Epidemiology of multidrug-resistant microorganisms among nursing home residents in Belgium

Prevalence and factors associated with methicillin-resistant Staphylococcus aureus colonization on admission to geriatric care units: impact on screening practices

OBJECTIVES

Universal screening for methicillin-resistant Staphylococcus aureus (MRSA) entails additional costs, and there is no consensus for targeted screening for high-risk units. The aims of this study were to determine the prevalence of MRSA in geriatric care units, and to identify the factors associated with MRSA colonization on admission.

METHODS

This retrospective case-control study (1:1) in the geriatric care unit of six Belgian hospitals covered the period from 1st January 2021 to 31st December 2022. Cases were patients with a positive MRSA screening result within 48 h of admission to the geriatric care unit, and controls were patients with a negative screening result.

RESULTS

In total, 556 patients were included in this study (278 in each group). Prevalence per 100 admissions for the total sample was 2.3 [95% confidence interval (CI) 2.2-2.6]. Significant multi-variate factors associated with MRSA carriage on admission were: history of MRSA, nursing home origin, and chronic skin lesions. Applying these three factors would give an area under the receiver operating characteristic (ROC) curve of 0.73 (95% CI 0.71-0.77), and would allow screening to be carried out in only 55.4% of cases (95% CI 51.2-59.6%).

CONCLUSIONS

Using these factors as screening criteria in geriatric care units could significantly reduce the number of patients screened for MRSA, while maintaining satisfactory sensitivity and specificity.

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.

Epidemiology and molecular typing of multidrug-resistant bacteria in tertiary hospitals and nursing homes in Flanders, Belgium

This study aimed to map MDRO carriage and potential transmission within and between three Flemish tertiary care hospitals and their neighbouring nursing homes. A cross-sectional MDRO prevalence survey was organized between October 2017 and February 2019. Perianal swabs were cultured for detection of MDRO. Determination of clonal relatedness based on wgMLST allelic profiles was performed. The prevalence of MDRO in Belgian hospitals and NHs is on the rise, compared to previous studies, and transmission in and between institutions is observed. These results re-emphasize the need for a healthcare network-wide infection prevention strategy in which WGS of MDRO strains can be supportive.

Risk factors for colonization by carbapenemase-producing bacteria in Spanish long-term care facilities: a multicentre point-prevalence study

BACKGROUND

The emergence of carbapenemase-producing bacteria (CPB) has become a major public health concern. Long-term care facilities (LTCF) are potential reservoirs for multidrug-resistant micro-organisms (MDRO). However, data on CPB is limited. The study aims to determine the prevalence of MDRO and risk factors for CPB colonization among residents of LTCFs.

METHODS

A point-prevalence study was conducted at 14 LTCFs in Tenerife (Spain) between October 2020 and May 2021. Nasal and rectal swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenemase-producing Enterobacterales, MDR Acinetobacter baumannii (MDR-Ab) and MDR Pseudomonas aeruginosa. Antimicrobial susceptibility testing and molecular detection of resistance genes were performed. Risk factors for colonization by carbapenemase-producing bacteria (CPB) were determined by univariate and multivariate analysis.

RESULTS

A total of 760 LTCF residents were recruited. The prevalence of colonization by CPB was 9.3% (n = 71) with the following distribution: 35 (49.3%) K. pneumoniae, 26 (36.6%) MDR-Ab, 17 (23.9%) E. coli, and 1 (1.4%) C. koseri. In addition, the prevalence of colonization by MRSA was 28.1% (n = 215) and only one case of VRE was isolated. Multivariate analysis identified male sex (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.86-3.11; P = 0.01), having a high health requirement (OR, 6.32; 95% CI, 1.91-20.92; P = 0.003) and previous hospitalization (OR, 3.60; 95% CI, 1.59-8.15 P = 0.002) as independent risk factors for CPB rectal carriage.

CONCLUSIONS

LTCFs are an important reservoir for MDRO, including CPB. We have identified some predictors of colonization by CPB, which enable a more targeted management of high-risk residents. Antimicrobial stewardship programmes and infection control preventive measures are needed to stop acquisition and transmission of MDRO.

Molecular Epidemiology of Staphylococcus aureus and MRSA in Bedridden Patients and Residents of Long-Term Care Facilities

At present, multidrug-resistant microorganisms are already responsible for community-acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) poses a serious public health risk worldwide because of the rapid spread and diversification of pandemic clones that are characterized by increasing virulence and antimicrobial resistance. The aim of this study was to identify the prevalence and factors associated with nasal, oral and rectal carriage of S. aureus and MRSA in bedridden patients and residents of long-term care facilities for the elderly (LTCFs) in Botucatu, SP, Brazil. Nasal, oral and rectal swab isolates obtained from 226 LTCF residents or home-bedridden patients between 2017 and 2018 were submitted to susceptibility testing, detection of the mecA gene, SCCmec characterization, and molecular typing by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Logistic regression analysis was used to identify risk factors associated with the presence of S. aureus and MRSA. The prevalence of S. aureus and MRSA was 33.6% (n = 76) and 8% (n = 18), respectively. At the nine LTCFs studied, the prevalence of S. aureus ranged from 16.6% to 85.7% and that of MRSA from 13.3% to 25%. Living in an LTCF, male gender, a history of surgeries, and a high Charlson Comorbidity Index score were risk factors associated with S. aureus carriage, while MRSA carriage was positively associated with male gender. This study showed a high prevalence of S. aureus among elderly residents of small (<15 residents) and medium-sized (15−49 residents) LTCFs and a higher prevalence of MRSA in the oropharynx.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Predictive value of surveillance cultures for bacteremia caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales among patients with hematological diseases

PURPOSE

Due to the increasing prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales, empirical therapies with cefepime or piperacillin/tazobactam for hematology patients with febrile neutropenia have become ineffective. Carbapenems should be administered as soon as possible in such patients with ESBL bacteremia. If the surveillance culture results are consistent with the blood culture findings, the time to adequate treatment initiation can be shortened.

METHODS

All consecutive patients with Enterobacterales bacteraemia who were admitted from January 2013 to December 2018 at the hematology wards were enrolled in this study. Surveillance rectal swab and blood culture results were compared.

RESULTS

In total, 67 patients with Enterobacterales bacteremia underwent surveillance culture prior to the onset of infection. Regarding the presence or absence of ESBL-producing Enterobacterales, 64 (95.5%) patients had surveillance results concordant with blood culture results. The positive predictive value of surveillance culture for bacteremia caused by ESBL-producing Enterobacterales was 95.0%. Moreover, the negative predictive value of surveillance culture for bacteremia caused by non-ESBL-producing Enterobacterales was 95.7%.

CONCLUSION

The concordance rate between the surveillance rectal swab and blood cultures was highly acceptable. Surveillance rectal swab cultures are useful for identifying patients at high risk for ESBL bacteremia.

Insights into the epidemiology of community-associated methicillin-resistant Staphylococcus aureus in special populations and at the community-healthcare interface

The current epidemic proportions of infections caused by Staphylococcus aureus strains and especially by methicillin-resistant S. aureus (MRSA) are one of today's many threats to global public health, particularly in underdeveloped countries where significant gaps on the subject exist. The rapid spread and diversification of pandemic clones that exhibit remarkably increasing virulence and antimicrobial resistance pose a risk to the effective prevention and treatment of a wide range of infections. Undoubtedly, the remarkable versatility involving the pathogenesis and resistance of these bacteria is perpetuated through geographic and temporal factors inherent to clonal evolution and is reflected in the dramatic epidemiological changes of MRSA which, after decades prevailing in healthcare settings, have emerged in the community. Denominated community-associated [CA]-MRSA, these strains are particularly prevalent in some population groups, facilitating the spread of successful clones that are potentially capable of triggering severe community-acquired infections. Therefore, a broad approach to local epidemiological aspects in less studied regions, but nonetheless at latent risk of endemic spread that may reach global proportions, is necessary. In Brazil, despite limited molecular epidemiology data, CA-MRSA strains predominantly characterized as SCCmec IV, often classified as CC30-ST30, CC5-ST5 and CC8-ST8, seem to be spreading across different population groups in different regions of the country. Another important fact addressed in this review is the identification of the ST398-MRSA-IV/V clone and methicillin-susceptible S. aureus (MSSA) in healthy individuals from the community. Although susceptible to methicillin, the ST398 clone is associated with severe infections in humans and animals, denominated livestock-associated MRSA. It is therefore important to encourage assertive actions by all government sectors and by society, with a reassessment of current public health measures in light of the new perspectives arising from the scientific and epidemiological data on MRSA.

