Recommendations for the prevention of healthcare-associated infections in nursing homes

1. INTRODUCTION

Nursing homes are one of the care services included in the Spanish System for Autonomy and Care for Dependency (SAAD in Spanish). They logically try to reproduce living conditions for their inhabitants as close as possible to those at home, favouring human contact with other residents, family members and visitors.

However, they are places favouring the transmission of infections, as people with frequent and important underlying diseases live in close proximity to each other, sharing caregivers in a common habitat thus hindering the existence of control and isolation zones.

We know a lot about infection prevention measures in hospitals and healthcare centres, but we know very little about infection prevention in smaller institutions with fewer resources for this purpose, such as nursing homes.

We are not currently aware of any regional or national programme on healthcare-associated infection prevention specific to nursing homes, so we have developed a practical set of recommendations aimed at the prevention and control of infection in nursing homes.

For this reason, the Board of Trustees of the Health Sciences Foundation conducted a review of the literature on the prevention of infection in nursing homes in our country and on the existing indicators used to monitor this process. The topics were distributed among a multidisciplinary group of experts, including the views of scientific societies, patient associations, the media, government officials, geriatricians, infectious disease specialists, microbiologists and other specialists. The lines that follow are the results of multiple meetings and discussions.

2. MATERIAL AND METHODS

Two of the authors conducted a systematic literature search in PubMed using keywords: Infection Prevention Control, Nursing Homes, Long Term Care Facilities, Health Care Related Infection; as well as in official documents of the Health Departments of the Autonomous Communities, the Ministry of Health, the World Health Organisation (WHO) and the European Centre for Diseases Control (eCDC).

With the data obtained, a first document with recommendations was drawn up for subsequent discussion by a multidisciplinary drafting team, which was reviewed by the rest of the authors representing the different scientific societies and organisations that endorse the document.

3. DEFINITION AND CLASSIFICATION OF NURSING HOMES

3.1. Some characteristics of nursing homes and the people who live in them:

Nursing homes are establishments intended for the temporary or permanent accommodation of dependent individuals, with services and intervention programmes adapted to the needs of the people being cared for, aimed at achieving a better quality of life and promoting their personal autonomy.

They represent a diverse group of social and health care settings serving people of various ages and functional abilities and providing an increasingly wide range of services with varying degrees of care.

In terms of infection control, some characteristics of these centres need to be taken into account:

1. People living in nursing homes accumulate a high number of chronic diseases: the most recent study in Spain on comorbidity and resource use of people living in nursing homes shows a very significant increase in morbidity in the last decade (1). Specifically, using average figures, the age was 87 years, there were 7 chronic diseases per person and 11 pharmacological active ingredients were consumed per person, with a high yearly mortality (20.4%). Compared to the non-institutionalised elderly population they had a higher multimorbidity rate (15.2% vs. 4.2%), with a higher number of chronic diseases, especially dementia (46.5% vs. 4.6%).

2. Hospital visits by these people are very frequent: compared to the non-institutionalised elderly population, this population has a higher number of hospital admissions (47.6% vs. 27.7%), a higher number of admissions to medium-stay hospitals (27.8% vs. 7.4%) and a longer hospital stay, once admitted (10 days vs. 7.2 days).

3. Staff and resident ratios are small and directed only to care and not to infection prevention. A recent study by the Spanish Society of Geriatrics and Gerontology (SEGG) on the regulations affecting nursing homes in Spain (2), highlights the existence of very tight staffing ratios mainly aimed at general care, with little emphasis on prevention and control of intercurrent diseases and infection in these centres. As an example, the average time spent with a geriatric carer per resident ranges from 43 minutes to 83 minutes and with a nurse from 5 to 22 minutes per day.

These figures make it very difficult to establish ambitious infection control programmes and encourage indiscriminate transfer to the referral hospital, where the risk of healthcare-associated infection (HAI) is ­elevated.

4. The health care provided in nursing homes depends on the national health system in Spain and the health services of each autonomous community, as stipulated in all regulations. This leads to the medical management of these people with such a high complexity and burden of chronic diseases falling on the primary care referral and, in the most severe cases, on the hospitals. Instead, care is episodic, with difficult or non-existent coordination between social and health services. This also means a loss of clinical information that is vital for infection control should infection occurs.

5. Only a few autonomous communities regulate the presence of a clinical professional (usually a nurse) as the person responsible for the hygienic-health care processes of these people.

Currently, the model is in a phase of change towards smaller nursing homes, with a closer, more person-centred model of care. The recent agreement reached in 2022 between the Autonomous Communities and the State favours a model of residential care based on the following principles (3):

a) Smaller centres (maximum 75, 90 or 120 places). The classification proposed in these recommendations already covers this standard.

b) Model of person-centred care, with respect for the preferences and participation of the family in an environment free of physical and chemical restraints.

c) Very modest increase in staffing ratios.

d) Health care remains in the hands of the health services, yet there is no regulation on how to do this.

The current model poses the difficult challenge of maintaining environments that are homey, familiar and open to the community, as well as respectful of people’s dignity and infection control (e.g. isolation is an enormous assault on their mental, functional and emotional balance and should be an exceptional measure).

