONCLUSION

LTCF residents had a higher rate of antibiotic resistance and a poor prognosis.

Gut colonization with vancomicyn-resistant enterococci among patients with hematologic malignancies

BACKGROUND

Vancomycin-resistant enterococci (VRE) are well known agents that colonize the gastrointestinal tract of immunocompromised patients, especially those with hematologic malignancies. The aim of the current study was to determine the incidence of and risk factors for colonization with VRE among patients with hematologic malignancies.

MATERIALS

For a nine-month period, all patients admitted to the Hematology ward at University Hospital in Pleven, Bulgaria who had hematologic malignancy and duration of hospitalization of more than 48 h were screened for colonization with VRE. The data collected from patients and their medical records during the entire hospital stay included: demographic characteristics, clinical information and information about all antimicrobials used. A longitudinal study was used to assesses the risk factors and statistical analysis was performed using SPSS version 27.0.

RESULTS

A total of 119 patients were enrolled in the study. Colonization with VRE was established in 18 of them. One patient carried two species, resulting in a total of 19 VRE: 12 Enterococcus gallinarum, 4 Enterococcus casseliflavus, 2 Enterococcus faecium and 1 Enterococcus faecalis. VanA phenotype, with high-level resistance of vancomycin (MIC ≥ 256 μg/ml) and teicoplanin (MIC = 96 μg/ml), was demonstrated by one E. faecium, which carried vanA. The other E. faecium and E. faecalis expressed low-level resistance to vancomycin (MICs: 8 μg/ml and 12 μg/ml), susceptibility to teicoplanin (MICs = 0.5 μg/ml) and vanB was detected. All E. gallinarum and E. casseliflavus showed low-level resistance to vancomycin and susceptibility to teicoplanin. E. gallinarum strains were positive for vanC1 and E. casseliflavus for vanC2. Only two patients were colonized with vanA or vanB enterococci and the rest 16 were positive for vanC. The univariate analysis revealed that patient's age (70-79 years; p = 0.025) and multiple myeloma (p = 0.001) are risk factors for VRE acquisition among the investigated patients. In addition, the multivariate analysis confirmed that patient's age (70-79 years) is an independent risk factor for VRE colonization.

CONCLUSIONS

Our results showed that 15.1% of patients with hematologic malignancies were colonized with VRE. There was a distinct prevalence of vanC enterococci. Among the analyzed risk factors, advanced age and multiple myeloma contributed to VRE acquisition.

Impact of Multidisciplinary Collaborative Intervention on Isolation Implementation in Prevention and Control of Multi-drug Resistance Infection

OBJECTIVE

Contact precautions, especially the initiation of isolation, are important measures to prevent and control multidrug-resistant organisms (MDROs). However, the implementation in clinical practice remains weak. This study aimed to analyze the impact of multidisciplinary collaborative intervention on isolation implementation in multidrug-resistant infection, and determine the factors that affect the implementation of isolation measures.

METHODS

A multidisciplinary collaborative intervention related to isolation was conducted at a teaching tertiary hospital in central China on November 1, 2018. The information of 1338 patients with MDRO infection and colonization at 10 months before and after the intervention was collected. Then, the issuance of isolation orders was retrospectively analyzed. Univariate analysis and multivariate logistic regression analysis were performed to analyze the factors that affected the isolation implementation.

RESULTS

The overall issuance rate of isolation orders was 61.21%, which increased from 33.12% to 75.88% (P<0.001) after the implementation of the multidisciplinary collaborative intervention. The intervention (P<0.001, OR=0.166) was a promoting factor for the issuance of isolation orders, in addition to the length of stay (P=0.004, OR=0.991), department (P=0.004), and microorganism (P=0.038).

CONCLUSION

The isolation implementation remains far lower than policy standards. Multidisciplinary collaborative interventions can effectively improve the compliance to isolation measures implemented by doctors, thereby promoting the standardized management of MDROs, and providing reference for further improving the quality of hospital infection management.

Interventions to Increase Patient Safety in Long-Term Care Facilities-Umbrella Review

INTRODUCTION

Patient safety in long-term care is becoming an increasingly popular subject in the scientific literature. Organizational problems such as shortages of medical staff, insufficient numbers of facilities or underfunding increase the risk of adverse events, and aging populations in many countries suggests that these problems will become more and more serious with each passing year. The objective of the study is to identify interventions that can contribute to increasing patient safety in long-term care facilities.

METHOD

A systematic review of secondary studies was conducted in accordance with the Cochrane Collaboration guidelines. Searches were conducted in Medline (via PubMed), Embase (via OVID) and Cochrane Library. The quality of the included studies was assessed using AMSTAR2.

RESULTS

Ultimately, 10 studies were included in the analysis. They concerned three main areas: promoting safety culture, reducing the level of occupational stress and burnout, and increasing the safety of medication use. Promising methods that have an impact on increasing patient safety include: preventing occupational burnout of medical staff, e.g., by using mindfulness-based interventions; preventing incidents resulting from improper administration of medications, e.g., by using structured methods of patient transfer; and the use of information technology that is more effective than the classic (paper) method or preventing nosocomial infections, e.g., through programs to improve the quality of care in institutions and the implementation of an effective infection control system.

