Emerging health care-associated infections in the geriatric population

Global, regional and national time trends in incidence of adverse effects of medical treatment, 1990-2019: an age-period-cohort analysis from the Global Burden of Disease 2019 study

BACKGROUND

Current adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework.

METHODS

AEMT was defined as harm resulting from a procedure, treatment or other contact with the healthcare system. The overall crude incidence rate, age-standardised incidence rate and their changes over time were analysed to evaluate temporal trends. Data were stratified by sociodemographic index (SDI) quintiles, age groups and sex to address heterogeneity across and within nations. An age-period-cohort model framework was used to differentiate the contributions of age, period and cohort effects on AEMT incidence changes. The model estimated overall and age-specific annual percentage changes in incidence rates.

FINDINGS

Although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950.

CONCLUSION

As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.

Association Between Lower Levels of Vitamin D and Inflammation in the Geriatric Population: A Systematic Review and Meta-Analysis

There have been suggestions that vitamin D has anti-inflammatory effects; however, the variabilities of vitamin D levels among specific groups of patients and its association with these inflammatory events have not been demonstrated. This study aims to study the association between vitamin D levels and vitamin D deficiency and inflammatory events among the elderly population. PubMed, Web of Science, Scopus, Science Direct, and ClinicalKey were systematically searched in December 2023 to include the relevant data. Comprehensive Meta-Analysis (version 3.0, Biostat, Inc., Englewood, NJ) was the software used for data analyses. A total of 12 studies were included in this analysis with 14,717 elderly patients. There was an overall significant decrease in vitamin D levels in elderly patients with high inflammatory markers compared to controls (Hedges' g = -0.221, 95% CI: -0.268, -0.173, P < 0.001), and event of vitamin D deficiency was found to be 0.321 (95% CI: 0.305, 0.337, P < 0.001). There is a significant decrease in vitamin D levels among the elderly with different inflammatory conditions. Future longitudinal studies and well-designed, large, randomized controlled trials are required to study the association between vitamin D deficiency and the incidence of inflammatory events in this specific group of patients.

Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study

BACKGROUND

Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention.

METHODS

We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate.

RESULTS

326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment).

CONCLUSIONS

An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT04798365.

Compromised Nutritional Status as a Risk Factor for the Incidence of Nosocomial Infections

Background Poor nutritional status may lead to longer hospital stays, increased mortality and morbidity, increased cost, and higher suffering. Nosocomial infections (NI) are a global health concern, and several risk factors are associated with their higher incidence. This study aimed to reveal that compromised nutritional status is one of the risk factors for developing NIs. Methodology The study was conducted in a tertiary care hospital in Pune, India. This was a prospective cohort study with a sample size of 200 hospitalized participants. Data collection was based on standard tools and structured forms which had two parts. In the first part, the assessment of nutritional status was done for which patients were categorized into two groups, namely, well-nourished and undernourished. Additionally, biochemical parameters (serum albumin) were also assessed. The second part included a follow-up of participants to evaluate the development of NIs including their laboratory investigation. Results were analyzed statistically using R software. Results Among 200 participants, 60 were female, of whom 15% developed NIs. Of the 140 males, 8% had NIs. Among 200 participants, 101 (51%) were well-nourished, of whom two (2%) developed NIs. Of the 99 (49%) undernourished participants, 18 (18%) had NIs. Those who were undernourished (univariate relative risk = 6.10, 95% confidence interval) were more prone to developing NIs compared to the well-nourished group. Conclusions NIs are widespread globally but are less studied and given less emphasis in developing countries. This study reports various types of NIs along with their incidence in well-nourished and undernourished groups. The incidence of NI observed in this study may reflect the higher severity of illness, age, poor nutritional status, and longer hospital stays. Identifying risk factors that can contribute to developing NI may help in their prevention by maximizing patient safety.

New Dimension on Quality of Life Differences among Older Adults: A Comparative Analysis of Digital Consumption in Urban and Rural Areas of China

The purpose of this study was to compare the variability in quality of life in the area of digital consumption among older adults in urban and rural China during the COVID-19 pandemic. This study proposed a low-cost mixed research method, and the methodology used a quantitative study of a large regional sample combined with a qualitative study of a small regional sample. Data for the large-scale area sample were obtained from the China family panel study (CFPS) dataset, and data for the small-scale regional sample were obtained from Nanjing, China. The quantitative analysis of the large-scale regional sample used the least squares regression analysis (OSL) and propensity score matching (PSM). The qualitative analysis of the small-scale regional sample used the selection optimization and compensation (SOC) model. The findings show that economic income is a direct driver of digital consumption. Digital consumption had a significant positive relationship with the quality of life for urban and rural older adults. In addition, the study established the semantic network relationships of the coping strategies of digital consumption of older adults and their drivers. Finally, the theoretical and practical implications of these findings are discussed in the context of other related studies.

Gram-negative infections in frail patients

Introduction

Gram-negative infections (GNIs) are frequently encountered both in community and hospital settings. Frail patients, defined as elderly individuals with multiple comorbidities, are particularly vulnerable to them. The presentation and the course of GNIs differ in aged patients compared with younger ones, making their management a unique challenge. This review aimed to outline the essential elements of the presentation, diagnosis, and outcome of GNIs in frail individuals.

Methods

MEDLINE/PubMed library search was performed using the following terms: frail, frailty, elderly, Gram-negative, infections, pneumonia, urinary tract infection, and bloodstream infection for the purpose of the review.

Conclusions

Elderly patients with multimorbidity represent a distinct population with relevant differences in GNIs presentation, diagnosis, and outcome. Several pitfalls should be avoided and appropriately addressed when facing GNIs in this group of patients. Future studies focusing on this population should be encouraged.

