Risk factors associated with antimicrobial resistant organism carriage in residents of residential aged care facilities: a systematic review protocol

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Abstract

Review question/objective

This review will aim to answer the following questions:

Review question/objective

1. What are the resident risk factors associated with antimicrobial resistant organism carriage in the residential aged care setting?

Review question/objective

2. What are the institutional risk factors associated with antimicrobial resistant organism carriage in the residential aged care setting?

Review question/objective

3. What are the environmental risk factors associated with antimicrobial resistant organism carriage in the residential aged care setting?

Review question/objective

The objective of this systematic review is to synthesize the best available evidence of the risk factors associated with antimicrobial resistant organism carriage in residents of residential aged care facilities. More specifically, the objective is to identify the factors that make some residents more at risk than others to either colonization or infection with an antimicrobial resistant organism. These may include patient/resident factors (predisposing medical conditions, immune status, functional capacity), institutional factors (staffing ratios, clinical policies and procedures, antibiotic use, indwelling devices) or environmental factors (cleaning of environment, cleaning of equipment, ward layout, hand hygiene facilities, shared and community living).

Background

Residential aged care facilities (RACFs) aim to provide nursing and personal care to the elderly who can no longer remain in their own home; in an environment that is safe and home-like.1 Unlike acute healthcare facilities, RACFs are places where residents reside for many months or even years. While they may require nursing and medical care within this time, this can often be provided to residents within the RACF setting without the need for transfer to an acute hospital.

Background

It has long been recognized that residents of RACFs are more susceptible to infections than the elderly living in the general community.2 This is primarily due to factors that challenge their already diminishing immune system, such as multiple chronic diseases, polypharmacy, and functional impairment, which affects their hygiene practice and communal living.3 Unlike the elderly living in their own homes, the RACF environment can be conducive for infection transmission by the nature of its shared living arrangements, where many people interact directly with residents on a daily basis. Each one of these interactions increases the chance of the transference of pathogenic organisms. Some infections affecting residents of RACFs are caused by antimicrobial resistant organisms (AROs).4

Background

Organisms may be become resistant to antimicrobials in a variety of ways: they may be intrinsically resistant to certain antimicrobial agents, or they may acquire resistance by mutation or via the acquisition of resistance genes from other organisms.5 The later occurs when new genetic material from resistant strains of bacteria is transferred to previously antimicrobial-susceptible bacteria. The use of antibiotics creates selective pressure for the emergence of such resistant strains.6 Bacteria that are resistant have an advantage over those that are susceptible and survive to multiply and continue to pass on that resistance.5

Background

AROs are commonly found in aged care settings7 and include: Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus faecalis (VRE), Multidrug Resistant Streptococcus pneumoniae (MDRSP), extended spectrum beta lactamase (ESBL) that produces Escherichia coli, and multi-resistant Pseudomonas aeruginosa.4 A recent study by Adam et al8 concluded that rates of antimicrobial resistance to these organisms are often higher in older age groups when compared to children, and adults under 64 years of age.

Background

Residents can either be colonized or infected with an ARO. Colonization occurs when a resident has an ARO in or on a body site, but has no clinical signs or symptoms of disease. A colonized resident may be a temporary or a longer term carrier of an ARO, and may act as a reservoir for the organism and a potential source of transmission. Infection with an ARO occurs when the organism enters a body site and multiplies in the tissues, causing disease. Signs of infection with any kind of organism can include: fever, a rise in the white blood cell count, redness, swelling, pain and/or purulent drainage from a wound or body cavity.9 Residents who are infected with an ARO can also act as reservoirs and are potential sources of transmission of the organism. Reservoirs in this case are defined as people who have the ability to pass on a pathogenic organism to others, while not necessarily being affected by that organism themselves. Residents who are either infected or colonised with an organism can act as reservoirs for that organism.10 While infections with AROs are uncommon in RACFs, when they do occur they are associated with both increased morbidity and mortality.11 Additionally, if residents need to enter the health system, they may act as reservoirs for these organisms and introduce them into the acute care setting.12