CONCLUSIONS

Taking into account the scientific evidence found and the guidelines of institutions dealing with patient safety, it is necessary for each long-term care facility to individually implement interventions aimed at continuous improvement of the quality of care and patient safety culture at the level of medical staff and management staff.

Aging in Place:

While aging in place is preferred by the vast majority of adults and can bring a host of psychological and physical benefits, older adults require community support in order to age in place safely and with dignity. In this commentary, we review the demographic changes and characteristics of older adults nationally and in Delaware, highlight some of the benefits and challenges to aging in place, and discuss the individual and system-level strategies that are needed to help older adults successfully age in place. Finally, we provide an overview of one creative solution that addresses instrumental and social needs among individuals aging in place with chronic illness.

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Mothers' hygiene experiences in confinement centres: A cohort study

Introduction

Ethnic Malaysian Chinese used to observe the 1-month postpartum confinement period at home and many families would engage a traditional postpartum carer to help care for the mother and newborn. A recent trend has been the development of confinement centres (CCs) which are private non-healthcare establishments run by staff not trained in health care. Concerns about hygiene in CCs arose after infections were reported. We describe the practice of hand hygiene observed in CCs, the availability of resources for hygiene, and the prevalence of health-related problems in CCs.

Methods

This is a cohort study of ethnic Chinese mothers intending to breastfeed their healthy infants. They were recruited post-delivery along with a comparison group who planned to spend their confinement period at home. After their 1-month confinement period, they were contacted for a structured telephone interview about their experience. To avoid any alteration in behaviour, mothers were not told at recruitment that they had to observe hygiene practices. Multiple logistic regression was used to assess the effect of place of confinement on rates of infant health problems.

Results

Of 187 mothers, 88(47%) went to 27 different CCs while 99(53%) stayed at home. Response rates for the 1-month interviews were 88%(CC) versus 97%(home). Mothers in CC group stayed in one to four-bedded rooms and 92% of them had their baby sleeping separately in a common nursery described to have up to 17 babies at a time; 74% of them spent less than six hours a day with their babies; 43% noticed that CC staff had inadequate hand hygiene practices; 66% reported no hand basins in their rooms; 30% reported no soap at hand basins; 28% reported inexperienced or inadequate staff and 4% reported baby item sharing. Among the mothers staying at home, 35% employed a traditional postpartum carer for her baby; 32% did not room-in with their babies, but only 11% spent less than 6 hours a day with their babies. Of mothers who employed traditional postpartum carers, 32% did not know if their carer washed hands after changing diapers and 18% reported that their carer did not. Health problems that were probably related to infection (HPRI) like fever and cough were similar between the groups: 14%(CC) versus 14%(home) (p = 0.86). Multiple logistic regression did not show that CCs were a factor for HPRI: aOR 1.28 (95% CI 0.36 to 4.49). Three mothers reported events that could indicate transmission of infection in CCs.

Conclusion

We found unsatisfactory hygiene practices in CCs as reported by mothers who spent their confinement period there. Although we were not able to establish any direct evidence of infection transmission but based on reports given by the mothers in this study, it is likely to be happening. Therefore, future studies, including intervention studies, are urgently needed to establish an appropriate hygiene standard in CCs as well as the best method to implement this standard. Training CC staff with hygiene knowledge so that they can be empowered to contribute to the development of these standards would be important.

Risk factors for methicillin-resistant Staphylococcus aureus colonization and infection in patients with human immunodeficiency virus infection: A systematic review and meta-analysis

OBJECTIVE

To investigate the potential factors affecting methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in patients with human immunodeficiency virus (HIV) infection.

METHODS

A systematic search of publications listed in electronic from inception up to August 2020 was conducted. A random-effects model was used to calculate odds ratio (OR) with 95% confidence interval (CI).

RESULTS

A total of 31 studies reporting 1410 MRSA events in 17 427 patients with HIV infection were included. Previous hospitalization (OR 1.80; 95% CI 1.37, 2.36), previous antibiotic therapy (OR 2.69; 95% CI 2.09, 3.45), CD4+ count (OR 1.79; 95% CI 1.41, 2.28), Centers for Disease Control and Prevention classification of stage C (OR 2.66; 95% CI 1.80, 3.93), skin lesions (OR 2.02; 95% CI 1.15, 3.55), intravenous device use (OR 2.61; 95% CI 1.59, 4.29) and an MRSA colonization history (OR 6.30; 95% CI 2.50, 15.90) were significantly associated with an increased risk of MRSA colonization and infection. Antiretroviral therapy (OR 0.71; 95% CI 0.50, 0.99) and current antibiotic use (OR 0.13; 95% CI 0.05, 0.32) were significantly associated with a reduced risk of MRSA colonization and infection.

CONCLUSION

MRSA colonization and infection in HIV-infected patients is associated with a number of risk factors.

Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities

Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

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.

Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region

IMPORTANCE

Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement.

OBJECTIVE

To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California.

DESIGN, SETTING, AND PARTICIPANTS

An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses.

EXPOSURES

Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities.

MAIN OUTCOMES AND MEASURES

MRSA and CRE prevalence and number of new carriers (ie, transmission events).

RESULTS

Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events).

CONCLUSIONS AND RELEVANCE

The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study

BACKGROUND

Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment.

METHODS

We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment.

RESULTS

Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44).