Barriers and facilitators to infection prevention and control in Dutch residential care facilities for people with intellectual and developmental disabilities: A theory-informed qualitative study

BACKGROUND

Care institutions are recognised to be a high-risk setting for the emergence and spread of infections and antimicrobial-resistant organisms, which stresses the importance of infection prevention and control (IPC). Accurate implementation is crucial for optimal IPC practice. Despite the wide promotion of IPC and research thereof in the hospital and nursing home setting, similar efforts are lacking in disability care settings. Therefore, this study aimed to assess perceived barriers and facilitators to IPC among professionals working at residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDD), as well as to identify professional-reported recommendations to improve IPC.

METHODS

This qualitative study involved semi-structured interviews (before COVID-19) with twelve professionals from five Dutch RCFs for people with IDD. An integrated theoretical approach was used to inform data collection and analysis. Thematic analysis using inductive and deductive approaches was conducted. This study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.

RESULTS

Our findings revealed barriers and facilitators at the guideline, client, professional, professional interaction, professional client interaction, client interaction, organisational, community, and societal level. Six main themes covering multiple barriers and facilitators were identified: (1) guidelines' applicability to (work)setting; (2) professionals' cognitions and attitude towards IPC (related to educational background); (3) organisational support and priority; (4) educational system; (5) time availability and staff capacity; and (6) task division and change coaches. The main professional-reported recommendations were the introduction of tailored and practical IPC guidelines, structural IPC education and training among all professionals, and client participation.

CONCLUSIONS

To promote IPC, multifaceted and multilevel strategies should be implemented, with a preliminary need for improvements on the guideline, professional, and organisational level. Given the heterogeneous character, i.e., different professionals, clients and care needs, there is a need for a tailored approach to implement IPC and sustain it successfully in disability care. Our findings can inform future IPC practice improvements.

Program development using intervention mapping in primary healthcare settings to address elder abuse: A randomized controlled pilot study

BACKGROUND

Abuse of elderly women is of great concern and yet relatively little is known about interventions.

OBJECTIVES

The aim of this study was to develop and test a culturally informed treatment, based on Intervention Mapping (IM), for primary healthcare settings. The intervention targets family members of elderly women and seeks to reduce elder abuse.

METHODS

N = 80 family members of elderly women were randomized to intervention or control. Elderly women completed assessment prior to randomization. Elder abuse was measured by self-reported frequency of neglect, physical, psychological, and financial abuse in the last 2 months across 16 items. Intervention included 4 sessions, each under 1 hr. At 2-month follow-up, elderly women completed an assessment. Linear mixed modeling was used for analyses.

RESULTS

Significant reduction in frequency of psychological abuse and neglect was found in comparison to control, with trend effects for financial abuse (F = 127.12, p < .005; F = 95.4; p < .005; and F = 16.53, p < .07, respectively). Physical abuse was infrequent.

CONCLUSION

This culturally tailored intervention reduced elder abuse. Given its basis in IM, it is well-positioned for roll-out and testing in a larger randomized trial to study adoption, implementation, and sustainability in practice settings.

Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria

Healthcare-associated infections (HCAI) are a common cause for residents’ mortality and morbidity associated with a significant socio-economic burden. Data on HCAIs in Austrian long-term care facilities are scare. Therefore, we evaluated the incidence rate of HCAIs per 1000 resident days in four LTC facilities in Graz, Austria, characterized the spectrum of HCAIs and the use of antimicrobial substances. We conducted a prospective surveillance study from 1 January to 31 December 2018 in four LTCFs of the Geriatric Health Centre of the City of Graz (total of 388 beds). Nursing staff collected data on HCAIs once a week using an electronic reporting system. During the 12-month surveillance period, 252 infections of 165 residents were recorded. The overall incidence rate of HCAIs was 2.1 per 1000 resident days. Urinary tract infections were the most commonly recorded HCAIs (49%, 124/252, 1.03 per 1000 resident days), followed by skin and soft tissue infections and respiratory tract infections. Beta-lactams (ATC class J01C) were prescribed most frequently (63/212), followed by fluoroquinolones (J01M; 54/212). In conclusion, the overall incidence rate for HCAIs was relatively low at 2.1 per 1000 resident days. Our real-life data can serve as a basis for future antimicrobial stewardship and infection prevention interventions.

Population Pharmacokinetics Analysis of Amikacin Initial Dosing Regimen in Elderly Patients

There are limited data of amikacin pharmacokinetics (PK) in the elderly population. Hence, we aimed to describe the population PK of amikacin in elderly patients (>70 years old) and to establish optimized initial dosing regimens. We simulated individual maximum concentrations in plasma (Cmax) and minimal concentrations (Cmin) for several dosing regimens (200–2000 mg every 24, 48, and 72 h) for patients with creatinine clearance (CCr) of 10–90 mL/min and analyzed efficacy (Cmax/minimal inhibitory concentration (MIC) ≥ 8) for MICs of 4, 8, and 16 mg/L and safety (Cmin < 4 mg/L). A one-compartment model best described the data. CCr was the only covariate associated with amikacin clearance. The population PK parameter estimates were 2.25 L/h for clearance and 18.0 L for volume of distribution. Dosing simulations recommended the dosing regimens (1800 mg) with dosing intervals ranging 48–72 h for patients with CCr of 40–90 mL/min based on achievement of both efficacy for the MIC of 8 mg/L and safety. None of the dosing regimens achieved the targets for an MIC of 16 mg/L. We recommend the initial dosing regimen using a nomogram based on CCr for an MIC of ≤8 mg/L in elderly patients with CCr of 40–90 mL/min.

Exploring determinants of hand hygiene compliance in LTCFs: a qualitative study using Flottorps' integrated checklist of determinants of practice

BACKGROUND

Elderly residents in long-term care facilities (LTCFs) are vulnerable to healthcare-associated infections. Although hand hygiene is a leading measure for preventing infection, the compliance of healthcare workers is low. The aim of this study is to identify determinants that influence hand hygiene compliance of nursing staff in LTCFs. This information on determinants can eventually be used to develop a tailored implementation strategy for LTCFs.

