national prevalence survey of methicillin-resistant
TRANSCRIPT
FINAL REPORT - AUGUST 2006
National prevalence survey of methicillin-resistant staphylococcus
aureus in nursing home residents, 2005
IPH - Unit of Epidemiology J. Wytsmanstraat 14 1050 Brussels | Belgium www.iph.fgov.be
Unit of Epidemiology | June 2009 | Brussels, Belgium No international reference: EPI-Report 2006-029 No deposit ISSN: D/2006/2505/39
Denis O1, Struelens MJ1, Suetens C2, Jans B2
1 MRSA Reference Laboratory, ULB-Hospital Erasme, Brussels, Belgium 2 Scientific Institute of Public Health, Unit of Epidemiology, Brussels, Belgium
Advisory group:
Buntinx F, Byl B, Gordts B, Niclaes L, Schuermans A, Van Elderen J. The project is financially supported by BICS (formerly GDEPIH/GOSPIZ) Federal Platform for Hospital Hygiene of the BAPCOC
Science at the service of Public health, Food chain safety and Environment.
© Scientific Institute of Public Health, Brussels 2009 This report may not be reproduced, published or distributed without the consent of the ISP | WIV.
TABLE OF CONTENTS I Aims of the study........................................................................................................................................ 5 II Study design............................................................................................................................................... 6 III Methodology ........................................................................................................................................... 6
III.1 Selection of nursing homes and participation rate.............................................................................. 6 III.1.1 Inclusion criteria eligible NH:........................................................................................................ 6 III.1.2 Random selection of NH, reserves and substitution of non-responders ..................................... 7
III.2 Selection of residents.......................................................................................................................... 9 III.3 Epidemiological component: study tools........................................................................................... 10
III.3.1 Resident risk factors questionnaire............................................................................................ 10 III.3.2 Nursing home questionnaire about structural and functional characteristics ............................ 10
III.4 Microbiological component................................................................................................................ 10 III.4.1 Screening method...................................................................................................................... 10 III.4.2 Laboratory methods ................................................................................................................... 11
III.4.2.1 MRSA screening ............................................................................................................... 11 III.4.2.2 Antimicrobial susceptibility testing for MRSA isolates....................................................... 11 III.4.2.3 Panton-Valentine Leukocidine (PVL) gene detection ....................................................... 12 III.4.2.4 Molecular typing ................................................................................................................ 12
III.5 Period of data collection.................................................................................................................... 12 III.6 Data analysis..................................................................................................................................... 12 III.7 Local feedback of MRSA- carriage prevalence rate ......................................................................... 13
IV Ethical approval and confidentiality ...................................................................................................... 13 V Results...................................................................................................................................................... 13
V.1 Characteristics of participating NH.................................................................................................... 13 V.1.1 Region and province .................................................................................................................. 13 V.1.2 Nursing Home size..................................................................................................................... 14 V.1.3 Care-level (case-mix) of the participating NH............................................................................ 14 V.1.4 Administrative status of the NH ................................................................................................. 15
V.2 Microbiological results....................................................................................................................... 15 V.2.1 Culture survey............................................................................................................................ 15 V.2.2 Antimicrobial susceptibility ......................................................................................................... 15 V.2.3 Resistance gene distribution...................................................................................................... 16 V.2.4 PVL gene detection.................................................................................................................... 16 V.2.5 Genotype distribution ................................................................................................................. 16 V.2.6 Correlation of antibiotic resistance profile with MRSA genotypes ............................................. 17 V.2.7 Geographical dispersion of MRSA epidemic clones.................................................................. 18
V.3 Prevalence of S. aureus carriage...................................................................................................... 19 V.4 Prevalence of Methicillin resistant S. aureus carriage ...................................................................... 20
V.4.1 Mean MRSA-prevalence rate by region..................................................................................... 20 V.4.2 Mean MRSA-prevalence rate by sub-sample ............................................................................ 21 V.4.3 Mean MRSA-prevalence rate by administrative status.............................................................. 21 V.4.4 Mean MRSA-prevalence rate by NH-size.................................................................................. 21 V.4.5 Mean MRSA-prevalence rate by proportion of MRS/RVT-beds in the NH................................ 21 V.4.6 Relation between MRSA-prevalence rate and S. aureus carriage in NH.................................. 22
V.5 Resistance proportion of S. aureus................................................................................................... 22 V.5.1 Resistance proportion by region ................................................................................................ 23 V.5.2 Resistance proportion by status ................................................................................................ 23 V.5.3 Resistance proportion by NH size ............................................................................................. 24 V.5.4 Resistance proportion and prevalence of MRSA carriage......................................................... 24
V.6 Institutional (structural and functional) characteristics and determinants of MRSA-carriage ........... 25 V.6.1 Outbreaks and problematic pathogens...................................................................................... 25 V.6.2 Role of the co-ordinating physician............................................................................................ 25
V.6.2.1 Development of care practices and hygiene protocols in the NH..................................... 25 V.6.2.2 Development of hygiene practices .................................................................................... 26 V.6.2.3 Development of care protocols ......................................................................................... 26 V.6.2.4 Antibiotic policy in the NH ................................................................................................. 27
V.6.3 Collaboration and information flow between NH and acute care hospitals ............................... 29 V.6.3.1 Collaboration with experts................................................................................................. 29 V.6.3.2 Information flow between acute hospitals and NH............................................................ 29
V.6.4 Availability of hand hygiene products and materials in NH........................................................ 30 V.6.4.1 Availability of hand hygiene products................................................................................ 30 V.6.4.2 Type of available towels.................................................................................................... 31 V.6.4.3 Availability of gloves and indications................................................................................. 31
V.6.4.4 Hand hygiene after removing gloves................................................................................. 32 V.6.5 MRSA screening, decontamination and surveillance ................................................................ 33
V.6.5.1 Screening of residents after discharge of the hospital ...................................................... 33 V.6.5.2 Screening of the nursing staff ........................................................................................... 33 V.6.5.3 Decontamination of resident-carriers ................................................................................ 33 V.6.5.4 Surveillance....................................................................................................................... 34
V.6.6 Additional measures for MRSA-carriers .................................................................................... 35 V.6.6.1 MRSA-prevalence and proportion of private rooms in the NH.......................................... 35 V.6.6.2 Isolation and cohorting of MRSA-carriers ......................................................................... 35 V.6.6.3 Cohort nursing of MRSA-carriers ...................................................................................... 36 V.6.6.4 Additional measures.......................................................................................................... 36
V.6.7 Manpower and MRSA -prevalence............................................................................................ 37 V.6.7.1 MRSA-prevalence and number of General practitioners/100 residents ........................... 37 V.6.7.2 MRSA-prevalence and number of qualified Nurses.......................................................... 37
V.6.7.2.1 Number of qualified Nurses/100 residents ........................................................................... 37 V.6.7.2.2 Number of FTE qualified Nurses/100 residents .................................................................. 37
V.6.7.3 MRSA-prevalence and number of nursing aids/100 residents ......................................... 38 V.6.7.4 MRSA-prevalence and number of non-qualified personnel/100 residents ....................... 38
V.7 Resident characteristics .................................................................................................................... 38 V.7.1 Age and sex distribution............................................................................................................. 38 V.7.2 Length of stay, number of beds and level of care...................................................................... 39 V.7.3 Antibiotic use.............................................................................................................................. 39 V.7.4 Previously known MRSA carriage ............................................................................................. 40
V.8 Determinants of MRSA carriage at the resident level ....................................................................... 40 V.8.1 Univariate analysis..................................................................................................................... 40 V.8.2 Multiple logistic regression......................................................................................................... 41
V.9 Multilevel analysis of resident and institutional determinants of MRSA carriage.............................. 41 V.9.1 Ratio of General Practitioners (GPs) in the nursing home/number of beds .............................. 41 V.9.2 MRSA control index (MCi) ......................................................................................................... 41 V.9.3 Other variables and multilevel model......................................................................................... 42
V.10 Determinants of epidemicity....................................................................................................... 43 VI Conclusions .......................................................................................................................................... 45 VII References............................................................................................................................................ 47 VIII Annexes ................................................................................................................................................ 48
VIII.1 Resident risk factors of MRSA carriage, univariate analysis, Belgium...................................... 48 VIII.2 Resident risk factors of MRSA carriage, univariate analysis, Vlaanderen ................................ 52 VIII.3 Resident risk factors of MRSA carriage, univariate analysis, Brussels ..................................... 56 VIII.4 Resident risk factors of MRSA carriage, univariate analysis, Wallonie ..................................... 60 VIII.5 Resident questionnaire .............................................................................................................. 64 VIII.6 Questionnaire on institutional characteristics and practices...................................................... 66 VIII.7 Institutional characteristics and practices by region .................................................................. 75
I AIMS OF THE STUDY
Considering the increasing proportion of imported MRSA cases in acute-care facilities, it was
important to investigate the extent of the reservoir of MRSA carriers in chronic-care facilities. The
better understanding of the MRSA reservoir in nursing homes (NH) should permit the adaptation of
the MRSA control policy in Belgian hospitals and other healthcare facilities.
The objectives of this survey were:
1. To study the National prevalence of MRSA colonisation in Belgian nursing home residents.
2. To identify risk factors for MRSA carriage among NH residents:
a) At resident level, verifying the relationship between MRSA carriage and:
previous antibiotic use (last 3 months)
the impact of previous hospitalisation (last year) and length of stay in the
NH presuming importation of MRSA from acute care hospitals into NH
the influence of other variables (room type, presence of wounds and
catheters and decreased patient mobility) suspected of spreading the
MRSA by cross contamination among NH-residents by the hands of the
nursing staff.
b) At nursing home level:
exploring and describing the study population and the structure and
functioning of the participating NH
verifying the relationship between MRSA carriage and:
- structural factors: case mix, manpower, size of the NH, statute
(ownership)
- functional characteristics: impact of the coordinating physician
(COP), antibiotic policy, communication and collaboration with
hospital infection control (IC)-teams, infection control, hand
hygiene, number of private rooms, etc….
3. To study the molecular epidemiology and susceptibility to non Beta-lactams antimicrobials
of MRSA strains isolated from residents living in these facilities
II STUDY DESIGN
A prevalence survey was performed prospectively in a representative sample obtained by random
stratified selection of 60 NH with RVT/MRS beds representing proportionally the different regions
of the country (selection list ordered by province) and care profile of the NH (ordered by number of
RVT-MRS beds).
Per NH, maximum 50 NH residents were randomly selected and screened (nose and throat,
wound or meatus if wound or urinary catheter was present) once during a single day survey for
MRSA carriage. Screening swabs were collected and sent to the National Reference Laboratory
for Staphylococci – MRSA for analysis.
Risk factors for MRSA carriage were collected both at resident level and at institutional level. Both
questionnaires were completed by the NH head nurse (ND) and/or by the general
practitioner/coordinating physician (COP)
III METHODOLOGY
III.1 SELECTION OF NURSING HOMES AND PARTICIPATION RATE
A representative sample (60 institutions) of NH (n=1698) was drawn from the RIZIV/INAMI list
containing all registered Belgian NH (Table 1).
III.1.1 Inclusion criteria eligible NH:
- All registered Belgian NH
- Institutions with a coordinating physician
- Institutions with at least 1 RVT/MRS bed: mixed and pure RVT-institutions (exclusion of
pure ROB/MR facilities)
Table 1: Total and eligible population of NH-institutions (Belgium 2005)
Number of institutions
Total number of registered NH 1698
Total number of eligible NH 985
Pure RVT/MRS 10
Mixed (ROB+RVT/MR+MRS) 975
Total number of non- eligible NH (pure ROB/MR) 713
III.1.2 Random selection of NH, reserves and substitution of non-responders
The total number of eligible nursing homes (985) was divided by 60 in order to obtain the sampling
interval k (985/60 = 16).
A random number x between 1 and 16 {8] was chosen so that the sample included the xth
institution, the x+kth institution, the x+2kth institution, and so on.
The list of NH was ordered by province and by number of MRS/RVT beds in the facility. By doing
so, provinces were represented proportionally regarding the number of eligible facilities. The
nursing homes sample were also representative with regard to the proportion of MRS/RVT beds in
the NH (Table 2).
60 NH were initially selected. During this random sampling procedure a reserve NH was selected
for each primary selected facility. It was the next institution on the list of eligible NH.
Table 2: Representative sample of NH-institutions (60 primary selected NH)
NH Study sample
Eligible NH
Total number of NH 60 (100%) 985 (100%)
Linguistic register:
Dutch 38 (63%) 607 (62%)
French 22 (37%) 378 (38%)
Statute of the institution:
Private NH 41 (68%) 624 (63%)
Public NH 19 (32%) 361 (37%)
Province:
Antwerpen 10 (17%) 159 (16%)
Brussel/Bruxelles 6 (10%) 95 (10%)
Brabant Wallon 1 (2%) 28 (3%)
Hainaut 7 (12%) 116 (12%)
Liège 7 (12%) 101 (10%)
Limburg 3 (5%) 54 (6%)
Luxembourg 1 (2%) 19 (2%)
Namur 2 (3%) 40 (4%)
Oost-Vlaanderen 10 (17%) 153 (16%)
Vlaams Brabant 5 (8%) 78 (8%)
West-Vlaanderen 8 (13%) 142 (14%)
The co-ordinating physicians from the initially selected NH were asked to participate in the study.
Information was provided to the study coordinators of the participating NH by the study team.
Figure 1 illustrates the participation and substitution of not-responding NH.
From the 60 initially selected NH, 37 of them accepted to participate in the study (cohort 1). 23
reserve institutions were invited to replace the not-participating facilities, 16 of them accepted
(cohort 2).
Finally, NH from the same province and with a comparable size than the not participating reserve
NH, replaced the 7 residual facilities (cohort 3).
Figure 1: Participation and substitution of not-responders
No participation: 23 primary selected NH
60 PRIMARY, RANDOM SELECTED NH FROM THE RIZIV-LIST
REPLACEMENT BY 23 RESERVE NH
Participation: 16 reserve NH
No participation: 7 reserve NH
REPLACEMENT BY 7 RESIDUAL NH
Participation: 7 residual NH
37 NH
53 NH
60 NH
Participation: 37 primary selected NH
III.2 SELECTION OF RESIDENTS
In order to select participating NH residents, beds were selected at random by the IPH study
coordinator in a list with the room-and-bed composition by department, provided by the study
coordinator from each participating NH.
The maximum sample size for 60 NH was calculated at 3000 residents, allowing estimation of a
national MRSA carriage prevalence rate of e.g. 5% with a 95% confidence interval of 4.0% to 6.3%
This allowed estimations at national level (and to a lesser extent for larger subgroups of nursing
homes sharing the same characteristics, e.g. region) but doesn’t provide a precise result at NH
level.
For each NH, a maximum of 50 NH residents (or less if the NH had less than 50 beds) and 10
reserve residents (for substitution of absent or refusing residents) were randomly selected in this
list.
The total number of beds from the list (B) were divided by the total number of rooms (R) to obtain
the mean number of residents/room (mr). The number of rooms to be sampled (r) was obtained by
the division of the number of residents to be selected (60 residents: 50 + 10 reserves) by the mean
number of residents/room (mr). To calculate the sampling interval (k) the total number of rooms
was divided by the number of rooms that will be sampled (R/r). A random number (x) from [1 to k]
was chosen so that the sample included the xth bed, the x+kth bed, the x+2kth bed, and so on.
Calculate the mean number of residents/room (mr):
mr = Total number of beds/ total number of rooms: B/R
Calculate the number of rooms to be sampled (r)
r = 60/ mr
Calculate the sampling interval (k)
k = R/r
Choose a random number between 1 and k (x)
Select the rooms to be sampled:
X
X+k
X+2k
X+3k
All residents living in a selected room were included. The inclusion of all residents sharing the
same room was done to have the possibility to estimate the risk of being colonized when at least
one other roommate is a MRSA carrier.
III.3 EPIDEMIOLOGICAL COMPONENT: STUDY TOOLS
Risk factors for MRSA carriage were collected by questionnaire, both at resident level (annexe 1)
as institution level (annexe 2). The questionnaires were largely based on a study previously
performed by the ‘Academisch Centrum voor Huisartsgeneeskunde’ of the KULeuven and the
Scientific Institute of Public Health. The questionnaires were completed by the nursing home head
nurse and/or by the general practitioner/coordinating physician.
III.3.1 Resident risk factors questionnaire
The resident questionnaire is given in annexe. Following information was collected for each
participating resident:
1. Demographic characteristics: age, sex, admission date in the NH, code of NH department,
room number and number of beds in room.
2. Activities of daily living: mobility (ambulatory, chair bound, bedridden), urinary incontinence,
urinary catheter, disorientation in time and space (scale from 1 to 5 integrated in the
“modified Katz-score” used in Belgian nursing homes to determine the workload of nursing
care)
3. Other risk factors: presence of pressure sores, other wounds, previous hospital admission
in last 12 months (including date and service), previous antibiotic use in last 3 months (date
and duration, product name)
4. Co-morbidity: Charlson’s co-morbidity index (19 diseases); parenteral, oral and topic drugs
used at time of the survey
The IPH study coordinator collected the completed questionnaires on the day of the prevalence
survey in the NH.
III.3.2 Nursing home questionnaire about structural and functional characteristics
The NH questionnaire included questions about structural characteristics (e.g. size, status, staffing,
..), functional characteristics (e.g. tasks executed by coordinating physician), practices and policies
in hygiene and nursing care and antibiotic policies. One part of the questionnaire was completed
by the head nurse and another by the coordinating physician.
III.4 MICROBIOLOGICAL COMPONENT
III.4.1 Screening method
A trained infection control nurse showed the screening technique and explained the study form for
residents to the local NH nurses (ward head nurses). Local nurses performed data collection and
sampling. Dry screening swabs from anterior nares, throat, chronic wounds (including gastrostomy,
tracheostomy, cystostomy, …) or urinary meatus (if urinary catheter in place) were collected and
sent for culture to the Reference Laboratory for Staphylococci - MRSA.
The swab collection in each nursing home was performed in one day. The IPH study coordinator
collected the samples the same day and transported them to the reference laboratory for storage
and analysis.
III.4.2 Laboratory methods
III.4.2.1 MRSA screening Swabs from each patient were pooled and inoculated in an enrichment broth made of BHI broth
supplemented with NaCl 7.5%. After 24h incubation, enrichment broth was sub-cultured onto a
selective agar SAID (BioMérieux, France) for S. aureus detection. Suspect colonies for S. aureus
were identified by the coagulase test and tested for their susceptibility to oxacillin by cefoxitin disk
diffusion method. Identification was confirmed by multiplex PCR for nuc, mecA and 16S rDNA
genes (Maes N, 20011). MRSA strains were conserved at –80°C in glycerol for further
characterization.
III.4.2.2 Antimicrobial susceptibility testing for MRSA isolates
Susceptibility to antimicrobials for MRSA including gentamicin, tobramycin, erythromycin,
clindamycin, ciprofloxacin, rifampin, linezolid, tetracycline, cotrimoxazole and fusidic acid was
determined by the Vitek 2 automated system with card AST-P536 (BioMérieux, France). Mupirocin
susceptibility was tested by agar supplemented with 4 mg mupirocin /l. Resistance level was
further tested by the E-test method (AB Biodisk, Sweden). Mupirocin resistant strains were
classified into two categories according to the British Society for Antimicrobial Chemotherapy
(BSAC): low level resistance (MIC = 8 – 256 mg/l) and high-level resistance (MIC > 256 mg/l).
Glycopeptide susceptibility was determined by teicoplanin screen agar method (5 mg/l) as
recommended by Comité de l’Antibiogramme de la Société Française de Microbiologie (CA-SFM).
Strains growing on TAS agar were further characterised by the ”E-test macromethod” (AB Biodisk,
Sweden) for vancomycin and teicoplanin. Results of glycopeptide inhibition concentration were
interpreted according to criteria described by Walsh et al. Strains inhibited by both vancomycin and
teicoplanin at ≥ 8 µg/ml or by teicoplanin alone at ≥ 12 µg/ml were considered as hetero-
glycopeptide intermediate S. aureus (hetero-GISA).
Resistance genes encoding for tetracycline efflux pump system tetK or for ribosomal protection
protein tetM, aminoglycoside modifying enzymes (AME) encoded by aac(6’)-Ie + aph(2”), ant(4’)-Ia
and aph(3’)-IIIa genes, ribosomal methylases encoded by ermA and ermC and the macrolide efflux
pumps encoded by msrA and msrB genes were tested by PCR as previously described2.
MRSA stains with decreased susceptibility to mupirocin (MIC > 8 mg/l) were tested by PCR for
mupA gene encoding for the isoleucyl-tRNA synthetase 2 (ileS-2) which confers high-level
resistance to mupirocin3.
