Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study.

BACKGROUND: Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs. METHODS: A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience. RESULTS: The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids. CONCLUSIONS: Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

Pre-Hospital Administration of Remdesivir During a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Outbreak in a Skilled Nursing Facility.

Completion of a 5-day course of remdesivir was associated with approximately 17-fold increased odds of survival among a sample of 54 nursing home residents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the course of an outbreak from October to December 2020. Remdesivir was well tolerated; administration was logistically feasible in a pre-hospital environment.

An Indoor-Monitoring LiDAR Sensor for Patients with Alzheimer Disease Residing in Long-Term Care Facilities.

This paper introduces an indoor-monitoring LiDAR sensor for patients with Alzheimer disease residing in long-term care facilities (LTCFs), and this sensor exploits an optoelectronic analog front-end (AFE) to detect light signals from targets by utilizing on-chip avalanche photodiodes (APDs) realized in a 180 nm CMOS process and a neural processing unit (NPU) used for motion detection and decisions, especially for incidents of falls occurring in LTCFs. The AFE consists of an on-chip CMOS P+/N-well APD, a linear-mode transimpedance amplifier, a post-amplifier, and a time-to-digital converter, whereas the NPU exploits network sparsity and approximate processing elements for low-power operation. This work provides a potential solution of low-cost, low-power, indoor-monitoring LiDAR sensors for patients with Alzheimer disease in LTCFs.

Physical performance as a predictor of mortality in nursing home residents: A five-year survival analysis.

This study developed a five-year survival analysis to verify the relationship between the Short Physical Performance Battery (SPPB) and death in older adults residing in nursing homes (NHs). A total of 114 residents of NHs in Northeast Brazil participated in the follow-up. In addition to the SPPB, the older adults answered questions about sociodemographic and health condition information. The relationship between physical performance and mortality was evaluated using the Kaplan Meier survival curves and Cox proportional regression. As a result, 61.40% of the participants presented low performance and 41.22% died. Low physical performance increased the chance of death by 2.77 times in five years (adjusted Hazard Ratio 2.77; 95% CI 1.40-5.50; p < 0.01). Low SPPB Gait Speed Test also represented a 2.58-fold increased risk of dying (adjusted HR 2.58; 95% CI 1.38-4.83; p < 0.01). The results of this study showed that low physical performance can predict the mortality of older adults residing in NHs over five years.

The revised index for social engagement (RISE) in long-term care facilities: reliability and validity in Japan.

BACKGROUND: This study aimed to establish the validity and reliability of a revised index for social engagement (RISE) in the Japanese context. METHODS: We analysed the data of 1377 participants over 65 years of age who had been admitted to two types of long-term care facilities (LTCF) in Japan: four health facilities for older adults and eight nursing homes. Resident level data based on the Japanese version of the interRAI assessment instrument were collected from 623 residents in the former and 754 in the latter. From these data, we calculated RISE by adding six dichotomous items on social engagement in the assessment form. Factorial validity was evaluated by exploratory factorial analysis and confirmatory factor analysis, convergent validity by the correlation between average activity time and the RISE score, and discriminant validity by the correlation between cognitive levels and the RISE scores. Lastly, we assessed internal consistency using Cronbach's alpha. RESULTS: We identified a two-factor model in the exploratory factorial analysis with a factor loading >0.40, except for one RISE item. The confirmatory factor analysis confirmed that the two-factor model had appropriate model fits. The correlation between time involved in activities and the RISE score was r = 0.45, while the correlation between cognitive function and the RISE score was r = -0.32. The convergent and discriminant validities supported the use of Japanese LTCF. Cronbach's alpha ranged 0.70-0.72. CONCLUSIONS: Although further revision may be needed to improve factorial validity, RISE is reliable and valid for assessing social engagement of older adults admitted to LTCF in Japan. By using the Japanese version of RISE, the positive aspects of social functioning can be appropriately assessed and provide more evidence for improving the quality of care in LTCF.

Relationship between administrative characteristics of long-term care institutions and use of antipsychotics and anxiolytics in residents with cognitive impairment.

