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Infection control in non‐hospital settings: the example of long‐term and ambulatory
care facilitiesMaria Luisa Moro
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In the past, health care was delivered mainly in acute‐
care facilities. Today, health care is delivered in hospital,
outpatient, transitional care, long‐term care,
rehabilitative care, home, and private office settings.
Jarvis WR, EID 2001
Hospital
OutpatientAmbulatory
facility
Nursing homes
Rehabilitation hospital
Home care
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Dimension of exposure
Ministry of Health. Stato di salute e prestazioni Stato di salute e prestazioni
sanitarie nella popolazione anzianasanitarie nella popolazione anziana, 2000
0 5000 10000 15000 20000 25000 30000 35000 40000
struttureresidenziali
ospedale (placuti)
ospedale (plriabilitazione)
ospedale (pllungodegenza)
N° di giornate (in migliaia)
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LONG‐TERM CARE FACILITIES
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WhyWhy isis itit a challenge?a challenge?
The resident* Elderly are at higher risk of infection compared to younger adults(↑ 3 fold pneumonia, 20 fold UTI)
* Infections are difficult to identify in the elderly (fewer and non specific symptoms , fever blunt or absent)
Beinginstitutionalized
* Cross infections* Antimicrobialpressure
Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002
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Clinical Infectious Diseases 2009; 48:149–71
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ML MoroSource: ESAC website; Emori University. An agenda for research,2001
WhyWhy antimicrobialantimicrobial resistantresistant organismsorganisms are are increasingincreasing? ?
Antibiotic pressure
European PrevalenceSurvey, 2009
0 20 40 60 80 100
% appropriate prescriptions
Loeb
Zimmer
Montgomery
Jones
Appropriateness of antibiotic prescriptions
in LTCFs
Skin UTI RTI
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WhyWhy isis itit a challenge?a challenge?
The resident* Elderly are at higher risk of infection compared to younger adults(↑ 3 fold pneumonia, 20 fold UTI)
* Infections are difficult to identify in the elderly (fewer and non specific symptoms , fever blunt or absent)
Beinginstitutionalized
* Cross infections* Antimicrobialpressure
The Care Home context* Permanent domicile* Staffing: physicians visitinfrequent; nurse under‐staffing; under‐qualification; high turn‐over* Lack of diagnostic tools* Under the label « LTC »different facilities* Private facilities/industrialchains
Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002
Frequent transfers to otherhealth facilities
* Cross infections* Antimicrobial resistant bugs
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CID 2011
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The setting: permanent domicile
….there are many situations and therapeutic
intervention (community dining areas, bingo, crafts,
spontaneous hugs & kissing on the cheek and/or hand
holding, …) that occurred daily and do not fit with the
WHO’5 moments….
Schweon S, AJIC 2011
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Clinical Infectious Diseases 2009; 48:149–71
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WhyWhy isis itit a challenge?a challenge?
High frequency of infections* Incidence: 3‐7/1000 resident‐care days; Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak
Strausbaugh LJ, EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22)
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OutbreaksOutbreaks ofof infectionsinfections
Source: Utsumi M, Age and Aging 2010; 39:299
Microorganism Median attackrate %
Median case fatality rate %
Median duration
RSV 40 20 60
Norovirus 45 0 18
GAS 8 50
Sarcoptes scabei 70 120
37 pathogens associated with 206 outbreaksin Nursing Homes, 1996‐2008
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WhyWhy isis itit a challenge?a challenge?
High frequency of infections* Incidence: 3‐7/1000 resident‐care days; Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak
Elderly as « sentinelchickens »
«The first to be affected
by new or emerging
infections in hospital and
other healthcare
environments»
Strausbaugh LJ, EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22)
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ElderlyElderly are are ““sentinelsentinel chickenchicken””
«The first to be affected by new or emerging infections in
hospital and other healthcare environments»
Source: Strausbaugh LJ, EID 2001; Birgand G, Eurosurv 2010
Large outbreak of Clostridium difficile infections (CDIs), PCR‐
ribotype 027; Northern France.
38 healthcare facilities, 529 CDIs over a 22‐month period (281
laboratory‐confirmed CDI 027)
The cases occurred mainly in long‐term care hospital
facilities and nursing homes, near the border between France
and Belgium.
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WhyWhy isis itit a challenge?a challenge?
High frequency of infections* Incidence: 3‐7/1000 resident‐care days; Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak
Elderly as « sentinelchickens »
«The first to be affected
by new or emerging
infections in hospital and
other healthcare
environments»
Antimicrobial resistance* colonization/infection with AMR organisms is frequent (varies according to geographical
location, type of care, patient
population)
* common AMR organisms (MRSA, MDR gram‐neg,
Enterobacteriaceae,
Pseudomonas, Acinetobacter)
* increasing trends
Strausbaugh LJ, EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22)
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WhyWhy isis itit a challenge?a challenge?