III.4.2.3 Panton-Valentine Leukocidine (PVL) gene detection
PCR for detection PVL genes was performed on ciprofloxacine susceptible isolates (n = 33) as
previously described4.
III.4.2.4 Molecular typing
Bacterial isolates were genotyped by SmaI macrorestriction analysis of genomic DNA resolved by
PFGE and analysed using BioNumerics software version 4.1 (Applied Maths, Belgium) as
previously described. PFGE patterns were classified according to the following nomenclature: (a)
PFGE Group included patterns showing ≤ 6 DNA fragments difference, equivalent to ≥ 65%
similarity. These groups were designated by a capital letter (e.g. A).; (b) PFGE Type included
PFGE patterns showing ≤ 3 DNA fragment difference equivalent to ≥ 80 % similarity. Types were
designated by the group letter followed by a Roman numeral suffix (e.g. A1); (c) PFGE Subtype
described any pattern profile within a type. Each subtype was designated by lower case letter suffix
(e.g. A1a). A epidemicity index was calculated for each NH to reflect the diversity of MRSA PFGE
types by NH.
MLST was performed as previously described6 on selected MRSA strains belonging to the major
epidemic types (n = 9). Allelic profiles were determined at the MLST database
(http://www.mlst.net). SCCmec type was determined each PFGE patterns (n =150) by multiplex
PCR as described by Oliveira et al5.
III.5 PERIOD OF DATA COLLECTION
The study started on 18 January 2005. Every Tuesday, the IPH study coordinator visited
participating NH (3-5 during one day) and collected the swabs and questionnaires. They were
transported to the national reference laboratory (ULB, Erasme, Brussels).
On 12 September 2005, the screening sessions in the 60 participating NH were completed.
An Epi-info data capture mask was created and data entry and analysis performed.
III.6 DATA ANALYSIS
Data were analysed using Stata 9.2. A two-tailed p-value of 0.01 was chosen as the cut-point for
statistical significance to correct for multiple testing. Data analysis will include following steps:
1. Calculation of MRSA prevalence “rate” (number MRSA carriers per 100 residents) with 95%
confidence interval taking into account the cluster design effect; comparison of MRSA
prevalence rates between regions. As a secondary indicator, given the use of a non-
selective culture medium, the proportion of methicillin resistant isolates among S. aureus
was calculated.
2. Identification of risk factors:
a. At NH level: After a descriptive analysis, NH and NH ward characteristics was
entered in the model (at patient level) using a multilevel analysis design (level
2=nursing home ward, level 3= nursing home) in order to identify structural and
organisational factors associated with MRSA carriage (glamm module in Stata).
This analysis has allowed to categorize nursing homes in e.g. low, medium and
high-risk institutions according to their characteristics.
b. At the resident’s level: calculation of crude odds ratio’s (OR) (univariate analysis)
and identification of independent risk factors using multiple random effects (NH
level) logistic regression analysis was performed, after categorisation of continuous
variables (e.g. length of stay in NH).
III.7 LOCAL FEEDBACK OF MRSA- CARRIAGE PREVALENCE RATE
The coordinating physicians and study coordinators received a local feedback by mail, with the
MRSA carriage prevalence rate in their institution and the recommendations for the practical
management of MRSA-carriers.
All general practitioners from residents who were identified as MRSA carrier in this study were
informed by letter and received the same recommendations.
IV ETHICAL APPROVAL AND CONFIDENTIALITY
The ethical committee of the Scientific Institute of Public Health has approved the study. All patient
identification data were anonymous.
V RESULTS
V.1 CHARACTERISTICS OF PARTICIPATING NH
The 60 randomly selected NH, represent 6.1% from 985 recognised Belgian NH with RVT/MRS
beds. Their 6365 beds represent 6.7% from the total number of beds in these NH (n= 94.515).
V.1.1 Region and province
Table 3: Participating Nursing Homes, distribution by province
Number of NH with RVT/MRS beds
Belgium N (%)
Participating NH N (%)
X2 p-value
Antwerpen 159 16.1 10 16.7 0.91 Brussel/Bruxelles 95 9.6 6 10 0.92 Brabant Wallon 28 2.8 1 1.7 0.59 Hainaut 116 11.8 7 11.7 0.97 Liège 101 10.3 7 11.7 0.72 Limburg 54 5.5 3 5 0.87 Luxembourg 19 1.9 1 1.7 0.88 Namur 40 4.1 2 3.3 0.78 Oost-Vlaanderen 153 15.5 10 16.7 0.81 Vlaams Brabant 78 7.9 5 8.3 0.90 West-Vlaanderen 142 14.4 8 13.3 0.81 Total 985 100 60 100
The participating NH’s were geographically representative (Table 3), as well as the mean size of
participating NH’s by province was representative for the total NH-population (Table 4).
From the 60 participating NH, 36 were located in the Flanders region, 18 in the Walloon region and
6 in the Brussels region.
V.1.2 Nursing Home size
The mean size of the participating NH was 106 beds (min 38, max. 279 beds) with mean 109 beds
in the Flanders region, 87 beds in the Walloon region and 144 beds in the Brussels region
(p=0.047).
Table 4: Mean size of participating Nursing Homes, distribution by province
Mean number beds/ NH Belgium Participating NH KW-H (p-value)
Antwerpen 103 115 0.85
Brussel/ Bruxelles 114 144 0.17
Brabant Wallon 90 85 0.95
Hainaut 101 85 0.47
Liège 83 98 0.88
Limburg 81 122 0.46
Luxembourg 70 76 0.64
Namur 79 58 0.25
Oost-Vlaanderen 99 106 0.54
Vlaams Brabant 98 115 0.14
West-Vlaanderen 92 98 0.74
Total 96 106
V.1.3 Care-level (case-mix) of the participating NH
The participating NH’s were mixed institutions having both ROB/MR and RVT/MRS beds (min 20,
max. 150). The mean proportion of RVT/MRS-beds in participating NH reached 46.5% (min. 15%,
max. 97%) and was not statistically significantly different by region: 45.7% in Flanders, 49.5% in
the Walloon region and 42.5% in the Brussels region (p=0.13).
One third of the NH (20) were low care institutions (less than 40% of the beds were MRS/RVT-
beds), 19 were middle-care NH (40 to 49% MRS/RVT-beds) and 21 were high care NH (50% +
MRS/RVT beds/NH).
Table 5: Mean proportion of RVT/MRS beds in participating NH, distribution by province
Mean proportion of RVT/MRS beds/NH (%)
Total number of participating NH
Antwerpen 48 10
Brussel/ Bruxelles 43 6
Brabant Wallon 41 1
Hainaut 48 7
Liège 51 7
Limburg 52 3
Luxembourg 46 1
Namur 56 2
Oost-Vlaanderen 44 10
Vlaams Brabant 46 5
West-Vlaanderen 43 8
Total 46 % 60 NH
V.1.4 Administrative status of the NH
41 (68%) were private, and 19 (32%) were public facilities. 37 (62%) belonged to the Dutch and 23
(38%) to the French linguistic register.
V.2 MICROBIOLOGICAL RESULTS
V.2.1 Culture survey
Among 2953 residents screened in 60 NH from January to September 2005, 1500 (51%) were
positive for S. aureus. 913 (61%) S. aureus isolates were susceptible to oxacillin and 587 (39%)
were resistant to oxacillin. The prevalence of MRSA carrier residents in NH was 19.5% (95% CI:
16.4%-21.5%).
V.2.2 Antimicrobial susceptibility
Susceptibility testing results 587 MRSA strains determined by Vitek 2 automated system are
shown in Table 6. Ninety-four percent of the strains of the strains were resistant to ciprofloxacin.
Resistance to macrolide – lincosamide –streptogramin (MLS) was frequent, ranging from 47% for
erythromycin to 26% for clindamycin. For aminoglycosides, resistance was more frequent to
tobramycin (35%) than to gentamicin (<1%). More than 90% of strains were susceptible to
tetracycline (90%), fusidic acid (97%), rifampin (99%) and cotrimoxazole (99%). All isolates were
susceptible to linezolid. Twenty-one (3.9%) isolates grew on TAS after 48h. By E-test
macromethod, 9 MRSA strains (1.5%) showed MIC ≥ 12 µg/ml to teicoplanin or ≥ 8 µg/ml to
vancomycin and teicoplanin by macro-method E-test. Twenty-one isolates grew on mupirocin
screen agar. By E-test, 16 (2.7%) were high-level resistant to mupirocin.
Table 6: Comparison of antimicrobial susceptibility of MRSA isolates from 60 Nursing Homes with MRSA isolates (n = 341) from 112 hospitals, Belgium 2005
Antimicrobial agent % of isolates (n = 587) from Nursing Homes
% of isolates (n = 341) from hospitals
S I R S I R
Erythromycin 52.6 0.3 47.0 54.5 0.9 44.6
Clindamycin 73.6 1.4 26.2 61.4 0 39.6
Ciprofloxacin 5.6 0 94.7 3.5 0.3 96.2
Linezolid 100 0 0 - - -
Gentamicin 99.1 0.2 0.7 97.4 0 2.6
Tobramycin 64.7 0.2 35.1 58.7 1.2 40.2
Tetracycline 90.3 0 9.7 - - -
Rifampin 99.3 0 0.7 - - -
Cotrimoxazole 99.8 0 0.2 - - -
Fusidic acid 97.4 1.4 1.2 - - -
Mupirocin 95.9 1.4 2.7 92 3 5
- in process
V.2.3 Resistance gene distribution
Among aminoglycoside-resistant isolates, 205 isolates (35%) carried the ant(4’) gene, 3 (%) the
aac(6’)-aph(2’’) gene and 1 (%) the aph(3’) gene. The aac(6’)-aph(2’’) gene was associated with
ant(4’) gene in 2 isolates and with aph(3’) in 1 isolate. Resistance to MLS was mainly mediated by
ermA gene (n = 131) (22%), ermC (n = 135) (23%) gene or both methylase genes (n = 9) (2%). Of
tetracycline resistant MRSA strains, tetM gene was detected in 22 (4%) isolates and tetK gene in
30 (5%), respectively. All 16 strains with a MIC of mupirocin above 524 mg/l carried the mupA
gene.
V.2.4 PVL gene detection
No PVL positive isolate was found among quinolone susceptible MRSA strains (n = 33).
V.2.5 Genotype distribution
PFGE patterns of SmaI macrorestriction fragments classified 586 isolates into 169 subtypes
categorized into 23 groups and 55 types (Table 7). Group A isolates (n = 150) were subdivided into
15 types and 62 subtypes of which type A20 (n = 56) and A22 (n = 74) represented 90% of total.
By MLST and SCCmec, type A20 and type A22 strains belonged to ST8-SCCmec IV clone. Group
B isolates (n = 296) were clustered in 5 types and 43 subtypes of which B2 (n = 287) was the most
frequent. By MLST and SCCmec, B2 belonged to the epidemic clone ST45-SCCmec IV. Group C
(n = 45) included 5 types and 18 subtypes of which C10 (n = 39) was predominant. Those isolates
belonged to ST225-SCCmec II. Two novel PFGE groups K (n = 25) and I (n = 20) were recovered.
By MLST and SCCmec, both clones belonged to ST5-SCCmec IV clone. Group K (n = 26) and I (n
= 22) were clustered into 6 and 3 types, respectively of which K1 (n = 15) and I1 (n = 12) were
predominant. Other isolates belonging to PFGE group G (n = 12) and L (n = 10) were found less
frequently. Those isolates belonged to clones ST5-SCCmec II and ST22-SCCmec IV, respectively.
Eighty-four percent of the isolates belonged to 8 PFGE types, of which three were predominant: B2
(49% of total), A22 (13% of total) and A20 (10% of total). These three epidemic MRSA types were
found in 55 (92%), 21 (35%) and 25 (42%) participating NH, respectively.
Table 7: PFGE typing of MRSA isolates (n = 586) from Nursing Home (n = 60), Belgium, 2005 PFGE group PFGE
type No. of
isolates No. of NH MLST type CC SCCmec
type
A A20 56 25 8 8 IV
A21 74 21 8 8 IV
Other 20 14
B B2 287 55 45 45 IV
Other 9 7
C C10 39 13 225 5 II
Other 6 5
K K1 15 7 5 5 IV
Other 11 5
I I1 12 5 5 5 IV
Other 10 5
G 11 7 4 5 5 II
Other 5 4
L 1 10 3 22 22 IV
Other 15 21 14
PFGE: Pulsed-field gel electrophoresis MLST: multi-locus sequence typing ST: sequence type CC: clonal complex SCCmec: staphylococcal cassette chromosome mec
V.2.6 Correlation of antibiotic resistance profile with MRSA genotypes
The distribution of genes encoding for resistance to aminoglycosides, tetracyclines and MLS was
highly correlated with to the MRSA clonal types (Table 8).
Table 8: Resistance genes and antimicrobial susceptibility of MRSA isolates from NH, Belgium 2005
PFGE typing No. of isolates
AME Tetracycline resistance genes
Methylase genes Resistance profile (> 50% of isolates)
Group Type ant(4’) tetM tetK ermA ermC
A A20 56 44 3 0 56 2 ERY, CLI, CIP, TOB
A21 74 68 2 2 1 19 CIP, TOB
Other 20 10 5 0 15 2
B B2 287 3 1 8 8 99 CIP
Other 9 0 0 0 1 1
C C10 39 37 0 0 39 2 ERY, CLI, CIP, TOB
Other 6 1 0 0 2 1
K K1 15 0 0 0 0 2 CIP
Other 11
I I1 12 11 0 12 0 0 CIP, TET, TOB
Other 10 10 0 10 7
G 11 7 7 7 0 7 0 ERY, CLI, CIP, TET, TOB
Other 5 4 5 0 5 0
L 1 10 1 0 0 1 5 ERY, CIP
Other 15 21
PFGE: Pulsed-field gel electrophoresis ERY: Erythromycin CLI: Clindamycin CIP: Ciprofloxacin TOB: Tobramycin TET: Tetracycline
V.2.7 Geographical dispersion of MRSA epidemic clones
B2-ST45-SCCmec IV isolates were widely disseminated into the whole country but were
predominant in the Northern part of the country. A20 and A21-ST8-SCCmec IV strains were
present mainly in the Southern and Western parts of the country. C10 ST225-SCCmec II strains
were recovered only from Liege Province. K1 and I1 -ST5-SCCmec IV and G11-ST5-SCCmec II
isolates were present in the Northern and Western part of the country. L1-ST22-SCCmec IV strains
were only isolated in Wallonia. The geographical dispersion of epidemic clones was observed with
a similar type distribution in hospitals and nursing homes of a given province, suggesting local
exchange of MRSA strains between these two care settings. Atypical strains, like C10-ST225-
SCCmec II and A20-ST8-SCCmec IV, were more frequent in some provinces bordering Germany
and France, where similar MRSA strains have been described, suggesting the possibility of cross-
border spread of epidemic MRSA strains.
Table 9 Number of isolates belonging to epidemic MRSA clones by provinces
Provinces B2-ST45-IV A20/A21-ST8-I C10-ST225-II K1/I1-ST5-IV G11-ST5-II L1-ST22-IV Antwerpen 48 4 2 11 0 0 Brussel/ Bruxelles 32 6 1 0 6 0
Brabant Wallon 1 0 0 0 5 0
Hainaut 16 33 2 4 0 0
Liège 19 15 31 0 0 4
Limburg 9 0 1 0 0 0
Luxembourg 0 4 0 0 0 2
Namur 12 16 1 0 0 5
Oost-Vlaanderen 68 10 1 4 0 0
Vlaams Brabant 36 6 0 0 2 0
West-Vlaanderen 43 35 0 6 0 0
V.3 PREVALENCE OF S. AUREUS CARRIAGE
The following analysis is based on the results by NH-level (n=60).
Complete microbiological results are available for all 60 participating NH, in total, 2958 residents
were screened and 50.7% of them carried S. aureus (min. 22%, max. 70.2%). This is similar to the
results in a healthy population where a 30 to 55% S. aureus carriage has been described7, 8.
Figure 2 represents the percentage of S. aureus carriage by participating NH. A study number
attributed at the beginning of the study represents each institution. Figure 2: Percentage of S. aureus carriers in participating NH (%)
59 14 24 41 37 60 36 3 53 29 1 7 13 2 58 22 25 8 39 48 34 33 5 11 57 26 44 9 32 23 21 47 28 45 56 43 38 52 10 12 19 42 50 35 31 40 55 6 17 27 49 51 30 4 46 18 54 15 16 20
participating NH
0
10
20
30
40
50
60
70
% S
. aur
eus
carr
iers
/NH
Median Q. 75Q. 25
V.4 PREVALENCE OF METHICILLIN RESISTANT S. AUREUS CARRIAGE
The weighted mean MRSA-prevalence (% MRSA carriers/screened residents) for Belgium was
19.02% [CI 95% 16.5-21.5]. None of the participating NH was free of MRSA-carriage. The lowest
prevalence rate by NH was 2%, the highest 42.9%. Figure 3 represents the MRSA-prevalence rate
by NH.
Figure 3: Percentage of MRSA-carriers in participating NH (%) 23 53 24 30 12 1 37 32 59 29 7 34 31 49 50 60 2 58 33 22 56 25 26 55 41 44 45 13 9 21 19 4 28 39 14 43 8 10 54 3 57 38 27 36 18 11 42 5 52 16 20 35 17 46 51 47 48 40 15 6
participating NH
0
10
20
30
40
50
% M
RSA
car
riers
/NH
Q. 25 Q. 75Median
V.4.1 Mean MRSA-prevalence rate by region
The mean weighted MRSA prevalence rate was similar in the Walloon region: 22.2% [CI 95% 17.2-
27.4] in the Flanders: 18.1% [CI 95% 15-21.3] and in the Brussels region: 17.2% [CI 95% 13.4-
21.0] (figure 4). These differences were not statistically significant [KW-H test: 4.03, 2df, p=0.13].
Figure 4: Prevalence of MRSA carriage (%) by region
010
2030
40M
RS
A c
arria
ge %
V la and eren Brussels W a llo nie
V.4.2 Mean MRSA-prevalence rate by sub-sample
In order to exclude the presence of a bias by refusing NH replacement, we calculated the MRSA-
prevalence rate in the different sub-samples. There was no significant difference (p=0.059)
between these sub-samples: in the 37 primary selected NH (Sub-sample 1) the weighted mean
prevalence rate was 18.1% [CI 95% 14.3-21.9]. This rate reached 19% [CI 95% 15.4-22.6] in the
reserve NH (n= 16 NH, sub-sample 2) who replaced the non-participating NH of the primary
selection and 23.1% [CI 95% 16.3-30] among sub-sample 3 NH (n=7).
V.4.3 Mean MRSA-prevalence rate by administrative status
In private NH the proportion of MRSA carriers (20.9%) was higher than in public NH (17.6%) but
this difference was not statistically significant (n.s.).
V.4.4 Mean MRSA-prevalence rate by NH-size
The median MRSA prevalence reached 22.5% in small NH (<75 beds, n=18) and decreased to
20.4% in medium NH (75-124 beds, n=26) and 17.2% in large NH (125+ beds, n= 16) (n.s.).
Figure 5: Prevalence of MRSA carriage (%) by NH-size
010
2030
40
% M
RSA
car
riers
/NH
< 75 beds (n=18) 75 - 124 beds (n=26) 125 beds + (n=16)
V.4.5 Mean MRSA-prevalence rate by proportion of MRS/RVT-beds in the NH
There was no association between the prevalence of MRSA carriage and the proportion of
MRS/RVT-beds in the NH (Pearsons r. = 0.100, p=0.44).
However, the proportion of MRSA beds in the NH could be a poor indicator and does not reflect the
true case mix (figure 6).
Figure 6: Prevalence of MRSA carriage (%) by proportion of high care beds (RVT/MRS) in the NH
V.4.6 Relation between MRSA-prevalence rate and S. aureus carriage in NH
As expected and illustrated by figure 7, there was a positive correlation between S. aureus.-
carriage and MRSA-carriage (Pearsons r: 0.46, p=0.0002) .
Figure 7: Relation between prevalence of MRSA carriage & S. aureus carriage in participating NH (%)
0 10 20 30 40 50 60 70Prevalence of SA (%)
0
10
20
30
40
50
MR
SA
pre
vale
nce
(%)
V.5 RESISTANCE PROPORTION OF S. AUREUS
The mean weighted resistance proportion (% MRSA/S. aureus) for all participating NH was 37.8%
[CI 95% 33.4-42.1]. The lowest resistance rate was 3.8%, the highest 75%. Figure 8 illustrates the
distribution of the resistance rate for each participating NH.
0
5
10
15
20
25
30
35
40
45
0 10 20 30 40 50 60 70 80 90 100
% MRS/RVT beds in the NH
Prev
alen
ce M
RSA
car
iers
(%)
.
