Methicillin-resistant Staphylococcus aureus in nursing homes. Epidemiology, prevention and management

Role of antiseptics in the prevention and treatment of infections in nursing homes

Inadequate infection control, wound care, and oral hygiene protocols in nursing homes pose challenges to residents' quality of life. Based on the outcomes from a focus group meeting and a literature search, this narrative review evaluates the current and potential roles of antiseptics within nursing home infection management procedures. We examine contemporary strategies and concerns within the management of meticillin-resistant Staphylococcus aureus (MRSA; including decolonization regimes), chronic wound care, and oral hygiene, and review the available data for the use of antiseptics, with a focus on povidone-iodine. Compared with chlorhexidine, polyhexanide, and silver, povidone-iodine has a broader spectrum of antimicrobial activity, with rapid and potent activity against MRSA and other microbes found in chronic wounds, including biofilms. As no reports of bacterial resistance or cross-resistance following exposure to povidone-iodine exist, it may be preferable for MRSA decolonization compared with mupirocin and chlorhexidine, which can lead to resistant MRSA strains. Povidone-iodine oral products have greater efficacy against oral pathogens compared with other antiseptics such as chlorhexidine mouthwash, highlighting the clinical benefit of povidone-iodine in oral care. Additionally, povidone-iodine-based products, including mouthwash, have demonstrated rapid in-vitro virucidal activity against SARS-CoV-2 and may help reduce its transmission if incorporated into nursing home coronavirus 2019 control protocols. Importantly, povidone-iodine activity is not adversely affected by organic material, such as that found in chronic wounds and the oral cavity. Povidone-iodine is a promising antiseptic agent for the management of infections in the nursing home setting, including MRSA decolonization procedures, chronic wound management, and oral care.

Synergistic Effect of Combination Interventions for Methicillin-Resistant Staphylococcus aureus Transmission Control in Nursing Homes: A Computation Modelling Evaluation with Heterogeneous Contact Mixing

The endemic threat of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes poses a serious and escalating challenge to public health administration in infection control. Nursing homes are considered as major reservoirs for MRSA colonization, with considerable high levels of colonization prevalence. We employed a computation model to evaluate effects of three intervention scenarios on MRSA colonization prevalence rate in nursing homes. Simulations were conducted using a deterministic compartmental model featuring heterogeneous contact matrix between residents and health-care workers (HCWs). Contact parameters were derived from a nursing home survey. Three intervention scenarios were simulated: (1) hand-hygiene compliance by HCWs, (2) screening-and-isolation upon admission, and (3) implementing both interventions at the same time. For every 10% reduction in average contamination duration in HCWs, the estimated average reduction in prevalence rate was 1.29 percentage point compared with the prevalence rate before the intervention was implemented. Screening-and-isolation intervention resulted in an average reduction of 19.04 percentage point in prevalence rate (S.D. = 1.58; 95% CI = 18.90-19.18). In intervention scenario 3, synergistic effects were observed when implementing hand-hygiene compliance by HCWs and screening-and-isolation together. Our results provide evidence showing that implementing multiple interventions together has a synergistic effect on colonization prevalence reduction.

Targeted gown and glove use to prevent Staphylococcus aureus acquisition in community-based nursing homes: A pilot study

OBJECTIVE

To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents.

DESIGN

Uncontrolled clinical trial.

SETTING

This study was conducted in 2 community-based nursing homes in Maryland.

PARTICIPANTS

The study included 322 residents on mixed short- and long-stay units.

METHODS

During a 2-month baseline period, all residents had nose and inguinal fold swabs taken to estimate S. aureus acquisition. The intervention was iteratively developed using a participatory human factors engineering approach. During a 2-month intervention period, healthcare personnel wore gowns and gloves for high-risk care activities while caring for residents with wounds or medical devices, and S. aureus acquisition was measured again. Whole-genome sequencing was used to assess whether the acquisition represented resident-to-resident transmission.

RESULTS

Among short-stay residents, the methicillin-resistant S. aureus acquisition rate decreased from 11.9% during the baseline period to 3.6% during the intervention period (odds ratio [OR], 0.28; 95% CI, 0.08-0.92; P = .026). The methicillin-susceptible S. aureus acquisition rate went from 9.1% during the baseline period to 4.0% during the intervention period (OR, 0.41; 95% CI, 0.12-1.42; P = .15). The S. aureus resident-to-resident transmission rate decreased from 5.9% during the baseline period to 0.8% during the intervention period.

CONCLUSIONS

Targeted gown and glove use by healthcare personnel for high-risk care activities while caring for residents with wounds or medical devices, regardless of their S. aureus colonization status, is feasible and potentially decreases S. aureus acquisition and transmission in short-stay community-based nursing-home residents.

Healthcare-associated pneumonia: a prospective study in Spain

Objective

The aim of the study was to describe the epidemiological characteristics and factors related to outcome in Streptococcus pneumoniae and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated pneumonia (HCAP).

Patients and method

A 3-year prospective observational epidemiological case study of HCAP was conducted in seven Spanish hospitals. Microbiological and patient characteristics and outcomes were collected and classified by causative pathogen into 4 categories: “S. pneumoniae”, “MRSA”, “Others” and “Unknown”. Patients were followed up 30 days after discharge.

