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Managing MDROs in the Long-Term Care Setting · The SHEA Podcast

• 1:06
  SPEAKER_00: Thank you.
• 1:07
  SPEAKER_00: Thank you for having me.
• 1:08
  unknown: Dr.
• 1:09
  SPEAKER_00: Cooper, does start everyone out on the same page?
• 1:11
  SPEAKER_00: How do you define long-term care?
• 1:15
  SPEAKER_01: So long-term health care refers to social, residential, health-related services that are provided to a patient who are these patients are mostly chronically disabled over a long period of time.
• 1:27
  SPEAKER_01: And these long-term care facilities include institutions like nursing homes, they include skilled nursing, intermediate care facilities, also residential care facilities.
• 1:40
  SPEAKER_01: In addition, they can include other long-stay hospitals, including psychiatric hospitals and also LTACs, which are long-term acute care hospitals that have chronically vintage patients and also patients who require, let's say, antibiotics for a long period of time or wound management for as long as up to 25 days medium.
• 2:06
  SPEAKER_00: And why are multidrug resistant organisms an issue in long-term care?
• 2:11
  SPEAKER_01: That's a great question.
• 2:12
  SPEAKER_01: So, you know, long-term patients who are residing in these facilities have a lot of devices, like invasive devices, like they are vented, they are intubated, they have foley catheters.
• 2:24
  SPEAKER_01: All of these are risk factors for multidrug resistant organisms.
• 2:27
  SPEAKER_01: And these long-term care facilities, they also lack the structural and human resources for implementing good infection control practices, good stewardship in antimicrobial stewardship, especially, you know, controlling antibiotics when we are treating infections and lack of infection control practitioners as well as physicians and the resources that leads to poor infection control practices, and this can also lead to inappropriate use of antimicrobials.
• 2:57
  SPEAKER_01: So all of these, you know, can lead to high rates of MDROs as well as C death.
• 3:03
  SPEAKER_00: And you mentioned invasive devices and infection control practices.
• 3:07
  SPEAKER_00: Are there any other risk factors for multi-drug resistant organisms and long-term care that we need to think about?
• 3:14
  SPEAKER_00: Sure, yeah.
• 3:15
  SPEAKER_01: In addition to having invasive devices, most of these long-term care residents are at increased risk of getting NDROs because of their age.
• 3:24
  SPEAKER_01: You know, uh a lot of these are older patients.
• 3:26
  SPEAKER_01: When I say older adults, I mean more than 65 years of age.
• 3:30
  SPEAKER_01: And also their comorbidities, they have multiple comorbidities, including diabetes, hypertension, COPD, and such.
• 3:39
  SPEAKER_01: In addition, other risk factors include their frequent movement of these patients from long-term care to acute care, and then being exposed to multiple antibiotics is also another risk factor.
• 3:52
  SPEAKER_01: Some studies have also shown that a lot of these patients are bed bound, and that is an independent risk factor for colonization for MD MDROs.
• 4:02
  SPEAKER_01: And you know, being colonized doesn't mean that they are infected, but that is being colonized means that they can get infected easily when they are exposed to a particular or to hospital environment or their immune status is low.
• 4:17
  SPEAKER_01: Being older also makes them have less lower immunity, and that also puts them at higher risk for infections.
• 4:25
  SPEAKER_00: And why are we becoming more worried about these resistant organisms in long-term care patients now?
• 4:32
  SPEAKER_01: There was a study done that showed that these patients in long-term care facilities have a higher rate of colonization of MDROs.
• 4:41
  SPEAKER_01: This study showed that more than 60% of long-term care residents were colonized by at least one MDRO.
• 4:48
  SPEAKER_01: So that's why it is worrisome because asymptomatic colonization with MDROs is actually the first step for developing really severe infections that are hard to treat because of more and more drug resistance uh in the community and lack of antibiotics to treat these severe infections.
• 5:09
  SPEAKER_01: Uh, we are seeing emerging infections and we don't have antibiotics in the pipeline to treat some of these emerging infections, and our long-term care residents unfortunately are at higher risk of these emerging infections.