Figure 8: Resistance proportion in participating NH (%)
23 53 30 12 241 32 49 31 50 37 34 56 7 2 33 58 55 29 22 45 26 44 4 25 60 9 54 19 28 21 18 43 10 13 20 16 27 39 38 8 57 42 41 52 46 35 11 59 5 3 51 15 17 36 40 47 48 6 14
participating NH
0
20
40
60
80
100
MR
SA/ S
tapy
loco
ccus
aur
eus
(%)
Q. 25 Q. 75Median
V.5.1 Resistance proportion by region
In the Walloon region, the mean weighted resistance proportion was higher (43.4%, CI 95%: 35.7-
51.1) than in the Flanders and Brussels region where it was 36.2% (CI 95% 30.4-41.9%) and
34.6% (CI 95% 27.5-41.7%), respectively (figure 9). These differences were not statistically
significant (p= 0.06).
Figure 9: Resistance proportion (%) by region
020
4060
80
% M
RSA
/ S.
aur
eus
Vlaanderen Brussels Wallonie
V.5.2 Resistance proportion by status
In private NH, the resistance proportion (40.4%) was not significantly higher than in public NH
(35.5%, p= 0.35).
V.5.3 Resistance proportion by NH size
There was no correlation between resistance proportion and size of the NH (figure 10).
Figure 10: S. aureus resistance proportion by NH-size
0
10
20
30
40
50
60
70
80
0 50 100 150 200 250 300
Number of beds in NH
S. a
. res
ista
nce
prop
ortio
n (%
)
V.5.4 Resistance proportion and prevalence of MRSA carriage
There was a linear relation (Pearson correlation coefficient: r=0,88, p<0.001) between these two
parameters: the prevalence of MRSA carriage was increasing with the resistance proportion in the
NH. There are some outliers who had a higher resistance proportion and a lower prevalence of
MRSA carriage (figure 11).
Figure 11: Relation between resistance proportion and prevalence of MRSA-carriage in participating NH (%)
0 10 20 30 40 50 60 70 80Resistance proportion (%)
0
10
20
30
40
50
MR
SA
pre
vale
nce
(%)
V.6 INSTITUTIONAL (STRUCTURAL AND FUNCTIONAL) CHARACTERISTICS AND DETERMINANTS OF MRSA-CARRIAGE
This part of the report explores the results based on the analysis of the institutional questionnaire
(n=60) completed partially by the co-ordinating physician (COP) and the responsible of the Nursing
department (ND).
V.6.1 Outbreaks and problematic pathogens
Outbreaks are frequent in NH’s. 22% (13/60) of the participating NH’s reported at least one or
more outbreaks during the last year. These NH declared a total number of 17 different outbreaks.
The most frequent diseases associated with outbreaks were gastro-enteritis (59%, 10/17) and
Clostridium difficile outbreaks (18%, 3/17). Only one outbreak was caused by MRSA.
Despite the low frequency of reported outbreaks with MRSA, 55% of the NH (33/60) considered
this pathogen as problematic in their institution. In these institutions, the mean MRSA prevalence
was 19%. In the NH reporting no problems with MRSA (13%, n= 8) the MRSA prevalence was
15% and 24% in NH who did not answer the question (32%, n=19) (n.s., p=0.03).
This suggests that NH not responding to the question probably underestimated the real situation.
One quarter of the respondents considered Gram negative bacteria as problematic such as E. coli ,
Pseudomonas, Proteus, Klebsiella, Enterobacter, etc.
Table 10: Problematic pathogens in the NH (n=60)
Problems No problems No answer TOTAL
N % n % n %
MRSA 33 55 8 13 19 32 100
Gram-negative bacteria 10 17 30 50 20 33 100
C. difficile 6 10 33 55 21 35 100
Other multiresistant bacteria than MRSA
1 2 38 63 21 35 100
TBC 1 2 38 63 21 35 100
The following sections of this report summarise the results of the analysis of institutional
determinants on the prevalence of MRSA-carriage. An exhaustive description of these variables
can be consulted in annexe.
V.6.2 Role of the co-ordinating physician
V.6.2.1 Development of care practices and hygiene protocols in the NH In the participating NH, the mean number of external, visiting general practitioners (GP) was 30/NH
(min 3. and max. 96). So, co-ordination of these activities is very important in order to standardise
the approach of problems having an impact on the public health aspects of residents living in a
community.
The co-ordinating physician is legally responsible (Royal Decree from 21 September 2004) for the
coordination of medical care related to potentially dangerous health conditions for residents and/or
staff: ex. prevention of infectious disease transmission and elaboration of hygiene policies in the
facility.
V.6.2.2 Development of hygiene practices Development of hygiene practices and training is an important mission for the COP: 85%
considered this as a part of their job. 83% provided training on hygiene to the nursing staff.
Efficient communication between the GPs and the COP about infectious matters with a possible
impact on the health of the other NH-residents is important. But in fact, such contacts were most of
the time (95%) only sporadic and half (48%) of the COPs were planning regular meetings with the
GPs. It was not surprising that only 67% of the COP develop a collective approach with the GPs.
However, COP’s supervision of the residents’ medical records was associated with a lower but not
significant mean MRSA-prevalence (17%) than in NH without this supervision (22%) (p=0.03). Table 11: Mean MRSA-prevalence and aspects about the co-ordinating role of the COP in the NH
Co-ordinating activities of the COP: YES NO Rate
% MRSA%
% MRSA %
ratio
Determine admission policy 10 25 90 19 0.76
Plan meetings with GPs 48 22 52 18 0.81
Development of hygiene policy in NH 85 20 15 19 0.95
Training Nursing staff about hygiene 83 20 17 20 1
Training GPs 81 20 19 20 1
Sporadic contacts with GPs 95 20 5 22 1.1
Develop collective approach GPs 67 20 33 19 0.95.
Organise medical guard duty 28 19 72 20 1.05
Supervision of medical records 43 17 57 22 1.29
V.6.2.3 Development of care protocols Specific protocols about hygiene and management of residents with infectious diseases should be
available in every NH: facilities having a ‘protocol for isolation of contagious residents’ available
(54%) had a lower, not significant MRSA-prevalence (17%) than NH without such a protocol.
(p=0.04).
A written protocol for care management of ‘MRSA-carriers’ was present in 80% of the NH, but this
was not associated with a difference in MRSA-prevalence.
Another important task of the COP consists in the elaboration of specific care protocols (ex.:
wound-care, catheter-care, aerosol-therapy, etc..). In fact, 67% of the COP’s accomplish this
assignment.
The availability of specific written care protocols and procedures is important for continuity and
standardisation of care and helps to prevent nosocomial infections and transmission of infectious
diseases in health-care institutions. Nevertheless, in this study, the presence of such written
protocols was not associated with a significantly lower MRSA-prevalence in the NH.
Very few (14%) NH had a written protocol for the management of residents with a urinary catheter.
Such catheters are probably rare (1.5% in a former study in 2000), but urinary tract infections
belong to the most frequent infections in NH.
Table 12: Availability of care-protocols in the participating NH
NH has a protocol for: YES NO Rate
% MRSA%
% MRSA %
ratio
Urinary catheter 14 22 86 20 0.90
Aerosol therapy 30 22 70 19 0.86
Wound care 76 20 24 20 1
Hygiene 47 20 53 19 0.90
Care management MRSA-carriers 80 19 20 20 1.05
Gastrostomy 25 18 75 20 1.11
Isolation of contagious disease 54 17 46 22 1.29
V.6.2.4 Antibiotic policy in the NH Standardisation and rationalisation of AB-use is essential for a good medical practice. This is an
important aspect for the COP-work. He is responsible for the development and use of the
pharmaceutical formulary in the facility.
Nation-wide, a therapeutic formulary, specially designed for NH (RVT-formularium, project
farmaka, leidraad bij het rationeel voorschrijven van geneesmiddelen bij ouderen.) has been
distributed in all NH, but only a limited number of facilities was using this. In each NH the COP and
the GPs should develop their own internal version. Actually, 58% of the COP’s considered this as
one of their tasks.
In fact, only 29% of the participating NH had a therapeutic formulary and were using this and the
remaining 71% had no own formulary or did not use it. NH with a formulary had a lower but not
statistically significant MRSA prevalence (15%) compared to those without (22%) (n.s., p=0.02).
Utilisation of a formulary was also associated with a lower mean resistance rate (27%) compared
to NH who don’t use this tool (44%) (n.s., p=0.03).
One third (32%) of the COP’s declared having agreements with the external GPs about AB-use in
the NH and very few (3%) of them report having written guidelines for AB-use developed in the
institution.
Limited AB-choice for prescription was present in only 7% of the NH. In these facilities, the MRSA-
prevalence was lower (16%) than in NH without limitation (20%) (n.s.).
Only in 18% of the NH, specific, practical agreements between GPs about AB-prescription exist:
ex. restriction of quinolones, limited choice (only 1 molecule/AB-class), good practice (GLEM),
restricted mupirocine-use, compliance with AB-formulary.
Sometimes, GPs consider the COP interventions as a transgression of their therapeutic liberty.
The position of the COP is very difficult and differs from those in acute care hospitals where
hygienists participate at the antibiotic policy commission and are active and efficient. In NH there
are no such committees, the COP has no support and it is difficult to him to accomplish this
mission.
Some other bad AB-practices were observed in this study: In two NH (3%), nurses still could use
AB-ointments without prescription. In these facilities the mean MRSA-prevalence was higher (29%)
than in those where the use of AB-ointments was regulated (19%, n.s.).
Despite repeated information, 71% of the NH still used mupirocine for decolonisation of MRSA-
positive wounds. In these NH the MRSA-prevalence was higher (21%) than in facilities who don’t
(15%) (n.s., p=0.02).
Table 13: AB-policy in the participating NH
AB- policy in the NH YES NO Rate
% MRSA%
% MRSA %
ratio
Nurses use AB-ointments without prescription Source*: ND
4 29 96 20 0.68
COP 3 29 97 20 0.68
We use AB-ointments (other than mupirocine) for decolonisation of MRSA+ wounds
ND
18 18 82 20 1.11
COP 27 21 73 19 0.90
We use mupirocine for decolonisation of MRSA+ wounds
ND
71 21 29 15 0.71
COP 73 19 27 21 1.10
The use of AB-ointments is regulated by formulary
ND
7 19 93 20 1.05
COP 25 16 75 21 1.31
The COP considers making AB-agreements with GP as his task
32 22 68 19 0.86
Specific AB-prescription agreements are made 18 22 82 19 0.86
Written guidelines for AB-use do exist 13 19 87 20 1.05
There is a limited AB-choice for prescription 7 16 93 20 1.25
The therapeutic formulary is available and used in the NH (ND)
29 15 71 22 1.46
*ND=head nurse; COP=Coordinating Physician
V.6.3 Collaboration and information flow between NH and acute care hospitals
V.6.3.1 Collaboration with experts In NH, there is less expertise about management of MRSA and other multi-resistant micro-
organisms compared to acute care hospitals. None of the 60 NH disposes of an indoor nurse or
physician specialised in hospital hygiene. In the absence of such specific expertise, NH should be
able to call external experts.
61% of the respondents had a partnership with acute care hospitals, allowing assistance from
hospital hygiene experts. Collaboration between the hospital hygiene team from the acute care
hospital and the COP’s is very important and should be enhanced and generalised. Both type of
institutions share a same problem.
In epidemic situations, 69% of the NH can took advice from the regional platform for hospital
hygiene. NH should be better informed about the assistance they could obtain from the regional
platform for hospital hygiene. The COP should be integrated in a sub-working group of the regional
platform in order to share the available expertise. Even if the NH situation is specific and need an
adapted approach, the knowledge of hospital hygiene workers is certainly very useful.
Table 14: Collaboration with experts
YES NO Rate
% MRSA%
% MRSA %
ratio
Advice from regional platform 69 21 31 18 0.85
Partnership with acute care hospital 61 20 39 19 0.95
Nurse/doctor in hospital hygiene 0 0 59 19 0
V.6.3.2 Information flow between acute hospitals and NH A good communication and transparency (transfer information flow) between acute care hospitals
and NH is necessary. All 60 participating NH declared receiving a transfer letter when one of their
residents leave the acute care hospital and return to the NH: 68% always receive this letter, 32% of
the NH only sometimes. This letter should inform the NH about MRSA-carriage of the resident.
An obsolete practice consists in the requirement of a certificate confirming the absence of an
infectious disease when admitting residents to the NH (20%). 90% of the participants were
considering residents who became MRSA-carrier since their hospitalisation as contagious.
In the absence of this certificate, NH sometimes refuses readmission of residents who became
MRSA-carrier during hospitalisation.
In fact, none of the responders answered that they refuse readmission: 72% readmit the resident
unconditionally, 23% only after decontamination, 6% if the resident was not infected.
Table 15: Information flow between the acute care hospital and the NH
YES NO Rate
% MRSA%
% MRSA %
ratio
Always receiving transfer letter 68 19 32 22 1.15
Readmission of MRSA-carriers unconditionally
72 21 28 17 0.80
V.6.4 Availability of hand hygiene products and materials in NH
V.6.4.1 Availability of hand hygiene products Hand hygiene is the cornerstone of infection prevention. The idea that these facilities should avoid
hospital practices lasted long time. The resident is living in this facility, replacing his home
situation. There is rather a ‘living culture’ than a ‘care culture’. This could explain that the hand
hygiene techniques of acute care hospitals are not well established in the NH.
A bar of solid soap is absolutely unacceptable for hand hygiene of the nursing staff, however,
2 NH has still this kind of soap. The MRSA-prevalence reaches 25% in these institutions and only
20% in NH without a bar of soap (n.s.).
All hand hygiene products present in hospitals were available in NH, 84% of these facilities have
alcoholic solutions. Liquid soap was available in 98%, and antiseptic soap in 75% of the NH. The
mean MRSA-prevalence was not significantly different according to the type of products available.
In 50% of the NH, both, antiseptic and alcoholic solutions were available. In 17% of the institutions
only antiseptic solutions were present and in 33% only alcoholic gels or lotions. Differences in
MRSA-prevalence between these 3 subgroups were not statistically significant.
Table 16: Availability of hand hygiene products in the nursing homes
Availability of hand hygiene YES NO p-value
Products in the NH % MRSA%
% MRSA %
Bar of solid soap 4 25 96 20 n.s.
Liquid soap 98 20 2 13 n.s.
Alcoholic gel or lotion 84 20 16 18 n.s.
Antiseptic solution 75 20 25 20 n.s.
In order to facilitate hand hygiene, it is important that the products are available on many locations.
They were available near the sink reserved for the nursing staff (100%), on the wound dressing
trolley (88%), in the office (79%), in the resident room (38%), near the sink reserved to the resident
(30%) and in the pocket of the apron (30%). Some NH also provide these products in the lavatories
for the nursing staff, utility, bathrooms, all water taps, central places, care room, kitchen, in front of
the room doors, doctors office, dressing room, physiotherapy room, living room, etc.
In NH, cognitively impaired residents could drink alcoholic solutions from dispensers in unguarded
collective places, or be injured in case of eye contact. Also because of fire safety reasons large
stocks of alcoholic solutions should be avoided. The use of pocket dispensers with alcoholic
solutions seems to be a good solution in these cases. But this solution is expensive and NH cannot
always support this financial effort. Financial support and hand hygiene campaigns are necessary
to optimise hand hygiene practices in these facilities.
V.6.4.2 Type of available towels Ninety percent of the participating NH used either a single use towel or an electric hand dryer. The
remaining 10% used linen towels for collective or for single use (roller towel).
This last system was associated with a higher (n.s.) MRSA-prevalence (26%) and was in fact not a
‘user-friendly’ system for the nursing staff, because often defective (p = 0.054).
Drying systems and towels for single use were not associated with significant differences in MRSA-
prevalence compared to systems for collective use.
Table 17: Type of towels available in the participating NH
Availability of towels YES NO Rate
% MRSA%
% MRSA %
ratio
Linen roller towel for single use 12 26 88 19 0.73
Linen towel for collective use 7 21 93 20 0.95
Towel for single use 90 19 10 22 1.15
Electric hand dryer 5 17 95 20 1.17
V.6.4.3 Availability of gloves and indications Wearing gloves avoids colonisation of the hands with transient flora acquired during care contacts
with the residents. An intelligent use of gloves should be encouraged in NH. There is always a risk
of misuse of gloves (bad indications, not replaced between two residents, no hand hygiene after
removal of gloves) procuring a false safety feeling.
In all participating NH, gloves were used. Among them, 83% wear gloves everywhere and the
remaining 17% did used gloves, but not everywhere. In the latter category, MRSA-prevalence was
lower (14%) than in those who used gloves everywhere (21%) (n.s., p=0.02).
In 16% of the NH, gloves were used for care activities to all residents, they had a not significantly
lower MRSA-prevalence (16%) than NH who were not (21%).
In all NH, gloves were used when taking care of a contagious resident. They were never used for
the distribution of medicines.
15% of the NH did not use gloves for care of residents with faecal incontinence. The mean MRSA-
prevalence was higher in these NH (27%) compared to NH who do use gloves for residents with
faecal incontinence (18%) (n.s., p=0.03).
Still 49% of the NH were not using gloves when taking care of residents with urinary incontinence,
and 33% in the presence of a urinary catheter.
Surprisingly, 34% used gloves for the care of residents with flu. In these facilities (n=19) the
MRSA-prevalence was significantly lower (15%) than in NH (n=37) where this precaution was not
taken (22%) (KW-H; 7.44, p=0.006) (OR: 0.14 [CI95% 0.03-0.52] p=0.003).
Table 18: Indications for glove use in the participating NH
Use gloves : YES NO Rate
% MRSA%
% MRSA %
Ratio
Feeding dependent residents 3 24 97 20 0.83
Disinfection of material 62 20 38 20 1
Wounds 77 19 23 22 1.15
Urinary incontinence 51 19 49 20 1.05
Urinary catheter 67 19 33 20 1.05
Faecal incontinence 85 18 15 27 1.50
Gastrostomy 54 18 46 21 1.16
Flu 34 15 66 22 1.46
Contagious illness 100 0
Distribution of medicines 0 100 .
V.6.4.4 Hand hygiene after removing gloves The national guidelines for the prevention of MRSA transmission in NH recommend disinfection
with an alcoholic solution after removing gloves.
In the participating NH there seems to be no standard technique after removing gloves: 7 different
scenario’s exist. 8% of the NH use none of those techniques.
Differences in MRSA-prevalence were not statistically significant for these different techniques
(soap, antiseptic solution, alcoholic solution).
In the NH there is a need for standardisation of hand hygiene techniques.
Table 19: Type of hand hygiene technique after removing gloves
Type of hand hygiene technique YES NO Rate
after removing gloves % MRSA%
% MRSA %
ratio
Disinfecting with antiseptic solution 65 21 35 18 0.85
Use of alcoholic solution 45 21 55 18 0.85
Hand washing with water and soap 64 18 36 23 1.27
None of these techniques 8 17 92 20 1.17
V.6.5 MRSA screening, decontamination and surveillance
V.6.5.1 Screening of residents after discharge of the hospital Except in epidemic situations, the national guidelines only recommend screening among residents
presenting risk factors and not to perform routine screening.
In the present study, residents readmitted to the NH after hospitalisation were screened in 44%
(26/59) of the responding NH: in 9 NH, always and in 17 NH, only in some conditions (when risk
factors were present, presence of catheters or wounds, multiple organ failure, if patient was
previously infected with MRSA, etc....) . 56% of the responders never take screening samples after
discharge from the hospital. The mean prevalence of MRSA in these subgroups was not
significantly different. Table 20: Screening of residents in the participating NH
Screening residents after discharge Nursing Homes MRSA
of the hospital N % %
Always 9 15 15
In some conditions 17 29 19
Never 33 56 21
V.6.5.2 Screening of the nursing staff Screening of the nursing staff was only indicated in epidemic situations. In this study, 22% of the
institutions were taking screening samples from the nursing staff: 3% routinely and 18% in some
circumstances (known carrier, prevalence study, return to work after illness). 78% never takes
screening samples from the nursing staff. Also, here no significant differences in MRSA-prevalence
were observed between subgroups.
Table 21: Screening of nursing staff in the participating NH
Screening of the nursing staff Nursing Homes MRSA
n % %
Routinely 2 3 16
In some conditions/units 11 18 19
Never 47 78 20
V.6.5.3 Decontamination of resident-carriers Screening of residents doesn’t make sense if MRSA-positive residents are not decontaminated
afterwards. 10% of the participants never decontaminates MRSA-carriers and 90% does (67%
always and 24% in some cases). Those who never decontaminate have a not significant, lower
prevalence rate (14%) compared to those who do it (21%).
Table 22: Decontamination of resident-carriers
Decontamination of carriers Nursing Homes MRSA
n % %
Always 34 67 20
In some conditions/units 12 24 22
Never 5 10 14
Forty-three percent of the respondents were using appropriate decontamination scheme.