Rectal Colonization by Drug Resistant Bacteria in Nursing Home Residents in Crete, Greece

(1) Background: In an area with a high prevalence of multi-drug resistant Gram-negative bacteria (MDR-GNB), we investigated the colonization of nursing home residents by such organisms. (2) Methods: A point prevalence study was performed in six nursing homes of the Heraklion area on the island of Crete. A rectal swab was taken and cultured from each participant, while additional risk factors such as recent hospitalization or antimicrobial usage were recorded and evaluated. (3) Results: A total of 137 nursing home residents were included in the study. Their mean age was 82.1 years and 19.7% were males. In total, cultures yielded 255 GNB; E. coli, K. pneumoniae and P. aeruginosa were the most common. Among the microorganisms cultured, 17.6% had the extended-spectrum beta-lactamase phenotype, while 18% were MDR. A statistically significant association was found between recent antimicrobial use and colonization by MDR-GNB; (4) Conclusions: Colonization by MDR-GNB was found to be highly prevalent in nursing home residents. Recent antimicrobial use was associated with MDR-GNB carriage.

Prevalence and Risk Factors for Multidrug-Resistant Organisms Colonization in Long-Term Care Facilities Around the World: A Review

Elderly people confined to chronic care facilities face an increased risk of acquiring infections by multidrug-resistant organisms (MDROs). This review presents the current knowledge of the prevalence and risk factors for colonization by MDROs in long-term care facilities (LTCF), thereby providing a useful reference to establish objectives for implementing successful antimicrobial stewardship programs (ASPs). We searched in PubMed and Scopus for studies examining the prevalence of MDROs and/or risk factors for the acquisition of MDROs in LTCF. One hundred and thirty-four studies published from 1987 to 2020 were included. The prevalence of MDROs in LTCF varies between the different continents, where Asia reported the highest prevalence of extended-spectrum ß-lactamase (ESBL) Enterobacterales (71.6%), carbapenem resistant (CR) Enterobacterales (6.9%) and methicillin-resistant Staphylococcus aureus (MRSA) (25.6%) and North America the highest prevalence to MDR Pseudomonas aeruginosa (5.4%), MDR Acinetobacter baumannii (15.0%), vancomycin-resistant Enterococcus spp. (VRE) (4.0%), and Clostridioides difficile (26.1%). Furthermore, MDRO prevalence has experienced changes over time, with increases in MDR P. aeruginosa and extended spectrum ß-lactamase producing Enterobacterales observed starting in 2015 and decreases of CR Enterobacterales, MDR A. baumannii, VRE, MRSA and C. difficile. Several risk factors have been found, such as male sex, chronic wounds, the use of medical devices, and previous antibiotic use. The last of these aspects represents one of the most important modifiable factors for reducing colonization with MDROs through implementing ASPs in LTCF.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

Prevention of the spread of multidrug-resistant organisms in nursing homes

The increase in the aged population led to a global rise in the demand for elderly healthcare services, such as long-term care facilities (LTCFs), nursing homes, residential homes. Unfortunately, the spread of multidrug-resistant organisms (MDROs) in these structures represent an urgent public health threat requiring immediate action. The aim of this review is to provide a practice guide for the prevention of infections in European LTCFs. A team of experts identify specific problems and proposed practical solutions for the management of colonized and infected patients residing in LTCFs. The heterogeneity of LTCF represents one of the main problems for the implementation of standardized surveillance and infection control programs. Crucial steps involved in the spread of infections among LTCF residents are represented by patient's accommodation, MDRO screening on admission, management of patients with rectal colonization by MDROs, management of patients at high risk of MDRO infections, MDRO transmission by staff and implementation of antimicrobial stewardship. Efforts to implement specific actions in each of these fields are required to reduce the infections in this setting.

Transmission and Long-Term Colonization Patterns of Staphylococcus aureus in a Nursing Home

Nursing homes might create an environment favorable for the transmission of Staphylococcus aureus because of the presence of hospitalized elderly, overcrowding and close contacts among people. We aimed at identifying risk factors for S. aureus colonization and determining the genetic relatedness of isolates demonstrating transmission among people. We investigated 736 swab samples from 92 residents and personnel for the presence of S. aureus. Swabs from anterior nares and throat were collected quarterly (2018) in a nursing home located in Poland. Genotyping was conducted using the multi-locus variable number of tandem repeats fingerprinting (MLVF) method. We observed high seasonal variation in the proportion of participants colonized with methicillin-resistant Staphylococcus aureus (MRSA) strains (0% to 13.5%). A multivariate analysis revealed that residents aged more than 85 years old are at risk for becoming intermittent S. aureus carriers (p = 0.013). The MLVF analysis revealed a high genetic diversity among methicillin-sensitive S. aureus (MSSA) strains and close genetic relatedness between MRSA strains. We proved the advanced aged were predisposed to intermittent S. aureus carriage. Genotyping revealed the transmission of S. aureus among the participants living in a closed environment. A high genetic relatedness among isolated MRSA suggests its clonal spread in the nursing home.

Prevalence and Molecular Genetics of Methicillin-Resistant Staphylococcus aureus Colonization in Nursing Homes in Saudi Arabia

Objective

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the main causative agents of nosocomial infections that has posed a major threat to those with compromised immune systems such as nursing home residents. The aim of this study was to determine the rates of MRSA strains and the types of Staphylococcal Cassette Chromosome mec (SCCmec)in nursing homes in Saudi Arabia.

Methods

A total of 188 nasal swabs were collected from the residents and nursing staff in two nursing homes in Riyadh, Saudi Arabia. All MRSA isolates were tested for antimicrobial susceptibility and analyzed for mecA and SCCmec typing by multiplex PCR assay. Detection of the Panton–Valentine leukocidin (PVL) gene was also tested in all positive MRSA isolates by multiplex PCR using specific primers.

Results

Among the 188 collected nasal swabs (105 males and 83 females), MRSA colonization rate was 9.04% (11 (5.85%) females and 6 (5.71%) males). About 47% of MRSA were multidrug resistant (MDR) as acquired resistance to beta-lactam, macrolide, and aminoglycoside antibiotics. However, all the MRSA isolates showed susceptibility to vancomycin, tigecycline, and linezolid. All the MRSA isolates (n = 17) were mecA-positive with the SCCmec IVc (n = 7, 41.18%) as the most common SCCmec type followed by SCCmec V (n = 5, 29.41%) and SCCmec IVa (n = 2, 11.76%). The remaining isolates (n = 3) were nontypeable (17.65%). In addition, the PVL toxin gene was only detected in four of the male samples.

Conclusion

MRSA nasal colonization is a common incident among nursing home residents. The prevalence of community-associated (CA) MRSA (SCCmec IV and V) was more common than hospital-associated (HA) MRSA in our study samples. It is crucial to investigate such rate of incidence, which is a key tool in preventive medicine and would aid in determining health policy and predict emergent outbreaks.

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.

Citrobacter freundii Foodborne Disease Outbreaks Related to Environmental Conditions in Yazd Province, Iran

BACKGROUND

The aim of this study was to assess associations of Citrobacter freundii foodborne outbreaks with environmental factors in various regions of Yazd Province, Iran, 2012-2016.