3.2. Classification of nursing homes for infection control: a proposal

The Institute for the Elderly and Social Services (IMSERSO) still classifies nursing homes into residences for the elderly, assisted living and mixed residences. But this is a classification that is clearly in disuse nowadays and there is a tendency to speak of nursing homes in general, regardless of their size and variety of services.

The classification of nursing homes according to the greater or lesser presence of professionals dedicated to carrying out therapeutic work such as convalescence or rehabilitation stays is also found in other countries (4).

In any case, these classifications shed very little light on how to grade the risk of transmission of infection, so a self-developed classification has been proposed in these consensus recommendations. This classification is detailed below.

Classification of the risk of infection in nursing homes

We know that in social and healthcare centres, due to their characteristics, the profile of the elderly who reside in them, the existence of multiple underlying conditions, polymedication and many other variables, there is a higher prevalence of infections. In order to be able to quantify the risk of HAI and then offer different recommendations, we propose a classification system based on a series of variables chosen at our discretion that we believe can serve as indicators of the risk of HAI in nursing homes (Table 1).

Table 1 System for classifying nursing homes according to their risk of HAI

We are aware of the limitations that this classification may have, but it can give us a rough idea of what we want to know. These variables could be:

• Number of residents: the greater overcrowding of spaces may favour the transmission of infections.
• Number of single/double/triple rooms: sharing rooms favours possible transmission.
• Degree of dependency assessed by the Barthel scale: many of the items assessed by the Barthel scale have a lot to do with factors that may predispose to infection (incontinence, toileting, immobility). We understand that the greater the dependency, the greater the risk. We distinguish between mild, moderate and severe.
• Proportion of residents (%) with bladder catheters or invasive devices in general: all these devices are known to be a potential source of infections.
• Medical staff, pharmacists and nursing professionals in the centres, as reference personnel who contribute to prevention, detection and treatment in the case of infectious processes.
• Existence or lack of infection prevention plans: vaccination protocols, protocols for the use of antibiotics for the most prevalent infections, protocols for general infection prevention measures, staff training.
• Possibility of isolation: assess whether it is possible, if necessary, to keep affected residents isolated from contact with other healthy residents, while maintaining the care they need and taking all possible precautions with regard to the staff attending to them.
• Existence of nursing home-primary care-hospital referral: there is a relationship and contact with the specialist in the hospital for the joint assessment of cases.
• Ratio of first level direct care staff (assistants/geriatric carers): in relation to the number of assistants caring for residents. The requirements in the different communities are very different and vary according to the type of residents in relation to their degree of dependency. According to the new accreditation criteria prepared by the Ministry of Social Rights (Accreditation and Quality Agreement 28/06/2022) this ratio starts from 0.31 to 0.43 for the coming years as a minimum requirement for centres with a majority of dependent residents (grade II/III).

With these parameters we summarise in the following table (Table 1) a point system that could roughly classify nursing homes according to their risk of HAI into:

• Low risk of HAI: between 0 and 5 points.
• Medium risk of HAI: between 6 and 10 points.
• High risk of HAI: between 11 and 20 points.

4. RECOMMENDATIONS FOR ACTION

The following are some recommendations for establishing the basis for an infection control programme in nursing homes.

4.1. The development of a programme for the prevention and control of HAI in nursing homes (PPCIR) at all levels is recommended

The main functions of the PPCIR are to prevent infection of residents through surveillance and early diagnosis activities, and to ensure that measures are in place to prevent the acquisition of infections and the transmission of pathogenic micro-organisms. To achieve these objectives in a cost-effective manner, we believe that all nursing homes should have a written plan with an active and effective programme throughout the organisation and its implementation should be supported continuously by the management.

A key component is to have written infection control protocols (including those related to environmental hygiene), and implement them so as to detect, contain and prevent the transmission of potential pathogens. Infection control programmes should be tailored to the type of facility, facility layout (including isolation facilities), risk factors among residents and available resources.

4.2. It is advisable to designate one person as PPCIR co-ordinating officer

We believe that in order to guarantee compliance with any protocol or PPCIR, it is preferable for it to be led by a healthcare professional who has the support and recognition of the centre’s management and who is a point of reference for the healthcare team to coordinate activities and improve communication with the rest of the professionals, both from the centre itself and from the Public Health Service.

Regarding the person assigned as responsible, it is desirable (although not essential) that he/she has knowledge of infectious disease control and management (clinical manifestations, mechanisms of transmission and spread, and prevention measures); leadership and communication skills, as well as teamwork skills. This person is the one who must transmit all information to the rest of the professionals in the institution, as well as to the residents and their relatives, ensuring that all necessary infection prevention measures are carried out. On the other hand, this person is the one who must inform the Public Health System of relevant events and also the Primary Care physician responsible for the care at the nursing home, as well as the Specialised Geriatric Hospital Services. This work is essential for the prevention of any communicable disease; as well as to quickly implement the contingency plan, and/or isolation precautions and avoid transmission to the rest of the residents, workers and visitors.

4.3. It is recommended that an annual education and training plan for healthcare workers be drawn up

Continuous training of workers is an aspect that certainly deserves a great deal of attention. We believe that successful implementation of HAI prevention programmes in nursing homes should have very specific objectives and include aspects of training for both staff and residents. The following is a list of recommendations which, although they are not the only ones that exist, are what we consider to be the minimum necessary for the development of an infection prevention and control plan in nursing homes.