Results

A total of 258 (84.6%) patients were enrolled (170 were men [65.9%]). Mean age was 72.4 years ± 15 years (95% CI [70.54-74.25]). The etiology of pneumonia was identified in 73 cases (28.3%):S. pneumoniae in 35 patients (13.6%), MRSA in 8 (3.1%), and other microorganisms in 30 patients (11.6%). Significant differences in rates of chronic obstructive pulmonary disease (p < 0.05), previous antibiotic treatment (p < 0.05), other chronic respiratory diseases, inhaled corticosteroids (p < 0.01), and lymphoma (p < 0.05) were observed among the four groups. Patients with MRSA pneumonia had received more previous antibiotic treatment (87.5%). Thirty-three (12.8%) patients died during hospitalisation; death in 27 (81.2%) was related to pneumonia.

Conclusions

The etiology of HCAP was identified in only one quarter of patients, with S. pneumoniae being the most prevalent microorganism. Patients with chronic respiratory diseases more frequently presented HCAP due to MRSA than to S. pneumoniae. Death at hospital discharge was related in most cases to pneumonia.

Antibiotic prescribing for the older adult: beliefs and practices in primary care

BACKGROUND

Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population.

OBJECTIVES

To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults.

METHODS

Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach.

RESULTS

GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group.

CONCLUSIONS

Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

Prevalence and molecular epidemiology of Staphylococcus aureus nasal colonization in four nursing home residents in Crete, Greece

Nursing homes are considered as reservoirs for methicillin-resistant Staphylococcus aureus (MRSA). The present study investigated the point prevalence and molecular epidemiology of S. aureus colonization among nursing home residents. The study population comprised of 227 residents, living in four nursing homes of the Heraklion, Crete, Greece area, between January and December 2015. From each nursing home, swabs from the anterior nares of all eligible participants were obtained within a 2-week period. The isolated S. aureus strains were identified and screened by standard microbiological and molecular epidemiological methods. S. aureus carriage was found in 62 out of 227 participants (38.4%) with 33 out of 62 (53.2%) being MRSA. The median age was 83 years (range 52-103). Females were more frequently colonized [47 (75.8%)]. All 33 methicillin resistant Staphylococcus aureus (MRSA) isolates were mecA-positive carrying SCCmec type IV, 30 (91%) the fnbA, and 17 (51.5%) the PVL genes. Thirty-two (97%) belonged to a single pulsotype C; among them, the PVL-positives belonged to ST80 clone, whereas, the PVL-negatives to ST225. Among the 33 MRSA isolates, 32 (97%) were clindamycin-resistant, carrying the ermA gene. Methicillin-susceptible Staphylococcus aureus (MSSA) strains showed polyclonality and 76% were PVL-positive. In conclusion the present study has shown that nursing homes in our area can be regarded as important reservoirs for community-associated MRSA (CA-MRSA).

Screening of nasal carriage of methicillin-resistant Staphylococcus aureus during admission of patients to Frantz Fanon Hospital, Blida, Algeria

A study was performed of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) strains isolated from nasal preoperative samples. Of 663 samples assessed, staphylococcus was detected in 143 (21.57%). The disc diffusion method (cefoxitin 30 μg), a screening test (oxacillin 6 μg/mL) and a search for Protein Binding Additional Penicillin 2 (PLP2a) allowed the detection and confirmation of resistance to methicillin for 36 strains, a rate of 5.43% of the total population studied. Eight MRSA carriers received care in the trauma service, 14 in cardiology, five in ear, nose and throat, four in neurosurgery and paediatrics, and one in SCI. Thirty-six methicillin-resistant of the nasal portage strains are in their great majority, 27 of 36, rather limited multi-R character (two to three families namely resistance: tetracyclines, fluoroquinolones, aminoglycosides, macrolides). One of the MRSA strains was found to have intermediate sensitivity to vancomycin.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

Understanding the Impact of Interventions to Prevent Antimicrobial Resistant Infections in the Long-Term Care Facility: A Review and Practical Guide to Mathematical Modeling

OBJECTIVES (1) To systematically search for all dynamic mathematical models of infectious disease transmission in long-term care facilities (LTCFs); (2) to critically evaluate models of interventions against antimicrobial resistance (AMR) in this setting; and (3) to develop a checklist for hospital epidemiologists and policy makers by which to distinguish good quality models of AMR in LTCFs. METHODS The CINAHL, EMBASE, Global Health, MEDLINE, and Scopus databases were systematically searched for studies of dynamic mathematical models set in LTCFs. Models of interventions targeting methicillin-resistant Staphylococcus aureus in LTCFs were critically assessed. Using this analysis, we developed a checklist for good quality mathematical models of AMR in LTCFs. RESULTS AND DISCUSSION Overall, 18 papers described mathematical models that characterized the spread of infectious diseases in LTCFs, but no models of AMR in gram-negative bacteria in this setting were described. Future models of AMR in LTCFs require a more robust methodology (ie, formal model fitting to data and validation), greater transparency regarding model assumptions, setting-specific data, realistic and current setting-specific parameters, and inclusion of movement dynamics between LTCFs and hospitals. CONCLUSIONS Mathematical models of AMR in gram-negative bacteria in the LTCF setting, where these bacteria are increasingly becoming prevalent, are needed to help guide infection prevention and control. Improvements are required to develop outputs of sufficient quality to help guide interventions and policy in the future. We suggest a checklist of criteria to be used as a practical guide to determine whether a model is robust enough to test policy. Infect Control Hosp Epidemiol 2017;38:216-225.