METHODS

This is an explorative, descriptive study using qualitative methods. We performed semi-structured focus group discussions with 31 nurses and nurse assistants from five Dutch LTCFs. Our focus group discussions continued until no new information could be identified from the data. We used Flottorps' comprehensive checklist for identifying determinants of practice (the TICD checklist) to guide data collection and analysis. The audiotapes were transcribed verbatim and two authors independently analysed the transcripts with Atlas.ti software.

RESULTS

LTCFs for the elderly have setting specific determinants that are decisive in explaining hand hygiene compliance. Most of these determinants are related to the residents with whom nurses build close relationships and for whom they want to create a homelike atmosphere. Residents can complicate the provision of care with unpredictable behaviour, being unwilling to receive care or use shared facilities. Our study also discovered setting-transcending determinants related to knowledge, professional interactions, guidelines, and incentives/resources.

CONCLUSIONS

Nurses in LTCFs are constantly pursuing a balance between working hygienically, responding adequately to acute care needs, and maintaining a homelike environment for their residents. As a result, setting-specific determinants affect hand hygiene compliance, as do the known determinants that are important in other care settings. To improve compliance in LTCFs, interventions should be selected on a theoretical base while linking these determinants to change interventions.

TRIAL REGISTRATION

Registration number 50-53000-98-113, Compliance With Hand Hygiene in Nursing Homes: Go for a Sustainable Effect (CHANGE) on ClinicalTrials.gov. Date of registration 28-6-2016.

Respiratory epidemics and older people

Coronavirus disease 2019 (COVID-19) has been particularly severe on older people. Past coronavirus epidemics namely Severe Acute Respiratory Syndrome and the Middle East Respiratory Syndrome have also been severe on older people. These epidemics lasted for only a limited period, however, and have proven short lived in the memories of both the public and public health systems. No lessons were learnt to mitigate the impact of future epidemics of such nature, on older people. This complacency we feel has claimed the lives of many older people during the current COVID-19 global epidemic. The nature of risks associated with acquiring infections and associated mortality among older people in respiratory epidemic situations are varied and of serious concern. Our commentary identifies demographic, biological, behavioural, social and healthcare-related determinants, which increase the vulnerability of older people to respiratory epidemics. We acknowledge that these determinants will likely vary between older people in high- and low-middle income countries. Notwithstanding these variations, we call for urgent action to mitigate the impact of epidemics on older people and preserve their health and dignity. Intersectoral programmes that recognise the special needs of older people and in unique contexts such as care homes must be developed and implemented, with the full participation and agreement of older people. COVID-19 has created upheaval, challenging humanity and threatening the lives, rights, and well-being of older people. We must ensure that we remain an age-friendly society and make the world a better place for all including older people.

Surveillance of infections in long-term care facilities (LTCFs): The impact of participation during multiple years on health care-associated infection incidence

We studied trends in the incidence of health care-associated infections (HAIs) in LTCFs between 2009 and 2015 and determined the effect of participation in our network. Elder-care physicians reported weekly the number of cases of influenza-like illness, gastroenteritis, (probable) pneumonia, urinary tract infections (UTIs) and all-cause mortality. Trends in the incidence of infection and mortality in relation to LTCF characteristics were calculated using multilevel univariate and multivariate logistic regression. Thirty LTCF participated for 3 years or more, 16 for 2 years and the remaining 12 LTCF for 1 year. During the study period, the median number of beds decreased from 158 to 139, whereas the percentage of residents with private bedrooms increased from 14% to 87%. UTIs were the most frequently reported infections, followed by (probable) pneumonia and gastroenteritis. Adjusted for calendar year and season, we observed a statistically significant decrease in the incidence of influenza-like illness (odds ratio (OR) = 0.8, P < 0.01) and (probable) pneumonia (OR = 0.8, P < 0.01) for each extra year an LTCF participated. Although there are other likely contributors, such as more private rooms and enhanced infection control measures, the decreasing trend of HAI in LTCFs participating in surveillance implies that surveillance is a valuable addition to current strategies to optimise infection control.

Association of Adverse Effects of Medical Treatment With Mortality in the United States: A Secondary Analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study

IMPORTANCE

More than 20 years have passed since the first publication of estimates of the extent of medical harm occurring in hospitals in the United States. Since then, considerable resources have been allocated to improve patient safety, yet policymakers lack a clear gauge of the progress made.

OBJECTIVES

To quantify the cause-specific mortality associated with adverse effects of medical treatment (AEMT) in the United States from 1990 to 2016 by age group, sex, and state of residence and to describe trends in types of harm and associations with other diseases and injuries.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using 1990-2016 data on mortality due to AEMT from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study, which assessed death certificates of US decedents.

EXPOSURES

Death with International Classification of Diseases (ICD)-coded registration.

MAIN OUTCOMES AND MEASURES

Mortality associated with AEMT. Secondary analyses were performed on all ICD codes in the death certificate's causal chain to describe associations between AEMT and other diseases and injuries.

RESULTS

From 1990 to 2016, there were an estimated 123 603 deaths (95% uncertainty interval [UI], 100 856-163 814 deaths) with AEMT as the underlying cause. Despite an overall increase in the number of deaths due to AEMT over time, the national age-standardized mortality rate due to AEMT decreased by 21.4% (95% UI, 1.3%-32.2%) from 1.46 (95% UI, 1.09-1.76) deaths per 100 000 population in 1990 to 1.15 (95% UI, 1.00-1.60) deaths per 100 000 population in 2016. Men and women had similar rates of AEMT mortality, and those 70 years or older had mortality rates nearly 20-fold greater compared with those aged 15 to 49 years (mortality rate in 2016 for both sexes, 7.93 [95% UI, 7.23-11.45] per 100 000 population for those aged ≥70 years vs 0.38 [95% UI, 0.34-0.43] per 100 000 population for those aged 15-49 years). Per 100 000 population, California had the lowest age-standardized AEMT mortality rate at 0.84 deaths (95% UI, 0.57-1.47 deaths), whereas Mississippi had the highest mortality rate at 1.67 deaths (95% UI, 1.19-2.03 deaths). Surgical and perioperative events were the most common subtype of AEMT, accounting for 63.6% of all deaths for which an AEMT was identified as the underlying cause.

