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Venditti N, Petronio GP, Pinti M, Cutolo G, Pietrangelo L, Massini L, Magnifico I, Cutuli MA, Petrone F, Papini S, Di Marco R, Corbi G. Self-isolation of an Italian long-term care facility during COVID-19 pandemic: A comparison study on care-related infectious episodes. Open Med (Wars) 2023; 18:20230822. [PMID: 37900963 PMCID: PMC10612528 DOI: 10.1515/med-2023-0822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023] Open
Abstract
The aim of this retrospective cohort study is to understand if and how much the preventive self-isolation approach might have been a valid model to avoid care-related infection, not only from COVID-19 but also from other non-viral infectious diseases. From March to May 2020, the healthcare and management staff of the Villa Santa Maria long-term care facilities, located in the village of Montenero di Bisaccia (Campobasso, Molise, Italy), decided to carry out a preventive self-isolation plan to safeguard the residents from SARS-CoV-2. The impact on other infectious diseases was evaluated by analyzing the antibiotic therapies prescription trend among the inpatients. Our data showed that although self-isolation protected residents and caregivers from SARS-CoV-2, it can also be associated with mobility reduction, leading to an increase in bedridden pathologies, namely, pressure ulcers and pressure sores. The simultaneous isolation of residents and caregivers in the same location significantly reduced any outside influence as a cause of possible infections.
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Affiliation(s)
- Noemi Venditti
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Giulio Petronio Petronio
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Melania Pinti
- Istituto Dottrina Cristiana (Largo Istituto Dottrina Cristiana, 1, 67100 L’Aquila AQ), U.O. RSD e Casa di Riposo “Villa Santa Maria”, Montenero di Bisaccia (CB)86036, Italy
| | - Giovanni Cutolo
- Istituto Dottrina Cristiana (Largo Istituto Dottrina Cristiana, 1, 67100 L’Aquila AQ), U.O. RSD e Casa di Riposo “Villa Santa Maria”, Montenero di Bisaccia (CB)86036, Italy
| | - Laura Pietrangelo
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Laura Massini
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Irene Magnifico
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Marco Alfio Cutuli
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Federica Petrone
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Stefano Papini
- UO Laboratorio Analisi, Responsible Research Hospital, Campobasso, Italy
| | - Roberto Di Marco
- Department of Medicine, Health Science “V. Tiberio”, Università degli Studi del Molise, Via De Sanctis snc, Campobasso86100, Italy
| | - Graziamaria Corbi
- Department of Translational Medical Sciences, University of Naples Federico IINapoli80126, Italy
- Italian Society of Gerontology and Geriatrics (SIGG), Campania Region section, Florence, Italy
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Azzini AM, Be G, Naso L, Lambertenghi L, Salerno ND, Coledan I, Bazaj A, Mirandola M, Miotti J, Mazzaferri F, Accordini S, Lo Cascio G, Tacconelli E. Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting. Front Cell Infect Microbiol 2023; 13:1155320. [PMID: 37377644 PMCID: PMC10292821 DOI: 10.3389/fcimb.2023.1155320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization. Methods A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models. Results In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%). Conclusion Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.
