Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities

Environmental sampling for SARS-CoV-2 in long term care facilities: lessons from a pilot study

Background: The SARS-CoV-2 pandemic has highlighted the risk of infection in long-term care facilities (LTCF) and the vulnerability of residents to severe outcomes. Environmental surveillance may help detect pathogens early and inform Infection Prevention and Control (IPC) measures in these settings. Methods: Upon notification of SARS-CoV-2 outbreaks, LTCF within a local authority in South West England were approached to take part in this pilot study. Investigators visited to swab common touch-points and elevated 'non-touch' surfaces (>1.5m above ground level) and samples were analysed for presence of SARS-CoV-2 genetic material (RNA). Data were collected regarding LTCF infrastructure, staff behaviours, clinical and epidemiological risk factors for infection (staff and residents), and IPC measures. Criteria for success were: recruitment of three LTCF; detection of SARS-COV-2 RNA; variation in proportion of SARS-CoV-2 positive surfaces by sampling zone; and collection of clinical and epidemiological data for context. Results: Three LTCFs were recruited, ranging in size and resident demographics. Outbreaks lasted 63, 50 and 30 days with resident attack rates of 53%, 40% and 8%, respectively. The proportion of sample sites on which SARS-CoV-2 was detected was highest in rooms occupied by infected residents and varied elsewhere in the LTCF, with low levels in a facility implementing enhanced IPC measures. The heterogeneity of settings and difficulty obtaining data made it unfeasible to assess association between environmental contamination and infection. A greater proportion of elevated surfaces tested positive for SARS-CoV-2 RNA than common touch-points. Conclusions: SARS-CoV-2 RNA can be detected in a variety of LTCF outbreak settings, both on common-touch items and in elevated sites out of reach. This suggests that further work is justified, to assess feasibility and utility of environmental sampling for infection surveillance in LTCF.

Novel Care Bundle of Established Basic and Practical Approaches Greatly Reduces Urinary Tract Infections in Nursing Facility Residents without Indwelling Catheters

BACKGROUND

Residents in nursing facilities (NFs) are at greater risk of developing urinary tract infections (UTIs) with higher hospitalizations and costs than people living in communities. These residents also have increased likelihood of uroseptic shock and death. The objective of the study was to prevent UTIs and to reduce UTI-associated costs among NF residents.

METHODS

Quality assurance performance improvement initiative conducted between 4-01-2018 and 3-31-2022 at a large skilled NF. Participants were 262 residents newly diagnosed with UTIs without indwelling catheters. The initiative consisted of: a) a 12-month baseline; b) a 12-month intervention; and c) a 24-month follow-up. A novel care bundle which included staff's hand hygiene monitoring, residents' hydration status, effective incontinence and perineal care, and in-house UTI treatment was implemented during the intervention. The plan-do-study-act cycle was used to gauge its effectiveness.

RESULTS

Quarterly UTI rates decreased from 4.2% at baseline to 0.9% at follow-up, a 79% reduction (P<0.001). All 262 residents were treated in-house with no UTI-related hospitalizations. Antibiotic prescriptions fell from 373 at baseline down to 143 at follow-up, a 62% reduction. Facility costs decreased from $42,188 at baseline to $8,281 at follow-up (P<0.001).

CONCLUSION

This bundle was very effective in preventing UTIs and reducing UTI-associated costs. Its use in other NFs is encouraged to determine suitability elsewhere.

Catheter-Associated Urinary Tract Infections: Current Challenges and Future Prospects

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and cause of secondary bloodstream infections. Despite many advances in diagnosis, prevention and treatment, CAUTI remains a severe healthcare burden, and antibiotic resistance rates are alarmingly high. In this review, current CAUTI management paradigms and challenges are discussed, followed by future prospects as they relate to the diagnosis, prevention, and treatment. Clinical and translational evidence will be evaluated, as will key basic science studies that underlie preventive and therapeutic approaches. Novel diagnostic strategies and treatment decision aids under development will decrease the time to diagnosis and improve antibiotic accuracy and stewardship. These include several classes of biomarkers often coupled with artificial intelligence algorithms, cell-free DNA, and others. New preventive strategies including catheter coatings and materials, vaccination, and bacterial interference are being developed and investigated. The antibiotic pipeline remains insufficient, and new strategies for the identification of new classes of antibiotics, and rational design of small molecule inhibitor alternatives, are under development for CAUTI treatment.

