Oral health care in private and small long-term care facilities: a qualitative study

Objective: Elderly people who are institutionalised receive qualified care. Among the services supplied, oral health care has not always been a priority. The aim of this study was to identify the characteristics of oral health care provided to the elderly residents in long‐term care facilities (LTC) in Porto Alegre/RS city. Methods: Twelve private and small‐size LTCs (less than 20 residents) participated in this study. All supervisors and 36 carers were interviewed. The data obtained were organised according to the offer of oral health under the following categories: responsibility for oral care, oral care routines, difficulties carrying out oral care routines. Results: The procedures used most often in order of frequency were tooth brushing, prostheses cleaning, use of mouthwashes, soaking of prostheses and cleaning of the tongue. Among the difficulties mentioned were the high cost of dental assistance, the lack of co‐operation both by family members and by the elderly themselves, the oral and general health status of the elderly and the limited time available for carers to carry out the tasks. Oral care is conducted empirically, and the responsibility is left to the carers. Conclusions: Analysis of the statements given reveals that oral care does not follow any kind of protocol or standardisation. The persistence of this situation could lead to unsatisfactory oral health care in private and small LTC facilities.     

Antibiotic utilization and Pseudomonas aeruginosa resistance in intensive care units

Pseudomonas aeruginosa is one of the most frequent and dangerous pathogens involved in the etiology of severe nosocomial infections. A retrospective observational study was conducted at all intensive care units of the University Hospital in Olomouc, Czech Republic (155 ICU beds). Complete antibiotic utilization data of the ICUs in the period of 1999 to 2008 were processed according to ATC/DDD system and expressed in defined daily doses per 100 bed-days (DBD). Utilization of meropenem, imipenem, ciprofloxacin, ofloxacin, pefloxacin, gentamicin, amikacin, ceftazidime, cefoperazone, cefoperazone/sulbactam and piperacillin/tazobactam was measured. Pseudomonas aeruginosa strains were isolated from clinical material obtained from patients hospitalized in ICUs. During the ten-year period, utilization of the entire group of antibiotics monitored grew. It increased from 23.52 DBD in 1999 to 27.48 DBD in 2008 with a peak of 33.04 DBD in 2007. P. aeruginosa accounted for as much as 42% of pneumonias and 23% of surgical wound infections. Our results show that P. aeruginosa strains became gradually resistant to all antibiotics used in the treatment of the infections caused by them, with the exception of amikacin and piperacillin/tazobactam.     

重症监护病房革兰阴性杆菌耐药性分析

目的了解深圳市人民医院重症监护病房(ICU)革兰阴性杆菌的分布及其耐药性,指导临床合理用药。方法收集来自重症监护病房各类标本分离的革兰阴性杆菌540株,用VITEK AMS-60或VITEK-Ⅱ全自动微生物分析仪进行菌种鉴定,用K-B法进行药敏试验。结果ICU检出的革兰阴性杆菌以鲍曼不动杆菌、大肠埃希菌、铜绿假单胞菌和肺炎克雷伯菌为主,ESBLs阳性的大肠埃希菌和肺炎克雷伯菌比例为61.6%和51.8%,各类细菌对常用抗菌药物表现为严重耐药和多重耐药。结论该院ICU检出的革兰阴性杆菌以鲍曼不动杆菌、大肠埃希菌、铜绿假单胞菌和肺炎克雷伯菌为主,且呈现多重耐药性。     

A scoping review and research synthesis on financing and regulating oral care in long-term care facilities

doi: 10.1111/j.1741‐2358.2011.00575.x A scoping review and research synthesis on financing and regulating oral care in long‐term care facilities Background: Oral health care for frail elders is grossly inadequate almost everywhere, and our knowledge of regulating and financing oral care in this context is unclear. Objective: This scoping study examined and summarised the published literature available and the gaps in knowledge about regulating and financing oral care in long‐term care (LTC) facilities. Methods: We limited the electronic search to reports on regulating and financing oral care, including reports, commentaries, reviews and policy statements on financing and regulating oral health‐related services. Results: The broad electronic search identified 1168 citations, which produced 42 references, including 26 pieces of grey literature for a total of 68 papers. Specific information was found on public and private funding of care and on difficulties regulating care because of professional segregation, difficulties assessing need for care, uncertainty on appropriateness of treatments and issues around scope of professional practice. A wide range of information along with 19 implications and 18 specific gaps in knowledge emerged relevant to financing and regulating oral healthcare services in LTC facilities. Conclusions: Effort has been given to enhancing oral care for frail elders, but there is little agreement on how the care should be regulated or financed within the LTC sector.     

