Prevalence of hospital-acquired infections in a home care setting

Epidemiology and Prevention of Healthcare-Associated Infections in Geriatric Patients: A Narrative Review

Demographic studies show that life expectancy is increasing in developed countries; increased longevity has also increased the share of the older population with often concomitant chronic conditions. An ageing population and increased comorbidities lead to more complex pharmacological therapies (polypharmacy). The particular picture provided by chronic conditions and polypharmacy can lead to longer hospital stays and a greater need for healthcare. Elderly patients are identified as being in the high-risk group for the development of healthcare-associated infections (HAIs) due to the age-related decline of the immune system, known as immunosenescence. Comorbid conditions can often complicate infections, diminishing our ability to treat them effectively. Respiratory tract infections are the most common healthcare-associated infections, followed by urinary tract infections. HAIs in geriatric patients are responsible for longer hospital stays, extended antibiotic therapy, significant mortality, and higher healthcare costs. This is because the microorganisms involved are multidrug-resistant and, therefore, more difficult to eliminate. Moreover, geriatric patients are frequently transferred from one facility (nursing homes, skilled nursing facilities, home care, and other specialty clinics) to another or from one hospital ward to another; these transitions cause care fragmentation, which can undermine the effectiveness of treatment and allow pathogens to be transferred from one setting to another and from one person to another. Multifactorial efforts such as early recognition of infections, restricted use of invasive devices, and effective infection control measures (surveillance, isolation practices, hand hygiene, etc.) can contribute to significant reduction of HAIs in geriatric patients.

Healthcare-associated infections in home healthcare: an extensive assessment, 2019

IntroductionThe number of patients and clinical conditions treated in home healthcare (HHC) is increasing. Care in home settings presents many challenges, including healthcare-associated infections (HAI). Currently, in Belgium, data and guidelines on the topic are lacking.AimTo develop a definition of HAI in HHC and investigate associated risk factors and recommendations for infection prevention and control (IPC).MethodsThe study included three components: a scoping literature review, in-depth interviews with individuals involved in HHC and a two-round Delphi survey to reach consensus among key informants on the previous steps' results.ResultsThe literature review included 47 publications. We conducted 21 in-depth interviews. The Delphi survey's two rounds had 21 and 23 participants, respectively. No standard definition was broadly accepted or known. Evidence on associated risk factors was impacted by methodological limitations and recommendations were inconsistent. Agreement was reached on defining HAI in HHC as any infection specifically linked with providing care that develops in a patient receiving HHC from a professional healthcare worker and occurs ≥ 48 hours after starting HHC. Risk factors were hand hygiene, untrained patients and caregivers, patients' hygiene and presence and management of invasive devices. Agreed recommendations were to adapt and standardise existing IPC guidelines to HHC and to perform a national point prevalence study to measure the burden of HAI in HHC.ConclusionsThis study offers an overview of available evidence and field knowledge of HAI in HHC. It provides a framework for a prevalence study, future monitoring policies and guidelines on IPC in Belgium.

Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach

BACKGROUND

A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives METHODS: Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition.

RESULTS

The numerator criterion was identified by participants as involving one of the 2 following: (1) recognized pathogen isolated from blood culture and pathogen is not related to infection at another site, or (2) one of the following signs or symptoms: fever of 38°C (100.4°F), chills, or hypotension (systolic blood pressure ≤90 mm Hg), and one of the 2 following: (A) common skin contaminant isolated from 2 blood cultures drawn on separate occasions and organism is not related to infection at another site, or (B) common skin contaminant isolated from blood culture from patient with intravascular access device and provider institutes appropriate antimicrobial therapy. The criteria for a denominator included days from the day of admission with a central venous catheter to day of removal of central venous catheter. In addition, 11 inclusion criteria and 4 exclusion criteria were included.

DISCUSSION

Home infusion therapy and healthcare epidemiology experts developed candidate criteria for a home infusion CLABSI surveillance definition.

CONCLUSIONS

Home care and home infusion agencies can use this definition to monitor their own CLABSI rates and implement preventative strategies.