Unfortunately, in 4 NH antibiotics were still used, alone or in combination with classic
decontamination. Incomplete decontamination schemes without antiseptic baths were frequent.
There were no statistically significant differences in MRSA-prevalence between these subgroups.
There is a need for compliance with standardised decontamination schemes and the use of
antibiotics should be banished, as well as the use of mupirocine for decontamination of colonised
wounds.
Table 23: Schemes used for decontamination of resident-carriers (n=40)
Schemes used for decontamination Nursing Homes MRSA
n % %
Nasal decontamination only
(mupirocine, chloorhexidine, fucidine)
11 28 18
Nasal decontamination and antiseptic bath 17 43 22
Non-conform decontamination scheme
(AB-use)
4 10 21
Other answer 8 20 19
After decontamination, a control sample has to be taken in order to verify the MRSA-status of the
resident. In this study only 3% never took a control sample.
V.6.5.4 Surveillance The Royal Decree specifies that a register of infections must be kept, but in order to supervise the
MRSA-situation in the NH MRSA-carriers should also be included in this register. The use of
different definitions and inclusion criteria in these facilities represents a major problem: data were
not standardised and thus no comparable between institutions. Only 64% performed MRSA
surveillance in the institution. Time and efforts should be given for the elaboration of a nation-wide,
standardised surveillance system for infections in NH allowing benchmarking and following-up of
the problem.
Table 24: Identification of the reservoir in the participating NH
YES NO Rate
% MRSA%
% MRSA %
ratio
Decontamination of MRSA-carriers 90 21 10 14 0.66
Control sampling after decontamination 97 20 3 14 0.7
Screening of the nursing staff 22 19 78 20 1.05
Keeping register of MRSA-residents 64 19 36 21 1.10
Screening residents at (re)admission 44 18 56 22 1.22
V.6.6 Additional measures for MRSA-carriers
V.6.6.1 MRSA-prevalence and proportion of private rooms in the NH During the last decade, NH increased the proportion of private rooms in their institutions.
In this study population, 83% of the rooms were private (min. 7%, max. 100%). There was no
difference in MRSA-prevalence between NH with a lower proportion of private rooms compared to
NH with a higher proportion.
Table 25: MRSA prevalence and proportion of private rooms in the NH (n=60)
Proportion of private rooms in the NH Nursing Homes MRSA
n % %
< 83% private rooms 23 38 20
83% and more private rooms 37 62 20
V.6.6.2 Isolation and cohorting of MRSA-carriers The national guidelines propose isolation (entry and exit restriction in single room) during
decolonisation only in specific situations, except in an epidemic context where isolation is
generalised to all MRSA-carriers. If case of insufficient private rooms, cohorting is also a
reasonable solution.
MRSA-carriers were isolated in a private room by 78% of the responders: among them, 18 NH
declared they always isolate and 27 only in some circumstances. 22% never isolated MRSA-
carriers. In these institutions the mean MRSA-prevalence was not significantly higher (25%) than in
NH who do isolate (19%).
The Interpretation of these answers is hazardous as the concept ‘isolation’ could be interpreted
differently. The concept ‘isolation’ goes beyond just ‘staying in a single room’.
46% of the responders never cohorted MRSA-carriers, 14% always did and 40% only in some
cases.
Table 26: Isolation of MRSA-carriers (n=58)
Isolation of MRSA-carriers Nursing Homes MRSA
n % %
Always 18 31 19
In some conditions 27 47 19
Never 13 22 25 Nine percent of the participants did not isolate and/or cohort residents, MRSA-carriers. The MRSA-
prevalence in these facilities was 24% compared to 19% in NH isolating and/or cohorting (n.s.). Table 27: Isolation and/or cohorting of MRSA-carriers (n=59)
Isolation and/or cohorting Nursing Homes of MRSA-carriers n % MRSA
%
Never 5 9 19
Always 54 91 24
V.6.6.3 Cohort nursing of MRSA-carriers Cohort nursing (limiting the number of care-givers, having always the same person taking care of
the MRSA-carriers) could reduce transmission of MRSA in NH. In this study, 32% of NH’s used this
system but the MRSA-prevalence was not significantly lower (18%) than in NH who did not use
cohort nursing (21%).
Table 28: Room arrangements
Room arrangements & MRSA carriers
YES NO Rate
% MRSA%
% MRSA %
Ratio
Cohorting of MRSA-carriers 54 20 46 20 1
Isolation in private room 78 19 22 25 1.31
Cohort nursing 32 18 68 21 1.16
V.6.6.4 Additional measures According to the guidelines; gloves, masks and aprons should be used by residents, MRSA-
carriers and in case of care-contacts (wound-care or body-care).
98% of the participants used gloves: 86% always and 12% in some conditions. Only one facility
answered never using gloves. 90% used an apron (58% always, 32% in some cases).
86% of the participants used a mask (always: 25%, in some cases: 61%). In this study, no
differences in prevalence of MRSA-carriage were observed in NH who used these additional
precautions.
Reinforced room cleaning (more often, more in detail, with disinfectants) is indicated in front of
MRSA-carriers. Only 8% did not reinforce room cleaning (more often, more in detail, with
disinfectans).
Table 29: Additional precautions in case of MRSA-carriage in the participating NH
If MRSA-carrier …. YES NO rate
% MRSA%
% MRSA %
ratio
Use gloves 98 20 2 3 0.15
Use mask 86 20 14 18 0.90
Use apron 90 20 10 20 1
Reinforced cleaning 92 20 8 18 0.90
V.6.7 Manpower and MRSA -prevalence
V.6.7.1 MRSA-prevalence and number of General practitioners/100 residents Data was available for 49 NH. The mean number of visiting GPs/100 residents was 29.9 (min. 2.7
residents and max 62.2).
In the institutional analysis, there was a no significant relation at the 0.01 level between the
proportion of GPs/100 residents and the MRSA prevalence in the NH: in NHs with a higher GP-
ratio (30 GPs +), the mean MRSA-prevalence was 24% and 18% in NH with a lower ratio (< 30
GPs) (n.s., p=0.03). In the multilevel analysis however, this variable appeared to be an important
determinant (see below).
V.6.7.2 MRSA-prevalence and number of qualified Nurses
V.6.7.2.1 Number of qualified Nurses/100 residents
Data were available for 50 NH. The mean number of qualified nurses/100 residents reached 15.6
(min 3.8, max. 25.8) .
There was no relationship between prevalence of MRSA-carriage and the number of nurses/100
residents (mean MRSA-prevalence: 19% in NH with small nurse ratio and 20% in NH with large
nurse-ratio).
V.6.7.2.2 Number of FTE qualified Nurses/100 residents
Data were available for 53 NH. The mean number of fulltime equivalent qualified nurses (FTE) /100
beds reached 12 (min. 3.6, max. 19).
There was no relationship between prevalence of MRSA-carriage and the number of FTE
nurses/100 residents (mean MRSA-prevalence: 18% in NH with small nurse ratio and 22% in NH
with large nurse-ratio).
V.6.7.3 MRSA-prevalence and number of nursing aids/100 residents Data were available for 53 NH. The mean number of nursing aids (FTE)/100 beds reached 17.4
(min. 6.7, max. 26.79).
There was no relationship between the prevalence of MRSA-carriage and the number of FTE
nursing aids/100 residents (mean MRSA-prevalence: 20% in NH with small ratio and 21% in NH
with large ratio).
V.6.7.4 MRSA-prevalence and number of non-qualified personnel/100 residents Data were available for only 14 NH. The mean number of non-qualified persons (FTE)/100 beds
reached 3.8 (min. 0.5, max. 18.5).
There was no relationship between prevalence of MRSA-carriage and the number of FTE non-
qualified persons/100 residents (mean MRSA-prevalence: 24% in NH with small ratio and 21% in
NH with large ratio).
Table 30: Number of GPs and nursing staff members in the NH
YES NO Rate
% MRSA% % MRSA % Ratio
< 30 GPs/100 residents 59 19 41 24 1.26
< 15.7 nurses/100 residents 54 19 46 20 1.05
< 12 FTE nurses/100 residents 47 18 53 22 1.22
< 17.4 FTE nursing aids/100 57 20 43 21 1.05
< 3.6 FTE non qualified persons/100 57 25 43 21 0.84
V.7 RESIDENT CHARACTERISTICS
V.7.1 Age and sex distribution
Complete data (patient data and microbiological results) were available for 2935 of 2965 patients.
The median age of the study population was 84 years (men: 82 years, women: 85 years). The age
percentile distribution is given in table 31. The sex ratio F:M was 3.7:1 (table 32).
Table 31. Age distribution of nursing home residents by region
N
NH N
patients p10 p25 p50
Median p75 p90 Vlaanderen 36 1716 75 80 85 90 93 Brussels 6 276 72 79 84.5 89 93 Wallonie 18 896 69 78 83 89 93 Belgium 60 2935 74 79 84 90 93
Table 32. Sex distribution of nursing home residents by region
N
patients M %
F %
Median age M
Median age F
Vlaanderen 1716 21.1 78.9 83 85 Brussels 276 25.8 74.2 83 85 Wallonie 896 20.7 79.3 79 84 Belgium 2935 21.4 78.6 82 85
V.7.2 Length of stay, number of beds and level of care
The median length of stay in the nursing home until the date of the survey was 29 months (2.4
years). As shown in table 33, 25% of the residents lived 5 years (60 months) or more in the nursing
home.
Table 33. Length of stay (in months) in the nursing home at the time of the survey
p10 p25 Median p75 p90 Vlaanderen 4 13 30 62 102 Brussels 3 10 26 55 81 Wallonie 4 12 30 59 103 Belgium 4 12 29 60 100
The mean percentage of single rooms in the nursing home was 74%, varying from 53.4% in
Brussels to 81.8% in Vlaanderen (p<0.001, see detailed tables in annexe).
The overall percentage of residents with the highest level of care (health insurance category CD)
was 26.7%, and varied from 0% to 60% according to the nursing home.
Logically, this percentage was correlated to the percentage of RVT/MRS-beds in the institution,
although not as strong as expected (Pearson’s correlation coefficient 0.45, p<0.001).
V.7.3 Antibiotic use
For 29.6 % of the patients an antibiotic was reported in the 3 months prior to the survey date. The
most frequently used antibiotics were amoxi/clav followed by fluoroquinolones, other penicillins
(aminopenicillins and small spectrum BL-resistant penicillins), cephalosporins, macrolides,
tetracyclines and cotrimoxazole (figure 12, details by molecule/class and by region in annexe).
Figure 12. Distribution of antibiotics used in the 3 months prior to the survey
0% 5% 10% 15% 20% 25% 30%
Linco/Clinda
CTMX
Tetracyclines
Macrolides
Cephalosporins
Penicillins
Fluoroquinolones
Penicillins + BLinhibitor
V.7.4 Previously known MRSA carriage
Of 587 MRSA positive residents, only 10% were known by the institution to either having been a
carrier in the past (n=40) or to be currently colonized (n=17) (table 34). Moreover, 70.6% of the
reportedly “known” previous carriers and 45.2% of current carriers were MRSA negative at the time
of the survey.
Table 34. Two by two table of MRSA carriage as a function of MRSA status reported by the institution
MRSA study results Known MRSA carrier? - + Total No MRSA/unknown 2238 530 2768 80.85 19.15 100 95.32 90.29 94.3 Previous MRSA 96 40 136 70.59 29.41 100 4.09 6.81 4.63 Current MRSA 14 17 31 45.16 54.84 100 0.6 2.90 1.06 Total 2348 587 2935 80 20 100 100 100 100
V.8 DETERMINANTS OF MRSA CARRIAGE AT THE RESIDENT LEVEL
V.8.1 Univariate analysis
The results of univariate risk factor analysis are given in annexe for the entire study population and
by region.
In univariate analysis, MRSA carriage was associated with age (more than 70 years vs <70)
(p=0.013), length of stay in the nursing home (less than 2 years) (p=0.006), patient mobility
(p<0.001), urinary incontinence (p<0.001), disorientation in time (p=0.005) and space (p=0.006),
health insurance category (p<0.001), decubitus (p<0.001), surgical and other wounds (p<0.001),
having received systemic antibiotics in the 3 months preceding the survey (p<0.001),
hospitalization in the year preceding the survey (p<0.001), known MRSA carriage (previous
p=0.004; current p<0.001), and Charlson co-morbidity index (p=0.007). Results by antibiotic class
or molecule and by disease (components of Charlson’s index) are given in the tables. In general,
antibiotics for which MRSA strains are co-resistant tended to be positively associated (e.g.
amoxiclav and fluoroquinolones) while antibiotics for which MRSA strains are mostly sensitive (e.g.
cotrimoxazole and tertracyclines) tended to be negatively associated (although not significantly
given the limited use of the latter).
V.8.2 Multiple logistic regression
Since many of the variables significant in univariate analysis are correlated with each other, only
previous hospitalisation, current known MRSA carriage, previous antibiotic use (amoxiclav and
fluoroquinolones), impaired mobility, health insurance category>O and presence of any wound or
ulcer remained significantly associated at the p<0.01 level in multiple logistic regression (random
effects with correction for the nursing home level).
V.9 MULTILEVEL ANALYSIS OF RESIDENT AND INSTITUTIONAL DETERMINANTS OF MRSA CARRIAGE
In order to assess the effect of institutional variables taking into account the patient risk profile of
each institution, institutional variables were fitted in a multilevel model including all significant
patient variables from the multivariate analysis. Because of the high number of variables, variables
were only kept in the model if p-values were lower than 0.01.
V.9.1 Ratio of General Practitioners (GPs) in the nursing home/number of beds
The number of GPs in the nursing home depended strongly on the total number of beds in the
institution. It was further positively related to several activities of the coordinating physician (CP):
the more GPs in the nursing home, the more likely the CP was involved in organizing meetings
with the GPs and with issuing written guidelines for antibiotic use, but the less likely the CP
reported to have an agreement on rational AB use and the less likely he was to supervise medical
records. For the multilevel analysis, missing data on the number of GPs in 13 nursing homes were
substituted based on a prediction by these 5 variables. Therefore, this analysis should be repeated
with completed data and needs to be interpreted with caution.
The mean GP to bed ratio after substitution was 27 GPs per 100 residents, or 1 GP per 3.65 beds.
The adjusted OR for being MRSA positive when the GP ratio was 1 per 4 beds or higher was 1.57
(1.15-2.15, p=0.005) . The effect of a high GP ratio however depended on the intensity of MRSA
control activities in the institution (see below, figure 13).
V.9.2 MRSA control index (MCi)
A score was constructed for following 6 variables: screening at admission from the hospital,
isolation (or placement in a single room) of MRSA patients, cohort nursing of MRSA patients and
wearing gloves, masks and an apron for care of MRSA patients. Each of these items was scored 0
if never done or if data were missing, 1 for sometimes and 2 for “always done”, resulting in a score
from 0 to 12 with a median of 7 (p10 = 3; p90 = 10).
As mentioned above, a statistical interaction was observed between the effect of the MRSA control
index and the GP to bed ratio: in nursing homes with a high GP to bed ratio, a high MRSA control
index was protective for MRSA carriage, while in nursing homes with a low GP to bed ratio, there
was no effect (p interaction < 0.001, see figure 13).
Figure 13. Effect of reported MRSA control activities on MRSA prevalence in the institution as a function of the GP to bed ratio
0%
5%
10%
15%
20%
25%
30%
<1GP/4 beds,MRSA control
index<8
<1GP/4 beds,MRSA control
index>=8
>=1GP/4 beds,MRSA control
index<8
>=1GP/4 beds,MRSA control
index>=8
MRS
A ca
rria
ge %
A possible explanation for this observation is based on the fact that the MRSA control measures
can both influence MRSA prevalence as well as be the consequence of a MRSA problem. In
institutions with a smaller number of GPs, the organisation of an infection control strategy is likely
to be easier for the coordinating physician, resulting in an earlier implementation of measures
when a MRSA problem emerges. So in these institutions, what we measure in our study is more a
mixture of “chicken and eggs”, i.e. the effect of MRSA control on MRSA transmission and
enhanced MRSA control measures as a consequence of MRSA problems that submerged during
recent years. The combination of these two opposite “associations” is likely to result in an absence
of a measurable difference.
In institutions with a large number of GPs, the implementation of infection control measures is likely
to be (or have been) delayed because compliance of each individual physician must be obtained
and coordinated. The collaboration of the GP is indeed primordial not only because of his or her
role in MRSA transmission and antibiotic prescribing, but also because of the GP’s influence on
nursing care and the implementation of infection control procedures for “his or her patients”. The
delay in strengthening MRSA control in some institutions has probably resulted in higher
prevalence rates at the time of the survey.
V.9.3 Other variables and multilevel model
Other institutional variables associated at the p<0.01 level in the multilevel model were the lack of
knowledge about the situation of MRSA in the institution and the fact that there is no therapeutic
formularium or that it is never used, as declared by the nurses. Two variables with significance
levels below 0.01 were not kept in the model: the fact that aerosol therapy is given by other
personnel than qualified nurses (higher risk) and the wearing of gloves for patients with flu
(protective factor). The presence of infection control or other relevant guidelines, and other
variables such as the reported availability of alcohol-based hand hygiene products were not
associated with MRSA carriage.
Table 35. Multilevel model for institutional and resident risk factors of MRSA carriage in 60 Belgian nursing homes, n=2935, January-September 2005
Adj OR (95% CI) p value
Previous hospital admission 1.31 (1.07 - 1.61) 0.009
Known MRSA carrier
No/unknown 1.00 -
Previous MRSA 1.33 (0.87 - 2.02) 0.183
Current MRSA 3.23 (1.49 - 7.01) 0.003
Antibiotic use in last 3m
Fluoroquinolones 1.59 (1.17 - 2.17) 0.003
Peni+enz.inh 1.59 (1.19 - 2.12) 0.002
Impaired mobility 1.41 (1.14 - 1.74) 0.002
Riziv > 0 1.63 (1.19 - 2.23) 0.003
Presence of wound/ulcer 1.57 (1.18 - 2.09) 0.002
N of GPs in NH and MRSA Control index (MCi)
<1GP/4beds, MCi <8 1.00 -
<1GP/4beds, MCi ≥8 1.30 (0.86 - 1.96) 0.209
≥1GP/4beds, MCi <8 2.03 (1.51 - 2.73) <0.001
≥1GP/4beds, MCi ≥8 1.03 (0.69 - 1.55) 0.879
MRSA situation unknown 1.51 (1.15 - 1.96) 0.003
No therapeutic formularium or never used 1.45 (1.11 - 1.90) 0.006
V.10 DETERMINANTS OF EPIDEMICITY
An epidemicity index was calculated for each nursing home taking into account the clustering of
MRSA genotypes and the prevalence of MRSA in the nursing home. It reflects the percentage
prevalence of MRSA carriage with similar clones in the nursing home. The relationship between
the epidemicity index and the prevalence rate is shown in figure 14. In nursing homes with 100%
identical PFGE type, the epidemicity index equals the MRSA prevalence (14 nursing home dots
that lie on the bisector line in the figure). As the diversity of clones increases, the dots on the graph
move further away of this line.
Figure 14. Relationship between the epidemicity index and the percentage of MRSA carriage
010
2030
40E
pide
mic
ity in
dex
0 10 20 30 40MRSA prevalence %
Other variables significantly associated with the epidemicity index are given in table 36.
Table 36: Variables significantly associated with the epidemicity index, institutional analysis (n=60)
Epidemicity index Variable Category N of nursing homes
Mean Median p-value (linear regression, log trans.)
MRSA prevalence < 20% 29 5.4 4 <0.001 ≥ 20% 31 12.7 10 MRSA resistance % < 40% 31 6.1 5 0.001 ≥ 40% 29 12.5 9 Cohort nursing No 41 10.6 9 0.004 Yes 19 6.2 4 GP to bed ratio <1GP/4 beds 28 6.5 5 0.033 ≥1GP/4 beds 32 11.5 9
No 37 6.6 5 <0.001 ≥1GP/4 beds + MRSA control index <8
Yes 23 13.3 12
The epidemicity index was higher in nursing homes with a high MRSA prevalence (MRSA carriage
%) and in nursing homes with a high MRSA resistance proportion (MRSA/SA%). Unlike the global
MRSA prevalence, it was also significantly associated to cohort nursing, a variable that was only
slightly associated to the MRSA control index (p=0.046). A similar effect as for the MRSA
prevalence was observed for the combined effect of the GP to bed ratio and the MRSA control
index, with the highest epidemicity index in the nursing homes with a high number of GPs (per
beds) and a lower reported MRSA control activity.