Updates on Infection Control in Alternative Health Care Settings

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

Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria

Healthcare-associated infections (HCAI) are a common cause for residents’ mortality and morbidity associated with a significant socio-economic burden. Data on HCAIs in Austrian long-term care facilities are scare. Therefore, we evaluated the incidence rate of HCAIs per 1000 resident days in four LTC facilities in Graz, Austria, characterized the spectrum of HCAIs and the use of antimicrobial substances. We conducted a prospective surveillance study from 1 January to 31 December 2018 in four LTCFs of the Geriatric Health Centre of the City of Graz (total of 388 beds). Nursing staff collected data on HCAIs once a week using an electronic reporting system. During the 12-month surveillance period, 252 infections of 165 residents were recorded. The overall incidence rate of HCAIs was 2.1 per 1000 resident days. Urinary tract infections were the most commonly recorded HCAIs (49%, 124/252, 1.03 per 1000 resident days), followed by skin and soft tissue infections and respiratory tract infections. Beta-lactams (ATC class J01C) were prescribed most frequently (63/212), followed by fluoroquinolones (J01M; 54/212). In conclusion, the overall incidence rate for HCAIs was relatively low at 2.1 per 1000 resident days. Our real-life data can serve as a basis for future antimicrobial stewardship and infection prevention interventions.

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

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

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

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

Scope of practice and educational needs of infection prevention and control professionals in Australian residential aged care facilities

BACKGROUND

Healthcare-associated infections are serious and significant complications present across healthcare services, including residential aged care facilities. Although ensuring high quality personal and clinical care delivered to older people residing in these facilities is a high national priority, there is a paucity of evidence published about outbreaks, governance and education programs held for healthcare workers within Australian residential aged care facilities. The aim of this study is to examine the scope of practice of Infection Prevention and Control professionals within Australian residential aged care facilities and the types of infection prevention and control education and training delivered.

METHODS

A cross-sectional study was conducted inviting all Australian residential aged care facilities to participate in an online survey.

RESULTS

A total of 134 residential aged care facilities completed the survey. The majority (88.1%) reported having a designated Infection Prevention and Control professional responsible for surveillance and educational activities. Hand hygiene (94%), personal protective equipment (PPE) (79.9%) and environmental cleaning (70.1%) were some of the available Infection Prevention and Control programs. The lack of access to Infection Prevention and Control education (69.5%) and lack of Infection Prevention and Control expert advice (67.2%) were also reported by some Residential aged care facilities.

CONCLUSION

Australian residential aged care facilities recognise the importance of Infection Prevention and Control training programs to manage infection surveillance and outbreaks. Considerable activities are carried out to increase knowledge on breaking the chain of infection. Yet, more support and resources are needed to assist these efforts.

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.

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

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

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

Background

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

Methods/design

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

Discussion

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

Infection Control in Alternative Health Care Settings: An Update

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Antibiotic Prescribing in 4 Assisted-Living Communities: Incidence and Potential for Improvement

Objective.

To describe the prevalence, characteristics, and appropriateness of systemic antibiotic use in assisted living (AL) and to conduct a preliminary quality improvement intervention trial to reduce inappropriate prescribing.

Design.

Pre-post study, with a 13-month intervention period.

Setting.

Four AL communities.

Participants.

All prescribers, all AL staff who communicate with prescribers, and all patients who had an infection during the baseline and intervention periods.

Intervention.

