Resistance In Long-term Care Facilities Research Articles

Oral and Rectal Colonization by Antimicrobial-Resistant Gram-Negative Bacteria and Their Association with Death among Residents of Long-Term Care Facilities: A Prospective, Multicenter, Observational, Cohort Study

Introduction: The prevalence of antimicrobial-resistant bacteria (ARB) in long-term care facilities (LTCFs) remains unclear. Furthermore, the effect of ARB colonization on the clinical outcomes of LTCF residents has not been explored. Methods: We conducted a prospective multicenter cohort study and investigated the residents (N = 178) of six Japanese LTCFs (three Welfare Facilities for the Elderly Requiring Long-term Care and three Geriatric Health Service Facilities) for oral and rectal carriage of ARB. The clinical outcomes of the residents were evaluated based on isolating bacterial strains and subjecting them to whole-genome sequencing. Results: Of the 178 participants, 32 belonging to Geriatric Health Service Facilities with no information on their clinical outcome were excluded, and the remaining 146 were followed up for at most 21 months. Extended-spectrum β-lactamases (ESBL)-producing Enterobacterales and Pseudomonas aeruginosa were detected in 42.7% (n = 76) and 2.8% (n = 5) of the rectal swabs and 5.6% (n = 10) and 3.4% (n = 6) of the oral swabs, respectively. Detection of ARB in the oral and rectal cavities showed remarkable association with enteral nutrition. Further, P. aeruginosa was significantly associated with an increase in mortality of the residents, but there were not significant association between ESBL-producing Enterobacterales and mortality. Core-genome phylogeny of P. aeruginosa revealed a wide-spread distribution of the isolated strains across the phylogeny, which included a cluster of ST235 strains with substantially higher biofilm formation ability than the other isolated P. aeruginosa strains. Discussion/Conclusion: This study is the first to investigate the carriage of both oral and rectal ARB, genomic relatedness and determinants of antimicrobial resistance in isolated strains, and clinical outcomes of LTCF residents. Our study provides the first direct evidence for the burden of antimicrobial resistance in LTCFs.

Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017.

Antimicrobials are commonly prescribed and contribute to the development of antimicrobial resistance in long-term care facilities (LTCFs). In 2010, the European Centre for Disease Prevention and Control initiated point prevalence surveys (PPS) of healthcare-associated infections and antimicrobial use in European LTCFs, performed by external contractors as the Healthcare-Associated infections in Long-Term care facilities (HALT) projects. Here, we investigated prevalence and characteristics of antimicrobial use and antimicrobial stewardship indicators in European LTCFs in 2016–17. Twenty-four European Union/European Economic Area (EU/EEA) countries, the former Yugoslav Republic of Macedonia and Serbia participated in the third PPS in European LTCFs. Overall, 4.9% (95% confidence interval: 4.8–5.1) of LTCF residents in the EU/EEA participating countries received at least one antimicrobial. The most commonly reported Anatomical Therapeutic Chemical (ATC) groups were beta-lactam antibacterials/penicillins (J01C), other antibacterials (J01X) (e.g. glycopeptide antibacterials, polymyxins), quinolones (J01M), sulfonamides and trimethoprim (J01E), and other beta-lactams (J01D). Urinary tract infections and respiratory tract infections were the main indications for antimicrobial prescription. This PPS provides updated and detailed information on antimicrobial use in LTCFs across the EU/EEA that can be used to identify targets for future interventions, follow-up of these interventions and promote prudent use of antimicrobials in European LTCFs.

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

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. 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. 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. 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.

Carriage of antimicrobial-resistant commensal bacteria in Dutch long-term-care facilities.

The objective of this study was to assess carriage of antimicrobial-resistant commensal microorganisms, i.e. Escherichia coli and Staphylococcus aureus, and its predictors in long-term-care facilities (LTCFs). Nasal swabs and/or urine or incontinence samples were collected from participating residents in 111 LTCFs and tested for the presence of S. aureus and/or E. coli, respectively. Antimicrobial resistance to eight antimicrobials was linked to antimicrobial usage in the year preceding sampling and to LTCF characteristics. Using multilevel logistic regression, predictors of carriage of ESBL-producing E. coli in LTCFs were identified. S. aureus was identified in 1269/4763 (26.6%) nasal swabs, including 13/4763 (0.3%) MRSA carriers in 9/107 (8%) LTCFs. Of the 5359 urine/incontinence samples, 2934 (55%) yielded E. coli, including 123 (4.2%) producing ESBL, which were found in 53/107 locations (range 1%-33%). For all but one antimicrobial (i.e. nitrofurantoin) >20% of isolated E. coli were resistant. Multilevel multivariable logistic regression identified two predictors of carriage of ESBL-producing E. coli: (i) antimicrobial usage (OR 1.8, 95% CI 1.1-3.0 for each extra 50 DDD/1000 residents/day); and (ii) presence of MRSA carriers in the LTCFs (OR 2.4, 95% CI 1.0-5.6). The low proportion of 4.2% ESBL-producing E. coli and the low prevalence of 0.3% MRSA carriage found in LTCF residents suggest that Dutch LTCFs are not yet an important reservoir of MDR potential pathogens. Nevertheless, the large variation between LTCFs warrants close monitoring of antimicrobial resistance in LTCFs. Integrated surveillance, i.e. linking data sources on antimicrobial usage, microbiological testing, clinical background data and epidemiological data, is needed.