METHODS

The public health surveillance data were used for one period of five years reported foodborne disease outbreaks in various regions of the Province. Multilevel regression statistical method was used to analyze associations of climatic and demographic variables with outbreaks. Significant associations were tested using likelihood ratio tests.

RESULTS

Results showed a significant association between C. freundii outbreaks and air dust conditions, age groups and various regional cities.

CONCLUSION

The current study revealed necessity of etiologic agent identification for use in foodborne disease outbreak guidance in future outbreaks. Systemic surveillance schemes can help prevent and control similar scenarios using reports of environmental effects on foodborne disease outbreaks.

Prevalence of multidrug-resistant organisms in nursing homes in Belgium in 2015

Objectives

Following two studies conducted in 2005 and 2011, a third prevalence survey of multidrug-resistant microorganisms (MDRO) was organised in Belgian nursing homes (NHs) using a similar methodology. The aim was to measure the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase producing Enterobacteriaceae (ESBLE) and carbapenemase-producing Enterobacteriaceae (CPE) in NH residents. Risk factors for MDRO carriage were also explored.

Methods

Up to 51 randomly selected residents per NH were screened for MDRO carriage by trained local nurses between June and October 2015. Rectal swabs were cultured for ESBLE, CPE and VRE, while pooled samples of nose, throat and perineum and chronic wound swabs were obtained for culture of MRSA. Antimicrobial susceptibility testing, molecular detection of resistance genes and strain genotyping were performed. Significant risk factors for MDRO colonization MDRO was determined by univariate and multivariable analysis.

Results

Overall, 1447 residents from 29 NHs were enrolled. The mean weighted prevalence of ESBLE and MRSA colonization was 11.3% and 9.0%, respectively. Co-colonization occurred in 1.8% of the residents. VRE and CPE carriage were identified in only one resident each. Impaired mobility and recent treatment with fluoroquinolones or with combinations of sulphonamides and trimethoprim were identified as risk factors for ESBLE carriage, while for MRSA these were previous MRSA carriage/infection, a stay in several different hospital wards during the past year, and a recent treatment with nitrofuran derivatives. Current antacid use was a predictor for both ESBL and MRSA carriage.

Conclusions

In line with the evolution of MRSA and ESBL colonization/infection in hospitals, a decline in MRSA carriage and an increase in ESBLE prevalence was seen in Belgian NHs between 2005 and 2015. These results show that a systemic approach, including surveillance and enhancement of infection control and antimicrobial stewardship programs is needed in both acute and chronic care facilities.

Antibiotic resistance in Swiss nursing homes: analysis of National Surveillance Data over an 11-year period between 2007 and 2017

Background

We evaluated data from isolates of nursing home (NH) patients sent to the Swiss centre for antibiotic resistance (ANRESIS). We focussed on carbapenem-resistance (CR) among Gram-negative pathogens, extended-spectrum cephalosporin-resistant (ESC-R) Escherichia coli/Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), and glycopeptide-resistant enterococci (GRE).

Methods

NH patient isolates from 01/2007 to 10/2017 were extracted. Temporal trends in resistance were described and risk factors associated with ESC-R and MRSA were assessed. For every administrative subdivision in Switzerland (i.e. canton), we calculated a coverage rate, defined as number of beds of governmentally-supported nursing homes, which sent ≥1 isolate in each 2014, 2015, and 2016, divided by the total number of supported beds.

Results

We identified 16'804 samples from 9'940 patients. A majority of samples (12'040; 71.6%) originated from the French/Italian speaking part of Switzerland. ESC-R E. coli increased from 5% (16/299) in 2007 to 22% (191/884) in 2017 (P < 0.01), whereas MRSA decreased from 34% (35/102) to 26% (21/81) (P < 0.01). Provenience from the German (vs. French/Italian) speaking part of Switzerland was associated with decreased risk for ESC-R (OR 0.5, 95% CI 0.4-0.7) and for MRSA (OR 0.1, 95% CI 0.1-0.2). CR among Pseudomonas aeruginosa was 10% (105/1096) and showed an increasing trend over time; CR among Enterobacteriaceae (37/12'423, 0.3%) and GRE (5/1'273, 0.4%) were uncommon. Overall coverage rate was 9% (range 0-58% per canton). There was a significant difference between the French/Italian (median 13%, interquartile range [IQR] 4-43%) and the German speaking cantons (median 0%, IQR 0-5%) (P = 0.02).

Conclusions

ESC-R among E. coli is emerging in Swiss NHs, whereas MRSA show a declining trend over time. A minority of NHs are represented in ANRESIS, with a preponderance of institutions from the French/Italian speaking regions. Efforts should be undertaken to improve resistance surveillance in this high-risk setting.

Colonization of long-term care facility residents in three Italian Provinces by multidrug-resistant bacteria

Background

Rationale and aims of the study were to compare colonization frequencies with MDR bacteria isolated from LTCF residents in three different Northern Italian regions, to investigate risk factors for colonization and the genotypic characteristics of isolates. The screening included Enterobacteriaceae expressing extended-spectrum β-lactamases (ESβLs) and high-level AmpC cephalosporinases, carbapenemase-producing Enterobacteriaceae, Pseudomonas aeruginosa or Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).

Methods

Urine samples and rectal, inguinal, oropharyngeal and nasal swabs were plated on selective agar; resistance genes were sought by PCR and sequencing. Demographic and clinical data were collected.

Results

Among the LTCF residents, 75.0% (78/104), 69.4% (84/121) and 66.1% (76/115) were colonized with at least one of the target organisms in LTCFs located in Milan, Piacenza and Bolzano, respectively. ESβL producers (60.5, 66.1 and 53.0%) were highly predominant, mainly belonging to Escherichia coli expressing CTX-M group-1 enzymes. Carbapenemase-producing enterobacteria were found in 7.6, 0.0 and 1.6% of residents; carbapemenase-producing P. aeruginosa and A. baumannii were also detected. Colonization by MRSA (24.0, 5.7 and 14.8%) and VRE (20.2, 0.8 and 0.8%) was highly variable. Several risk factors for colonization by ESβL-producing Enterobacteriaceae and MRSA were found and compared among LTCFs in the three Provinces. Colonization differences among the enrolled LTCFs can be partially explained by variation in risk factors, resident populations and staff/resident ratios, applied hygiene measures and especially the local antibiotic resistance epidemiology.

Conclusions

The widespread diffusion of MDR bacteria in LTCFs within three Italian Provinces confirms that LTCFs are an important reservoir of MDR organisms in Italy and suggests that future efforts should focus on MDR screening, improved implementation of infection control strategies and antibiotic stewardship programs targeting the complex aspects of LTCFs.

Evaluation of the Swabbing of Disposable Absorbent Incontinence Products for Assessing the Carriage of Multiresistant Enterobacteriaceae in Nursing Home Residents

We compared the performance of incontinence product (IP) and rectal swabbing for the detection of multidrug-resistant Enterobacteriaceae (MDRE) carriage in a large multicenter study conducted in February 2017 among the residents of 23 French nursing homes. The study included 547 residents who habitually wore IP, 88 of whom were MDRE carriers (16.1%). Positive results were obtained for both rectal and IP swabs for 64 of these residents, for rectal swabs only for 22 and for IP swabs only for two of these patients. The estimated prevalence of MDRE carriage depended on the type of sample: 15.7% for rectal swabs and 12.1% for IP swabs (p < 0.001). The positive percent agreement was 84.2% and the negative percent agreement was 97.4%. Rectal swabbing remains the best method for detecting MDRE carriage in elderly residents, but our findings provide support for the use of swabs from IP used overnight to increase response rates in MDRE surveys in elderly residents that habitually wear IP, when rectal swabbing is not feasible.