Barriers to provision of dental care in long-term care facilities: the confrontation with ageing and death

Objective: The aim of the study was to reveal barriers to providing dental care for residents in long‐term care (LTC) facilities. Design: Participants were selected randomly from the dentist register in Berlin and Saxony, Germany. The sample consisted of 60 self‐employed and 60 employed dentists, a further 60 dentists worked in their own dental practice but also part‐time in an LTC facility. In semi‐structured interviews a questionnaire with 36 statements concerning working conditions, administration and cost, insecurity concerning treatment decisions as well as confrontation with ageing and death was employed. Subsequently, the study participants were asked to rank the four dimensions concerning their impact on the decision against providing dental care in an LTC facility. Results: The random sample was representative in age and gender for the dental register in Berlin and Saxony. Fifty‐six per cent of the participants (63% of the men and 51% of the women; 52% of the self‐employed, 60% of the employed and 56% of the consultant dentists) indicated unfavourable working conditions as biggest obstacle in providing dental care in an LTC‐facility. Thirty‐two per cent of participants rated administration and cost, 7% the insecurity in treatment decisions as major hindrance. Only 5% of the participants rated the confrontation with age and death as substantial barrier. There were no age and gender differences. Dentists in Berlin seemed more concerned about administration and cost of a consultancy activity and less secure in their therapy decisions than the colleagues from Saxony (p < 0.001). Dentists who work partly in LTC facilities were the least concerned about the confrontation with ageing and death (not significant), employed dentist showed the least secure in their treatment decisions (p > 0.001). Conclusion: It can be concluded that the awareness of infra‐structural and financial aspects in providing dental care in LTC facilities should be raised with health politicians and that these aspects should be considered when inaugurating or re‐structuring the consultancy services to LTC facilities. Further it would be desirable to establish more postgraduate training programmes to increase clinical and ethical competence in the area of gerodontology.     

Reduction of femoral fractures in long-term care facilities: the Bavarian fracture prevention study

Background

Hip fractures are a major public health burden. In industrialized countries about 20% of all femoral fractures occur in care dependent persons living in nursing care and assisted living facilities. Preventive strategies for these groups are needed as the access to medical services differs from independent home dwelling older persons at risk of osteoporotic fractures. It was the objective of the study to evaluate the effect of a fall and fracture prevention program on the incidence of femoral fracture in nursing homes in Bavaria, Germany.

Methods

In a translational intervention study a fall prevention program was introduced in 256 nursing homes with 13,653 residents. The control group consisted of 893 nursing homes with 31,668 residents. The intervention consisted of staff education on fall and fracture prevention strategies, progressive strength and balance training, and on institutional advice on environmental adaptations. Incident femoral fractures served as outcome measure.

Results

In the years before the intervention risk of a femoral fracture did not differ between the intervention group (IG) and control group (CG). During the one-year intervention period femoral fracture rates were 33.6 (IG) and 41.0/1000 person years (CG), respectively. The adjusted relative risk of a femoral fracture was 0.82 (95% CI 0.72-0.93) in residents exposed to the fall and fracture prevention program compared to residents from CG.

Conclusions

The state-wide dissemination of a multi-factorial fall and fracture prevention program was able to reduce femoral fractures in residents of nursing homes.     

Impact and control of methicillin-resistant Staphylococcus aureus (MRSA) in long-term care facilities

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are a growing concern in long-term care facilities (LTCF). Epidemiologic studies performed in our area have shown high rates of MRSA colonization in elderly residents, and very high rates in some centres. However, the clinical impact of nasal MRSA colonization is often slight. Prevention of MRSA transmission in LTCF includes the application of simple preventive measures with proven effectiveness, such as hand washing, adequately covering of infected wounds, and proper use of antibiotics, without limiting the activities of colonized residents or carrying out active surveillance.     