Point prevalence surveys of health-care-associated infections: a systematic review

Health-care-associated infections (HAIs) are considered a serious public health issues that contribute substantially to the global burden of mortality and morbidity with respect to infectious diseases. The aim is to assess the burden of health-care-associated infections by collation of available data from published point prevalence surveys (PPS) on HAIs to give future guidance. Study protocol and methodology were designed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Published research papers that conducted a point prevalence survey of HAIs in hospital settings by following the structured survey methodology employed by European Centre of Disease Prevention and Control (ECDC) were included. Of 1212 articles, 67 studies were included in the final analysis conducted across different countries. Overall, 35 studies were conducted in Europe, 21 in Asia, 9 in America, and 2 in Africa. The highest prevalence of HAIs was recorded in a study conducted in adult ICU settings of 75 regions of Europe (51.3%). The majority of the studies included HAI data on urinary tract infections, respiratory tract infections, and bloodstream infections. Klebsiella pneumonia, Pseudomonas aeruginosa and E. coli were the most frequent pathogens responsible for HAIs. PPS is an useful tool to quantify HAIs and provides a robust baseline data for policymakers. However, a standardize surveillance method is required. In order to minimize the burden of HAIs, infection prevention and control programs and antibiotic stewardship may be effective strategies to minimize the risk of HAIs.

Urinary tract infections and antimicrobial use among Finnish home care clients, April-September 2014

The 30-day prevalence of urinary tract infection (UTI) among Finnish home care clients (N = 6,887) estimated by the Resident Assessment Instrument was 4.5%, and 5.9% of the clients received antimicrobial agents, most commonly for UTI prophylaxis. Urinary catheter and female gender were the strongest factors independently associated with antimicrobial use and UTI. The Resident Assessment Instrument provides data that could be used when training home care providers and primary health care workers in the appropriate use of antimicrobial agents and UTI prevention.

National point prevalence survey of healthcare-associated infections and antimicrobial use in French home care settings, May to June 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Risk factors for urinary catheter associated bloodstream infection

OBJECTIVES

Urinary catheter associated bloodstream infection (UCABSI) causes significant morbidity, mortality and healthcare costs. We aimed to define the risk factors for UCABSI.

METHODS

A case-control study was conducted at two Australian tertiary hospitals. Patients with urinary source bloodstream infection associated with an indwelling urinary catheter (IDC) were compared to controls with an IDC who did not develop urinary source bloodstream infection.

RESULTS

There were 491 controls and 67 cases included in the analysis. Independent statistically significant risk factors for the development of UCABSI included insertion of the catheter in operating theatre, chronic kidney disease, age-adjusted Charlson comorbidity index, accurate urinary measurements as reason for IDC insertion and dementia. IDCs were inserted for valid reasons in nearly all patients, however an appropriate indication at 48 h post-insertion was found in only 44% of patients. Initial empiric antibiotics were deemed inappropriate in 23 patients (34%).

CONCLUSION

To our knowledge, this is the first study to look specifically at the risk factors for bloodstream infection in urinary catheterised patients. Several risk factors were identified. IDC management and empiric management of UCABSI could be improved and is likely to result in a decreased incidence of infection and its complications.

A review of infection control in community healthcare: new challenges but old foes

The demographics of the healthcare population are changing, with an ever-greater proportion of people being treated outside the traditional hospital setting through community healthcare. This shift in the way that healthcare is delivered raises new concerns over community healthcare-associated infections (HCAIs). A literature search between 2000 and December 2013 was conducted in databases including PubMed, SciVerse ScienceDirect and Google Scholar. National and international guideline and policy documents were searched using Google. Many terms were used in the literature searches, including ‘nosocomial’, ‘healthcare infection’, ‘community’ and ‘nursing home’. The rates of HCAI in community healthcare are similar to the rates found in the acute hospital setting, but the types of infection differ, with a greater focus on urinary tract infections (UTIs) in the community and ventilator-associated pneumonias in the hospital setting. Patients who acquire a community HCAI are more likely to exhibit reduced physical condition, have increased levels of morbidity and have higher mortality rates than individuals without infection. Infection control programmes have been developed worldwide to reduce the rates of hospital HCAIs. Such interventions are equally as valid in the community, but how best to implement them and their subsequent impact are much less well understood. The future is clear: HCAIs in the community are going to become an ever-increasing burden and it is critical that our approach to these infections is brought quickly in line with present hospital sector standards.

The prevalence of infections and patient risk factors in home health care: a systematic review

BACKGROUND

Home health care (HHC) has been the fastest growing health care sector for the past 3 decades. The uncontrolled home environment, increased use of indwelling devices, and the complexity of illnesses among HHC patients lead to increased risk for infections.

METHODS

A systematic review of studies evaluating infection prevalence and risk factors among adult patients who received HHC services was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature was searched using Medline, PubMed, and the Cumulative Index to Nursing and Allied Health as well as hand searching. Two reviewers independently assessed study quality using validated quality assessment checklists.

RESULTS

Twenty-five studies met the inclusion criteria and were reviewed. The infection rates and identified risk factors for infections varied dramatically between studies. In general, patients receiving home parental nutrition treatments had higher infection rates than patients receiving home infusion therapy. The identified risk factors were limited by small sample sizes and other methodologic flaws.