Background

Many infection control guidelines, for example the Australian Guidelines for the Prevention and Control of Infection in Healthcare 201010, Guidelines for the Control of Multidrug-resistant organisms in New Zealand 200713, UK MRSA Guidelines14, and the Public Health Ontario Guidelines15 are for primary use by acute healthcare facilities. They provide detailed and rigorous infection prevention strategies and additional infection control precautions for use with patients in acute healthcare facilities who are colonized or infected with AROs. They all also briefly mention how these strategies can be modified to suit residents colonized or infected with AROs in the RACF setting. In recognizing that this setting is fundamentally different, they recommend a risk-management approach to implementation of infection prevention strategies for dealing with residents with AROs. A risk management approach in this context consists of the healthcare facility conducting its own risk assessment, including how to avoid, identify, analyze, evaluate and treat risks in that setting. All healthcare facilities need to be able to determine the risks in their own context and select the appropriate course of action. Facilities are advised to regularly conduct infection prevention risk assessments within their facility. Identifying risk in such a way requires a systematic and comprehensive process that ensures no potential risk is missed.10

Background

In practice, utilizing risk management strategies as outlined in these types of guidelines is difficult for staff in RACFs because it presumes an awareness of the ARO burden in a facility, and that the at-risk population has been fully identified. Furthermore, the risk factors associated with carriage of AROs in this setting are not well understood. Where specific guidelines applicable to RACFs are available, such as in the US16, they concentrate mainly on interventions designed to prevent transmission of AROs, and where resident risk factors are discussed, these guidelines describe resident, institutional and, to a lesser extent, environmental risk factors. On examination of the references provided in these guidelines to support the information around risk factors, it appears they are not based on systematic reviews of the literature or other strong evidence.16

Background

With the exception of the US, the lack of aged care specific guidelines for the management of AROs often sees acute care guidelines adapted with minimal modification and use by staff in RACFs. This can result in the introduction of rigorous infection prevention strategies that, while appropriate for the acute care setting, are often inappropriate in the aged care setting. Such strategies often result in limiting a resident’s activity and engagement with the residential care community.3 In addition they impose potentially unnecessary financial burdens on facilities. Kim et al.17 determined the costs associated with isolation and management of colonized patients in the acute care setting as $1,363 per admission. Information on similar costing in the RACF setting, where length of stay would be much longer, is not readily available.

Background

A preliminary review of the literature revealed several cross-sectional studies that determined potential risk factors for colonization with AROs in residential aged care settings. Raab et al.18 found risk factors associated with MRSA in residents of a German nursing home were: low body mass index (P=.005), presence of cerebral circulatory disorder (P=.07), and non-mobility status (P=.09). Pop-Vicas et al19 looked at factors associated with colonization with multi-drug resistant gram-negative bacteria in residents of a RACF in Boston and found a diagnosis of advanced dementia (adjusted odds ratio = 2.9, 95% confidence interval = 1.2-7.35, P=.02) and non-mobility status (adjusted odds ratio = 5.7, 95% confidence interval = 1.1-28.9, P=.04) were significant risk factors for colonization. A study by Mody et al20 concluded that the use of indwelling devices (i.e., urinary catheters and feeding tubes) was associated with colonization with MRSA at any site (odds ratio = 2.0, P=.04).

Background

A retrospective cohort study conducted by Nuorti et al21 concluded that an outbreak of multidrug-resistant Pneumococcal pneumonia in residents was associated with antibiotic use, previous hospitalization, previous pneumonia, and the need for assistance to take oral medication. A systematic review conducted in 2012 by Xue and Gyi12 looked at risk factors for MRSA colonization among adults in acute care settings. Notably, this review found that previous admission to a long term care facility (such as a RACF) within the last 18 months was associated with MRSA colonization. Xue and Gyi suggested that systematic reviews on risk factors in geriatric patients were a potential area for further research and their findings support the need for this review. While Xue and Gyi looked at a specific type of ARO (MRSA) in the acute setting, no systematic review has been conducted on risk factors for carriage of MRSA in the residential aged care setting. Similarly, a preliminary search has revealed that no systematic reviews appear to have been conducted for any other types of AROs in the aged care setting. Consequently, this proposed review will look at a previously unexamined area of the literature.

Background

Identifying risk factors that influence the colonization or infection of residents of RACFs with AROs will inform risk identification and mitigation protocols for use in this setting. It may potentially lead to the development of a reliable assessment tool that staff can use to identify those residents most at risk. This review will provide an evidence base on which to build a planned approach to risk management and the implementation of transmission prevention strategies to prevent AROs in residents of RACFs.

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