Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003

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.

COVID-19 Cycle Threshold/Cycle Number Testing at a Community Living Center

BACKGROUND

COVID-19 imposes a special risk to the nursing home population, including community living centers (CLCs) for veterans. Cycle threshold/cycle number (CT/CN) values obtained by serial reverse transcriptase polymerase chain reaction (RT-PCR) testing could yield valuable information about viral load and potential infectiousness. Serial testing for COVID-19 with CT/CN correlates in a nursing home population during an outbreak has not yet been reported in the literature.

METHODS

A retrospective review of serial RT-PCR testing for COVID-19 during an outbreak at a CLC was performed from March 28 to April 4, 2020, with follow-up of identified patients until November 10, 2020. Testing was performed on the Abbot m2000 or Cepheid platform.

RESULTS

Of 80 patients tested, 25 (31%) were positive for COVID-19. CT/CN values corresponded to the infection course as expected.

CONCLUSIONS

Repeat testing for COVID-19 accompanied by CT/CN values could provide clinical and epidemiologic information about the likely stage of the patients' disease course, which may aid public health measures and clinical management.

Analysis of Continuous Prevalence Survey of Healthcare-Associated Infections Based on the Real-Time Monitoring System in 2018 in Shandong in China

Background

Healthcare-associated infection (HAI) is a serious threat to the safety of patients worldwide. The prevalence survey is widely used to explore and study the characteristics of HAI. However, the annual continuous prevalence survey of hospital-acquired infections has not been reported so far.

Aim

This study is aimed at examining the occurrence and development trend of HAIs dynamically and accurately.

Methods

An annual continuous HAI prevalence survey based on the real-time monitoring system was conducted in representative hospitals from different regions in Shandong in China. Findings. A total of 64 hospitals participated in the survey, and 2,741,433 patients were monitored in 2018. The highest prevalence of HAIs in Shandong was 3.83% (February 15), the lowest was 1.85% (February 28), and the average was 2.45%. The percentile distribution of prevalence of HAIs in this study was as follows: P10, 2.23%; P25, 2.31%; P50, 2.41%; P75, 2.55%; and P90, 2.73%.

Conclusion

This study dynamically and accurately showed the occurrence and development trend of HAIs in Shandong in 2018. The results of this study can be used as a reference for the HAI prevalence survey in various medical institutions in Shandong and provide the basis for the regional HAI prevention and control strategy.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals?

Background

Norwegian nursing homes (NHs) have over the last 10 years increasingly applied the use of parenteral treatment, which in turn allows more broad-spectrum use of antibiotics. Previous studies from Norwegian NHs have for the most part not described parenteral formulations.

Objectives

To describe systemic antibiotic use in Norwegian NHs.

Methods

Thirty-seven NHs in the county of Østfold, Norway, were invited to participate in this retrospective cross-sectional study. Associated pharmacies provided sales data for systemic antibiotic use for the participating NHs for 1 year (October 2015 to October 2016). General institutional characteristics were collected through a questionnaire.

Results

Thirty-four NHs participated in the study. Mean use of antibiotics was 9.5 DDD/100 bed days (range 0.6–30.9 DDD/100 bed days). Oral antibiotics accounted for 83% and parenteral antibiotics for 17% of the total antibiotic use. Of parenteral antibiotics, ampicillin was most used (31.1%) followed by cefotaxime (17.7%) and penicillin G (16.6%). The proportion of antibiotics compliant with guideline recommendations was 60%. Being a short-term NH was associated with increased antibiotic use, with an unstandardized coefficient of 13.1 (95% CI 4.2–21.9; P = 0.005).

Conclusions

We found a high level of total and parenteral antibiotic use compared with previous studies from Norwegian NHs. Data showed wide variations in total antibiotic use and that only a moderate proportion of the antibiotic use was considered guideline compliant. This highlights the necessity of further implementation strategies regarding the national guidelines for antibiotic use in NHs.

Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis

OBJECTIVES

There are high levels of inappropriate antibiotic use in long-term care facilities (LTCFs). Our objective was to examine evidence of the effectiveness of interventions designed to reduce antibiotic use and/or inappropriate use in LTCFs.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and CINAHL from 1997 until November 2018.

ELIGIBILITY CRITERIA

Controlled and uncontrolled studies in LTCFs measuring intervention effects on rates of overall antibiotic use and/or appropriateness of use were included. Secondary outcomes were intervention implementation barriers from process evaluations.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently applied the Cochrane Effective Practice and Organisation of Care group's resources to classify interventions and assess risk of bias. Meta-analyses used random effects models to pool results.

RESULTS

Of include studies (n=19), 10 had a control group and 17 had a high risk of bias. All interventions had multiple components. Eight studies (with high risk of bias) showed positive impacts on outcomes and included one of the following interventions: audit and feedback, introduction of care pathways or an infectious disease team. Meta-analyses on change in the percentage of residents on antibiotics (pooled relative risk (RR) (three studies, 6862 residents): 0.85, 95% CI: 0.61 to 1.18), appropriateness of decision to treat with antibiotics (pooled RR (three studies, 993 antibiotic orders): 1.10, 95% CI: 0.64 to 1.91) and appropriateness of antibiotic selection for respiratory tract infections (pooled RR (three studies, 292 orders): 1.15, 95% CI: 0.95 to 1.40), showed no significant intervention effects. However, meta-analyses only included results from intervention groups since most studies lacked a control group. Insufficient data prevented meta-analysis on other outcomes. Process evaluations (n=7) noted poor intervention adoption, low physician engagement and high staff turnover as barriers.

CONCLUSIONS

There is insufficient evidence that interventions employed to date are effective at improving antibiotic use in LTCFs. Future studies should use rigorous study designs and tailor intervention implementation to the setting.

Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus in long-term care facilities in eastern Taiwan

Objective:

The prevention of infections is crucial in long-term care programs. Investigations of the occurrence and sources of pathogens in long-term care facilities (LTCFs) are still lacking, especially in eastern Taiwan. In this study, we conducted a surveillance of two common pathogens, Acinetobacter baumannii (AB) and methicillin-resistant Staphylococcus aureus (MRSA), in LTCFs in Hualien.

Materials and Methods:

Pathogenic assays including isolation, identification, and antimicrobial susceptibility tests were conducted for AB and MRSA at LTCFs in Eastern Taiwan. Staphylococcal cassette chromosome mec typing assays were done to understand the relatedness of clonal strains of MRSA.

Results:

All AB-positive samples in the LTCFs were mainly from water-rich samples and were drug susceptible. Our data indicated that the AB strains from LTCFs were similar to those from Puzi River watersheds in Taiwan, which were not drug resistant to commonly used antibiotics. On the other hand, the drug resistance analysis of MRSA indicated that the genotypes from the LTCFs were similar to those from nearby hospitals. Eight strains of MRSA were isolated from four LTCFs, of which five were identified as hospital-acquired strains according to SSCmed typing assays.

Conclusion:

These findings suggest that MRSA in LTCFs might propagate from hospitals and could be transmitted between hospitals and LTCFs. Health authorities should be aware of this risk. The long-term follow-up of MRSA is recommended in local medical institutions as well as in LTCFs for correlative analysis.

