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.

Sustained Increase in Very Low Influenza Vaccination Coverage in Residents and Healthcare Workers of Long-Term Care Facilities in Austria after Educational Interventions.

Residents of long-term care facilities (LTCFs) are particularly at risk for influenza infections. We aimed to improve influenza vaccination coverage among residents and healthcare workers (HCWs) in four LTCFs by implementing educational programs and enhanced vaccination services. We compared vaccination coverage before and after the interventions (2017/18 and 2018/19 seasons). Data on vaccination adherence were recorded during a four-year observational period (2019/20 to 2022/23 seasons). Following the interventions, vaccination coverage increased significantly from 5.8% (22/377) to 19.1% (71/371) in residents and from 1.3% (3/234) to 19.7% (46/233) in HCWs (p < 0.001). During the observational period (2019/20 to 2022/23 seasons), vaccination coverage remained high in residents but decreased in HCWs. Vaccination adherence was significantly higher in residents and HCWs in LTCF 1 compared to the other three LTCFs. Our study suggests that a bundle of educational interventions and enhanced vaccination services can be an effective method for improving influenza vaccination coverage in LTCFs in both residents and HCWs. However, vaccination rates are still well below the recommended targets and further efforts are needed to increase vaccine coverage in our LTCFs.

Analysis of COVID-19 outbreaks in 3 long-term care facilities in Graz, Austria.

BACKGROUND: Nursing homes and long-term care facilities (LTCF) caring for elderly and chronically ill residents are at high risk to experience severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) outbreaks. We report an outbreak of coronavirus disease 2019 (COVID-19) in 3 LTCFs of the Geriatric Health Centres of Graz, Austria lasting from March 22 to April 14, 2020. AIM: The objectives of our study were: (1) to elucidate contributing factors and transmission pathways of SARS-CoV-2, (2) to analyze symptoms of COVID-19 in the residents and health care workers. METHODS: We carried out a retrospective outbreak analysis. FINDINGS: Thirty-six of /277 residents of 3 LTCFs were infected with SARS-CoV-2. Only a quarter of COVID-19 cases among residents had fever ≥38.1°C and 19% suffered from cough. Six of 36 residents remained asymptomatic. Hospitalization rate was 58% in residents. Overall, 33% (12/36) residents infected with SARS-CoV-2 died. Nineteen of 214 health care workers were tested positive for SARS-CoV-2. Universal rt-PCR testing for SARS-CoV-2 of all residents and health care workers as well as infection control measures contributed to ending the outbreaks. CONCLUSIONS: Delayed recognition of possible COVID-19 cases due to either mild symptoms or symptoms that were perceived as atypical early in the pandemic contributed to the transmission of SARS-CoV-2 in LTCFs. This emphasizes the importance of low-threshold testing in LTCF residents.

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.

Effect of a Multispecies Probiotic on Intestinal and Skin Colonization by Multidrug-Resistant Gram-Negative Bacteria in Patients in a Long-Term Care Facility: A Pilot Study.

Residents in long-term care facilities (LTCFs) are frequently colonized by multidrug-resistant Gram-negative bacteria, putting them at risk for subsequent infections. We aimed to evaluate the effect of the multispecies probiotic Omnibiotic10AAD® on the intestinal and inguinal skin colonization of patients by multidrug-resistant Gram-negative bacteria in LTCFs. Patients colonized by multidrug-resistant Gram-negative bacteria received a 12 week oral course of Omnibiotic10AAD®. Inguinal swabs and stool samples were collected during and after treatment for microbiological and microbiome analysis. The median age of patients was 76 years. Twelve patients completed the pilot study. Intestinal colonization was reduced to 42% of patients 8 weeks after the end of treatment, but increased to 66% 24 weeks after the end of probiotic treatment. Colonization of inguinal skin was lowest during probiotic treatment and increased thereafter. Fecal microbiome analysis revealed statistically significant increases of the genus Enterococcus comparing start and end of probiotic treatment. In conclusion, a 12 week course of a multispecies probiotic led to a transient reduction of intestinal colonization 8 weeks after the end of treatment. The findings of our pilot study warrant further research in the area of probiotics and intestinal colonization by multidrug-resistant bacteria.