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Affiliation(s)
- Anna Maria Azzini
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giorgia Be
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Disease Unit, Mater Salutis Hospital - ULSS 9 Scaligera, Legnago, Italy
| | - Laura Naso
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ilaria Coledan
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- SerT Suzzara, SC Ser.D. Mantova, ASST Mantova, Suzzara, Italy
| | - Alda Bazaj
- Microbiology Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Massimo Mirandola
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jessica Miotti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giuliana Lo Cascio
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
- Microbiology Unit, AUSL Piacenza, Piacenza, Italy
| | - Evelina Tacconelli
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Zhou W, Li Y, Li Z, Ma B, Jiang X, Hu C, Ai Y, Luo P. Genomic Changes and Genetic Divergence of Vibrio alginolyticus Under Phage Infection Stress Revealed by Whole-Genome Sequencing and Resequencing. Front Microbiol 2021; 12:710262. [PMID: 34671325 PMCID: PMC8521149 DOI: 10.3389/fmicb.2021.710262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 11/13/2022] Open
Abstract
Bacteriophages (phages) and their bacterial hosts were the most abundant and genetically highly diverse organisms on the earth. In this study, a series of phage-resistant mutant (PRM) strains derived from Vibrio alginolyticus were isolated and Infrequent-restriction-site PCR (IRS-PCR) was used to investigate the genetic diversity of the PRM strains. Phenotypic variations of eight PRM strains were analyzed using profiles of utilizing carbon sources and chemical sensitivity. Genetic variations of eight PRM strains and coevolved V. alginolyticus populations with phages were analyzed by whole-genome sequencing and resequencing, respectively. The results indicated that eight genetically discrepant PRM stains exhibited abundant and abundant phenotypic variations. Eight PRM strains and coevolved V. alginolyticus populations (VE1, VE2, and VE3) contained numerous single nucleotide variations (SNVs) and insertions/indels (InDels) and exhibited obvious genetic divergence. Most of the SNVs and InDels in coding genes were related to the synthesis of flagellar, extracellular polysaccharide (EPS), which often served as the receptors of phage invasion. The PRM strains and the coevolved cell populations also contained frequent mutations in tRNA and rRNA genes. Two out of three coevolved populations (VE1 and VE2) contained a large mutation segment severely deconstructing gene nrdA, which was predictably responsible for the booming of mutation rate in the genome. In summary, numerous mutations and genetic divergence were detected in the genomes of V. alginolyticus PRM strains and in coevolved cell populations of V. alginolyticus under phage infection stress. The phage infection stress may provide an important force driving genomic evolution of V. alginolyticus.
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Affiliation(s)
- Wenjie Zhou
- College of Animal Science, Jilin University, Changchun, China
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
| | - Yingying Li
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
- Geological Survey Institute of Guangzhou, Guangzhou, China
| | - Zhuobo Li
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Bo Ma
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xiao Jiang
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
| | - Chaoqun Hu
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
| | - Yongxing Ai
- College of Animal Science, Jilin University, Changchun, China
| | - Peng Luo
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology (LMB), Guangdong Provincial Key Laboratory of Applied Marine Biology (LAMB), South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, China
- Southern Marine Science and Engineering Guangdong Laboratory (Guangzhou), Guangzhou, China
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Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel. Infect Control Hosp Epidemiol 2020; 41:1028-1034. [PMID: 32624031 DOI: 10.1017/ice.2020.214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited. OBJECTIVE To support nursing home providers with the selection and adoption of ASP interventions. DESIGN AND SETTING A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting. PARTICIPANTS A 16-member multidisciplinary panel of experts and resident representatives. RESULTS From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions. CONCLUSIONS Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.
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Rowan-Nash AD, Araos R, D'Agata EMC, Belenky P. Antimicrobial Resistance Gene Prevalence in a Population of Patients with Advanced Dementia Is Related to Specific Pathobionts. iScience 2020; 23:100905. [PMID: 32106056 PMCID: PMC7044522 DOI: 10.1016/j.isci.2020.100905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
Long-term care facilities are significant reservoirs of antimicrobial-resistant organisms, and patients with advanced dementia are particularly vulnerable to multidrug-resistant organism (MDRO) acquisition and antimicrobial overuse. In this study, we longitudinally examined a group of patients with advanced dementia using metagenomic sequencing. We found significant inter- and intra-subject heterogeneity in microbiota composition, suggesting temporal instability. We also observed a link between the antimicrobial resistance gene density in a sample and the relative abundances of several pathobionts, particularly Escherichia coli, Proteus mirabilis, and Enterococcus faecalis, and used this relationship to predict resistance gene density in samples from additional subjects. Furthermore, we used metagenomic assembly to demonstrate that these pathobionts had higher resistance gene content than many gut commensals. Given the frequency and abundances at which these pathobionts were found in this population and the underlying vulnerability to MDRO of patients with advanced dementia, attention to microbial blooms of these species may be warranted.
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Affiliation(s)
- Aislinn D Rowan-Nash
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Rafael Araos
- Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile; Millenium Nucleus for Collaborative Research on Bacterial Resistance (MICROB-R), Santiago, Chile; Advanced Center for Chronic Diseases (ACCDiS), Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Erika M C D'Agata
- Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Peter Belenky
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA.
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Yoshikawa TT, Norman DC. Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management. J Am Geriatr Soc 2017; 65:631-641. [PMID: 28140454 DOI: 10.1111/jgs.14731] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.