Incidence of pneumonia in nursing home residents with dementia in the Netherlands: an estimation based on three differently designed studies

Pneumonia leads to considerable morbidity and mortality in nursing home residents with dementia. We assessed pneumonia incidence based on data from three different studies: (1) real-time national surveillance of healthcare-associated infections in nursing home residents in 2009-2015; (2) a randomized controlled trial in 2012-2015 to assess effects of a practical guideline in nursing home residents with dementia and pneumonia; and (3) a study in 2007-2010 to assess quality of dying in newly admitted nursing home residents with dementia. In national surveillance data, pneumonia incidence was calculated separately for psychogeriatric and somatic beds, as a proxy for residents with and without dementia. Weekly pneumonia incidence was significantly lower per 1000 psychogeriatric beds (3·9; 95% confidence interval (CI) 3·2-4·6) compared with 1000 somatic beds (5·7; 95% CI 5·1-6·3). Annual incidence per 1000 psychogeriatric beds was similar in national surveillance (range 78·9-117·1) and the trial (range 71·0-94·3), and significantly higher in newly admitted dementia residents (range 267·3-363·2). The incidence was highest during the first months after admission when compared with residents with longer stay. In conclusion, follow-up of pneumonia in newly admitted dementia residents may result in higher incidence, possibly due to higher risk in this population.

Antimicrobial Use in Patients with Dementia: Current Concerns and Future Recommendations

Infections are common in people with dementia, and antibiotic use is widespread, albeit highly variable, across healthcare settings and countries. The few studies conducted to date that consider the appropriateness of antibiotic prescribing specifically for people with dementia focus on people with advanced dementia and suggest that much of the prescribing of antibiotics for these patients may be potentially inappropriate. We suggest that clinicians must consider a number of factors to determine appropriateness of antimicrobial prescribing for people with dementia, including the risks and benefits of assessing and treating infections, the uncertainty regarding the effects of antibiotics on patient comfort, goals of care and treatment preferences, hydration status, dementia severity and patient prognosis. Future research should examine antibiotic prescribing and its appropriateness across the spectrum of common infections, dementia severities, care settings and countries, and should consider how antibiotic therapy should be considered in discussions regarding treatment preferences, goals of care and/or advance care planning between clinicians, patients and families.

Antibiotic use and infections in nursing homes

BACKGROUND

Residents in nursing homes have a higher risk of developing infections that require antibiotic treatment than elderly people living at home. Use of antibiotics may cause adverse effects and result in the development of antimicrobial resistance.

MATERIAL AND METHOD

Data on healthcare-associated infections and antibiotic use in 540 Norwegian nursing homes were retrieved from the Norwegian Institute of Public Health’s point prevalence survey in the spring of 2016. Based on information on drug, dosage and indication, we assessed whether the use of antibiotics for the treatment of UTIs was in accordance with the National Guidelines for the Use of Antibiotics in Primary Care.

RESULTS

UTI was the most commonly occurring type of infection, with a prevalence of 2.7 %. Prescription of first-line antibiotics accounted for approximately 60 % of the prescriptions for treatment of this illness. Choice of drug, dosage and microbiological testing when treating lower UTIs was not always in accordance with the national guidelines. The study showed widespread use of methenamine in Norwegian nursing homes.

INTERPRETATION

The survey indicates that compliance with the national guidelines when treating lower UTIs could be improved with regard to the choice of drug, dosage and microbiological testing. Norwegian nursing home doctors should also consider whether their use of methenamine is in accordance with national and international recommendations.

Prevention and control of catheter-associated urinary tract infections - implementation of the recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) in nursing homes for the elderly in Frankfurt am Main, Germany

Introduction: Urinary tract infections range among the most frequent infections not only in hospital patients but also in residents of long-term care facilities for the elderly. Urinary catheters are the greatest risk factor for urinary tract infections. In the guidance paper on the “prevention of infections in nursing homes” (2005) as well as in the updated recommendations for the “prevention and control of catheter-associated urinary tract infections” (2015), the Commission for Hospital Hygiene and Infection Prevention (KRINKO) has recommended adequate preventive measures. In 2015, the implementation of these KRINKO recommendations was investigated.

Method: All of Frankfurt’s 40 nursing homes were evaluated using a checklist based on the KRINKO recommendations. The evaluation included assessing the availability of operating instructions, appropriate indications for the placement of catheters etc. Age, sex and duration of catheterization, as well as current and previous infections within the past 6 months were documented for every resident with a catheter.

Results: In 35 (87.5%) of the nursing homes, operating instructions for the handling of urinary tract catheters were available. The decision as to whether a catheter is indicated is made by physicians, while its placement is often delegated to the nursing service. Typically, silicon catheters are used. In three-quarters of the nursing homes, regular intervals of 4–6 weeks for changing catheters were reported. On the respective survey day, 7.3% of the residents were catheterized. On the survey day, 3.6% (4.2%) and in the previous 6 months a total of 28% (28.9%) of the residents had a urinary tract infection (prevalence of antibiotic therapy in parentheses). Ciprofloxacin was used most often followed by cefuroxime and cotrimoxazole.

Discussion: In the current evaluation, fewer nursing home residents were catheterized than in previous years and the rate of urinary tract infections was low. This indicates an increasingly cautious and apparently appropriate usage of urinary tract catheters. Also, the prevalence of antibiotic therapy was low for residents with urinary tract catheters (4.2%). However, broad spectrum antibiotics are still preferentially administered (particularly quinolones), which may favor the high rate of colonization with ESBL-producing bacteria and 3MRGN. Given this background, a coordinated approach including resistance-based antibiotic stewardship appears increasingly important in nursing homes and other health care facilities.

Assessing the Burden of Healthcare-Associated Infections through Prevalence Studies: What Is the Best Method?

Objective.

To explore differences in the prevalence of healthcare-associated infections (HAIs) according to survey methodology.

Design.

Repeated point and period prevalence survey strategies.

Setting.

University-affiliated primary and tertiary care center.

Methods.

Analysis of data collected from 2006 to 2012 from annual HAI prevalence surveys using definitions proposed by the US Centers for Disease Control and Prevention. The study design allowed the analysis of the same data in the format of a point or a period prevalence survey.

Results.

Pooled point and period HAI prevalence was 7.46% and 9.84% (+32%), respectively. This additional 32% was mainly attributable to infections of the lower respiratory tract (2.42% vs 3.20% [+32%]) and the urinary tract (1.76% vs 2.62% [+49%]). Differences in surgical site infections (1.02% vs 1.20% [+19%]) and bloodstream infections (0.76% vs 0.86% [+13%]) were smaller. HAI prevalence for the point and period methodology in acute and long-term care were 7.47% versus 9.38 (+26%) and 8.37% versus 11.89% (+42%), respectively. Differences were stable over time. Focusing on the 4 major HAIs (respiratory tract, urinary tract, surgical site, and bloodstream infections) misses one-quarter of all HAIs.

Conclusions.

More HAIs are identified by the period prevalence method, especially those of shorter duration (lower respiratory and urinary tract), which would make this method more suitable to be used in long-term care. Results of the 2 study methods cannot be benchmarked against each other.

