Controlling infection in British nursing homes. It is time for a national strategy

Infection control policies and procedures for meticillin-resistant Staphylococcus aureus in care homes for older people in Northern Ireland: a questionnaire study

ackground: Limited information is available regarding the role of infection control in the prevention of infection in nursing and residential care homes.

Objectives: To determine what infection control policies and procedures are in place in care homes for older people in Northern Ireland.

Methods: Anonymous postal questionnaire survey of all 410 nursing and residential homes in Northern Ireland that provide care to residents over the age of 65.

Results: A total of 318 (78%) questionnaires were returned. Visits from infection control nurses from health boards or community trusts were infrequent, with only 23% of homes receiving such a visit. Nearly all homes (99.7%) had a policy on infection control, with 72.4% and 84.3% of homes having a policy on the admission and care of residents with meticillin-resistant Staphylococcus aureus (MRSA) respectively. Of those respondents that had a policy on admission of persons with MRSA, only a small percentage (9.2%) would not admit residents with MRSA. Only 11% of respondents believed that MRSA was a problem in their particular home, but at least 30% agreed that there was a problem with MRSA in care homes. A desire was expressed for more information and support, with 75% of respondents agreeing that more information should be provided to homes on MRSA.

Conclusions: There is a clear need for additional infection control advice to be available to care homes and for the development of uniform policies and an infection control audit tool. The audit tool could then be used to ensure that the appropriate policies and standards are in place within care homes and that these standards are met on an ongoing basis.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library), Ovid MEDLINE, OVID MEDLINE (In-process and Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Web of Science and the Health Technology Assessment (HTA) website. Research in progress was sought through Current Clinical Trials, Gateway to Reseach, and HSRProj (Health Services Research Projects in Progress).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this third update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, involving residents and staff to test interventions that have been specifically designed for this unique environment.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 2), the Cochrane Wounds Group Specialised Register (searched May 27th, 2011). We also searched Ovid MEDLINE (from 1950 to April Week 2 2011), OVID MEDLINE (In-process and Other Non-Indexed Citations, April 26th 2011) Ovid EMBASE (1980 to 2011 Week 16), EBSCO CINAHL (1982 to April 21st 2011), DARE (1992 to 2011, week 16), Web of Science (1981 to May 2011), and the Health Technology Assessment (HTA) website (1988 to May 2011). Research in progress was sought through Current Clinical Trials (www.controlled-trials.com), Medical Research Council Research portfolio, and HSRPRoj (current USA projects).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this second update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.

Antimicrobial prescribing in European nursing homes

OBJECTIVES

The aim of this study was to investigate antimicrobial prescribing in nursing homes in countries across Europe.

METHODS

Point prevalence studies were completed in April and November 2009 in 85 nursing homes in 15 European countries and two UK administrations.

RESULTS

A total of 10,388 and 9430 residents participated in April and November 2009, respectively. The mean prevalence of antimicrobial prescribing in the nursing homes was 6.5% in April and 5.0% in November. The most commonly prescribed antimicrobials were methenamine (17.5%), trimethoprim (11.4%) and co-amoxiclav (11.1%) in April and co-amoxiclav (12.2%), nitrofurantoin (12.2%) and methenamine (11.5%) in November. There was large variation in the overall mean antimicrobial prescribing in the selected nursing homes from each of the contributing countries, ranging from 1.4% in Germany and Latvia to 19.4% in Northern Ireland in April and 1.2% in Latvia to 13.4% in Finland in November. Furthermore, differences in prescribing were apparent within countries with the largest variation evident in nursing homes in Northern Ireland (21.5%) in April and Finland in November (30.1%).

CONCLUSIONS

This is the first study to investigate antimicrobial prescribing in nursing homes in a large number of European countries. The findings suggest that there is considerable variation in antimicrobial prescribing in nursing homes across and within European countries. Nursing homes provide a significant service to the European community and must be supported in order to optimize antimicrobial use and limit the development of antimicrobial resistance.