CONCLUSIONS AND RELEVANCE

This study's findings suggest a modest reduction in the mortality rate associated with AEMT in the United States from 1990 to 2016 while also observing increased mortality associated with advancing age and noted geographic variability. The annual GBD releases may allow for tracking of the burden of AEMT in the United States.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND

Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance.

AIM

To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection.

METHODS

A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS.

FINDINGS

The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey.

CONCLUSION

HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

The infection risk scan (IRIS): standardization and transparency in infection control and antimicrobial use

Background

Infection control needs user-friendly standardized instruments to measure the compliance to guidelines and to implement targeted improvement actions. This abstract describes a tool to measure the quality of infection control and antimicrobial use, the Infection Risk Scan (IRIS). It has been applied in a hospital, several nursing homes and a rehabilitation clinic in the Netherlands.

Method

The IRIS consists of a set of objective reproducible measurements, combining patient- and healthcare related variables, such as: hand hygiene compliance, environmental contamination using ATP measurements, prevalence of resistant microorganisms by active screening, availability of infection control preconditions, personal hygiene of healthcare workers, appropriate use of indwelling medical devices and appropriate use of antimicrobials. Results are visualized in a spider plot using traffic light colors to facilitate the interpretation.

Results

The IRIS provided ward specific results within the hospital that were the basis for targeted improvement programs resulting in measurable improvements. Hand hygiene compliance increased from 43% to 66% (more than 1000 observations per IRIS, p < 0.000) and ATP levels were significantly reduced (p < 0.000). In the nursing homes, large differences were observed with environmental contamination as common denominator. Most remarkable were the difference in Extended Spectrum Beta-Lactamase Enterobacteriaceae (ESBL-E) prevalence (mean 11%, range 0–21%).

Conclusion

The bundle approach and visualization of the IRIS makes it a useful infection prevention tool providing standardization and transparency. Targeted interventions can be started based on the results of the improvement plot and repeated IRIS can show the effect of interventions. In that way, a quality control cycle with continuous improvement can be achieved.

Prognostic factors of health care-associated bloodstream infection in adult patients ≥40 years of age

We investigated 401 geriatric patients and 453 middle-aged patients with health care-associated bloodstream infection (HABSI) at a medical center during January-December 2014. Compared with middle-aged patients, the geriatric group had higher 30-day mortality (31.2% vs 23.4%, P = .01). Body mass index, serum albumin concentration, Charlson comorbidity index score, vancomycin-resistant Enterococcus bacteremia, and high C-reactive protein levels predict poor outcomes for HABSI among adult patients.

Development of prediction models for upper and lower respiratory and gastrointestinal tract infections using social network parameters in middle-aged and older persons -The Maastricht Study

The ability to predict upper respiratory infections (URI), lower respiratory infections (LRI), and gastrointestinal tract infections (GI) in independently living older persons would greatly benefit population and individual health. Social network parameters have so far not been included in prediction models. Data were obtained from The Maastricht Study, a population-based cohort study (N = 3074, mean age (±s.d.) 59.8 ± 8.3, 48.8% women). We used multivariable logistic regression analysis to develop prediction models for self-reported symptomatic URI, LRI, and GI (past 2 months). We determined performance of the models by quantifying measures of discriminative ability and calibration. Overall, 953 individuals (31.0%) reported URI, 349 (11.4%) LRI, and 380 (12.4%) GI. The area under the curve was 64.7% (95% confidence interval (CI) 62.6-66.8%) for URI, 71.1% (95% CI 68.4-73.8) for LRI, and 64.2% (95% CI 61.3-67.1%) for GI. All models had good calibration (based on visual inspection of calibration plot, and Hosmer-Lemeshow goodness-of-fit test). Social network parameters were strong predictors for URI, LRI, and GI. Using social network parameters in prediction models for URI, LRI, and GI seems highly promising. Such parameters may be used as potential determinants that can be addressed in a practical intervention in older persons, or in a predictive tool to compute an individual's probability of infections.

Incidence of pneumonia in nursing home residents with dementia in the Netherlands: an estimation based on three differently designed studies

Pneumonia leads to considerable morbidity and mortality in nursing home residents with dementia. We assessed pneumonia incidence based on data from three different studies: (1) real-time national surveillance of healthcare-associated infections in nursing home residents in 2009-2015; (2) a randomized controlled trial in 2012-2015 to assess effects of a practical guideline in nursing home residents with dementia and pneumonia; and (3) a study in 2007-2010 to assess quality of dying in newly admitted nursing home residents with dementia. In national surveillance data, pneumonia incidence was calculated separately for psychogeriatric and somatic beds, as a proxy for residents with and without dementia. Weekly pneumonia incidence was significantly lower per 1000 psychogeriatric beds (3·9; 95% confidence interval (CI) 3·2-4·6) compared with 1000 somatic beds (5·7; 95% CI 5·1-6·3). Annual incidence per 1000 psychogeriatric beds was similar in national surveillance (range 78·9-117·1) and the trial (range 71·0-94·3), and significantly higher in newly admitted dementia residents (range 267·3-363·2). The incidence was highest during the first months after admission when compared with residents with longer stay. In conclusion, follow-up of pneumonia in newly admitted dementia residents may result in higher incidence, possibly due to higher risk in this population.

Where to go if not the hospital? Reviewing geriatric bed utilization in an acute care hospital in Singapore

AIM

Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25 years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients.

METHODS

We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns.

RESULTS

Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity = 62%; specificity = 88%).

CONCLUSIONS

In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.

What's the Clinical Features of Colitis in Elderly People in Long-Term Care Facilities?