• 5:24
  SPEAKER_00: You mentioned infection control earlier.
• 5:26
  SPEAKER_00: Are there differences in infection control practices between acute care and long-term care facilities?
• 5:33
  SPEAKER_01: Yes, there are.
• 5:35
  SPEAKER_01: You know, acute care facilities have a lot of resources as far as bed availability, private rooms to isolate a lot of these patients who have NDROs and they can be put in private rooms.
• 5:47
  SPEAKER_01: But you know, long-term care facilities, residents are there for a longer period of time and you cannot restrict them in separate rooms and not let them mingle with each other.
• 5:56
  SPEAKER_01: They have a lot of common activities in long-term care facilities, like they have physical therapy, they have entertainment uh and things like that where they do mingle with their uh other residents and that cannot be completely stopped because of their social and emotional needs as well.
• 6:14
  SPEAKER_01: So infection control is not as stringent in these facilities.
• 6:19
  SPEAKER_01: So I think that is a big factor.
• 6:21
  SPEAKER_01: Secondly, the stewardship practices, antibiotics, stewardship programs are extremely rigid in acute hospitals, academic facilities in particular, but not so much in long-term care facilities.
• 6:33
  SPEAKER_01: As you know, long-term care facilities don't have physicians who actually are required to visit every single day.
• 6:39
  SPEAKER_01: A lot of them uh are just required to, you know, they are consulted or uh they pay a visit once a week or once a month to check on the residents because they don't have any acute health care needs.
• 6:51
  SPEAKER_01: So stewardship practices are not very good in these facilities.
• 6:57
  SPEAKER_00: You mentioned stewardship then in these different settings.
• 7:01
  SPEAKER_00: Can you talk a little more specifically about the use of antimicrobials in long-term care versus in acute care?
• 7:08
  SPEAKER_01: Sure.
• 7:09
  SPEAKER_01: You know, these long-term care facilities they don't have on-site resources like a microbiology lab that can monitor their MDROs.
• 7:18
  SPEAKER_01: A lot of them don't have on-site pharmacy and ancillary services, so they outsource a lot of their needs, and that makes it difficult to monitor their antimicrobial use.
• 7:31
  SPEAKER_01: So both diagnostic and other resources make it difficult to differentiate true infection from colonization.
• 7:37
  SPEAKER_01: So a lot of these residents are may may not have a true uh true infection and may just be colonized, and yet they are treated with inappropriate antimicrobials, and that leads to more resistance when you are exposing these individuals to a lot of antibiotics.
• 7:53
  SPEAKER_01: So there's a lot of uh empiric use of antibiotics in long-term care facilities as compared to acute care settings, and that has found to have poor outcomes when you use antibiotics inappropriately.
• 8:06
  SPEAKER_01: Also, there is a more uh correlation between acquisition of MDROs and use of antimicrobials inappropriately and for colonization versus true infection.
• 8:19
  SPEAKER_01: So that is a big concern uh as far as antimicrobial uses in long-term care facilities.
• 8:26
  SPEAKER_01: In addition, you know, regulating antimicrobial use, how many days of therapy, all of that is not done in long-term care facilities.
• 8:34
  SPEAKER_01: They don't have stewardship programs, they are not mandatory for them.
• 8:38
  SPEAKER_01: Whereas now there are more laws and regulations to manage stewardship programs in every facility, and that is yet to happen.
• 8:45
  SPEAKER_01: And once that happens, we can probably see better outcomes and better regulation of antimicrobials use in these facilities.
• 8:53
  SPEAKER_01: So that is a big gap, I would say, in uh antimicrobial stewardship and long-term care facilities.
• 9:01
  SPEAKER_00: Touched on this a little bit in your last answer, but I wanted to dig a little bit more because there's concern about inappropriate diagnosis of MDROs in long-term facilities.
• 9:12
  SPEAKER_00: What's the issue with that?
• 9:13
  SPEAKER_00: What's happening with that?
• 9:15
  SPEAKER_01: In long-term care facilities, infection is a very common complication of these patients.