Infect Control Hosp Epidemiol2014;35(6):674–684

Antimicrobial susceptibility patterns: a three-year surveillance study in a rehabilitation setting

INTRODUCTION

To analyze the susceptibility patterns in a rehabilitation center.

METHODS

This retrospective observational study was conducted between January 2011 and to January 2013 at Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Kingdom of Saudi Arabia. Number of the patients, specimen type, pathogen detected and antibiogram were entered in database for analysis using Inter System Track care software.

RESULTS

A total of 4525 isolates were available from 5148 patients. Most (74%) of the isolates were from urine samples and were due to Eschericia coli (49.8%), Enterococcus faecalis (15%) and (Proteous mirabilis(9.49%). Of all the isolates, Eschericia coli was the commonest (49.8%) Gram negative organism, while(Stahylococcus aureus was the commonest (51%) among Gram positive organisms. The most effective antibiotics against Pseudomonas aeroginosa were ciprofloxacin and gentamicin. Meropenem shows excellent activity against Gram negative bacteria. Methicillin resistant Staphylococcus aureus (MRSA) was susceptible to Vancomycin and Rifampicin in 97% and 85% cases.

CONCLUSION

A high incidence of urinary tract infections caused by Eschericia coli, Enterococcus faecalis and Proteous mirabilis was reported. Staphylococcus aureus was the commonest pathogen isolated from infected bed sores.

Infections and antimicrobial use among institutionalized residents in Hungary: increasing need of microbiological surveillance

As a result of the age-related changes, more elders live in long-term care facilities (LTCFs). Due to their susceptibility, infections and excess use of antimicrobials are common. The aim was to estimate the burden of infections and antimicrobial use in Hungarian LTCFs in order to increase the attention given to the prevention. European-wide point prevalence survey was conducted between April and May 2013. For each resident who had a signs and symptoms of an infection and/or treated with an antibacterial for systemic use a resident questionnaire was completed. Descriptive statistics were used to present the data. In total, 91 LTCFs with 11,823 residents were selected in this survey. The 252 residents had a sign/symptom of an infection (2.1%) and 156 received antimicrobial (1.3%). Skin and soft tissues (36.5%) was the most frequent infection. However, antimicrobials were mostly prescribed for respiratory tract infections (40.4%). The most common therapeutic antimicrobial agent (97.5%) belonged to the quinolone antibacterials (34.2%). Our results emphasise the need for targeted improvement of antimicrobial use including: reducing the use of quinolone antibacterials in order to prevent the spread of Clostridium difficile and other antimicrobial resistant microorganisms among institutionalized residents.

Black chokeberry juice (Aronia melanocarpa) reduces incidences of urinary tract infection among nursing home residents in the long term--a pilot study

Urinary tract infection (UTI) is a major problem in nursing homes, and the mainstay of treatment is antibiotics. The increasing prevalence of uropathogens resistant to antimicrobial agents has stimulated interest in specific nutrients, for example, cranberries, to prevent recurring UTI. Black chokeberry (Aronia melanocarpa [Michx] Elliott) is a rich source of phenolics, and thus, dietary intake of black chokeberry juice may reduce the incidences of UTI requiring medical treatment. In this pilot study, we examined the frequency of medically treated UTI among residents in 6 nursing homes who were offered black chokeberry juice or a placebo during a 6-month crossover intervention. The residents were offered a placebo drink for a 3-month period followed by chokeberry juice for the next 3 months (group A) or vice versa (group B). The juice was characterized by a high content of total phenolics (715 mg gallic acid equivalent, 100 mL(-1)), including B-type procyanidins, anthocyanins, and chlorogenic acids. Daily intake of chokeberry juice was 156 mL per resident in group A (n = 110) and 89 mL per resident in group B (n = 126). Urinary tract infection comprised 55% of all medically treated infections during the study period. The results revealed no immediate reduction in the frequency of UTI or the total use of antibiotics; however, during the subsequent 3-month period of juice administration, a reduction in antibiotics toward UTI was observed in both groups. The incidence of UTI was reduced by 55% in group A and 38% in group B. No changes in other infections or in use of prophylactics were observed.

Antimicrobial use in Hungarian long-term care facilities: high proportion of quinolone antibacterials

The aim of this survey was to estimate the burden of antimicrobial use and to describe the determinants for antimicrobial use in Hungarian long-term care facilities (LTCFs) in order to increase the attention given to the proper prescription for this vulnerable population. A one-day point-prevalence study was undertaken between April and May 2013. Data on resident treated with an antibacterial, antimycotic or tuberculostatic for systemic use were collected prospectively on a single day in each participating LTCF with over 50 beds. Descriptive statistics were used to present the data. 91 LTCFs with 11,823 residents participated in this survey. 156 residents (1.3%) were given antimicrobials. 96.8% of antimicrobials were mostly prescribed for therapy included urinary tract infections (40.3%), respiratory tract infections (38.4%) and skin and soft tissue infections (13.2%). The most common therapeutic antimicrobials (97.5%) belonged to the ATC J01 class of 'antibacterials for systemic use'. The most important J01 subclasses were J01M quinolone antibacterials (32.7%), J01C beta-lactam antibacterials (25.2%), J01D other beta-lactam antibacterials (11.3%) and J01F macrolides, lincosamides and streptogramins (11.3%). Antimicrobials were mostly prescribed empirically whereas 3.8% was microbiologically documented treatments. 3.2% of all prescribed antimicrobials were prescribed for the prophylaxis of urinary tract infections (60%) and ear, nose, mouth infections (40%). Our results emphasize the need of a national recommendation for good practice in LTCFs in order to avoid inappropriate antimicrobial therapy leading to spread of multidrug resistant pathogens. In addition, continuing education of prescribers on antimicrobial treatment is essential.

Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives

Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of particular concern is the recent emergence of multidrug-resistant organisms among this vulnerable population. Accordingly, antimicrobial stewardship (AMS) programs have started to be introduced into the residential aged care facilities setting to promote judicious antimicrobial use. However, to successfully implement AMS programs, there are unique challenges pertaining to this resource-limited setting that need to be addressed. In this review, we summarize the epidemiology of infections in this population and review studies that explore antibiotic use and prescribing patterns. Specific attention is paid to issues relating to inappropriate or suboptimal antibiotic prescribing to guide future AMS interventions.

Use of antibiotics in nursing homes--surveillance with different methods

BACKGROUND

Residents in nursing homes have a heightened risk of developing infections that should be treated with antibiotics. Inappropriate use of antibiotics may generate drug-related problems and increase resistance. In this study, we describe the use of antibiotics in nursing homes on the basis of prevalence surveys and drug sales statistics.

MATERIAL AND METHODS

Five nursing homes in Oslo participated in two one-day surveys in 2009. All use of systemic antibiotics was registered. The data collection was undertaken according to a protocol developed by the European Surveillance of Antimicrobial Consumption (ESAC) Network and was part of a European study. The nursing homes' drug sales statistics for systemic antibiotics during 2009, distributed by the number of bed days for each nursing home, were estimated. Information on indications for each antibiotic from the prevalence surveys was collated with sales data to achieve an estimate of how the purchased antibiotics were used.