A standardized form for AL staff, an online education course and 5 practice briefs for prescribers, and monthly quality improvement meetings with AL staff.

Measurements.

Monthly inventory of all systemic antibiotic prescriptions; interviews with the prescriber, AL staff member, closest family member, and patient (when capable) regarding 85 antibiotic prescribing episodes (30 baseline, 55 intervention), with data review by an expert panel to determine prescribing appropriateness.

Results.

The mean number of systemic antibiotic prescriptions was 3.44 per 1,000 resident-days at baseline and 3.37 during the intervention, a nonsignificant change (P = .30). Few prescribers participated in online training. AL staff use of the standardized form gradually increased during the program. The proportion of prescriptions rated as probably inappropriate was 26% at baseline and 15% during the intervention, a nonsignificant trend (P = .25). Drug selection was largely appropriate during both time periods.

Conclusions.

AL antibiotic prescribing rates appear to be approximately one-half those seen in nursing homes, with up to a quarter being potentially inappropriate. Interventions to improve prescribing must reach all physicians and staff and most likely will require long time periods to have the optimal effect.

Infections in Australian Aged-Care Facilities: Evaluating the Impact of Revised McGeer Criteria for Surveillance of Urinary Tract Infections

Our survey of 112 Australian aged-care facilities demonstrated the prevalence of healthcare-associated infections to be 2.9%. Urinary tract infections (UTIs) defined by McGeer criteria comprised 35% of all clinically defined UTIs. To estimate the infection burden in these facilities where microbiologic testing is not routine, modified surveillance criteria for UTIs are necessary.

Infect Control Hosp Epidemiol 2016;37:610–612

Antimicrobial stewardship in long-term care facilities

Although antimicrobial stewardship has been shown to improve microbiologic susceptibility patterns, decrease drug toxicities, and lower overall drug costs in the inpatient setting, there are few studies assessing programs in the long-term care (LTC) setting. Implementing antimicrobial stewardship programs in LTC settings can be challenging as the LTC setting houses a unique population of frail and older adults with several preexisting conditions and multiple risk factors for colonization with multidrug-resistant organisms. Antimicrobial stewardship has an important role in decreasing inappropriate antibiotic use, encouraging targeted treatment of specific disease states, and limiting the untoward effects and costs of antimicrobials in this vulnerable population.

The Burden of Infectious Gastroenteritis in Elderly Residents and Staff of Long-Term Care Facilities, Australia

We estimated the incidence of gastroenteritis in 16 Australian long-term care facilities. During 12 months' surveillance, 245 (96%) of 254 episodes of gastroenteritis among long-term care residents were associated with 17 outbreaks in 11 facilities. Incidence in long-term care residents was 0.64 episodes per 1,000 bed-days (95% confidence interval, 0.29-1.42).

Catheter associated urinary tract infections

Urinary tract infection attributed to the use of an indwelling urinary catheter is one of the most common infections acquired by patients in health care facilities. As biofilm ultimately develops on all of these devices, the major determinant for development of bacteriuria is duration of catheterization. While the proportion of bacteriuric subjects who develop symptomatic infection is low, the high frequency of use of indwelling urinary catheters means there is a substantial burden attributable to these infections. Catheter-acquired urinary infection is the source for about 20% of episodes of health-care acquired bacteremia in acute care facilities, and over 50% in long term care facilities. The most important interventions to prevent bacteriuria and infection are to limit indwelling catheter use and, when catheter use is necessary, to discontinue the catheter as soon as clinically feasible. Infection control programs in health care facilities must implement and monitor strategies to limit catheter-acquired urinary infection, including surveillance of catheter use, appropriateness of catheter indications, and complications. Ultimately, prevention of these infections will require technical advances in catheter materials which prevent biofilm formation.

Infections and antimicrobial use in Australian residential aged care facilities: a comparison between local and international prevalence and practices

INTRODUCTION

In July 2011, 29 residential aged care facilities (RACF) located in the Grampians rural region, Victoria, participated in the Grampians healthcare-associated infection (HAI) and antimicrobial use point prevalence study.