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

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

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

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

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

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

Methicillin-Resistant Staphylococcus aureus in Saarland, Germany: The Long-Term Care Facility Study

Background

Multiresistant organisms pose a threat for patients and care recipients. Control interventions need to be tailored to region, the type of institution considered, and risk factors. The German state of Saarland is ideally suited to study colonisation epidemiology throughout its various health and care institutions. After conclusion of a large admission prevalence study in acute care hospitals, we now performed a methicillin-resistant Staphylococcus aureus (MRSA) point prevalence study in Saarland long term care facilities (LTCF), allowing for a direct comparison with respect of MRSA prevalence and associated risk factors between these two institutional types located within a confined region.

Methodology and Principal Findings

Of all LTCF of the region, 65/136 participated in the study performed between 09/2013 and 07/2014. Overall, complete microbiological specimen and questionnaires of 2,858 of 4,275 (66.8%) LTCF residents were obtained. 136/2,858 (4.8%) screened residents revealed MRSA carrier status. Multivariate risk factor analysis yielded ulcer/deep soft tissue infection, urinary tract catheter, and MRSA history with multiple MRSA decolonisation cycles to be independently associated with MRSA carrier status.

Conclusion

As already known from previous studies, colonisation with MRSA is common in LTCF residents even in an area with relatively low MRSA prevalence. This found prevalence can now be related to the acute care admission prevalence (2.2%) as well as to the admission prevalence in acute care geriatric departments (7.6%). The common clonal attribution (spa type) of MRSA isolates prevalent in the LTCF population as well as in the acute care admission population points towards a close relationship between both types of institutions. However, the ostensible absence of risk factors such as “previous hospitalisation” in conjunction with newly identified factors such as “multiple decolonisation cycles” refers to MRSA colonisation risks independent of contact with acute care facilities. Overall, this large LTCF point prevalence study allows data-based, region-tailored decisions on MRSA screening policies and provides a basis for additional preventative measures.

Methicillin-resistant Staphylococcus aureus: Prevalence, incidence, risk factors, and effects on survival of patients in a specialist palliative care unit: A prospective observational study

BACKGROUND

Little is known about the impact of methicillin-resistant Staphylococcus aureus in palliative care settings. To date, the clinical impact of methicillin-resistant Staphylococcus aureus in palliative care is unknown.

AIM

To determine prevalence and incidence of methicillin-resistant Staphylococcus aureus colonisation in a specialist palliative care setting, to identify risk factors for methicillin-resistant Staphylococcus aureus colonisation, to determine the eradication success rate and to determine the impact of methicillin-resistant Staphylococcus aureus on survival.

DESIGN

Prospective cohort study.

SETTING/PARTICIPANTS

Data were collected for consecutive admissions to an inpatient palliative care service. Patients were screened for methicillin-resistant Staphylococcus aureus colonisation on admission and 1 week post admission. Methicillin-resistant Staphylococcus aureus eradication was attempted in methicillin-resistant Staphylococcus aureus positive patients.

RESULTS

Data were collected from 609 admissions for 466 individual patients. Admission screening data were available in 95.5%. Prevalence of methicillin-resistant Staphylococcus aureus colonisation was 11.59% (54 patients). One week incidence of methicillin-resistant Staphylococcus aureus colonisation was 1.2%. Risk factors for methicillin-resistant Staphylococcus aureus colonisation were determined using Chi-Squared test and included high Waterlow score (p < 0.01), high palliative performance scale score (p < 0.01), methicillin-resistant Staphylococcus aureus status prior to admission (p < 0.01), admission from hospital (p < 0.05), presence of urinary catheter or percutaneous endoscopic gastrostomy tube (p < 0.05) and poor dietary intake (p < 0.05). Regression analysis did not identify independent risk factors. Methicillin-resistant Staphylococcus aureus was eradicated in 8.1% of admissions, while 46 patients commenced on the protocol (62.2%) died before completing it. Methicillin-resistant Staphylococcus aureus did not significantly impact survival but was significantly associated with having infection episodes and longer length of stay.

CONCLUSION

This study identified risk factors for methicillin-resistant Staphylococcus aureus colonisation in palliative care patients. Methicillin-resistant Staphylococcus aureus was eradicated in 8.1% of patients. Hence, restricting methicillin-resistant Staphylococcus aureus screening to high-risk palliative care patients may be prudent.

Risk Factors for Methicillin-Resistant Staphylococcus Aureus Carriage in Residents of German Nursing Homes

Objectives:

To determine the prevalence of and the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage in nursing home residents in the Rhine-Neckar region of southern Germany.

Design:

Point-prevalence survey.

Setting:

Forty-seven nursing homes in the region.

Participants:

All residents of the approached nursing homes who agreed to participate.

Methods:

After informed consent was obtained, all participants had their nares swabbed, some personal data collected, or both. All swabs were examined for growth of MRSA All S. aureus isolates underwent oxacillin susceptibility testing and polymerase chain reaction for demonstration of the meek gene. All MRSA isolates were typed using pulsed-field gel electrophoresis after digestion with SmaI.

Results:

Swabs from 3,236 nursing home residents yielded 36 MRSA strains, contributing to a prevalence rate of 1.1%. Significant risk factors for MRSA carriage in the multivariate analysis were the presence of wounds or urinary catheters, limited mobility, admission to a hospital during the preceding 3 months, or stay in a medium-size nursing home. One predominant MRSA strain could be detected in 30 of the 36 MRSA carriers.

