February 9, 2017February 9, 2017 by Gillian Robinson

Infection Prevention and Control – 2017 review

Antimicrobial stewardship for aged residential care

The below article was contributed by Ruth Barrett – RN, BSc, MAdvPrac (Hons); Independent Infection Prevention & Control Advisor

What is your New Year resolution for 2017 in the world of infection prevention and control (IPC)? If you haven’t thought of it I would suggest looking at antimicrobial stewardship in your facility.

I was fortunate to attend a recent international IPC conference in Melbourne (ACIPC Conference 2016) and was pleased that aged residential care was a popular theme for both oral presentations and posters. One of the topical subjects was feedback from the first survey of antimicrobial use in residential care facilities in Australia. The results of this research are freely available and make interesting reading[1][2]. A good deal of the findings could equally apply to ARC in New Zealand.

Antimicrobial resistance and antimicrobial stewardship are two topics that go hand in hand.

As rates of antibiotic resistant bacteria continue to rise in New Zealand, then the responsibility for and management of the use of antibiotics becomes more important. Aged residential care (ARC) facilities are an important reservoir for MDRO transmission within the community. In the ARC setting, there are frequent transfers between the acute hospital setting and back to the rest home. This along with an over-use of antibiotics in the community can lead to a higher prevalence of multi-drug resistant organisms (MDRO) in ARC.

Even if a resident does not usually receive antibiotics, the resident is still at risk of picking up an MDRO if a lot of antibiotics are used. Managers, nurses and carers who work in a residential care facility all have apart to play in reducing the amount of antibiotics used and minimising the increase and spread of MDRO.

Some of the ways you can do this include-

Ensuring hand hygiene compliance is high for all staff and providing hand sanitiser close at hand for carers.
Using other specific contact precautions to control the spread of MDRO in your facility according to local policy.
Not using topical antimicrobial creams unless prescribed e.g. don’t routinely use Mupiricin (Bactroban) on wounds.
Only sending wound swabs, urines etc if there are obvious signs and symptoms of infection.
Recognising influenza or other respiratory outbreaks earlier to avoid secondary chest infections in the elderly, which would require antibiotics. Remember that in the winter season, many respiratory infections are caused by viruses and do not need antibiotic treatment.
Ensuring the residents finish their course of antibiotics.
Monitoring infections using a surveillance programme.
Monitoring the incidence of MDRO in the facility.
Accessing specialist IPC advice if infection or MDRO rates are of a concern.

So why don’t you make antimicorbial stwardship your IPC focus for 2017?

Contributed by:

Ruth Barratt RN, BSc, MAdvPrac (Hons)

Independent Infection Prevention & Control Advisor

Infectprevent@gmail.com

^[1] Antibiotic use in residential aged care facilities, Australian Family Physician, Volume 44, No.4, April 2015

^[2] Antimicrobial Stewardship in Residential Aged Care Facilities. Result of survey.

in News

December 1, 2015December 7, 2015 by Gillian Robinson

Multidrug resistant organisms

Multidrug resistant organisms – an update for residential care

The increase in bacteria that are resistant to antibiotics is now a major concern for healthcare providers across the world. Recently the UK’s top doctor, Dame Sally Davies, described antibiotic resistance as ‘serious a threat as terrorism’, predicting that people may die from routine post operative infections within 20 years as there would be no effective antibiotics available.

Multidrug resistant organisms (MDRO or MRO) are organisms that are resistant to several antibiotics to which they would normally be susceptible or two or more classes of antibiotics¹. This means that the choice of antibiotics to treat an infection with an MDRO is usually not the first one and may have limited effect.

The MDRO that are most commonly encountered in residential care are MRSA (methicillin resistant Staphylococcus aureus) and extended-spectrum β-lactamase (ESBL) producing organisms. However there are some new kids on the block, which, although seen more in the acute healthcare sector, are finding their way into our residential care facilities. These very resistant superbugs include Vancomycin resistant enterococci (VRE) and Carbapenem resistant enterobacteraciae (CRE).

Some of the characteristics of these MDRO are summarised in the table below

Summary of MDRO characteristics

MDRO	Normal habitat	Infections	Mode of transmission
MRSA	Skin (nares, groin)	Skin, urinary tract, chest, wound	Contact – colonised or infected skin/ulcer Contaminated items/surfaces
ESBLs	Bowel	Urinary tract, wound, pneumonia	Contact with faecal or urine contaminated items. Contact with colonised wound/ulcer
VRE	Bowel	Urinary tract, wound, pneumonia	Contact as for ESBLs Contaminated environment
CRE	Bowel	Urinary tract, wound, pneumonia	Contact as for ESBLs

High prevalence rates of MDRO colonisation in long term and aged residential care facilities are frequently reported in the literature. Although MDRO are often introduced into a facility from a resident who has recently been in hospital or has had multiple courses of antibiotics, they can spread easily through ARC. This may be due to poor infection prevention and control (IPC) practices, poor facility design or inadequate number of toilets or merely through social contact between residents. However despite the high rates of MDRO in residential care, it does not appear that residents are at greater risk of infection with these organisms.

Residential care facilities can play their part in helping to reduce the spread of MDRO by having an effective infection prevention and control programme which includes the following specific to MDRO:

the use of standard IPC precautions and adherence to good hand hygiene practices
Additional IPC measures when indicated
surveillance of infections
antimicrobial stewardship e.g. reducing inappropriate use of antibiotics for asymptomatic bacteriuria.
Informing the emergency department or ward of the resident’s MDRO colonisation if admitted to hospital. This is important because additional precautions may be necessary in the acute hospital setting.

The care of a resident with an MDRO in an ARC facility must reach a balance of the needs of the resident to live a normal life within their ‘home’ and the responsibility to the wider society to prevent further transmission of the MDRO, which contributes to the increase in antibiotic resistance.

Staff and colonised or infected residents should understand the methods of spread of the MDRO and use suitable precautions to break this chain of infection transmission. In many cases this will be the use of routine standard precautions, particularly hand hygiene.

A risk assessment for each resident should be undertaken and the precautions tailored to their risk factors for spread. For example, emptying and handling urinary catheters and bags increases the risk of spread of ESBLs and apron and gloves should always be worn for this task.

Most MDRO colonise the bowel so faecal incontinence is always a risk factor for transmission.

For some of the more resistant organisms such as VRE and CRE, it is advisable that the colonised resident has their own room and toilet facilities and that staff wear a gown/apron and gloves for all cares that involve direct contact with wounds, emptying catheter bags, toileting or other intimate cares.

By ensuring staff are informed, regularly use standard precautions and good hand hygiene practices and implement antibiotic stewardship, together we can help reduce the rate of increase in MDRO in our society.

Ministry of Health. 2007. Guidelines for the Control of Multidrug-resistant Organisms in New Zealand. Wellington: Ministry of Health