RESULTS

The prevalence surveys showed that more than 8% of the residents received antibiotics. Prophylactic treatment accounted for 33% of the prescriptions. A prevalence of antibiotic use of 10% was estimated from the drug sales statistics. Urinary tract infection was the most frequently registered indication. Pivmecillinam and methenamine were most frequently prescribed and most frequently purchased. Most courses of treatment were prescribed in accordance with the national guidelines for antibiotic use.

INTERPRETATION

The results from the drug sales statistics concurred well with the prevalence surveys, and the methods can thus be relevant for purposes of monitoring the use of antibiotics.

[The challenge of infections and multiresistant bacteria among the elderly living in long-term care facilities]

Healthcare-associated infections not only affect patients in acute care hospitals but also patients in need of long-term care. As the elderly are generally most affected, the demographic change in Germany faces a range of increasing challenges in the field of infection control. The ageing process itself is accompanied by several physiological and pathological changes which may result in an increase in the risk of infectious diseases. Elderly living in long-term care facilities (LTCFs) may in addition be exposed to further risks due to their everyday life in a community, nursing care and the, to some extent, inappropriate use of antibiotics. Bacteria that have become resistant to commonly used antimicrobial agents are meanwhile prevalent in nursing homes. Caregivers often feel left alone when facing the task of achieving a balance between the need for a comfortable familiar environment and the application of infection control measures according to a resolute prevention strategy. This review aims to give an overview about the characteristics of infections among the elderly, especially with respect to long-term care.

Assessing prevalence of antimicrobial use and infections using the minimal data set in Finnish long-term care facilities

Of all residents (n = 12,784) for whom a minimum data set 2.0 form was completed in long-term care facilities (n = 253) using a Resident Assessment Instrument in April and September 2011 in Finland, 16% received antimicrobials, most commonly methenamine (42%) and trimethoprim (24%). The prevalence of urinary tract infections was 8%, wound infection 2%, and pneumonia 2%. Minimum data set form provides a feasible tool for collecting data on antibiotic use and infections in long-term care facilities.

Reduction in inappropriate prevention of urinary tract infections in long-term care facilities

BACKGROUND

Urinary tract infection (UTI) is the most common diagnosis made in prescribing antimicrobials in long-term care facilities (LTCF). The diagnostic criteria for UTI vary among institutions and prescribers. Our aim was to reduce the inappropriate use of antimicrobials in LTCFs.

METHODS

A team comprising infectious disease consultant, infection control nurse, and geriatrician visited all LTCFs for older persons (2,321 patients in 25 primary care hospitals and 39 nursing homes and dementia units) in the Central Finland Healthcare District (population 267,000) during 2004-2005. The site visits consisted of a structured interview concerning patients, ongoing systematic antimicrobials, and diagnostic practices for UTI. Following the visits, regional guidelines for prudent use of antimicrobials in LTCFs were published, and the use of antimicrobials was followed up by an annual questionnaire.

RESULTS

The proportions of patients receiving antimicrobials in 2005, 2006, 2007, and 2008 were 19.9%, 16.9%, 16.2%, and 15.4%, respectively. Most of the antibiotics were used for UTI (range by year, 66.6%-81.1%). From 2005 through 2008, the proportion of patients on antibiotic prophylaxis for UTI decreased from 13% to 6%. The decrease was statistically significant in both types of settings.

CONCLUSION

The visits and guidelines were associated with a reduction in the usage of antimicrobials. To sustain this, UTI surveillance and close collaboration between infection control experts and LTCFs are crucial.

Antimicrobial prescribing in nursing homes in Finland: results of three point prevalence surveys

PURPOSE

The purpose of this study was to analyse the Finnish European Surveillance of Antimicrobial Consumption (ESAC) nursing home (NH) point prevalence surveys' (PPSs) data in detail, i.e. to evaluate the variability in the prevalence of antimicrobial prescription between NHs and its relationship to resident characteristics.

METHODS

All residents present in NHs for ≥ 24 h and receiving systemic antimicrobials on the day of the survey were included. Data on antimicrobials and their indications (prophylaxis or treatment, type of infection) were collected.

RESULTS

Three PPSs were performed: eight NHs participated in April and November 2009 and nine in May-September 2010. In total, there were 5,691 eligible residents (range by survey, 1,706-2,320; range by NH, 60-688), 716 (12.6 %; range by NH, 3.2-33.3 %) of which received at least one antimicrobial and 40 residents received two. The most common indication was prophylaxis (487/5,691, 8.6 %), mainly for urinary tract infection (UTI) (460/487, 94.5 %). Of the residents, 269/5,691 (4.7 %, range by NH, 1.5-6.0 %) were on antimicrobial treatment. UTI (119/269; 44.2 %) was the most common indication for treatment. Methenamine (306/756, 40.5 %) was the most commonly used antimicrobial, followed by trimethoprim (13.6 %) and pivmecillinam (11.0 %). In the eight NHs participating in all three surveys, the prevalence of residents receiving antimicrobials decreased from 16.6 to 9.7 %.

CONCLUSIONS

Antimicrobial use was common in NHs in Finland and most were used for UTI prophylaxis and treatment. The usage, however, varied among NHs and tended to decrease during the surveys. NHs may benefit from antimicrobial stewardship interventions focused on UTI.

Antibiotic use and resistance in long term care facilities

INTRODUCTION

The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance.

METHODS

Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations.

RESULTS

A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship.

CONCLUSION

The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.

Parenteral versus oral administration of systemic antimicrobials in European nursing homes: a point-prevalence survey

BACKGROUND

Residents in long-term care facilities are predisposed to healthcare-associated infections that are likely caused by antimicrobial-resistant micro-organisms. Long-term care facilities are increasingly able to offer parenteral antimicrobial treatment but there are few data on the use and appropriateness of such treatment in this setting. Information on the use of parenteral antimicrobials and associated factors in long-term care facilities is necessary to assess the risks and benefits of this treatment and to support the development of antimicrobial policies aimed at minimizing the emergence and spread of antimicrobial resistance.

OBJECTIVE

The aim of this study was to describe the extent of parenteral and oral antimicrobial use in participating European nursing homes (NHs) and to analyse the resident characteristics and determinants associated with route of antimicrobial administration.

METHODS

Data on resident characteristics and antimicrobials were collected by means of a point-prevalence survey. Logistic regression was used to analyse the data.

RESULTS

Based on data from 21 European countries for 2046 antimicrobial prescriptions, an average of 9.0% (range by country: 0.0-66.7%) of treatment was administered parenterally. Multivariate analysis showed that residents receiving parenteral antimicrobials had greater morbidity, such as increased risk of having a urinary catheter (p < 0.001), a vascular catheter (p < 0.001), impaired mobility (p = 0.007) and disorientation (p = 0.005). Residents receiving parenteral antimicrobials also had been admitted more recently into the NH (p = 0.007). Empirical treatment of respiratory tract infections (RTIs) accounted for the majority of parenteral antimicrobials, while prophylaxis of urinary tract infection (UTI) was the most common indication for oral antimicrobials. Beta-lactam antibacterials (cephalosporins and aminopenicillins) were the predominant classes used.

