Prév’Ehpad: Healthcare-associated infections and antibiotic use in nursing homes, 2016 national results
Santé publique France and the CClin-Arlin network have released the results of the first national epidemiological survey on the prevalence of healthcare-associated infections and antibiotic use in nursing homes for the elderly in 2016.
What is Prév'Ehpad?
Prév'Ehpad 2016 is a prevalence survey of healthcare-associated infections and antibiotic treatments conducted on a specific day among residents in a sample of long-term care facilities (Ehpad) located throughout France.
This survey was conducted by the CClin-Arlin network as part of Raisin (National Network for Alert, Investigation, and Surveillance of Nosocomial and Healthcare-Associated Infections) in partnership with Santé publique France.
Its objective is to mobilize all healthcare professionals in nursing homes and potential prescribers regarding infection risk management and the appropriate use of antibiotics to help improve the safety of care for residents and identify priorities for action and follow-up at both the local and national levels.
Nursing homes committed to infection risk prevention
In France, 7,500 nursing homes house approximately 600,000 residents. The Prév’Ehpad survey was conducted between May and June 2016 among all residents of a sample of 719 nursing homes selected at random. The participation of half of the nursing homes surveyed (a 51% response rate) and the inclusion of 28,277 residents in the survey demonstrate the nursing homes’ commitment to preventing infectious risks.
A high degree of heterogeneity among nursing homes, both in their structure and organization
The nursing homes surveyed are public (50.9%), private nonprofit (27.2%), or private (21.9%), and a quarter of them are affiliated with a healthcare facility (27.9%). The average capacity of the nursing homes is 80 beds.
In terms of organization, the availability of hand sanitizer (99.5%) appears to be standard practice. A coordinating physician (90.3%) or a coordinating nurse (89.7%) is also present in the majority of nursing homes. However, there is significant room for improvement regarding access to hygiene expertise (64.6%), the presence of a hygiene liaison (59.4%), or access to an antibiotic therapy consultant (45.3%).
Residents are primarily women over the age of 85 with little exposure to medical devices or invasive procedures
Nursing home residents are approximately three women to one man (73.5%), and nearly two-thirds are over 85 years old. Residents’ exposure to invasive devices is infrequent: catheter placement (3.3%), mostly subcutaneous; indwelling urinary catheterization (1.7%); and surgical procedures within 30 days (0.9%). However, there are significant variations, particularly among nursing homes.
A lower-than-expected frequency of healthcare-associated infections
The national prevalence of residents with at least one active infection on the day of the survey is estimated at 2.93% (95% CI [2.57–3.29]). It ranges from 0% to 21.1% among responding nursing homes, with no significant regional disparities.
The prevalence of infections (a resident may have multiple infections) is 3.04% (95% CI [2.65–3.42]): 36.9% urinary tract infections, 24.0% lower respiratory tract infections, 11.0% pneumonia, 20.4% skin and soft tissue infections, 5.6% pressure ulcer infections, 1.3% catheter-related infections, 0.3% scabies, and 0.1% Clostridium difficile infections. The most frequently observed pathogens for urinary tract infections confirmed by cytological and bacteriological urine testing (68.8%) are Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae.
The prevalence rates observed are lower compared to previous French or international surveys conducted in the medical-social sector, although the methodologies are difficult to compare.
Long-term antibiotic treatments primarily targeting the pulmonary and urinary tracts, with a high proportion of prophylactic treatments for the latter
The national prevalence of residents receiving at least one systemic antibiotic treatment on the day of the survey is estimated at 2.76% (95% CI [2.46–3.07]), with no significant variation between regions.
In the majority of cases, treatment is administered orally (85.1%), and the main sites targeted by antibiotics are pulmonary (36.2%), urinary (33.3%), and skin and soft tissue (14.8%).
Among the main classes of antibiotics, the most commonly prescribed are third-generation cephalosporins (20.9%, of which 12.9% is ceftriaxone), followed by penicillins A (19.0%), amoxicillin-clavulanic acid (16.0%), macrolides and related drugs (12.3%), and fluoroquinolones (11.4%).
Prophylactic treatments are common (13.7%), primarily for urinary tract infections. As of the survey date, the duration of curative treatments exceeded 7 days in 34.4% of cases, and systematic reevaluation within 3 days was performed in only 31.4% of cases.
Prév'Ehpad: useful national reference data for identifying areas for improvement
Organizational improvements will focus on access to hygiene expertise and an antibiotic therapy consultant, as well as the presence of hygiene liaisons in nursing homes.
Regarding the diagnostic and therapeutic management of infections, microbiological documentation of infections, assessment of the appropriateness of prophylactic treatments (urinary tract), the use of prescribing support tools, reduction of treatment duration, and systematic reevaluation within 3 days are practices that must be strengthened. Awareness campaigns on the appropriate use of antibiotics should be organized for the many prescribers working in nursing homes. Adherence to standard precautions, particularly hand hygiene, remains the key element in preventing cross-transmission of infections and antibiotic resistance.
Repeating this national survey every 5 years will allow for long-term monitoring of indicators of healthcare-associated infection prevalence and antibiotic treatment, as well as changes in practices and organizational structures.
