A practice guide on antimicrobial stewardship in nursing homes

A practice guide to help nursing homes set up an antimicrobial stewardship (AMS) program was developed based on experiences gained during a project at one of the largest providers of elderly care in the South-east of the Netherlands. The guideline for the implementation of AMS in Dutch hospitals served as a starting point and were tailored to the unique characteristics of a nursing home setting. This practice guide offers recommendations and practical tools while emphasizing the importance of establishing a multidisciplinary approach to oversee AMS efforts. The recommendations and practical tools address various elements of AMS, including the basic conditions to initiate an AMS program and a comprehensive approach to embed an AMS program. This approach involves educating nurses and caregivers, informing volunteers and residents/their representatives, and the activities of an antibiotic team (A-team). The practice guide also highlights a feasible work process for the A-team. This process aims to achieve a culture of continuous learning and improvement that can enhance the overall quality of antibiotic prescribing rather than making individual adjustments to client prescriptions. Overall, this practice guide aims to help nursing homes establish an AMS program through collaborative efforts between involved physicians, pharmacists, clinical microbiologists, and infection control practitioners. The involved physician plays a crucial role in instilling a sense of urgency and developing a stepwise strategy.

Evaluation of the Abbott Panbio™ COVID-19 antigen detection rapid diagnostic test among healthcare workers in elderly care

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been especially dangerous for elderly people. To reduce the risk of transmission from healthcare workers to elderly people, it is of utmost importance to detect possible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive healthcare workers as early as possible. We aimed to determine whether the Abbott Panbio™ COVID-19 antigen detection rapid diagnostic test (Ag-RDT) could be used as an alternative to reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The second aim was to compare the cycle threshold (Ct) in RT-qPCR with the results of the Ag-RDT.

METHODS

A prospective diagnostic evaluation of the Abbott Panbio™ COVID-19 Ag-RDT among healthcare workers across three elderly care facilities as well as home-based elderly care workers who met clinical criteria for COVID-19 during the second wave of the COVID-19 pandemic. Per healthcare worker, the first nasopharyngeal swab was obtained to perform the Ag-RDT and the second swab for RT-qPCR. A Ct-value of < 40 was interpreted as positive, ≥ 40 as negative.

RESULTS

A total of 683 healthcare workers with COVID-19 symptoms were sampled for detection of SARS-CoV-2 by both Ag-RDT and RT-qPCR. Sixty-three healthcare workers (9.2%) tested positive for SARS-CoV-2 by RT-qPCR. The overall sensitivity of Ag-RDT was 81.0% sensitivity (95%CI: 69.6-88.8%) and 100% specificity (95%CI: 99.4-100%). Using a cut-off Ct-value of 32, the sensitivity increased to 92.7% (95% CI: 82.7-97.1%). Negative Ag-RDT results were moderately associated with higher Ct-values (r = 0.62) compared to positive Ag-RDT results.

CONCLUSION

The Panbio™ COVID-19 Ag-RDT can be used to quickly detect positive SARS-CoV-2 healthcare workers. Negative Ag-RDT should be confirmed by RT-qPCR. In case of severe understaffing and with careful consideration, fully vaccinated healthcare workers with Ag-RDT negative results could work with a mask pending PCR results.

Product dose considerations for real-world hand sanitiser efficacy

BACKGROUND

Alcohol based hand rubs (ABHR) are extremely effective at reducing microbial contamination and have an essential role in best practice hand hygiene described by the World Health Organization.

METHODS

We determined ABHR drying time when performing hand hygiene in a laboratory setting. Which was followed by identifying the amount of ABHR needed for complete hand coverage. When the aforementioned was analyzed real-time data were gathered to examine the amount used for hand hygiene in a hospital setting. In parallel hands of healthcare workers (HCWs) were monitored for drying time and perception on ABHR use.