CONCLUSIONS

Establishing a surveillance system for HHC infections, identifying patients at high risk for infections, tailoring HHC and patient education based on patient living conditions, and facilitating communication between different health care facilities will enhance infection control in HHC settings. Future studies should use a nationally representative sample and multivariate analysis for the identification of risk factors for infections.

The prevalence of infections and patient risk factors in home health care: a systematic review

BACKGROUND

Home health care (HHC) has been the fastest growing health care sector for the past 3 decades. The uncontrolled home environment, increased use of indwelling devices, and the complexity of illnesses among HHC patients lead to increased risk for infections.

METHODS

A systematic review of studies evaluating infection prevalence and risk factors among adult patients who received HHC services was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature was searched using Medline, PubMed, and the Cumulative Index to Nursing and Allied Health as well as hand searching. Two reviewers independently assessed study quality using validated quality assessment checklists.

RESULTS

Twenty-five studies met the inclusion criteria and were reviewed. The infection rates and identified risk factors for infections varied dramatically between studies. In general, patients receiving home parental nutrition treatments had higher infection rates than patients receiving home infusion therapy. The identified risk factors were limited by small sample sizes and other methodologic flaws.

CONCLUSIONS

Establishing a surveillance system for HHC infections, identifying patients at high risk for infections, tailoring HHC and patient education based on patient living conditions, and facilitating communication between different health care facilities will enhance infection control in HHC settings. Future studies should use a nationally representative sample and multivariate analysis for the identification of risk factors for infections.

Caracterización clínica, microbiológica y de sensibilidad a antimicrobianos en pacientes con infección nosocomial del tracto urinario: cuatro años y medio de vigilancia epidemiológica

Antecedentes: Las infecciones nosocomiales son entidades importantes por su aumento en la morbimortalidad y en los costos de tratamiento. En Medellín, Colombia, la del tracto urinario (ITU)  es  la segunda infección nosocomial  más incidente, 16,3% del total. El objetivo del presente estudio fue realizar  una caracterización de los  aspectos  clínicos  y microbiológicos de los pacientes con infección nosocomial del tracto urinario en una clínica privada de Medellín, Colombia. Métodos: Estudio retrospectivo, longitudinal, descriptivo de las historias clínicas de los pacientes con infección nosocomial del tracto urinario entre enero/2005 y julio/2009. Resultados: Se diagnosticaron 134 casos en 130 pacientes (tasa institucional de 0,27 infecciones por 100 egresos), con alza de 0,21 por cada 100 egresos en 2005 a 0,59 en 2009. La mayoría de los pacientes fueron mujeres (67,7%), con edad promedio de 55 (IQ 27-72) años.  Las comorbilidades más comunes fueron hipertensión arterial  (48,5%)  y enfermedad renal  crónica (16,3%). Los gérmenes más comunes fueron E. coli (54,9%) y K. pneumoniae (12,8%). Hay alta proporción de resistencia a ciprofloxacina,  ampicilina/sulbactam y  trimetoprim/sulfametoxazol.  Conclusión:  La ITU nosocomial  es una entidad relativamente común en la institución estudiada, aunque su tasa es consistentemente inferior a la encontrada en estudios similares. Para el manejo empírico de esta infección parece recomendable iniciar con amikacina o ceftriaxona, utilizando imipenem o meropenem en pacientes sépticos con comorbilidad seria o con alto riesgo de gérmenes multirresistentes. Para el tratamiento de ITU nosocomial por E. coli, la amikacina y la gentamicina parecen buenas  opciones,  al  igual  que la ceftriaxona.

Mapping a Research Agenda for Home Care Safety: Perspectives from Researchers, Providers, and Decision Makers

Le but de cette conception qualitative et interprétative était d’examiner les perspectives des chercheurs, des pourvoyeurs de soins de santé et et des décideurs aux sujets des risques principaux, des préoccupations et des problèmes émergents rattachées à la sécurité de soins à domicile qui informerait une ligne d’enquête de recherche. La sécurité, tel qu’elle s’applique spécifiquement à ce context des soins à domicile, n’a pas encore été définie. Par conséquent, afin de profiter de diverses parties prenantes sur les questions de securité relatives aux soins à domicile est nécessaire afin d’informer les orientations stratégiques pour la recherche future. Afin de commencer à tracer un programme de recherche, une analyse en trois parties de l’environnement a été realisée: (a) une étude pilote avec les bénéficiaires et les fournisseurs de soins à domicile; (b) des entretiens avec des informateurs clés, les chercheurs, les fournisseurs de soins de santé, et les décideurs; et (c) une revue de la littérature dans trois domaines thématiques. Seulement les résultats des entrevues des informateurs clés sont présentés ici.

