Long-term care certification in infection prevention: The time is…now!

The complexity and risks of long-term care (LTC) resident care has continued to increase, including infection risk, as regulatory agencies and the LTC industry seek credible and knowledgeable infection preventionists for their facilities. Developing an LTC infection prevention and control certification exam indicates infection preventionists can proficiently manage infection prevention and control programs.

Diphtheria update

ABSTRACT

Travelers from parts of the world where diphtheria is endemic and vaccines are underutilized or unavailable may carry diphtheria, become ill, and spread the disease. This article provides an overview of diphtheria as well as management updates that are particularly critical amid new travel records and a climate of vaccine hesitancy.

Group A Streptococcal infections on the rise

ABSTRACT

Increasing cases of invasive group A Streptococcal (GAS) disease have been reported in Europe and the US, particularly after the relaxation of lockdowns and mitigation strategies related to the COVID-19 pandemic. This article provides an overview of GAS infection, with updates on testing, treatment, and patient education.

Diphtheria update

ABSTRACT

Travelers from parts of the world where diphtheria is endemic and vaccines are underutilized may carry diphtheria and become ill. This article provides an overview of diphtheria as well as management updates that are particularly critical amid a pandemic with healthcare disruptions and vaccine hesitancy.

A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents

IMPORTANCE

Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections.

OBJECTIVE

To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents.

DESIGN, SETTING, AND PARTICIPANTS

A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018.

INTERVENTIONS

Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death.

RESULTS

Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]).

CONCLUSIONS AND RELEVANCE

This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.

Recommendations for Mandatory Influenza Vaccinations for Health Care Personnel From AMDA's Infection Advisory Subcommittee

Preventing influenza infections is a national health priority, particularly among geriatric and adults with frailty who reside in post-acute and long-term care (PALTC) settings. Older adults account for more than 70% of deaths from influenza, a reflection of decreased vaccine effectiveness in that age group. Annually vaccinating health care personnel (HCP) working with these patients against influenza is critical to reducing influenza morbidity and mortality among patients. PALTC HCP have the lowest influenza vaccination rate when compared to HCP in other settings. The Advisory Committee on Immunization Practices recommends that all HCP receive an annual influenza vaccination, including those who do not have direct patient care responsibilities. Here, we discuss the importance of influenza vaccination for HCP, detail recommendations for influenza vaccination practice and procedures for PALTC settings, and offer support to PALTC settings and their staff on influenza vaccinations.

The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents

OBJECTIVE

To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality.

DESIGN

Two-round modified Delphi survey.

PARTICIPANTS

Expert panel of 19 clinical pharmacists.

MEASUREMENTS

Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score.

RESULTS

The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine).

CONCLUSION

An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents

Objectives:

To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in non-catheterized nursing home residents ≥ 65 years of age using consensus based methods informed by a literature review.

Design:

Literature review and modified Delphi survey with strict inclusion criteria.

Setting and Participants:

Expert panel of 20 physicians certified in geriatric medicine and / or medical direction, actively practicing in post-acute and long-term care settings.

Methods:

The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including non-specific “quality control” items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert scale (1= strongly disagree to 5= strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use.

Results:

The literature review identified 16 signs and symptoms that were evaluated in three Delphi survey rounds. The response rate was 100% for round one and 95% for the second two rounds. Consensus agreement for inclusion was achieved for dysuria on round one with exclusion of the three quality controls, and “offensive smelling urine”. Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round three evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached.

Conclusions/Implications

The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute / long-term care populations.

Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings

In response to a rising concern for multidrug resistance and Clostridium difficile infections, the Centers for Medicare and Medicaid services (CMS) will require all long-term care (LTC) facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in LTC facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA-The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the LTC setting. The intent of this policy, which can be adapted by individual facilities, is to help LTC facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in LTC settings, including a list of free resources to support those efforts.

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

IMPORTANCE

Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms.

OBJECTIVE

To develop, implement, and evaluate an intervention to reduce catheter-associated UTI.

DESIGN, SETTING, AND PARTICIPANTS

A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016.

INTERVENTIONS

The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication.

MAIN OUTCOMES AND MEASURES

Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist.

RESULTS

In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001).

CONCLUSIONS AND RELEVANCE

In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Evaluation of two organosilane products for sustained antimicrobial activity on high-touch surfaces in patient rooms

A controlled trial of applying 2 organosilane-based products with antimicrobial properties to high-touch surfaces was conducted in 9 patient rooms. Cultures of surfaces obtained before daily cleaning with a quaternary ammonium disinfectant showed no significant residual antimicrobial activity of the organosilane products, although a modest reduction could not be excluded.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility

BACKGROUND

Alcohol-based hand rubs play a key role in reducing the transmission of pathogens in acute care settings, especially as part of a comprehensive hand hygiene program. However, their use in long-term care facilities (LTCFs) has been virtually unstudied.

METHODS

Infection data, including those meeting McGeer et al and the Pennsylvania Patient Safety Authority's surveillance definitions, for lower respiratory tract infections (LRTIs) and skin and soft-tissue infections (SSTIs), as well as hospitalization data were collected in a 174-bed LTCF for 22 months (May 2009 to February 2011). In March 2010, a comprehensive hand hygiene program including increased product availability, education for health care personnel (HCP) and residents, and an observation tool to monitor compliance, was implemented.

RESULTS

Infection rates for LRTIs were reduced from 0.97 to 0.53 infections per 1,000 resident-days (P = .01) following the intervention, a statistically significant decline. Infection rates for SSTIs were reduced from 0.30 to 0.25 infections per 1,000 resident-days (P = .65). A 54% compliance rate was observed among HCP.

CONCLUSION

This study demonstrates that the use of alcohol-based hand rubs, as part of a comprehensive hand hygiene program for HCP and residents, can decrease infection rates in LTCFs.