Extended-spectrum β-lactamase-producing Enterobacteriaceae colonisation in long-term care facilities: a systematic review and meta-analysis

The objectives of this study were to estimate the colonisation rate by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) among residents of long-term care facilities (LTCFs) and to identify pertinent risk factors. A systematic search of PubMed and EMBASE databases for studies published up to May 2016 that provided raw data for gastrointestinal colonisation by ESBL-PE among LTCF residents was performed. Twenty-three studies reporting data on 9775 screened subjects met the inclusion criteria. The pooled prevalence of ESBL-PE among LTCF residents was 18% [95% confidence interval (CI) 12-24%]. Risk factors for colonisation included recent antibiotic use (within 6 months) [odds ratio (OR) = 2.06, 95% CI 1.78-2.38], previous hospitalisation (within 2.5 years) (OR = 1.50, 95% CI 1.04-2.15), history of invasive procedures (within 2 years) (OR = 2.79, 95% CI 1.66-4.70), previous ESBL-PE colonisation or infection (OR = 6.77, 95% CI 1.33-34.62), history of urinary tract infection (OR = 2.66, 95% CI 1.76-4.01) and urinary catheter use (OR = 2.55, 95% CI 1.29-5.04). In conclusion, almost one in five LTCF residents is colonised with ESBL-PE, and colonised residents are more likely to have a history of recent antibiotic use or healthcare facility utilisation. Strict adherence to antimicrobial stewardship in LTCFs is needed to address these high resistance rates.

Longitudinal genomic surveillance of multidrug-resistant Escherichia coli carriage in a long-term care facility in the United Kingdom

BACKGROUND

Residents of long-term care facilities (LTCF) may have high carriage rates of multidrug-resistant pathogens, but are not currently included in surveillance programmes for antimicrobial resistance or healthcare-associated infections. Here, we describe the value derived from a longitudinal epidemiological and genomic surveillance study of drug-resistant Escherichia coli in a LTCF in the United Kingdom (UK).

METHODS

Forty-five of 90 (50%) residents were recruited and followed for six months in 2014. Participants were screened weekly for carriage of extended-spectrum beta-lactamase (ESBL) producing E. coli. Participants positive for ESBL E. coli were also screened for ESBL-negative E. coli. Phenotypic antibiotic susceptibility of E. coli was determined using the Vitek2 instrument and isolates were sequenced on an Illumina HiSeq2000 instrument. Information was collected on episodes of clinical infection and antibiotic consumption.

RESULTS

Seventeen of 45 participants (38%) carried ESBL E. coli. Twenty-three of the 45 participants (51%) had 63 documented episodes of clinical infection treated with antibiotics. Treatment with antibiotics was associated with higher risk of carrying ESBL E. coli. ESBL E. coli was mainly sequence type (ST)131 (16/17, 94%). Non-ESBL E. coli from these 17 cases was more genetically diverse, but ST131 was found in eight (47%) cases. Whole-genome analysis of 297 ST131 E. coli from the 17 cases demonstrated highly related strains from six participants, indicating acquisition from a common source or person-to-person transmission. Five participants carried highly related strains of both ESBL-positive and ESBL-negative ST131. Genome-based comparison of ST131 isolates from the LTCF study participants with ST131 associated with bloodstream infection at a nearby acute hospital and in hospitals across England revealed sharing of highly related lineages between the LTCF and a local hospital.

CONCLUSIONS

This study demonstrates the power of genomic surveillance to detect multidrug-resistant pathogens and confirm their connectivity within a healthcare network.

Estimation of the incidence of MRSA patients: evaluation of a surveillance system using health insurance claim data

Because sentinel surveillance systems cannot obtain information about patients who visit non-sentinel medical facilities, the characteristics of patients identified by these systems may be biased. In this study, we evaluated the representativeness of a methicillin-resistant Staphylococcus aureus (MRSA) surveillance system using health insurance claim (HIC) data, which does not depend on physician notification. We calculated the age-specific incidence of MRSA patients using data from the Japan Nosocomial Infections Surveillance (JANIS) programme, which is based on sentinel surveillance systems, and inpatient HICs submitted to employee health insurance organizations in 2011, and then computed age-specific incidence ratios between the HIC and JANIS data. Age-specific MRSA incidence in both datasets followed J-shaped curves with similar shapes. For all age groups, the ratios between HIC and JANIS data were around 10. These findings indicate that JANIS notification of MRSA cases was not affected by patients’ age.

Colonization by multidrug-resistant organisms in long-term care facilities in Italy: a point-prevalence study

OBJECTIVES

To determine prevalence and risk factors for colonization by multidrug-resistant organisms (MDROs) in long-term care facility (LTCF) residents in Italy. Genotypes of MDRO isolates were investigated.

METHODS

A point-prevalence study was conducted at 12 LTCFs located in four Italian cities (2 February to 14 March 2015). Rectal swabs, faeces and nasal/auxiliary swabs were cultured for extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacteriaceae, Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) respectively. Antimicrobial susceptibility testing, detection of ESBL and/or carbapenemase genes and molecular typing of MDROs were performed. Risk factors for colonization were determined by univariate and multivariate analysis.

RESULTS

A total of 489 LTCF residents aged ≥65 years were enrolled. The prevalence of colonization by ESBL-producing Enterobacteriaceae, MRSA and C. difficile was 57.3% (279/487), 17.2% (84/487) and 5.1% (21/409) respectively. Carriage rate of carbapenemase-producing Enterobacteriaceae was 1% (5/487). Being bedridden was a common independent risk factor for colonization by all MDROs, although risk factors specific for each MDRO were identified. ESBL-producing Escherichia coli carriage was associated with the sequence type (ST) 131-H30 subclone, but other minor STs predominated in individual LTCF or in LTCFs located in the same city, suggesting a role for intrafacility or local transmission. Similarly, MRSA from LTCF residents belonged to the same spa types/ST clones (t008/ST8 and t032/ST22) commonly found in Italian acute-care hospitals, but infrequent spa types were recovered in individual LTCFs. The prevalent C. difficile PCR ribotypes were 356/607 and 018, both common in Italian acute-care hospitals.

CONCLUSIONS

MDRO colonization is common among residents in Italian LTCFs.

Presence of multidrug-resistant organisms in the residents and environments of long-term care facilities in Taiwan

OBJECTIVES

This study investigated the prevalence of multidrug-resistant organisms (MDROs) in the residents and environments of long-term care facilities (LTCFs) in Taiwan.

METHODS

We prospectively investigated the distribution of MDROs in residents of six LTCFs and their environments from January 2015 to December 2015 (intervention period). Active surveillance of colonization of MDROs was performed by culturing rectal and nasal swab samples every 3 months for the residents: 63, 79, and 73 in the first, second, and third surveillance investigations, respectively. If MDROs, including methicillin-resistant Staphylococcus aureus, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa, and MDR Acinetobacter baumannii were identified, then swab specimens from environmental sources were also collected and cultured. During the study period, several infection control measures were also implemented.

RESULTS

The overall infection density decreased significantly from 2.69 per 1000 patient-days in the preintervention (January 2014 to December 2014) to 2.39 per 1000 patient-days during the intervention period (p < 0.001). A total of 154 samples from residents and environmental sources were positive for MDROs. Methicillin-resistant S. aureus (n = 83, 53.9%) was the predominant organism, followed by carbapenem-resistant Enterobacteriaceae (n = 35, 22.7%), MDR A. baumannii (n = 30, 19.5%), and carbapenem-resistant P. aeruginosa (n = 6, 3.9%). The rates of detection of MDROs were 27.9% (60/215) in nasal swabs, 15.8% (34/215) in rectal swabs, and 11.1% (60/542) in the environmental sources.

CONCLUSIONS

The distribution and persistence of MDROs varied among the different LTCFs and time periods.