METHODS

On a single day, trained infection control consultants collected data using two surveys. The RACF survey enabled collection of information (e.g. occupancy levels) about each RACF and its residents. The resident survey was completed for eligible high-level care residents who presented with signs and symptoms of a HAI and/or were prescribed an antimicrobial. A literature review was undertaken so comparisons could be made against similar studies.

RESULTS

The Grampians prevalence of residents presenting with ≥1 HAI (3.8%) was higher than the pooled prevalence (2.3%) for four international studies (P=0.01). The Grampians prevalence of residents prescribed ≥1 antimicrobial (8.3%) was higher than the pooled prevalence (5.8%) for eight international studies (P=0.009).

CONCLUSION

The prevalence of the Grampians residents presenting with ≥1 HAI and residents prescribed ≥1 antimicrobial were both observed to be significantly higher than pooled data from similar international studies.

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.

Benchmarking French regions according to their prevalence of healthcare-associated infections

OBJECTIVE

To propose an original method of benchmarking regions based on their prevalence of healthcare-associated infections (HAIs) and to identify regions with unusual results.

DESIGN

To study between-region variability with a three-level hierarchical logistic regression model and a Bayesian non-parametric method.

SETTING

French 2006 national HAIs point prevalence survey.

PARTICIPANTS

A total of 336 858 patients from 2289 healthcare facilities in 27 regions. Patients with an imported HAI (1% of the data, 20.7% of infected patients), facilities with <5 patients and patients who had at least one missing value for the variables taken into account were excluded (5.0% of patients).

MAIN OUTCOME MEASURE

Binary outcome variable indicates whether a given patient was infected.

RESULTS

Two clusters of regions were identified: one cluster of five regions had a lower adjusted prevalence than the other one of 22 regions, while no region with unusually high prevalence could be identified. Nevertheless, the degree of heterogeneity of odds ratios between facilities for facility-specific effects of use of invasive devices was more important in some regions than in others.

CONCLUSIONS

The adjusted regional prevalence of HAIs can serve as an adequate benchmark to identify regions with concerning results. Although no outlier regions were identified, the proposed approach could be applied to the data of the 2012 national survey to benchmark regional healthcare policies. The estimation of facility-specific effects of use of invasive devices may orient future regional action plans.

Urogenital consequences in ageing women

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

Infection control: point prevalence study versus incidence study in Polish long-term care facilities in 2009-2010 in the Małopolska Region

OBJECTIVE

The objective of this study was to evaluate the epidemiology of infection in Polish long-term care facilities (LTCFs) and to analyse the capabilities and legitimacy of implementing continuous targeted surveillance.

METHODS

The study investigated the relationship between the presence of infection and health status, tested using a point prevalence study (PPS) and incidence study. A 1-day PPS was carried out in October 2009, with prospective continuous surveillance between December 2009 and November 2010. Infections were defined according to McGeer's criteria.

RESULTS

The surveillance encompassed 193 people. The prevalence was 14.0 % in residential homes (RHs) and 18.7 % in the nursing home (NH). Various types of infections (in the PPS) were observed significantly more frequently in patients with asthma, wounds, atherosclerosis of lower extremities, tracheotomy tubes and conditions in patients hospitalised in intensive care units (ICUs) up to 1 year before the PPS day. The incidence rate was 2.7/1,000 patient days (pds).

CONCLUSIONS

The factors determined to be important for the risk of infection (in the continuous study) include the general status of patients, expressed using Barthel, abbreviated mental and Katz scales, as well as limited physical activity, stool incontinence and urinary catheterisation. In the PPS study, only a slight relationship was shown between the general status of residents and the risk of infection. None of the general status scales used clinically were shown to be helpful in estimating that risk, similarly to the five-point physical activity scale. Prospective continuous surveillance shows a possibility of limiting the range of infection control in the LTCFs within targeted surveillance in a population of patients that requires intensive nursing procedures. As a marker, one could point to the low score in the Barthel or Katz scales or low physical activity/bedridden persons.