Conclusions:

The prevalence of MRSA in German nursing homes is still low. These residents seemed to acquire their MRSA in the hospital and transfer it to their nursing home. Apart from well-known risk factors for the acquisition of MRSA we identified the size of the nursing home as an independent risk factor. This might be due to an increased use of antimicrobials in nursing homes of a certain size.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[The challenge of infections and multiresistant bacteria among the elderly living in long-term care facilities]

Healthcare-associated infections not only affect patients in acute care hospitals but also patients in need of long-term care. As the elderly are generally most affected, the demographic change in Germany faces a range of increasing challenges in the field of infection control. The ageing process itself is accompanied by several physiological and pathological changes which may result in an increase in the risk of infectious diseases. Elderly living in long-term care facilities (LTCFs) may in addition be exposed to further risks due to their everyday life in a community, nursing care and the, to some extent, inappropriate use of antibiotics. Bacteria that have become resistant to commonly used antimicrobial agents are meanwhile prevalent in nursing homes. Caregivers often feel left alone when facing the task of achieving a balance between the need for a comfortable familiar environment and the application of infection control measures according to a resolute prevention strategy. This review aims to give an overview about the characteristics of infections among the elderly, especially with respect to long-term care.

Diversity of methicillin-resistant Staphylococcus aureus strains isolated from residents of 26 nursing homes in Orange County, California

Nursing homes represent a unique and important methicillin-resistant Staphylococcus aureus (MRSA) reservoir. Not only are strains imported from hospitals and the community, strains can be transported back into these settings from nursing homes. Since MRSA bacteria are prevalent in nursing homes and yet relatively poorly studied in this setting, a multicenter, regional assessment of the frequency and diversity of MRSA in the nursing home reservoir was carried out and compared to that of the MRSA from hospitals in the same region. The prospective study collected MRSA from nasal swabbing of residents of 26 nursing homes in Orange County, California, and characterized each isolate by spa typing. A total of 837 MRSA isolates were collected from the nursing homes. Estimates of admission prevalence and point prevalence of MRSA were 16% and 26%, respectively. The spa type genetic diversity was heterogeneous between nursing homes and significantly higher overall (77%) than the diversity in Orange County hospitals (72%). MRSA burden in nursing homes appears largely due to importation from hospitals. As seen in Orange County hospitals, USA300 (sequence type 8 [ST8]/t008), USA100 (ST5/t002), and a USA100 variant (ST5/t242) were the dominant MRSA clones in Orange County nursing homes, representing 83% of all isolates, although the USA100 variant was predominant in nursing homes, whereas USA300 was predominant in hospitals. Control strategies tailored to the complex problem of MRSA transmission and infection in nursing homes are needed in order to minimize the impact of this unique reservoir on the overall regional MRSA burden.

Antibiotic use and resistance in long term care facilities

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.

Modeling the spread of methicillin-resistant Staphylococcus aureus in nursing homes for elderly

Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in many hospital settings, including nursing homes. It is an important nosocomial pathogen that causes mortality and an economic burden to patients, hospitals, and the community. The epidemiology of the bacteria in nursing homes is both hospital- and community-like. Transmission occurs via hands of health care workers (HCWs) and direct contacts among residents during social activities. In this work, mathematical modeling in both deterministic and stochastic frameworks is used to study dissemination of MRSA among residents and HCWs, persistence and prevalence of MRSA in a population, and possible means of controlling the spread of this pathogen in nursing homes. The model predicts that: (i) without strict screening and decolonization of colonized individuals at admission, MRSA may persist; (ii) decolonization of colonized residents, improving hand hygiene in both residents and HCWs, reducing the duration of contamination of HCWs, and decreasing the resident∶staff ratio are possible control strategies; (iii) the mean time that a resident remains susceptible since admission may be prolonged by screening and decolonization treatment in colonized individuals; (iv) in the stochastic framework, the total number of colonized residents varies and may increase when the admission of colonized residents, the duration of colonization, the average number of contacts among residents, or the average number of contacts that each resident requires from HCWs increases; (v) an introduction of a colonized individual into an MRSA-free nursing home has a much higher probability of leading to a major outbreak taking off than an introduction of a contaminated HCW.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Taking stock of infections and antibiotic resistance in the elderly and long-term care facilities: A survey of existing and upcoming challenges

Treating elderly patients with infections represents one of the greatest challenges to health-care providers. Older adults are the largest growing sector of the population and suffer excessively from infectious diseases such as pneumonia, urinary tract infections (UTIs), and skin and soft-tissue infections. Often because of disabilities, the elderly require treatment of infectious diseases in long-term care facilities (LTCFs). As a result of antibiotic use, LTCFs have become "reservoirs of resistance" and multi-drug resistant (MDR) pathogens are frequently recovered. Clinicians also need to be aware of the impairment of immune function and other emerging chronic infections (HIV, HCV) that are now present in the elderly. Despite vigilance regarding this issue, delays in diagnosis and initiation of therapy are common. This article reviews the changing landscape of infections in the elderly and the challenge these syndromes present in the context of an increasing older population that requires dedicated resources.

"Somebody else's problem?" Staff perceptions of the sources and control of meticillin-resistant Staphylococcus aureus

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) is endemic within the United Kingdom health care sector. Recent campaigns to reduce health care-associated infection have rested on increasing staff accountability and ownership of the problem and its solutions. However, the existence of reservoirs of colonization in the community now creates ambiguity about sources, which may undermine preventative strategies.

METHODS

The theoretical framework of causal attribution was applied to explore staff biases in perceptions and effects on infection control behaviors on both sides of the hospital/care home interface. Forty-four staff from 1 acute care hospital and 53 staff from 6 care homes estimated prevalence, risk, and sources of MRSA. Focus groups (6 care home and 8 hospital) were used to elicit group perceptions.