RESULTS

In 86% (24,446,397/28,280,383) of the events a single dose of ABHR was used on clinical wards. Twenty-four HCWs expected hand hygiene to take 7.5 seconds (median; range 3-30 seconds). Forty-three HCWs show that 1.5 mL ABHR dose achieves the desired drying time according to World Health Organization guidelines (av. median 26 seconds), but is consistently perceived to have a longer drying time than expected (av. median 18 seconds). In-vivo results (n = 10) indicate that 2.25 mL ABHR is required for adequate coverage (82%-90%) of both sides of the hand.

CONCLUSIONS

Results indicate that set standards for the use of ABHR do not match "in-vivo" behaviour of HCWs. Perceived drying times are shorter than actual drying time. The needed drying time to reach acceptable antimicrobial efficacy of ABHRs should be revisited.

Dutch guideline for preventing nosocomial transmission of highly-resistant micro-organisms (HRMO) in long-term care facilities (LTCFs)

In 2012, the Dutch Working Party for Infection Control (WIP) issued the first Guideline for prevention of transmission of highly-resistant micro-organisms (HRMO) in Hospitals. The next step was to focus on long-term care facilities (LTCFs) both for nursing homes as for small-scale living facilities with nursing home care. These facilities providing care for residents with functional disabilities, chronical illnesses and cognitive disorders, such as dementia. The objective was to adapt the Guideline for prevention of transmission of HRMO in hospitals to LTCFs with a strong accent on living conditions and social interactions.

Residents of LTCFs may be carriers of HRMO over a long period of time and most of the residents of the LTCF stay for extended periods of time. To respect individual living circumstances and to prevent unnecessary limitations in the social life of the residents due to the use of isolation measures, the WIP has chosen to describe infection control precautions per individual micro-organism instead of a ‘one size fits all’ method. The term “isolation” was therefore replaced by the term “additional” precautions. This guideline describes the screening policies for residents in LTCFs, definition and detection of HRMO carriage, standard and additional infection control precautions for HRMO positive residents, documentation and communication of HRMO carriage and discontinuation of additional infection control precautions. It also describes contact tracing of HRMO, environmental control/investigation, surveillance of HRMO and what is important when there is an outbreak.

Prevalence of healthcare-associated infections in Dutch nursing homes: follow-up 2010-2017

Following the first point-prevalence study in Dutch nursing homes conducted each November from 2007 to 2009, we conducted a follow-up point-prevalence study of healthcare-associated infections (HCAIs) each November from 2010 to 2017. Similar methods and criteria were used. Resident characteristics were recorded, data collection was performed by the attending elderly care physicians via an online survey, as well as via a specifically designed App from 2012. As of the same year, information on incontinence was added. Between 2010 until 2017 on average 1786 residents per year were included, ranging from 1571 to 2185. HCAI prevalence with respect to age (mean: 83 years) and sex (31% men and 69% women) were similar over all the years. The overall mean prevalence rate in the first four years was 6.7% versus 2.2% in the last six years. Urinary tract infection was the most prevalent HCAI (1.5%). Most HCAIs occurred among residents of rehabilitation units. The prevalence of HCAI varied by nursing home (0.0-37.0%). The average use of antibiotics was stable over the years (6.0%) irrespective of HCAI rate. Use of incontinence materials was on average 73.5% with 64.3% of residents being reported as incontinent. Those implementing improvement of infection control and surveillance within a new setting do need to continue for multiple years before seeing the success of their endeavour.

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.

Methicillin-resistant Staphylococcus aureus in veterinary doctors and students, the Netherlands

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the Netherlands, at 1.0%, is among the lowest in Europe. In 2004, a relationship between pig farming and a high risk for MRSA carriage was found. To investigate if those in professional contact with livestock are at higher risk for MRSA carriage, we screened 80 veterinary students and 99 veterinarians and questioned them about animal contacts and known MRSA risk factors. Of these, 27 students who did not have livestock contact were excluded from further analysis. We found 7 carriers of MRSA, a prevalence of 4.6%, which is similar to that found in patients who had previously been treated at foreign hospitals. A correlation of MRSA carriage with a specific animal group could not be established. To preserve the low prevalence of MRSA in the Netherlands, persons involved in the care of livestock should be isolated and screened on admission to the hospital.