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.

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.

Risk of infection following a visit to the emergency department: a cohort study

BACKGROUND

The risk of infection following a visit to the emergency department is unknown. We explored this risk among elderly residents of long-term care facilities.

METHODS

We compared the rates of new respiratory and gastrointestinal infections among elderly residents aged 65 years and older of 22 long-term care facilities. We used standardized surveillance definitions. For each resident who visited the emergency department during the study period, we randomly selected two residents who did not visit the emergency department and matched them by facility unit, age and sex. We calculated the rates and proportions of new infections, and we used conditional logistic regression to adjust for potential confounding variables.

RESULTS

In total, we included 1269 residents of long-term care facilities, including 424 who visited the emergency department during the study. The baseline characteristics of residents who did or did not visit the emergency department were similar, except for underlying health status (visited the emergency department: mean Charlson Comorbidity Index 6.1, standard deviation [SD] 2.5; did not visit the emergency department: mean Charlson Comorbidity index 5.5, SD 2.7; p < 0.001) and the proportion who had visitors (visited the emergency department: 46.9%; did not visit the emergency department: 39.2%; p = 0.01). Overall, 21 (5.0%) residents who visited the emergency department and 17 (2.0%) who did not visit the emergency department acquired new infections. The incidence of new infections was 8.3/1000 patient-days among those who visited the emergency department and 3.4/1000 patient-days among those who did not visit the emergency department. The adjusted odds ratio for the risk of infection following a visit to the emergency department was 3.9 (95% confidence interval 1.4-10.8).

INTERPRETATION

A visit to the emergency department was associated with more than a threefold increased risk of acute infection among elderly people. Additional precautions should be considered for residents following a visit to the emergency department.

Infection prevention in alternative health care settings

With the changing health care delivery, patients receive care at various settings, including acute care hospitals, skilled nursing facilities (SNFs), and ambulatory clinics, thus becoming exposed to pathogens. Various health care settings face unique challenges requiring individualized infection control programs. The programs in SNFs should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs. In ambulatory clinics, the program should address triage and standard transmission-based precautions; cleaning, disinfection, and sterilization principles; surveillance in surgical clinics; safe injection practices; and bioterrorism and disaster planning.

Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation

The global population is aging. With the high prevalence of dementia and functional decline in older Americans, many aging adults with disabilities reside in nursing homes in their final stage of life. Immunosenescence, multiple comorbid diseases, and grouped quarter living all coalesce in nursing home residents to increase the risk for infectious disease. The unique issues involved with diagnosis, prognosis, and management of infectious diseases in nursing home residents make research based in the nursing home setting both necessary and exciting for the physician investigator. This review discusses the opportunities and challenges involved with research of the evolving public health problem of infections among nursing home residents.

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).

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

[Surveillance of nosocomial infections in a long-term care facility. Incidence and risk factors]