RESULTS

Staff tended to attribute the causes of MRSA to external (not self) human factors including patient risk factors and poor infection control practices of others. Teams tend to attribute their "successes" in infection control to dispositional attributions (good team policy and performance) and attribute "lapses" to situational factors (client group, patient movement, work pressures).

CONCLUSION

Variations in information needs, ownership, and infection control practices could be addressed by better interorganizational working and support for staff teams to assess their own responses to the problem.

Prevalence and molecular epidemiology of meticillin-resistant Staphylococcus aureus in nursing home residents in northern Germany

Nursing home residents are a population at risk for carrying meticillin-resistant Staphylococcus aureus (MRSA). To better guide infection control and healthcare network initiatives, we investigated the point prevalence and molecular epidemiology of MRSA colonisation among nursing home residents in Brunswick, northern Germany. Among the 32 participating nursing homes of the available 34 in the region, 68% of residents (1827 of 2688) were screened for nasal and/or wound colonisation. A total of 139 residents (7.6%; 95% confidence interval: 6.4-8.8%) were identified as MRSA positive, almost six-fold more than the 24 MRSA carriers (0.9%) expected according to the nursing homes' pre-test information. Although known risk factors including urinary tract catheters, wounds, preceding hospital admission, and high grade resident care were confirmed, none was sensitive enough to be considered as the sole determinant of MRSA carriage. spa typing revealed that more than 70% of isolates belonged to the Barnim strain (ST-22, EMRSA-15, CC22) typical for hospital-acquired MRSA in northern Germany. There was no evidence for the presence of community-acquired or livestock-associated S. aureus strains. These data show that in northern Germany MRSA has spread from the hospital environment to other healthcare institutions, which must now be regarded as important reservoirs for MRSA transmission.

Staphylococcus aureus: An old pathogen with new weapons

Staphylococcus aureus has been recognized as an important human pathogen for more than 100 years. S aureus has been able to adapt and evolve in terms of its resistance traits and virulence factors; it is among the most important causes of human infections in the twenty-first century. Rapid molecular identification in the clinical microbiology laboratory of these resistance and virulence factors expressed by S aureus will play an important role in the future in decreasing the morbidity and mortality of infections. This article addresses the emerging aspects of infections caused by S aureus, including microbiology, epidemiology, clinical presentation, pathogenesis, diagnosis, treatment and prognosis, and immunity.

Daptomycin: The First Approved Lipopeptide Antimicrobial

OBJECTIVE

To review the literature concerning the first Food and Drug Administration-approved lipopeptide antimicrobial, daptomycin.

DATA SOURCES

A PUBMED search was conducted to identify pertinent English-language journal articles between 1985 and November 2003, and additional references were obtained from the bibliographies of these articles. Abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy meetings from 1985 through 2003 also were reviewed.

STUDY SELECTION

All studies evaluating any aspect of daptomycin.

DATA SYNTHESIS

Daptomycin is a semisynthetic lipopeptide, the first such antimicrobial agent to reach the marketplace. Its mechanism of action differs from that of the related agent vancomycin in that much of its effect is not because of inhibition of peptidoglycan biosynthesis, but instead is a result of alterations in cell-membrane electrical charge and transport. It exhibits a broad spectrum of activity against gram-positive aerobes and anaerobes, including methicillin-, penicillin-, aminoglycoside-, and vancomycin-resistant strains. In subjects with normal renal function, the terminal disposition half-life is about 7 to 10 hours. It is principally eliminated as unchanged drug in the urine. Available clinical trial data demonstrate efficacy in complicated skin and skin-structure infections resulting from susceptible gram-positive pathogens, but not in pneumonia. The principal adverse event of concern, although rare, is myotoxicity, manifested by muscle pain and/or weakness and elevated serum creatine phosphokinase (CPK) concentrations. The approved dosage regimen is 4 mg/kg intravenously over 30 minutes once daily for 7 days to 14 days. Studies are underway evaluating doses of up to 8 mg/kg once daily.

CONCLUSIONS

Daptomycin, the first lipopeptide antimicrobial to be marketed, exhibits activity against multiresistant gram-positive pathogens, including linezolid- and quinupristindalfopristin-resistant strains. As such, it is a potentially valuable agent to treat infections resulting from such pathogens. To preserve its utility, it should not be used indiscriminately for infections resulting from pathogens sensitive to other antimicrobials. It is probably best used with restricted access and used only for multiresistant gram-positive pathogens where alternative agents cannot be employed. If used, careful monitoring for the signs and symptoms of myotoxicity, including obtaining weekly serum CPK levels, is mandatory. In addition, bacterial sensitivities to this agent should be prospectively monitored by national antimicrobial surveillance programs like SENTRY, TRUST, and LIBRA.

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

OBJECTIVES

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

DESIGN

Point prevalence study.

SETTING

Nursing homes.

PARTICIPANTS

Residents and staff in nursing homes.