CONCLUSIONS

Our study showed that risk and care-load factors (i.e. the presence of a urinary or vascular catheter, impaired mobility, disorientation and relatively short length of stay) were associated with parenteral administration of antimicrobials in NHs. Furthermore, both the indication and the class of antimicrobial agent used were associated with administration route. For empirical treatment of RTIs, antimicrobials were most often administered parenterally.

Antimicrobial prescribing in nursing homes in Northern Ireland: results of two point-prevalence surveys

BACKGROUND

In 2005, the European Commission recommended that all member states should establish or strengthen surveillance systems for monitoring the use of antimicrobial agents. There is no evidence in the literature of any surveillance studies having been specifically conducted in nursing homes (NHs) in Northern Ireland (NI).

OBJECTIVE

The aim of this study was to determine the prevalence of antimicrobial prescribing and its relationship with certain factors (e.g. indwelling urinary catheterization, urinary incontinence, disorientation, etc.) in NH residents in NI.

METHODS

This project was carried out in NI as part of a wider European study under the protocols of the European Surveillance of Antimicrobial Consumption group. Two point-prevalence surveys (PPSs) were conducted in 30 NHs in April and November 2009. Data were obtained from nursing notes, medication administration records and staff in relation to antimicrobial prescribing, facility and resident characteristics and were analysed descriptively.

RESULTS

The point prevalence of antimicrobial prescribing was 13.2% in April 2009 and 10.7% in November 2009, with a 10-fold difference existing between the NHs with the highest and lowest antimicrobial prescribing prevalence during both PPSs. The same NH had the highest rate of antimicrobial prescribing during both April (30.6%) and November (26.0%). The group of antimicrobials most commonly prescribed was the penicillins (April 28.6%, November 27.5%) whilst the most prevalent individual antimicrobial prescribed was trimethoprim (April 21.3%, November 24.3%). The majority of antimicrobials were prescribed for the purpose of preventing urinary tract infections (UTIs) in both April (37.8%) and in November (46.7%), with 5% of all participating residents being prescribed an antimicrobial for this reason. Some (20%) antimicrobials were prescribed at inappropriate doses, particularly those which were used for the purpose of preventing UTIs. Indwelling urinary catheterization and wounds were significant risk factors for antimicrobial use in April [odds ratio {OR} (95% CI) 2.0 (1.1, 3.5) and 1.8 (1.1, 3.0), respectively] but not in November 2009 [OR (95% CI) 1.6 (0.8, 3.2) and 1.2 (0.7, 2.2), respectively]. Other resident factors, e.g. disorientation, immobility and incontinence, were not associated with antimicrobial use. Furthermore, none of the NH characteristics investigated (e.g. number of beds, hospitalization episodes, number of general practitioners, etc.) were found to be associated with antimicrobial use in either April or November 2009.

CONCLUSIONS

This study has identified a high overall rate of antimicrobial use in NHs in NI, with variability evident both within and between homes. More research is needed to understand which factors influence antimicrobial use and to determine the appropriateness of antimicrobial prescribing in this population in general and more specifically in the management of recurrent UTIs.

Healthcare-associated infection in Irish long-term care facilities: results from the First National Prevalence Study

BACKGROUND

Prevalence of healthcare-associated infection (HCAI) and antimicrobial use in Irish long-term care facilities (LTCFs) has never been studied.

AIM

To collect baseline data on HCAI prevalence and antibiotic use in Irish LTCFs to inform national LTCF policy and plan future HCAI prevention programmes.

METHODS

A prevalence study of HCAI and antibiotic use was undertaken in Irish LTCFs. Participation was voluntary. Data on HCAI risk factors, signs and symptoms of infection and antimicrobial use were collected prospectively on a single day in each institution.

FINDINGS

Sixty-nine Irish LTCFs participated and 4170 eligible residents were surveyed; 472 (11.3%) had signs/symptoms of infection (266, 6.4%) and/or were on antibiotics (426, 10.2%). A third of residents (1430, 34.3%) were aged ≥85 years and more than half disorientated (2110, 50.6%) with impaired mobility (2101, 50.4%). HCAI prevalence was 3.7% (range: 0-22.2%). The most common HCAI was urinary tract infection (UTI) (62 residents, 40% of HCAI). Presence of a urinary catheter was associated with UTI (P < 0.0000001). Antibiotics were prescribed for treatment (262 residents, 57.8%) and prophylaxis (182 residents, 40.2%) of infection. The most common indication for prophylaxis was UTI prevention (35.8% of total prescriptions). Fourteen (10.2%) residents on UTI prophylaxis had a urinary catheter. The most common indications for therapy included respiratory tract infections (35.1%), UTI (32.1%) and skin infection (21.8%).

CONCLUSION

This study highlights the frequency of prophylactic antimicrobial prescribing and provides an important baseline to inform future preventive strategies.

Indications for antimicrobial prescribing in European nursing homes: results from a point prevalence survey

PURPOSE

In light of the emerging problem with multiresistant microorganisms in nursing homes (NHs), the European Surveillance of Antimicrobial Consumption NH subproject was set up to measure and describe antimicrobial use across Europe. The aim of this paper was to investigate the indications for antimicrobial use and hence identify targets for quality improvement.

METHODS

Data were obtained from a point prevalence survey conducted in 323 NHs across 21 European countries. A resident questionnaire had to be completed for each resident receiving an antimicrobial, collecting data such as compound name and indication for antimicrobial prescribing. Four main indications for antimicrobial use were recorded: nasal decolonisation of methicillin-resistant Staphylococcus aureus (MRSA) carriage with mupirocin, prophylactic, empirical, and microbiologically documented treatments. The latter three treatment types were further subdivided according to the targeted infections.

RESULTS

In total, 1966 residents were treated with 2046 antimicrobials. Empirical treatments were most common (54.4% of all antimicrobial therapies; prevalence: 3.39 per 100 eligible residents), followed by prophylactic (28.8%; prevalence: 1.87%) and microbiologically documented (16.1%; prevalence: 1.01%) regimes. MRSA decolonisation with nasal mupirocin (0.7%; prevalence: 0.02%) was uncommon. Antimicrobials were most frequently prescribed for the prevention or treatment of urinary (49.5%; prevalence: 3.23%) and respiratory (31.8%; prevalence: 1.81%) tract infections. A very high proportion of uroprophylaxis was reported (25.6% of all prescribed antimicrobials; prevalence: 1.67%).

CONCLUSIONS

The indications for antimicrobial prescribing varied markedly between countries. We identified uroprophylaxis as a possible target for quality improvement.

Evaluation of the national surveillance system for point-prevalence of healthcare-associated infections in hospitals and in long-term care facilities for elderly in Norway, 2002-2008

Background

Since 2002, the Norwegian Institute of Public Health has invited all hospitals and long-term care facilities for elderly (LTCFs) to participate in two annual point-prevalence surveys covering the most frequent types of healthcare-associated infections (HAIs). In a comprehensive evaluation we assessed how well the system operates to meet its objectives.