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Affiliation(s)
- Thomas T Yoshikawa
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Dean C Norman
- Department of Veterans Affairs San Diego Healthcare System, San Diego, California.,University of California at Los Angeles, Los Angeles, California
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Stevenson KB, Moore J, Colwell H, Sleeper B. Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities. Infect Control Hosp Epidemiol 2016; 26:231-8. [PMID: 15796273 DOI: 10.1086/502532] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractObjectives:To measure infection rates in a regional cohort of long-term-care facilities (LTCFs) using standard surveillance methods and to analyze different methods for interfacility comparisons.Setting:Seventeen LTCFs in Idaho.Design:Prospective, active surveillance for LTCF-acquired infections using standard definitions and case-finding methods was conducted from July 2001 to June 2002. All surveillance data were combined and individual facility performance was compared with the aggregate employing a variety of statistical and graphic methods.Results:The surveillance data set consisted of 472,019 resident-days of care with 1,717 total infections for a pooled mean rate of 3.64 infections per 1,000 resident-days. Specific infections included respiratory (828; rate, 1.75), skin and soft tissue (520; rate, 1.10), urinary tract (282; rate, 0.60), gastrointestinal (77; rate, 0.16), unexplained febrile illnesses (6; rate, 0.01), and bloodstream (4; rate, 0.01). Initially, methods adopted from the National Nosocomial Infections Surveillance System were used comparing individual rates with pooled means and percentiles of distribution. A more sensitive method appeared to be detecting statistically significant deviations (based on chi-square analysis) of the individual facility rates from the aggregate of all other facilities. One promising method employed statistical process control charts (U charts) adjusted to compare individual rates with aggregate monthly rates, providing simultaneous visual and statistical comparisons. Small multiples graphs were useful in providing images valid for rapid concurrent comparison of all facilities.Conclusion:Interfacility comparisons have been demonstrated to be valuable for hospital infection control programs, but have not been studied extensively in LTCFs.
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Abstract
AbstractObjectives:This article reviews published studies of nursing home-acquired BSI in North America to determine whether there have been changes in the epidemiology of this infection in the past 20 years and to define indications for blood cultures in the nursing home setting.Methods:A Medline search was conducted for the period from 1980 to August 2003.Results:Seven studies of nursing home-acquired BSI were identified. The incidence of nursing home-acquired BSI was low (0.3 episode per 1,000 resident care-days). Sources of BSI changed little during the past two decades, with urinary tract infection representing approximately 50% of the episodes. The bacteriology also did not change substantially during the past 20 years; gram-negative bacilli were isolated in approximately 50% of the episodes and Escherichia coli was the most commonly isolated organism. In the most recent study, covering the period 1997-2000, resistance to fluoroquinolones and broad-spectrum penicillins and cephalosporins was uncommon among gram-negative blood isolates; MRSA was the most common resistant organism causing nursing home-acquired BSI. Case-fatality rates changed little during the past 20 years; urinary tract infection was associated with the lowest mortality and pneumonia had the highest case-fatality rate.Conclusion:There has been little change in the epidemiology of nursing home-acquired BSI in the past 20 years. Given the low incidence of BSI and the low overall yield of positive results of blood cultures (probably ≤ 6%), there is currently no support for the routine use of blood cultures in the nursing home setting.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA.
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Abstract
Antibiotic use is common in older adults, and much of it is deemed unnecessary. Complications of antibiotic use may occur as a consequence of changes in age-related physiology and dosing with resulting drug toxicity and secondary infection. Knowing when it is appropriate to initiate antibiotics may help reduce unnecessary antibiotic use and prevent adverse drug events. Careful attention to antibiotic selection, dosing adjustments, and drug-drug interactions may also help prevent antibiotic-related adverse events.
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Affiliation(s)
- Suzanne F Bradley
- Infectious Diseases Section 111i, Rm B804 Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA.