CONCLUSION

In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

Knowledge, Attitudes, and Practices of Pediatric Long-term Care Facility Staff Regarding Infection Control for Acute Respiratory Infections and Influenza Vaccination

We surveyed clinical staff and on-site teachers working at pediatric long-term care facilities regarding prevention and control of acute respiratory infections and influenza in staff and residents. We uncovered knowledge gaps, particularly among teachers and clinical staff working <5 years at sites, thereby elucidating areas for targeted staff education.

Multidrug-Resistant Bacterial Infections in Geriatric Hospitalized Patients before and after the COVID-19 Outbreak: Results from a Retrospective Observational Study in Two Geriatric Wards

The impact of the COVID-19 pandemic on multidrug-resistant (MDR) bacteria is unknown. The purpose of this study was to assess prevalence, etiology, and association with mortality of MDR bacteria in older adult patients before and after the first peak of the COVID-19 pandemic in Italy. An observational retrospective study was conducted in two geriatric wards of the Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano, and of the INRCA, IRCCS, Ancona, in the Marche Region, Italy, from December 2019 to February 2020 and from May to July 2020. A total of 73 patients (mean age 87.4 ± 5.9, 27.4% men) and 83 cultures (36 pre-COVID-19 and 47 post-COVID-19) were considered. Overall, 46 cultures (55.4%) reported MDR bacteria (50% in pre- and 59.6% in post-COVID-19 period, p = 0.384). MDR bacteria in bloodstream significantly increased in post-COVID-19 period (68.8% vs. 40.0% p = 0.038) and MDR bacteria in urine did not change (51.6 vs. 54.8%, p = 0.799). Escherichia coli was the main MDR bacterium in pre-COVID-19, p = 0.082 and post-COVID-19, p = 0.026. Among patients with MDR infection, in-hospital mortality was 37.5% and 68.8% in pre- and post-COVID-19, respectively (p = 0.104), and mortality at 30 days was higher in post-COVID-19 period (78.9% vs. 27.3%, p = 0.012). An increased number of MDR bacteria in bloodstream and mortality after MDR infection have been observed in the post-COVID-19 period.

Aging, Frailty, and the Microbiome-How Dysbiosis Influences Human Aging and Disease

The human gut microbiome is a collection of bacteria, protozoa, fungi, and viruses that coexist in our bodies and are essential in protective, metabolic, and physiologic functions of human health. Gut dysbiosis has traditionally been linked to increased risk of infection, but imbalances within the intestinal microbial community structure that correlate with untoward inflammatory responses are increasingly recognized as being involved in disease processes that affect many organ systems in the body. Furthermore, it is becoming more apparent that the connection between gut dysbiosis and age-related diseases may lie in how the gut microbiome communicates with both the intestinal mucosa and the systemic immune system, given that these networks have a common interconnection to frailty. We therefore discuss recent advances in our understanding of the important role the microbiome plays in aging and how this knowledge opens the door for potential novel therapeutics aimed at shaping a less dysbiotic microbiome to prevent or treat age-related diseases.

Association between length of residence and prevalence of MRSA colonization among residents in geriatric long-term care facilities

Background

A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization has been reported among residents in geriatric long-term care facilities (LTCFs). Some studies indicate that MRSA might be imported from hospitals into LTCFs via resident transfer; however, other studies report that high MRSA prevalence might be caused by cross-transmission inside LTCFs. We aimed to assess which factors have a large impact on the high MRSA prevalence among residents of geriatric LTCFs.

Methods

We conducted a cohort study among 260 residents of four geriatric LTCFs in Japan. Dividing participants into two cohorts, we separately analyzed (1) the association between prevalence of MRSA carriage and length of LTCF residence (Cohort 1: n = 204), and (2) proportion of residents identified as MRSA negative who were initially tested at admission but subsequently identified as positive in secondary testing performed at ≥2 months after their initial test (Cohort 2: n = 79).

Results

Among 204 residents in Cohort 1, 20 (9.8%) were identified as positive for MRSA. Compared with residents identified as MRSA negative, a larger proportion of MRSA-positive residents had shorter periods of residence from the initial admission (median length of residence: 5.5 vs. 2.8 months), although this difference was not statistically significant (p = 0.084). Among 79 residents in Cohort 2, 60 (75.9%) were identified as MRSA negative at the initial testing. Of these 60 residents, only one (1.7%) had subsequent positive conversion in secondary MRSA testing. In contrast, among 19 residents identified as MRSA positive in the initial testing, 10 (52.6%) were negative in secondary testing.

Conclusions

The prevalence of MRSA was lower among residents with longer periods of LTCF residence than among those with shorter periods. Furthermore, few residents were found to become MRSA carrier after their initial admission. These findings highlight that MRSA in LTCFs might be associated with resident transfer rather than spread via cross-transmission inside LTCFs.

Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care

An outbreak of SARS-CoV-2 in a skilled nursing facility (SNF) can be devastating for residents and staff. Difficulty identifying asymptomatic and presymptomatic cases and lack of vaccination or treatment options make management challenging. We created, implemented, and now present a guide to rapidly deploy point-prevalence testing and 3-tiered cohorting in an SNF to mitigate an outbreak. We outline key challenges to SNF cohorting.