OBJECTIVES: To identify the facility characteristics that are associated with prescribing practices of typical and atypical antipsychotics, and anxiolytics in residents with cognitive impairment in long-term care (LTC) institutions. METHODS: A cross-sectional analysis of a country-representative sample of 23 LTC institutions in Poland was conducted in 2015-2016. Trained staff from each facility used the InterRAI-LTCF tool and drug dispensary cards on the day of resident's assessment to collect data on medication use from 455 residents with cognitive impairment. We used the anatomical therapeutic chemical classification and a multiple correspondence analysis. RESULTS: We identified facility characteristics associated with higher rate of prescribing of: typical antipsychotics (nursing home, private ownership status, higher staff/bed ratio of physicians and nurses, and lower as refers to care assistants); atypical antipsychotics (residential home, public ownership status, higher staff/bed ratio of care assistants, and lower as refers to physicians); and anxiolytics (residential home, facilities of small size, public ownership status, higher staff/bed ratio of care assistants, lower of nurses and physicians). In the facilities where less residents received typical antipsychotics, anxiolytics were prescribed more often, and vice versa (rho = -0.442; p = 0.035). CONCLUSION: This study showed a considerable variation in the use of typical and atypical antipsychotics, and anxiolytics between nursing and residential homes, which was associated with their organization (type, size, ownership status, and employment rate). We found a negative correlation between prescribing typical antipsychotics and anxiolytics, which made us aware that these medications may be used interchangeably in LTC facilities, despite the fact that both should be avoided.

Effectiveness of mRNA COVID-19 vaccines in preventing SARS-CoV-2 infections and COVID-19 hospitalisations and deaths in elderly long-term care facility residents, Spain, weeks 53 2020 to 13 2021.

Residents in long-term care facilities (LTCF) experienced a large morbidity and mortality during the COVID-19 pandemic in Spain and were prioritised for early COVID-19 vaccination. We used the screening method and population-based data sources to obtain estimates of mRNA COVID-19 vaccine effectiveness for elderly LTCF residents. The estimates were 71% (95% CI: 56-82%), 88% (95% CI: 75-95%), and 97% (95% CI: 92-99%), against SARS-CoV-2 infections (symptomatic and asymptomatic), and COVID-19 hospitalisations and deaths, respectively.

Current prevention and control of health care-associated infections in long-term care facilities for the elderly in Japan.

Residents of long-term care facilities for the elderly are vulnerable to health care-associated infections. However, compared to medical institutions, long-term care facilities for the elderly lag behind in health care-associated infection control and prevention. We conducted a epidemiologic study to clarify the current status of infection control in long-term care facilities for the elderly in Japan. A questionnaire survey on the aspects of infection prevention and control was developed according to SHEA/APIC guidelines and was distributed to 617 long-term care facilities for the elderly in the province of Osaka during November 2016 and January 2017. The response rate was 16.9%. The incidence rates of health care-associated infection outbreaks and residents with health care-associated infections were 23.4 per 100 facility-years and 0.18 per 1,000 resident-days, respectively. Influenza and acute gastroenteritis were reported most frequently. Active surveillance to identify the carrier of multiple drug-resistant organisms was not common. The overall compliance with 21 items selected from the SHEA/APIC guidelines was approximately 79.2%. All facilities had infection control manuals and an assigned infection control professional. The economic burdens of infection control were approximately US$ 182.6 per resident-year during fiscal year 2015. Importantly, these data implied that physicians and nurses were actively contributed to higher SHEA/APIC guideline compliance rates and the advancement of infection control measures in long-term care facilities for the elderly. Key factors are discussed to further improve the infection control in long-term care facilities for the elderly, particularly from economic and social structural standpoints.

Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017.

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals (ACH) in 28 countries and 117,138 residents from 2,221 long-term care facilities (LTCF) in 23 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in ACH and 3.9% (95% cCI: 2.4-6.0%) residents in LTCF had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in ACH and 129,940 (95% cCI: 79,570-197,625) residents in LTCF had an HAI. HAI episodes per year were estimated at 8.9 million (95% cCI: 4.6-15.6 million), including 4.5 million (95% cCI: 2.6-7.6 million) in ACH and 4.4 million (95% cCI: 2.0-8.0 million) in LTCF; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year in ACH. Antimicrobial resistance (AMR) to selected AMR markers was 31.6% in ACH and 28.0% in LTCF. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA and indicated that AMR in HAI in LTCF may have reached the same level as in ACH.

Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017.

Antimicrobials are commonly prescribed and contribute to the development of antimicrobial resistance in long-term care facilities (LTCFs). In 2010, the European Centre for Disease Prevention and Control initiated point prevalence surveys (PPS) of healthcare-associated infections and antimicrobial use in European LTCFs, performed by external contractors as the Healthcare-Associated infections in Long-Term care facilities (HALT) projects. Here, we investigated prevalence and characteristics of antimicrobial use and antimicrobial stewardship indicators in European LTCFs in 2016-17. Twenty-four European Union/European Economic Area (EU/EEA) countries, the former Yugoslav Republic of Macedonia and Serbia participated in the third PPS in European LTCFs. Overall, 4.9% (95% confidence interval: 4.8-5.1) of LTCF residents in the EU/EEA participating countries received at least one antimicrobial. The most commonly reported Anatomical Therapeutic Chemical (ATC) groups were beta-lactam antibacterials/penicillins (J01C), other antibacterials (J01X) (e.g. glycopeptide antibacterials, polymyxins), quinolones (J01M), sulfonamides and trimethoprim (J01E), and other beta-lactams (J01D). Urinary tract infections and respiratory tract infections were the main indications for antimicrobial prescription. This PPS provides updated and detailed information on antimicrobial use in LTCFs across the EU/EEA that can be used to identify targets for future interventions, follow-up of these interventions and promote prudent use of antimicrobials in European LTCFs.

Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017.

BackgroundThe 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis.AimOur aim was to identify institutional and resident risk factors of AMU and HAI.MethodsHALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data.ResultsOf 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2-0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1-0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9-1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1-0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7-1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3-1.0) with less HAI. AMU and HAI varied significantly between LTCF.ConclusionsMultilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.

Determinants of late-life depression in residents of long-term care facility.

Mental disorders, such as dementia and depression, are beside chronic somatic diseases, the most common problem in residents of longterm care facilities (LTCF). Late-life depression refers to depressive symptoms that arise in adults older than 65 years. According to literature review, older people tend to differ from middle-aged adults in presentation of depression. AIM: Mental disorders, such as dementia and depression, are beside chronic somatic diseases, the most common problem in residents of longterm care facilities (LTCF). Late-life depression refers to depressive symptoms that arise in adults older than 65 years. According to literature review, older people tend to differ from middle-aged adults in presentation of depression. MATERIALS AND METHODS: This cross-sectional study was conducted over 290 residents in the LTCF in Cracow, using the interRAI-LTCF questionnaire for comprehensive geriatric assessment. The logistic regression was applied in analysis of data. RESULTS: Depression symptoms were observed in 33.8% of LTCF residents. In this population we found some independent of age variables significantly associated with depression, such as: daily pain, existence of psychiatric disorders other than depression, presence of behavioral and/or psychotic symptoms, sleep disturbances, dyspnea and feeling of loneliness. Interestingly, we noticed some differences in the manifestation of depression depending on age in older people. In "old-old" (aged 80 and older) LTCF residents, moderate dependency in activities of daily living (ADL), dyspnea and tendency to conflict with others, were significantly associated with higher prevalence of depression. In turn, "young-old" (younger than 80 years) residents presented more often symptoms of depression in response to stress experienced in last 90 days. CONCLUSIONS: In the light of our study results, depression in older people manifests with dominance of behavioral and/or psychotic symptoms what should be included in the diagnosis and differentiation with dementia and other psychiatric disorders. Moreover, findings from this study make a conclusion that late-life depression has more frequently organic background in very old residents and reactive nature in younger old residents.

Exploring faecal incontinence in nursing home patients: a cross-sectional study of prevalence and associations derived from the Residents Assessment Instrument for Long-Term Care Facilities.