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10
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Antimicrobial Stewardship and Infection Prevention in Long-Term Care Settings: New Strategies to Prevent Resistant Organisms. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Giannella M, Tedeschi S, Bartoletti M, Viale P. Prevention of infections in nursing homes: antibiotic prophylaxis versus infection control and antimicrobial stewardship measures. Expert Rev Anti Infect Ther 2016; 14:219-30. [PMID: 26655286 DOI: 10.1586/14787210.2016.1132161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Because of the lack of structural and human resources for implementing more effective and safe preventive procedures, antimicrobial prophylaxis is often used to prevent infections in nursing homes. However, if data on the efficacy of antibiotic prophylaxis in nursing homes are null, there is a plenty of evidence that the inappropriate use of antimicrobials in this setting is associated with a high rate of colonization and infection with multi-drug-resistant organisms (MDROs), and of Clostridium difficile infection (CDI). Here, we have reviewed the infection epidemiology, the burden of MDROs and CDI, the antibiotic use and some potential infection preventive measures in nursing homes, pointing up the peculiarities of this setting and the absolute need of a more prudential use of antimicrobials.
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Affiliation(s)
- Maddalena Giannella
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Sara Tedeschi
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Michele Bartoletti
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Pierluigi Viale
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
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Dyar OJ, Pagani L, Pulcini C. Strategies and challenges of antimicrobial stewardship in long-term care facilities. Clin Microbiol Infect 2014; 21:10-9. [PMID: 25636921 DOI: 10.1016/j.cmi.2014.09.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/17/2014] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- O J Dyar
- North Devon District Hospital, Barnstaple, UK
| | - L Pagani
- Bolzano Central Hospital, Infectious Diseases Unit, Bolzano, Italy
| | - C Pulcini
- CHU de Nancy, Service de Maladies Infectieuses, Nancy, France; Université de Lorraine, Université Paris Descartes, EA 4360 Apemac, Nancy, France.
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Olsho LE, Bertrand RM, Edwards AS, Hadden LS, Morefield GB, Hurd D, Mitchell CM, Sloane PD, Zimmerman S. Does Adherence to the Loeb Minimum Criteria Reduce Antibiotic Prescribing Rates in Nursing Homes? J Am Med Dir Assoc 2013; 14:309.e1-7. [DOI: 10.1016/j.jamda.2013.01.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/01/2013] [Accepted: 01/03/2013] [Indexed: 11/30/2022]
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van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, Essink RTGM, van Benthem BHB, Natsch S, Hertogh CMPM. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc 2012; 13:568.e1-13. [PMID: 22575772 DOI: 10.1016/j.jamda.2012.04.004] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/07/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance. METHODS Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations. RESULTS A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship. CONCLUSION The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.
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Affiliation(s)
- Laura W van Buul
- EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
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Abstract
Antimicrobial stewardship programs in hospitals seek to optimize antimicrobial prescribing in order to improve individual patient care as well as reduce hospital costs and slow the spread of antimicrobial resistance. With antimicrobial resistance on the rise worldwide and few new agents in development, antimicrobial stewardship programs are more important than ever in ensuring the continued efficacy of available antimicrobials. The design of antimicrobial management programs should be based on the best current understanding of the relationship between antimicrobial use and resistance. Such programs should be administered by multidisciplinary teams composed of infectious diseases physicians, clinical pharmacists, clinical microbiologists, and infection control practitioners and should be actively supported by hospital administrators. Strategies for changing antimicrobial prescribing behavior include education of prescribers regarding proper antimicrobial usage, creation of an antimicrobial formulary with restricted prescribing of targeted agents, and review of antimicrobial prescribing with feedback to prescribers. Clinical computer systems can aid in the implementation of each of these strategies, especially as expert systems able to provide patient-specific data and suggestions at the point of care. Antibiotic rotation strategies control the prescribing process by scheduled changes of antimicrobial classes used for empirical therapy. When instituting an antimicrobial stewardship program, a hospital should tailor its choice of strategies to its needs and available resources.
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Affiliation(s)
- Conan MacDougall
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia 23298, USA.