Antibiotic resistance in Burkina Faso

Burkina Faso is one of the Subsaharan African nations. No national services for monitoring of antibiotic resistance are available, so the number of reports of resistance patterns among hospital pathogens are inconsistent. In order to evaluate antibiotic resistance, a total of 1998 valuable microrganisms were analysed during 2000 at the Medical Centre St. Camille of Ouagadougou, Burkina Faso's capital. They were isolated as follows: 1012 from urine-culture, 503 from tonsil swabs, 398 from pus, 53 from sputum and 32 from blood-cultures. Escherichia coli was the most isolated microrganism from urine (44%); Enterococcus faecalis from tonsil swabs (96.4%), Staphylococcus aureus from pus (17%) and K. pneumoniae (70%) from sputum. In general, resistance to the old antibiotics, such as aminopenicillins and cotrimoxazole was shown. The most active antibiotic was norfloxacin, a rarely used antibiotic in this country. In conclusion, our study shows that it is necessary to create antibiotic-resistance surveillance centers in the developing countries to adopt an accurate therapy to avoid exporting of antibiotic resistance to the developed countries linked to increased emigration.     

Acquired AmpC type beta-lactamases: an emerging problem in Italian long-term care and rehabilitation facilities

We report the multiple detection of Proteus mirabilis isolates, from 4 different long-term care and rehabilitation facilities (LTCRFs) of Northern Italy, resistant to expanded-spectrum cephalosporins and cephamycins and producing an acquired ampC-like beta-lactamase, named CMY-16. Genotyping by PFGE showed that isolates were clonally related to each other, although not identical. In all isolates the bla(CMY16) gene was not transferable by conjugation and was found to be carried on the chromosome. These results revealed multifocal spreading of a CMY-16 producing P. mirabilis clone in Northern Italy and emphasize the emergence of similar acquired resistance determinants in the LTCRFs setting.     

Antibiotic resistance of Streptococcus pneumoniae isolated from patient with home care pneumonia

The monitoring of the resistance of Streptococcus pneumoniae, one of the most important causative agents of extrahospital pneumonia, has been carried out. The data on its sensitivity to antibacterial preparations, widely used in clinical practice, have been summarized.     

Antibiotic resistance of biofilms

Microbial biofilms are notably recalcitrant towards treatment with antibiotics, biocides or disinfectants that would adequately control the same organisms growing in planktonic mode. Much of this resistance has been attributed to an organisation of the biofilm cells within exopolymer matrices. Whilst such exopolymers are unlikely to hinder the diffusion and access of antimicrobial agents to the underlying cells, they will chemically quench reactive biocides such as chlorine and peroxygens, and bind highly charged antibiotics, such as tobramycin and gentamycin, thereby providing some protection to the more deep lying cells. Extracellular enzymes, bound within the glycocalyx and able to degrade the treatment agents, will further reduce the access of susceptible compounds. Diffusion limitation however, is unlikely to be the sole moderator of the resistance properties of microbial biofilms. In addition, gradients of oxygen and nutrients established across the biofilm community will cause growth rates to be much reduced at points remoted from the accessible nutrient. Slow growth rates, and the associated induction of stringent responses further contribute towards this resistance. Finally, there have been recent demonstrations that attachment of microorganisms to surfaces promotes the expression of genes that are not normally expressed in planktonic culture. Whether or not the expression of such genes alters the phenotype in a manner which alters the response of the cells to antimicrobial agents remains to be demonstrated.     

Antibiotic resistance of biofilms

Microbial biofilms are notably recalcitrant towards treatment with antibiotics, biocides or disinfectants that would adequately control the same organisms growing in planktonic mode. Much of this resistance has been attributed to an organisation of the biofilm cells within exopolymer matrices. Whilst such exopolymers are unlikely to hinder the diffusion and access of antimicrobial agents to the underlying cells, they will chemically quench reactive biocides such as chlorine and peroxygens, and bind highly charged antibiotics, such as tobramycin and gentamycin, thereby providing some protection to the more deep lying cells. Extracellular enzymes, bound within the glycocalyx and able to degrade the treatment agents, will further reduce the access of susceptible compounds. Diffusion limitation however, is unlikely to be the sole moderator of the resistance properties of microbial biofilms. In addition, gradients of oxygen and nutrients established across the biofilm community will cause growth rates to be much reduced at points remoted from the accessible nutrient. Slow growth rates, and the associated induction of stringent responses further contribute towards this resistance. Finally, there have been recent demonstrations that attachment of microorganisms to surfaces promotes the expression of genes that are not normally expressed in planktonic culture. Whether or not the expression of such genes alters the phenotype in a manner which alters the response of the cells to antimicrobial agents remains to be demonstrated.