Methods

Surveillance protocols and the national database were reviewed. Data managers at national level, infection control practitioners and ward personnel in hospitals as well as contact persons in LTCFs involved in prevalence data collection were surveyed.

Results

The evaluation showed that the system was structurally simple, flexible and accepted by the key partners. On average 87% of hospitals and 32% of LTCFs participated in 2004-2008; high level of data completeness was achieved. The data collected described trends in the prevalence of reportable HAIs in Norway and informed policy makers. Local results were used in hospitals to implement targeted infection control measures and to argue for more resources to a greater extent than in LTCFs. Both the use of simplified Centers for Disease Control and Prevention (CDC) definitions and validity of data seemed problematic as compliance with the standard methodology were reportedly low.

Conclusions

The surveillance system provides important information on selected HAIs in Norway. The system is overall functional and well-established in hospitals, however, requires active promotion in LTCFs. Validity of data needs to be controlled in the participating institutions before reporting to the national level.

Prevention of urinary tract infections in nursing homes: lack of evidence-based prescription?

Background

Urinary tract infections (UTIs, including upper and lower symptomatic) are the most common infections in nursing homes and prevention may reduce patient suffering, antibiotic use and resistance. The spectre of agents used in preventing UTIs in nursing homes is scarcely documented and the aim of this study was to explore which agents are prescribed for this purpose.

Methods

We conducted a one-day, point-prevalence study in 44 Norwegian nursing homes during April-May 2006. Nursing home residents prescribed any agent for UTI prophylaxis were included. Information recorded was type of agent and dose, patient age and gender, together with nursing home characteristics. Appropriateness of prophylactic prescribing was evaluated with references to evidence in the literature and current national guidelines.

Results

The study included 1473 residents. 18% (n = 269) of the residents had at least one agent recorded as prophylaxis of UTI, varying between 0-50% among the nursing homes. Methenamine was used by 48% of residents prescribed prophylaxis, vitamin C by 32%, and cranberry products by 10%. Estrogens were used by 30% but only one third was for vaginal administration. Trimethoprim and nitrofurantoin were used as prophylaxis by 5% and 4%, respectively.

Conclusions

The agents frequently prescribed to prevent UTIs in Norwegian nursing homes lack documented efficacy including methenamine and vitamin C. Recommended agents like trimethoprim, nitrofurantoin and vaginal estrogens are infrequently used. We conclude that prescribing of prophylactic agents for UTIs in nursing homes is not evidence-based.

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.

Healthcare-acquired infections in rehabilitation units of the Lombardy Region, Italy

BACKGROUND

Little data are available on the frequency and risk factors for infection in patients in rehabilitation units.

METHODS

This was a 2-year retrospective cohort study conducted in 131 rehabilitation units (RUs) of the Lombardy Region, including those for patients requiring musculoskeletal, cardiac, respiratory, neurological and general geriatric rehabilitation. RUs were stratified into three groups by infection rate calculated from administrative data, and a random sample of RUs in each group was selected for analysis. Discharges from these RUs were randomly selected for chart review, and healthcare-acquired infection was confirmed using CDC/NHSN definitions. A logistic regression analysis explored the association among demographic variables of age, sex, type of rehabilitation unit, Charlson comorbidity score, and location prior to RU admission for selected infections.

RESULTS

For the 3,028 discharges from 28 RUs, hospital administrative data had a sensitivity of 0.45 and a positive predictive value of 0.89 to identify infections in the chart review. At least one infection occurred in 14.9% of patient discharges, with 71% of infections being urinary, 8.0% respiratory, and 5% skin and soft tissue. Urinary infection was associated with female sex [odds ratio (OR) 1.48, 95% confidence interval (CI) 1.13-1.93], age 75-85 years (OR 2.21, 95% CI 1.12-4.34), Charlson comorbidity score of ≥3 (OR 1.54, 95% CI 1.10-2.17), and the transfer from acute care (OR 1.45, 95% CI 1.04-2.02). For respiratory infection, male sex (OR 3.06, 95% CI 1.51-6.18), comorbidity score of 1 or 2 (OR 2.16, 95% CI 1.08-4.36), and transfer from a healthcare setting other than an acute care hospital were independent risks (OR 3.14, 95% CI 1.15-8.53).

CONCLUSION

Infections are common in residents of these rehabilitation units, and risk factors may differ with type of infection. The proportion of infections which may be prevented and effective prevention strategies need to be determined.

A prospective study of nosocomial urinary tract infection in hip fracture patients

AIM

To investigate risk factors and consequences of nosocomial urinary tract infection in hip fracture patients.

BACKGROUND

Nosocomial urinary tract infection is a well-known problem in hip fracture patients. There are several risk factors for nosocomial urinary tract infection described in the literature.

DESIGN

Prospective observational study with a descriptive and comparative design.

METHODS

Hip fracture patients were included consecutively between April 2006-March 2007. Excluded were those under 50, having an indwelling urinary catheter, signs of cognitive impairment or additional severe physical problems at the time of admission. To verify nosocomial urinary tract infection, a urine specimen was taken at admission and discharge. Patients with and without nosocomial urinary tract infection were compared.

RESULTS

The study included 86 hip fracture patients, of whom 45 (52·3%) contracted nosocomial urinary tract infection in hospital. Earlier reported risk factors for nosocomial urinary tract infection were not confirmed in this study, with one exception: diabetes. All diabetic patients in the study contracted urinary tract infections. Patients receiving cloxacillin as antibiotic prophylaxis for wound infection contracted UTI less often than other patients. There were no statistical differences between groups with regard to urinary tract infection frequency four months after fracture or with regard to mortality after one year.

CONCLUSION

Diabetes was the only previously known risk factor for nosocomial urinary tract infection confirmed among hip fracture patients in this study. Cloxacillin as antibiotic prophylaxis for surgery seemed to offer a certain protection against nosocomial urinary tract infection.

RELEVANCE TO CLINICAL PRACTICE

Nurses in clinical practice should be aware of the risk of urinary tract infections in hip fracture patients and especially in hip fracture patients with diabetes. Patients given cloxacillin as antibiotic prophylaxis seem less likely to contract nosocomial urinary tract infection.

How are antibacterials used in nursing homes? Results from a point-prevalence prescription study in 44 Norwegian nursing homes

PURPOSE

To describe the use of antibacterials among nursing home residents in Norway according to diagnosis, therapy choice, doses and expected duration of treatment.

METHODS

A one-day point-prevalence study was carried out in 44 Norwegian nursing homes, spring 2006. Use of systemic antibacterials was recorded by indication, antibiotic name, dose and expected length of treatment.

RESULTS

Of the 1473 nursing home residents, 224 (15%) were prescribed antibiotics. 149 (10%) were given antibiotics as prophylaxis, while 85 residents (6%) were treated with an antibiotic for an infection. 10 residents received both prophylaxis and treatment simultaneously. Antibiotics for treatment were in 66% of the cases for urinary tract infections (UTI) and in 20% for respiratory tract infections (RTI) with pivmecillinam and phenoxymethylpenicillin most frequently used, respectively.