Prevalence of methicillin-resistant Staphylococcus aureus colonization in residents and staff in nursing homes in Northern Ireland

OBJECTIVES

To determine the prevalence of, and factors associated with, methicillin-resistant Staphylococcus aureus (MRSA) colonization in residents and staff in nursing homes in one geographically defined health administration area of Northern Ireland.

DESIGN

Point prevalence study.

SETTING

Nursing homes.

PARTICIPANTS

Residents and staff in nursing homes.

MEASUREMENTS

Nasal swabs were taken from all consenting residents and staff. If relevant, residents also provided urine samples, and swabs were taken from wounds and indwelling devices.

RESULTS

A total of 1,111 residents (66% of all residents) and 553 staff (86% of available staff) in 45 nursing homes participated. The combined prevalence rate of MRSA in the resident population was 23.3% (95% confidence interval (CI)=18.8-27.7%) and 7.5% in staff (95% CI=5.1-9.9%). Residents who lived in nursing homes that were part of a chain were more likely to be colonized with MRSA (odds ratio (OR)=1.91, 95% CI=1.21-3.02) than those living in independently owned facilities. Residents were also more likely to be colonized if they lived in homes in which more than 12.5% of all screened healthcare staff (care assistants and nurses) were colonized with MRSA (OR=2.46, 95% CI=1.41-4.29) or if they lived in homes in which more than 15% of care assistants were colonized with MRSA (OR=2.64, 95% CI=1.58-4.42).

CONCLUSION

The findings suggest that there is substantial colonization of MRSA in nursing home residents and staff in this one administrative health area. Implementation of infection control strategies should be given high priority in nursing homes.

Effectiveness of short-term, enhanced, infection control support in improving compliance with infection control guidelines and practice in nursing homes: a cluster randomized trial

In this prospective cluster randomized controlled trial we evaluated the impact of short-term provision of enhanced infection control support on infection control practice in nursing homes in South London. Twelve nursing homes were recruited, six each in intervention (300 residents) and control (265 residents) groups. Baseline observations of hand hygiene facilities, environmental cleanliness and safe disposal of clinical waste showed poor compliance in both groups. Post-intervention observations showed improvement in both groups. There was no statistical difference between the two groups in the compliance for hand hygiene facilities (P=0·69); environmental cleanliness (P=0·43) and safe disposal of clinical waste (P=0·96). In both groups, greatest improvement was in compliance with safe disposal of clinical waste and the least improvement was in hand hygiene facilities. Since infection control practice improved in intervention and control groups, we could not demonstrate that provision of short-term, enhanced, infection control support in nursing homes had a significant impact in infection control practice.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

The objective of this review was to determine the effects of infection control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 1), the Cochrane Wounds Group Specialised Register (searched April 2007); the Infectious Diseases Group and EPOC also searched their Specialised Registers for this review (both May 2006). We also searched MEDLINE (from 1966 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March Week 3 2007), British Nursing Index (1985 to March 2007), DARE (1992 to March 2007), Web of Science (1981 to March 2007), and the Health Technology Assessment (HTA) database (1988 to March 2007). Research in progress was identified through the National Research Register, Current Clinical Trials (www.controlled-trials.com), Medical Research Council Register, Current Research in Britain (CRIB), and HSRPRoj (current USA projects). SIGLE was also searched in order to identify atypical material which was not accessible through more conventional sources.

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the results of the searches.

MAIN RESULTS

Since no studies met the selection criteria, neither a meta-analysis nor a narrative description of studies was possible.

AUTHORS' CONCLUSIONS

The lack of studies in this field is surprising. Nursing homes for older people provide an environment likely to promote the acquisition and spread of infection, with observational studies repeatedly reporting that being a resident of a nursing home increases the risk of MRSA colonisation. Much of the evidence for recently-issued United Kingdom guidelines for the control and prevention of MRSA in health care facilities was generated in the acute care setting. It may not be possible to transfer such strategies directly to the nursing home environment, which serves as both a healthcare setting and a resident's home. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.