Infection prevention and control and antimicrobial stewardship in European long-term care, 2016-2017

Background

Europe's population is ageing. Long-term care facilities (LTCFs) for this vulnerable population are often relatively homelike with low staff-to-resident ratios. In 2016-2017, ECDC coordinated its third point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European long-term care facilities (LTCFs). It included collection of data on structure and process indicators (SPIs) of infection prevention and control (IPC) and antimicrobial stewardship, to support countries' identification of national and local interventions in LTCFs.

Methods

In each country, national contacts recruited a convenience sample of LTCFs. National/LTCF PPS teams used a standard protocol that included case definition algorithms (adapted US CDC/SHEA definitions) applied to each resident with signs/symptoms of infection on the PPS day, and questions for LTCF staff on SPIs of IPC and antimicrobial stewardship activities. Denominators indicate the number of responses available for analysis.

Results

3,052 LTCFs in 24 EU/EEA countries were recruited, with 102,301 residents included. The prevalence of HAIs (residents with ≥1 HAI) was 3.7%. Although 1,524/1,623 (94%) LTFS had a hand hygiene (HH) protocol, only 1,046/1,585 (66%) LTCFs had organised ≥1 HH training session for care professionals during the previous year. 1,185/1,561 (76%) LTCFs reported IPC training of nursing and paramedical staff. Only 340/1,639 (21%) of LTCFs reported training on appropriate prescribing and 493/1,623 (30%) LTCFs had provided feedback to GPs on antimicrobial consumption. On the PPS day, annual antimicrobial consumption data were available to only 530/1,623 (32%) LTCFs.

Conclusions

Even in LTCFs with the capacity to perform this PPS, IPC training was non-ubiquitous and antimicrobial stewardship activities, including training, were rarely reported. ECDC encourages EU/EEA countries to recruit LTCFs to participate in future PPSs, to allow them to benchmark HAI rates and practices.

Key messages

The prevalence of healthcare-associated infections in European long-term care facilities (LTCFs) highlights their requirement for infection prevention and control (IPC) and antimicrobial stewardship. This multi-national point prevalence survey (PPS) indicates that European countries can consider reinforcing IPC, antimicrobial stewardship practices and participation in PPSs in LTCFs.

Strategies to control antibiotic resistance: results from a survey in Italian children's hospitals

BACKGROUND

Antimicrobial stewardship programs and comprehensive infection control programs represent the main strategies to limit the emergence and transmission of multi-drug resistant bacteria in hospital settings. The purpose of this study was to describe strategies implemented in Italian children's hospitals for controlling antibiotic resistance.

STUDY DESIGN

Cross sectional multicenter study.

METHODS

Four tertiary care Italian children's hospitals were invited to participate in a survey aimed at collecting information on activities implemented as of December 2015 using a self-administered online questionnaire. The questionnaire was divided in three sections focalizing on: i) policies for prevention and control of hospital-acquired infection, ii) prevention and control of multi-drug resistant bacteria, and iii) antibiotic prescribing policies and Antimicrobial stewardship programs. Questionnaires were compiled between May and July 2016.

RESULTS

All hospitals had multidisciplinary infection control committee, procedures on hand hygiene, isolation measures, disinfection/sterilization, waste disposal and prevention on infections associated to invasive procedures. All sites screened patients for multi-drug resistant bacteria colonization in selected units, and adopted contact precautions for colonized patients. Screening during hospitalization, or in case of infections in the same ward were not universally implemented. All hospitals had policies on surgical prophylaxis, while policies on medical prophylaxis and treatment of bacterial infections varied among sites. Two sites recommended to review the appropriateness of antibiotic prescribing after 48-72 hours and one recommended de-escalation therapy.

CONCLUSIONS

This study highlighted several areas of improvement, such as actions for screening patients in case of occurrence of multi-drug resistant bacteria, antimicrobial stewardship programs and implementation of policies targeting antibiotic prescriptions for therapeutic purposes and medical prophylaxis.

Prevalence and incidence of surgical site infections in the European Union/European Economic Area: how do these measures relate?

BACKGROUND

In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs).

AIM

To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data.

METHODS

In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS.

FINDINGS

The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40).

CONCLUSION

Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

Colonization by multidrug-resistant organisms in long-term care facilities in Italy: a point-prevalence study

OBJECTIVES

To determine prevalence and risk factors for colonization by multidrug-resistant organisms (MDROs) in long-term care facility (LTCF) residents in Italy. Genotypes of MDRO isolates were investigated.

METHODS

A point-prevalence study was conducted at 12 LTCFs located in four Italian cities (2 February to 14 March 2015). Rectal swabs, faeces and nasal/auxiliary swabs were cultured for extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacteriaceae, Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) respectively. Antimicrobial susceptibility testing, detection of ESBL and/or carbapenemase genes and molecular typing of MDROs were performed. Risk factors for colonization were determined by univariate and multivariate analysis.