MRSA Prevalence and Risk Factors among Health Personnel and Residents in Nursing Homes in Hamburg, Germany - A Cross-Sectional Study

Introduction

The increase of multidrug-resistant organisms in hospitals causes problems in nursing homes. Staff in geriatric nursing homes are at greater risk of MRSA colonisation. The aim of the study was to describe the occupational exposure to MRSA among health personnel in geriatric nursing.

Methods

A point prevalence survey was conducted among health personnel and residents of geriatric nursing homes within the greater Hamburg district. Nasal swabs and, where relevant, wound swabs were collected for the screening survey. Risk factors for MRSA colonisation were identified by means of a questionnaire and using the files held on the residents. Where tests on nursing staff were positive, a control swab was taken; when the results were confirmed positive, decolonisation was performed. The responsible general practitioners were notified of positive MRSA findings among residents. A molecular biological examination of the MRSA samples was performed.

Results

A total of 19 institutions participated in the study. Nasal swabs were taken from 759 nursing staff and 422 residents. Prevalence of MRSA was 1.6% among staff and 5.5% among residents. MRSA colonisation among health personnel indicated a correlation with male gender (OR 4.5, 95% CI 1.4–14.1). Among the residents, chronic skin diseases (OR 3.2, 95% CI 1.0–10.3) and indwelling devices (OR 3.2, 95% CI 1.2–8.1) were identified as risk factors. No link between MRSA in residents and in health personnel could be established.

Conclusion

The number of MRSA colonisations among nursing staff and residents of geriatric nursing homes in Hamburg was rather low at 1.6% and 5.5% respectively and equates to the results of other surveys in non-outbreak scenarios.

Prolonged colonisation with Escherichia coli O25:ST131 versus other extended-spectrum beta-lactamase-producing E. coli in a long-term care facility with high endemic level of rectal colonisation, the Netherlands, 2013 to 2014

The extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli clone ST131 (ESBL-ST131) has spread in healthcare settings worldwide. The reasons for its successful spread are unknown, but might include more effective transmission and/or longer persistence. We evaluated the colonisation dynamics of ESBL-producing E. coli (ESBL-EC), including ESBL-ST131, in a long-term care facility (LTCF) with an unusually high prevalence of rectal ESBL-EC colonisation. During a 14-month period, rectal or faecal samples were obtained from 296 residents during six repetitive prevalence surveys, using ESBL-selective culture. Transmission rates, reproduction numbers, and durations of colonisation were compared for ESBL-ST131 vs other ESBL-EC. Furthermore, the likely time required for ESBL-ST131 to disappear from the LTCF was estimated. Over time, the endemic level of ESBL-ST131 remained elevated whereas other ESBL-EC returned to low-level prevalence, despite comparable transmission rates. Survival analysis showed a half-life of 13 months for ESBL-ST131 carriage, vs two to three months for other ESBL-EC (p < 0.001). Per-admission reproduction numbers were 0.66 for ESBL-ST131 vs 0.56 for other ESBL-EC, predicting a mean time of three to four years for ESBL-ST131 to disappear from the LTCF under current conditions. Transmission rates were comparable for ESBL-ST131 vs other ESBL-EC. Prolonged rectal carriage explained the persistence of ESBL-ST131 in the LTCF.

Proton Pump Inhibitor Use Is Associated With Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae Rectal Carriage at Hospital Admission: A Cross-Sectional Study

In this cross-sectional study, 8.5% of patients using proton pump inhibitors (PPIs) were rectal carriers of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E), compared with 2.9% of non-PPI users. In multivariable analysis, PPI use was independently associated with ESBL-E rectal carriage at hospital admission (adjusted odds ratio, 3.89; 95% confidence interval, 1.65 - 9.19).

Profiling the fecal carriage of β-lactamase genes in long-term care facility residents: A longitudinal study

BACKGROUND

The fecal carriage of β-lactamase (BL)-producing bacteria may play a major role in the spread of these organisms in long-term care facilities (LTCFs). The aims of this study were (1) to describe the gene profiles of fecal BL in 3 LCTFs in Taiwan and (2) to analyze the fecal carriage burden of BL genes between the residents (patient group) and staff (staff group) of LTCFs.

METHODS

Thirty fecal samples were collected during June 2013 and July 2015: 20 were obtained from 10 residents both during hospitalization (T1) and 1 month after discharge (T2), and 10 were obtained from 10 staff members.

RESULTS

In total, 80%, 70%, and 50% of the samples in the patient group at T1, staff group at T2, and patient group at T2, respectively, contained >2 BL genes. In the patient group, the predominant genes belonged to extended-spectrum BL genes (90%-100%) and AmpC BL genes (90%-100%). Furthermore, carbapenemase genes were approximately 20% during T1 and T2. The relative levels of SHV-type BLs were significantly higher (P < .05) in the patient group at T2 compared with the staff group.

CONCLUSIONS

In this study, we found a high carriage of fecal BLs among LTCF residents and staff. The monitoring of fecal BL carriage in LTCFs is needed for infection control measures and antibiotic choice for health care-associated infections.

Review on colonization of residents and staff in Italian long-term care facilities by multidrug-resistant bacteria compared with other European countries

BACKGROUND

Rates of colonization and infection with multidrug-resistant (MDR) bacteria are increasing worldwide, in both acute care hospitals and long-term care facilities (LTCFs). Italy has one of the highest prevalence of MDR bacteria in European countries, especially with regard to methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL) or carbapenemase producing Enterobacteriaceae (CPE).

METHOD

Review of studies on colonization by MDR bacteria from Italian LTCFs, risk factors for colonization and molecular characteristics of surveillance and clinical isolates, compared with other European countries.

RESULTS

High variability of MDR colonization has been reported within and especially between European countries. Only a few surveillance studies have been performed in Italian LTCFs; these show MRSA colonization prevalence of 7.8-38.7 % for residents and 5.2-7.0 % for staff members, ESBL prevalence of 49.0-64.0 % for residents and 5.2-14.5 % for staff and prevalence of CPE of 1.0-6.3 % for residents and 0.0-1.5 % for staff. In Italian LTCFs, as well as in other European countries, the most prevalent ESBLs from surveillance or clinical Escherichia coli isolates were found to be CTX-M-type enzymes, particularly CTX-M-15, expressed by the pandemic ST131 clonal group; this lineage also expresses carbapenemase genes of the blaVIM and blaKPC types. Various risk factors for colonization of residents by MDR bacteria were identified.

CONCLUSIONS

The limited data from Italian LTCFs confirms these settings as important reservoirs for MDR organisms, allowing important considerations regarding the infection risk by these organisms. Nevertheless, more extended and countrywide screening studies for MDR colonization in Italian LTCFs are required. To promote further studies of various microbiological aspects related to LTCFs, the Association of Italian Clinical Microbiologists (Associazione Microbiologi Clinici Italiani; AMCLI) in 2016 has set up a new Working Group for the Study of Infections in LTCFs (Gruppo di Lavoro per lo Studio delle Infezioni nelle Residenze Sanitarie Assistite e Strutture Territoriali assimilabili; GLISTer), consisting of Clinical Microbiologists represented by the authors of this review article.

The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time-Series Analysis

BACKGROUND

The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia.

METHODS

This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls.

RESULTS

A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile.

CONCLUSIONS

Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.

Not just a matter of size: a hospital-level risk factor analysis of MRSA bacteraemia in Scotland

Background

Worldwide, there is a wealth of literature examining patient-level risk factors for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. At the hospital-level it is generally accepted that MRSA bacteraemia is more common in larger hospitals. In Scotland, size does not fully explain all the observed variation among hospitals. The aim of this study was to identify risk factors for the presence and rate of MRSA bacteraemia cases in Scottish mainland hospitals. Specific hypotheses regarding hospital size, type and connectivity were examined.