Prevalence of colonization with MRSA in LTCFs
4 Namnyak S, J Infect 1998; 5 von Baum H ICHE 2002; 6 Barr B, ICHE 2007; 7 Manzur A, CMI2008; 8 Denis O, JAC 2010; 9 Brugnaro P, Infection 2009
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Antimicrobial resistant isolates in urine cultures (Emilia‐Romagna Region, 4 mil inhab)
Micro‐organism
Resistant to % patientshospit.> 2
days
% residentsLTCFs
E.coli 3° gen. ceph.Cipro/levo.
2340
3661
Proteusmirabilis
3° gen. ceph.Cipro/levo.
4245
5659
Klebsiellapneumoniae
3° gen. ceph.Cipro/levo.
3332
3032
Source: ASSR. Report data 2009, Emilia‐Romagna
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New New ””multidrugmultidrug resistantresistant bugsbugs””
A‐nursing home;
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FactorsFactors associatedassociated withwith AMR in the AMR in the elderlyelderly• Transfer to the LTCF of patients who are colonized or
infected with such pathogens at other institutions.
• Excessive and inappropriate use of antibiotics, especiallybroad‐spectrum antimicrobial agents:– Prescribing antibiotics for unproven bacterial infections (e.g.,
upper respiratory viral infections) or “prophylactic”antibioticsfor residents/patients with chronic urinary catheters.
– Prolonged use beyond the standard recommended durationfor treating common infections.
• Factors that increase the probability of microbialcolonization (and subsequent infection) (malnutrition, immunosuppressed state, urinary catheters, feeding tubespressure ulcers, and chronic immobility).
• Inadequate adherence to infection‐control measures.
Yoshikawa TT, J Am Geriatr Soc 50:S206–S209, 2002
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WhyWhy isis itit a challenge?a challenge?
High frequency of infections
Elderly as « sentinel chickens » Antimicrobial
resistance
Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002
Scarcity of resources for
Infection Control
Lack of awareness of the
problem
Research gaps* Effective measures* Avoidable infections
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HALT European PPS in 722 LTCFs, 2010
(IPSE European survey in 33 countries, 2006)In In EuropeanEuropean countriescountries
In In selectedselected LTCFsLTCFs
IC IC resourcesresources
in in LTCFsLTCFs
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• Hand hygiene• Personal protective equipment• Safe handling and disposal ofsharps
• Environmental cleaning• Decontamination• Waste• Food hygiene• Water• Laundry and linen• Immunisation• Antimicrobial prescribing• Management of infectedresidents
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IC IC PoliciesPolicies and and proceduresprocedures:: availableavailableevidencesevidences
Source:Hughes CM, et al MRSA in LTCFs. Cochrane Database Syst Reviews 2008
Transmission of MRSA in nursing homes
The lack of studies in this field is surprising. ………….. Much of the evidence ……was generated in the acute care setting. It may not be possible to transfer suchstrategies directly to the nursing home environment, which serves as both a healthcare setting and a resident’s home. Rigorous studies should be conductedin nursing homes, to test interventions that have beenspecifically designed for this unique environment.
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Pneumonia: prevention, diagnosis and treatment
treatment according to a clinical pathway reduces
hospitalizations in nursing home residents with pneumonia
(Loeb M, JAMA 2006)
oral hygiene in elderly nursing home residents reduces the
risk of pneumonia and respiratory tract infection: NNT 8.6‐
15.3 in RCTs (Sjögren P, J Am Geriatr Soc. 2008)
Urinary tract infection: diagnosis and treatment implementation with a multifaced approach of a diagnostic and
treatment algorithm reduces the # of AB prescriptions for suspected UTI in NH residents (Loeb M, BMJ. 2005)
IC IC PoliciesPolicies and and proceduresprocedures::availableavailable evidencesevidences fromfrom RCTsRCTs
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ML Moro
InfectionInfection controlcontrol programsprograms in in longlong‐‐termtermcarecare
IC Structure: Infection Control Practitioner (full‐time every 250‐300 beds?)