4.4. There should be a protocol for environmental prevention measures

We would particularly like to stress that except in the circumstances of immunocompromised residents, air quality control measures cannot be extrapolated to those carried out in hospital environments. We have not found any specific legislation for nursing homes in terms of air quality monitoring.

In some Autonomous Communities, there are regulations that establish the environmental cleanliness measures that all centres, in addition to complying with the general legislation in force on hygiene and health, must guarantee. These recommendations are summarised below.

• General and permanent cleaning of the building and its dependencies, especially those under heavy use, as well as disinfection using detergents with disinfectant capacity (chlorinated detergents, quaternary ammonium compounds, etc.). Disinfectants for sanitary use or products accepted by the Spanish Agency for Medicines and Medical Devices (AEMPS) for application in the sanitary field shall preferably be used.
• Annual insect and rat extermination, or as often as circumstances require.
• Cleaning and disinfection of crockery and cutlery after use, by means of automatic hot washing, as well as other commonly used instruments.
• Suitable space should be available for the temporary storage of waste in closed bins (intermediate storage).

4.5. It is recommended to have written instructions for a hand hygiene plan for staff and visitors

Hand hygiene is one of the most important infection control measures. Residents should be cared for with clean hands and the lowest microbial load to avoid infections and the transmission of potentially pathogenic microorganisms. Each nursing home needs to have a plan in place to promote proper hand hygiene for workers, detailing when, how and with which products to perform hand hygiene. In addition, it must ensure the availability of products and devices, as well as the regular training and education of workers.

Hand hygiene of workers should preferably be carried out with hydroalcoholic solutions, if the hands are not visibly soiled. The facility should be equipped with an adequate supply of alcohol-based products at the main points of resident care or provide individual flasks for staff use. If this is not the case, washing with soap and water should be carried out. The hand hygiene technique established by the WHO should always be performed and the WHO 5 Moments for Hand Hygiene should be followed in the nursing home (5).

Different complementary strategies can be used to improve compliance with this basic hygiene measure. One is the monitoring of compliance through direct observation as all hand hygiene opportunities can be explicitly accounted for, those who do not practice hand hygiene can be identified and the reasons for non-compliance explored. The observation should be carried out by a healthcare professional previously trained in the subject (6). Another indirect and less costly measure of compliance is the monitoring of consumption (quarterly, yearly, etc.) of hydro-alcoholic and/or soap solutions, and of course it is good practice to have dispensers in rooms, common areas such as gyms, consulting rooms, bathrooms and living spaces.

4.6. It is advisable to have a written document on the proper use of gloves

Common, disposable, single-use, non-sterile gloves are a protective measure for the worker. However, the use of such gloves has been identified as a barrier to proper hand hygiene and as a factor in the spread of micro-organisms.

Therefore, gloves should only be used when contact with non-intact skin, blood or body fluids such as secretions, urine, faeces, etc. is anticipated. When contact is to be made with clean whole skin or with objects that are not stained with the above liquids, gloves need not be worn.

4.7. It is desirable to have a document of recommendations for the prevention of both catheter-associated (CA-UTI) and non-catheter-associated urinary tract infection (UTI)

Residents without bladder catheters

Although the management of UTI is not the main focus of this document, we wish to emphasise that more than 20% of older people may have asymptomatic bacteriuria, which at some point could be mistaken for UTI. Current management guidelines do not recommend the indiscriminate screening for bacteriuria as a marker of infection in residents without manifestations directly attributable to the urinary tract, nor the use of urine strips as a diagnostic method for UTI. From a preventive point of view, hygiene and toileting of continent residents is very important in this group of residents, as well as frequent nappy changing and perineal hygiene in incontinent residents.

Residents with temporary urinary catheters

Below, we highlight some of the basic strategies for preventing CA-UTIs:

• Insert catheters only for appropriate indications.
• Leave catheters in place only as long as necessary.
• Ensure that only duly trained persons insert and maintain catheters.
• Insert catheters using aseptic technique and sterile equipment. Extreme hand hygiene measures before putting on gloves and after removing them.
• After aseptic insertion, maintain a closed drainage system.
• Maintain unobstructed urine flow.

Residents with indwelling bladder catheters

To reduce the incidence and duration of catheterisation, it is important to assess and communicate the presence of a urinary catheter to the medical team and reassess the indication periodically. A simple continuous quality improvement programme based on nurses asking physicians if continued catheterisation is necessary significantly reduces the duration of urinary catheterisation as well as the rate of catheter-associated urinary tract infections.

For further information, please consult the guidelines for the prevention and management of catheter-associated urinary tract infection on the European Centre for Disease Prevention and Control (ECDC) website (7).

4.8. It is advisable to have a protocol with recommendations for the prevention of respiratory infection

Outbreaks of respiratory infections occur in all residences throughout the year, but are most frequent from autumn to early spring. Such outbreaks can cause considerable morbidity and mortality, so we believe it is imperative that every nursing home, regardless of level, should have in place a set of written policies and procedures related to outbreaks of respiratory infections, including early detection of infection, staff and resident education, and vaccination requirements.

