Antimicrobial resistance and stewardship in long-term care settings

Antimicrobial prescribing in French nursing homes and interventions for antimicrobial stewardship: a qualitative study

BACKGROUND

Overuse of antibiotics is frequent in nursing homes (NHs) leading to adverse events and selection of resistant bacteria. Antimicrobial stewardship interventions showed heterogeneous effects on reducing inappropriate use of antimicrobials in NHs.

OBJECTIVES

This study aimed (1) to analyze antimicrobial prescribing determinants in NHs; (2) to identify which resources for antimicrobial prescribing are used by NHs' physicians (3) understand which antimicrobial stewardship interventions are required and how they should be implemented in NHs.

METHODS

We conducted individual semi-directed interviews with NHs' prescribing physicians in Ile-de-France, France. A thematic content analysis was conducted iteratively.

RESULTS

Thirteen interviews were conducted. Participants were mostly women, with a median age of 48 years and a median professional experience in NHs of three years. Participants included medical coordinators, general practitioners and salaried physicians. Main determinants of antimicrobial prescribing in NHs were the perceived risk of infectious complications and discomfort in residents, the difficulty in obtaining microbiological samples and the lack of healthcare professionals to monitor patients. Most participants reported using national guidelines and electronic decision support systems to guide their antimicrobial prescribing. Institutional constraints accentuate situations of doubt and prompt physicians to prescribe antimicrobials "just in case" despite the will to follow guidelines and the known risks of antimicrobial misuse. Physicians stated that proper antimicrobial use in NHs would require a major effort but was not judged a priority as compared to other medical issues. Producing guidelines tailored to the NH's context, performing good practice audits with feedback on antimicrobial prescribing, and reinforcing multidisciplinary relationships and discussions between city and hospital professionals were cited as potential interventions. The role of the medical coordinator was described as central. According to physicians, collaboration among stakeholders, providing support and training during the process might prove effective strategies to ensure successful implementation.

CONCLUSION

Antimicrobial prescribing is a complex decision-making process involving different factors and actors in NHs. Tailored guidelines, good practice audits, strengthened multidisciplinary collaboration were proposed as key AMS interventions. Physicians emphasized the central role of the medical coordinator supported by stakeholder engagement, collaboration, training and ongoing support for successful implementation.

Evaluating antimicrobial utilization in 20 Korean long-term care hospitals: a call to action for antimicrobial stewardship

BACKGROUND

Evaluation of hospital-specific antimicrobial use is necessary for successful national antimicrobial stewardship. This study aimed to identify antimicrobial use in long-term care hospitals (LCHs) in Korea.

METHODS

A multi-centre retrospective study was conducted to evaluate the prescription patterns and appropriateness of antimicrobials in 20 LCHs in Korea. The medical record data of hospitalized patients who were newly prescribed antimicrobials at each hospital were collected manually between 10th July and 31st October 2023 to evaluate the appropriateness of antimicrobial use.

RESULTS

The prevalence of antimicrobial prescriptions was 8.9% (365/4086) and 10.3% (402/3892) on 12th July 2023 and 18th October 2023, respectively. In total, 885 antimicrobials were prescribed to 740 patients. Among the antimicrobials, third- or fourth-generation cephalosporins (31.9%) represented the most prescribed antimicrobial class. A large majority of antimicrobials (96.6%, 855/885) were prescribed for the treatment of infectious diseases; however, only 37.7% (322/855) of antimicrobials were prescribed appropriately for infections. The route of administration, dosage and prescribed antimicrobial were appropriate in 99.6% (852/855), 56.1% (480/855) and 62.0% (530/855) of cases, respectively. In total, 35.2% (252/715) of patients were prescribed antimicrobials appropriately. The diagnosis of infectious disease was appropriate for 52.9% (472/892) of cases. Of the five, 15 and 10 antimicrobials used for surgical site infection prophylaxis, medical prophylaxis and other purposes, respectively, none were used appropriately.

CONCLUSION

The proportion of antimicrobials used appropriately is low in Korean LCHs. These data highlight the importance of establishing antimicrobial stewardship in LCHs.

Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study

BACKGROUND

Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention.

METHODS

We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate.

RESULTS

326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment).

CONCLUSIONS

An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT04798365.

Cross-border differences in the prevalence and risk factors for carriage of antimicrobial resistance in children attending daycare centers: a point prevalence study in the Netherlands and Belgium

BACKGROUND

Day care centres (DCCs) are ideal settings for drug-resistant bacteria to emerge. Prevalence numbers of faecal carriage of antimicrobial resistant bacteria in these settings are rare. We aimed to determine the prevalence of faecal antimicrobial resistant bacteria carriage in children attending DCCs and to assess and identify infection risk factors within DCCs in The Netherlands and Belgium.

METHODS

A point-prevalence study was conducted in 28 Dutch (499 children) and 18 Belgian (448 children) DCCs. Stool samples were taken from the children's diapers and a questionnaire was filled in by their parents. Hygiene related to stool and toilet use, hygiene related to food, environmental contamination, hand hygiene and hygiene guidelines were assessed conform a standardized questionnaire by the infection prevention and control expert visiting the DCC. Multilevel logistical regression analyses were used to define which characteristics predicted the presence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Enterobacterales (CipR-E).

RESULTS

The ESBL-E prevalence was 16% (n = 71) in Belgium and 6% (n = 30) in the Netherlands. The CipR-E prevalence was 17% (n = 78) in Belgium and 8% (n = 38) in the Netherlands. Antimicrobial use (RR: 0.30; 95% CI: 0.33-0.48) and hospital admissions (RR: 0.37; 95% CI: 0.25-0.54) were lower in the Netherlands. Children travelling to Asia were at higher risk of being an ESBL-E carrier. Children using antimicrobials were at higher risk of being a CipR-E carrier. Cleaning the changing mat after each use was found as a protective factor for CipR-E carriage.

CONCLUSIONS

We established a significant difference in ESBL-E and CipR-E carriage and antimicrobial use and hospital admissions between the Netherlands and Belgium among children attending DCCs. The differences between both countries should be further studied to improve the policy on anti-microbial use and hospital admissions in children.

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

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

Resistome and Virulome of Multi-Drug Resistant E. coli ST131 Isolated from Residents of Long-Term Care Facilities in the Northern Italian Region

Long-term care facilities (LTCFs) are important reservoirs of antimicrobial-resistant (AMR) bacteria which colonize patients transferred from the hospital, or they may emerge in the facility as a result of mutation or gene transfer. In the present study, we characterized, from a molecular point of view, 43 E. coli strains collected from residents of LTCFs in Northern Italy. The most common lineage found was ST131, followed by sporadic presence of ST12, ST69, ST48, ST95, ST410 and ST1193. All strains were incubators of several virulence factors, with iss, sat, iha and senB being found in 84%, 72%, 63% and 51% of E. coli, respectively. Thirty of the ST131 analyzed were of the O25b:H4 serotype and H30 subclone. The ST131 isolates were found to be mainly associated with IncF plasmids, CTX-M-1, CTX-M-3, CTX-M-15, CTX-M-27 and gyrA/parC/parE mutations. Metallo-β-lactamases were not found in ST131, whereas KPC-3 carbapenemase was found only in two ST131 and one ST1193. In conclusion, we confirmed the spread of extended-spectrum β-lactamase genes in E. coli ST131 isolated from colonized residents living inside LTCFs. The ST131 represents an incubator of fluoroquinolones, aminoglycosides and other antibiotic resistance genes in addition to different virulence factors.

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.

Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools

BACKGROUND

Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available.

METHODS

We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts.

RESULTS

A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement.

CONCLUSIONS

Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.

Assessment and management of urinary tract infections in aged care facilities

OBJECTIVES

To compare assessment and management of urinary tract infections (UTI) for residents in aged care facilities (ACF) with evidence-based infection criteria and recommended therapy.

METHODS

A retrospective clinical audit was conducted for all short-course antibiotics (SCA) prescribed to treat presumed UTIs (p-UTIs). Surveillance, microbiological and dispensing data determined whether p-UTIs met the revised McGeer criteria for infection and the extent to which SCAs complied with guideline recommendations.