Investigation of varicella outbreak among residents and healthcare workers in psychiatric hospital- Saudi Arabia

Outbreak is an infection control challenge in health care setting especially when it occurs in a special setting as psychiatric hospitals. Objectives: Investigate and control an outbreak of varicella among patients and healthcare workers (HCWs) in a psychiatric hospital of Saudi Arabia. Methods: A multidisciplinary team of different specialties assigned to assess the situation, confirm the diagnosis, identify the causes and put an action plan to deal with such a situation. Results: The team investigated the varicella outbreak as per the Ministry of Health's (MOH) outbreak guidelines. Multiple risk factors contributed to this outbreak as the location of the outbreak in a psychiatric hospital, breaches in the hospital infection control program. Conclusion: Investigation of this outbreak was conducted as per MOH and CDC definitions and guidelines. Outbreak control plan was instituted and successfully implemented including enforcement of infection control program, the establishment of an employee health program, basic infection control orientation programs.

Implementation of a Urinary Tract Infection Treatment Protocol to Improve Prescribing Practices in the Long-Term Care Facility of a Veteran’s Healthcare System

Urinary tract infections (UTIs) are a commonly diagnosed problem in long-term care facilities (LTCFs), but antimicrobial treatment is often incorrectly prescribed. Although bacterial resistance to antimicrobials commonly used for UTIs, such as trimethoprim/sulfamethoxazole and fluoroquinolones, has been dramatically increasing, they are still commonly prescribed. The purpose of this project was to determine if implementation of a standard treatment protocol for UTIs, which emphasized correct UTI diagnosis and use of nitrofurantoin and cefpodoxime/ceftriaxone as empiric therapy per the institutional antibiogram, changed clinician prescribing practices. This quasi-experimental model utilized two years of pre-intervention and two years of post-intervention data. Three hundred patient encounters were included. Antibiotics prescribed in the pre-intervention period included: trimethoprim/sulfamethoxazole (32%), ciprofloxacin (14%), amoxicillin (13%), levofloxacin (9%), cefpodoxime (9%), ceftriaxone (8%), amoxicillin/clavulanate (5%), nitrofurantoin (4%), and other (6%). By contrast, antibiotics prescribed in the post-intervention period included: cefpodoxime (46%), nitrofurantoin (30%), ceftriaxone (10%), trimethoprim/sulfamethoxazole (8%), amoxicillin/clavulanate (1%), and other (5%). These differences in prescribed drug between the pre-intervention and post-intervention encounters were statistically significant (p < 0.001). Overall, appropriate empiric treatment was prescribed in only 48/217 encounters (22%) during the pre-intervention period, but this increased to 73/83 encounters (88%) in the post-intervention period (p < 0.001). The results indicate that the treatment protocol was successful in changing prescribing practices and decreasing the use of inappropriate antimicrobials at the LTCF.

Renovation in hospitals: a case study on the use of control cubes for local repairs in health-care facilities

Purpose

The purpose of this study is to evaluate the effectiveness of the control cubes for dust control in health-care facilities. Research shows that more than 80% of pathogenic agents in hospitals are spread into the air, where they either remain airborne or deposit on the surface. At the same time, renovation and repair activities, including regular maintenance, are a necessity in active health-care facilities and a multitude of studies have documented their impact on indoor air quality. The dust that is generated by construction activities may potentially carry pathogenic agents, varying from coarse particles (≤10 µm, PM10) to fine particles (≤2.5 µm, PM2.5), including airborne bacteria, and fungal spores linked to high patient mortality in immune-compromised patients.

Design/methodology/approach

This study measures the impact and effectiveness of one such preventative measure, namely, the control cube (CC), on air quality during renovation and repair. CC is a temporary structure, typically made from stainless steel, around the local repair zone to minimize the spread of dust and potential microorganisms. The current paper presents a comparative analysis to identify the effectiveness of a CC equipped with the high-efficiency particulate filtration (HEPA) filter in a hospital setting by simulating construction renovation and repair work.

Findings

A baseline was established to measure the effectiveness of CCs and the impact of negative pressure on the indoor air quality in a hospital during simulated renovation work. Results showed that CCs are very effective in minimizing the spread of dust due to construction activities in the hospital. However, it is imperative to ensure that the air inside the CC is cleaned via filtration.

Originality/value

CCs are very effective, and this paper investigates the best approach for facility managers to implement this strategy.

High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect"

OBJECTIVE

Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).

DESIGN

Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.

SETTING

Twenty-eight NHs in Southern California from 2016 to 2017.

PARTICIPANTS

NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.

METHODS

Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).

RESULTS

A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.

CONCLUSIONS AND IMPLICATIONS

In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

Application of tools to monitor environmental conditions, identify exposures, and inform decision-making to improve infection prevention and control practices in Malawian maternity wards

Healthcare-acquired infections (HAIs) contribute to maternal and neonatal morbidity and mortality, especially in low- and middle-income countries (LMICs). Deficient environmental health (EH) conditions and infection prevention and control (IPC) practices in healthcare facilities (HCFs) contribute to the spread of HAIs, but microbial sampling of sources of contamination is rarely conducted nor reported in low-resource settings. The purpose of this study was to assess EH conditions and IPC practices in Malawian HCFs and evaluate how EH deficiencies contribute to pathogen exposures and HAIs, and to provide recommendations to inform improvements in EH conditions using a mixed-methods approach. Thirty-one maternity wards in government-run HCFs were surveyed in the three regions of Malawi. Questionnaires were administered in parallel with structured observations of EH conditions and IPC practices and microbial testing of water sources and facility surfaces. Results indicated significant associations between IPC practices and microbial contamination. Facilities where separate wards were not available for mothers and newborns with infections and where linens were not used for patients during healthcare services were more likely to have delivery tables with surface contamination (relative risk = 2.23; 1.49, 3.34). E. coli was detected in water samples from seven (23%) HCFs. Our results suggest that Malawian maternity wards could reduce microbial contamination, and potentially reduce the occurrence of HAIs, by improving EH conditions and IPC practices. HCF staff can use the simple, low-cost EH monitoring methods used in this study to incorporate microbial monitoring of EH conditions and IPC practices in HCFs in low-resource settings.