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Molecular epidemiology of methicillin-resistant Staphylococcus aureus in residential care homes for the elderly in Hong Kong

This territory-wide study evaluated the molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in residential care homes for elderly (RCHEs) in Hong Kong. MRSA colonization was assessed by taking swab culture from anterior nares and active skin lesions. Of 487 RCHEs surveyed, 80 MRSA strains were recovered from 1563 residents, giving a prevalence of 5.1%. Twenty-four isolates had SCCmec II, 2 had SCCmec III, 17 had SCCmec IV, 36 had SCCmec V, and 1 had a composite SCCmec type. Pulsed-field gel electrophoresis typing clustered 75 isolates into 7 clones (HKU10 to 50, HKU80, and HKU90). Two predominant types, HKU30 and HKU50, which together account for 75% of all MRSA strains, were found in 13 and 15 of the 18 geographic districts in Hong Kong, respectively. The main features for HKU50 strains were spa t1081/ST45-IV or V, capsular type 8, agrIV, and hla, seg, sei positive. On the other hand, HKU30 strains had spa t002/ST5-II, capsular type 5, agrII, and were hla, seg, sei positive. HKU30 strains were often multidrug resistant (MDR, involving ciprofloxacin, erythromycin, gentamicin, and tetracycline). In contrast, HKU50 strains exhibit both multidrug resistance (MDR) (involving ciprofloxacin, erythromycin, and tetracycline, but not gentamicin) and non-MDR patterns.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the results of the searches.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Staphylococcus aureus colonization among nursing home residents in a large Finnish nursing home

We studied colonization with methicillin-resistant and -sensitive Staphylococcus aureus (MRSA, MSSA) in the second largest nursing home in Finland, in which the residents volunteered had their nostrils, throats, perineums, skin lesions, and catheter exit sites swabbed, and catheter urines cultured. The specimens were cultured onto non-selective and selective agar, with or without enrichment in salt-containing trypticase soy broth (TSB). S. aureus was identified by routine methods, methicillin resistance was detected by oxacillin and cefoxitin disk diffusion and MIC E-tests, and GenoType MRSA -test was used for mecA gene confirmation. A total of 663 cultures were obtained from 213 residents. Of those, 165 specimens (25%) from 94 residents (44%) were positive for S. aureus, and 3 specimens (0.4%) from 2 (0.9%) residents were positive for MRSA. Of the 165 S. aureus isolates, 31 (19%) from 25 (27%) residents were found only from sites other than nostrils (30 MSSA and 1 MRSA). TSB enrichment detected additional 33 (5%) S. aureus isolates (32 MSSA and 1 MRSA), resulting in 8 (5%) additional residents. None of the MRSA strains would have been found if only nostrils and throat had been screened, and no enrichment broth had been used.

Epidemiology and genetic diversity of methicillin-resistant Staphylococcus aureus strains in residential care homes for elderly persons in Hong Kong

OBJECTIVE

To determine the prevalence and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) strains among residents in residential care homes for the elderly in Hong Kong.

DESIGN

Cross-sectional and descriptive study.

PARTICIPANTS

A total of 949 residents in 13 residential care homes for elderly persons in Hong Kong in January 2005.

METHODS

MRSA colonization was assessed by culture of swab specimens from anterior nares and active skin lesions. Characteristics of residents were obtained by a standard questionnaire. All MRSA isolates were analyzed by polymerase chain reaction for their staphylococcal cassette chromosome (SCC) mec content and were typed by pulsed-field gel electrophoresis (PFGE) and multilocus sequencing.

RESULTS

MRSA colonization was detected in 27 residents (2.8%). No MRSA was found in 2 facilities. The rate of MRSA carriage in the other 11 facilities ranged from 1.9% to 4.2%. In univariate analysis, functional immobility (odds ratio [OR], 1.4), history of hospital admission (OR, 2.3), and the use of nebulized medication (OR, 5.4) were significantly associated with MRSA colonization. The isolates had 11 unique antibiograms, with 14 isolates susceptible to all but 1 or 2 of the non- beta -lactam antimicrobial agents tested. The isolates exhibited SCCmec types I (1 isolate), II (2 isolates), III (1 isolate), IV/IVA (10 isolates), and V (13 isolates). No isolates had the Panton-Valentine leukocidin genes. PFGE analysis clustered all except 1 isolate into 7 PFGE types, designated HKU10 to HKU70. Between 1 and 4 unique PFGE types were found in the individual residential care facilities.

CONCLUSION

This study documented the emergence of SCCmec types IV and V among genetically diverse MRSA strains in residential care homes for elderly persons in Hong Kong.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS RISK PERCEPTION BY HEALTHCARE PERSONNEL IN A PUBLIC HOSPITAL

This study examines perceived risk of contamination by methicillin-resistant staphylococcus aureus (MRSA) among healthcare personnel in a French university hospital. MRSA poses a public health threat for healthcare staff who work in a hospital environment. This study is part of a pluridisciplinary research project on the risk factors of MRSA contamination. In many studies (Kouabenan, 1998; Slovic, 1987; Slovic et al., 1981), risk perception appears to be an important factor in understanding attitudes towards accident prevention and selfprotective behavior. A questionnaire measuring several dimensions of perceived MRSA risk (risk for oneself, risk for others, severity, controllability, frequency, preventive efforts) and a questionnaire assessing optimism were administered to 187 hospital staff members of various occupations. The results revealed that the risk of MRSA contamination was well perceived as a whole by healthcare personnel. However, certain factors like proximity to patients and length of service tended to be accompanied by an underestimation of the risk, while other factors like little education, working part-time, and a lack of experience tended to cause overestimation. Preventive measures are recommended.

The point prevalence and associated factors of nasal methicillin-resistant Staphylococcus aureus colonisation in eight geriatric hospitals in Korea

The prevalence and associated factors of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonisation were investigated among patients in geriatric hospitals in Korea. S. aureus was isolated from 317 (50.2%) of 632 patients. The nasal MRSA colonisation prevalence was 36.1%. In bivariate analysis, stay in an intensive care unit, decreased functional status, recent use of antibiotics, use of urinary catheters and the existence of skin breaks were associated with nasal MRSA colonisation (p < 0.05). Of these factors, only decreased functional status and recent use of systemic antibiotics were associated independently with nasal MRSA colonisation following logistic regression analysis.