RESULTS

Ten out of 74 (14%) p-UTIs were confirmed infections, that is met both the clinical and microbiological criteria for infection. Thirty-four out of 74 (46%) p-UTIs were classified as asymptomatic bacteriuria. The dose and frequency of the prescribed SCA were concordant with guideline recommendations for 87% and 85% of the courses, respectively; however, only 42% of the SCAs followed the recommended duration of therapy.

CONCLUSION

Overdiagnosis of UTIs and consequent overprescribing of antibiotics, specifically extended duration, are consistent with similar studies.

Recommendations for the surveillance of multidrug-resistant bacteria in Italian long-term care facilities by the GLISTer working group of the Italian Association of Clinical Microbiologists (AMCLI)

Long-term care facilities (LTCFs) are an important reservoir of multidrug-resistant organisms (MDROs). Colonization of LTCF residents by MDROs is generally higher in Italy compared to other European countries. The present review by the working group for the study of infections in LTCFs (GLISTer) of the Italian Association of Clinical Microbiologists (AMCLI) aims to propose criteria for a laboratory-based surveillance of MDROs in Italian LTCFs.We recommend the adhesion to three levels of laboratory-based MDROs surveillance in LTCFs: i) mandatory MDRO surveillance by cumulative retrospective analysis of antimicrobial susceptibility data, obtained as part of routine care of clinical specimens. ii) strongly recommended surveillance by active rectal swab cultures or molecular screening to determine colonization with carbapenemase-producing Enterobacterales, should a resident be proven infected. iii) voluntary surveillance by prospective MDRO surveys, mainly based on point prevalence colonization studies, allowing to determine the MDROs baseline prevalence in the facility.Laboratory-based surveillance of MDROs in LTCFs is aimed at providing useful epidemiological information to healthcare providers operating in the facility, but it is only effective if the collected data are used for infection prevention and control purposes, targeting the peculiar aspects of LTCFs.

Antibiotic prescribing for the older adult: beliefs and practices in primary care

BACKGROUND

Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population.

OBJECTIVES

To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults.

METHODS

Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach.

RESULTS

GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group.

CONCLUSIONS

Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

Antibiotic-prescribing and antibiotic-resistance patterns among elderly citizens residing in two Nordic regions

Objective: The objective of this study was to compare antibiotic-prescribing rates in 2016 and antibiotic-resistance rates in 2017 among citizens aged ≥85 years between the Capital Region in Denmark and the Skåne Region in Sweden, with regards to overall antibiotic use and antibiotics of choice for urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs). Methods: Inhabitants ≥85 year old on the date of prescription during 2016 and residing in the Capital Region or the Skåne Region were included for antibiotic-prescription analyses. Samples from 2017 from residents of the same regions who were ≥85 years old were included for antibiotic-resistance analyses. Antimicrobial use was determined according to the drugs of choice for UTIs and SSTIs in Denmark and Sweden. Students t-tests were used to compare antibiotic prescribing while a Chi-Squared test was performed to compare antibiotic resistance. Results: There was a significantly higher overall prescription rate among citizens ≥85 years in the Capital Region than in the Skåne Region. The same pattern was evident for the antibiotics of choice for UTIs and SSTIs except for clindamycin. Antibiotic resistance against all antibiotics included was more prominent in the Capital Region than in the Skåne Region. Conclusion: Considerable variation in antibiotic prescribing and resistance exists among elderly citizens between these two adjacent Nordic regions. Information and reflection on current practices and resistance patterns may direct attention towards antimicrobial stewardship as a higher priority and may help inform and motivate prescribing behaviours.

Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities

BACKGROUND

Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting.

OBJECTIVES

This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting.

SOURCE

PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively.

CONTENT

Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions.

IMPLICATIONS

There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.