Figure 15. Epidemicity index by GP to bed ratio and MRSA control index
010
2030
40E
pide
mic
ity in
dex
<4GP/B,MCi<8 <4GP/B,MCi>=8 >=4GP/B,MCi<8 >=4GP/B,MCi>=8
The association with a high MRSA control index alone (independent of the number of GPs)
(p=0.018) and one of its components, the isolation of MRSA patients (p=0.017) were at the limit of
statistical significance. As can be seen in figure 15, there indeed seems to be a trend to lower
epidemicity in nursing homes with a smaller number of GPs and a high MCi as well.
VI CONCLUSIONS
• The present study is the first national survey of prevalence of MRSA carriage among
residents of nursing homes in Belgium. Based on a representative sample of 3000
residents in 60 institutions, a prevalence of 19 % carriage was noted. This prevalence was
similar in institutions of all regions and was significantly higher than observed in a study of
residents in 24 Flemish NH in 2000. This prevalence of MRSA carriage is also high
compared to those reported from neighbouring countries. Importantly, 90% of MRSA
carriers found in the survey were not identified as such by the nursing and medical
personnel in spite of the practice of admission MRSA screening and receipt of discharge
letter in case of hospital transfer in a majority of participating NHs.
• Analysis of risk factors likely to explain MRSA carriage at resident-level confirmed the
predisposing role of recent hospitalisation and antibiotic treatment as well as that of being
cared for in NH where the number of physicians per resident is higher than the average.
The latter variable appeared to be particularly important in nursing homes that report a
lower activity for MRSA prevention and control.
• Analysis of risk factors for high MRSA prevalence at institutional level showed that NHs
where the coordinating physician reported supervising all medical records had a lower
MRSA prevalence. Since this variable was closely related to the GP to bed ratio, it did not
remain significant in the multivariate analysis.
• The antibiotic resistance profile of MRSA isolates from NH residents to antimicrobial agents
other than beta-lactams was similar to that of MRSA isolates from the national survey
conducted in 2005 in hospitalised patients.
• The molecular typing showed that MRSA strains colonizing NH residents were closely
related to endemic nosocomial strains associated with infection among patients admitted to
Belgian acute care hospitals in 2003. Three major epidemic clones ST45-SCCmec IV
PFGE type B2, ST8-SCCmec IV PFGE type A20 and ST8-SCCmec A22 were strongly
predominant in NHs as well as in acute care hospitals. Some geographical diversity was
observed with a similar type distribution in hospitals and nursing homes of a given province,
suggesting local exchange of MRSA strains between these two care settings. Atypical
strains were more frequent in some provinces bordering France and Germany, where
similar MRSA strains have been described, suggesting the possibility of cross-border
spread of epidemic MRSA strains.
• MRSA genotype distribution at NH level indicated high epidemicity indices which were
directly related to the local prevalence level. These findings argue for intra-NH transmission
of MRSA strains. Therefore, complementary studies should be conducted in these care
facilities to determine the relative contribution of intra-NH spread and import-export rates
between acute and chronic care sectors to the high prevalence rates.
• National guidelines to prevent the spread of MRSA in NH have been developed in 2005.
The impact of these guidelines on the evolution of MRSA carriage in NH should be verified
by a new prevalence survey in the near future. Since questionnaire data (as used in the
present survey) only provide reported (and thus possibly biased) data on infection control
practices, a more objective method such as direct observation should be considered in the
next survey.
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2. Denis , O., A. Deplano, C. Nonhoff, M. Hallin, R. De Ryck, R. Vanhoof, R. de Mendonca, and M. J. Struelens. 2006. In-vitro activity of ceftobiprole, tigecycline, daptomycin and 19 other antimicrobials against methicillin-resistant Staphylococcus aureus (MRSA) strains from a national survey of Belgian hospitals. Antimicrob.Agents Chemother. 50:In press.
3. Denis, O., A. Deplano, C. Nonhoff, R. De Ryck, R. de Mendonca, S. Rottiers, R. Vanhoof, and M. J. Struelens. 2004. National surveillance of methicillin-resistant Staphylococcus aureus in Belgian hospitals indicates rapid diversification of epidemic clones. Antimicrob.Agents Chemother. 48:3625-3629.
4. Denis, O., A. Deplano, H. De Beenhouwer, M. Hallin, G. Huysmans, M. G. Garrino, Y. Glupczynski, X. Malaviolle, A. Vergison, and M. J. Struelens. 2005. Polyclonal emergence and importation of community-acquired methicillin-resistant Staphylococcus aureus strains harbouring Panton-Valentine leucocidin genes in Belgium. J.Antimicrob.Chemother. 56:1103-1106.
5. Oliveira, D. C. and H. de Lencastre. 2002. Multiplex PCR strategy for rapid identification of structural types and variants of the mec element in methicillin-resistant Staphylococcus aureus. Antimicrob.Agents Chemother. 46:2155-2161
6. Enright, M. C., N. P. Day, C. E. Davies, S. J. Peacock, and B. G. Spratt. 2000. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J.Clin.Microbiol. 38:1008-1015.
7. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev 1997; 10:505-520.
8. Kluytmans JA, Wertheim HF. Nasal carriage of Staphylococcus aureus and prevention of nosocomial infections. Infection 2005; 33:3-8.
VIII ANNEXES
VIII.1 RESIDENT RISK FACTORS OF MRSA CARRIAGE, UNIVARIATE ANALYSIS, BELGIUM
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Age <69 181 6.2 23 12.7 1.0 - 70-79 568 19.6 119 21.0 1.8 (1.1-2.9) 80-89 1384 47.7 278 20.1 1.7 (1.1-2.7) 90+ 769 26.5 159 20.7 1.8 (1.1-2.9) Gender M 622 21.4 132 21.2 1.0 - F 2284 78.6 444 19.4 0.9 (0.7-1.1) Length of stay in NH (months) <24m 1233 43.3 269 21.8 1.0 - >=24m 1613 56.7 293 18.2 0.8 (0.7-1.0) N of beds in room 1b 2161 74.0 430 19.9 1.0 - 2b 654 22.4 136 20.8 1.1 (0.9-1.3) 3-4b 104 3.6 16 15.4 0.7 (0.4-1.3) Patient mobility ambulatory 1567 54.9 241 15.4 1.0 - chairbound 1197 41.9 302 25.2 1.9 (1.5-2.2) bedridden 92 3.2 30 32.6 2.7 (1.7-4.2) Urinary incontinence no 1319 45.8 211 16.0 1.0 - yes 1564 54.3 365 23.3 1.6 (1.3-1.9) Urinary catheter no 2824 98.4 560 19.8 1.0 - yes 45 1.6 13 28.9 1.6 (0.9-3.2) Disorientation in time (score 1-5) <3 1567 54.1 284 18.1 1.0 - >=3 1331 45.9 297 22.3 1.3 (1.1-1.6) Disorientation in space (score 1-5) <3 1587 54.8 289 18.2 1.0 - >=3 1310 45.2 292 22.3 1.3 (1.1-1.5) Health insurance category O 538 18.3 60 11.2 1.0 - A 513 17.5 99 19.3 1.9 (1.3-2.7) B 557 19.0 100 18.0 1.7 (1.2-2.5) C 477 16.3 118 24.7 2.6 (1.9-3.7) CD 783 26.7 195 24.9 2.6 (1.9-3.6) unknown 67 2.3 15 22.4 2.3 (1.2-4.3) Decubitus or skin ulcer no 2647 93.7 502 19.0 1.0 - yes 177 6.3 61 34.5 2.3 (1.6-3.1) Surgical and other wounds no 2791 95.1 541 19.4 1.0 - yes 144 4.9 46 31.9 2.0 (1.4-2.8) Systemic antibiotics in previous 3 months no 1960 66.8 326 16.6 1.0 - yes 975 33.2 261 26.8 1.8 (1.5-2.2) Number of antibiotics none 1960 66.8 326 16.6 1.0 -
Variable N % of total
N MRSA
% MRSA OR (95%CI)
1 708 24.1 185 26.1 1.8 (1.4-2.2) 2 184 6.3 57 31.0 2.3 (1.6-3.1) >=3 83 2.8 19 22.9 1.5 (0.9-2.5) Time since last antibiotics <1m 275 28.2 65 23.6 1.0 - 1-2m 255 26.2 75 29.4 1.4 (0.9-2.0) 2-3m 197 20.2 65 33.0 1.6 (1.1-2.4) >3m 105 10.8 23 21.9 0.9 (0.5-1.6) unkown 143 14.7 33 23.1 1.0 (0.6-1.6) Penicillins no 2523 86.0 466 18.5 1.0 - yes 412 14.0 121 29.4 1.8 (1.5-2.3) BL-resistant small spectr penicillins no 2889 98.4 575 19.9 1.0 - yes 46 1.6 12 26.1 1.4 (0.7-2.8) BL-sensitive penicillins no 2758 94.0 540 19.6 1.0 - yes 177 6.0 47 26.6 1.5 (1.1-2.1) Penicillins + BL-inhibitor no 2658 90.6 495 18.6 1.0 - yes 277 9.4 92 33.2 2.2 (1.7-2.8) Cephalosporins no 2781 94.8 550 19.8 1.0 - yes 154 5.3 37 24.0 1.3 (0.9-1.9) C1 cefadroxil/cefazoline no 2895 98.6 575 19.9 1.0 - yes 40 1.4 12 30.0 1.7 (0.9-3.4) C2 cefaclor/cefuroxim no 2818 96.0 561 19.9 1.0 - yes 117 4.0 26 22.2 1.2 (0.7-1.8) Fluoroquinolones no 2697 91.9 512 19.0 1.0 - yes 238 8.1 75 31.5 2.0 (1.5-2.6) Ciprofloxacin no 2833 96.5 558 19.7 1.0 - yes 102 3.5 29 28.4 1.6 (1.0-2.5) Norfloxacin no 2912 99.2 584 20.1 1.0 - yes 23 0.8 3 13.0 0.6 (0.2-2.0) Ofloxacin no 2889 98.4 574 19.9 1.0 - yes 46 1.6 13 28.3 1.6 (0.8-3.0) Levofloxacin no 2909 99.1 576 19.8 1.0 - yes 26 0.9 11 42.3 3.0 (1.4-6.5) Moxifloxacin no 2838 96.7 559 19.7 1.0 - yes 97 3.3 28 28.9 1.7 (1.1-2.6) Macrolides no 2856 97.3 571 20.0 1.0 - yes 79 2.7 16 20.3 1.0 (0.6-1.8) Tetracyclines no 2864 97.6 575 20.1 1.0 - yes 71 2.4 12 16.9 0.8 (0.4-1.5) Cotrimoxazole
Variable N % of total
N MRSA
% MRSA OR (95%CI)
no 2895 98.6 582 20.1 1.0 - yes 40 1.4 5 12.5 0.6 (0.2-1.5) Lincocin/clindamycin no 2912 99.2 580 19.9 1.0 - yes 23 0.8 7 30.4 1.8 (0.7-4.3) Vancomycin no 2929 99.8 585 20.0 1.0 - yes 6 0.2 2 33.3 2.0 (0.4-11.0) Metronidazole no 2930 99.8 586 20.0 1.0 - yes 5 0.2 1 20.0 1.0 (0.1-9.0) Urinary antibacterials no 2781 94.8 553 19.9 1.0 - yes 154 5.3 34 22.1 1.1 (0.8-1.7) Nitrofurantoin no 2832 96.5 558 19.7 1.0 - yes 103 3.5 29 28.2 1.6 (1.0-2.5) Fosfomycin no 2881 98.2 580 20.1 1.0 - yes 54 1.8 7 13.0 0.6 (0.3-1.3) Other AB/unknown no 2906 99.0 577 19.9 1.0 - yes 29 1.0 10 34.5 2.1 (1.0-4.6) Hospital admission in previous year no 2056 70.1 363 17.7 1.0 - yes 879 30.0 224 25.5 1.6 (1.3-1.9) Time since last hospital admission none<12m 2056 71.1 363 17.7 1.0 - 1-3m 172 6.0 46 26.7 1.7 (1.2-2.4) 4-6m 156 5.4 32 20.5 1.2 (0.8-1.8) 7-12m 188 6.5 49 26.1 1.6 (1.2-2.3) unknown 319 11.0 84 26.3 1.7 (1.3-2.2) Hospital department none 2056 70.1 363 17.7 1.0 - geriatrics 275 9.4 70 25.5 1.6 (1.2-2.1) internal_med 205 7.0 57 27.8 1.8 (1.3-2.5) surgery 179 6.1 42 23.5 1.4 (1.0-2.1) neuro/psych 49 1.7 7 14.3 0.8 (0.3-1.7) other/unknown 171 5.8 48 28.1 1.8 (1.3-2.6) Known MRSA carriage no/unknown 2656 94.1 514 19.4 1.0 - previously 136 4.8 40 29.4 1.7 (1.2-2.5) currently 31 1.1 17 54.8 5.1 (2.5-10.3) Charlson co-morbidity index none/mild (0-1) 1216 41.4 213 17.5 1.0 - Moderate (2-4) 1541 52.5 334 21.7 1.3 (1.1-1.6) Severe (>=5) 178 6.1 40 22.5 1.4 (0.9-2.0) Myocardial infarction no 2745 94.2 548 20.0 1.0 - yes 170 5.8 36 21.2 1.1 (0.7-1.6) Heart failure no 1883 64.6 368 19.5 1.0 - yes 1033 35.4 216 20.9 1.1 (0.9-1.3) Peripheral vasc. disease no 2374 81.3 468 19.7 1.0 - yes 545 18.7 117 21.5 1.1 (0.9-1.4)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Cerebrovascular disease no 2167 74.2 411 19.0 1.0 - yes 754 25.8 173 22.9 1.3 (1.0-1.6) Hemiplegia no 2680 91.8 520 19.4 1.0 - yes 238 8.2 64 26.9 1.5 (1.1-2.1) Dementia no 1763 60.4 342 19.4 1.0 - yes 1155 39.6 242 21.0 1.1 (0.9-1.3) Chronic obstr. lung dis. no 2600 89.1 509 19.6 1.0 - yes 318 10.9 75 23.6 1.3 (1.0-1.7) Mild diabetes no 2537 86.9 529 20.9 1.0 - yes 381 13.1 56 14.7 0.7 (0.5-0.9) Diabetes+organ dis. no 2770 95.1 557 20.1 1.0 - yes 144 4.9 27 18.8 0.9 (0.6-1.4) Mild liver disease no 2847 97.7 569 20.0 1.0 - yes 67 2.3 15 22.4 1.2 (0.6-2.1) Moderate/severe liver dis. no 2878 98.8 575 20.0 1.0 - yes 36 1.2 9 25.0 1.3 (0.6-2.9) Peptic ulcer no 2641 90.6 536 20.3 1.0 - yes 273 9.4 48 17.6 0.8 (0.6-1.2) Cancer no 2747 94.3 549 20.0 1.0 - yes 167 5.7 35 21.0 1.1 (0.7-1.6) Metastatic cancer no 2879 98.8 575 20.0 1.0 - yes 35 1.2 9 25.7 1.4 (0.6-3.0) Systemic disease no 2684 92.1 546 20.3 1.0 - yes 231 7.9 38 16.5 0.8 (0.5-1.1) Lymphoma no 2908 99.8 583 20.1 1.0 - yes 6 0.2 1 16.7 0.8 (0.1-6.8) Leucemia no 2905 99.7 584 20.1 1.0 - yes 9 0.3 0 0.0 - - Moderate/severe renal dis. no 2735 93.8 534 19.5 1.0 - yes 180 6.2 50 27.8 1.6 (1.1-2.2) Recid. urinary infections no 2720 93.3 528 19.4 1.0 - yes 195 6.7 56 28.7 1.7 (1.2-2.3) Total 2935 100.0 587 20.0 1.0 -
VIII.2 RESIDENT RISK FACTORS OF MRSA CARRIAGE, UNIVARIATE ANALYSIS, VLAANDEREN
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Age <69 69 3.9 7 10.1 1.0 - 70-79 332 19.0 64 19.3 2.1 (0.9-4.8) 80-89 850 48.6 166 19.5 2.2 (1.0-4.8) 90+ 499 28.5 102 20.4 2.3 (1.0-5.1) Gender M 367 21.1 86 23.4 1.0 - F 1375 78.9 248 18.0 0.7 (0.5-0.9) Length of stay in NH (months) <24m 729 42.8 158 21.7 1.0 - >=24m 976 57.2 172 17.6 0.8 (0.6-1.0) N of beds in room 1b 1438 81.8 282 19.6 1.0 - 2b 272 15.5 51 18.8 1.0 (0.7-1.3) 3-4b 47 2.7 7 14.9 0.7 (0.3-1.6) Patient mobility ambulatory 878 52.0 129 14.7 1.0 - chairbound 748 44.3 179 23.9 1.8 (1.4-2.3) bedridden 64 3.8 21 32.8 2.8 (1.6-4.9) Urinary incontinence no 771 45.0 122 15.8 1.0 - yes 942 55.0 209 22.2 1.5 (1.2-1.9) Urinary catheter no 1673 98.4 322 19.3 1.0 - yes 27 1.6 6 22.2 1.2 (0.5-3.0) Disorientation in time (score 1-5) <3 936 53.6 171 18.3 1.0 - >=3 811 46.4 167 20.6 1.2 (0.9-1.5) Disorientation in space (score 1-5) <3 947 54.2 174 18.4 1.0 - >=3 799 45.8 164 20.5 1.2 (0.9-1.5) Health insurance category O 292 16.6 33 11.3 1.0 - A 295 16.8 49 16.6 1.6 (1.0-2.5) B 350 19.9 58 16.6 1.6 (1.0-2.5) C 287 16.3 70 24.4 2.5 (1.6-4.0) CD 501 28.5 122 24.4 2.5 (1.7-3.8) unknown 36 2.0 9 25.0 2.6 (1.1-6.0) Decubitus or skin ulcer no 1581 94.4 288 18.2 1.0 - yes 93 5.6 35 37.6 2.7 (1.7-4.2) Surgical and other wounds no 1685 95.7 312 18.5 1.0 - yes 76 4.3 29 38.2 2.7 (1.7-4.4) Systemic antibiotics in previous 3 months no 1169 66.4 191 16.3 1.0 - yes 592 33.6 150 25.3 1.7 (1.4-2.2) Number of antibiotics none 1169 66.4 191 16.3 1.0 - 1 430 24.4 105 24.4 1.7 (1.3-2.2) 2 115 6.5 34 29.6 2.2 (1.4-3.3) >=3 47 2.7 11 23.4 1.6 (0.8-3.1)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Time since last antibiotics <1m 180 30.4 39 21.7 1.0 - 1-2m 144 24.3 40 27.8 1.4 (0.8-2.3) 2-3m 126 21.3 42 33.3 1.8 (1.1-3.0) >3m 66 11.2 16 24.2 1.2 (0.6-2.3) unkown 76 12.8 13 17.1 0.8 (0.4-1.5) Penicillins no 1483 84.2 260 17.5 1.0 - yes 278 15.8 81 29.1 1.9 (1.4-2.6) BL-resistant small spectr penicillins no 1730 98.2 331 19.1 1.0 - yes 31 1.8 10 32.3 2.0 (0.9-4.3) BL-sensitive penicillins no 1630 92.6 308 18.9 1.0 - yes 131 7.4 33 25.2 1.5 (1.0-2.2) Penicillins + BL-inhibitor no 1583 89.9 282 17.8 1.0 - yes 178 10.1 59 33.2 2.3 (1.6-3.2) Cephalosporins no 1669 94.8 324 19.4 1.0 - yes 92 5.2 17 18.5 0.9 (0.5-1.6) C1 cefadroxil/cefazoline no 1734 98.5 335 19.3 1.0 - yes 27 1.5 6 22.2 1.2 (0.5-3.0) C2 cefaclor/cefuroxim no 1693 96.1 329 19.4 1.0 - yes 68 3.9 12 17.7 0.9 (0.5-1.7) Fluoroquinolones no 1621 92.1 299 18.5 1.0 - yes 140 8.0 42 30.0 1.9 (1.3-2.8) Ciprofloxacin no 1713 97.3 327 19.1 1.0 - yes 48 2.7 14 29.2 1.8 (0.9-3.3) Norfloxacin no 1748 99.3 340 19.5 1.0 - yes 13 0.7 1 7.7 0.4 (0.0-2.7) Ofloxacin no 1729 98.2 332 19.2 1.0 - yes 32 1.8 9 28.1 1.7 (0.8-3.6) Levofloxacin no 1743 99.0 336 19.3 1.0 - yes 18 1.0 5 27.8 1.6 (0.6-4.5) Moxifloxacin no 1707 96.9 325 19.0 1.0 - yes 54 3.1 16 29.6 1.8 (1.0-3.3) Macrolides no 1728 98.1 335 19.4 1.0 - yes 33 1.9 6 18.2 0.9 (0.4-2.3) Tetracyclines no 1723 97.8 334 19.4 1.0 - yes 38 2.2 7 18.4 0.9 (0.4-2.2) Cotrimoxazole no 1731 98.3 339 19.6 1.0 - yes 30 1.7 2 6.7 0.3 (0.1-1.2) Lincocin/clindamycin
