Healthcare-associated infections and antimicrobial use in long-term care facilities (HALT3): an overview of the Italian situation

Summary

Background

Awareness of healthcare-associated infections (HAIs) and antimicrobial use in long-term care facilities (LTCFs) is increasing. In 2017, the third national point prevalence survey (PPS) was conducted in Italy as part of the third ‘Healthcare-Associated Infections in European Long-Term Care Facilities’ (HALT3) study.

Aim

To report the results of HALT3 and analyse the resident population of LTCFs, implementation of good practices, prevalence of infections and antimicrobial use.

Methods

The survey was designed as a PPS, carried out from April to June 2017. All residents who lived full-time in the institution were included. All facilities were asked to complete an institutional questionnaire, a ward list for all residents, and a resident questionnaire for those residents presenting with signs/symptoms of active infection and/or receiving an antimicrobial agent.

Findings

In total, 418 facilities took part in the study; 24,132 residents were eligible, and most were aged >85 years, disoriented and incontinent. The prevalence of HAIs was 3.9%, and 50% of the institutions reported that they had a professional trained in infection control on their staff. Only 26.4% of infections were confirmed by a microbiological sample, and 26.9% of the isolated micro-organisms were resistant to at least one antimicrobial class. In total, 1022 residents received at least one antimicrobial agent, and cephalosporins were prescribed most commonly.

Conclusion

The number of infection control and antimicrobial stewardship measures implemented was found to be considerably higher in this study compared with previous studies. This could lead to a reduction in the prevalence of HAIs, antimicrobial use and antimicrobial resistance. Further studies are needed to monitor these aspects.

Introduction

A rapidly ageing population is causing increased demand for intermediate health care in patients recently discharged from hospitals and patients who struggle to manage with their chronic healthcare needs [1]. At the same time, the number of long-term care facilities (LTCFs) that provide these services is increasing, together with awareness of healthcare-associated infections (HAIs) and use of antimicrobial agents [2]. In fact, infections at LTCFs are a common cause of residents' morbidity and mortality, and represent an important socio-economic burden [3]. Moreover, the elderly, who usually comprise the large majority of the LTCF population, are more vulnerable to infections, due to their reduced immunological competence, due to multiple morbidities and chronic illness [4], [5], [6], [7].

Other factors can favour the spread of HAIs in these facilities, including difficulties in diagnosing infections because of atypical clinical presentation and cognitive impairment in the elderly, limited access to laboratories or radiology, low levels of physician input and unfavourable nurse/patient ratios [8], [9]. Together, these aspects may lead to inappropriate prescription of antimicrobials, enhancing the possible development of high colonization rates of multi-resistant bacteria [10], [11] and micro-organisms [5], [6], [7], [8], [9], [10], [11], [12], [13]. Furthermore, as shown by other studies, more than half of the antibiotic courses prescribed and started in LTCFs are unnecessary; overuse and misuse of antibiotics in LTCFs represent major causes of adverse drug events and future infections [14].

On the other hand, the improvement and correct implementation of basic good practices, such as antimicrobial stewardship programmes or hand hygiene and infection control precautions, may lead to substantial improvement in the main outcomes for HAIs, the appropriateness of antibiotic prescriptions and a reduction in the infections caused by Clostridium difficile and other multi-drug-resistant organisms (MDROs) [2], [15], [16].

To increase awareness of the abovementioned topics and estimate the burden of HAIs in LTCFs, the European Centre for Disease Prevention and Control (ECDC) started and funded the ‘Healthcare-Associated Infections in European Long-Term Care Facilities’ (HALT) project in 2009. The main purpose of this project was to develop and implement a sustainable methodology to help estimate the prevalence of infections, antimicrobial resistance and antimicrobial use across European LTCFs, and assess the status of infection control programmes in the European Union (EU). On these premises, ECDC commissioned three point prevalence surveys (PPS) [17], [18]. The first HALT PPS was conducted in 2010 [8] across 28 countries [19]; this was followed by a second survey in 2013 (HALT2) across 19 countries [20]. Italy joined these previous studies and conducted the third PPS within the ECDC's HALT project (HALT3) in 2017.

The aim of this paper is to report the results of the Italian HALT3 survey, analysing the prevalence of infections and antimicrobial use, verifying the presence and implementation of specific protocols and guidelines for the management of critical issues, and describing the characteristics of LTCF structures and their resident populations.