• 9:21
  SPEAKER_01: I mean, one of the common reasons why long-term care facility patients come to acute care is because they have an infection, which could either be urinary tract infection, or they come in with sepsis, or they come in with CDEF, or with any kind of uh multidrug resistant organism in their lungs as a pneumonia, because they are chronically vented.
• 9:42
  SPEAKER_01: And that causes frequent admissions to acute care hospitals and that leads to higher morbidity and mortality.
• 9:49
  SPEAKER_01: Again, one of the reasons why they are frequently transferred is because they lack that care that acute facilities have.
• 9:56
  SPEAKER_01: They lack on-site diagnostic testing to make diagnosis of uh of an infection.
• 10:02
  SPEAKER_01: In addition, as I'd mentioned previously, these patients get colonized with NDROs because of frequent inappropriate antimicrobial exposure, and hence it further leads to more antimicrobial resistance.
• 10:17
  SPEAKER_01: So all of this becomes a vicious cycle, and these patients keep getting transferred to acute care hospitals and then back and forth to either an LTAC or to a nursing home.
• 10:29
  SPEAKER_01: And they remain chronically vented in these facilities, and that poses a risk for them to be colonized with more and more multi-drug resistant organisms.
• 10:41
  SPEAKER_00: And narrowing down a little bit, in your view, what's the current status of carbapenum resistant organisms with respect to long-term care?
• 10:50
  SPEAKER_01: Carbopenum resistant organisms are one of the global threats that has been labeled by WHO to our community because we don't have enough antibiotics to treat these CREs, especially the emerging ones.
• 11:03
  SPEAKER_01: A particular, these are carpapenemase producers, and they we we lack the antibiotics in the pipeline to treat these infections.
• 11:11
  SPEAKER_01: So they are very, very severe infections.
• 11:13
  SPEAKER_01: They have a mortality as high as 50%.
• 11:16
  SPEAKER_01: And uh, you know, we did a study of the epidemiology of these CREs at a long-term acute care hospital in Detroit, Michigan, and we found that majority of patients with CRE presented several days or weeks after an LTAC admission to an acute hospital.
• 11:33
  SPEAKER_01: So that indicates that these facilities probably the CRE is acquired and spread in the LTAC from one patient to another patient.
• 11:43
  SPEAKER_01: Also, we did genetic studies of these isolates that we published out of Detroit and found there was horizontal transmission of these pathogens inside the facility.
• 11:53
  SPEAKER_01: Again, this is due to inappropriate antimicrobial use and lack of infection control practices, including hand hygiene and contact precautions, and that's why there is genetic transmission from one patient to another patient.
• 12:07
  SPEAKER_01: And uh unless and until there are better infection control procedures in these facilities, we can't control this horizontal transmission.
• 12:18
  SPEAKER_00: Looking to the future, what are the emerging infections and the unmet needs in long-term care?
• 12:25
  SPEAKER_01: So, you know, the findings that I just indicated from the study that we did in Detroit, it suggests that active surveillance is one way, you know, which is done through rapid molecular diagnostic testing or using selective ra rapid erectile cultures, they should be considered among residents at uh the time of an LTAC admission and during their stay in an LTAC uh or a long-term care facility, especially if a facility has an ongoing issue with an organism, including CRV or MGROs, and to understand if there is CRV colonization or infection, it's I think critical to do active surveillance in such institutes, and it can help in preventing transmission to other patients who are in the same facility or in during transitions of care when patients are being transferred from acute care facility to from long-term care facility to acute care facility.
• 13:19
  SPEAKER_01: And then, you know, implementing CRE preventive strategies in these long-term care facilities as recommended by CDC is also, I think, urgently needed to control their strat.
• 13:32
  SPEAKER_00: Excellent advice.
• 13:33
  SPEAKER_00: Dr.
• 13:33
  SPEAKER_00: Chapra, I want to thank you for sharing your expertise with us today about long-term care.
• 13:38
  SPEAKER_00: Thank you.
• 13:39
  SPEAKER_00: Thank you for having me.