Variable N % of total
N MRSA
% MRSA OR (95%CI)
no 1751 99.4 337 19.3 1.0 - yes 10 0.6 4 40.0 2.8 (0.8-10.0) Vancomycin no 1756 99.7 339 19.3 1.0 - yes 5 0.3 2 40.0 2.8 (0.5-16.7) Metronidazole no 1759 99.9 341 19.4 1.0 - yes 2 0.1 0 0.0 - - Urinary antibacterials no 1670 94.8 322 19.3 1.0 - yes 91 5.2 19 20.9 1.1 (0.7-1.9) Nitrofurantoin no 1699 96.5 324 19.1 1.0 - yes 62 3.5 17 27.4 1.6 (0.9-2.8) Fosfomycin no 1732 98.4 339 19.6 1.0 - yes 29 1.7 2 6.9 0.3 (0.1-1.3) Other AB/unknown no 1742 98.9 335 19.2 1.0 - yes 19 1.1 6 31.6 1.9 (0.7-5.1) Hospital admission in previous year no 1268 72.0 220 17.4 1.0 - yes 493 28.0 121 24.5 1.6 (1.2-2.0) Time since last hospital admission none<12m 1237 71.5 212 17.1 1.0 - 1-3m 115 6.7 34 29.6 2.0 (1.3-3.1) 4-6m 99 5.7 18 18.2 1.1 (0.6-1.8) 7-12m 124 7.2 31 25.0 1.6 (1.0-2.5) unknown 155 9.0 38 24.5 1.6 (1.1-2.3) Hospital department none 1237 70.2 212 17.1 1.0 - geriatrics 186 10.6 42 22.6 1.4 (1.0-2.1) internal_med 102 5.8 23 22.6 1.4 (0.9-2.3) surgery 84 4.8 25 29.8 2.1 (1.3-3.3) neuro/psych 26 1.5 1 3.9 0.2 (0.0-1.4) other/unknown 126 7.2 38 30.2 2.1 (1.4-3.1) Known MRSA carriage no/unknown 1580 93.1 289 18.3 1.0 - previously 98 5.8 29 29.6 1.9 (1.2-3.0) currently 20 1.2 13 65.0 8.3 (3.3-21.0) Charlson co-morbidity index none/mild (0-1) 664 37.7 95 14.3 1.0 - Moderate (2-4) 983 55.8 219 22.3 1.7 (1.3-2.2) Severe (>=5) 114 6.5 27 23.7 1.9 (1.1-3.0) Myocardial infarction no 1636 93.7 318 19.4 1.0 - yes 111 6.4 21 18.9 1.0 (0.6-1.6) Heart failure no 1089 62.3 198 18.2 1.0 - yes 658 37.7 141 21.4 1.2 (1.0-1.6) Peripheral vasc. disease no 1422 81.2 273 19.2 1.0 - yes 329 18.8 67 20.4 1.1 (0.8-1.5) Cerebrovascular disease no 1245 71.1 219 17.6 1.0 - yes 507 28.9 120 23.7 1.5 (1.1-1.9)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Hemiplegia no 1608 91.9 301 18.7 1.0 - yes 142 8.1 38 26.8 1.6 (1.1-2.3) Dementia no 1005 57.4 193 19.2 1.0 - yes 745 42.6 146 19.6 1.0 (0.8-1.3) Chronic obstr. lung dis. no 1550 88.6 291 18.8 1.0 - yes 200 11.4 48 24.0 1.4 (1.0-1.9) Mild diabetes no 1500 85.7 301 20.1 1.0 - yes 250 14.3 39 15.6 0.7 (0.5-1.1) Diabetes+organ dis. no 1651 94.6 322 19.5 1.0 - yes 95 5.4 17 17.9 0.9 (0.5-1.5) Mild liver disease no 1703 97.5 327 19.2 1.0 - yes 43 2.5 12 27.9 1.6 (0.8-3.2) Moderate/severe liver dis. no 1727 98.9 335 19.4 1.0 - yes 19 1.1 4 21.1 1.1 (0.4-3.4) Peptic ulcer no 1582 90.6 311 19.7 1.0 - yes 164 9.4 28 17.1 0.8 (0.5-1.3) Cancer no 1648 94.4 316 19.2 1.0 - yes 98 5.6 23 23.5 1.3 (0.8-2.1) Metastatic cancer no 1725 98.8 332 19.3 1.0 - yes 21 1.2 7 33.3 2.1 (0.8-5.2) Systemic disease no 1605 91.9 309 19.3 1.0 - yes 141 8.1 30 21.3 1.1 (0.7-1.7) Lymphoma no 1742 99.8 339 19.5 1.0 - yes 4 0.2 0 0.0 - - Leucemia no 1740 99.7 339 19.5 1.0 - yes 6 0.3 0 0.0 - - Moderate/severe renal dis. no 1624 93.0 305 18.8 1.0 - yes 123 7.0 34 27.6 1.7 (1.1-2.5) Recid. urinary infections no 1639 93.8 312 19.0 1.0 - yes 108 6.2 27 25.0 1.4 (0.9-2.2) Total 1761 100.0 341 19.4 1.0 -
VIII.3 RESIDENT RISK FACTORS OF MRSA CARRIAGE, UNIVARIATE ANALYSIS, BRUSSELS
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Age <69 23 8.4 3 13.0 1.0 - 70-79 50 18.3 11 22.0 1.9 (0.5-7.5) 80-89 133 48.5 25 18.8 1.5 (0.4-5.6) 90+ 68 24.8 9 13.2 1.0 (0.3-4.1) Gender M 71 25.8 13 18.3 1.0 - F 204 74.2 36 17.7 1.0 (0.5-1.9) Length of stay in NH (months) <24m 124 45.6 23 18.6 1.0 - >=24m 148 54.4 25 16.9 0.9 (0.5-1.7) N of beds in room 1b 142 53.4 26 18.3 1.0 - 2b 115 43.2 20 17.4 0.9 (0.5-1.8) 3-4b 9 3.4 0 0.0 - - Patient mobility ambulatory 163 59.9 15 9.2 1.0 - chairbound 97 35.7 30 30.9 4.4 (2.2-8.8) bedridden 12 4.4 3 25.0 3.3 (0.8-13.5) Urinary incontinence no 149 54.6 13 8.7 1.0 - yes 124 45.4 35 28.2 4.1 (2.1-8.2) Urinary catheter no 266 97.8 45 16.9 1.0 - yes 6 2.2 3 50.0 4.9 (1.0-25.1) Disorientation in time (score 1-5) <3 162 59.3 26 16.1 1.0 - >=3 111 40.7 23 20.7 1.4 (0.7-2.5) Disorientation in space (score 1-5) <3 164 60.1 27 16.5 1.0 - >=3 109 39.9 22 20.2 1.3 (0.7-2.4) Health insurance category O 61 22.1 4 6.6 1.0 - A 46 16.7 5 10.9 1.7 (0.4-6.9) B 61 22.1 12 19.7 3.5 (1.1-11.5) C 40 14.5 12 30.0 6.1 (1.8-20.7) CD 59 21.4 14 23.7 4.4 (1.4-14.4) unknown 9 3.3 2 22.2 4.1 (0.6-26.4) Decubitus or skin ulcer no 248 92.5 43 17.3 1.0 - yes 20 7.5 4 20.0 1.2 (0.4-3.7) Surgical and other wounds no 254 92.0 45 17.7 1.0 - yes 22 8.0 4 18.2 1.0 (0.3-3.2) Systemic antibiotics in previous 3 months no 207 75.0 35 16.9 1.0 - yes 69 25.0 14 20.3 1.3 (0.6-2.5) Number of antibiotics none 207 75.0 35 16.9 1.0 - 1 57 20.7 12 21.1 1.3 (0.6-2.7) 2 11 4.0 2 18.2 1.1 (0.2-5.3) >=3 1 0.4 0 0.0 - -
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Time since last antibiotics <1m 13 18.8 2 15.4 1.0 - 1-2m 16 23.2 3 18.8 1.3 (0.2-9.0) 2-3m 10 14.5 4 40.0 3.7 (0.5-26.2) >3m 9 13.0 0 0.0 - - unkown 21 30.4 5 23.8 1.7 (0.3-10.5) Penicillins no 252 91.3 42 16.7 1.0 - yes 24 8.7 7 29.2 2.1 (0.8-5.3) BL-resistant small spectr penicillins no 273 98.9 49 18.0 1.0 - yes 3 1.1 0 0.0 - - BL-sensitive penicillins no 269 97.5 48 17.8 1.0 - yes 7 2.5 1 14.3 0.8 (0.1-6.5) Penicillins + BL-inhibitor no 260 94.2 42 16.2 1.0 - yes 16 5.8 7 43.8 4.0 (1.4-11.4) Cephalosporins no 262 94.9 46 17.6 1.0 - yes 14 5.1 3 21.4 1.3 (0.3-4.8) C1 cefadroxil/cefazoline no 273 98.9 47 17.2 1.0 - yes 3 1.1 2 66.7 9.6 (0.9-108.3) C2 cefaclor/cefuroxim no 265 96.0 48 18.1 1.0 - yes 11 4.0 1 9.1 0.5 (0.1-3.6) Fluoroquinolones no 266 96.4 47 17.7 1.0 - yes 10 3.6 2 20.0 1.2 (0.2-5.7) Ciprofloxacin no 270 97.8 48 17.8 1.0 - yes 6 2.2 1 16.7 0.9 (0.1-8.1) Norfloxacin no 275 99.6 49 17.8 1.0 - yes 1 0.4 0 0.0 - - Ofloxacin no 275 99.6 49 17.8 1.0 - yes 1 0.4 0 0.0 - - Levofloxacin no 276 100.0 49 17.8 1.0 - Moxifloxacin no 270 97.8 48 17.8 1.0 - yes 6 2.2 1 16.7 0.9 (0.1-8.1) Macrolides no 273 98.9 49 18.0 1.0 - yes 3 1.1 0 0.0 - - Tetracyclines no 271 98.2 49 18.1 1.0 - yes 5 1.8 0 0.0 - - Cotrimoxazole no 275 99.6 49 17.8 1.0 - yes 1 0.4 0 0.0 - - Lincocin/clindamycin no 275 99.6 49 17.8 1.0 -
Variable N % of total
N MRSA
% MRSA OR (95%CI)
yes 1 0.4 0 0.0 - - Vancomycin no 275 99.6 49 17.8 1.0 - yes 1 0.4 0 0.0 - - Metronidazole no 274 99.3 48 17.5 1.0 - yes 2 0.7 1 50.0 4.7 (0.3-76.6) Urinary antibacterials no 263 95.3 48 18.3 1.0 - yes 13 4.7 1 7.7 0.4 (0.0-2.9) Nitrofurantoin no 267 96.7 48 18.0 1.0 - yes 9 3.3 1 11.1 0.6 (0.1-4.7) Fosfomycin no 272 98.6 49 18.0 1.0 - yes 4 1.5 0 0.0 - - Other AB/unknown no 274 99.3 48 17.5 1.0 - yes 2 0.7 1 50.0 4.7 (0.3-76.6) Hospital admission in previous year no 187 67.8 22 11.8 1.0 - yes 89 32.3 27 30.3 3.3 (1.7-6.2) Time since last hospital admission none<12m 182 67.2 22 12.1 1.0 - 1-3m 17 6.3 4 23.5 2.2 (0.7-7.5) 4-6m 17 6.3 5 29.4 3.0 (1.0-9.4) 7-12m 28 10.3 11 39.3 4.7 (2.0-11.3) unknown 27 10.0 7 25.9 2.6 (1.0-6.7) Hospital department none 182 65.9 22 12.1 1.0 - geriatrics 36 13.0 11 30.6 3.2 (1.4-7.4) internal_med 25 9.1 9 36.0 4.1 (1.6-10.4) surgery 20 7.3 4 20.0 1.8 (0.6-5.9) neuro/psych 6 2.2 2 33.3 3.6 (0.6-21.0) other/unknown 7 2.5 1 14.3 1.2 (0.1-10.5) Known MRSA carriage no/unknown 214 93.5 40 18.7 1.0 - previously 13 5.7 4 30.8 1.9 (0.6-6.6) currently 2 0.9 0 0.0 - - Charlson co-morbidity index none/mild (0-1) 141 51.1 22 15.6 1.0 - Moderate (2-4) 127 46.0 25 19.7 1.3 (0.7-2.5) Severe (>=5) 8 2.9 2 25.0 1.8 (0.3-9.5) Myocardial infarction no 256 94.1 47 18.4 1.0 - yes 16 5.9 2 12.5 0.6 (0.1-2.9) Heart failure no 204 74.7 39 19.1 1.0 - yes 69 25.3 10 14.5 0.7 (0.3-1.5) Peripheral vasc. disease no 229 84.2 39 17.0 1.0 - yes 43 15.8 10 23.3 1.5 (0.7-3.2) Cerebrovascular disease no 218 79.9 32 14.7 1.0 - yes 55 20.2 17 30.9 2.6 (1.3-5.2)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Hemiplegia no 246 90.4 38 15.5 1.0 - yes 26 9.6 11 42.3 4.0 (1.7-9.4) Dementia no 161 59.2 26 16.2 1.0 - yes 111 40.8 23 20.7 1.4 (0.7-2.5) Chronic obstr. lung dis. no 245 90.1 43 17.6 1.0 - yes 27 9.9 6 22.2 1.3 (0.5-3.5) Mild diabetes no 248 91.2 46 18.6 1.0 - yes 24 8.8 3 12.5 0.6 (0.2-2.2) Diabetes+organ dis. no 261 96.0 48 18.4 1.0 - yes 11 4.0 1 9.1 0.4 (0.1-3.5) Mild liver disease no 267 98.2 49 18.4 1.0 - yes 5 1.8 0 0.0 - - Moderate/severe liver dis. no 265 97.4 46 17.4 1.0 - yes 7 2.6 3 42.9 3.6 (0.8-16.5) Peptic ulcer no 256 94.1 47 18.4 1.0 - yes 16 5.9 2 12.5 0.6 (0.1-2.9) Cancer no 265 97.4 48 18.1 1.0 - yes 7 2.6 1 14.3 0.8 (0.1-6.4) Metastatic cancer no 271 99.6 48 17.7 1.0 - yes 1 0.4 1 100.0 - - Systemic disease no 265 97.1 48 18.1 1.0 - yes 8 2.9 1 12.5 0.7 (0.1-5.4) Lymphoma no 272 100.0 49 18.0 1.0 - Leucemia no 271 99.6 49 18.1 1.0 - yes 1 0.4 0 0.0 - - Moderate/severe renal dis. no 261 96.0 47 18.0 1.0 - yes 11 4.0 2 18.2 1.0 (0.2-4.8) Recid. urinary infections no 252 92.7 44 17.5 1.0 - yes 20 7.4 5 25.0 1.6 (0.5-4.6) Total 276 100.0 49 17.8 1.0 -
VIII.4 RESIDENT RISK FACTORS OF MRSA CARRIAGE, UNIVARIATE ANALYSIS, WALLONIE
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Age <69 89 10.1 13 14.6 1.0 - 70-79 186 21.2 44 23.7 1.8 (0.9-3.6) 80-89 401 45.7 87 21.7 1.6 (0.9-3.1) 90+ 202 23.0 48 23.8 1.8 (0.9-3.6) Gender M 184 20.7 33 17.9 1.0 - F 705 79.3 160 22.7 1.3 (0.9-2.0) Length of stay in NH (months) <24m 380 43.7 88 23.2 1.0 - >=24m 489 56.3 96 19.6 0.8 (0.6-1.1) N of beds in room 1b 581 64.8 122 21.0 1.0 - 2b 267 29.8 65 24.3 1.2 (0.9-1.7) 3-4b 48 5.4 9 18.8 0.9 (0.4-1.8) Patient mobility ambulatory 526 58.8 97 18.4 1.0 - chairbound 352 39.4 93 26.4 1.6 (1.1-2.2) bedridden 16 1.8 6 37.5 2.7 (0.9-7.5) Urinary incontinence no 399 44.5 76 19.1 1.0 - yes 498 55.5 121 24.3 1.4 (1.0-1.9) Urinary catheter no 885 98.7 193 21.8 1.0 - yes 12 1.3 4 33.3 1.8 (0.5-6.0) Disorientation in time (score 1-5) <3 469 53.4 87 18.6 1.0 - >=3 409 46.6 107 26.2 1.6 (1.1-2.1) Disorientation in space (score 1-5) <3 476 54.2 88 18.5 1.0 - >=3 402 45.8 106 26.4 1.6 (1.1-2.2) Health insurance category O 185 20.6 23 12.4 1.0 - A 172 19.2 45 26.2 2.5 (1.4-4.3) B 146 16.3 30 20.6 1.8 (1.0-3.3) C 150 16.7 36 24.0 2.2 (1.3-4.0) CD 223 24.8 59 26.5 2.5 (1.5-4.3) unknown 22 2.5 4 18.2 1.6 (0.5-5.0) Decubitus or skin ulcer no 818 92.7 171 20.9 1.0 - yes 64 7.3 22 34.4 2.0 (1.2-3.4) Surgical and other wounds no 852 94.9 184 21.6 1.0 - yes 46 5.1 13 28.3 1.4 (0.7-2.8) Systemic antibiotics in previous 3 months no 584 65.0 100 17.1 1.0 - yes 314 35.0 97 30.9 2.2 (1.6-3.0) Number of antibiotics none 584 65.0 100 17.1 1.0 - '1 221 24.6 68 30.8 2.2 (1.5-3.1) '2 58 6.5 21 36.2 2.8 (1.5-4.9) >=3 35 3.9 8 22.9 1.4 (0.6-3.2)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Time since last antibiotics <1m 82 26.1 24 29.3 1.0 - 1-2m 95 30.3 32 33.7 1.2 (0.6-2.3) 2-3m 61 19.4 19 31.2 1.1 (0.5-2.2) >3m 30 9.6 7 23.3 0.7 (0.3-1.9) unkown 46 14.7 15 32.6 1.2 (0.5-2.5) Penicillins no 788 87.8 164 20.8 1.0 - yes 110 12.3 33 30.0 1.6 (1.0-2.5) BL-resistant small spectr penicillins no 886 98.7 195 22.0 1.0 - yes 12 1.3 2 16.7 0.7 (0.2-3.3) BL-sensitive penicillins no 859 95.7 184 21.4 1.0 - yes 39 4.3 13 33.3 1.8 (0.9-3.6) Penicillins + BL-inhibitor no 815 90.8 171 21.0 1.0 - yes 83 9.2 26 31.3 1.7 (1.0-2.8) Cephalosporins no 850 94.7 180 21.2 1.0 - yes 48 5.4 17 35.4 2.0 (1.1-3.8) C1 cefadroxil/cefazoline no 888 98.9 193 21.7 1.0 - yes 10 1.1 4 40.0 2.4 (0.7-8.6) C2 cefaclor/cefuroxim no 860 95.8 184 21.4 1.0 - yes 38 4.2 13 34.2 1.9 (1.0-3.8) Fluoroquinolones no 810 90.2 166 20.5 1.0 - yes 88 9.8 31 35.2 2.1 (1.3-3.4) Ciprofloxacin no 850 94.7 183 21.5 1.0 - yes 48 5.4 14 29.2 1.5 (0.8-2.9) Norfloxacin no 889 99.0 195 21.9 1.0 - yes 9 1.0 2 22.2 1.0 (0.2-4.9) Ofloxacin no 885 98.6 193 21.8 1.0 - yes 13 1.5 4 30.8 1.6 (0.5-5.2) Levofloxacin no 890 99.1 191 21.5 1.0 - yes 8 0.9 6 75.0 11.0 (2.2-54.8) Moxifloxacin no 861 95.9 186 21.6 1.0 - yes 37 4.1 11 29.7 1.5 (0.7-3.2) Macrolides no 855 95.2 187 21.9 1.0 - yes 43 4.8 10 23.3 1.1 (0.5-2.2) Tetracyclines no 870 96.9 192 22.1 1.0 - yes 28 3.1 5 17.9 0.8 (0.3-2.0) Cotrimoxazole no 889 99.0 194 21.8 1.0 - yes 9 1.0 3 33.3 1.8 (0.4-7.2) Lincocin/clindamycin
Variable N % of total
N MRSA
% MRSA OR (95%CI)
no 886 98.7 194 21.9 1.0 - yes 12 1.3 3 25.0 1.2 (0.3-4.4) Vancomycin no 898 100.0 197 21.9 1.0 - Metronidazole no 897 99.9 197 22.0 1.0 - yes 1 0.1 0 0.0 - - Urinary antibacterials no 848 94.4 183 21.6 1.0 - yes 50 5.6 14 28.0 1.4 (0.7-2.7) Nitrofurantoin no 866 96.4 186 21.5 1.0 - yes 32 3.6 11 34.4 1.9 (0.9-4.0) Fosfomycin no 877 97.7 192 21.9 1.0 - yes 21 2.3 5 23.8 1.1 (0.4-3.1) Other AB/unknown no 890 99.1 194 21.8 1.0 - yes 8 0.9 3 37.5 2.2 (0.5-9.1) Hospital admission in previous year no 645 71.8 134 20.8 1.0 - yes 253 28.2 63 24.9 1.3 (0.9-1.8) Time since last hospital admission none<12m 637 71.6 129 20.3 1.0 - 1-3m 40 4.5 8 20.0 1.0 (0.4-2.2) 4-6m 40 4.5 9 22.5 1.1 (0.5-2.5) 7-12m 36 4.0 7 19.4 1.0 (0.4-2.2) unknown 137 15.4 39 28.5 1.6 (1.0-2.4) Hospital department none 637 70.9 129 20.3 1.0 - geriatrics 53 5.9 17 32.1 1.9 (1.0-3.4) internal_med 78 8.7 25 32.1 1.9 (1.1-3.1) surgery 75 8.4 13 17.3 0.8 (0.4-1.5) neuro/psych 17 1.9 4 23.5 1.2 (0.4-3.8) other/unknown 38 4.2 9 23.7 1.2 (0.6-2.6) Known MRSA carriage no/unknown 862 96.2 185 21.5 1.0 - previously 25 2.8 7 28.0 1.4 (0.6-3.5) currently 9 1.0 4 44.4 2.9 (0.8-11.0) Charlson co-morbidity index none/mild (0-1) 411 45.8 96 23.4 1.0 - Moderate (2-4) 431 48.0 90 20.9 0.9 (0.6-1.2) Severe (>=5) 56 6.2 11 19.6 0.8 (0.4-1.6) Myocardial infarction no 853 95.2 183 21.5 1.0 - yes 43 4.8 13 30.2 1.6 (0.8-3.1) Heart failure no 590 65.9 131 22.2 1.0 - yes 306 34.2 65 21.2 1.0 (0.7-1.3) Peripheral vasc. disease no 723 80.7 156 21.6 1.0 - yes 173 19.3 40 23.1 1.1 (0.7-1.6) Cerebrovascular disease no 704 78.6 160 22.7 1.0 - yes 192 21.4 36 18.8 0.8 (0.5-1.2)
Variable N % of total
N MRSA
% MRSA OR (95%CI)
Hemiplegia no 826 92.2 181 21.9 1.0 - yes 70 7.8 15 21.4 1.0 (0.5-1.8) Dementia no 597 66.6 123 20.6 1.0 - yes 299 33.4 73 24.4 1.2 (0.9-1.7) Chronic obstr. lung dis. no 805 89.8 175 21.7 1.0 - yes 91 10.2 21 23.1 1.1 (0.6-1.8) Mild diabetes no 789 88.1 182 23.1 1.0 - yes 107 11.9 14 13.1 0.5 (0.3-0.9) Diabetes+organ dis. no 858 95.8 187 21.8 1.0 - yes 38 4.2 9 23.7 1.1 (0.5-2.4) Mild liver disease no 877 97.9 193 22.0 1.0 - yes 19 2.1 3 15.8 0.7 (0.2-2.3) Moderate/severe liver dis. no 886 98.9 194 21.9 1.0 - yes 10 1.1 2 20.0 0.9 (0.2-4.2) Peptic ulcer no 803 89.6 178 22.2 1.0 - yes 93 10.4 18 19.4 0.8 (0.5-1.4) Cancer no 834 93.1 185 22.2 1.0 - yes 62 6.9 11 17.7 0.8 (0.4-1.5) Metastatic cancer no 883 98.6 195 22.1 1.0 - yes 13 1.5 1 7.7 0.3 (0.0-2.3) Systemic disease no 814 90.9 189 23.2 1.0 - yes 82 9.2 7 8.5 0.3 (0.1-0.7) Lymphoma no 894 99.8 195 21.8 1.0 - yes 2 0.2 1 50.0 3.6 (0.2-57.6) Leucemia no 894 99.8 196 21.9 1.0 - yes 2 0.2 0 0.0 - - Moderate/severe renal dis. no 850 94.9 182 21.4 1.0 - yes 46 5.1 14 30.4 1.6 (0.8-3.1) Recid. urinary infections no 829 92.5 172 20.8 1.0 - yes 67 7.5 24 35.8 2.1 (1.3-3.6) Total 898 100.0 197 21.9 1.0 -
VIII.5 RESIDENT QUESTIONNAIRE
Section Epidémiologie
Etude de la prévalence du Staphylococcus aureus résistant à la méticilline dans les MR et MRS Belges
COLLEZ ICI L’ETIQUETTE AVEC LE NUMERO DE L’ETUDE
DATE DE L’ETUDE: .. / .. /2005
Nom ou cachet du médecin traitant : Dr. ……………………………………….