BACKGROUND/AIMS

As life expectancy has increased, the number of elderly patients who need long-term care has grown rapidly. Mortality in patients with colitis in long-term care facilities (LTCFs) is increasing. We intend to investigate the main causes of colitis in LTCFs compared to those of colitis in local communities, and to identify the clinical features and risk factors of patients with colitis in LTCFs.

METHODS

We retrospectively analyzed epidemiology, medical conditions, laboratory values, diagnoses, and clinical courses of elderly patients aged ≥65 who were admitted to the Ewha Womans University hospital with colitis between January 2007 and July 2012.

RESULTS

Patients with colitis in LTCFs (n=20) were compared with elderly patients with colitis in local communities (n=154). Fifty-five percent of colitis in LTCFs was caused by Clostridium difficile infection (CDI), 30% was due to ischemic colitis, and 15% was due to non-specific colitis. Non-specific colitis was the most common (63%) in the community group. Clinical outcomes were also significantly different between both groups: higher mortality (10.0% vs. 0.64%, P=0.021), higher requirement for intensive care units care (50.0% vs. 18.8%, P<0.01) in LTCFs group. In univariate analysis, the most significant risk factor for death in patients in LTCFs was decreased mental faculties.

CONCLUSIONS

Patients in LTCFs showed worse clinical outcomes and a much higher prevalence of CDI compared to patients from local communities. We suggest early and active evaluation, such as endoscopic examination, for differential diagnosis in patients in LTCFs.

Evidence-Based Infection Control Planning Based on National Healthcare-Associated Infection Prevalence Data

This study identifies factors associated with a high prevalence of healthcare-associated infection (HAI) in the Scottish inpatient population, on the basis of the Scotland National HAI Prevalence Survey data set. The multivariate models developed can be used to predict HAI prevalence in specific patient groups to help with planning and policy in infection control.

[Infections and use of antibiotics in residents of long-term care facilities in Hungary]

INTRODUCTION

Healthcare associated infections and antimicrobial use are common among residents of long-term care facilities. Faced to the lack of standardized data, the European Centre for Disease Prevention and Control funded a project with the aim of estimating prevalence of infections and antibiotic use in European long-term care facilities.

AIM

The aim of the authors was to present the results of the European survey which were obtained in Hungary.

METHOD

In Hungary, 91 long-term care facilities with 11,823 residents participated in the point-prevalence survey in May, 2013.

RESULTS

The prevalence of infections was 2.1%. Skin and soft tissues infections were the most frequent (36%), followed by infections of the respiratory (30%) and urinary tract (21%). Antimicrobials were mostly prescribed for urinary tract infections (40.3%), respiratory tract infections (38.4%) and skin and soft tissue infections (13.2%). The most common antimicrobials (97.5%) belonged to the ATC J01 class of "antibacterials for systemic use".

CONCLUSIONS

The results emphasise the need for a national guideline and education for good practice in long-term care facilities.

Measuring the quality of infection control in Dutch nursing homes using a standardized method; the Infection prevention RIsk Scan (IRIS)

Background

We developed a standardised method to assess the quality of infection control in Dutch Nursing Home (NH), based on a cross-sectional survey that visualises the results. The method was called the Infection control RIsk Infection Scan (IRIS). We tested the applicability of this new tool in a multicentre surveillance executed June and July 2012.

Methods

The IRIS includes two patient outcome-variables, i.e. the prevalence of healthcare associated infections (HAI) and rectal carriage of Extended-Spectrum Beta-Lactamase (ESBL) producing Enterobacteriaceae (ESBL-E); two patient-related risk factors, i.e. use of medical devices, and antimicrobial therapy; and three ward-related risk factors, i.e. environmental contamination, availability of local guidelines, and shortcomings in infection prevention preconditions. Results were categorised as low-, intermediate- and high risk, presented in an easy-to-read graphic risk spider-plot. This plot was given as feedback to management and healthcare workers of the NH.

Results

Large differences were found among most the variables in the different NH. Common shortcomings were the availability of infection control guidelines and the level of environmental cleaning. Most striking differences were observed in the prevalence of ESBL carriage, ranged from zero to 20.6% (p < 0.001).

Conclusions

The IRIS provided a rapid and easy to understand assessment of the infection control situation of the participating NH. The results can be used to improve the quality of infection control based on the specific needs of a NH but needs further validation in future studies. Repeated measurement can determine the effectiveness of the interventions. This makes the IRIS a useful tool for quality systems.

Infection in long term care facility in the kingdom of Bahrain

Infections in long term care facilities (LTCF) are common and are considered a major cause of mortality and morbidity. Endemic infections and outbreaks are observed in LTCF. Of particular concern is the growth of multi-drug resistant organisms. A study was conducted in the Kingdom of Bahrain concerning infections among the residents in a LTCF. The aim was to define the rate, type and outcomes of institutional infections. The different treatment modalities and antimicrobials used were evaluated. Our facility cares for the elderly and a heterogeneous group of patients from different populations (e.g., mentally retarded, bedbound due to various disabilities and other forms of consciousness impairment such as post stroke disability, cerebral palsy and anoxic brain damage). The initial span of six months was changed to seven months to increase the sample size and improve the data analysis. This was a prospective study conducted in Muharaq Geriatric Hospital in the Kingdom of Bahrain. The study was conducted over seven months from January 2013 to July 2013 on 104 patients. During that period, patients with new positive cultures from different sites were included. The clinical features, microbiological features and outcomes of the bacteremic episodes were included. The information was collected by a questionnaire created by the research team. From a total of 104 patients staying in the LTFC, 19 had positive cultures from different sites at different times. The study showed that infections are common, especially urinary tract infections.