We believe that daily active surveillance is the most effective way to prevent and detect respiratory infections, which involves staff identifying symptoms of respiratory infection. Although it is beyond the scope of this document, we wish to recommend the use of self-diagnostic tests in people with new-onset respiratory manifestations. As the sensitivity of these tests does not allow the diagnosis to be excluded, it is recommended that residents with clinical manifestations avoid contact with other residents and that visitors wear masks. While a negative result does not exclude the diagnosis, a positive result has a high positive predictive value.

Some of the official recommendations currently available can be consulted in detail (8, 9). At the core of these recommendations will be the isolation of infected residents, reduction of visits and vaccination policy.

4.9. There should be a system of regular assessment of the vaccination status of residents and workers by the nursing homes

Vaccination is one of the most important cost-effective strategies for the prevention of infectious diseases available today. We consider it essential for all nursing homes to have a written protocol to verify and enhance the local vaccination programme; to this end, it is recommended that a record be kept of each resident’s vaccination and that a protocol be established for action when a resident is detected who needs to update his/her vaccination schedule (10).

While we understand that it is not legally enforceable for workers or residents to provide vaccination information, a voluntary attempt to obtain such information on vaccination status is desirable and should be recorded in the medical records and medical information of the nursing home. Vaccination of workers against influenza and COVID-19 should be promoted by the nursing homes management as a principle of solidarity, ethics and protection of vulnerable people.

For further information, we refer interested parties to a recently published document entitled The situation of vaccines for the prevention of infections in adults: An opinion paper on the situation in Spain (11).

4.10 It is advisable to have a protocol for the prevention of any type of skin and soft tissue injury with risk of infection

It should be pointed out that in this field not only infections caused by bacteria should be considered, but also those potentially caused by viruses (Herpes zoster); fungi (Candida spp) and parasites (scabies). To this end, daily skin checks are appropriate in facilities with a high risk of infection and with more than 50% of residents with a calculated Barthel score ≤ 55 points and in residents at the end of life. In addition to observing the skin daily for warning signs of pressure ulcer (PU), residents with predisposing factors (altered mental status, incontinence, obesity, malnutrition, smoking, reduced mobility, dehydration, etc.) should be identified early. And, of course, we should stress the importance of prevention of pressure injuries and also of moisture-associated skin damage, as well as monitoring for signs of infection in injuries that have already occurred.

The Norton scale (Table 2), which measures a patient’s risk of pressure ulcers (PU), is also added.

Some recommendations for skin care include:

• Keep the skin clean and dry, thus limiting the skin’s exposure to moisture, urine and faeces.
• Use moisture barrier creams to protect the skin from urine and faeces.
• Change bed linen and clothing as often as necessary.
• Pay attention to buttons on clothing and wrinkles in sheets that may irritate the skin and frequent nappy changing (at least twice a shift).

For more detail on skin care considerations, see the SEGG’s protocols for basic care of the elderly (12), or the website of the National Group for the Study and Advice on Pressure Ulcers and Chronic Wounds (GNEAUPP) where a specific library can be consulted at the following link: https://gneaupp.info/biblioteca-internacional-de-heridas/.

4.11. Recommendations for the prevention and control of gastrointestinal infection

Infections by viruses (norovirus, rotavirus, etc.) and bacteria (Salmonella, Shigella, Campylobacter) are common causes of diarrhoeal disorders in people living in nursing homes, although C. difficile infection is particularly prevalent in this population and is related to antibiotic use.

At this point it is particularly important to take into account antimicrobial stewardship (AMS) programmes for the appropriate management of antibiotics in this population (13) of which the incidence of C. difficile infection (CDI) would be an indirect marker of antibiotic use or abuse.

CDI is a cause of severe diarrhoea in the elderly. Prevention of C. difficile transmission and infection remains a serious and difficult challenge in infection prevention and patient safety. We consider the control of antibiotic consumption to be the most important measure for the prevention of CDI and therefore recommend that all centres should keep a register of residents on antibiotic treatment, review the appropriate duration of treatment and avoid the use of empirical antibiotic treatment as much as possible.

Once a case of diarrhoea has been detected, other measures should be put in place to prevent the spread of infection, either by direct or indirect contact with the patient or their environment, and it is therefore recommended that residents be placed in contact isolation (single room; use of disposable gloves; hand hygiene with soap and water to wash away C. difficile spores as these are resistant to alcohols; use of disposable gowns if contact with the patient or their belongings is anticipated). In some care settings, where private rooms may not be available, other actions may be considered, including the use of spatial separation (a minimum distance of 1 metre between beds is recommended) to reduce the possibility of sharing items between the ‘isolated’ patient and others.

In addition, it is very important to reduce contamination of the resident’s room by intensifying cleaning and disinfection measures, especially of objects or surfaces that are touched by hand, with chlorinated products for sanitary use.

4.12. Written protocols are needed to deal with potential outbreaks of HAIs

Outbreaks can be defined as unusual increases in diseases above baseline levels; surveillance and control of outbreaks should be a high priority. Issues to be considered in an outbreak management plan include: development of a case definition, case finding, outbreak analysis, formulation of a transmission hypothesis, design and evaluation of control measures, and reporting to Public Health.

