Nosocomial Infections in Nursing Homes: How to Prevent Them

June 11, 2020

nurse sitting with a nursing home patient

Nearly 1.4 million American seniors permanently reside in nursing homes and an additional 4 million seniors receive short-term care in nursing home facilities1,2.  Unfortunately, the combination of a high population density in nursing homes, the likelihood of immunosenescence in the elderly, and a regular influx of patients and staff from hospital settings leaves seniors at increased risk for acquiring new and potentially dangerous bacteria3.  In addition to nursing home residents, staff and visitors are also at risk of acquiring nosocomial infections. 

Infections that are acquired in a health care setting are called nosocomial infections. Nosocomial infection rates in nursing homes have increased rapidly in recent years. An estimated 2-3 million seniors will be diagnosed with nosocomial infections in 20203. A major contributor to this increase is an expanding population of antibiotic resistant organisms, which complicate treatment and increase the risk of developing a life-threatening infection. While antibiotic-resistant bacteria pose a serious threat to people of all ages, the elderly are particularly susceptible due to diminished immune responses3. Preventing nosocomial infections in nursing homes is a key step to improving health and longevity among seniors.

What are the most common infections in nursing homes?

The most common nosocomial infections in nursing homes include urinary tract infections, respiratory infections, skin or wound infections and gastroenteritis. Although sepsis is less common, it is one of the most lethal infections that nursing home residents could develop. With few exceptions, inhibiting bacterial colonization and pathogen transmission could help to prevent these infections. 

Urinary tract infections 

Among the most commonly reported infections in nursing homes are urinary tract infections (UTIs). While Escherichia coli is often the most frequent type of bacteria observed in UTIs, the majority of cases are polymicrobial, which means that the infection includes more than one type of bacterial organism. Nursing home residents are more likely than non-residents to experience a UTI, which cause an estimated 50% of sepsis cases in residents of nursing homes3. UTIs are also linked to Enterococcus bacterial infections, and elderly residents of nursing homes have a 40% higher risk of having antibiotic-resistant Enterococcus bacteria in their urine than elderly people who do not live in nursing homes4.

Respiratory infections

Lower respiratory tract infections (LTRIs) are among the most lethal and most preventable nosocomial infections reported in nursing home settings. Elderly residents of nursing homes are up to 30 times more likely to develop one of these deep lung infections than elderly people who do not live in nursing homes3. Streptococcus pneumoniae and Staphylococcus aureus (S. aureus) are among the most common bacterial causes of LRTIs in nursing home residents. 

Skin infections

Approximately 10% of nursing home residents will develop a skin or soft tissue infection, often related to pressure ulcers (bed sores)5. Among the dangerous bacteria that cause these infections are methicillin-resistant Staphylococcus aureus (MRSA), which can survive on dry surfaces for over 1 month before being transferred to a susceptible individual6.

Gastroenteritis

Gastroenteritis in elderly populations is often caused by Clostridium difficile infections, which are a significant contributor to preventable deaths related to nosocomial infections7. C. difficile bacteria are rapidly developing antibiotic resistance, underscoring the importance of judicious antibiotic use and implementation of other methods to control bacterial colonization and transmission. 

Sepsis

Elderly residents of nursing homes are about 20 times more likely to be diagnosed with sepsis than their non-resident peers and are 7 times more likely to develop severe sepsis8. In addition, sepsis mortality rates are substantially higher for nursing home residents than non-residents. These alarming statistics underscore the critical need for improved prevention of bacterial spread in nursing home settings.

What are the most common causes of the spread of infection in the care home?

The most common causes of the spread of infection in nursing homes are related to direct and indirect contact with an infected person. Physical contact between people or contact with a contaminated surface are efficient modes of bacterial transmission. Infected droplets can be aerosolized, often via sneezing and coughing, which can drive both airborne transmission and surface contamination. Contaminated food or water are also potential sources of infectious material.

Notably, all of these modes of transfer rely on bacterial transfer from a colonized person. Recent studies have identified bacterial colonization in the nasal vestibule (or anterior nares) as a major reservoir for pathogenic bacteria, including S. aureus and MRSA. Up to 30% of healthy, asymptomatic people in the United States have permanent nasal colonization of S. aureus, and most people will experience intermittent nasal colonization by S. aureus9. Nasal colonization by S. aureus occurs in nearly 7% of healthcare providers10, compared to approximately 1% in the general public11.

Bacteria from the nasal vestibule are readily transferred after hand-to-nose contact, potentially resulting in both self-infection and cross-transmission to other people and inanimate objects. Self-infection is frequently overlooked as a mode of infection spread, but one multicenter study found that more than  80% of S. aureus blood stream infections were clonally identical to the S. aureus in the anterior nares of the patient12, 13.

Indwelling devices (e.g. urinary catheters, artificial joints) are associated with an increased risk for developing a potentially life-threatening infection as a result of biofilm development. Biofilms are an aggregation of bacteria and their extracellular products, and are notoriously challenging to manage14. Chronic urinary catheterization is significantly correlated with biofilm-induced bacteremia, and sepsis related to indwelling catheters is common. 

Taken together, these data point to bacterial colonization in the nasal vestibule as an important contributor to bacterial spread and suggest that the spread of infection could be slowed by nasal decolonization. 

What preventative measures can be taken in nursing homes?

Nursing home staff and patients alike are typically well-versed in the standard precautionary measures, including proper hand hygiene and avoidance of touching the face. However, because elderly residents of nursing facilities are likely to have some level of immune system compromise and skin abrasions, preventative measures should include additional steps to minimize bacterial transfer.