Survey of long-term-care facilities in Iowa for policies and practices regarding residents with methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci

OBJECTIVES

To identify infection control policies and practices used by long-term-care facilities (LTCFs) in Iowa for residents with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), and to estimate the prevalence of residents known to have these organisms.

DESIGN

Survey.

SETTING

LTCFs in Iowa from December 2002 through March 2003.

RESULTS

Of the 429 LTCFs in Iowa, 331 (77%) responded to the survey. The estimated prevalence of residents known to have MRSA was 13.4 per 1,000 and that of residents known to have VRE was 2.3 per 1,000. Facilities owned by the government or those with an average of more than 86 occupied beds were more likely to have residents known to have MRSA and VRE (P = .002 and .007, respectively). Of the responding facilities, 7.3% acknowledged that they refused to accept individuals known to have MRSA and 16.9% acknowledged that they refused to accept those known to have VRE. Facilities in large communities (population, > 100,000) were least likely to deny admission to an individual known to have either MRSA or VRE (P = .05). Most facilities reported adhering to the national guidelines, but fewer than half (44.7%) of the respondents had heard of the Iowa Antibiotic Resistance Task Force's guidelines regarding residents with MRSA or VRE.

CONCLUSIONS

Many LTCFs in Iowa care for residents known to have MRSA or VRE, but some refuse to admit these individuals. Infection control personnel and public health officials should work together to educate LTCF staff so that residents receive proper care and resistant organisms do not spread within this setting.

Clinical and epidemiologic features of methicillin-resistant Staphylococcus aureus in elderly hospitalized patients

We describe characteristics of elderly patients with MRSA identified in 37 Canadian hospitals between 1995 and 2002. Of these inpatients, 6,613 (66%) were older than 65 years. They were more likely than younger patients to have been colonized without infection and to have had MRSA isolated from urine or the perineum. The epidemiology and clinical features of these patients is distinct from that of younger patients.

Prevalence and nosocomial spread of methicillin-resistant Staphylococcus aureus in a long-term-care facility in Slovenia

OBJECTIVES

To determine the prevalence and incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among residents and healthcare workers (HCWs) of a long-term-care facility (LTCF), to assess possible routes of nosocomial spread, and to determine genetic relatedness of the isolates.

SETTING

A 351-bed community LTCF for the elderly.

DESIGN AND PARTICIPANTS

Study investigators made two visits, approximately 3 months apart, to the facility. Samples for cultures were obtained from 107 residents during the first visit, 91 residents during the second visit, and 38 HCWs.

RESULTS

The prevalence of MRSA colonization among residents was 9.3% during the first visit and 8.8% during the second visit. During the first visit, two HCWs were colonized. During the second visit, no HCWs were colonized. The colonization of HCWs suggested a potential role in the transmission of MRSA. Molecular typing showed that two of three roommates in one room had the same strain, whereas two in another room differed from one another. All isolates, except one, belonged to two related clonal groups. It seems that the clonal group to which most isolates belonged had the greatest potential for spreading among both residents and HCWs.

CONCLUSIONS

Similar prevalence rates of MRSA colonization have been found in other European countries, but such studies have usually involved residents with better functional status than that of the participants in this study. Nosocomial spread of MRSA occurred in the facility examined, but not frequently. More attention should be focused on the hand hygiene of HCWs.

Risk factors for colonization with methicillin-resistant Staphylococcus aureus in a long-term-care facility in Slovenia

OBJECTIVE

To evaluate risk factors associated with methicillin-resistant Staphylococcus aureus (MRSA) colonization in a long-term-care facility (LTCF) for the elderly in Slovenia.

SETTING

A 351-bed community LTCF for the elderly.

DESIGN AND PARTICIPANTS

This was a case-control study. MRSA carriage was identified in 102 of 127 residents of the facility's nursing unit. Two swabs were taken: one from the anterior nares and one from the largest skin lesion. If no skin lesions were present, the axillae and the groin area were swabbed. Data were collected regarding gender, age, length of stay in the facility, underlying conditions, functional status, presence of wounds or pressure sores, presence of catheters, antibiotic treatments, and hospital admissions.

RESULTS

We detected MRSA in 12 participants. Risk factors independently and significantly associated with MRSA colonization on the multivariate analysis were antibiotic treatments within 1 month before the investigation (odds ratio, 5.087; 95% confidence interval, 1.02 to 25.48; P = .048) and multiple hospital admissions in the 3 months before the investigation (odds ratio, 6.277; 95% confidence interval, 1.31 to 30.05; P = .022).

CONCLUSIONS

This is the first assessment of risk factors for colonization with MRSA in an LTCF in Slovenia. MRSA poses a problem in this LTCE Our observations may be valuable in implementing active surveillance cultures in infection control programs in Slovenian LTCFs.