RESULTS

A total of 489 LTCF residents aged ≥65 years were enrolled. The prevalence of colonization by ESBL-producing Enterobacteriaceae, MRSA and C. difficile was 57.3% (279/487), 17.2% (84/487) and 5.1% (21/409) respectively. Carriage rate of carbapenemase-producing Enterobacteriaceae was 1% (5/487). Being bedridden was a common independent risk factor for colonization by all MDROs, although risk factors specific for each MDRO were identified. ESBL-producing Escherichia coli carriage was associated with the sequence type (ST) 131-H30 subclone, but other minor STs predominated in individual LTCF or in LTCFs located in the same city, suggesting a role for intrafacility or local transmission. Similarly, MRSA from LTCF residents belonged to the same spa types/ST clones (t008/ST8 and t032/ST22) commonly found in Italian acute-care hospitals, but infrequent spa types were recovered in individual LTCFs. The prevalent C. difficile PCR ribotypes were 356/607 and 018, both common in Italian acute-care hospitals.

CONCLUSIONS

MDRO colonization is common among residents in Italian LTCFs.

Hospital statistics for antibiotics: defined versus prescribed daily dose

PURPOSE

Defined daily doses (DDD) are widely used as a unit to measure drug use in hospital and community settings. However, discrepancies exist between DDD and actual prescribed daily dose (PDD). The present study aims at estimating an alternative PDD (PDD-proxy) to calculate rates of systemic antibiotic consumption and to compare these results with those obtained using DDD.

METHODS

The study considered a 9-year period (2004-2012) and included the 17 Health Trusts (HTs) in the Emilia-Romagna Region, Italy. Drugs under study were antibacterials for systemic use (group J01). Data were obtained from the database for hospital drug prescription of Emilia-Romagna Region. The PDD-proxy was estimated by averaging the doses of antibiotic prescriptions from a point prevalence survey for healthcare-associated infections and antimicrobial use, conducted in Emilia-Romagna hospitals in 2012.

RESULTS

Significant discrepancies between DDD and PDD were observed, especially for some antibiotics, resulting in DDD rates that were systematically higher than PDD-proxy rates. In 2012, HT median rates of antibiotic consumption were 90 DDD/100 bed days and 70 PDD-proxy/100 bed-days. However, PDD-proxy and DDD rates showed comparable trends within HTs, although some HTs ranked differently when one or the other measure was used. Interquartile ranges of DDD rates were systematically wider than those of PDD-proxy rates in most years in the period of interest.

CONCLUSIONS

Comparison of HT antibiotic consumption using DDDs may artificially increase observed differences and affect the true HT ranking. Therefore, an additional unit of measurement is useful for in-depth analysis at the local level.

Development and assessment of national performance indicators for infection prevention and control and antimicrobial stewardship in European long-term care facilities

BACKGROUND

Healthcare-associated infections in long-term care facilities (LTCFs) are of increasing importance.

AIM

To develop consensus national performance indicators (NPIs) for infection control (ICPI) and antimicrobial stewardship (ASPI) in LTCFs, and assess the performance of 32 European countries against these NPIs.

METHODS

Previously established European standards were the basis for consensus and the same iterative approach with national representatives from the 32 countries. A World Health Organization scoring system recorded how close each country was to implementing each standard.

FINDINGS

The 42 agreed component indicators were grouped into six NPI categories: 'national programme', 'guidelines', 'expert advice', 'IC structure' (not present in the ASPI), 'surveillance' and 'composite'. 'Guidelines' scored the highest mean total possible score (60%, range 20-100%), followed by 'composite' (53%, range 30-100%), 'expert advice' (48%, range 20-100%), 'surveillance' (47%, range 20-83%), 'national programme' (42%, range 20-100%) and 'IC structure' (39%, range 20-100%). Although several scores were low, some countries were able to implement all NPIs, indicating that this was feasible. Most NPIs were very significantly related, indicating that they were considered to be important by the countries. 'Guidelines' and 'IC structure' were significantly related to European region (P ≤ 0.05). Accreditation/inspection was not evident in seven (22%) countries, nine (28%) countries had accreditation/inspection that included IC assessments, and seven (22%) countries had accreditation/inspection that included IC and antimicrobial stewardship assessments. Multi-variable analysis found that only the NPI and the ICPI 'expert advice' were associated with accreditation/inspection which included IC and antimicrobial stewardship.

CONCLUSION

The identified gaps represent significant potential patient safety issues. The NPIs should serve as a basis for monitoring improvements over the coming years.

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

BACKGROUND

A point prevalence survey (PPS) was conducted in Italy in 2010, as part of the first European PPS in Long Term Care Facilities (LTCFs), conducted within the HALT Project.

METHODS

The PPS was aimed at estimating the prevalence of infections, antimicrobial resistance, and antibiotic use and to assess the status of infections control programs in this setting.

RESULTS

Ninety two LTCFs, located in 11 different Italian regions, participated to the study: 9391 residents were enrolled, 9285 of whom were eligible according to the study criteria. The prevalence of residents with signs/symptoms of infection was 6.5% (606 residents); 438 residents were on antimicrobial treatment (4.7%) and 526 had signs/symptoms (5.7%) but in 324 residents only (3.5/100 residents) the infection satisfied the modified McGeer criteria and was considered confirmed. The most frequent infection site was the respiratory tract (1.27/100 residents). Mostly of the antibiotics were prescribed for respiratory tract infections (42.8% of the antibiotics) and for urinary tract infections (26.6%). The most frequently prescribed classes were quinolones, followed by penicillin plus beta-lactamase inhibitor and 3rd generation cephalosporins. Few infection had a microbiological confirmation, but among the 143 isolated microorganisms 24% were multidrug resistant.

CONCLUSIONS

The burden of infections and antimicrobial resistance in LTCFs is significant and infection control and surveillance program are urgently needed.