Surveillance of infections in long-term care facilities (LTCFs): The impact of participation during multiple years on health care-associated infection incidence

We studied trends in the incidence of health care-associated infections (HAIs) in LTCFs between 2009 and 2015 and determined the effect of participation in our network. Elder-care physicians reported weekly the number of cases of influenza-like illness, gastroenteritis, (probable) pneumonia, urinary tract infections (UTIs) and all-cause mortality. Trends in the incidence of infection and mortality in relation to LTCF characteristics were calculated using multilevel univariate and multivariate logistic regression. Thirty LTCF participated for 3 years or more, 16 for 2 years and the remaining 12 LTCF for 1 year. During the study period, the median number of beds decreased from 158 to 139, whereas the percentage of residents with private bedrooms increased from 14% to 87%. UTIs were the most frequently reported infections, followed by (probable) pneumonia and gastroenteritis. Adjusted for calendar year and season, we observed a statistically significant decrease in the incidence of influenza-like illness (odds ratio (OR) = 0.8, P < 0.01) and (probable) pneumonia (OR = 0.8, P < 0.01) for each extra year an LTCF participated. Although there are other likely contributors, such as more private rooms and enhanced infection control measures, the decreasing trend of HAI in LTCFs participating in surveillance implies that surveillance is a valuable addition to current strategies to optimise infection control.

A research proposal testing a new model of ambulation activity among long-term care residents with dementia/cognitive impairment: the study protocol of a prospective longitudinal natural history study

Background

Excessive and patterned ambulation is associated with falls, urinary tract infections, co-occurring delirium and other acute events among long-term care residents with cognitive impairment/dementia. This study will test a predictive longitudinal data model that may lead to the preservation of function of this vulnerable population.

Methods/design

This is a single group, longitudinal study with natural observations. Data from a real-time locating system (RTLS) will be used to objectively and continuously measure ambulation activity for up to 2 years. These data will be combined with longitudinal acute event and functional status data to capture patterns of change in health status over time. Theory-driven multilevel models will be used to test the trajectories of falls and other acute conditions as a function of the ambulation activity and demographic, functional status, gait quality and balance ability including potential mediation and/or moderation effects. Data-driven machine learning algorithms will be applied to run screening of the high dimensional RTLS data together with other variables to discover new and robust predictors of acute events.

Discussion

The findings from this study will lead to the early identification of older adults at risk for falls and the onset of acute medical conditions and interventions for individualized care.

Hospital Influenza Admissions as a Harbinger for Nursing Home Influenza Cases

OBJECTIVES

To determine temporal associations of local measures of influenza morbidity and mortality by the Centers for Disease Control and Prevention (CDC) with influenza hospitalizations in nursing home residents.

DESIGN

Retrospective, longitudinal panel study.

SETTING AND PARTICIPANTS

Long-stay nursing home residents, aged 65 years or older in 823 nursing homes from 2011 to 2015.

MEASURES

CDC-reported rates of influenza and pneumonia mortality and laboratory-confirmed influenza hospitalizations. We compared the CDC measures to nursing home resident hospitalizations due to (1) all-cause, (2) a primary diagnosis of respiratory or circulatory illness, and (3) a primary diagnosis of pneumonia or influenza based on Medicare Part A Claims data.

RESULTS

Our final sample included 273,743 unique residents in 819 nursing homes in 108 cities. National laboratory-confirmed influenza-associated hospitalizations for the group aged 65 and older occurred 0 to 1 week prior to nursing home resident influenza-related hospitalizations (Spearman ρ = 0.54). CDC-reported influenza hospitalizations occurred 3 weeks prior to CDC-reported influenza deaths (ρ = 0.59). Nursing home resident influenza hospitalizations occurred 2 weeks before local CDC-reported pneumonia and influenza deaths occurred (ρ = 0.44).

CONCLUSIONS/IMPLICATIONS

Publicly reported CDC measures correlate well with nursing home hospitalizations for pneumonia and influenza. Rates of laboratory-confirmed influenza hospitalizations (as reported by the CDC) may be a useful surrogate for nursing home influenza outbreaks but should be considered along with local indicators of disease outbreaks. Early community signals could be clinically leveraged as a trigger for increased infection control measures in nursing homes.

Nurses' knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study

Background

Effective hand hygiene is one of the most important measures for protecting nursing home residents from nosocomial infections. Infections with multi-resistant bacteria’s, associated with healthcare, is a known problem. The nursing home setting differs from other healthcare environments in individual and organisational factors such as knowledge, behaviour, and attitude to improve hand hygiene and it is therefore difficult to research the influential factors to improve hand hygiene. Studies have shown that increasing knowledge, behaviour and attitudes could enhance hand hygiene compliance in nursing homes. Therefore, it may be important to examine individual and organisational factors that foster improvement of these factors in hand hygiene. We aim to explore these influences of individual and organisational factors of hand hygiene in nursing home staff, with a particular focus on the function of role modelling by nursing managers.