The most common causes of outbreaks are respiratory and gastrointestinal infections. In some cases, a single case may be sufficient to trigger a response of the infection prevention and control programme. Examples of residential outbreaks include: influenza, tuberculosis, meningococcal meningitis, Legionella spp. infection, norovirus, salmonellosis, group A streptococcal soft tissue infection, viral hepatitis, scabies and infection with antibiotic resistant pathogens.

4.13. It is recommended that nursing homes that do not have their own pharmacy service establish an agreement with a community or hospital pharmacy in order to receive the necessary pharmaceutical coverage and care and to collaborate in epidemiological surveillance

The new regulation differentiates, as did RDL 16/2012, between homes with more and less than 100 beds for the purpose of establishing pharmaceutical provision. For nursing homes with more than 100 beds, a pharmacy service must be installed, while for homes with less than 100 beds, a variable system is established depending on whether the nursing homes are public or private.  

4.14. The development of written recommendations for the prevention of transmission of eye infections and conjunctivitis is recommended

Outbreaks of ocular infection in nursing homes by both bacterial and viral pathogens are well described (14).

Prevention is therefore important to ensure the eye and general health of residents and should basically include measures such as hand hygiene of residents, visitors and caregivers and eyelid washing with clean, warm water or the use of special eyelid cleansing wipes (15, 16).

4.15. Infection prevention and oral health issues

Oral health and hygiene are essential in reducing infections such as aspiration pneumonia (17) but it has also been shown that oral health can significantly affect overall health and is clearly related to the quality of life of older people. Therefore, we believe that oral health programmes should be promoted in nursing homes (18) providing information related to dental care and its importance both to the elderly and to their carers and relatives in order to detect oral diseases and treat them appropriately (19). All this establishes the need for a close relationship between nursing homes and dental professionals (20-24).

5. DATA COLLECTION

Surveillance is important to detect outbreaks, changes in infection rates and other issues requiring infection control intervention (including the need for additional training or education of staff). The components of a monitoring system include a mechanism for data collection, a timetable and procedure for data evaluation, dissemination of results, and mechanisms for action and follow-up. Monitoring disease patterns over time can provide information on the effectiveness of changes in infection control practices and policies.

Surveillance data can be collected through regular review of medical records, laboratory reports and other records. Monitoring compliance with infection control measures (process indicators such as hand hygiene compliance, catheter care and vaccination rates of staff and residents) is also an important component of infection prevention and control.

The frequency of data review will depend on the size and nature of the centre. Facilities at higher risk (High Risk) of HAI may need to review data at least monthly, while facilities at lower risk could be reviewed on a quarterly (Intermediate Risk) or six-monthly (Low Risk) basis.

Information on trends should be provided to units and employees, and be accompanied by action plans and follow-up.

This data set we advocate can result in an individual’s data programme and an institution’s data programme. The following are recommendations of its key features.

5.1. Individual monitoring programme: data collection at different points in time

On admission

We consider it necessary to have an individual file for each resident, which includes a complete geriatric assessment on admission, pharmacological treatments, and a social and medical assessment that allows for a complete final assessment of each resident.

Therefore, at the time of admission to a care home, in addition to the Individual Care Plan (ICP) drawn up by the interdisciplinary team of the centre, we believe it is necessary to have the following information in the file:

Checking the current adult vaccination schedule.

Episodes of infection, hospital admission and antibiotic use should be recorded for each individual. For persons with infections that are managed in the nursing home, at least daily recordings should be made of the following:

• Temperature, blood pressure, heart rate and oxygen saturation.
• Presence of bladder catheter.
• Presence of venous catheter.
• Presence of pressure injuries or moisture-associated skin damage.
• Presence of diarrhoea (>3 bowel movements/24 hours).
• Use of antibiotics (1 or more).
• Type of infection.

A sample data collection sheet is tentatively provided ( see Annex 2).

Data Collection in Special Situations

After Hospital Admission

There is no data in the literature to support the mandatory systematic search for colonisation by Multi-Resistant (MR) Microorganisms in institutions that care for the elderly. However, we believe it is advisable to record infections caused by MR microorganisms and to record the carrier status of all residents returning from a hospital admission of more than 24 hours ( see Annex 1: Resident Transfer Sheet); this pertains to the following microorganisms: Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, Carbapenemase-producing Enterobacteriaceae, MR Pseudomonas aeruginosa, MR Acinetobacter baumanii and MR Stenotrophomonas maltophilia. Gram-positive microorganisms should include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and C. difficile, although the latter is not genuinely MR.

5.2. Institution’s data collection programme

As mentioned above, the collection, examination and evaluation of these data allow the detection of HAI problems and the search for solutions, the effectiveness of which can be recorded.

We understand that this programme cannot be the same in all institutions, because of the inequality of size and resources. The following is a list of parameters and recommendations according to the risk of HAI in nursing homes, which should be available to staff at these facilities (Table 3).

Table 3 List of recommendations for the collection of data from institutions
Table 3 List of recommendations for the collection of data from institutions

REFERENCES

1. Amblàs-Novellas J, Santaeugènia SA-O, Vela E, Clèries M, Contel JC. What lies beneath: a retrospective, population-based cohort study investigating clinical and resource-use characteristics of institutionalized older people in Catalonia. (1471-2318 (Electronic)).