In Germany, surveillance of nosocomial infections is obligatory by law in hospitals, but not in long-term care facilities. In long-term care facilities, neither X-ray nor laboratory facilities are available; therefore, special criteria for infection surveillance in these facilities were developed by Mc Geer et al. (1991), based only on observations of the medical staff and foregoing laboratory methods. The practicability of these criteria was assessed in a long-term care facility with an electronic medical documentation system. In a retirement home in Frankfurt/Main, Germany, the residents' symptoms according to McGeer et al. were recorded from January, 1 to June 31, 2006. The study included 278 residents, 45,710 resident days, including 4413 "urinary catheter days" und 6009 "gastric tube days". Based on the symptoms documented in the electronic medical documentation system, the respective diagnoses were obtained. Data on gastrointestinal, bronchial, urinary, and eye infections are reported here, including number of cases as well as incidences per 1000 resident days. The overall incidence rate was 5.07/1000 resident days, including 1.9 gastrointestinal infections, 0.95 bronchitis/pneumonia, and 0.44 urinary infections. Incidence of urinary infections in residents with an indwelling urinary catheter was 2.26/1000 catheter days compared to 0.242/1000 days for those without a catheter. Urinary catheter, however, was not only a risk factor for urinary infections (OR 9.4, 95CI 3.4-25.8) but also for bronchial infections (OR 3.0, 95CI 1.3-6.8), and eye infections (OR 1.6, 95CI 0.4-5.8). Gastric tubes were associated with bronchial infections (OR 3.7; CI 1.7-7.9), eye infections (OR 5.4, CI 1.9-15.2), and urinary infections (OR 2.7, 95CI 0.9-8.2). Urinary or fecal incontinence were not associated with any infections, and age (>80 years) was negatively associated with urinary infections (OR 0.35, significant) and bronchial infections (OR 0.51, significant). Compared with published studies, the incidence rates were comparable. The practicability of the criteria of McGeer et al. could be confirmed - with only slight modification - in a long-term care facility with electronic medical documentation.

Investigation into the effect of an alcohol-based hand product on infection rate in a nursing home setting

The study assessed the impact on nursing home (NH) resident infection rates of providing staff with a personal alcohol-based hand product (ABHP) with and without training on its use.

Fifteen North Wales NHs were recruited and randomly allocated into one of three groups. All monitored infection rates throughout the study period of 18 weeks (Phase I [weeks 1—9], Phase II [weeks 11—19]). NHs used liquid soap and water for hand washing throughout the study. Groups B and C introduced interventions during week ten: Group B were provided with personal ABHPs without training on use; Group C personal ABHPs with standard training from the sponsoring hand hygiene company. Infection rates between groups and pre- and post-intervention were compared.

Infection rates (per 1,000 bed days) for Phase I vs. Phase II of the study were: Group A: 6.99 vs. 7.16; Group B: 6.08 vs. 3.46; and Group C: 5.04 vs. 6.78 respectively. Change in infection rates in Groups B and C pre- and post-intervention did not reach statistical significance, p = 0.097 and p = 0.072 respectively.

Comparison of rates in non-intervention Group A with the intervention groups indicated a significantly lower rate after the intervention in Group B ( p = 0.035) but not Group C ( p = 0.765).

Findings are limited due to sample size; introduction of personal ABHPs with training did not reduce infection rates. This conflicts with other studies examining education and improvement of hand hygiene compliance. However, infection rates fell in NHs not receiving training, possibly mediated through a sense of `ownership' of the intervention.

Infections in the Long-Term Care Setting

In the long-term care setting

The diagnosis of infection is primarily based from the clinical assessment.

Infection is a common cause of fever, when present, and acute change in functional status.

Infection can often present atypically; usual symptoms, physical findings, and diagnostic abnormalities may be lacking.

Evaluation of fever and suspected infection should initially focus on the most common clinical syndromes.

Treatment should initially focus on the most common organisms that are present at the most likely suspect site of infection.

Variation in mortality rates among long-term care facilities for residents with lower respiratory tract infection

OBJECTIVE

To identify variables contributing to interfacility differences in mortality among residents of long-term care facilities who have lower respiratory tract infection.

DESIGN

Multicenter, prospective, 1-year observational study.

SETTING

Twenty-one long-term care facilities in 4 geographic areas of Canada.

PARTICIPANTS

Residents of long-term care facilities prescribed antimicrobials for treatment of lower respiratory tract infection.

METHODS

Mortality rates were calculated for 3 definitions of lower respiratory tract infection: episodes with a clinical or radiographic diagnosis and treated with antimicrobials (definition 1); episodes with a physician diagnosis of pneumonia (definition 2); and episodes with chest radiography findings consistent with pneumonia (definition 3). Multilevel modeling was used to evaluate variables describing premorbid resident status, clinical presentation, management, and facility characteristics. Multivariable models were developed to identify independent predictors of mortality and determine whether facility-level variables remained independently associated with mortality rate after incorporation of individual-level variables.

