Nursing Homes in ‘Post-Antibiotic Era’: Infection Prevention Confronts Deadly Superbugs, New Regulatory Scrutiny 

On the heels of warnings about the spread of deadly fungal infection of Candida auris, the World Health Organization (WHO) is now raising alarms about widespread resistance against antimicrobial drugs — with long-term care settings particularly at risk of some resulting “superbugs.”

Medical experts and government agencies are cautioning that unless the use of antimicrobial drugs is curbed and more closely monitored, multidrug-resistant organisms (MDROs), commonly referred to as superbugs, will be on the rise, with dire consequences for nursing homes. That’s because — as seen during the Covid-19 pandemic — infectious diseases can spread quickly through nursing homes.

“We have a little saying in the medical community that hospitals make MDROs. Nursing homes can spread MDROs,” said Dr. Swati Gaur, medical director at New Horizons Long Term Care Facilities, told SNN.

Aside from Candida auris, or C. auris, superbugs include antibiotic-resistant bacteria known to cause infections that include respiratory, urinary tract and skin infections. These bacteria easily spread and evolve to make healthy bacteria in the body become antibiotic-resistant, which is why it is so important for nursing homes to control their use.

Moreover, there is also now a known link between use of antibiotics and C. auris. People who have been treated with certain types of antibiotics called Carbapenems, for instance, are also found to have an increased incidence of C. auris.

“What we are seeing is that there is some association,” Dr. Gaur said. “So if you treat people with broader spectrum antibiotics or previous episodes of antifungals, then there’s a higher chance” of drug resistance to treat C. auris, she said.

This is just one example of the risks posed by the rise of antibiotic- and antifungal-resistant drugs, and the lack of new drugs in the pipeline, as highlighted in an NBC News article published Wednesday. That article included sobering words from Dr. Venkatasubramanian Ramasubramanian, president of the Clinical Infectious Diseases Society of India:

“We have arrived in the post-antibiotic era. The current antibacterial pipeline is woefully insufficient to make a difference in tackling the ongoing threat of antibiotic resistance.”

A worsening situation

Antimicrobial drug overuse has been a concern for decades, with health officials issuing regular warnings.

According to a recent WHO report released this month, just 27 new antibiotics for the most threatening infections are in the clinical trial stage of drug development, as noted in the NBC News article. It’s a low number compared to drugs in clinical trials for diseases like cancer, for example.

Meanwhile, of the antibiotics in trials, only six show promise of overcoming antibiotic resistance, with only two being considered effective for killing the most resistant bacteria, the WHO report states.

Given that in the last four years or so, only one new antibiotic has emerged as effective in treating superbugs such as Enterobacteriaceae, the outlook is grim for disease control and prevention.

Bacteria are responsible for a range of serious infections in the lungs, urinary tract, ears, blood, open wounds, or even the brain and the spinal cord. And drug-resistant ones are on the rise. More than 2.8 million people in the U.S. develop drug-resistant infections each year, and more than 35,000 people die as a result, according to the CDC.

Antifungal drug-resistant infections, such as from C. auris also increased 60% in 2020, CDC reported.

Steps to prevent drug resistance

Gaur recommends that health care providers, including skilled nursing facilities, implement antimicrobial stewardship programs that track patient data on how much, how often and for how long antimicrobials are used at a particular facility. Then, using this information, often mapped by labs as a snapshot in time, facilities can more responsibly use antimicrobial drugs.

“Let’s make sure that we are being good stewards of not just using the right antibiotics for the right indication for the right time, and not overusing them, especially the broader spectrum antibiotics,” she said.

At her organization, Gaur said, the stewardship program began many years ago and is implemented with the help of the medical director and nursing leadership, but also the infection preventionist and consultant pharmacists. At regular meetings, the organization will review usage data for a range of antimicrobial drugs to make decisions on a resident’s treatment plan.

“Every month we are assessing the number of infections that we are treating. We are assessing them against what is called the McGeary criteria, a surveillance criteria,” to monitor the treatment of infections, she said. “It is a very intensive interdisciplinary effort.”

Steps to prevent infection spread

Advocacy groups for nursing homes, medical experts and government agencies alike are all urging collection and reporting of more data and ramped up prevention methods.

Recently, the Government Accountability Office (GAO) urged more infection prevention research, training and “non-monetary” means of infection control, to evaluate and implement protocols beyond the acute care setting.

Centers for Disease Control and Prevention (CDC) officials were supportive of the idea, and noted that increased funding and resources would need to be made available to SNFs and agencies for these endeavors.

And following these recommendations, officials from nursing home advocacy group LeadingAge said in a conference call that infection control has been getting significant attention from the Biden administration, signaling that changes are likely on the way.

Beyond collection and scrutiny of data, the role of infection preventionists in curbing the spread of disease is absolutely key, said Gaur, who is also affliated with AMDA – the Society for Post-Acute and Long-Term Care Medicine.

“You need the leadership of a medical director. However, you also need the clear role and designation of infection preventionist, and they need to have time to work on these programs,” she said.

She emphasized the specialized nature of the infection preventionist role and the need for such a position to be supported through training, certification and being given ample time to focus on IP-related work. “When you talk about Candida auris, for example, there’s a huge role of infection preventionists here,” Gaur said.

The Association for Professionals in Infection Control and Epidemiology (APIC) applauded the GAO for identifying actions to improve infection prevention and control practices in nursing homes, in a statement issued on Wednesday. The association said it was in favor of regulation that required each nursing home facility to have at least one full-time, dedicated infection preventionist on staff.

The group also called upon the CDC to increase reporting requirements of the healthcare-associated infection (HAI) tracking system.

“[CDC] should build on current reporting requirements in nursing homes to include surveillance of HAIs and drug-resistant pathogens, such as Candida auris.”

Certain common sense measures that became popular during the pandemic should continue as well. Gaur recommends steps such as robust hand washing, wiping down surfaces (even windowsills), washing equipment, and making staff aware of the cleaning requirements, and ultimately placing an infected resident in a single-occupancy room.

In addition, Gaur suggests staff wear personal protective equipment (PPE) for “enhanced barrier precautions,” such as gowns, gloves and masks.

All these efforts are not cheap. These prevention initiatives also increase the workload of the staff, and with the labor shortage, pursuing infection control will not be easy, she said, noting the commitment required:

“These programs are not really cost neutral. In order to have a good program you have to invest in creating the infrastructure to have successful, quality programs.”