CONCLUSIONS

Antibiotics are often used in nursing homes, both as treatment and prophylaxis. The most common infections treated with antibiotics were UTIs, followed by RTIs. Choice of antibacterial, dosage and duration of treatment were in accordance with recommendations in guidelines.

[Infection epidemiology in gerontology centres]

INTRODUCTION

Infection processes in gerontology centres (GC) are one of the main causes of mortality and aggravation of concomitant chronic diseases. An epidemiological surveillance system was set up to find out their magnitude and distribution.

MATERIAL AND METHODS

A prevalence study was conducted during the years 2006-2009 in 4 GCs of the Matia Foundation. Prevalence was measured by making an annual cut-off, recording: infection type, demographic data, risk factors and antibiotic use. The incidence was measured for two years in one GC as a pilot centre, recording: infection type and antibiotic use.

RESULTS

The prevalence in the GCs varied between 4.8% and 6.44%. The infection incidence density in the pilot study was between 3.45-5.77 infections per 1,000 resident days. The most common infection location and in this order were, respiratory, urinary and cutaneous. The incidence of respiratory infection is more statistically significant in the presence of dysphagia, malnutrition and COPD. However, no significant relationship was seen in the incidence of urinary infection with the different risk factors analysed.

CONCLUSIONS

The frequency and repercussions of nosocomial infections in GCs demonstrate the need for intervention plans and the development of adequate prevention measures.

The burden of healthcare‐associated infections in European long‐term care facilities

Since 2006, several projects have been initiated in Europe to describe the distribution and characteristics of infection control programs in long&#x2010;term care facilities and to quantify the burden of infections, antimicrobial resistance, and antimicrobial use in long&#x2010;term care facilities. This article summarizes the results and activities that are underway.

Surgical site infections in adults patients undergoing of clean and contaminated surgeries at a university Brazilian hospital

CONTEXT: Surgical site infections are a risk inherent to surgical procedures, especially after digestive surgeries. They occur up to 30 days after surgery, or up to a year later if a prosthesis is implanted. The Surgical-site Infection Risk Index (SIRI), NISS (National Nosocomial Infection Surveillance) methodology, is a method to evaluate the risk of surgical site infections, which takes into account the potential contamination of the surgery, the patient's health status and surgery duration. OBJECTIVES: To evaluate the correlation between the surgical-site infection risk index score on the 1st day postoperatively, and the development of surgical site infection up to 30 days postoperatively. METHODS: The postoperative surgical site infections (NNIS) was evaluated by following-up in hospital and as an outpatient. The patients followed prospectively were those submitted to elective surgeries, clean (hernioplasties) or contaminated (colorretal), performed by conventional approach at a university hospital, during the period from June 2007 to August 2008. The mean age of the patients was 55.5 years, 133 (65.5%) male; 120 (59.1%) submitted to clean surgeries and 83 (40.9%) contaminated. RESULTS: The global index of surgical site infections was 10.3%; 10 (8.3%) in clean procedures and 111(3.2%) in contaminated ones. Four (19.1%) of the surgical site infections were diagnosed at the time of hospitalization and 17 (80.9%) at post-discharge follow-up. Twelve (57.1%) of the surgical site infections were superficial, 2 (9.5%) deep and 7 (33.3%) at a specific site. Of these, 5 (6.6%) were in patients classified as SIRI 0 (76); 9 (15%) for SIRI 1 (60); 5 (9.1%) for SIRI 2 (55) and 2 (16.7%) for SIRI 3. CONCLUSION: The global index of surgical site infections and its incidence among contaminated procedures are within the expected limits. On the other hand according to SIRI, the surgical site infection indexes are above the expected standards both for the clean and for the contaminated procedures.

Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents

BACKGROUND

many elderly suffer from urinary incontinence and use absorbent pads. Pad use per day (PPD) is a frequently used measure of urinary incontinence. Nursing home residents are often dependent on help from nursing staff to change pads. This study was performed in order to determine whether PPD is a reliable method to quantify urinary incontinence in nursing home residents. Furthermore, the association between urinary tract infections (UTIs), PPD and fluid intake was studied.

METHODS

data were retrieved from a multicentre, prospective surveillance among nursing home residents. Data on the use of absorbent pads, fluid intake and incontinence volumes were collected during 48 h. During a 1-year follow-up period, data on UTIs were collected.

RESULTS

in this study, 153 residents were included, of whom 118 (77%) used absorbent pads. Residents who used absorbent pads were at increased risk of developing UTIs compared to residents who did not use pads (41 vs 11%; P = 0.001). Daily fluid intake was not associated with UTIs (P = 0.46). The number of pad changes showed no correlation with the risk of developing UTIs (P = 0.62). Patients with a given PPD presented a wide range of incontinence volumes.

CONCLUSION

the use of absorbent pads is associated with an increased risk of developing UTIs. PPD and daily fluid intake are not correlated with the risk of developing UTIs. PPD is an unreliable measure of urinary incontinence in nursing home residents.

Nurses' experiences of caring for non-catheterised older infirmed patients: a descriptive study of what nurses actually do?

AIMS

This study aims to explore nurses' experiences of caring for non-catheterised older infirmed patients who had suffered from recurrent urinary tract infection and strategies adopted to prevent and manage the problem.

BACKGROUND

Urinary tract infection is a complex and significant infection affecting frail older patients. Most literature focuses on prescribing treatment to treat the micro-organisms causing the infection, with less emphasis to understand nursing perspectives of caring for frail and highly dependent older patients suffering from this condition.

DESIGN

Qualitative.

METHODS

A qualitative research methodology was conducted in a hospital-based infirmary unit (composing of four wards) in Hong Kong. Fourteen nurses were interviewed using a semi-structured interview guide.

RESULTS

When managing recurrent urinary tract infection of non-catheterised older patients, nurses described the need to promptly recognise the urinary tract infection symptoms and to know the causes of the symptoms before administering any care. These formed the basis for deciding whether the patient's urinary condition should be managed by nurses themselves or be referred to the physician for medical treatment. Based on this initial judgement, subsequent non-invasive measures perceived by nurses to be effective were undertaken to manage the non-medically intervened problem. Ways to improve nurses' existing roles and work practices to better manage recurrent urinary tract infection of non-catheterised older patients were also identified.

CONCLUSION

Nurses working in infirmary wards refocused on the value of providing basic nursing care to manage this emergent and overlooked clinical problem.

RELEVANCE TO CLINICAL PRACTICE

Asymptomatic urinary tract infection cases should continue to receive 'basic urinary tract infection care' on a daily basis, as ignoring these symptoms could bring on adverse consequences. Prior knowledge and experiences acquired by nurses who cared for previously infected patients can assist in the development of interventions, so comparison of different nursing measures is possible to determine which one is the most effective in managing this clinical issue.

Healthcare associated infection in care homes for older people in Scotland: results from a pilot survey

The prevalence of infection in Scottish care homes is currently unknown. The aim of this survey was to estimate the prevalence of infection within a small sample of care homes for older people and to develop and test a methodology for point prevalence surveys which would allow local care home staff to monitor infection in care homes for older people that employ trained nurses.

