Device-Related Infections in Long-term Healthcare Facilities: The Challenge of Prevention

Nico T Mutters; Frank Günther; Alexandra Heininger; Uwe Frank


Future Microbiol. 2014;9(4):487-495. 

In This Article

Abstract and Introduction


The world is aging and the number of elderly multimorbid patients is steadily increasing. The limited numbers of acute care beds in hospitals, in addition to the need to reduce costs, has led to the introduction of efficient discharge policies, which in turn have increased demand for beds in nursing homes and long-term care facilities (LTCFs). As a consequence, the number of postacute LTCF residents is rising, as is the number of residents requiring complex medical care delivered by use of indwelling medical devices. These devices place patients at a heightened risk for infection. Furthermore, infection control resources in LTCFs are often limited. This article reviews the preventive measures that should be taken in LTCFs to reduce the risk of device-related infections.


The world is aging and owing to demographic change, healthcare providers face new challenges. The number of adults aged 65 years or older in Europe and worldwide is growing rapidly. The percentage of adults aged ≥65 years in the EU increased from 9.6% in 1960 to 16.0% in 2010, and is projected to increase to 29.3% (152.6 million) by 2060.[1] As healthcare systems strive to optimize costs, often resulting in early patient discharge, demand for accommodation of the elderly in long-term care facilities (LTCFs) is growing steadily.[1]

Owing to age-related dysfunctions of the immune system, physiological changes, functional disability and comorbidities, the elderly are highly susceptible to infections such as urinary tract infections (UTIs), pneumonia, skin and soft tissue infections and gastrointestinal infections.[1,2] Healthcare-associated infections (HAIs) are a common cause of morbidity, functional decline and mortality in the elderly.[3,4] In addition, diagnosis and treatment is often difficult owing to underlying comorbidities, unspecific signs for infection and changed pharmacokinetics and dynamics. Many patients in this group are immobile, suffer from fecal and urinary incontinence and/or need indwelling devices.[3] Owing to the high rate of underlying chronic diseases, frequent hospitalization, antimicrobial therapy and invasive procedures, elderly patients are often exposed to and colonized with multidrug-resistant organisms such as MRSA, multidrug-resistant Gram-negatives and vancomycin-resistant enterococci. Furthermore, they may transmit these bacteria to residents and patients in nursing homes, hospitals and LTCFs.[3,5,6] Antimicrobial therapy is a notable reason why these multidrug-resistant organisms emerge and persist in LTCFs.

The problem is exacerbated by limited infection control resources in the facilities where the elderly reside.[7] In addition, active or passive surveillance programs in LTCFs are quite difficult to implement in these settings compared with surveillance programs in hospitals. Although they exist in US LTCFs, surveillance programs are usually scaled down to hospital versions. The proposed and revised McGeer criteria to measure infections in LTCFs do not require microbiological or radiological confirmation of infection, are deliberately clinical and hence less specific than the CDC definitions for hospital acquired infection.[8,9] Furthermore, infection control specialists are very scarce in LTCFs in Europe, and local staff may not have the relevant resources or the expertise to meet the requirements for developing sustainable infection prevention and control programs. Infection control specialists are more commonly encountered in LTCFs in the USA than in Europe, albeit usually only on a part time basis. The prerequisites vary considerably between LTCFs since this very heterogeneous setting differs greatly in classification and type of facility. Recognizing the need for improving infection control in LTCFs, the EU CDC provided funding to conduct the HALT project from 2008 through to 2011, and subsequently the HALT-2 project.[1] The HALT project estimated that, in 2010, at least 62,000 LTCFs existed in the EU and these had a capacity of approximately 3.1 million beds, 58% of which were situated in general nursing homes (residents who require 24-h medical or highly skilled nursing supervision), 32% in residential homes (residents who require 24-h supervision of daily activities) and 10% in mixed facilities.[1] Since LTCF residents are at risk for HAIs due to aging-associated organ changes, underlying comorbidities and use of invasive medical devices, among other reasons, contribute to the high burden of infection in LTCFs.[10,11]