Lymphopenia and poor performance status as major predictors for infections among residents in long-term care facilities (LTCFs): a prospective cohort study

The main aim of this study was to investigate the risk factors and consequence of LTCFs-acquired infections in Taiwan through a 16-month follow-up. This prospective cohort study invited residents of 10 private LTCFs in Taipei for study. For each participant, Karnofsky Performance Scale (KPS), use of feeding tube and/or urinary catheters, serum levels of albumin, total cholesterol, complete blood count, occurrence of LTCF-acquired infections, all-cause mortality were recorded. Overall, a total of 198 LTCF residents entered the study for a total of 67,395 resident-days, and 156 participants (79.8±9.7 years, 51.3% males) complete the follow-up with a total of 67,395 resident-days. During the study period, 360 LTCF-acquired infections occurred, and the incidence was estimated to be 5.34 episodes per 1000 resident-days. Subjects with LTCF-acquired infections were more likely to die than those without infections. Besides, subjects with lymphopenia and long-term use of feeding tube and/or urinary catheters were significant risk factors for LTCF-acquired infections. However, poorer functional status and occurrence of lower respiratory tract infections were significant predictive factors for all-cause mortality. In conclusion, the period prevalence of LTCF-acquired infections was higher in Taiwan than previous reports, but the incidence was similar. In addition to traditional risk factors, lymphopenia, a surrogate indicator for immunosenescence, was a significant risk factor for LTCF-acquired infections.

Community-acquired pneumonia: 2012 history, mythology, and science

Pneumonia remains one of the major disease entities practicing physicians must manage. It is a leading cause of infection-related morbidity and mortality in all age groups, and a leading cause of death in those older than 65 years of age. Despite its frequency and importance, clinical questions have remained in the therapy of community-acquired pneumonia including when to start antibiotics, when to stop them, who to treat, and what agents to use. Answers to these questions have involved historical practice, mythology, and science-sometimes good science, and sometimes better science. How clinical decisions are made for patients with community-acquired pneumonia serves as an illustrative model for other problem areas of medicine and allows for insight as to how clinical decisions have been made and clinical practice established.

Impact of functional status on the onset of nosocomial infections in an acute care for elders unit

OBJECTIVE

To assess the role of functional status as a risk factor for nosocomial infections in the elderly.

DESIGN

Prospective study.

SETTING

Acute care for elders units of university hospital of Grenoble.

PARTICIPANT

All patients over 75 years old consecutively hospitalized between January and April 2007.

MEASUREMENT

The main judgement criteria was the rate of nosocomial infection during the hospital stay, defined according to the French technical comity against nosocomial infections. Other data included functional status at baseline and admission (Katz' ADL), usual risk factors for nosocomial infections, demographic and geriatric assessment data.

RESULTS

The study included 223 patients. The mean age was 86.7±6.5 years. A nosocomial infection was diagnosed for 17.0% of the patients. In univariate analysis, the number of medicines, pressure sore, pneumonia diagnosis, illness severity, indwelling bladder catheter, IADL at baseline, and all disability parameters (ADL at baseline, ADL at admission, recent functional decline) were significantly associated with nosocomial infection (p<0.05). In multivariate analysis considering functional status at admission, indwelling bladder catheter (OR=4.43), severe disability at admission (OR=4.42) and illness severity (OR=2.68) were independently associated with nosocomial infection (p<0.05). In a second analysis considering functional status at baseline, only disability at baseline was independently associated with the onset of a nosocomial infection (OR=2.21).

CONCLUSION

Our results suggest a significant impact of functional impairment on the incidence of nosocomial infections in hospitalized elderly population. Disability is a higher risk factor for nosocomial infections than the usual and well-known other parameters. Larger prospective studies are needed to examine the power of this relationship.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use

DESIGN

We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF.

SETTING

A 160-bed VA LTCF.

METHODS

Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series.

RESULTS

Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β-lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04).

CONCLUSIONS

Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Infection control: point prevalence study versus incidence study in Polish long-term care facilities in 2009-2010 in the Małopolska Region

OBJECTIVE

The objective of this study was to evaluate the epidemiology of infection in Polish long-term care facilities (LTCFs) and to analyse the capabilities and legitimacy of implementing continuous targeted surveillance.

METHODS

The study investigated the relationship between the presence of infection and health status, tested using a point prevalence study (PPS) and incidence study. A 1-day PPS was carried out in October 2009, with prospective continuous surveillance between December 2009 and November 2010. Infections were defined according to McGeer's criteria.

RESULTS

The surveillance encompassed 193 people. The prevalence was 14.0 % in residential homes (RHs) and 18.7 % in the nursing home (NH). Various types of infections (in the PPS) were observed significantly more frequently in patients with asthma, wounds, atherosclerosis of lower extremities, tracheotomy tubes and conditions in patients hospitalised in intensive care units (ICUs) up to 1 year before the PPS day. The incidence rate was 2.7/1,000 patient days (pds).

CONCLUSIONS

The factors determined to be important for the risk of infection (in the continuous study) include the general status of patients, expressed using Barthel, abbreviated mental and Katz scales, as well as limited physical activity, stool incontinence and urinary catheterisation. In the PPS study, only a slight relationship was shown between the general status of residents and the risk of infection. None of the general status scales used clinically were shown to be helpful in estimating that risk, similarly to the five-point physical activity scale. Prospective continuous surveillance shows a possibility of limiting the range of infection control in the LTCFs within targeted surveillance in a population of patients that requires intensive nursing procedures. As a marker, one could point to the low score in the Barthel or Katz scales or low physical activity/bedridden persons.

Antimicrobial prescribing in nursing homes in Finland: results of three point prevalence surveys

PURPOSE

The purpose of this study was to analyse the Finnish European Surveillance of Antimicrobial Consumption (ESAC) nursing home (NH) point prevalence surveys' (PPSs) data in detail, i.e. to evaluate the variability in the prevalence of antimicrobial prescription between NHs and its relationship to resident characteristics.

METHODS

All residents present in NHs for ≥ 24 h and receiving systemic antimicrobials on the day of the survey were included. Data on antimicrobials and their indications (prophylaxis or treatment, type of infection) were collected.