The infection risk scan (IRIS): standardization and transparency in infection control and antimicrobial use

Background

Infection control needs user-friendly standardized instruments to measure the compliance to guidelines and to implement targeted improvement actions. This abstract describes a tool to measure the quality of infection control and antimicrobial use, the Infection Risk Scan (IRIS). It has been applied in a hospital, several nursing homes and a rehabilitation clinic in the Netherlands.

Method

The IRIS consists of a set of objective reproducible measurements, combining patient- and healthcare related variables, such as: hand hygiene compliance, environmental contamination using ATP measurements, prevalence of resistant microorganisms by active screening, availability of infection control preconditions, personal hygiene of healthcare workers, appropriate use of indwelling medical devices and appropriate use of antimicrobials. Results are visualized in a spider plot using traffic light colors to facilitate the interpretation.

Results

The IRIS provided ward specific results within the hospital that were the basis for targeted improvement programs resulting in measurable improvements. Hand hygiene compliance increased from 43% to 66% (more than 1000 observations per IRIS, p < 0.000) and ATP levels were significantly reduced (p < 0.000). In the nursing homes, large differences were observed with environmental contamination as common denominator. Most remarkable were the difference in Extended Spectrum Beta-Lactamase Enterobacteriaceae (ESBL-E) prevalence (mean 11%, range 0–21%).

Conclusion

The bundle approach and visualization of the IRIS makes it a useful infection prevention tool providing standardization and transparency. Targeted interventions can be started based on the results of the improvement plot and repeated IRIS can show the effect of interventions. In that way, a quality control cycle with continuous improvement can be achieved.

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.

Multidrug-resistant infections in long-term care facilities: extended-spectrum β-lactamase-producing Enterobacteriaceae and hypervirulent antibiotic resistant Clostridium difficile

Infections due to multidrug-resistant (MDR) organisms in long-term care facilities (LTCFs) residents constitute a public health concern. This multicenter study investigated the frequency of ESBL-producing pathogens and MDR Clostridium difficile in clinical specimens from LTCF residents in Italy. During October 2014-March 2015, all urine and diarrheic fecal samples from LTCF residents (≥65 years) with suspected urinary tract infection or C. difficile infection, respectively, received for diagnosis by 4 hospital laboratories located in different cities were analyzed. Antibiotic susceptibility testing, characterization of resistance genes, and molecular typing of pathogens were performed. Of 806 urine cultures collected from 626 residents at 44 different LTCFs, 492 were positive for microbial infection. Of these, 158 were positive for at least an ESBL-producing Enterobacteriaceae species (32.1%), with Escherichia coli as the most frequent ESBL pathogen (23.4%) followed by Klebsiella pneumoniae (4.5%). Furthermore, 4 carbapenemase producers (0.8%) (1 E. coli with VIM-1and 3 K. pneumoniae with KPC-3) were detected. The CTX-M-15 type ESBL predominated in both E. coli (71.3%) and K. pneumoniae (77.3%). Most E. coli isolates (82.6%) belonged to the ST131/H30 clone/subclone. For K. pneumoniae, ST307 and ST15 were frequent (31.8% and 22.7%, respectively), but isolates harboring bla_KPC-3 belonged to CC258. Of 136 diarrheic fecal samples collected from 111 residents at 26 different LTCFs, 21 (15.4%) were positive for toxigenic C. difficile; of these, 13 (62%) were MDR (resistant to 3 or more antimicrobial agents of different classes). The predominant C. difficile polymerase chain reaction ribotype was 356/607 (42.9%), followed by 018, 449, and 078 (14% each). Public health efforts are needed to contain the diffusion of CTX-M-producing Enterobacteriaceae and MDR C. difficile in LTCF settings.

Antimicrobial susceptibility of long term care facility and general practice urine samples in patients 65 years and older: an observational study

Background

Antimicrobial resistance in long-term care facilities (LTCFs) poses a risk to elderly residents. The aim of this observational study was to investigate recent patterns of antimicrobial susceptibility in urine samples submitted to the Microbiology Laboratory at Cork University Hospital (CUH) from LTCFs in the greater Cork region. The antimicrobial susceptibilities of LTCF and General Practitioner (GP) urine samples sent to CUH, for patients aged over 65 years of age, were compared.