Données concernant le séjour
AGE: .......... ans SEXE: Homme Femme DATE D’ADMISSION DANS LA MR/MRS: .... / .... / ….... NOM/CODE DE L’UNITE OU SEJOURNE LE RESIDENT : ………………….................................................. NUMERO DE LA CHAMBRE ET DU LIT : Chambre : ………….. Lit : ………… NOMBRE DE LITS DANS LA CHAMBRE ? ................................. lits TYPE DE FORFAIT-INAMI DU RESIDENT (0, A, B, C, CD) : ………………………
Données concernant les Activités de la Vie Journalière (AVJ)
AMBULANT LIT/CHAISE ALITE CONTINENCE INCONTINENCE INCONTINENCE SONDE A
DEMEURE URIN.& FECALE URINAIRE FECALE DESORIENTATION TEMPORELLE (ECHELLE DE KATZ) 1 2 3 4 5 DESORIENTATION SPATIALE (ECHELLE DE KATZ) 1 2 3 4 5 PLAIE DE DECUBITUS ET/OU ULCERE: Oui Non AUTRE PLAIE (CHIRURGIE, TRAUMA,…): Oui Non
Traitement par antibiotiques pendant les 3 derniers mois
TRAITEMENT PAR ANTIBIOTIQUES PENDANT LES 3 DERNIERS MOIS ? oui non SI OUI, REMPLISSEZ LA GRILLE SUIVANTE POUR LES 3 DERNIERS MOIS: Date du début nom de l’antibiotique prescrit duree du traitement 1-2 sem. 3-4 sem. >1 mois …. / … / 20... …………………………………. …. / … / 20... …………………………………. …. / … / 20... …………………………………. …. / … / 20... ………………………………….
Dernière hospitalisation (pendant les 12 derniers mois) DATE DE L’HOSPITALISATION: .. / .. / 20….
Quel hôpital ? …………………………………………….……………………………….. Quel service? (médecine, chirurgie, soins intensifs, gériatrie?) .............………………......................... Raison(s) de l’hospitalisation: …………................................................................……………….......
Données de Co-morbidité* FONCTION DE LA PERSONNE QUI A REMPLI CES DONNEES ?
.................................................................
infarctus du myocarde défaillance cardiaque souffrance vasculaire périphérique souffrance cérébro-vasculaire hémiplégie démence affection pulmonaire chronique diabète léger diabète avec atteinte des organes affection hépatique légère
atteinte hépatique moyennement grave ulcères peptiques cancer cancer métastasé atteinte systémique lymphome leucémie atteinte rénale moyennement grave infection urinaire récidivante (> 3 fois
durant la dernière année)
Portage de MRSA
Le résident : a été porteur de MRSA antérieurement est porteur de MRSA aujourd’hui
Traitement médicamenteux au moment de l’étude per os (p.o.), IM (im), IV (iv), SC (sc), pommade/onguents/crèmes (topique), aérosol (aero)
Nom du médicament mode d’administration (p.o., im, iv, sc, topique, aero) …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… …………………………………………………………………….. ……………………………… * COMMENTAIRE: Infarctus du myocarde: diagnostic formel dans les antécédents (un ECG par hasard positif ne score pas). Défaillance cardiaque: diagnostiquée et/ou médicalement traitée. Souffrance vasculaire périphérique: diagnostic formel ou souffrance traitée chirurgicalement. Souffrance cérébro-vasculaire: antécédents d’AVC avec ou sans lésions résiduelles mineures, AIT. Quadri-hémiplegie: quelle qu’en soit l’origine. Atteinte systémique: lupus systémique, polymyosite, polymyalgie rhumatismale, arthrite rhumatoïde. Affection pulmonaire chronique: poussées de dyspnée, dyspnée léger à l’effort ou dyspnée au repos. Diabète: léger: pas d’atteinte des organes, diabète traité avec de l’insuline – avec des médicaments hypoglycémiants (un régime seul ne score pas). Diabète: avec atteinte des organes: rétinopathie, angiopathie, néphropathie. Atteinte hépatique légère: cirrhose sans hypertension portale ou hépatite chronique. Cirrhose moyennement grave avec hypertension portale avec ou sans varices oesophagiennes. Affection rénale: moyennement grave: patient dialysé, transplanté rénal, créatininémie > 3 mg %, urémie. Cancer: tumeur sans métastases documentées, traité pendant les 5 dernières années. Lymphome: Hodgkin, lymphosarcome, macroglobulinémie de Waldenström, myélome et autres lymphomes. Leucémie: leucémie aiguë-chronique, polycythémie.
VIII.6 QUESTIONNAIRE ON INSTITUTIONAL CHARACTERISTICS AND PRACTICES
Section Epidémiologie
Etude de la prévalence du Staphylococcus aureus résistant à la méthicilline dans les MR et MRS belges
Enquête concernant les caractéristiques institutionnelles Institution: ……………………………. Numéro d’étude attribué à l’établissement: ……. I – Partie à remplir par le médecin COORDINATEUR de la MR/MRS 1. Cochez les tâches que vous exécutez en tant que médecin coordinateur dans la MR/MRS: (plusieurs réponses, barrez les mentions inutiles) Oui / Non Régler la politique d’admission Oui / Non Organiser régulièrement des réunions avec les médec ins traitants Oui / Non Contacts sporadiques avec les médecins traitants Oui / Non Contrôler les dossiers Oui / Non Organiser le service de garde médicale
Oui / Non Développer une politique et une approche commune avec les médecins (soins de plaies, cathéters, etc..)
Oui / Non Elaborer un formulaire thérapeutique avec les médecins Oui / Non Arriver à un accord entre les médecins généralistes au sujet de l’utilisation rationnelle d’AB dans l’institution Oui / Non Elaborer des recommandations écrites au sujet de l’utilisation d’AB (quel AB, dans quel cas ?) Oui / Non Développer une politique d’hygiène dans l ‘établissement Oui / Non Organiser une formation du personnel médical Oui / Non Organiser des formations pour le personnel infirmier/ soignant concernant l’hygiène dans l’établissement Oui / Non Autres tâches? Lesquelles ? …………………………………………………………………………………………………
Politique d’antibiotiques dans l’institution 2. Le choix des antibiotiques pouvant être prescrits dans la MR/MRS, est-il limité?
(cochez la bonne réponse) □ Oui □ Non 3. Existe-t-il entre les médecins certains accords au sujet de la prescription des antibiotiques (ex: jamais un tel type d’antibiotique dans tel cas)? (cochez la bonne réponse) □ Oui □ Non Si oui, quelles conventions? ………………………………………………………………………………………………… …………………………………………………………………………………………………
4. Des affirmations suivantes, lesquelles sont vraies dans la MR/MRS ou vous travaillez? (plusieurs réponses, cochez la/les bonnes réponses)
□ L’infirmière utilise librement des pommades à base d’antibiotiques (sans prescription) □ On les utilise uniquement sur prescription médicale □ Leur prescription est fortement réglementée (formulaire thérapeutique) □ On n’utilise jamais ces pommades pour le soin d’une plaie □ On utilise des pommades à base d’antibiotiques (autre que la mupirocine) pour décontaminer
une plaie contaminée par un MRSA □ On utilise de la pommade à base de mupirocine (BACTROBAN) pour décontaminer une plaie
contaminée par un MRSA
La communication entre l’hôpital et la MR/MRS 5. A l’occasion du retour d’un résident, après une hospitalisation dans un hôpital aigu, reçoit-il une lettre de
transfert de cet hôpital ? (cochez la bonne réponse) □ Oui, toujours □ Oui, parfois □ Non, jamais 6. Si non, y a t il un contact téléphonique avec l’hôpital ? (cochez la bonne réponse) □ Oui, toujours □ Oui, parfois □ Non, jamais 7. Exigez-vous une attestation de non-contagion au retour du résident? (cochez la bonne réponse) □ Oui, toujours □ Oui, parfois □ Non, jamais
L’approche du problème infectieux en MR/MRS 8. En cas de problèmes infectieux de type épidémique, pouvez-vous compter sur l’aide d’une plate-
forme régionale d’hygiène hospitalière ? (cochez la bonne réponse □ Oui □ Non 9. Pendant cette dernière année, avez-vous eu une épidémie dans l’établissement (plus de cas que
d’habitude, pour une période donnée)? (cochez la bonne réponse) □ Oui □ Non Si oui, quel(s) germe(s) étai(en)t à l’origine ? …………………………………………………… 10 Si un résident au retour de l’hôpital est devenu porteur de MRSA, considérez-vous qu’il est atteint d’une affection contagieuse ? (cochez la bonne réponse) □ Oui, toujours □ Oui, parfois □ Non, jamais 11. Si un résident est devenu porteur de MRSA à la sortie de l’hôpital, peut-il réintégrer sa place dans la
maison de repos ? (cochez la bonne réponse) □ Oui, sans condition □ Non, jamais □ Oui, s’il n’est pas infecté □ Oui, après avoir été décontaminé (devenu MRSA négatif après traitement à la Mupirocine (Bactroban) et toilette avec antiseptique) □ Autre réponse: …………………………………………………………………………………
12. Au retour d’une hospitalisation, réalisez-vous des prélèvements de dépistage pour détecter le portage de MRSA chez vos résidents? (cochez la bonne réponse)
□ Non, jamais □ Oui, toujours □ Oui, seulement dans certains cas Lesquels : …………………………………………………………………………………….. 13. Si un de vos résidents est porteur de MRSA : (plusieurs réponses, cochez les bonnes réponses) Vous l’isolez en chambre seule ? □ Jamais □ Toujours □ Dans certains cas Le personnel porte des gants pour les soins □ Jamais □ Toujours □ Dans certains cas Le personnel porte un masque □ Jamais □ Toujours □ Dans certains cas Le personnel porte un tablier □ Jamais □ Toujours □ Dans certains cas Vous soignez le résident en chambre commune avec un autre porteur de MRSA? □ Jamais □ Toujours □ Dans certains cas Vous décolonisez le résident □ Jamais □ Toujours □ Dans certains cas Comment ? …………………………………………………………………………………………..
Vous procédez à un nettoyage renforcé de la chambre (plus fréquent, approfondi, avec désinfectant) ? □ Jamais □ Toujours □ Dans certains cas
Vous faites des prélèvements de suivi ? □ Jamais □ Toujours □ Dans certains cas 14. Faites-vous une surveillance ou tenez-vous un registre répertoriant les résidents porteurs de ou
infectés par MRSA dans l’institution? (cochez la bonne réponse) □ Non □ Oui, toujours □ Oui, dans certains cas 15. Faites-vous un cohorting sur le plan du nursing : c.à.d. est-ce qu’un nombre restreint
d’infirmières, toujours les mêmes soignent un résident, porteur ou infecté à MRSA ? (cochez la bonne réponse)
□ Oui, toujours □ Oui, parfois □ Non, jamais 16. Le personnel soignant de l’institution est-il sousmis à un dépistage pour détecter le portage de
MRSA? (cochez la bonne réponse) □ Oui (routine) Depuis quand ? …………………………………………………… □ Seulement dans certains cas/services, lesquels : ………………………………………… □ Non, jamais
II – Partie à remplir par la responsable des soins infirmiers
L’approche du problème infectieux en MR/MRS 17. Dans l’établissement, quels germes causent le plus de problèmes ? (plusieurs réponses, cochez les bonnes réponses)
□ MRSA □ Clostridium difficile □ Autres germes multirésistants, lesquels □ Mycobacterium tuberculosis □ Autre gram négatif, lequel : ………………………………………………………….
18. Durant la dernière année, avez-vous eu une épidémie dans la MR/MRS ? (plus de cas que
d’habitude, pour une période donnée) (cochez la bonne réponse) □ Oui □ Non Si oui, quel(s) germe(s) étai(en)t à l’origine ? …………………………………………………… 19. L’institution dispose t-il d’un formulaire thérapeutique incluant les antibiotiques (liste restrictive de
médicaments à utiliser dans l’institution)? (cochez la bonne réponse) □ Oui □ Non □ Oui, mais il n’est utilisé nulle part □ Oui, mais il n’est utilisé que dans certains services 20. Laquelle des affirmations suivantes est vraie ? (plusieurs réponses, barrez la mention inutile)
□ L’infirmière utilise librement des pommades à base d’antibiotiques (sans prescription) □ On les utilise uniquement sur prescription médicale □ Leur prescription est fortement réglementée (formulaire thérapeutique) □ On n’utilise jamais ces pommades pour le soin d’une plaie □ On utilise des pommades à base d’antibiotiques (autre que la mupirocine) pour décontaminer
une plaie contaminée par un MRSA □ On utilise de la pommade à base de mupirocine (BACTROBAN) pour décontaminer une plaie
contaminée par un MRSA
21. L’institution dispose t-elle d’un infirmier/médecin hygiéniste hospitalier ? (cochez la bonne réponse) □ Oui □ Non 22. En ce qui concerne l’hygiène, existe t-il un accord de collaboration entre l’établissement et un hôpital
aigu ? (Ex. un hygiéniste hospitalier peut être consulté au sujet d’un problème d’hygiène spécifique dans l’établissement) (cochez la bonne réponse)
□ Oui □ Non Si Oui, avec quel hôpital aigu ? ………………………………………………………
Politique d’hygiène et de soins dans l’établissement 23. Disposez-vous dans l’établissement d’un protocole spécifique (règles écrites, procédures) pour:
(plusieurs réponses, barrez la mention inutile) Oui / Non les soins de plaies / d’escarres Oui/ Non les résidents porteurs de sonde urinaire Oui/ Non l’administration d’un aérosol Oui/ Non les soins aux gastrostomisés, trachéostomisés, … Oui/ Non l’isolement de résidents contagieux Oui/ Non les soins aux résidents porteurs de MRSA Oui/ Non l’hygiène dans le service Oui/ Non autres, lesquels: ……………………………………………………………………….. 24. En ce qui concerne l’aérosol thérapie dans l’institution : (plusieurs réponses, barrez les mentions inutiles) Oui / Non seul le kiné fait l’aérosol thérapie Oui / Non seul l’infirmière fait l’aérosol thérapie Oui / Non le kiné et l’infirmière font aérosol thérapie Oui / Non l’aérosol thérapie est réalisée par quelqu’un d’autre que l’infirmière ou le kiné Oui / Non l’appareil à aérosol est commun (utilisé pour plusieurs résidents le même jour) Oui / Non le médicament excédentaire (dans petit pot) est gardé pour un prochain aérosol Oui / Non le récipient (petit pot) est commun (utilisé pour plusieurs résidents le même jour) Oui / Non le masque est commun (utilisé pour plusieurs résidents le même jour) Oui / Non le kiné met des gants lors d’une kiné respiratoire chez un résident Oui / Non le kiné met un masque lors d’une kiné respiratoire chez un résident
Hygiène des mains 25. De quel type de produits de lavage des mains le personnel soignant dispose t-il ? (plusieurs réponses, barrez les mentions inutiles) Oui/ Non une brique de savon Oui/ Non un savon liquide Nom du produit? ………………………………... Oui/ Non une solution antiseptique Nom du produit? ………………………………... Oui/ Non une lotion, un gel à base d’alcool? Nom du produit? ………………………... Oui/ Non autres, lesquels ………………………………………………………………………… ………………………………………………………………………… 26. Où se trouvent ces produits? (plusieurs réponses, barrez les mentions inutiles) Oui / Non à côté du lavabo réservé au personnel Oui/ Non à côté du lavabo du résident Oui/ Non sur le chariot de soins, à pansements Oui/ Non dans la chambre du résident Oui/ Non dans la poche du personnel soignant Oui/ Non au bureau du service Oui/ Non ailleurs, où ? ………………………………………………………………………….