and IC Committee
Surveillance
Outbreak control
Isolation and precautions
Hand hygiene
Resident health
Employee health
Antibiotic stewardship
Education
Other aspects: policies and procedures, facility management, disease reporting, performance improvement/resident safety)
Source: SHEA/APIC Guidelines, ICHE 2008; 29: 785
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Local organisation: IC mechanism in each LTCF (short term):
• Designate a suitably trained ”contact point” for coordination of IC and antimicrobial issues and define tasks to be undertaken by this ”contact point”
•Designate a suitably trained ”contact point” for communication with health authorities in outbreak situations(medium term)
Basic infastructure
Brussels November 2010
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Basic infastructure
Hand hygiene
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tivoLTCFsLTCFs and and handhand hygienehygiene
Few studies have addressed the issue of HH & infectionAuthor Type of study Setting Intervention Results
YeungWK, 2011
Clusteredrandomizedcontrolledtrial, before‐after
Hong‐KongLTCFs withelderlyresidents
Pocket‐ sizedcontainers ofalcohol‐basedgel, remindermaterials, education
HH adherencefrom 25.8% to33.3%. Incidenceof serious infect. from 1.42/ 1000 to 0.65/ 1000
Huang TT, 2008
Before‐after Taiwan, LTCFs
Hand hygienetraining program
HH compliancefrom 9.3% to30.4%. Infectionincidence from1.74% to 1.52%
MakrisAT, 2000
Controlledtrial, before‐after
LTCFs in US IC educational programincluding HH
Incidence from6.33 to 4.15
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LTCFs and hand hygiene
Few studies have quantified the compliance to HH,
which is generally lower than in acute care hospitals
Author Setting Results
Smith A, 2008 LTCFs in Ontario HH compliance 14.7%; mean HH time 15.9 sec.
Pan A, 2008 LTCF in Italy HH compliance 17.5%
NH N° ofobservations
% compliance
% of not compliantwith gloves
A 1347 3.8 76
B 1761 8 74
C 406 15.4 77
D 842 17 78
Hand Hygieneobservation in 4 Italian NHsusing the WHO tool(Pozzetti C)
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Basic infastructure
Hand hygiene
To improve the compliance with
hand hygiene:
• Dedicated guidelines with
identification of the patient care
practices were HH is a priority
•Monitoring of compliance
(direct observation or alcohol
consumption) and training
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Basic infastructure
Hand hygiene
MDROs policy
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ocial
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Area
Risc
hio in
fettiv
oRecommendations for KPC colonized
patients in LTCFs – Emilia‐Romagna Region
Hand Hygiene
Gloves (standard precautions) (change them!)
Overcoat for close contact
Cover eventual wounds
Environmental hygiene
Inform the facility if the patient must be transferred (tohospital, to another facility)
No screening
No isolation in single room
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Basic infastructure
Hand hygiene
MDROs policy
Antimicrobial
stewardship
To decrease antimicrobial
pressure, inappropiate
antimicrobial courses should be
avoided:
• Dedicated guidelines focused
on problems driving
inappropriate use
• Audit and training
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EuropeanEuropean prevalenceprevalence surveysurvey ofof antibioticantibiotic& & infectioninfection in in NHsNHs, 2010, 2010
Antimicrobials (n=2720) weremainly prescribed for the urinary
tract (48.9%; 2.15 /100) (21.4% prophylactic and 25.3%
therapeutic use), followed by skin or wounds (27.8%; 1.22/100).
UTI treatment
26,4
18,218,1
14,4
18,2 3,31,4
quinolones nitrofurantoina beta-lactams, penicillinsother beta-lactames sulfonamides & trimethoprim nifurtoinolofosfomicina metenamina
Source: Moro ML, Jans B, Cookson B, Fabry J. HALT Project (under publication)HALT Project funded by the ECDC
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Antimicrobial resistance and UTI
• there is compelling evidence to support not treating
asymptomatic bacteriuria in elderly residents of long‐
term care facilities
• In 5 randomized trials no differences in morbidity or
mortality were demonstrated between treated and
untreated residents. In one of these trials antibiotic
treatment was associated with more adverse events.
Walker S, CMAJ • AUG. 8, 2000; 163 (3)
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RegionalRegional guidelineguideline
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AMBULATORY CARE & HOME CARE
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Home care Home care infectionsinfections
On average, 1 patient of 100 in home care acquires
an infection (Jarvis W, EID 2001)
A recent study in North Carolina has reported a
decrease of CRB and CV‐UTI rates from 1998 to 2008:
0,49 BSI/1000 CVC days in 1998‐2002 to 0,05/1000
in 2003‐2008
1,8 UTIs/1000 CV days in 1998‐2002 to 0,9/1000 in
2003‐2008 (Weber DJ, ICHE 2009)
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Outbreaks in ambulatory care
• Medical clinics and day hospital
• Odontoiatric clinics
• Dyalisis centers
• Eye clinics
• Gastrointestinal endoscopy & bronchoscopy
• Surgical clinics
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Among the key recommendations is having an individual at each facility who is responsible for ensuring that infection control practices are being followed.Other recommendations include:• Providing regular infection prevention training to clinicians• Conducting regular audits to ensure good practices are followed• Following proper hand hygiene protocols• Avoiding reinserting a syringe into a medication vial• Avoiding reuse of single‐dose vials or intravenous bags for multiple patients• Ensuring that reusable equipment is cleaned according to the manufacturer’s directions.
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