Battle of the Bugs: Progress in the Fight Against Antibiotic Resistance

Battle of the Bugs: Progress in the Fight Against Antibiotic Resistance

Infection prevention issues in long-term care.

Infections and antimicrobial use are common in residents of long-term care facilities. This review discusses recent articles that address infection prevention and control and antimicrobial stewardship in these facilities. National surveys confirm the continuing high prevalence of infections in residents of long-term care facilities, with the greatest risk for patients with the highest acuity and greatest functional disability. Long-term acute care facilities are a unique environment where residents are characterized by high levels of indwelling device use and antimicrobial-resistant organisms. The major determinant of antimicrobial resistance in long-term care facilities is antimicrobial use. The Centers for Disease Control (CDC) has proposed revised evidence-based definitions for surveillance of infections on the basis of the original McGeer criteria. Consensus national performance standards for infection prevention and antimicrobial stewardship programs in long-term care facilities have been developed in a European initiative. Evidence to support the efficacy of infection control programs is limited. Antimicrobial stewardship programs may, however, be effective in reducing inappropriate antimicrobial use. The extent to which endemic infections or antimicrobial resistance in long-term care facilities can be prevented remains unclear. Efforts to limit infections in these facilities should focus on outbreak prevention and standard procedures for environmental cleaning, food preparation, and hand hygiene, together with optimal resident medical care. Antimicrobial stewardship programs should be implemented.

Infections and antimicrobial resistance in long term care facilities: a national prevalence study.

A point prevalence survey (PPS) was conducted in Italy in 2010, as part of the first European PPS in Long Term Care Facilities (LTCFs), conducted within the HALT Project. The PPS was aimed at estimating the prevalence of infections, antimicrobial resistance, and antibiotic use and to assess the status of infections control programs in this setting. Ninety two LTCFs, located in 11 different Italian regions, participated to the study: 9391 residents were enrolled, 9285 of whom were eligible according to the study criteria. The prevalence of residents with signs/symptoms of infection was 6.5% (606 residents); 438 residents were on antimicrobial treatment (4.7%) and 526 had signs/symptoms (5.7%) but in 324 residents only (3.5/100 residents) the infection satisfied the modified McGeer criteria and was considered confirmed. The most frequent infection site was the respiratory tract (1.27/100 residents). Mostly of the antibiotics were prescribed for respiratory tract infections (42.8% of the antibiotics) and for urinary tract infections (26.6%). The most frequently prescribed classes were quinolones, followed by penicillin plus beta-lactamase inhibitor and 3rd generation cephalosporins. Few infection had a microbiological confirmation, but among the 143 isolated microorganisms 24% were multidrug resistant. The burden of infections and antimicrobial resistance in LTCFs is significant and infection control and surveillance program are urgently needed.

Antimicrobial Resistance in Long-Term Care Facilities

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term–care facilities (LTCFs). Gramnegative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified (Infect Control Hosp Epidemiol 1996;17:129-140).

Clonal Dissemination and mupA Gene Polymorphism of Mupirocin-Resistant Staphylococcus aureus Isolates from Long-Term-Care Facilities in South Korea

We identified 25 high-level mupirocin-resistant (MuH) and 21 low-level mupirocin-resistant (MuL) Staphylococcus aureus isolates from eight long-term-care facilities (LTCFs). The pulsed-field gel electrophoresis patterns of 19 MuH and 19 MuL isolates from two facilities were identical for 18 and 15 isolates, respectively. The most predominant mupA restriction fragment length polymorphism type was found in 21 MuH isolates. We conclude that clonal transmission of MuH and MuL S. aureus strains occurred in these LTCFs. This is the first report of clonal transfer of mupirocin resistance in LTCFs.