27. Quel type d’essuie-mains est utilisé par le personnel pour se sécher les mains ? (plusieurs réponses, barrez les mentions inutiles) Oui/ Non une serviette de toilette commune en coton ou éponge Oui/ Non des essuies jetables en papier Oui/ Non des essuie-mains en coton pour utilisation unique (en rouleau) Oui/ Non un sèche-main électrique 28. Utilise-t-on des gants à jeter dans l’établissement ? (cochez la bonne réponse) □ Oui, partout □ Oui, mais pas partout □ Non 29. Dans quels cas utilisez-vous des gants à jeter dans l’institution? (plusieurs réponses, barrez les mentions inutiles) Oui/ Non les soins à tous les résidents Oui/ Non les soins à certains résidents: Oui/ Non atteint d’une maladie contagieuse Oui/ Non présentant une plaie Oui/ Non porteurs de sonde urinaire Oui/ Non gastrostomisés Oui/ Non incontinents pour les selles Oui/ Non incontinents urinaires Oui/ Non grippés Oui/ Non pour l’entretien et la désinfection du matériel de soins Oui/ Non pour nourrir les résidents dépendants Oui/ Non pour la distribution des médicaments Oui/ Non pour d’autres activités Lesquelles? ………………………………………………………………………………. 30. Que fait le personnel après avoir ôté les gants? (plusieurs réponses, barrez les mentions inutiles) Oui/ Non il se lave les mains avec de l’eau et du savon normal Oui/Non il se désinfecte les mains avec une solution antiseptique Oui/Non il utilise une solution alcoolique uniquement Oui/Non il ne fait rien
Les caractéristiques structurelles de l’institution 31. Nombre total de lits dans la MR/MRS ? ……………………
Dont : Nombre de lits MR : …………………… Nombre de lits MRS : …………………… Nombre de lits autres : …………………… Quel type de lits ? ………………………………………………..
32. L’établissement a-t-il un statut privé ou public ? (cochez la bonne réponse) □ CPAS □ Privé □ Autres (si oui, lequel ?) ……………………………………………………………………………………………………………
33. Veuillez remplir pour chaque service les renseignements suivants: Service: Nom du service:
Service 1 ………..
Service 2 ………..
Service 3 ………..
Service 4 ………..
Service 5 ………..
Service 6 ………..
Service 7 ………..
Service 8 ………..
Service 9 ………..
Serv. 10 ………..
Serv. 11 ………..
Serv. 12 ………..
Nombre de résidents dans le service
………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ……….
Type de lits dans le service: - MR - MRS - Mixte
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Oui/Non Oui/Non Oui/Non
Nombre de chambres dans le service: - privé - à 2 personnes - à 3 personnes - à 4 personnes - plus de 4
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
………. ……….. ……….. ……….. ………..
Le service dispose-t-il d’un lavabo exclusivement réservé au lavage des mains du personnel?
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Oui/Non
Chaque résident dispose-t-il d’un lavabo individuel ? Dans sa chambre?
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Oui/Non Oui/Non
Y a-t’il dans l’unité une solution alcoolique pour l’hygiène des mains du personnel ?
Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non Oui/Non
34. Vers quels hôpitaux transférez-vous vos résidents qui présentent un problème de santé aigu ? Nom de l’hôpital, code postal (éventuellement la commune ou ville) Parmi l’ensemble des hospitalisations, quel pourcentage de résidents est
orienté vers cet hôpital spécifique* (exprimé en %) *ex: dans notre établissement, 80% des hospitalisations se fait dans l’hôpital X, 10% dans l’hôpital Y et 10% dans l’hôpital Z. 35. De quel nombre (en nombre de personnes et en équivalent temps plein) dispose l’institution pour les catégories professionnelles suivantes : nombre de personnes Equival. temps plein
Médecins généralistes qui viennent voir leur patient en MR/MRS ………………………… ……………… ETP Personnel contractuel infirmier* (infirmières graduées, brevetées, assistants en soins hospitaliers) ………………………… ……………… ETP Personnel contractuel soignant, non-infirmier* (aides familiales, puéricultrices, aides-séniors, aides sanitaires, …) ………………… ……………… ETP Personnel contractuel soignant, n’étant pas en possession d’un des diplômes cités ci-dessus*. ………………………… ……………… ETP Personnel indépendant infirmier ………………………… ……………… ETP Autre personnel infirmier/soignant ………………………… ……………… ETP
* Il s’agit ici uniquement du personnel désigné aux soins (d’hygiène et infirmiers) des résidents. Sont inclus : les remplaçants de personnel malade ou en congé de longue durée, le personnel de nuit, l’infirmière en-chef. Sont exclus : le personnel en congé de maladie ou de maternité, le personnel chargé de l’entretien ménager et de cuisine, les bénévoles, les stagiaires.
Nous vous remercions de votre collaboration, Jans Béatrice
VIII.7. ANNEXE: INSTITUTIONAL CHARACTERISTICS BY REGION
INSTITUTIONAL QUESTIONNAIRE COMPLETED BY THE COORDINATING PHYSICIAN
REGION TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
COORDINATING TASKS OF THE COP
Admission policy in the NH Yes No
59
0 6
0
100
3 32
9 91
3 15
17 93
6 53
10 53
Organise meetings with GP’s Yes No
59 3 3
50 50
14 22
39 61
11 6
65 35
28 31
48 52
Sporadic contacts with GP’s Yes No
59 6 0
100
0
33 2
94 6
17 1
94 6
56 3
95 5
Supervision of medical records Yes No
60 2 4
33 67
14 22
39 61
10 8
56 44
26 34
43 57
Organise the on call service Yes No
60 3 3
50 50
10 26
28 72
4 14
22 78
17 43
28 72
Develop collective care approach in NH Yes No
60 4 2
67 33
22 14
61 39
14 4
78 22
40 20
67 33
Develop therapeutic formulary Yes No
59 1 5
17 83
25 11
69 31
8 9
47 53
34 25
58 42
Make agreements (GP’s) on AB-use Yes No
60 0 6
0
100
12 24
33 67
7 11
39 61
19 41
32 68
Elaborate written recommendations on AB-use Yes No
60
1 5
17 83
4 32
11 89
3 15
17 83
8 52
13 87
Develop hygiene policy in NH Yes No
59 5 1
83 17
27 8
77 23
18 0
100
0
50 9
85 15
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N % Organise training for GP’s Yes No
58 6 0
100
0
29 7
81 19
12 4
75 25
47 11
81 19
Organise training for Nursing staff on hygiene Yes No
59 5 1
83 17
28 7
80 20
16 2
89 11
49 10
83 17
Limited AB-choice for prescription Yes
No
59 0 6
0
100
4 31
11 89
0 18
0
100
4 55
7 93
Agreements between GP’s on AB-prescription Yes
No
60 0 6
0
100
8 28
22 78
3 15
17 83
11 49
18 82
WITCH IF THE FOLLOWING STATEMENTS ARE TRUE?
The nurse can use AB-ointments without prescription Yes No
60
0 6
0 100
1 35
3 97
1 17
6 94
2 58
3 97
AB-ointments are only used under prescription Yes No
60 6 0
100
0
35 1
97 3
16 2
89 11
57 3
95 5
The use of AB-ointments is regulated (formulary) Yes No
60 1 5
17 83
7 29
19 81
7 11
39 61
15 45
25 75
We never use these ointments for wound care Yes No
60 0 6
0
100
2 34
6 94
0 18
0
100
2 58
3 97
We use AB-ointments for decolonisation of MRSA+ wounds Yes No
60
1 5
17 83
9 27
25 75
6 12
33 67
16 44
27 73
We use mupirocine ointments for decolonisation of MRSA+ wounds Yes No
60
5 1
83 17
24 12
67 33
15 3
83 17
44 16
73 27
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
COMMUNICATION BETWEEN HOSPITALS AND NH’S We receive a transfer letter when patients are discharged from the hospital Always Sometimes Never
60
6 0 0
100 0 0
21 15 0
58 42 0
14 4 0
78 22 0
41 19 0
68 32 0
We require a certificate of absence of contagious disease Always Sometimes Never
60
1 2 3
17 33 50
3 3 30
8 8 83
1 2 15
6 11 83
5 7 48
8 12 80
APPROACH OF INFECTIOUS PROBLEMS IN NH
Receive assistance of regional platform for hospital hygiene in epidemic situations Yes
No
51
4 0
100 0
22 8
73 27
9 8
53 47
35 16
69 31
Epidemic in the NH during the last year? Yes
No
58 1 5
17 83
4 32
11 89
1 15
6 94
6 52
10 90
Considering a MRSA carrier as contagious? Always Sometimes
No, never
60 4 1 1
67 17 17
23 9 4
64 25 11
14 3 1
78 17 17
41 13 6
68 22 10
Are MRSA-carriers readmitted to the NH after discharge of the hospital? Yes, without conditions No, never Yes, if not infected Yes, after decontamination
53
1 0 0 2
33 0 0 67
29 0 2 3
85 0 6 9
8 0 1 7
50 0 6 44
38 0 3 12
72 0 6 23
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N % After discharge of the hospital are you performing screening for detection of MRSA-carriage? Yes, always Yes, only in some conditions No, never
59
1 4 1
17 67 17
6 6 23
17 17 66
2 7 9
11 39 50
9 17 33
15 29 56
Do you isolate MRSA-carriers in a private room? Always Yes, only in some conditions No, never
58 2 4 0
33 67 0
9 15 10
27 44 29
7 8 3
39 44 17
18 27 13
31 47 22
Nurses use gloves for care activities? Always Yes, only in some conditions No, never
57 6 0 0
100
0 0
26 6 1
79 18 3
17 1 0
94 6 0
49 7 1
86 12 2
Nurses use a mask for care activities? Always Yes, only in some conditions No, never
59 4 2 0
67 33 0
5 24 6
14 69 17
6 10 2
33 56 11
15 36 8
25 61 14
Nurses use an apron for care activities? Always Yes, only in some conditions No, never
59 4 2 0
67 33 0
16 14 5
46 40 14
14 3 1
78 17 17
34 19 6
58 32 10
Are you cohorting MRSA-carriers? Always Yes, only in some conditions No, never
57
0 3 3
0 50 50
8 9 16
24 27 49
0 11 8
0 61 39
8 23 26
14 40 46
Are you decolonising MRSA-carriers? Always Yes, only in some conditions No, never
51 5 0 0
100
0 0
17 10 5
53 31 16
12 2 0
86 14 0
34 12 5
67 24 10
Do you perform a reinforced room cleaning? Always Yes, only in some conditions No, never
59 4 2 0
67 33 0
22 10 3
63 29 9
15 1 2
83 6 11
41 13 5
70 22 9
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N % Do you take a follow-up sample? Always Yes, only in some conditions No, never
58 4 2 0
67 33 0
23 11 1
66 31 3
11 5 1
65 29 6
38 18 2
66 31 3
Are you doing surveillance/ do you keep a register from residents carriers or infected with MRSA? Yes always Yes, in some conditions No, never
59
4 0 2
67 0 33
13 8 14
37 23 40
12 1 5
67 6 28
29 9 21
49 15 36
Are you performing cohort nursing? Yes always Yes, sometimes No, never
59 1 2 2
20 40 40
2 10 24
6 28 67
2 2 14
11 11 78
5 14 40
9 24 68
Do you perform screening of the nursing staff for detection of MRSA-carriage? Yes routinely Yes, only in some conditions/units No, never
60
1 0 5
17 0 83
1 7 28
3 19 78
0 4 14
0 22 78
2 11 47
3 18 78
INSTITUTIONAL QUESTIONNAIRE COMPLETED BY THE HEAD OF THE NURSING
REGION TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
APPROACH OF INFECTIOUS PROBLEMS IN NH
WITCH PATHOGENS ARE PROBLEMATIC IN THE NH?
MRSA? Yes No
41 6 0
100
0
17 6
74 26
10 2
83 17
33 8
80 20
Clostridium difficile? Yes No
39 1 5
17 83
4 17
19 81
1 11
8 92
6 33
15 85
Other multiresistant pathogens? Yes No
39 0 6
0
100
1 20
5 95
0 12
0
100
1 38
3 97
Mycobacterium tuberculosis? Yes No
39 0 6
0
100
0 21
0
100
1 11
8 92
1 38
3 97
Other Gram – germs? Yes No
40 1 5
17 83
4 18
18 82
5 7
42 58
10 30
25 75
Was there an epidemic in the NH during the last year? Yes No
58
2 4
33 67
6 29
17 83
3 14
18 82
11 47
19 81
Is there a therapeutic formulary including antibiotics in the NH? Yes Yes, but it is not used Yes, but it is only used in some units No
56
0 1 0 5
0 17 0 83
13 9 1 11
38 27 3 32
1 4 1 10
6 25 6 63
14 14 2 26
25 25 4 46
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
WITCH IF THE FOLLOWING STATEMENTS ARE TRUE? The nurse can use AB-ointments without prescription Yes No
57
0 6
0 100
1 34
3 97
1 15
6 94
2 55
4 97
AB-ointments are only used under prescription Yes No
57 5 1
83 17
32 3
91 9
15 1
94 6
52 5
91 9
The use of AB-ointments is regulated (formulary) Yes No
56 2 4
33 67
0 35
0
100
2 13
13 87
4 52
7 93
We never use these ointments for wound care Yes No
57 0 6
0
100
1 34
3 97
1 15
6 94
2 55
4 97
We use AB-ointments for decolonisation of MRSA+ wounds Yes No
57
1 5
17 83
6 29
17 83
3 13
19 81
10 47
18 83
We use mupirocine ointments for decolonisation of MRSA+ wounds Yes No
56
2 4
33 67
25 10
71 29
13 2
87 13
40 16
71 29
There is a hospital hygiene Nurse/Doctor in the NH? Yes No
59
0 6
0 100
0 35
0 100
0 18
0 100
0 59
0 100
There is a collaboration agreement between the NH and the acute care hospital? Yes No
59
2 4
33 67
22 13
63 37
12 6
67 33
36 23
61 39
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
HYGIENE AND CARE PROTOCOLS IN THE NH
DO YOU HAVE A SPECIFIC PROTOCOL IN YOUR NH ABOUT
Wound care? Yes No
58 2 4
33 67
29 6
83 17
13 4
77 24
44 14
76 24
Care of residents with an urinary catheter? Yes No
57 1 5
17 83
4 30
12 88
3 14
18 82
8 49
14 86
Administration of aerosoltherapy? Yes No
57 1 5
17 83
9 25
27 74
7 10
41 59
17 40
30 70
Care of residents with a gastrostomy? Yes No
56 1 5
17 83
9 25
27 74
4 12
25 75
14 42
25 75
Isolation of contagious residents? Yes No
56 4 2
67 33
18 18
51 49
8 7
53 47
30 26
54 46
Care of MRSA-carriers? Yes No
56 4 2
67 33
32 2
94 6
9 7
56 44
45 11
80 20
Hygiene in the unit? Yes No
57 2 4
33 67
17 18
49 51
8 8
50 50
27 30
47 53
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
AEROSOL THERAPY IN THE NH
Aerosols are only administrated by the physiotherapist? Yes No
58
0 6
0 100
0 34
0 100
0 18
0 100
0 58
0 100
Only the nurse administrates aerosols? Yes No
59 0 6
0
100
22 13
63 37
5 13
28 72
27 32
46 54
Both are administrating aerosols? Yes No
55 6 0
100
0
7 24
23 77
15 3
83 17
28 27
51 49
Someone else can administrate the aerosols? Yes No
56 2 4
33 67
11 21
34 66
7 11
39 61
20 36
36 64
The aerosol equipment is for common use? Yes No
59
4 2
67 33
5 30
14 86
4 14
22 78
13 46
22 78
The remaining aerosol medicine is kept for the next administration? Yes No
58
2 4
33 67
4 30
12 88
1 17
6 94
7 51
12 88
The cup is for common use? Yes No
59 0 6
0
100
0 35
0
100
0 18
0
100
0 59
0
100 The mask is for common use? Yes No
58 0 6
0
100
0 34
0
100
0 18
0
100
0 58
0
100 The physiotherapist is using gloves when performing breathing exercises? Yes No
58
1 5
17 83
4 31
11 89
5 12
29 71
10 48
17 83
The physiotherapist is using a mask when performing breathing exercises? Yes No
58
0 6
0 100
2 33
6 94
1 16
6 94
3 55
5 95
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
AVAILABILITY OF HAND HYGIENE PRODUCTS AND MATERIAL
WHICH HAND HYGIENE PRODUCTS ARE AVAILABLE IN THE NH?
Bar of solid soap? Yes No
50 0 5
0
100
2 28
7 93
0 15
0
100
2 48
4 96
Liquid soap? Yes No
58 5 1
83 17
34 0
100
0
18 0
100
0
57 1
98 2
Antiseptic solution? Yes No
52 3 2
60 40
22 8
73 27
14 3
82 18
39 13
75 25
Alcoholic gel or lotion? Yes No
57 6 0
100
0
27 7
79 21
15 2
88 12
48 9
84 16
WHERE CAN YOU FIND THESE PRODUCTS?
Near the sink, reserved for the staff? Yes No
59 6 0
100
0
35 0
100
0
18 0
100
0
59 0
100
0 Near the sink, reserved for the resident? Yes No
56 3 3
50 50
10 23
30 70
4 13
24 77
17 39
30 70
On the wound dressing trolley? Yes No
59 4 2
67 33
31 4
89 11
17 1
94 6
52 7
88 12
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N % In the residents room? Yes No
58 3 3
50 50
15 19
44 56
4 14
22 78
22 36
38 62
In the pocket of the nursing staff? Yes No
57 2 4
33 67
7 26
21 79
8 10
44 56
17 40
30 70
In the office of the unit? Yes No
58
6 0
100
0
25 9
74 27
15 3
83 17
46 12
79 21
Elsewhere? Yes No
44 2 4
33 67
15 8
65 35
6 9
40 60
23 21
52 48
TYPE OF TOWELS USED BY NURSING STAFF FOR DRIYING HANDS
Linnen towel for common use? Yes No
57 0 6
0
100
3 30
9 91
1 17
6 94
4 53
7 93
Disposable towel (paper)? Yes No
59 6 0
100
0
31 4
89 11
16 2
89 11
53 6
90 10
Linnen roller towel for single use? Yes No
57 1 5
17 83
3 30
9 91
3 15
17 83
7 50
12 88
Electric hand dryer? Yes No
57 0 6
0
100
2 31
6 94
1 17
6 94
3 54
5 95
Are you using disposable gloves in the NH? Yes Yes, but not everywhere No
59 4 2 0
67 33 0
28 7 0
80 20 0
17 1 0
94 6 0
49 10 0
83 17 0
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N %
WHEN DO YOU USE DISPOSABLE GLOVES IN THE NH?
When taking care of all residents? Yes No
56 1 5
17 83
5 30
14 86
3 12
20 80
9 47
16 84
When taking care of certain residents? Yes No
57 6 0
100
0
33 0
100
0
17 1
94 6
56 1
98 2
Gloves for taking care of residents with contagious diseases? Yes No
58
6 0
100 0
34 0
100 0
18 0
100 0
58 0
100 0
Gloves for taking care of residents with wounds? Yes No
56 5 1
83 17
25 8
76 24
13 4
77 24
43 13
77 23
Gloves for taking care of residents with an urinary catheter? Yes No
57
5 1
83 17
18 15
54 46
15 3
83 17
38 19
67 33
Gloves for taking care of residents with a gastrostomy? Yes No
56
4 2
67 33
12 20
38 63
14 4
78 22
30 26
54 46
Gloves for taking care of residents with urinary incontinence? Yes No
57
3 3
50 50
15 18
46 55
11 7
61 39
29 28
51 49
Gloves for taking care of residents with faecal incontinence? Yes No
58
5 1
83 17
28 6
82 18
16 2
89 11
49 9
85 16
REGION
TOTAL Brussels Flanders Walloon Belgium
n n % n % n % N % Gloves for taking care of residents with flu? Yes No
56 2 4
33 67
9 23
28 72
8 10
44 56
19 37
34 66
Gloves for cleaning and disinfection of care material? Yes No
58
3 3
50 50
20 14
59 41
13 5
72 28
36 22
62 38
Gloves for feeding of dependant residents? Yes No
59 0 6
0
100
0 35
0
100
2 16
11 89
2 57
3 97
Gloves for the distribution of medicines? Yes No
59 0 6
0
100
0 35
0
100
0 18
0
100
0 59
0
100
HAND HYGIENE TECHNIQUE AFTER REMOVING GLOVES
Washing hands with water and soap? Yes No
55 4 1
80 20
20 13
61 39
11 6
65 35
35 20
64 36
Disinfecting hands with antiseptic solution? Yes No
57 4 2
67 33
18 15
55 46
15 3
83 17
37 20
65 35
Use only alcoholic solution? Yes No
56 2 4
33 67
16 17
49 52
7 10
41 59
25 31
45 55
Using none of these techniques? Yes No
58 1 5
33 67
2 32
6 94
0 18
0
100
3 55
5 95