Methods

A retrospective analysis of the antimicrobial susceptibilities of urine samples submitted to the microbiology laboratory at CUH in quarter one of 2011-2014 was conducted. LTCF and GP urine sample susceptibilities, for patients over 65 years of age, were compared using Chi square statistics.

Results

Overall, the LTCF urine samples were less susceptible than GP urine samples to the antimicrobials recommended in the national urinary tract infection guidelines; trimethoprim, nitrofurantoin, cephalexin, co-amoxiclav, ciprofloxacin and amoxicillin ( P < 0.001). Important trends in antimicrobial susceptibility over the time period were noted. A significant reduction in susceptibility to co-amoxiclav was found between Q1 2011 and Q1 2014 in both settings (GP P = 0.013, LTCF P = 0.005). This study provides important information which will contribute to the revision of antimicrobial prescribing guidelines in the future.

Conclusion

This study highlights the need for continuous surveillance of antimicrobial susceptibility trends in LTCFs. Antimicrobial stewardship strategies are urgently required to address antimicrobial resistance and appropriate antimicrobial prescribing in the LTCF setting.

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.

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.

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.

Evaluation of Remel Spectra CRE Agar for Detection of Carbapenem-Resistant Bacteria from Rectal Swabs Obtained from Residents of a Long-Term-Care Facility

We compared the Remel Spectra CRE agar plate to CDC standard methodology for the isolation of carbapenem-resistant Enterobacteriaceae (CRE) from 300 rectal swab specimens obtained from patients residing in a long-term-care facility (LTCF). Multiplex PCR experiments were performed on isolates to identify specific Klebsiella pneumoniae carbapenemases (KPC) and additional β-lactamases. Of the 300 patients, 72 (24%) harbored CRE and were PCR positive for KPC enzymes. The Remel Spectra CRE plates detected KPC-type CRE in isolates from 70 of 72 patients (97.2%), while the CDC method detected CRE in 56 of 72 (77.8%). CRE identification results were available in 18 h compared to 36 h for the CDC method. Remel Spectra CRE agar plates can provide useful means for a fast and reliable method for detecting KPC-type CRE and for accelerated institution of appropriate infection control precautions.

Effect of hand sanitizer location on hand hygiene compliance

BACKGROUND

Hand hygiene is the most important intervention to prevent infection in hospitals. Health care workers should clean their hands at least before and after contact with patients. Hand sanitizer dispensers are important to support hand hygiene because they can be made available throughout hospital units. The aim of this study was to determine whether the usability of sanitizer dispensers correlates with compliance of staff in using the sanitizer in a hospital. This study took place in a Midwest, 404-bed, private, nonprofit community hospital with 15 inpatient care units in addition to several ambulatory units.

METHODS

The usability and standardization of sanitizers in 12 participating inpatient units were evaluated. The hospital measured compliance of staff with hand hygiene as part of their quality improvement program. Data from 2010-2012 were analyzed to measure the relationship between compliance and usability using mixed-effects logistic regression models.

RESULTS

The total usability score (P = .0046), visibility (P = .003), and accessibility of the sanitizer on entrance to the patient room (P = .00055) were statistically associated with higher observed compliance rates. Standardization alone showed no significant impact on observed compliance (P = .37).

CONCLUSION

Hand hygiene compliance can be influenced by visibility and accessibility of dispensers. The sanitizer location should be part of multifaceted interventions to improve hand hygiene.

Bloodstream infections: epidemiology and resistance

Bloodstream infections in the neonatal intensive care unit (NICU) are associated with many adverse outcomes in infants, including increased length of stay and cost, poor neurodevelopmental outcomes, and death. Attention to the insertion and maintenance of central lines, along with careful review of when the catheters can be safely discontinued, can minimize central-line-associated bloodstream infections rates. Good antibiotic stewardship can further decrease the incidence of bloodstream infections, minimize the emergence of drug-resistant organisms or Candida as pathogens in the NICU, and safeguard the use of currently available antibiotics for future infants.

Strategies and challenges of antimicrobial stewardship in long-term care facilities

As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.