Prevalence and risk factors of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in an Israeli long-term care facility

The purpose of this study was to ascertain the prevalence of extended-spectrum beta-lactamases (ESBLs) among Escherichia coli and Klebsiella pneumoniae strains obtained from urine samples of residents of a long-term care facility and to determine the risk factors for acquisition of ESBL-producing strains. All urine samples collected from January 2003 to October 2003 that were positive for E. coli or K. pneumoniae were tested for the presence of ESBL. Records of patients with ESBL-positive (ESBL-P) samples were analyzed for clinical and demographic data. The records of a matched control group of patients whose urine samples were positive for E. coli or K. pneumoniae but were ESBL-negative (ESBL-N) were also analyzed. The overall rate of ESBLs among the E. coli and K. pneumoniae samples was 25.6%. Of 350 urine samples that grew E. coli, 77 (22%) were positive for ESBL; 34 of 84 (40.5%) samples that grew K. pneumoniae were ESBL-P. Male sex, treatment in the subacute care unit, recent antimicrobial treatment, pressure sores, (percutaneous endoscopic gastrostomy) PEG tube, anemia, hypoalbuminemia, permanent urinary catheter, and any recent invasive procedure were all associated with ESBL-P bacteria in the univariate analysis. The multivariate analysis revealed three independent risk factors for the presence of an ESBL-producing strain: anemia, permanent urinary catheter, and previous antibiotic use. Fluoroquinolones were most strongly associated with the development of ESBL-producing bacteria. The prevalence of ESBL-producing E. coli and K. pneumoniae in the long-term care facility investigated was unexpectedly high and corroborates the notion that long-term care facilities could be important reservoirs of resistant bacteria. Identification of the risk factors for ESBLs is the first step in formulating an effective strategy to curtail the spread of ESBL resistance in long-term care facilities.

Infectious diseases and antibiotic resistance in long-term care facilities

Infectious diseases in the institutionalized elderly are emerging as 1 of the major issues challenging physicians treating adult patients. The most common syndromes encountered are nursing home-acquired pneumonia, urinary tract infections, and skin and soft tissue infections. As a complicating factor, immunocompromised elderly patients are often infected with bacteria highly resistant to antibiotics. The use of broad-spectrum agents in the nursing home may be accelerating this process. Developing algorithms for appropriate treatment of nursing home-acquired infections, assessing the factors that encourage the development of resistance, and finding interventions that can stem these processes are urgent priorities. Important clinical research questions include determining how frequently elderly patients are colonized with multiresistant pathogens and how these pathogens disseminate in this population. The future possibility of altering the aging immune system still remains an elusive goal.

Vancomycin-Resistant Enterococci in Long-Term-Care Facilities

The Society for Healthcare Epidemiology of America (SHEA) Committee on Long-Term Care decided in 1996 that there was need to develop a position document about vancomycin-resistant enterococci (VRE) in long-term–care facilities (LTCFs). This document is intended to complement the two previous position statements from our committee that discuss antibiotic use and antibiotic resistance in LTCFs. It is designed to supplement Hospital Infection Control Practice Advisory Committee (HICPAC) recommendations and to provide realistic guidelines for the LTCF.

Vancomycin-resistant enterococci in long-term-care facilities.

The Society for Healthcare Epidemiology of America (SHEA) Committee on Long-Term Care decided in 1996 that there was need to develop a position document about vancomycin-resistant enterococci (VRE) in long-term—care facilities (LTCFs). This document is intended to complement the two previous position statements from our committee that discuss antibiotic use and antibiotic resistance in LTCFs. It is designed to supplement Hospital Infection Control Practice Advisory Committee (HICPAC) recommendations and to provide realistic guidelines for the LTCF.

Treatment implications of antibacterial resistance in long-term care facilities

Treatment implications of antibacterial resistance in long-term care facilities

Antimicrobial resistance in long-term-care facilities.

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term-care facilities (LTCFs). Gram-negative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified.

Antibiotic Resistance in Long-Term Care Facilities

Long-term care facilities are comprised of a heterogeneous group of institutions caring for residential patients over prolonged periods of time. Included as long-term care facilities in this review are private and Veterans' Affairs (VA) nursing homes, rehabilitation centers, institutions for the developmentally disabled, and hospital wards for both long-term and intermediate care. Patients in long-term care facilities incur bacterial infections at a prevalence of 10% to 16%. These infections usually are caused by common bacterial pathogens that invade the compromised host residing within a complex physical environment. The high prevalence of institutional infections leads, in turn, to the need for multiple courses of antimicrobials or for hospitalization. This process selects strains more resistant to antibiotics, which are then available for repeated dispersal in the long-term care facility.

Antibiotic Resistance in Long-Term Care Facilities

Long-term care facilities are comprised of a heterogeneous group of institutions caring for residential patients over prolonged periods of time. Included as long-term care facilities in this review are private and Veterans' Affairs (VA) nursing homes, rehabilitation centers, institutions for the developmentally disabled, and hospital wards for both long-term and intermediate care. Patients in long-term care facilities incur bacterial infections at a prevalence of 10% to 16%. These infections usually are caused by common bacterial pathogens that invade the compromised host residing within a complex physical environment. The high prevalence of institutional infections leads, in turn, to the need for multiple courses of antimicrobials or for hospitalization. This process selects strains more resistant to antibiotics, which are then available for repeated dispersal in the long-term care facility.