Methods

We conducted a mixed-methods study surveying 165 nurses and interviewing 27 nursing managers from nursing homes in Germany.

Results

Most nurses and nursing managers held the knowledge of effective hand hygiene procedures. Hygiene standards and equipment were all generally available but compliance to standards also depended upon availability in the immediate work area and role modelling. Despite a general awareness of the impact of leadership on staff behaviour, not all nursing managers fully appreciated the impact of their own consistent role modelling regarding hand hygiene behaviours.

Conclusion

These results suggest that improving hand hygiene should focus on strategies that facilitate the provision of hand disinfectant materials in the immediate work area of nurses. In addition, nursing managers should be made aware of the impact of their role model function and they should implement this in daily practice.

Randomized Noninferiority Trial of Cefoperazone-Sulbactam versus Cefepime in the Treatment of Hospital-Acquired and Healthcare-Associated Pneumonia

Cefoperazone, a third-generation cephamycin with broad-spectrum antibacterial activity and the ability to permeate bacterial cell membranes, is active against commonly encountered multidrug-resistant pathogens for hospital-acquired pneumonia (HAP) and health care-associated pneumonia (HCAP). To clarify the clinical effects of cefoperazone-sulbactam in the treatment of HAP and HCAP, we conducted an open-label, randomized, noninferiority trial that recruited patients aged ≥18 years suffering HAP/HCAP. Participants were randomly assigned to the cefoperazone-sulbactam (2 g of each per 12 h) or cefepime (2 g per 12 h) arm. Clinical and microbiological responses were evaluated at early posttherapy and test-of-cure visits. Recruited patients were allocated to subpopulations for intent-to-treat (n = 154), per-protocol (n = 147), and safety (n = 166) analyses. Intent-to-treat analysis demonstrated that (i) at the early posttherapy visit, 87.3% of patients receiving cefoperazone-sulbactam and 84.3% of patients receiving cefepime achieved clinical improvement or cure (risk difference of 3.0%; 95% confidence interval [CI], -9.0% to 15.0%), and (ii) at the test-of-cure visit, 73.1% of patients receiving cefoperazone-sulbactam and 56.8% of patients receiving cefepime were assessed as cured (risk difference of 16.3%; 95% CI, 0.0% to 33.0%). These results indicated the noninferiority of cefoperazone-sulbactam to cefepime, which was confirmed by per-protocol analysis. The chest radiographic consolidation/infiltration resolution rate, microbiological eradiation rate, and percentage of adverse events were comparable in both groups. Serious adverse events were rare, and none was judged to be related to the study drugs. Cefoperazone-sulbactam at 2 g every 12 h was noninferior to cefepime at 2 g every 2 h for patients with HCAP.

Effectiveness of antibiotics versus ibuprofen in relieving symptoms of nosocomial urinary tract infection: A comparative study

BACKGROUND AND PURPOSE

Antibiotic therapy has been the mainstay of treatment in the management of hospitalized patients with nosocomial urinary tract infection (UTI); however, its use is associated with an increase in resistance and high cost. Ibuprofen showed effectiveness in relieving symptoms of UTI, but its superiority is questionable. The goal of this study was to compare the effectiveness of antibiotics against ibuprofen in relieving symptoms of UTI and to identify factors that affect symptom relief.

METHODS

This study was conducted in three public hospitals in Jordan. Patients with nosocomial UTI were assigned to either antibiotics or ibuprofen. Symptoms of UTI were assessed at the time of initiation of treatment and 5 days later.

CONCLUSIONS

Antibiotics were more effective in relieving symptoms of UTI than Ibuprofen. Comorbidity and length of hospitalization affected symptom relief during the treatment of UTI.

IMPLICATION FOR PRACTICE

Nurse practitioners in the clinical settings can take an active role in helping patients with UTI to achieve relief of symptoms by supporting the use of antibiotics over ibuprofen in symptom resolution.

Environmental disinfection with photocatalyst as an adjunctive measure to control transmission of methicillin-resistant Staphylococcus aureus: a prospective cohort study in a high-incidence setting

Background

Environmental disinfection with continuously antimicrobial surfaces could offer superior control of surface bioburden. We sought to decide the efficacy of photocatalyst antimicrobial coating in reducing methicillin-resistant Staphylococcus aureus (MRSA) acquisition in high incidence setting.

Methods

We performed prospective cohort study involving patients hospitalized in medical intensive care unit. A titanium dioxide-based photocatalyst was coated on high touch surfaces and walls. Five months of pre-intervention data were compared with five months of post-intervention data. The incidence rates of multidrug-resistant organism acquisition and the rates of hospital-acquired blood stream infection, pneumonia, urinary tract infection, and Clostridium difficile–associated diseases were compared using Cox proportional hazards regression analysis.

Results

In total, 621 patients were included. There was significant decrease in MRSA acquisition rate after photocatalyst coating (hazard ratio, 0.37; 95% confidence interval, 0.14–0.99; p = 0.04). However, clinical identification of vancomycin-resistant Enterococcus spp. and multidrug-resistant Acinetobacter baumannii did not decrease significantly. The hazard of contracting hospital-acquired pneumonia during the intervention period compared to baseline period was 0.46 (95% confidence interval, 0.23–0.94; p = 0.03).