RESULTS

Facility mortality rates varied from 0% to 17.8% for definition 1, from 0% to 47.1% for definition 2, and from 0% to 37.5% for definition 3. There were significant differences in mortality rate depending on which definition was used; for definitions 1 and 2, there were significant differences in mortality rate across facilities. Poorer premorbid resident status and a more severe presentation remained independent predictors of mortality in the multivariable analysis. There were also significantly increased mortality rates for episodes in which a fluoroquinolone was prescribed for initial treatment. For definitions 1 and 3, facility-level variables remained independently associated with mortality rate in the final multivariable model.

CONCLUSIONS

Rates of mortality due to lower respiratory tract infection varied among long-term care facilities and differed within a facility, depending on the definition applied. Variables describing premorbid resident status, severity of presentation, and management did not fully explain the variation in mortality rate. Some facility-level variables remained independent predictors of mortality.

Infection control issues in older adults

Older adults receive care from various settings, including acute care hospitals, skilled nursing facilities, nursing homes, group homes, outpatient primary care, specialty clinics, and home. In these various settings, older adults are exposed to pathogens, which makes them "vectors" that transport pathogens from one setting to another and makes them vulnerable to care fragmentation. These health care settings face unique challenges that require individualized infection control programs. Infection control programs should address: surveillance for infections and antimicrobial resistance, outbreak investigation and a control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Asymptomatic bacteriuria and urinary tract infection in older adults

Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are common in older community dwellers (ages 65 and older) and nursing home residents. The challenge involved in distinguishing ASB from UTI in this population results from other comorbid illnesses that may present with symptoms similar to UTI and from elderly adults who have cognitive impairment not being able to report their symptoms. This article reviews the most updated information on diagnosis, microbiology, management, and prevention of ASB and UTI as they pertain to older community dwellers and nursing home residents.

Nursing home practitioner survey of diagnostic criteria for urinary tract infections

OBJECTIVES

To identify clinical and laboratory criteria used by nursing home practitioners for diagnosis and treatment of urinary tract infections (UTIs) in nursing home residents. To determine practitioner knowledge of the most commonly used consensus criteria (i.e., McGeer criteria) for UTIs.

DESIGN

Self-administered survey.

SETTING

Three New Haven-area nursing homes.

PARTICIPANTS

Physicians (n=25), physician assistants (PAs, n=3), directors/assistant directors of nursing (n=8), charge nurses (n=37), and infection control practitioners (n=3).

MEASUREMENTS

Open- and closed-ended questions.

RESULTS

Nineteen physicians, three PAs, and 41 nurses completed 63 of 76 (83%) surveys. The five most commonly reported triggers for suspecting UTI in noncatheterized residents were change in mental status (57/63, 90%), fever (48/63, 76%), change in voiding pattern (44/63, 70%), dysuria (41/63, 65%), and change in character of urine (37/63, 59%). Asked to identify their first diagnostic step in the evaluation of UTIs, 48% (30/63) said urinary dipstick analysis, and 40% (25/63) said urinalysis and urine culture. Fourteen of 22 (64%) physicians and PAs versus 40 of 40 (100%) nurses were aware of the McGeer criteria for noncatheterized patients (P<.001); 12 of 22 (55%) physicians and PAs versus 38 of 39 (97%) nurses used them in clinical practice (P<.001).

CONCLUSION

Although surveillance and treatment consensus criteria have been developed, there are no universally accepted diagnostic criteria. This survey demonstrated a distinction between surveillance criteria and criteria practitioners used in clinical practice. Prospective data are needed to develop evidence-based clinical and laboratory criteria of UTIs in nursing home residents that can be used to identify prospectively tested treatment and prevention strategies.