2. (SEGG SEdGyG. Normativa de Residencias en España. 2020; Available from: https://www.segg.es/media/descargas/Cuadro_resumen_SEGG_Normativa_Residencias_Rev.17junio2020.pdf.

3. Criterios comunes de acreditación y calidad de los centros y servicios del Sistema para la Autonomía y Atención a la Dependencia. [cited 2022]; Available from: https://www.boe.es/eli/es/res/2022/07/28/(12).

4. Aging NIo. Residential Facilities, Assisted Living, and Nursing Homes. 2017; Available from: https://www.nia.nih.gov/health/residential-facilities-assisted-living-and-nursing-homes.

5. Organization WH. Your Moments for Hand Hygiene. 2012.

6. Organization WH. WHO guidelines on hand hygiene in healt care (advance draft): a summary: clean hands are safer hands. 2005; Available from: https://apps.who.int/iris/handle/10665/69143.

7. Control ECfDPa. Protocol for point prevalence surveys of healthcare-associated infections and antimicrobial use in European long-term care facilities – version 4.0. 2023; Available from: https://www.ecdc.europa.eu/en/publications-data/protocol-point-prevalence-surveys-healthcare-associated-infections-4-0.

8. España MdSGd. Adaptación de las medidas en residencias de mayores y otros centros de servicios sociales de carácter residencial en un contexto de alta transmisión comunitaria. 2021; Available from: https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/sanidad14/Documents/2021/110821-Centros_sociosanitarios_actuacion.pdf.

9. Madrid Cd. Guía de medidas en centros residenciales para personas mayores de la Comunidad de Madrid. 2022.

10. Salud CISNd. Calendario Común de Vacunación a lo Largo de Toda la Vida. Consejo interterritorial Sistema Nacional de Salud; 2023.

11. Bouza E, Ancochea-Bermúdez J Fau - Campins M, Campins M Fau - Eirós-Bouza JM, Eirós-Bouza Jm Fau - Fargas J, Fargas J Fau - García Rojas A, García Rojas A Fau - Gracia D, et al. The situation of vaccines for the prevention of infections in adults: An opinion paper on the situation in Spain. (1988-9518 (Electronic)).

12. Gerontología SEdGy. PROTOCOLOS PARA EL CUIDADO BÁSICO DE PERSONAS MAYORES. SISTEMA DE ACREDITACIÓN DE SERVICIOS SOCIALES. 2019; Available from: https://www.segg.es/media/descargas/Protocolos_de_cuidados_basicos_para_personas_mayores_sistema_de_acreditacion_SEGG.pdf.

13. Peñalva G, Crespo-Rivas JC, Guisado-Gil AB, Rodríguez-Villodres Á, Pachón-Ibáñez ME, Cachero-Alba B, et al. Clinical and Ecological Impact of an Educational Program to Optimize Antibiotic Treatments in Nursing Homes (PROA-SENIOR): A Cluster, Randomized, Controlled Trial and Interrupted Time-Series Analysis. (1537-6591 (Electronic)).

14. Domínguez-Berjón MF, Hernando-Briongos P Fau - Miguel-Arroyo PJ, Miguel-Arroyo Pj Fau - Echevarría JE, Echevarría Je Fau - Casas I, Casas I. Adenovirus transmission in a nursing home: analysis of an epidemic outbreak of keratoconjunctivitis. (1423-0003 (Electronic)).

15. Asbell PA, Sanfilippo CM, Pillar CM, DeCory HH, Sahm DF, Morris TW. Antibiotic Resistance Among Ocular Pathogens in the United States: Five-Year Results From the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) Surveillance Study. (2168-6173 (Electronic)).

16. Esparcia Rodríguez Ó, Gómez Martínez A, Martínez Nieto MJ, Salmerón Cifuentes MS, Rodolfo Saavedra R, de la Cruz de Julián I. [Outbreak of epidemic keratoconjunctivitis caused by human adenovirus serotype 8 in a nursing home.]. LID - e202009100 [pii]. (2173-9110 (Electronic)).

17. Scannapieco FA. Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia. Clin Geriatr Med. 2023 May;39(2):257-71.

18. Liu F, Song S, Ye X, Huang S, He J, Wang G, et al. Oral health-related multiple outcomes of holistic health in elderly individuals: An umbrella review of systematic reviews and meta-analyses. Front Public Health. 2022;10:1021104.

19. Janto M, Iurcov R, Daina CM, Neculoiu DC, Venter AC, Badau D, et al. Oral Health among Elderly, Impact on Life Quality, Access of Elderly Patients to Oral Health Services and Methods to Improve Oral Health: A Narrative Review. J Pers Med. 2022 Feb 28;12(3).

20. Gao SS, Chu CH, Young FYF. Oral Health and Care for Elderly People with Alzheimer’s Disease. Int J Environ Res Public Health. 2020 Aug 7;17(16).

21. Azami-Aghdash S, Pournaghi-Azar F, Moosavi A, Mohseni M, Derakhshani N, Kalajahi RA. Oral Health and Related Quality of Life in Older People: A Systematic Review and Meta-Analysis. Iran J Public Health. 2021 Apr;50(4):689-700.

