Issue 42 / 7 November 2011

NEW measures to control the spread of multiresistant bacteria in Australian residential aged-care facilities are urgently needed, according to experts.

High levels of an antimicrobial-resistant strain of Escherichia coli were found in three Melbourne aged-care facilities, according to a study published in the latest MJA. (1)

The researchers found that 12% of residents overall, and up to 27% of residents in one aged-care facility, were colonised with a multidrug resistant strain of E. coli, while colonisation rates with vancomycin-resistant enterococci and Clostridium difficile were low.

The authors described the emergence of multiresistant bacteria as a major public health concern, and noted that aged-care residents may become a source of infection in the acute hospital setting.

Poor hand hygiene and overuse of antibiotics were the biggest contributors to the problem, according to the authors. The study found that 10 out of 12 E. coli-colonised residents had received antibiotics within the previous 6 months.

It also found that antibiotics were often prescribed without clinical samples being collected and that 44% of those patients prescribed antibiotics did not fulfil published criteria for clinical infection.

“[Aged care facilities] should have programs emphasising processes that will limit spread of these organisms, namely good hand hygiene compliance, enhanced environmental cleaning and dedicated antimicrobial stewardship programs”, the authors wrote.

However, Sydney GP Dr Brian Morton, who chairs the AMA’s Council of General Practice, said this wouldn’t be enough.

He said the move towards replacing skilled nursing staff with less-skilled carers in aged-care facilities had boosted hospitalisation rates of residents, which could lead to spread of these multiresistant bacteria. All staff needed to be re-educated for this to change.

Dr Morton said antibiotic use could be better managed if the federal government made it easier for GPs to provide services to aged-care facilities, such as by funding video conferencing equipment.

“[Aged-care facility] work is a loss leader. You do it out of loyalty to patients. Video conferencing between nurses and GPs is a modern way of solving that problem.”

Dr Richard Reed, head of the discipline of general practice at Flinders University, said the research indicated the need for a clinical team to jointly develop strategies within aged-care facilities to control these infections.

He suggested that this include GPs, lead nurses, administrative staff, geriatricians and infectious disease experts.

”Those structures are starting to develop but they’re not yet funded and that’s what’s required”, Dr Reed said.

In an accompanying editorial in the MJA, Dr Timothy Inglis, a medical microbiologist with PathWest Laboratory Medicine, agreed the study highlighted a need for new measures in aged-care facilities. (2)

“This could include a gamut of aged-care measures aimed at reducing transmission, such as decreasing long-term care facility transfers to hospital through the use of advance care planning and hospital-in-the-home treatment”, Dr Inglis said.

He said the “search and destroy” tactics used in hospitals were difficult to implement in aged-care facilities because of issues such as incontinence and the freedom of residents to mingle.

Dr Inglis suggested aged-care facilities should instead focus efforts on the skilled nursing care given to those at identifiably higher risk of infection with multiresistant bacteria, without prior surveillance culture for bacteria.

– Amanda Bryan

1. MJA 2011; 195: 530-533
2. MJA 2011; 195: 489-490

Posted 7 November 2011

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