AIM: To explore prevalence and associations of faecal incontinence among nursing home patients, to examine the effect of clustering of observations and to study the variation in faecal incontinence rates on both the level of nursing home units and individual patients. BACKGROUND: Faecal incontinence affects 40-55% of the patients in nursing homes and is associated with increased risk of morbidity and reduced quality of life. There is a lack of studies investigating faecal incontinence with validated instruments. More studies need to include models of analyses that allow for clustering of observations. DESIGN: Cross-sectional. METHODS: Data on 261 patients from 20 nursing home units were collected during September-October 2014. The Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities was used. Mixed effect models were conducted. RESULTS: Prevalence of faecal incontinence was 42·1% or 54% depending on the frequency labelling chosen. The effect of clustering by nursing home unit was not statistically significant. Most of the variation in faecal incontinence rates was explained by differences in patient characteristics, the most important being deficiencies in activities of daily living, cognitive impairment, diarrhoea and not participating in activities. CONCLUSION: Nursing home patients should be offered individualized assessment and continence care matching their patient characteristics. The Resident Assessment Instrument for Long-Term Care Facilities is a useful instrument because of its' combination of a comprehensive range of individual items and scales allowing for comparison of immediate or long-term change in patients status. Studies evaluating interventions targeting faecal incontinence are warranted.

Characterization of methicillin-resistant Staphylococcus aureus from residents and the environment in a long-term care facility.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major public health concern associated with residence in a long-term care facility (LTCF). The aim of this prospective study was to characterize MRSA isolated from residents over a 1-year period and their physical environment over a 2-year period. MRSA was recovered from 17/64 residents (R) of a LTCF and from 42 environmental (E) sites. All isolates carried the mecA gene and lacked the mecC and Panton-Valentine leukocidin (PVL) genes. Thirteen spa types were identified with t032 being the most frequent (41% of total; n = 8R, 16E), followed by t727 (22% of total; n = 13E), and t8783 (10% of total; n = 6E). Five spa types were each represented by single isolates. Thirty-nine isolates were of spa types associated with the multilocus sequence type ST22 (t032, 41%; spa-CC22, 68%) and reflect the predominance of ST22 in Irish hospitals. The uncommon spa types t727, t8783, t1372, t3130, t10038 were present in the environment but not detected in residents and are infrequently observed in Ireland.

Use of antibiotics in long-term care facilities for the elderly in Germany - point prevalence as a possible first step for data-based antibiotic stewardship.

Introduction: In Germany, hospitals, rehabilitation facilities and outpatient surgery facilities are required by law to perform antibiotic-consumption surveillance. Established IT programs are available for recording the defined daily doses. These do not exist for long-term care facilities (LTCFs). Antibiotic stewardship is also recommended for LTCFs. In view of the lack of IT solutions for consumption surveillance, this study investigated whether point prevalence studies could be a suitable basis for a data-based antibiotic stewardship program in LTCFs. Method: In May 2023, 18 elderly-care facilities in Berlin, Germany, participated in a point prevalence survey on antibiotic consumption according to the established HALT (healthcare-associated infections in long-term care facilities) method. The number of residents present and their risk factors (including the use of catheters and antibiotic therapy) were recorded. The results were compared with comparable data from previous surveys in LTCFs in Berlin, Germany as well as with the HALT data for Europe as a whole and for Germany. Results: On the day of the survey, 2040 residents were present, 7.7% of whom bore a urinary catheter and 0.5% a vascular catheter. 0.2% of the residents had a port access, 0.4% a dialysis catheter and one resident (0.05%) a tracheostoma. Twenty-seven (1.3%) residents were receiving an antibiotic on the day of the survey. Of these, 29.6% had a urinary tract catheter. 63.0% of the antibiotics were given for a urinary tract infection, 14.8% for a respiratory tract infection and 11.1% for a wound/soft tissue infection. The overall prevalence of antibiotics was in the range of previous surveys from Germany (1.2-2.4%) and significantly lower than in the Europe-wide HALT survey overall (4.3-4.5%). Discussion: The survey showed low use of antibiotics in the LTCFs in comparison with Europe-wide surveys. The time required was less than 2 hours for a 100-bed facility. Until appropriate IT programs to determine the defined daily doses are also available for LTCFs, such easy-to-perform and standardized point-prevalence surveys - if repeated several times a year - can be a suitable method for recording the use of antibiotics in nursing homes for the elderly.