22. Badewy R, Singh H, Quiñonez C, Singhal S. Impact of Poor Oral Health on Community-Dwelling Seniors: A Scoping Review. Health Serv Insights. 2021;14:1178632921989734.

23. Chan AKY, Tamrakar M, Jiang CM, Lo ECM, Leung KCM, Chu CH. Common Medical and Dental Problems of Older Adults: A Narrative Review. Geriatrics (Basel). 2021 Aug 6;6(3).

24. Imai K, Iinuma T, Sato S. Relationship between the oral cavity and respiratory diseases: Aspiration of oral bacteria possibly contributes to the progression of lower airway inflammation. Jpn Dent Sci Rev. 2021 Nov;57:224-30.

Other reference documents

Department of Health and Human resources, Agency for Helthcare Research and Quality. A Unit Guide To Infection Prevention for Long-Term Care Staff. . Disponible en: https://wwwahrqgov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-preventhtml. 2017;Publication No. 16(17)-0003-4-EF March 2017.

Serrano M, Barcenilla F, Limón E. [Nosocomial infections in long-term health care facilities]. Enfermedades infecciosas y microbiologia clinica. 2014;32(3):191-8.

Dwyer LL, Harris-Kojetin LD, Valverde RH, Frazier JM, Simon AE, Stone ND, et al. Infections in long-term care populations in the United States. Journal of the American Geriatrics Society. 2013;61(3):342-9.

Department of Health and Health Protection Agency UK. Prevention and control of infection in care homes - an information resource Available at: https:// assetspublishingservicegovuk/government/uploads/system/uploads/attachment_data/file/ 214930/Care-Home-Resource-Summary-Feb14-2013pdf. 2013.

Chami K, Gavazzi G, de Wazières B, Lejeune B, Carrat F, Piette F, et al. Guidelines for infection control in nursing homes: a Delphi consensus web-based survey. The Journal of hospital infection. 2011;79(1):75-89.

Tinelli M, Tiseo G, Falcone M. Prevention of the spread of multidrug-resistant organisms in nursing homes. Aging Clin Exp Res. 2021;33(3):679-87.

Gouin KA, Kabbani S, Anttila A, Mak J, Mungai E, McCray TT, et al. Implementation of core elements of antibiotic stewardship in nursing homes-National Healthcare Safety Network, 2016-2018. Infection control and hospital epidemiology. 2021:1-5.

Crespo-Rivas JC, Guisado-Gil AB, Peñalva G, Rodríguez-Villodres Á, Martín-Gandul C, Pachón-Ibáñez ME, et al. Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2021.

Aliyu S, Travers JL, Heimlich SL, Ifill J, Smaldone A. Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis. J Appl Gerontol. 2021:7334648211018299.

Agarwal M, Estrada LV, Stone PW. Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013-2017. Journal of the American Medical Directors Association. 2021.

Hospital Geaneral de Granollers. Doce intervenciones PROA en Centros Sociosanitarios.. Available at https://wwwsaludcastillayleones/portalmedicamento/es/boletines/ boletin-mensual/noticias-destacadas/12-intervenciones-proa-centros-sociosanitarios. 2019.

Serrano M, Barcenilla F, Limón E, Pujol M, Gudiol F. Prevalence of healthcare- associated infections in long-term care facilities in Catalonia. VINCat Program. Enfermedades infecciosas y microbiologia clinica. 2017;35(8):505-10.

Ricchizzi E, Latour K, Kärki T, Buttazzi R, Jans B, Moro ML, et al. Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017. Euro Surveill. 2018;23(46).

Morrill HJ, Caffrey AR, Jump RL, Dosa D, LaPlante KL. Antimicrobial Stewardship in Long-Term Care Facilities: A Call to Action. Journal of the American Medical Directors Association. 2016;17(2):183.e1-16.

Glette MK, Røise O, Kringeland T, Churruca K, Braithwaite J, Wiig S. Nursing home leaders’ and nurses’ experiences of resources, staffing and competence levels and the relation to hospital readmissions - a case study. BMC health services research. 2018;18(1):955.

Junta de Andalucía, Consejería para la Igualdad y Bienestar Social, Mayores. DGdP. Normativa sobre Centros Residenciales de Personas Mayores. Consejería de Igualdad y Bienestar Social. Junta de Andalucía. Disponible en: https://wwwjuntadeandaluciaes/export/ drupaljda/Normativa_centros_mayorespdf. 2007:1- 78.

Organización Mundial de la Salud. Prevención y control de infecciones en los centros de atención de larga estancia en el contexto de la COVID-19. 2020:6.

Ministerio de derechos sociales y agenda 2030. Secretaría de Estado. Informe del grupo de trabajo de Covid en Residencias. Ministerio de Derechos Sociales y Agenda 2030. Available at: https://wwwmscbsgobes/ssi/imserso/docs/GTCOVID_19_RESIDENCIASpdf. 2020:115.

Ministerio de Sanidad Consumo y Bienestar Social. Guía de prevención y control frente al COVID-19 en residencias de mayores y otros centros de servicios sociales de carácter residencial. 2020.