Methods

Data from 198 mainland Scottish hospitals (defined as having at least one inpatient per year) were analysed for financial year 2007-08 using logistic regression (Model 1: presence/absence of MRSA bacteraemia) and Poisson regression (Model 2: rate of MRSA bacteraemia). The significance of risk factors representing various measures of hospital size, type and connectivity were investigated.

Results

In Scotland, size was not the only significant risk factor identified for the presence and rate of MRSA bacteraemia. The probability of a hospital having at least one case of MRSA bacteraemia increased with hospital size only if the hospital exceeded a certain level of connectivity. Higher levels of MRSA bacteraemia were associated with the large, highly connected teaching hospitals with high ratios of patients to domestic staff.

Conclusions

A hospital’s level of connectedness within a network may be a better measure of a hospital’s risk of MRSA bacteraemia than size. This result could be used to identify high risk hospitals which would benefit from intensified infection control measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1563-6) contains supplementary material, which is available to authorized users.

Methicillin-Resistant Staphylococcus aureus in Saarland, Germany: The Long-Term Care Facility Study

Background

Multiresistant organisms pose a threat for patients and care recipients. Control interventions need to be tailored to region, the type of institution considered, and risk factors. The German state of Saarland is ideally suited to study colonisation epidemiology throughout its various health and care institutions. After conclusion of a large admission prevalence study in acute care hospitals, we now performed a methicillin-resistant Staphylococcus aureus (MRSA) point prevalence study in Saarland long term care facilities (LTCF), allowing for a direct comparison with respect of MRSA prevalence and associated risk factors between these two institutional types located within a confined region.

Methodology and Principal Findings

Of all LTCF of the region, 65/136 participated in the study performed between 09/2013 and 07/2014. Overall, complete microbiological specimen and questionnaires of 2,858 of 4,275 (66.8%) LTCF residents were obtained. 136/2,858 (4.8%) screened residents revealed MRSA carrier status. Multivariate risk factor analysis yielded ulcer/deep soft tissue infection, urinary tract catheter, and MRSA history with multiple MRSA decolonisation cycles to be independently associated with MRSA carrier status.

Conclusion

As already known from previous studies, colonisation with MRSA is common in LTCF residents even in an area with relatively low MRSA prevalence. This found prevalence can now be related to the acute care admission prevalence (2.2%) as well as to the admission prevalence in acute care geriatric departments (7.6%). The common clonal attribution (spa type) of MRSA isolates prevalent in the LTCF population as well as in the acute care admission population points towards a close relationship between both types of institutions. However, the ostensible absence of risk factors such as “previous hospitalisation” in conjunction with newly identified factors such as “multiple decolonisation cycles” refers to MRSA colonisation risks independent of contact with acute care facilities. Overall, this large LTCF point prevalence study allows data-based, region-tailored decisions on MRSA screening policies and provides a basis for additional preventative measures.

Antimicrobial stewardship in long-term care facilities in Belgium: a questionnaire-based survey of nursing homes to evaluate initiatives and future developments

Background

The use of antimicrobials is intense and often inappropriate in long-term care facilities. Antimicrobial resistance has increased in acute and chronic care facilities, including those in Belgium. Evidence is lacking concerning antimicrobial stewardship programmes in chronic care settings. The medical coordinator practicing in Belgian nursing homes is a general practitioner designated to coordinate medical activity. He is likely to be the key position for effective implementation of such programmes. The aim of this study was to evaluate past, present, and future developments of antimicrobial stewardship programmes by surveying medical coordinators working in long-term care facilities in Belgium.

Methods

We conducted an online questionnaire-based survey of 327 Belgian medical coordinators.

The questionnaire was composed of 33 questions divided into four sections: characteristics of the respondents, organisational frameworks for implementation of the antimicrobial stewardship programme, tools to promote appropriate antimicrobial use and priorities of action. Questions were multiple choice, rating scale, or free text.

Results

A total of 39 medical coordinators (12 %) completed the questionnaire. Past or present antimicrobial stewardship initiatives were reported by 23 % of respondents. The possibility of future developments was rated 2.7/5. The proposed key role of medical coordinators was rated <3/5 by 36 % of respondents. General practitioners, nursing staff, and hospital specialists are accepted as important roles. The use of antimicrobial guidelines was reported by only 19 % of respondents. Education was considered the cornerstone for any future developments. Specific diagnostic recommendations were considered useful, but chest x-rays were judged difficult to undertake. The top priority identified was to reduce unnecessary treatment of asymptomatic urinary infections.

Conclusions

Our study shows that the implementation of an antimicrobial stewardship programme is reported only in a minority of nursing homes. The possibility of future developments is uncertain. Nevertheless, the self-selected medical coordinators who responded to the survey reported a good knowledge of this complex problem. Despite a lack of optimism, medical coordinators seem to have the appropriate competencies to play a key role in antimicrobial stewardship in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0106-7) contains supplementary material, which is available to authorized users.

The prevalence of ESBL-producing Enterobacteriaceae in a nursing home setting compared with elderly living at home: a cross-sectional comparison

Background

The aim of the study was to investigate the prevalence of faecal carriage of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae among residents living in nursing homes and to compare it with a corresponding group of elderly people living in their own homes.

Methods

A total of 160 persons participated in the study between February and April 2014, 91 were residents in nursing homes (n = 10) and the remaining 69 were elderly living in their own homes. In addition to performing faecal samples, all participants answered a standardized questionnaire regarding known risk factors for ESBL-carriage.

Results

There was no significant difference between the groups, as 10 of the 91 (11 %) residents from nursing homes were ESBL-carriers compared with 6 of 69 (8,7 %) elderly living in their own homes. There was no significant difference between the groups. The total prevalence was 10 %. A univariate analysis revealed that the only studied risk factor significantly associated with ESBL-carriage was recent foreign travel (p = 0,017). All ESBL-positive isolates were Escherichia coli and there was a high degree of co-resistance to other antibiotics. All isolates (n = 17) were susceptible to imipenem and amikacin.

Conclusion

Residents of nursing homes as well as elderly living in their own homes have high rates of faecal carriage of ESBL-producing bacteria. These findings may affect the choice of empirical antibiotic treatment of severe infections in older adults.

Carriage of beta-lactamase-producing Enterobacteriaceae among nursing home residents in north Lebanon

BACKGROUND

Multidrug-resistant (MDR) Enterobacteriaceae can cause severe infections with high morbidity, mortality, and health care costs. Individuals can be fecal carriers of these resistant organisms. Data on the extent of MDR Enterobacteriaceae fecal carriage in the community setting in Lebanon are very scarce. The aim of this study was to investigate the fecal carriage of MDR Enterobacteriaceae among the elderly residents of two nursing homes located in north Lebanon.

METHODS

Over a period of 4 months, five fecal swab samples were collected from each of 68 elderly persons at regular intervals of 3-4 weeks. Fecal swabs were subcultured on selective media for the screening of resistant organisms. The phenotypic detection of extended-spectrum beta-lactamase (ESBL), AmpC, metallo-beta-lactamase (MBL), and Klebsiella pneumoniae carbapenemase (KPC) production was performed using the beta-lactamase inhibitors ethylenediaminetetraacetic acid, phenylboronic acid, and cloxacillin. A temocillin disk was used for OXA-48. Multiplex PCRs were used for the genotypic detection of ESBL and carbapenemase genes, and sequencing was performed to identify CTX-M-15. The medical records of each subject were reviewed on a regular basis in order to assess the risk factors associated with MDR Enterobacteriaceae fecal carriage.

RESULTS

Over the study period, 76.5% of the recruited elderly persons were at least one-time carriers. A total of 178 isolates were obtained. Phenotypic testing revealed that 91.5% of them were ESBL producers, 4% were AmpC producers, 2.8% were co-producers of ESBL and AmpC, and 1.7% were co-producers of OXA-48 and ESBL. Recent antibiotic intake was found to be the only independent risk factor associated with the fecal carriage of MDR Enterobacteriaceae.