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Bradley SE. Double, double, toil and trouble: infections still spreading in long-term-care facilities. Infect Control Hosp Epidemiol 2005; 26:227-30. [PMID: 15796272 DOI: 10.1086/502531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Viray M, Linkin D, Maslow JN, Stieritz DD, Carson LS, Bilker WB, Lautenbach E. Longitudinal trends in antimicrobial susceptibilities across long-term-care facilities: emergence of fluoroquinolone resistance. Infect Control Hosp Epidemiol 2005; 26:56-62. [PMID: 15693409 DOI: 10.1086/502487] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Antibiotic resistance in the longterm-care facility (LTCF) setting is of increasing concern due to both the increased morbidity and mortality related to infections in this debilitated population and the potential for transfer of resistant organisms to other healthcare settings. Longitudinal trends in antibiotic resistance in LTCFs have not been well described. DESIGN Correlational longitudinal survey study. SETTING Four LTCFs in Pennsylvania. SUBJECTS All clinical cultures of residents of the participating LTCFs (700 total beds) from 1998 through 2003. We assessed the annual prevalence of resistance to various antimicrobials of interest for the following organisms: Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and enterococcus species. RESULTS A total of 4,954 clinical isolates were obtained during the study. A high prevalence of antimicrobial resistance was noted for many organism-drug combinations. This was especially true for fluoroquinolone susceptibility among the Enterobacteriaceae (susceptibility range, 51.3% to 92.2%). In addition, the prevalence of resistance to various agents differed significantly across study sites. Finally, significant increasing trends in resistance were noted over time and were most pronounced for fluoroquinolone susceptibility among the Enterobacteriaceae. CONCLUSIONS The prevalence of antimicrobial resistance has increased significantly in LTCFs, although trends have varied substantially across different institutions. These trends have been particularly pronounced for fluoroquinolone resistance among the Enterobacteriaceae. These findings demonstrate that antimicrobial resistance is widespread and increasing in LTCFs, highlighting the need for future studies to more clearly elucidate the risk factors for, and potential interventions against, emerging resistance in these settings.
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Affiliation(s)
- Melissa Viray
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA
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Vander Stichele RH, Elseviers MM, Ferech M, Blot S, Goossens H. European surveillance of antimicrobial consumption (ESAC): data collection performance and methodological approach. Br J Clin Pharmacol 2005; 58:419-28. [PMID: 15373935 PMCID: PMC1884596 DOI: 10.1111/j.1365-2125.2004.02164.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Europe is a continent with strong public healthcare systems, but diverging antibiotic policies and resistance patterns. AIMS To describe the performance and methodological approach in a retrospective data collection effort (1997-2001), through an international network of surveillance systems, aiming to collect publicly available, comparable and reliable data on antibiotic use in Europe. METHODS A central multidisciplinary management team co-ordinated a network of national representatives, liasing with national data providers and bodies responsible for antibiotic policy. The data collected were screened for bias, using a checklist. We focused on detection bias in sample and census data; errors in assigning medicinal product packages to the Anatomical Therapeutic Chemical Classification (ATC); errors in calculations of defined daily doses (DDD) per package; bias by over-the-counter sales and parallel trade; and bias in ambulatory care (AC)/hospital care (HC) mix. Datasets were corrected after national feedback, and classified as valid; valid but with minor bias; not valid. RESULTS Of the 31 participating countries, 21 countries delivered AC data suitable for cross-national comparison (14 for all 5 years). Of these, 17 countries provided data on a quarterly basis for at least 1 year. For HC, 14 countries were able to deliver valid data (nine for all 5 years). A valid estimate of the total exposure of national populations to human antibiotic consumption could be made in 17 countries. CONCLUSION In cross-national comparisons of antibiotic consumption in Europe, methodological rigour in correcting for various sources of bias and checking the validity of ATC/DDD assignment is needed.
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Affiliation(s)
- R H Vander Stichele
- ESAC Management Team, Department of Microbiology, University of Antwerp, Antwerp, Belgium.
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Viksveen P. Antibiotics and the development of resistant microorganisms. Can homeopathy be an alternative? HOMEOPATHY 2003; 92:99-107. [PMID: 12725252 DOI: 10.1016/s1475-4916(03)00016-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Antibiotic resistance is a global public health problem. Once confined primarily to hospitals it is now increasingly common in primary care. The prevalence of resistant bacteria is rising, and organisms resistant to almost all antibiotics have been identified. The main causes are indiscriminate prescribing and the use of antibiotics in animal feeds and other agricultural applications. Policies to restrict use of antibiotics have had limited success. Homeopathy may have a role to play in combating the development of antibiotic resistance. Clinical research suggests that homeopathy is effective in the treatment of upper respiratory tract infections in children, a frequent cause of inappropriate antibiotic prescribing. The EU recommends the use of homeopathy in organic animal husbandry, and it is used by significant numbers of farmers. At present there is little data on the effectiveness of homeopathy in this setting. Further research should be done.