Low prevalence of Clostridium difficile colonization in patients in long-term care facilities in Graz, Austria: A point-prevalence study.

BACKGROUND: We aimed to determine the prevalence of asymptomatic colonization by C. difficile in stool of residents in four long-term care facilities (LTCFs) in Graz, Austria and to identify factors associated with colonization. METHODS: We conducted a point-prevalence study in March 2018. Stool samples were examined by GDH enzyme immunoassay and when positive a toxin A/B-enzyme immunoassay was carried out. Additionally, all samples were tested by toxin A and B PCR and were plated manually as well as in automated fashion onto selective C. difficile agar. RESULTS: In 4/144 (2.8%) residents the GDH assay was positive. Each resident was colonized by a different C. difficile ribotype. C. difficile was not detected in any of the environmental samples. Significantly more colonized residents (60%) had stayed at a hospital in the 3 months previous to the study compared to 10% of non-colonized patients (p=0.01). CONCLUSIONS: The prevalence of colonization by toxigenic C. difficile was 2.8% in patients in LTCFs in Graz, Austria.

Low prevalence of colonization with multidrug-resistant gram-negative bacteria in long-term care facilities in Graz, Austria.

BACKGROUND: Residents in long-term care facilities (LTCFs) are increasingly found to be an important reservoir of multidrug-resistant gram-negative (MRGN) bacteria. AIMS: We aimed to determine colonization by MRGN bacteria over 6 months in LTCFs and geriatric wards in Graz, Austria, and to evaluate risk factors for such colonization. METHODS: During August 2015, we conducted a point-prevalence survey at LTCFs and geriatric wards of the Geriatric Health Centers of the City of Graz. Inguinal and perianal swabs were taken from 137 patients and screened for MRGN using standard procedures. Six months after the initial investigation all colonized patients were sampled again and use of antibiotics, hospital admissions, and mortality was registered. Genetic relatedness of MRGN bacteria was evaluated. RESULTS: We detected 12 patients harboring MRGN isolates (prevalence, 8.7%). Overall inguinal colonization was 5.1%. After 6 months, only 2 out of 12 patients were still colonized. Presence of a urinary catheter was associated with a higher risk of MRGN colonization (odds ratio [OR], 17.5; 95% CI, 1.6-192). Chronic wounds and gastrostomy were also risk factors of MRGN colonization (OR, 10.7; 95% CI, 1.6-69.3 and OR, 18.3; 95% CI, 2.4-139.4, respectively). There was no difference in mortality between colonized and noncolonized patients. CONCLUSIONS: Prevalence of colonization with MRGN bacteria was low in patients in LTCFs and geriatric wards in Graz, Austria.

Colonization of long term care facility patients with MDR-Gram-negatives during an Acinetobacter baumannii outbreak.

BACKGROUND: We aimed to determine the prevalence of colonization by multidrug-resistant Gram-negative bacteria including ESBL-producing enterobacteriaceae, carbapenem-resistant enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii at two wards caring long term for patients with disorder of consciousness at the Geriatric Health Centers Graz, Austria. During our study we detected two A. baumannii outbreaks. METHODS: In August 2015, we conducted a point-prevalence study. Inguinal and perianal swabs were taken from 38 patients and screened for multidrug-resistant Gram-negative rods using standard procedures. Six months after the initial investigation all patients were sampled again and use of antibiotics during the past 6 months and mortality was registered. Genetic relatedness of bacteria was evaluated by DiversiLab system. RESULTS: Fifty percent of patients were colonized by multidrug-resistant Gram-negative isolates. Five patients harboured ESBL-producing enterobacteriaceae. No carbapenem-resistant enterobacteriaceae were detected. 13/38 patients were colonized by A. baumannii isolates (resistant to ciprofloxacin but susceptible to carbapenems). There was a significant difference in the prevalence of colonization by A. baumannii between ward 2 and ward 1 (60% vs. 5.6%, p < 0.001). Two clusters of A. baumannii isolates were identified including one isolate detected on a chair in a patient's room. CONCLUSIONS: We detected a high prevalence of two multidrug-resistant A. baumannii strains in patients with disorder of consciousness at a LTCF in Graz, Austria. Our findings strongly suggest nosocomial cross-transmission between patients. An active surveillance strategy is warranted to avoid missing newly emerging pathogens.