RESULTS

Three PPSs were performed: eight NHs participated in April and November 2009 and nine in May-September 2010. In total, there were 5,691 eligible residents (range by survey, 1,706-2,320; range by NH, 60-688), 716 (12.6 %; range by NH, 3.2-33.3 %) of which received at least one antimicrobial and 40 residents received two. The most common indication was prophylaxis (487/5,691, 8.6 %), mainly for urinary tract infection (UTI) (460/487, 94.5 %). Of the residents, 269/5,691 (4.7 %, range by NH, 1.5-6.0 %) were on antimicrobial treatment. UTI (119/269; 44.2 %) was the most common indication for treatment. Methenamine (306/756, 40.5 %) was the most commonly used antimicrobial, followed by trimethoprim (13.6 %) and pivmecillinam (11.0 %). In the eight NHs participating in all three surveys, the prevalence of residents receiving antimicrobials decreased from 16.6 to 9.7 %.

CONCLUSIONS

Antimicrobial use was common in NHs in Finland and most were used for UTI prophylaxis and treatment. The usage, however, varied among NHs and tended to decrease during the surveys. NHs may benefit from antimicrobial stewardship interventions focused on UTI.

The prevalence of health care-associated infection in older people in acute care hospitals

OBJECTIVE

To determine the prevalence of health care-associated infection (HAI) in older people in acute care hospitals, detailing the specific types of HAI and specialties in which these are most prevalent.

DESIGN

Secondary analysis of the Scottish National Healthcare Associated Infection Prevalence Survey data set.

PATIENTS AND SETTING

All inpatients in acute care (n = 11,090) in all acute care hospitals in Scotland (n = 45).

RESULTS

The study found a linear relationship between prevalence of HAI and increasing age (P<.0001) in hospital inpatients in Scotland. Urinary tract infections and gastrointestinal infections represented the largest burden of HAI in the 75-84- and over-85-year age groups, and surgical-site infections represented the largest burden in inpatients under 75 years of age. The prevalence of urinary catheterization was higher in each of the over-65 age groups (P<.0001). Importantly, this study reveals that a high prevalence of HAI in inpatients over the age of 65 years is found across a range of specialties within acute hospital care. An increased prevalence of HAI was observed in medical, orthopedic, and surgical specialties.

CONCLUSIONS

HAI is an important outcome indicator of acute inpatient hospital care, and our analysis demonstrates that HAI prevalence increases linearly with increasing age (P<.0001). Focusing interventions on preventing urinary tract infection and gastrointestinal infections would have the biggest public health benefit. To ensure patient safety, the importance of age as a risk factor for HAI cannot be overemphasized to those working in all areas of acute care.

Evaluation of food handler practices and microbiological status of ready-to-eat foods in long-term care facilities in the Andalusia region of Spain

Food safety measures in long-term care facilities (LTCFs) are being improved by the introduction of quality control management systems during food production and by the implementation of good manufacturing practices. This study was conducted in LTCFs (geriatric homes) in Andalusia, Spain, during 2008 and 2009 to evaluate sanitary conditions and the microbiological quality and safety of salads and cooked meat products served. A regulation-based checklist was applied to the evaluated centers. Samples of ready-to-eat foods (n = 60) were examined for mesophilic aerobic bacteria (MAB), total coliforms, coagulase-positive staphylococci (CPS), Escherichia coli, Listeria spp., and Salmonella. In parallel, food contact surfaces (working tables, cutting boards, sinks, and faucets) were swabbed and analyzed for MAB and Enterobacteriaceae. The air quality in processing rooms, near sinks, and in canteens also was measured through an active air sampling method for MAB and Staphyloccocus spp. The results obtained revealed some deficiencies regarding handling practices and sanitary conditions tested (i.e., use and change of gloves, hand washing, and cleanliness of work surfaces). The microbial safety of foods examined indicated the absence of pathogens. Average levels of coagulase-positive staphylococci were below 10² CFU/g, and prevalence of E. coli was 6.3% in samples collected. Surface counts were higher on cutting boards and faucets, indicating insufficient cleanliness procedures. This study provides a descriptive analysis of the sanitary conditions of food service systems in LTCF, and this information can help risk managers to better define control measures needed to prevent foodborne infections.

Challenges for Home Health Care Providers: A Needs Assessment

Home health care provides substantial benefits over traditional, hospital-based health care, such as supporting older adults' independence and quality of life, as well as being more cost effective. This aspect of the health care industry could be enhanced through increased technological supports. When providing health care in a home setting, caregivers are faced with many challenges that impede their ability to perform their jobs. Technological interventions have the potential to alleviate many of these challenges. However, to achieve this potential, new technologies must be created to meet the needs of home health care providers. To date, these providers' specific and most critical needs are not thoroughly understood. This understanding can be gained by conducting a detailed needs assessment that captures the common challenges and difficulties that home health care providers encounter. We conducted a needs assessment comprising three phases: 1) an extensive literature review; 2) subject matter expert interviews; and 3) structured interviews with home health care providers. We identified several significant sources of frustration and difficulty faced by providers including: medical device usage; patient education; family involvement; provider isolation; and barriers to communication. This analysis provides an understanding of the challenges confronting home health care providers that can provide guidance for interventions. Future home health care technology can be developed to specifically target these workers' most urgent needs and allow them to perform their jobs with greater ease.

Clustered randomized controlled trial of a hand hygiene intervention involving pocket-sized containers of alcohol-based hand rub for the control of infections in long-term care facilities

OBJECTIVE

To investigate the effectiveness of a multifaceted hand hygiene program involving the use of pocket-sized containers of antiseptic gel in long-term care facilities (LTCFs) with elderly residents.

METHODS

In this clustered randomized controlled trial, Hong Kong LTCFs for elderly persons were recruited via snowball sampling. Staff hand hygiene adherence was directly observed, and residents' infections necessitating hospitalization were recorded. After a 3-month preintervention period, LTCFs were randomized to receive pocket-sized containers of alcohol-based gel, reminder materials, and education for all HCWs (treatment group) or to receive basic life support education and workshops for all healthcare workers (HCWs) (control group). A 2-week intervention period (April 1-15, 2007) was followed by 7 months of postintervention observations.

