Debra A. Hagberg, MT (ASCP),CIC

America’s age 65 and older population is expected to nearly double in size in the coming decades, from 49 million in 2016 to 95 million in 2060. With this aging of the population comes the reality of a greater number of older adults entering an extended care or nursing home facility temporarily or permanently in the coming years. 

With the rising admission of residents into long-term care facilities also comes a significant increase in the risk of infections for an already susceptible population due to numerous factors, including:

  • Residents’ aging immune system and/or underlying chronic conditions
  • Potential infection transmission due to a high number of daily interactions with healthcare professionals and lack of contact precautions
  • Potential infection spread due to high number of daily interactions with other residents in shared spaces
  • Often limited resources (i.e., inadequate staffing and infection prevention supplies and personnel, and lack of specialized training)

Increased LTC infections

Recent research has shown the concerning issue of infection prevalence in extended care facilities. One report revealed that up to 15% of nursing home residents may acquire an infection while staying in facilities (1.8–13.5 infections per 1000 patient-care days).  A systematic review of the literature shows that multidrug-resistant gram-negative bacteria (MDR-GNB) are associated with increased infections due to high colonization in the residents. 

Another point prevalence study performed in 28 nursing homes in Southern California from 2016 to 2017 showed that the median prevalence of multidrug-resistant organism (MDRO) carriage per facility was 50% with Methicillin Resistant Staphylococcus aureus (MRSA) as the leading pathogen. A median of 45% of residents harbored an MDRO without a known MDRO history, and environmental MDRO contamination was found in 74% of resident rooms and 93% of communal areas. 

These studies seemingly support the notion that MDROs are clearly at home and taking up residence in nursing homes. 

Environmental impacts of infections

What role does the environment play in transmission? And how can this factor be mitigated to make a difference in residents’ lives and prevention of infection?

At a June 2022 APIC pre-conference workshop, David Weber, MD, MPH, with UNC at Chapel Hill, presented several studies that highlighted the impact of the environment on infections for this population. Cited studies examined the role of rehabilitation gym equipment and the transfer of MDRO to residents, the potential role of privacy curtains and MDRO transmission, and the impact of roommate status on MDRO transmission. 

Key results support the role of common LTC environmental factors in infection transmission, including:

  • As a result of 60 monthly gym visits with culture sampling, 55% (33/60) had at least one MDRO-positive specimen. Ten rehabilitation sessions identified 35 opportunities for transfer during which MDRO transfer occurred in 17.1% (6/35).
  • Twenty-two percent of privacy curtains (334/1521) cultured were contaminated with MDRO; in 19 visits where both privacy curtain and environment/resident samples were available, 78.9% had identical strains of MRSA and 56% had identical strains of VRE.
  • Roommate contamination was associated with source resident’s colonization for MRSA, and source resident’s immediate environment contamination for VRE; the side table and the nurse call button stood out for MRSA along with resident hands in the case of VRE.

Infection prevention challenges

Weber also presented information on studies showing the results of mitigation strategies to reduce risk of MDRO transmission. Based on the studies presented, the interventions targeted for MDRO reduction did not demonstrate a significant reduction in MDRO colonization or infection of the resident. 

Weber concluded that prevention of MDRO colonization/infection is challenging in nursing homes and has been handicapped by the following factors: 

  • Limited trained infection preventionists and environmental services in nursing homes
  • Low funding
  • Rapid staff turnover
  • COVID-19 infections
  • High-risk patients (comorbidities, advanced age, indwelling devices)
  • Long-term stay and congregate living situations
  • Shared rooms/communal areas
  • Infrequent terminal disinfection 

Bundled approach

His recommendations on how to combat infection focused on continued quality research (randomized control trials) evaluating specific bundles (hand hygiene, surface disinfection, antimicrobial stewardship) with substantial education of staff and new disinfection methods (e.g., surface disinfectants with prolonged activity) along with increased funding for infection prevention. 

Bundled or layered interventions (i.e., addressing patient, environment, and healthcare worker with appropriate products, protocols, and education) have worked well in acute care settings with designated guidance for reductions in central line-associated bloodstream infections, surgical site infections, ventilator-associated pneumonia infections and catheter-associated urinary tract infections. 

However, long-term care settings present different challenges and, therefore, require creative solutions using the success of the acute care layered strategy in a modified manner. The call to action is to take advantage of lessons learned from the COVID-19 pandemic and forge ahead, focusing on a variety of methods to help eliminate MDRO presence from the LTC environment.   

Debra A. Hagberg, MT(ASCP) is the Director of Clinical Affairs at PDI.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.