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Mylotte JM, Neff M. Trends in antibiotic use and cost and influence of case-mix and infection rate on antibiotic-prescribing in a long-term care facility. Am J Infect Control 2003; 31:18-25. [PMID: 12548253 DOI: 10.1067/mic.2003.47] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antibiotic use and cost indicators have been developed specifically for the long-term care facility (LTCF) setting. Approximately 50% of the variation in these indicators was explained by the variation in infection rate. The objectives of this study were to further assess the utility of the antibiotic use and cost indicators in a different LTCF and to determine the correlation of case-mix and these indicators. METHODS Antibiotic use and cost indicators were collected monthly by unit (N = 10) and by physician (N = 6) at a 433-bed LTCF in Syracuse, New York, from February 1999 to September 2001. Indicators included incidence (number of antibiotic courses per 1000 resident care-days) of antibiotic use, antibiotic utilization ratio ([AUR]; ratio of the number of antibiotic-days to the number of resident care-days), cost per antibiotic-day, and cost per resident care-day. Case-mix variation was measured with the case-mix index (CMI) of the Resource Utilization Group II system. Simple linear and multilinear regression analyses were used to evaluate correlations of continuous variables. RESULTS Among the 10 units or 6 physicians, there was a significant difference in the average values for all indicators. Correlation between unit- or physician-specific CMI and antibiotic use or cost indicators or infection rate was poor. However, there was a significant positive correlation between unit- or physician-specific infection rate and incidence of antibiotic use, AUR, and cost per resident care-day but not cost per antibiotic-day. With use of multilinear regression analysis to control for CMI and cost per antibiotic-day, infection rate was a significant predictor of incidence of antibiotic use (R2 = 0.65; P <.001) and AUR (R2 = 0.78; P <.001). CONCLUSIONS This study provides further evidence that the antibiotic use and cost indicators developed specifically for LTCFs can detect significant variation among units within a facility and among physicians. However, there was no correlation between CMI and antibiotic use or cost indicators. After controlling for case-mix variation and cost per antibiotic-day, variation in infection rate explained most of the variation in incidence of antibiotic use and AUR.
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Affiliation(s)
- Joseph M Mylotte
- Departments of Medicine and Microbiology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, NY 14215, USA
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Mylotte JM, Tayara A, Goodnough S. Epidemiology of bloodstream infection in nursing home residents: evaluation in a large cohort from multiple homes. Clin Infect Dis 2002; 35:1484-90. [PMID: 12471567 DOI: 10.1086/344649] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2002] [Accepted: 08/15/2002] [Indexed: 02/04/2023] Open
Abstract
This study sought to reevaluate the epidemiology of bloodstream infection in nursing home residents. The records of 166 nursing home residents admitted to an urban, public, university-affiliated hospital with 169 episodes of bloodstream infection between January 1997 and April 2000 were retrospectively reviewed. The most common organisms isolated were Escherichia coli (27% of isolates), Staphylococcus aureus (18%; 29% were methicillin-resistant strains), and Proteus mirabilis (13%). There was minimal resistance to quinolones and third-generation cephalosporins among aerobic gram-negative bacilli. The most common sources were the urinary tract (51% of episodes) and the lungs (11%); a source was not identified in 22% of episodes. Hospital mortality was 18%. Independent predictors of hospital mortality were a pulmonary source of infection, systolic blood pressure <90 mm Hg, and leukocytosis >20,000 cells/mm3. Compared with other studies published in the past 2 decades, mortality was lower. The most common resistant organism was methicillin-resistant S. aureus.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002; 50:570-6. [PMID: 11943058 DOI: 10.1046/j.1532-5415.2002.50128.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.
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Affiliation(s)
- Chesley Richards
- Wesley Woods Center of Emory University, 1841 Clifton Road NE, Room 545, Atlanta, GA 30329, USA.
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Faulks JT, Drinka P, Gauerke C, Miller J. Pharmacy review of culture and sensitivity with prompting of physicians to reduce antibiotic pressure. J Am Geriatr Soc 2001; 49:1259-60. [PMID: 11559392 DOI: 10.1046/j.1532-5415.2001.49250.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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