Approaches to multidrug-resistant organism prevention and control in long-term care facilities for older people: a systematic review and meta-analysis

Abstract

Background: Current guidelines recommend infection prevention and control (IPC) interventions to limit the spread of multidrug-resistant organisms (MDROs) in long-term care facilities (LTCFs). Despite clear evidence of benefits in acute-care hospital settings, the effectiveness of IPC programmes in LTCFs has not been quantified.Objective: To investigate the effects of IPC interventions on MDRO colonization and infections in LTCFs. Data sources: Ovid MEDLINE, EMBASE, and CINAHL from inception to September 2020. Eligibility criteria: Original and peer-reviewed articles examining the post-intervention effects of IPC interventions on MDRO colonization and infections in LTCFs for older adults. Interventions: i) Horizontal interventions: administrative engagement, barrier precautions, education, environmental cleaning, hand hygiene, performance improvement, and source control; and ii) vertical intervention: decolonization. Study appraisal and synthesis: We employed random-effects meta-analysis to estimate the pooled risk ratios (pRRs) for Methicillin-resistant Staphylococcus aureus (MRSA) colonization by intervention durations; and conducted subgroup analyses on different intervention components. Study quality was assessed using Cochrane risk of bias tools. Results: Of 3877 studies initially identified, 19 were eligible for inclusion (eight randomized controlled trials (RCTs) and 11 non-RCTs). Studies reported outcomes associated with MRSA (15 studies), Vancomycin-resistant Enterococci (VRE) (four studies), Clostridium difficile (two studies), and Gram-negative bacteria (GNB) (two studies). Eleven studies included in the meta-analysis. The pRRs were closed to unity regardless of intervention durations (long: RR 0.81 [95%CI 0.60-1.10]; medium: RR 0.81 [95%CI 0.25-2.68]; short: RR 0.95 [95%CI 0.53-1.69]). All studies involving active administrative engagement reported reductions. The risk of bias was high in all but two studies.Conclusions: Our meta-analysis did not show beneficial effects from IPC interventions on MRSA reductions in LTCFs. Administrative engagement was crucial in all programmes with reductions. Before more evidence is available, LTCFs should elucidate their goals and weigh cautiously for the benefits and risks before implementing IPC interventions, which may have potential negative impacts on residents. An alternative approach would be to reinforce strict compliance to standard precautions through administrative engagement. We call for high-quality trials with detailed execution and exit plans to refine the existing IPC strategies in LTCFs.

Knowledge, attitude, and practice towards bacterial multidrug-resistance and structural equation modeling analysis among intensive care unit nurses and physicians

“…In the present study, attitudes were positive, but some aspects still needed improvements, including the risk of carrying MDR bacteria back home and the need for wearing a face shield when there is a risk of being exposed to droplets or aerosols from patients with MDR infections. The ICU is a breeding ground for MDR bacteria [7,26], and preventing them from exiting the ICU and spreading in the community is important to prevent large-scale MDR in the community. That particular point should be improved in future training, and strict decontamination and cleaning protocols should be emphasized.…”

“…ICU nurses and physicians are at the frontline of clinical care provided to ICU patients and play critical roles in preventing bacterial MDR by applying the strict principles of MDR prevention, including antimicrobial stewardship, hand hygiene, microbial screening, isolation precautions, empiric isolation, decolonization, skin antisepsis, transmission prevention from the ICU environment, and transmission prevention of known MDR bacteria (e.g., methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecium, MDR Gram-negative bacteria, etc.) [7,8]. Thus, the knowledge, attitude, and practice of ICU medical staff towards bacterial MDR might be paramount to reducing the incidence.…”