Psychological Resilience in Older Residents of Long-Term Care Facilities: Occurrence and Associated Factors.

OBJECTIVES: The researchers aimed to (1) explore the occurrence of psychological resilience in the face of a major life stressor and conflict in older residents of long-term care facilities (LTCFs), and (2) identify factors associated with resilience in this population. DESIGN: Longitudinal cohort study using the Dutch InterRAI-LTCF cohort. SETTING AND PARTICIPANTS: Older residents (≥60 years old) of 21 LTCFs in the Netherlands. METHODS: The researchers selected 2 samples of residents who had at least 2 assessments surrounding (1) an incident major life stressor, or (2) incident conflict with other resident or staff. A resilient outcome was operationalized as not having clinically meaningful mood symptoms at the post-stressor assessment and equal or fewer mood symptoms at the post-stressor relative to the pre-stressor assessment. The researchers used 2 resilience outcomes per stressor: 1 based on observer-reported mood symptoms and 1 based on self-reported mood symptoms. The most important factors from among 21 potential resilience factors for each of the 4 operationalizations of resilience were identified using a backward selection procedure with 2-level generalized estimating equations analyses. RESULTS: Forty-eight percent and 50% of residents were resilient in the face of a major life stressor, based on observer-reported (n = 248) and self-reported (n = 211) mood, respectively. In the face of conflict, 26% and 51% of the residents demonstrated resilience, based on the observer-reported (n = 246) and self-reported (n = 183) mood, respectively. Better cognitive functioning, a strong and supportive relationship with family, participation in social activities, and better self-reported health were most strongly associated with resilience in the face of a major life stressor. Better communicative functioning, absence of psychiatric diagnoses, a strong and supportive relationship with family, not being lonely, social engagement, and not reminiscing about life were most strongly associated with resilience in the face of conflict. CONCLUSIONS AND IMPLICATIONS: Factors with a social aspect appear to be particularly important to psychological resilience in older LTCF residents, and provide a potential target for intervention in the LTCF setting.

Assessment of COVID-19 outbreaks in long-term care facilities.

BACKGROUND: The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities. AIM: To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant. METHODS: Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures. FINDINGS: During April 22nd to July 29th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities. CONCLUSION: Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting.

Introduction: Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization. Methods: A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models. Results: In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%). Conclusion: Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.

Work in nursing homes and occupational exposure to endotoxin and bacterial and fungal species.

Indoor microbial exposure may cause negative health effects. Only little is known about the occupational microbial exposure in nursing homes and the factors that influence the exposure. The exposure in nursing homes may be increased due to close contact with elderly persons who may carry infectious or antimicrobial-resistant microorganisms and due to handling of laundry, such as used clothing and bed linen. We investigated the microbial exposure in 5 nursing homes in Denmark, by use of personal bioaerosol samples from different groups of staff members taken during a typical working day, stationary bioaerosol measurements taken during various work tasks, sedimented dust samples, environmental surface swabs, and swabs from staff members' hands. From the samples, we explored bacterial and fungal concentrations and species composition, endotoxin levels, and antimicrobial resistance in Aspergillus fumigatus isolates. Microbial concentrations from personal exposure samples differed among professions, and geometric means (GM) were 2,159 cfu/m3 (84 to 1.5 × 105) for bacteria incubated on nutrient agar, 1,745 cfu/m3 (82 to 2.0 × 104) for bacteria cultivated on a Staphylococcus selective agar, and 16 cfu/m3 air for potential pathogenic fungi incubated at 37 °C (below detection limit to 257). Bacterial exposures were elevated during bed making. On surfaces, the highest bacterial concentrations were found on bed railings. The majority of bacterial species found were related to the human skin microflora, such as different Staphylococcus and Corynebacterium species. Endotoxin levels ranged from 0.02 to 59.0 EU/m3, with a GM of 1.5 EU/m3. Of 40 tested A. fumigatus isolates, we found one multiresistant isolate, which was resistant towards both itraconazole and voriconazole, and one isolate resistant towards amphotericin B. In conclusion, we give an overview of the general microbial exposure in nursing homes and show that microbial exposures are higher for staff with more care and nursing tasks compared with administrative staff.