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Infection control in non‐hospital settings: the example of long‐term and ambulatory

care facilitiesMaria Luisa Moro

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In the past, health care was delivered mainly in acute‐

care facilities. Today, health care is delivered in hospital, 

outpatient, transitional care, long‐term care, 

rehabilitative care, home, and private office settings.

Jarvis WR, EID 2001

Hospital

OutpatientAmbulatory

facility

Nursing homes

Rehabilitation hospital

Home care

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Dimension of exposure

Ministry of Health.  Stato di salute e prestazioni Stato di salute e prestazioni 

sanitarie nella popolazione anzianasanitarie nella popolazione anziana, 2000

0 5000 10000 15000 20000 25000 30000 35000 40000

struttureresidenziali

ospedale (placuti)

ospedale (plriabilitazione)

ospedale (pllungodegenza)

N° di giornate (in migliaia)

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LONG‐TERM CARE FACILITIES

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WhyWhy isis itit a challenge?a challenge?

The resident* Elderly are at higher risk of infection compared to younger adults(↑ 3 fold pneumonia, 20 fold UTI)

* Infections are difficult to identify in the elderly (fewer and non specific symptoms , fever blunt or absent)

Beinginstitutionalized

* Cross infections* Antimicrobialpressure

Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002

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Clinical Infectious Diseases 2009; 48:149–71

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ML MoroSource: ESAC website; Emori University. An agenda for research,2001

WhyWhy antimicrobialantimicrobial resistantresistant organismsorganisms are are increasingincreasing? ? 

Antibiotic pressure

European PrevalenceSurvey, 2009

0 20 40 60 80 100

% appropriate prescriptions

Loeb

Zimmer

Montgomery

Jones

Appropriateness of antibiotic prescriptions

in LTCFs

Skin UTI RTI

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WhyWhy isis itit a challenge?a challenge?

The resident* Elderly are at higher risk of infection compared to younger adults(↑ 3 fold pneumonia, 20 fold UTI)

* Infections are difficult to identify in the elderly (fewer and non specific symptoms , fever blunt or absent)

Beinginstitutionalized

* Cross infections* Antimicrobialpressure

The Care Home context* Permanent domicile* Staffing: physicians visitinfrequent; nurse under‐staffing; under‐qualification; high turn‐over* Lack of diagnostic tools* Under the label « LTC »different facilities* Private facilities/industrialchains

Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002

Frequent transfers to otherhealth facilities

* Cross infections* Antimicrobial resistant bugs  

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CID 2011

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The setting: permanent domicile

….there are many situations and therapeutic

intervention (community dining areas, bingo, crafts, 

spontaneous hugs & kissing on the cheek and/or hand

holding, …) that occurred daily and do not fit with the 

WHO’5 moments….

Schweon S, AJIC 2011

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Clinical Infectious Diseases 2009; 48:149–71

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WhyWhy isis itit a challenge?a challenge?

High frequency of infections* Incidence: 3‐7/1000 resident‐care days;  Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak

Strausbaugh LJ,  EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22) 

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OutbreaksOutbreaks ofof infectionsinfections

Source: Utsumi M, Age and Aging 2010; 39:299

Microorganism Median attackrate %

Median case fatality rate %

Median duration

RSV 40  20 60

Norovirus 45 0 18

GAS 8 50

Sarcoptes scabei 70 120

37 pathogens associated with 206 outbreaksin Nursing Homes, 1996‐2008

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WhyWhy isis itit a challenge?a challenge?

High frequency of infections* Incidence: 3‐7/1000 resident‐care days;  Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak

Elderly as « sentinelchickens »

«The first to be affected

by new or emerging

infections in hospital and 

other healthcare

environments»

Strausbaugh LJ,  EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22) 

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ElderlyElderly are are ““sentinelsentinel chickenchicken””

«The first to be affected by new or emerging infections in 

hospital and other healthcare environments»

Source: Strausbaugh LJ,  EID 2001; Birgand G, Eurosurv 2010

Large outbreak of Clostridium difficile infections (CDIs), PCR‐

ribotype 027; Northern France. 

38 healthcare facilities, 529 CDIs over a 22‐month period (281 

laboratory‐confirmed CDI 027)

The cases occurred mainly in long‐term care hospital 

facilities and nursing homes, near the border between France 

and Belgium.

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WhyWhy isis itit a challenge?a challenge?

High frequency of infections* Incidence: 3‐7/1000 resident‐care days;  Prevalence: 6‐10/100 resid.* 26‐50% of the transfers to hospitals from LTCFs due to infections* 19% of the infections occurs in clusters/outbreak

Elderly as « sentinelchickens »

«The first to be affected

by new or emerging

infections in hospital and 

other healthcare

environments»

Antimicrobial resistance* colonization/infection with AMR organisms is frequent (varies according to geographical 

location, type of care, patient 

population)

* common AMR organisms  (MRSA, MDR gram‐neg, 

Enterobacteriaceae, 

Pseudomonas, Acinetobacter)

* increasing trends

Strausbaugh LJ,  EID 2001; Birgand G, Eurosurv 2010; M Schulz, Eurosurv 2011; 16 (22) 

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WhyWhy isis itit a challenge?a challenge?