CONCLUSIONS

The high prevalence of MDR Enterobacteriaceae detected in this study and the emergence of carbapenem resistance is alarming. Efficient infection control measures and antibiotic stewardship programs are urgently needed in these settings in order to limit the spread of resistant strains.

[Healthcare-associated infections and antimicrobial use in long term care facilities (HALT-2): German results of the second European prevalence survey]

Prevention of infections and strategies for the prudent use of antimicrobials in long-term care facilities have gained importance in view of the demographic changes, not only in Germany. To generate appropriate data and to identify relevant aspects of infection prevention in this field, the European Centre for Disease Prevention and Control (ECDC) launched the second point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities in 2013 (HALT-2). Despite methodical adjustments in the collection of data on healthcare-associated infections, in this second survey healthcare workers in the participating facilities were intensively trained in methodology and data collection. Overall, 221 German facilities participated and collected data from 17,208 residents. Well-established structures of regional networks facilitated the recruitment of participants as well as the preparations for training and survey. The median prevalence of residents receiving at least one antimicrobial agent was 1.1% (95 %-CI 0,7-1,6)), which is remarkably low. However, the most frequently used antimicrobials in German facilities beside beta-lactams (penicillins 18.2%, other beta-lactams 17.2%) were quinolones (28.2%). Data collection of infections was performed based on signs and symptoms in detailed decision algorithms according to the recently updated McGeer surveillance criteria and yielded a median prevalence of 1.7% (95 %-CI 1,1-2,2). Symptomatic urinary tract infections (28.4%), skin and soft tissue infection (27.9%), and respiratory tract infections (24.7%) were identified both as the most common types of infections and the most common indications for the use of systemic antimicrobials. Clinical implications evolve mainly from the high use of quinolones. In terms of infection prevention measures, compliance of health care workers with a hand hygiene regimen revealed further potential for improvement.

Extensive dissemination of extended spectrum β-lactamase-producing Enterobacteriaceae in a Dutch nursing home

OBJECTIVE

Risk factors for rectal carriage of ESBL-E and transmission were investigated in an outbreak of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E).

DESIGN

Rectal carriage of ESBL-E was determined in a cross-sectional survey by culture of perianal swabs or fecal samples. Both phenotypical and genotypical methods were used to detect the production of ESBL. Nosocomial transmission was defined as the presence of genotypically related strains in ≥2 residents within the NH. Patient characteristics and variables in infection control practices were registered to investigate risk factors for transmission.

SETTING

A nursing home (NH) in the southern Netherlands.

PARTICIPANTS

Of 189 residents, 160 residents (84.7%) were screened for ESBL-E carriage. Of these 160 residents, 33 (20.6%) were ESBL-E positive. ESBL carriage rates varied substantially between wards (range, 0-47%). Four different ESBL-E clusters were observed. A bla CTX-M1-15 positive E. coli ST131 constituted the largest cluster (n=21) and was found in multiple wards (n=7).

RESULTS

Our investigation revealed extensive clonal dissemination of bla CTX-M1-15-positive E. coli ST131 in a nursing home. Unexplained differences in ESBL prevalence were detected among the wards.

CONCLUSIONS

As NHs constitute potential sources of multidrug-resistant bacteria, it is important to gain a better understanding of the risks factors and routes of transmission of ESBL-E.

Colonisation with ESBL-producing and carbapenemase-producing Enterobacteriaceae, vancomycin-resistant enterococci, and meticillin-resistant Staphylococcus aureus in a long-term care facility over one year

Background

This study examined colonisation with and characteristics of antimicrobial-resistant organisms among residents of a long-term care facility (LTCF) over one year, including strain persistence and molecular diversity among isolates of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.

Methods

Sixty-four residents of a LTCF were recruited (51 at baseline, 13 during the year). Data on dependency levels, hospitalisations, and antimicrobial prescribing were collected. Nasal and rectal swabs and catheter urine specimens were examined quarterly, using chromogenic agars, for ESBL-producing Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae (CPE), vancomycin-resistant enterococci (VRE), and meticillin-resistant S. aureus (MRSA). All ESBL-producing E. coli (ESBL-EC) were characterised by pulsed-field gel electrophoresis (PFGE) and PCR to assess for sequence type (ST) ST131, its resistance-associated H30 and H30-Rx subclones, and bla_CTX-M,bla_TEM,bla_SHV, and bla_OXA-1.

Results

The overall number of residents colonised, by organism, was as follows: ESBL-EC, 35 (55%); MRSA, 17 (27%); ESBL-producing K. pneumoniae (ESBL-KP), 5 (8%); VRE, 2 (3%) and CPE, 0 (0%). All 98 ESBL-EC isolates were H30-Rx ST131, with bla_{CTX-M-group 1.} By PFGE, a group of 91 ESBL-EC (from 33 participants) had ≥ 85% similar profiles and resembled UK epidemic strain A/ international pulsotype PFGE812. Sequential ESBL-EC from individual residents were closely related. Six ESBL-KP isolates, from five participants, had bla_{CTX-M-group 1} and by PFGE were closely related. Colonisation with ESBL and MRSA was associated with location within the LTCF and previous exposure to antimicrobials.

Conclusions

Among LTCF residents, colonisation with ESBL-EC and MRSA was common. All ESBL-EC were H30-Rx ST131, consistent with clonal dissemination.

Collateral benefit of screening patients for methicillin-resistant Staphylococcus aureus at hospital admission: isolation of patients with multidrug-resistant gram-negative bacteria

BACKGROUND

Surveillance at hospital admission for multidrug-resistant (MDR) gram-negative bacteria (GNB) is not often performed, potentially leaving patients carrying these organisms unrecognized and not placed in transmission precautions until they develop infection. Veterans Affairs (VA) facilities screen all admissions for methicillin-resistant Staphylococcus aureus (MRSA) and place positive patients in contact precautions. We assessed how often patients with MDR GNB in clinical cultures obtained within 30 days following admission would have been in contact precautions because of a positive MRSA admission screen.

METHODS

MRSA screening and MDR GNB culture results were extracted from a database of patients admitted to all VA acute care medical facilities from January 2009-December 2012.

RESULTS

Of patients with MDR GNB-positive cultures within 30 days following admission, up to 44.3% (dependent on bacterial species) would have been in contact precautions because of a clinical positive admission MRSA nasal screen. Admissions with a positive MRSA screen had odds for MDR GNB in a culture 2.5 times greater than those with a negative screen (95% confidence interval [CI], 2.4-2.6). Odds ratios were 2.4 (95% CI, 2.3-2.5) for MDR Enterobacteriaceae, 2.7 (95% CI, 2.5-2.9) for MDR Pseudomonas aeruginosa, and 4.3 (95% CI, 3.8-4.8) for MDR Acinetobacter spp.

CONCLUSIONS

Patients may be serendipitously placed in contact precautions for MDR GNB when isolated for a positive admission MRSA screen.

Extended-spectrum β-lactamase-producing Enterobacteriaceae in French nursing homes: an association between high carriage rate among residents, environmental contamination, poor conformity with good hygiene practice, and putative resident-to-resident transmission

OBJECTIVE

We evaluated the spread of multidrug-resistant Enterobacteriaceae in 38 nursing homes (NHs) in the Centre region of France.

METHODS

We conducted a multicenter prevalence study and evaluated extended-spectrum β-lactamase- and carbapenemase-producing Enterobacteriaceae (ESBLE and CPE, respectively) colonization of 1,155 residents. The colonizing isolates were studied by randomly amplified polymorphic DNA typing. We observed hygiene practices and studied the contamination of the environment in 8 NHs.