Adverse events experienced by homecare patients: a scoping review of the literature

PURPOSE

The paper summarizes the results of a scoping review that focused on the occurrence of adverse events experienced by homecare patients.

DATA SOURCES

The literature search covered published and grey literature between 1998 and 2007. Databases searched included: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library, AGELINE, the National Patient Safety Foundation Bibliography, Agency for Healthcare Research and Quality and the Patient Safety Net bibliography.

STUDY SELECTION

Papers included research studies, review articles, policy papers, opinion articles and legal briefs. Inclusion criteria were: (i) homecare directed services provided in the home by healthcare professionals or caregivers; (ii) addressed a characteristic relevant to patient experienced adverse events (e.g. occurrences, rates, definitions, prevention or outcomes); and (iii) were in English. Data extraction A pool of 1007 articles was reduced to 168 after analysis. Data were charted according to six categories: definitions, rates, causes, consequences, interventions and policy.

RESULTS

Eight categories emerged: adverse drug events, line-related, technology-related, infections and urinary catheters, wounds, falls, studies reporting multiple rates and other. Reported overall rates of adverse events ranged from 3.5 to 15.1% with higher rates for specific types. Few intervention studies were found. Adverse events were commonly associated with communication problems. Policy suggestions included the need to improve assessments, monitoring, education, coordination and communication.

CONCLUSION

A standardized definition of adverse events in the homecare setting is needed. Prospective cohort studies are needed to improve estimates and intervention studies should be undertaken to reduce the risk that homecare patients will experience adverse events.

Proteomic analysis of Escherichia coli biofilms reveals the overexpression of the outer membrane protein OmpA

Bacterial colonisation and biofilm formation on the surface of urinary catheters is a common cause of nosocomial infection, and as such is a major impediment to their long-term use. Understanding the mechanisms of biofilm formation on urinary catheters is critical to their control and will aid the future development of materials used in their manufacture. In this report we have used proteomic analysis coupled with immunoassays to show that the major outer membrane protein (OmpA) of Escherichia coli is overexpressed during biofilm formation. A series of synthetic hydrogels being developed for potential use as catheter coatings were used as the substrata and OmpA expression was increased in biofilms on all these surfaces, as well as being a feature of both a laboratory and a clinical strain of E. coli. Up-regulation of OmpA may, therefore, be a common feature of E. coli biofilms. These findings present OmpA as a potential target for biofilm inhibition and may contribute to the rational design of biofilm inhibiting hydrogel coatings for urinary catheters.

Influx of extended-spectrum beta-lactamase-producing enterobacteriaceae into the hospital

BACKGROUND

The prevalence of infections caused by extended-spectrum beta -lactamase (ESBL)-producing Enterobacteriaceae is increasing worldwide. The influx of these bacteria into hospitals has major implications for infection-control and empirical treatment strategies.

METHODS

Isolates from 2 patient cohorts--patients with gram-negative bacteremia within 2 days after admission and patients screened for fecal colonization at admission--were assessed for ESBL production. ESBL phenotype was confirmed according to Clinical and Laboratory Standards Institute guidelines. Predictors of ESBL phenotype were examined by univariate and multivariate analyses.

RESULTS

Of 80 Enterobacteriaceae isolates from blood samples obtained at admission to the hospital, 13.7% produced ESBL. Thirty-eight patients with ESBL-positive isolates and 72 with ESBL-negative isolates were included in a case-control study. Predictors of ESBL production were male sex and nursing home residence (area under receiver operator characteristic curve, 0.7). Of 241 persons screened at admission, 26 (10.8%) had fecal carriage of ESBL-producing Enterobacteriaceae. Predictors of fecal carriage were poor functional status, antibiotic use, chronic renal insufficiency, liver disease, and use of histamine2 blockers (area under receiver operator characteristic curve, 0.8). Four (15.4%) of the 26 individuals with fecal carriage had subsequent bacteremia with ceftazidime-resistant Enterobacteriaceae, compared with 1 (0.5%) noncarrier (odds ratio, 38.9; P<.001). Of 80 ESBL-producing Enterobacteriaceae isolates obtained at admission, 65 were health care associated, and 15 were community acquired. The 15 community-acquired ESBL-producing Enterobacteriaceae belonged to diverse clones. The most prevalent ESBL gene among these isolates was CTX-M-2 (found in 53.3% of the isolates).

CONCLUSIONS

We report high rates of bacteremia and colonization with ESBL-producing Enterobacteriaceae at admission to our institution, which may undermine infection-control measures and complicate the selection of empirical treatment.