Prevalence of colonization with MRSA in LTCFs

4 Namnyak S, J Infect 1998; 5 von Baum H ICHE 2002; 6 Barr B, ICHE 2007; 7 Manzur A, CMI2008; 8 Denis O, JAC 2010; 9 Brugnaro P, Infection 2009

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Antimicrobial resistant isolates in urine cultures (Emilia‐Romagna Region, 4 mil inhab)

Micro‐organism

Resistant to % patientshospit.> 2 

days

% residentsLTCFs

E.coli 3° gen. ceph.Cipro/levo.

2340

3661

Proteusmirabilis

3° gen. ceph.Cipro/levo.

4245

5659

Klebsiellapneumoniae

3° gen. ceph.Cipro/levo.

3332

3032

Source: ASSR. Report data 2009, Emilia‐Romagna

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New New ””multidrugmultidrug resistantresistant bugsbugs””

A‐nursing home; 

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FactorsFactors associatedassociated withwith AMR in the AMR in the elderlyelderly• Transfer to the LTCF of patients who are colonized or 

infected with such pathogens at other institutions. 

• Excessive and inappropriate use of antibiotics, especiallybroad‐spectrum antimicrobial agents:– Prescribing antibiotics for unproven bacterial infections (e.g., 

upper respiratory viral infections) or “prophylactic”antibioticsfor residents/patients with chronic urinary catheters. 

– Prolonged use beyond the standard recommended durationfor treating common infections.

• Factors that increase the probability of microbialcolonization (and subsequent infection) (malnutrition, immunosuppressed state, urinary catheters, feeding tubespressure ulcers, and chronic immobility).

• Inadequate adherence to infection‐control measures.

Yoshikawa TT, J Am Geriatr Soc 50:S206–S209, 2002

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WhyWhy isis itit a challenge?a challenge?

High frequency of infections

Elderly as « sentinel chickens » Antimicrobial

resistance

Strausbaugh LJ, Emerg Infect Dis 2001; Gavazzi G, Lancet Infect Dis 2002

Scarcity of resources for 

Infection Control

Lack of awareness of the 

problem

Research gaps* Effective measures* Avoidable infections

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HALT European PPS in 722 LTCFs, 2010 

(IPSE European survey in 33 countries, 2006)In In EuropeanEuropean countriescountries

In In selectedselected LTCFsLTCFs

IC IC resourcesresources

in in LTCFsLTCFs

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• Hand hygiene• Personal protective equipment• Safe handling and disposal ofsharps

• Environmental cleaning• Decontamination• Waste• Food hygiene• Water• Laundry and linen• Immunisation• Antimicrobial prescribing• Management of infectedresidents

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IC IC PoliciesPolicies and and proceduresprocedures:: availableavailableevidencesevidences

Source:Hughes CM, et al MRSA in LTCFs. Cochrane Database Syst Reviews 2008

Transmission of MRSA in nursing homes

The lack of studies in this field is surprising. ………….. Much of the evidence ……was generated in the acute care setting. It may not be possible to transfer suchstrategies directly to the nursing home environment, which serves as both a healthcare setting and a resident’s home. Rigorous studies should be conductedin nursing homes, to test interventions that have beenspecifically designed for this unique environment.

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Pneumonia: prevention, diagnosis and treatment 

treatment according to a clinical pathway reduces 

hospitalizations in nursing home residents with pneumonia 

(Loeb M, JAMA 2006)  

oral hygiene in elderly nursing home residents reduces the 

risk of pneumonia and respiratory tract infection: NNT 8.6‐

15.3 in RCTs (Sjögren P, J Am Geriatr Soc. 2008)

Urinary tract infection: diagnosis and treatment implementation with a multifaced approach of a diagnostic and 

treatment algorithm reduces the # of AB prescriptions for suspected UTI in NH residents (Loeb M, BMJ. 2005) 

IC IC PoliciesPolicies and and proceduresprocedures::availableavailable evidencesevidences fromfrom RCTsRCTs

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ML Moro

InfectionInfection controlcontrol programsprograms in in longlong‐‐termtermcarecare

IC Structure: Infection Control Practitioner (full‐time every 250‐300 beds?) 

and IC Committee

Surveillance

Outbreak control

Isolation and precautions

Hand hygiene

Resident health

Employee health

Antibiotic stewardship

Education

Other aspects: policies and procedures, facility management, disease reporting, performance improvement/resident safety)

Source: SHEA/APIC Guidelines, ICHE 2008; 29: 785

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Local organisation: IC mechanism in each LTCF (short term):

• Designate a suitably trained ”contact point” for coordination of IC and antimicrobial issues and define tasks to be undertaken by this ”contact point”