RESULTS

A total of 114 residents were ESBLE carriers (9.9%); none were CPE carriers. A total of 82.6% of the ESBLE were Escherichia coli. ESBLE colonization was associated with poor health status (P = .002), malignancy (P = .006), urinary incontinence (P = .007), fecal incontinence (P = .002), previous hospitalization (P = .033), and carbapenem treatment (P = .040). The clonal relationship between isolates within NHs suggested resident-to-resident ESBLE transmission in 15 NHs. ESBLE isolates were recovered from 6 of 232 bedrooms studied. A total of 1,533 observations revealed low rates of conformity for hand hygiene (25.7%), the use of gloves (45.9%) and protective clothing (13.3%), and waste management (46.7%). Conformity rates correlated inversely with ESBLE carriage rates.

CONCLUSIONS

In most of the participating NHs, improved application of standard precautions during incontinence care is needed, and greater efforts to clean the environment of residents are required.

Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus strains isolated in a multicenter study of nursing home residents in Croatia

BACKGROUND

Residents of nursing homes (NHs) are often hospitalized and could present a potential reservoir for methicillin-resistant Staphylococcus aureus (MRSA). The aim of the study was to determine the prevalence for MRSA carriage in residents and staff in Croatian NHs and to characterize MRSA strains using genotyping techniques.

METHODS

A cross-sectional study was performed among 877 residents and staff of 7 NHs representing 3 major Croatian regions. Nasal swabs from residents and staff and other samples from residents with invasive devices were obtained. Identified isolates were submitted to susceptibility testing and genotyping with SCCmec typing, S aureus protein A (spa) locus typing, and pulsed-field gel electrophoresis (PFGE).

RESULTS

The overall prevalence of MRSA colonization was 7.1% (95 confidence interval, 5.4%-8.8%), ranging from 0% to 28.8%. Four MRSA isolates were found in NH staff. All MRSA isolates were negative for Panton-Valentine leukocidin-encoding genes. SCCmec type II was found in 32 MRSA strains; SCCmec IV, in 27 strains; SCCmec I, in 3 strains. The predominant spa type was t008, found in 49 strains; PFGE analysis revealed 2 major clonal groups.

CONCLUSIONS

MRSA strains were found to be colonizing residents and staff of 7 NHs in Croatia. Our study demonstrates the spread of 2 clones within and among Croatian NHs. The data presented here provide an important baseline for future surveillance of MRSA in NH.

[Norovirus outbreaks in geriatric centers: importance of an early detection]

BACKGROUND AND OBJECTIVES

Acute gastroenteritis (AGE) outbreaks of norovirus (NV) occur frequently in nursing homes. Gastrointestinal disorders and degree of dependence of residents complicate early detection and implementation of control measures. Our study's aim was to determine the incidence of NV in elderly care centers, transmission mechanisms and circulating genotypes.

PATIENTS AND METHODS

An epidemiological study of NV outbreaks reported to the Public Health Agency of Barcelona 2010-2012 was performed. The attack rate, outbreak duration, symptomatology and identified NV genotypes were analyzed.

RESULTS

In total, 27 NV outbreaks were reported and 5 (18.5%) occurred in nursing homes (95 cases with lethality of 1.05%). The etiology of one of the five outbreaks could not be confirmed because of late notification. Four of the outbreaks were attributed to person-to-person transmission. The outbreak duration and attack rate among resident person-to-person transmission were significantly higher compared to common exposure transmission. Genotype GII.4 was predominant.

CONCLUSIONS

The identification of critical points and the use of clinical alarm systems could prevent and minimize the spreading and severity of these outbreaks.

Inguinal skin colonization with multidrug-resistant bacteria among residents of elderly care facilities: frequency, persistence, molecular analysis and clinical impact

Frequency, persistence and molecular characteristics of multidrug resistant bacteria colonizing inhabitants of long term care facilities are topics of current concern. We performed a point-prevalence survey of 402 residents in 7 elderly care facilities in Berlin, Germany. Inguinal swabs were analyzed for the presence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and multidrug-resistant gram-negative bacteria. Three and six months following the initial investigation, all colonized residents were sampled again and the occurrence of intercurrent infections, hospital admissions and use of antimicrobials were registered. Genetic relatedness of the bacteria was investigated using multi-locus sequence typing (MLST), spa-typing and SmaI/XbaI-macrorestriction analysis. 33 (8.2%) residents were skin-colonized with multidrug-resistant bacteria. MRSA were found in 19 (4.7%) and ESBL-producing Enterobacteriaceae in 16 residents (3.98%). Independent risk factors for colonization with multidrug-resistant bacteria were a high level of care and the presence of chronic wounds. A large proportion of the observed bacteria persisted up to six months and showed a high degree of inter-individual diversity. Outcome analysis revealed that infections tend to occur slightly more often in residents colonized by multiresistant pathogens. We assume that a perceptible population of residents in nursing homes is at risk for individual colonization with multidrug-resistant bacteria as well as healthcare associated infections.

Measuring the quality of infection control in Dutch nursing homes using a standardized method; the Infection prevention RIsk Scan (IRIS)

Background

We developed a standardised method to assess the quality of infection control in Dutch Nursing Home (NH), based on a cross-sectional survey that visualises the results. The method was called the Infection control RIsk Infection Scan (IRIS). We tested the applicability of this new tool in a multicentre surveillance executed June and July 2012.

Methods

The IRIS includes two patient outcome-variables, i.e. the prevalence of healthcare associated infections (HAI) and rectal carriage of Extended-Spectrum Beta-Lactamase (ESBL) producing Enterobacteriaceae (ESBL-E); two patient-related risk factors, i.e. use of medical devices, and antimicrobial therapy; and three ward-related risk factors, i.e. environmental contamination, availability of local guidelines, and shortcomings in infection prevention preconditions. Results were categorised as low-, intermediate- and high risk, presented in an easy-to-read graphic risk spider-plot. This plot was given as feedback to management and healthcare workers of the NH.

Results

Large differences were found among most the variables in the different NH. Common shortcomings were the availability of infection control guidelines and the level of environmental cleaning. Most striking differences were observed in the prevalence of ESBL carriage, ranged from zero to 20.6% (p < 0.001).

Conclusions

The IRIS provided a rapid and easy to understand assessment of the infection control situation of the participating NH. The results can be used to improve the quality of infection control based on the specific needs of a NH but needs further validation in future studies. Repeated measurement can determine the effectiveness of the interventions. This makes the IRIS a useful tool for quality systems.

Risk factors for methicillin resistant Staphylococcus aureus: a multi-laboratory study

Background

The present study aimed to investigate the dose response relationship between the prescriptions of antimicrobial agents and infection/colonization with methicillin resistant Staphylococcus aureus (MRSA) taking additional factors like stay in a health care facility into account.

Methods

Multi-centre retrospective study on a cohort of patients that underwent microbiological diagnostics in Belgium during 2005. The bacteriological results retrieved from 17 voluntary participating clinical laboratories were coupled with the individual antimicrobial consumption patterns (July 2004-December 2005) and other variables as provided by pooled data of health insurance funds. Multivariate analysis was used to identify risk factors for MRSA colonization/infection.

Results

A total of 6844 patients of which 17.5% died in the year 2005, were included in a logistic regression model. More than 97% of MRSA was associated with infection (clinical samples), and only a minority with screening/colonization (1.59%). Factors (95% CI) significantly (p≤<0.01) associated with MRSA in the final multivariate model were: admission to a long term care settings (2.79–4.46); prescription of antibiotics via a hospital pharmacy (1.30–2.01); age 55+ years (3.32–5.63); age 15–54 years (1.23–2.16); and consumption of antimicrobial agent per DDD (defined daily dose) (1.25–1.40).

Conclusions

The data demonstrated a direct dose-response relationship between MRSA and consumption of antimicrobial agents at the individual patient level of 25–40% increased risk per every single day. In addition the study indicated an involvement of specific healthcare settings and age in MRSA status.