top papers on infection control in nursing homes

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AndreasVossMD,PhD

(potentiële)Belangenverstrengeling 3M,Ecolab,Deb,bioMerieux,Obhardt,

Momentum,ZonMW,IMI,Interreg

Voorbijeenkomstmogelijkrelevante

relatiesmetbedrijven

Geen

• Sponsoringofonderzoeksgeld

•Honorariumofander(financiële)vergoeding

• Aandeelhouder• Andererelaties,namelijk…

• JA•Geen

•Geen•Geen

¤ BRMO&MRSA¤ AMS¤ Clostridium difficile¤ Handhygiene &other IPinterventions


Cheng al.ICHE2016;37:983(Hong-Kong)

¤ 28nursing homesinHong-Kong¤ Nasal,axillary and rectal swabs tested for CRAB,

CRE,MRSA,and VRE

Cheng al.ICHE2016;37:983(Hong-Kong)

¤ OverallMDROcolonization 35.1%¤ MRSA 32.2%¤ CRAB 6.5%¤ CREonly 1isolate,noVRE

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CRAB(OR) MRSA(OR)

Bed-bound 2.70* 2.50*

Incontinence (diaper) 5.01* 1.78*

Nasgastric tube 2.98* 2.64*

Chron cerebral condition ns 1.55*

Beta-lactam inhibitors ns 2.34*

Cheng al.ICHE2016;37:983(Hong-Kong) Cunha etal.AJIC2016;44:126

¤Pointprevalence surveyto detect fecal carriage ofCREamong 500consecutive admissions from local nursinghomesto 2hospitals inProvidence,Rhode Island.

¤Weperformed acase-controlstudy to identify riskfactorsassociated with carriage ofCRE.

¤CREwasfoundin23(4.6%)ofthe 500hospitaladmissions

¤Use ofagastrostomy tubewasassociated with CREcarriage (P = .04).

Cunha etal.AJIC2016;44:126 Nillius etal.PlosOne 2016;April

Nillius etal.PlosOne 2016;April

MAJORvariations

denkaanregio’s

Nillius etal.PlosOne 2016;April

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Rondeauetal.FrontiersMicrobiol 2016;JAnuary

¤ WorryinglyhighprevalenceoftheqacA/BgeneinMRSAisolates.²Antisepsismeasuresbeingcrucialtopreventhealthcare-associatedinfections,ourfindingsraisequestionsaboutthepotentialriskassociatedwithchlorhexidineuseinqacA/B+MRSAcarriers

¤ NHsareaweaklinkinMRSAcontrol.¤ NHstoserveasreservoirsofUSA300clone

forlocalHCFs

Rondeauetal.FrontiersMicrobiol 2016;JAnuary

Batina etal.AntimicrobialResistanceInfectControl2016;5:32

mathematical modeling

¤Usemathematical modeling to assess the epidemicpotential ofMRSAinnursing homes

¤MRSAeradication wastheoretically achievable byelimination ofMRSA-positive admissions overthecourseofyears.Substantial reductions inMRSAprevalence could be attained throughmarked increaseinclearancerates orreduction inMRSA-positiveadmissions

¤Based onour model,MRSAelimination from nursinghomes,while theoretically possible,wasunlikely to beachieved inpractice

Batina etal.AntimicrobialResistanceInfectControl2016;5:32(Madison,USA)

KeepMRSAoutaslongaspossible,oncein,it’shard/impossibleto

getout

VandenDooletal.ICHE2016;37:761 VandenDooletal.ICHE2016;37:761

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¤ Nursing homesaresufficiently connected to thehospital network to drivenational epidemics

¤ Emerging pathogens can,inthe absenceofcontrolmeasures,sustain orinitiate nationwide outbreaks

¤ Negative surveillancedata,which areoften based onclinical infections and usually donot coverthe entirehealthcare system,should be interpreted with careand should not leadus to conclude prematurely thatthe healthcare network iswellprotected againstoutbreaks !

VandenDooletal.ICHE2016;37:761


Morrill al.ICHE2016;37:979(Rhode-Island,USA)

¤ Formal AMSprograms: 28%¤ Budgetsupportfor AMS: 15%¤ FTEfor infection control: 74%¤ FTEfor AMS: 26%

Morrill al.ICHE2016;37:979(Rhode-Island,USA)

Facility-wide AMS-specificInfectionpreventionist 0.35 0.15IDphysician 0.03 0.02Pharmacist 0.26 0.06IDpharmacist 0.01 0.01

VanBuul al.JAmMed DirAssoc 2015;16:229(NL)

¤ Investigate the appropriateness ofdecisions to prescribeorwithhold antibiotics for nursing homeresidents withinfections ofthe urinary tract,respiratory tract,and skin.