While antibacterial agents are the gold standard for decontaminating surfaces, they are not a panacea. The evolution of antimicrobial resistant strains of bacteria is a major concern for healthcare providers and patients alike. Therefore, it is imperative that infection prevention measures do not contribute to antimicrobial resistance. Similarly, overuse of prescription antibiotics is significantly associated with the spread of dangerous antibiotic-resistant bacteria like MRSA. 

A growing body of literature supports the use of ethanol-based antiseptic products, which are highly effective at reducing bacteria colonization without contributing to antimicrobial resistance. Recent studies have shown that alcohol-based nasal antiseptics like Nozin® Nasal Sanitizer® Advanced Antiseptic lead to highly significant reductions in nasal colonization of S. aureus, thus effectively limiting the potential for transmission10

Particularly relevant to nursing homes are the clinical findings that nasal decolonization with Nozin® Nasal Sanitizer® significantly reduces surgical site infections and infections related to indwelling devices like urinary catheters15. In addition, several clinical studies have shown that MRSA bacteremia was significantly reduced in hospitals that incorporated Nozin® nasal decolonization protocols. One year-long study found a 96% reduction in hospital-wide MRSA bacteremia after inpatients were treated with an alcohol-based nasal antiseptic twice daily16.

Incorporating regular daily use of nasal decolonization techniques among nursing home staff, patients and visitors is a new and highly effective strategy to help reduce nosocomial infections in long-term care facilities. 

Summary

Nosocomial infections in nursing homes are a key contributor to morbidity and mortality among residents, but they are often preventable following regular hygiene techniques. Numerous studies have shown that even asymptomatic S. aureus nasal colonization significantly increases the risk for transmission of pathogenic bacteria between patients and staff, with more recent studies specifically implicating the nasal vestibules as a key reservoir for potentially life-threatening bacteria, including MRSA.

Prevention of bacterial transmission among the elderly is a key step toward increasing overall health and longevity. Nozin is a pioneer in the field of bacterial nasal decolonization and helping reduce risk of infection. Mounting data supports the use of Nozin® Nasal Sanitizer® antiseptic to reduce the burden of MRSA and other dangerous bacteria in both clinical- and non-clinical settings.

Infection control in nursing homes is not limited to residents.  Staff, residents, and visitors can all take steps to protect themselves. Non-prescription Nozin® Nasal Sanitizer® antiseptic is simple to use and provides unparalleled protection against both self-infection and cross-transmission of bacteria, including MRSA. This product is notably easy to use without a prescription and is a great tool to aid in the prevention of nosocomial infections in nursing homes.

References

  1. Harris-Kojetin L., et al. (2019). Long-term care providers and services users in the United States, 2015–2016 (Table VIII). National Center for Health Statistics. Vital Health Stat 3(43).
  2. Grigg C. et al. (2018). Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections in Nursing Home Residents. Journal of the American Geriatrics Society. doi:10.1111/jgs.15451
  3. Montoya, A., Cassone, M., & Mody, L. (2016). Infections in Nursing Homes: Epidemiology and Prevention Programs. Clinics in Geriatric Medicine. doi:10.1016/j.cger.2016.02.004
  4. Pulcini, C., et al. (2019). Antibiotic resistance of Enterobacteriaceae causing urinary tract infections in elderly patients living in the community and in the nursing home: a retrospective observational study. Journal of Antimicrobial Chemotherapy. doi:10.1093/jac/dky488
  5. Mitchell, E. (2017). Nursing Homes and Infection Control: The Most Common Infections. EOScu Blog. 
  6. Neely, A. N., & Maley, M. P. (2000). Survival of enterococci and staphylococci on hospital fabrics and plastic. Journal of clinical microbiology, 38(2), 724–726.
  7. Jump, R. L., & Donskey, C. J. (2015). Clostridium difficile in the Long-Term Care Facility: Prevention and Management. Current Geriatric Reports. doi:10.1007/s13670-014-0108-3
  8. Ginde, A. A., et al. (2013). Impact of Older Age and Nursing Home Residence on Clinical Outcomes of U.S. Emergency Department Visits for Severe Sepsis. Journal of Critical Care. doi:10.1016/j.jcrc.2013.03.018
  9. Sakr, A., et al. (2018). Staphylococcus aureus Nasal Colonization: An Update on Mechanisms, Epidemiology, Risk Factors, and Subsequent Infections. Frontiers in Microbiology. doi:10.3389/fmicb.2018.02419
  10. Steed, L. L., et al. (2014). Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2014.04.008
  11. Kyoung-Bok, M., et al. (2019). Nasal colonization with methicillin-resistant Staphylococcus aureus associated with elevated homocysteine levels in the general US adults. Medicine, 98(18):e15499.
  12. Coates, T., Bax, R., & Coates, A. (2009). Nasal decolonization of Staphylococcus aureus with mupirocin: strengths, weaknesses and future prospects. Journal of Antimicrobial Chemotherapy. doi:10.1093/jac/dkp159
  13. von Eiff C, Becker K Machka K, et. al. (2001) Nasal carriage as a source of Staphylococcus aureus bacteremia. NEJM 344:11-16.
  1. Trautner, B. W., & Darouiche, R. O. (2004). Role of biofilm in catheter-associated urinary tract infection.  American Journal of Infection Control. doi:10.1016/j.ajic.2003.08.005
  2. Clinical Outcomes Matter. (n.d.). Retrieved February 3, 2020, from https://www.nozin.com/clinical-outcomes-matter/.
  3. Arden, S. (2019). 567-Does Universal Nasal Decolonization with an Alcohol-Based Nasal Antiseptic Reduce Infection Risk and Cost? Poster presented at: IDWeek; 2019 October 2-6; Washington D.C.


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