RESULTS

In the 3 treatment LTCFs, adherence to hand rubbing increased from 5 (1.5%) of 333 to 233 (15.9%) of 1,465 hand hygiene opportunities (P = .001)and total hand hygiene adherence increased from 86 (25.8%) of 333 to 488 (33.3%) of 1,465 opportunities (P = .01)after intervention; the 3 control LTCFs showed no significant change. In the treatment group, the incidence of serious infections decreased from 31 cases in 21,862 resident-days (1.42 cases per 1,000 resident-days) to 33 cases in 50,441 resident-days (0.65 cases per 1,000 resident-days) (P = .002), whereas in the control group, it increased from 16 cases in 32,726 resident-days (0.49 cases per 1,000 resident-days) to 85 cases in 81,177 resident-days (1.05 cases per 1,000 resident-days) (P = .004]). In the treatment group, the incidence of pneumonia decreased from 0.91 to 0.28 cases per 1,000 resident-days (P = .001) and the death rate due to infection decreased from 0.37 to 0.10 deaths per 1,000 resident-days (P = .01); the control group revealed no significant change.

CONCLUSIONS

A hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.

[Surveillance of nosocomial infections in a long-term care facility. Incidence and risk factors]

In Germany, surveillance of nosocomial infections is obligatory by law in hospitals, but not in long-term care facilities. In long-term care facilities, neither X-ray nor laboratory facilities are available; therefore, special criteria for infection surveillance in these facilities were developed by Mc Geer et al. (1991), based only on observations of the medical staff and foregoing laboratory methods. The practicability of these criteria was assessed in a long-term care facility with an electronic medical documentation system. In a retirement home in Frankfurt/Main, Germany, the residents' symptoms according to McGeer et al. were recorded from January, 1 to June 31, 2006. The study included 278 residents, 45,710 resident days, including 4413 "urinary catheter days" und 6009 "gastric tube days". Based on the symptoms documented in the electronic medical documentation system, the respective diagnoses were obtained. Data on gastrointestinal, bronchial, urinary, and eye infections are reported here, including number of cases as well as incidences per 1000 resident days. The overall incidence rate was 5.07/1000 resident days, including 1.9 gastrointestinal infections, 0.95 bronchitis/pneumonia, and 0.44 urinary infections. Incidence of urinary infections in residents with an indwelling urinary catheter was 2.26/1000 catheter days compared to 0.242/1000 days for those without a catheter. Urinary catheter, however, was not only a risk factor for urinary infections (OR 9.4, 95CI 3.4-25.8) but also for bronchial infections (OR 3.0, 95CI 1.3-6.8), and eye infections (OR 1.6, 95CI 0.4-5.8). Gastric tubes were associated with bronchial infections (OR 3.7; CI 1.7-7.9), eye infections (OR 5.4, CI 1.9-15.2), and urinary infections (OR 2.7, 95CI 0.9-8.2). Urinary or fecal incontinence were not associated with any infections, and age (>80 years) was negatively associated with urinary infections (OR 0.35, significant) and bronchial infections (OR 0.51, significant). Compared with published studies, the incidence rates were comparable. The practicability of the criteria of McGeer et al. could be confirmed - with only slight modification - in a long-term care facility with electronic medical documentation.

Infection Control and the Long-Term Care Facility

Approximately 70% of health care associated pathogens are resistant to one or more antibiotics. Experts maintain that most antimicrobial-resistant pathogens develop from antibiotic overuse and inappropriate antibiotic selection or treatment duration. Up to 70% of long-term care residents receive at least one course of an antimicrobial agent during a one-year period. Four types of infections occur most often among long-term care residents: urinary tract, respiratory tract, skin and soft tissue, and gastrointestinal tract, and outbreaks are common. Diagnostic uncertainty, failure to recognize fever's clinical manifestation in the elderly, treatment of asymptomatic bacteriuria, and bacterial colonization contribute to antibiotic overuse. Recent infection control guidelines recommend more targeted antibiotic utilization review. Recommendations are presented for implementing antibiotic utilization programs. Hand washing and other measures, such as droplet precautions, are discussed. Economic disincentives surrounding antimicrobial research are highlighted.

Cryptosporidiosis in the elderly population of the United States

BACKGROUND

Although cryptosporidiosis has been a nationally notifiable disease since 1995, surveillance estimates are undermined by limited diagnostic testing and incomplete reporting of cases to health authorities. Further, existing surveillance systems do not capture the specific risks of cryptosporidiosis to sensitive populations, such as the elderly population. The Centers for Medicare and Medicaid Services databases present a novel means to investigate the cryptosporidiosis burden in the US elderly population.

METHODS

We abstracted records for all Medicare-covered persons aged >or= 65 years who received a diagnosis of a cryptosporidiosis-related illness between 1991 and 2004 (n = 1304) in the United States. Annual rates of cryptosporidiosis-related hospitalization were calculated and compared with surveillance data published by the Centers for Disease Control and Prevention. The total burden of disease and outcomes of hospitalization were also assessed.

RESULTS

Cryptosporidiosis-related hospitalizations increased during the study period at a rate of 0.15-0.39 cases per 100,000 elderly persons each year; this increase was probably attributable to increased awareness and testing. Comparison between cryptosporidiosis-related hospitalization and Centers for Disease Control and Prevention surveillance data revealed considerable state-to-state variation. The rate of hospitalization among persons aged >or= 85 years was more than double that among persons aged 65-74 years. Volume depletion and noninfectious diseases of the digestive system were common concurrent diagnoses. The highest case-fatality rates were among persons aged >or= 85 years (7.8%) and among persons infected with HIV (10.3%).

CONCLUSIONS

Although awareness of cryptosporidiosis has increased, underdiagnosis and underreporting of cases remains a major barrier to accurate surveillance in many states. Infection among elderly persons is associated with volume depletion and negative hospital outcomes, including death.