Conclusions

In conclusion, MRSA rate was significantly reduced after photocatalyst coating. We provide evidence that photocatalyst disinfection can be an adjunctive measure to control MRSA acquisition in high-incidence settings.

Trial registration

ISRCTN Registry (ISRCTN31972004). Registered retrospectively on November 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3555-1) contains supplementary material, which is available to authorized users.

Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach

The emergence and spread of extensively multidrug-resistant organisms is a public health crisis, and long-term care settings have been identified as a reservoir for the cultivation of these organisms. Long-term care settings are now taking on increasingly ill residents with complicated medical problems, indwelling devices, and significant healthcare exposure, all of which are considered risk factors selecting for resistant organisms. Despite this, guidelines addressing infection prevention procedures in long-term care remain vague, and implementation of these guidelines is challenging, largely due to staff turnover, limited resources, knowledge gaps, and lack of organizational support. Human factors engineering approaches have emerged as an important innovation to address patient safety issues and develop interventions in the healthcare work system (ie, tools and technologies, tasks, organization, physical environment) that support human performance, which, in turn, lead to improvements in processes (eg, compliance with infection prevention guidelines) and outcomes (eg, reduced infection rates). We propose the concept of using the methods and approaches from the scientific field of human factors engineering to address the unique challenges of implementing infection prevention in the long-term care setting.

A recipe for antimicrobial stewardship success: Using intervention mapping to develop a program to reduce antibiotic overuse in long-term care

OBJECTIVE

To better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program.

METHODS

Information on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change.

RESULTS

In total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders.

CONCLUSIONS

The use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.

Identifying safe practices for use of the urinary leg bag drainage system in the postacute and long-term care setting: An integrative review

BACKGROUND

In the postacute and long-term care setting, the practice of changing the indwelling urinary catheter large sterile drainage bag to a small-size leg drainage bag is intended to maintain a person's mobility, dignity, and comfort. There is scant evidence that assesses the impact of intermittent use of a leg bag on frequency of urinary tract infection since this breaks the closed urinary drainage system.

METHODS

We reviewed research published between 1993 and 2014 for the answers to 20 practice questions developed by experts and long-term care clinicians on the risks and benefits, cleaning, connection, and storage of reusable leg bags.

RESULTS

Seventeen of the 26 publications and studies provided varying advice on the risk of breaking the closed system and on practices for changing, disinfecting, and storing leg bags between uses. Thirteen of 20 practice questions were answered by ≥1 publications, few of which were evidence based.

CONCLUSIONS

We identified the existence of low-level evidence that leg bags pose no evident, disproportionate risk of infection compared with maintaining a closed system. The lack of uniformity in evidence in the literature suggests aseptic technique should guide practice. Available evidence suggests that aseptic technique should guide practice.

The effect of timing of oseltamivir chemoprophylaxis in controlling influenza A H3N2 outbreaks in long-term care facilities in Manitoba, Canada, 2014-2015: a retrospective cohort study

Objective

This study examined the effect of the timing of administration of oseltamivir chemoprophylaxis for the control of influenza A H3N2 outbreaks among residents in long-term care facilities (LTCFs) in Manitoba, Canada, during the 2014–2015 influenza season.

Methods

A retrospective cohort study was conducted of all LTCF influenza A H3N2 outbreaks (n=94) using a hierarchical logistic regression analysis. The main independent variable was how many days passed between the start of the outbreak and commencement of oseltamivir chemoprophylaxis. The dependent variable was whether each person in the institution developed influenza-like illness (yes or no).

Results

Delay of oseltamivir chemoprophylaxis was associated with increased odds of infection in both univariate (t=5·41; df=51; P<·0001) and multivariable analyses (t=6·04; df=49; P<·0001) with an adjusted odds ratio of 1.3 (95% confidence interval [CI], 1·2–1·5) per day for influenza A H3N2.

Conclusions

The sooner chemoprophylaxis is initiated, the lower the odds of secondary infection with influenza in LTCFs during outbreaks caused by influenza A H3N2 in Manitoba. For every day that passed from the start of the outbreak to the initiation of oseltamivir, the odds of a resident at risk of infection in the facility developing symptomatic infection increased by 33%.

Antimicrobial photodynamic therapy mediated by methylene blue and potassium iodide to treat urinary tract infection in a female rat model

Drug-resistant urinary tract infections (UTIs) are difficult and sometimes impossible to treat. Many UTIs are caused by uropathogenic Escherichia coli (UPEC). We developed an intact rat model of UTI, by catheterizing female rats and introducing a bioluminescent UPEC strain into the female rat bladder which lasted for up to six days. We recently showed that antimicrobial photodynamic inactivation (aPDI) of a bacterial infection mediated by the well-known phenothiazinium salt, methylene blue (MB) could be strongly potentiated by addition of the non-toxic salt potassium iodide (KI). In the intact rat model we introduced MB into the bladder by catheter, followed by KI solution and delivered intravesicular illumination with a diffusing fiber connected to a 1 W 660 nm laser. Bioluminescent imaging of the bacterial burden was carried out during the procedure and for 6 days afterwards. Light-dose dependent loss of bioluminescence was observed with the combination of MB followed by KI, but recurrence of infection was seen the next day in some cases. aPDT with MB + KI gave a significantly shorter duration of infection compared to untreated controls. aPDT with MB alone was the least effective. No signs of aPDT damage to the bladder lining were detected. This procedure to treat urinary tract infections without antibiotics by using already approved pharmaceutical substances (MB and KI) may have clinical applicability, either initially as a stand-alone therapy, or as an adjunct to antibiotic therapy by a rapid and substantial reduction of the bacterial burden.

Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: A cluster randomized trial

BACKGROUND

The aim of this study was to assess the impact of a multifaceted hand hygiene (HH) program on the infectious risk in nursing homes (NHs).

METHODS

This was a 2-arm cluster randomized trial; French NHs were allocated randomly to the intervention (13 NHs) or control (13 NHs) groups. The intervention consisted of implementing a bundle of HH-related measures over 1 year, including increased availability of alcohol-based handrub, HH promotion, staff education, and local work groups. The primary end point was the incidence rate of acute respiratory infections and gastroenteritis reported in the context of clustered cases episodes. Secondary end points were mortality, hospitalization, and antibiotic prescription rates.

RESULTS

Baseline characteristics did not differ between groups. The overall handrub consumption was higher in the intervention group over the 1-year intervention period. Because of underreporting, data on the primary end points were of insufficient quality for analysis. Hospitalizations did not differ between the 2 groups. However, the intervention group showed significantly lower mortality (2.10 vs 2.65 per 100 residents per month, respectively; P = .003) and antibiotic prescriptions (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < .001). These results were confirmed by the longitudinal multivariate analysis adjusted for NH and resident characteristics and for seasonality (mortality rate ratio, 0.76).

CONCLUSIONS

A multifaceted HH intervention may have a short-term impact on mortality in NHs. Nevertheless, other strategies may remain necessary to reduce morbidity.

Urinary tract infection surveillance in residential aged care

OBJECTIVES

The aim of this research was to determine the prevalence of urinary tract infections (UTIs) in 2 aged care homes (ACHs) and examine the extent to which presumed UTIs met the 2012 McGeer infection surveillance definitions.

DESIGN

Retrospective observational study.

SETTING

Two ACHs: a 30-bed facility and a 100-bed facility PARTICIPANTS: Residents of the 2 ACHs diagnosed with UTI.

METHODS

A retrospective review was conducted of UTIs clinically diagnosed at the 2 facilities over a 16-month period, utilizing surveillance and microbiologic data, resident progress notes, and medication charts. This data was reviewed to determine how many diagnosed UTIs met the revised McGeer definitions.

RESULTS

Overall, 119 UTIs were diagnosed in 57 residents over 16 months. Only 7 of the diagnosed UTIs met the McGeer definitions. Forty-seven did not meet the clinical evidence, 17 did not meet the microbiologic evidence, and 48 did not meet either surveillance criteria.

CONCLUSIONS

This study demonstrated the disparity between the clinical diagnosis of UTI and the surveillance definitions for UTI, and highlights the limitations of the McGeer definitions in those with cognitive or communication deficits. There is an urgent need for antimicrobial stewardship programs and education in the ACH setting.

Preventing Respiratory Viral Transmission in Long-Term Care: Knowledge, Attitudes, and Practices of Healthcare Personnel

OBJECTIVE

To examine knowledge and attitudes about influenza vaccination and infection prevention practices among healthcare personnel (HCP) in a long-term-care (LTC) setting.

DESIGN

Knowledge, attitudes, and practices (KAP) survey.

SETTING

An LTC facility in St Louis, Missouri.

PARTICIPANTS

All HCP working at the LTC facility were eligible to participate, regardless of department or position. Of 170 full- and part-time HCP working at the facility, 73 completed the survey, a 42.9% response rate.

RESULTS

Most HCP agreed that respiratory viral infections were serious and that hand hygiene and face mask use were protective. However, only 46% could describe the correct transmission-based precautions for an influenza patient. Correctly answering infection prevention knowledge questions did not vary by years of experience but did vary for HCP with more direct patient contact versus less patient contact. Furthermore, 42% of respondents reported working while sick, and 56% reported that their coworkers did. In addition, 54% reported that facility policies made staying home while ill difficult. Some respondents expressed concerns about the safety (22%) and effectiveness (27%) of the influenza vaccine, and 28% of respondents stated that they would not get the influenza vaccine if it was not required.

CONCLUSIONS

This survey of staff in an LTC facility identified several areas for policy improvement, particularly sick leave, as well as potential targets for interventions to improve infection prevention knowledge and to address HCP concerns about influenza vaccination to improve HCP vaccination rates in LTCs.

Infect Control Hosp Epidemiol 2017;38:1449–1456

How are nursing homes cleaned? Results of a survey of 6 nursing homes in Southeast Michigan

This brief report details 2 surveys that were conducted to better understand current cleaning practices in 6 nursing home facilities in Southeast Michigan. Each facility's environmental services supervisor answered questions regarding cleaning policy and procedures, roles and responsibilities of the staff, and frequency of education and training; one environmental services employee from each facility answered questions addressing education and training, employer evaluation and feedback, and workload. We identify gaps in knowledge and behaviors and note substantial variations in cleaning practices.