¤Prospective study in10NH’s.¤Physicians completed aregistration formfor any

suspected infection overan 8-monthperiod,includingpatient characteristics,signs and symptoms,andtreatmentdecisions.

¤Analgorithm,developed by an expertpaneland basedonnational and international guidelines,wasused toevaluate treatmentdecisions for appropriateness ofinitiating orwithholding antibiotics.


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¤Of598treatmentdecisions 76%were appropriate,² 74%with casesthat were prescribed antibiotics² 90%with casesinwhich antibiotics were withheld (90%)

(p =.003).¤Decisions around UTIwere least often appropriate

(68%),compared with 87%for RTIand 94%for SI.¤Themostcommonsituations inwhich antibiotic

prescribing wasconsidered inappropriate were thoseindicative ofasymptomatic bacteriuria orviral RTI.

¤Antibiotic consumption can be reduced by improvingappropriateness oftreatmentdecisions,especially forUTI.



ChopraetalClin InfectDis2015;60:S72(LA,USA) ChopraetalClin InfectDis2015;60:S72(LA,USA)

¤ Bundleapproachwith acombination ofinfectioncontroland antimicrobial managementstrategies

ChopraetalClin InfectDis2015;60:S72(LA,USA)

ClinicalPracticeGuidelines(fromAPIC,SHEA/IDSA,ESCMID,…)donotadherewelltoAGREEIIreportingstandards...

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...andIthoughtit’sallaboutthattheywork

Biswas etal.JHosp Infect 2015;90:267-270

n = 66 patients (rooms) and 264 surfaces for vancomycin / metronidazole, and 68 patients (rooms) and 272 surfaces for fidaxomycin. p<0.05 for both rooms and surfaces.

Biswas etal.JHosp Infect 2015;90:267-270

0

10

20

30

40

50

60

Vancomycin / metronidazole

Fidaxomicin Vancomycin / metronidazole

Fidaxomicin

Rooms Sites in rooms

% c

onta

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C. d

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ile


Hooine &Temime AJIC2015;43:e47(France)

¤Systematically reviewofstudiesonHHinnursinghomes.

¤56studiesmetthe inclusion criteria.²Mostwere outbreak reports (39%),followed byobservational studies(23%),controlled trials(23%),andbefore-after intervention studies(14%).

¤35studies(63%)reported results infavor ofHHonatleast one oftheir outcome measures;inaddition,the infection controlsuccess rate washigher when atleast one HH-related interventionwasincluded (70%vs 30%for nointervention).

Hooine &Temime AJIC2015;43:e47(France)

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¤ Littleemphasisonpatient handhygiene

¤ Systematicreview

² 10studies,uncontrolled,before-after

² Multi-modalinterventionmanyincludingHCWs

¤ Interventionstoimprovepatienthandhygienemay

reducetheincidenceofHAIsandimprovehandhygiene

rate,butthequalityofevidenceislow.

Srigley etal.JHosp Infect2016;94:23-29

Thuet al.ICHE2007;28:583

Hand sanitizer was provided in 500-mL, wall-mountedand bed-mounted dispensersfor useby staff, patients, and visitors. Additional bottles of hand sanitizer were availableon medication and treatment carts. Portable 100mL bottles also were provided tonursing staff and doctors to carry intheir pockets.

Thu etal.ICHE2007;28:583

Bestofthe 10studiesbutiswasmainly directed atHCWs and wasthe changefrom soapand waterto

alcohol-based handrub!

Yes,they can (and should)….ButtheevidencethattheirHHhelpsisZERO!

Assab etal.BMCInfectDis2016(France)

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¤ Stochastic compartmental modelofnorovirustransmissionbased onthe residents and staffofa100-bedNHinFrance.

¤Usingthis model,weinvestigated how the sizeofa100-daynorovirus outbreak changedfollowing three interventions:² increasing staff handhygiene (HH)² increasing residentHH² isolating symptomatic residents

Assab etal.BMCInfectDis2016(France) Assab etal.BMCInfectDis2016(France)

88%75%

HHclientHHstaffIsolation

Zhiqiu etal.InfectControlHosp Epidemiol 2015;36:759(Rochester,USA)

¤ NHs donot routinely performMRSA/BRMOadmissionscreening(96.4%)

¤ Isolation strategies vary substantially,with gloves beingmostcommonly used.

¤ MostNHs (75.1%)donot decolonize MRSAcarriers

¤ NHs tend to followvoluntary infection controlguidelinesonly if doing so doesnot require substantial financialinvestmentinnew/dedicated staff orinfrastructure


Soundsfamiliar?

¤NHs devoted 10.5hours perweek(median)per100residents to infection controlandpreventionactivities,with interquartile range(IQR)of5.6– 18.7.²Aapproximately 6.5%ofthe NHs reported over40hours perweekper100residents.


¤ Verycommon(14.2%–20.9%)


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top papers on infection control in nursing homes

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