An investigation of MRSA infection in a hospice

This study investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage and infection among patients admitted to a hospice. Under the existing policy at this hospice, only patients admitted from hospital wards where MRSA is known to be present are screened for MRSA prior to transfer. Hence the investigators were keen to study patients transferred from settings other than this. One hundred and twenty patients, all either from the community or from hospital wards without known MRSA, were entered into the study ('study group') and were swabbed for MRSA on admission to the hospice. Swabbing was continued at weekly intervals until discharge or death. Of the 120 patients, seven (5.8%) were MRSA positive on admission. A further four patients who were negative on admission showed MRSA on later swabs. Another two patients developed symptomatic infections during admission that were proven to be due to MRSA, but neither of these had shown MRSA on any swabs taken during the study. During the study period, a separate group of 156 patients was swabbed routinely before transfer from hospital wards where MRSA was known to be present in accordance with hospice policy ('non-study group'). Of these patients, 11 (7.1%) were found to be colonized with MRSA but none developed associated symptomatic infection. It appears that the risk of symptomatic infection with MRSA in hospice patients is low, and the burden placed on this vulnerable group by conventional eradication regimes may be disproportionate to any benefit derived.

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.

Epidemiological relatedness of methicillin-resistant Staphylococcus aureus from a tertiary hospital and a geriatric institution in Spain

From January 2000 to June 2002, 24 Staphylococcus aureus isolates were recovered from decubitus ulcers of patients in a geriatric institution, of which 17 (70.8%) were methicillin-resistant S. aureus (MRSA). Antibiotic resistance and DNA macrorestriction (pulsed-field gel electrophoresis; PFGE) patterns of the MRSA isolates were compared with a collection of 161 MRSA isolates from patients admitted to the institution's reference hospital. PFGE revealed the presence of five clonal types (found also in hospitalised patients) among the 17 MRSA isolates. The findings suggest nosocomial acquisition of the MRSA strains by five patients, with subsequent dissemination of the strains within the institution. The high rate of MRSA highlights the need for epidemiological analysis to control the dissemination of MRSA in long-term care facilities.

Incidence and prevalence of methicillin-resistant Staphylococcus aureus nasal carriage among healthcare workers in geriatric departments: relevance to preventive measures

Methicillin-resistant Staphylococcs aureus (MRSA) nasal carriage was assessed among healthcare workers caring for elderly patients in contact precautions in geriatric departments. Monthly incidence ranged from 0% to 3.3%. Carriage was observed only among nurses and nursing assistants. MRSA was thus infrequently acquired using precautions and carriage was usually transient.

Methicillin-resistant Staphylococcus aureus (MRSA) in the practice of otolaryngology--an emerging community acquired organism?

Soon after antibiotics were introduced to treat bacterial infections, resistance to these agents began to emerge. Staphylococcus aureus, a common organism in human infection, quickly became resistant to penicillin; however, semisynthetic penicillins seemed to have tremendous staying power. The recent emergence of methicillin-resistant S. aureus (MRSA) created a difficult problem in treating many hospital-acquired infections soon after it was discovered. However, now it appears to be spreading into the community at large. Although newer antibiotics have been developed to help manage this threat, multiple-drug resistance remains a fear among healthcare professionals. Eradication of MRSA appears to be an unachievable goal at this time, so attention has focused on decreasing the spread of this organism, often through simple hand-washing protocols. The continued spread of MRSA will have tremendous impact on the practice of medicine and otolaryngology during the next decade and beyond.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus in nursing homes: a cross-sectional study

A cross-sectional study of methicillin-resistant Staphylococcus aureus carriage in 2,857 nursing home residents showed an overall prevalence of 4.9%. The three clones identified by genetic analysis were identical to those in the acute care facilities; only their relative prevalence differed. Clone 2 took epidemic proportions in five of these nursing homes.

Ethical concerns in isolating patients with methicillin-resistant Staphylococcus aureus on the rehabilitation ward: a case report

Concern about methicillin-resistant Staphylococcus aureus (MRSA) is increasing in rehabilitation facilities. Those affected are often isolated to prevent the spread of MRSA to other patients. Because this isolation often interferes with the traditional rehabilitative approach, rehabilitation team members find themselves in an ethical dilemma as to how to approach these patients. Some patients may feel that strict isolation protocols violate their rights. We report a case showing the ethical dilemmas that an MRSA-positive patient brings to the rehabilitation setting. Isolation techniques make it difficult to treat rehabilitation patients using the current standards of care without compromising the medical ethics principles of autonomy and beneficence. Further study is required to establish protocols for patients with MRSA in the rehabilitation setting.

Containing methicillin-resistant S aureus. Surveillance, control, and treatment methods

In the past two decades, the prevalence of MRSA has increased in healthcare facilities in many countries around the world. The organism, which has caused nosocomial outbreaks, also has become endemic in many hospitals and long-term care facilities. Recently, reports of community-acquired MRSA in persons without known risk factors for the organism have been increasing. Transmission occurs primarily from colonized or infected patients to others through the hands of healthcare personnel. MRSA infection may be life-threatening and cause considerable morbidity, the need for prolonged hospitalization, and increased costs. Treatment options are limited because organisms are typically resistant to multiple antibiotics, but newer agents are being developed. However, there is also reason for concern about the recent emergence of MRSA resistant to glycopeptides, such as vancomycin. Efforts to limit the spread of MRSA should include surveillance and control measures, such as adequate hand hygiene and appropriate contact isolation or barrier precautions.

The role of the laboratory in infection prevention and control programs in long-term-care facilities for the elderly

Hospital infection prevention and control programs rely extensively on diagnostic microbiology laboratory testing. However, specimens for microbiological evaluation are less likely to be obtained from elderly residents of long-term-care facilities (LTCFs). In this article, issues regarding laboratory utilization and the potential role of the microbiology laboratory in infection prevention and control programs in LTCFs are reviewed. The role of the laboratory in infection surveillance, in the management of antimicrobial resistance, and in outbreak investigation are highlighted.