•Designate a suitably trained ”contact point” for communication with health authorities in outbreak situations(medium term)

Basic infastructure

Brussels November 2010

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Basic infastructure

Hand hygiene

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tivoLTCFsLTCFs and and handhand hygienehygiene

Few studies have addressed the issue of HH & infectionAuthor Type of study Setting Intervention Results

YeungWK, 2011

Clusteredrandomizedcontrolledtrial, before‐after

Hong‐KongLTCFs withelderlyresidents

Pocket‐ sizedcontainers ofalcohol‐basedgel, remindermaterials, education

HH adherencefrom 25.8% to33.3%. Incidenceof serious infect. from 1.42/ 1000 to 0.65/ 1000

Huang TT, 2008

Before‐after Taiwan, LTCFs

Hand hygienetraining program

HH compliancefrom 9.3% to30.4%. Infectionincidence from1.74% to 1.52%

MakrisAT, 2000

Controlledtrial, before‐after

LTCFs in US IC educational programincluding HH

Incidence from6.33 to 4.15

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LTCFs and hand hygiene

Few studies have quantified the compliance to HH, 

which is generally lower than in acute care hospitals

Author Setting Results

Smith A, 2008 LTCFs in Ontario HH compliance 14.7%; mean HH time 15.9 sec.

Pan A, 2008 LTCF in Italy HH compliance 17.5%

NH N° ofobservations

% compliance

% of not compliantwith gloves

A 1347 3.8 76

B 1761 8 74

C 406 15.4 77

D 842 17 78

Hand Hygieneobservation in 4 Italian NHsusing the WHO tool(Pozzetti C)

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Basic infastructure

Hand hygiene

To improve the compliance with

hand hygiene:

• Dedicated guidelines with 

identification of the patient care 

practices were HH is a priority

•Monitoring of compliance 

(direct observation or alcohol 

consumption) and training

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Basic infastructure

Hand hygiene

MDROs policy

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Area

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hio in

fettiv

oRecommendations for KPC colonized

patients in LTCFs – Emilia‐Romagna Region

Hand Hygiene

Gloves (standard precautions) (change them!)

Overcoat for close contact

Cover eventual wounds

Environmental hygiene

Inform the facility if the patient must be transferred (tohospital, to another facility)

No screening

No isolation in single room

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Basic infastructure

Hand hygiene

MDROs policy

Antimicrobial

stewardship

To decrease antimicrobial

pressure, inappropiate

antimicrobial courses should be

avoided:

• Dedicated guidelines focused 

on problems driving 

inappropriate use

• Audit and training

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EuropeanEuropean prevalenceprevalence surveysurvey ofof antibioticantibiotic& & infectioninfection in in NHsNHs, 2010, 2010

Antimicrobials (n=2720) weremainly prescribed for the urinary

tract (48.9%; 2.15 /100) (21.4% prophylactic and 25.3% 

therapeutic use), followed by skin or wounds (27.8%; 1.22/100).

UTI treatment

26,4

18,218,1

14,4

18,2 3,31,4

quinolones nitrofurantoina beta-lactams, penicillinsother beta-lactames sulfonamides & trimethoprim nifurtoinolofosfomicina metenamina

Source: Moro ML, Jans B, Cookson B, Fabry J. HALT Project (under publication)HALT Project funded by the ECDC

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Antimicrobial resistance and UTI

• there is compelling evidence to support not treating

asymptomatic bacteriuria in elderly residents of long‐

term care facilities

• In 5 randomized trials no differences in morbidity or 

mortality were demonstrated between treated and 

untreated residents. In one of these trials antibiotic

treatment was associated with more adverse events.

Walker S, CMAJ • AUG. 8, 2000; 163 (3)

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RegionalRegional guidelineguideline

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AMBULATORY CARE & HOME CARE

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Home care Home care infectionsinfections

On average, 1 patient of 100 in home care acquires

an infection (Jarvis W, EID 2001)

A recent study in North Carolina has reported a 

decrease of CRB and CV‐UTI rates from 1998 to 2008: 

0,49 BSI/1000 CVC days in 1998‐2002 to 0,05/1000 

in 2003‐2008

1,8 UTIs/1000 CV days in 1998‐2002 to 0,9/1000 in 

2003‐2008 (Weber DJ, ICHE 2009)

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Outbreaks in ambulatory care

• Medical clinics and day hospital

• Odontoiatric clinics

• Dyalisis centers

• Eye clinics

• Gastrointestinal endoscopy & bronchoscopy

• Surgical clinics

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Among the key recommendations is having an individual at each facility who is responsible for ensuring that infection control practices are being followed.Other recommendations include:• Providing regular infection prevention training to clinicians• Conducting regular audits to ensure good practices are followed• Following proper hand hygiene protocols• Avoiding reinserting a syringe into a medication vial• Avoiding reuse of single‐dose vials or intravenous bags for multiple patients• Ensuring that reusable equipment is cleaned according to the manufacturer’s directions.