The pilot survey was undertaken by Health Protection Scotland (HPS) in collaboration with the Care Commission and two volunteer service providers. Data collection within 18 volunteer care homes was undertaken between 6 April 2009 and 1 May 2009. A total of 922 residents from 18 care homes were included. On the day of survey, 87 infections were identified in 86 residents. The prevalence of infection was 9.3%. The most common infections types were urinary tract infections and respiratory tract infections.

The results from this small survey of volunteer care homes have provided valuable insight into the previously unmeasured prevalence of infection in Scottish care homes for older people.

It is hoped that the rollout of a larger scale survey that includes a representative sample of all Scottish care homes can be implemented.

Nursing home-associated infections in Department of Veterans Affairs community living centers

BACKGROUND

Little is known about factors contributing to nursing home-associated infections (NHAIs). We conducted a survey of residents in 133 Department of Veterans Affairs community living centers to determine the roles of indwelling device use, bed locations, and treatment codes on NHAIs.

METHODS

A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted on November 14, 2007.

RESULTS

Among 10,939 residents, 575 had at least one NHAI, for a point prevalence rate of 5.3%. Urinary tract infection, skin infection, asymptomatic bacteriuria, and pneumonia were the most prevalent NHAIs. A total of 2687 residents had one or more indwelling devices; 290 of these also had an NHAI, for a prevalence of 10.8%. In contrast, the prevalence of NHAIs in residents without indwelling devices was 3.5% (P < .0001). Indwelling urinary catheters, percutaneous gastrostomy tubes, peripherally inserted central catheters, and suprapubic urinary catheters were the most commonly used devices. There were 4027 residents in designated units and 6912 residents in dispersed units. The rate of device use was 21.4% in the designated units and 26.4% in the dispersed units (P < .0001). The prevalence of NHAIs was 4.5% in the designated units and 5.7% in the dispersed units (P < .001). Rates of NHAIs and device use varied greatly among the various treatment codes; however, there was a positive correlation between the rates of NHAIs and device use. Stepwise logistic regression analysis of data from long-stay and short-stay skilled nursing care residents revealed that only the presence of an indwelling device, not length of stay or bed location, affected the rate of NHAIs.

CONCLUSION

Indwelling device use, but not bed location or treatment code, was found to be associated with increased rate of NHAIs.

Survey of healthcare-associated infection rates in a nursing home resident population

In this study we assessed the incidence and types of healthcare-associated infection (HCAI) in a nursing home resident population. The influences of home size, resident category, gender and age were also examined. Fifteen homes were recruited and infection rates recorded from 1 October 2006 to 2 December 2006. A rate of 6.04 infections/1000 bed days was recorded for the complete study. Infection rates for the four main categories of infection (number of infections/ 1000 bed days) were respiratory (2.52), urinary (1.87), skin and soft tissue (1.57) and gastrointestinal (0.41). Infection rates for small, medium and large homes were 4.64 (range 1.95—6.51), 5.9 (range 0.49—10.76) and 7.79 (range 5.79—9.39), respectively; however, statistical significance was not achieved ( p = 0.335). Results indicate that respiratory infection rates are higher in larger homes (4.08) than in small (1.88) or medium size homes (2.22). Urinary infection rates were similar in small (1.89), medium (1.88) and large (1.82) homes and skin and soft tissue infections were lower in small homes (0.87) but similar in medium (1.69) and large (1.90) homes. We found a statistically significant relationship between the type of infection acquired and both resident category ( p = 0.017) and gender ( p = 0.005); the relationship between type of infection and age did not reach statistical significance ( p = 0.346).

Infection probability score, APACHE II and KARNOFSKY scoring systems as predictors of infection onset in haematology-oncology patients

AIM

To assess the predictive power of three systems: Infection Probability Score, APACHE II and KARNOFSKY score to the onset of healthcare-associated infections in haematology-oncology patients.

BACKGROUND

The high incidence of healthcare-associated infections is a frequent problem in haematology-oncology patients that affects morbidity and mortality of these patients.

DESIGN

A retrospective surveillance survey.

METHOD

The survey was conducted for seven months in the haematology unit of a general hospital in Greece to assess the predictive power of Infection Probability Score, APACHE II and KARNOFSKY score to the onset of healthcare-associated infections. The sample consisted of 102 hospitalised patients. The diagnosis of healthcare-associated infections was based on the definitions proposed by CDC.

RESULTS

Among the participants, 53 (52%) were males and 49 (48%) were females with a mean age of 53.30 (SD 18.59) years old (range, 17-85 years). The incidence density of healthcare-associated infections (the number of new cases of healthcare-associated infections per 1000 patient-days) was 21.8 infections per 1000 patient-days. Among the 102 patients, healthcare-associated infections occurred in 32 (31.4%) patients who had a total of 48 healthcare-associated infections (47.5%). Among the 38 patients with neutropenia, 26 (68.4%) had more than one healthcare-associated infection. Of the 48 detected healthcare-associated infections, the most frequent type was blood-stream infection (n = 17, 35.4%), followed by Clostridium difficile infection (n = 11, 22.9%) and respiratory tract infection (n = 8, 3.4%). The best cut-off value of Infection Probability Score (IPS) for the prediction of a healthcare-associated infection was 10 with sensitivity of 59.4% and specificity of 74.3%.

CONCLUSIONS

Between the three different prognostic scoring systems, IPS had the best sensitivity in predicting healthcare-associated infections.

RELEVANCE TO CLINICAL PRACTICE

IPS is an effective tool and should be used from nurses for the early detection of haematology-oncology patients who are susceptible to the onset of a healthcare-associated infection.

Early nonspecific signs and symptoms of infection in institutionalized elderly persons: perceptions of nursing assistants

AIM

To explore early nonspecific signs and symptoms of infection in elderly institutionalized individuals as described by nursing assistants.

BACKGROUND

Nonspecific signs and symptoms and lack of specific ones are common in connection with infection in institutionalized elderly persons and contribute to a delayed diagnosis and treatment. In clinical care, the nurse makes notes on the individual status of the patient on a daily basis and decides whether to contact the physician or not. However, in Sweden nursing assistants provide most of the daily care and therefore have many opportunities to observe subtle changes that may be early signs of infection.

METHOD

Data were collected in 2006 from focus interviews with 21 female nursing assistants. The interviews were verbatim transcripted and analysed with qualitative content analysis for manifest content with no preconceived categories.

FINDINGS

Nursing assistants' descriptions of nonspecific signs and symptoms of infection comprised two exclusive categories. Is not as usual described general signs and symptoms of discomfort related to possible infection, such as discomfort, unrestrained behaviour, aggressiveness, restlessness, confusion, tiredness and feebleness, and decreased eating. Seems to be ill was more distinctly related to signs and symptoms of established infection in general terms of fever and pain or more specifically related to pneumonia, urinary tract infection, skin infection, cold and eye infection.

CONCLUSION

Nursing assistants have a keen observational ability to detect early signs that might help to confirm suspected infections in elderly nursing home residents early on. Whether or not the cited categories are actual early signs and symptoms of infectious disease needs to be further investigated.