Junta de Andalucia CdSyF. Estrategia de actuación en residencias de mayores y centros sociosanitarios de la consejería de salud y familias Plan de actuación en Residencias, Consejería de Salud Junta de Andalucía Available at:https://wwwjuntadeandaluciaes/export/ drupaljda/SyF-DocumentoPlanActuacionResidenciaspdf. 2020:34.

SERGAS. Medidas de prevención y control de riesgo de diseminación del covid-19 y otras enfermedades infecciosas de transmisión por contacto (incluido gotas) en las residencias de ancianos. Available at https://coronavirussergasgal/Contidos/Documents/263/ IRR_060420_Residencias_Control_infecci %c3 %b3npdf. 2020:9.

Médicos sin Fronteras. Plan de contingencia para residencias. Organización de servicios y estructuras.5.

Sociales GdADdSyDdCyD. Guía para la elaboración del plan de contingencia destinado a centros de servicios sociales de naturaleza residencial para la atención de personas mayores y personas con discapacidad. 2020.

Organization WH. Prevención y control de infecciones en los centros de atención de larga estancia en el contexto de la Covid-19 Available at: https://appswhoint/iris/bitstream/ handle/10665/331643/WHO-2019-nCoV-IPC_long_term_care-20201-spapdf? sequence=1&isAllowed=y. 2021.

Consumo. MdSy. Documento técnico. Recomendaciones a Residencias de Mayores y Centros Sociosanitarios para el Covid-19. . Available at https://wwwmscbsgobes/profesionales/ saludPublica/ccayes/alertasActual/nCov/documentos/Centros_sociosanitariospdf. 2021.

al MRe. La Geriatría de Enlace con residencias en la época de la Covid-19. Un nuevo modelo de coordinación que ha llegado para quedarse. Revista Española de Geriatría y Gerontología. 2021;56:157-65.

Organización Médica Colegial O. Covid-19 y las residencias y centros sociosanitarios. Organización Médica Colegial.17.

Sociedad Española de Geriatría y Gerontología. Recomendaciones para el manejo de la epidemia Covid en Residencias de Mayores. Sociedad Española de Geriatría y Gerontología. 2020:4.

Comunidad Autónoma de Madrid. Orden por al que se desarrolla el decreto 91/1990, de 26 de octubre, relativo al régimen de autorización de servicios y centros de acción social y servicios sociales.. Available at :http://wwwmadridorg/wleg_pub/secure/normativas/contenidoNormativajsf? opcion=VerHtml&nmnorma=3158#no-back-button. 1990.

Spreckelsen O, Luque Ramos A, Freitag M, Hoffmann F. Influenza vaccination rates before and after admission to nursing homes in Germany. Aging Clin Exp Res. 2018;30(6):609-16.

Ye P, Fry L, Liu H, Ledesma S, Champion JD. COVID outbreak after the 1st dose of COVID vaccine among the nursing home residents: What happened? Geriatr Nurs. 2021;42(5):1105-8.

Unroe KT, Evans R, Weaver L, Rusyniak D, Blackburn J. Willingness of Long-Term Care Staff to Receive a COVID-19 Vaccine: A Single State Survey. Journal of the American Geriatrics Society. 2021;69(3):593-9.

Salmerón Ríos S, Mas Romero M, Cortés Zamora EB, Tabernero Sahuquillo MT, Romero Rizos L, Sánchez-Jurado PM, et al. Immunogenicity of the BNT162b2 vaccine in frail or disabled nursing home residents: COVID-A study. Journal of the American Geriatrics Society. 2021;69(6):1441-7.

Senderovich H, Grewal J, Mujtaba M. Herpes zoster vaccination efficacy in the long- term care facility population: a qualitative systematic review. Curr Med Res Opin. 2019;35(8):1451-62.

Sasahara T, Ae R, Yoshimura A, Kosami K, Sasaki K, Kimura Y, et al. Association between length of residence and prevalence of MRSA colonization among residents in geriatric long-term care facilities. BMC geriatrics. 2020;20(1):481.

Harrison EM, Ludden C, Brodrick HJ, Blane B, Brennan G, Morris D, et al. Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks. Genome Med. 2016;8(1):102.

Szabó R. [Prevalence and predisposing factors of methicillin-resistant Staphylococcus aureus in long-term care facilities. An international view]. Orv Hetil. 2016;157(27):1071-8.

Schora DM, Boehm S, Das S, Patel PA, O’Brien J, Hines C, et al. Impact of Detection, Education, Research and Decolonization without Isolation in Long-term care (DERAIL) on methicillin-resistant Staphylococcus aureus colonization and transmission at 3 long-term care facilities. American journal of infection control. 2014;42(10 Suppl):S269-73.

Evans ME, Kralovic SM, Simbartl LA, Freyberg RW, Obrosky DS, Roselle GA, et al. Nationwide reduction of health care-associated methicillin-resistant Staphylococcus aureus infections in Veterans Affairs long-term care facilities. American journal of infection control. 2014;42(1):60-2.

Brugnaro P, Fedeli U, Pellizzer G, Buonfrate D, Rassu M, Boldrin C, et al. Clustering and risk factors of methicillin-resistant Staphylococcus aureus carriage in two Italian long-term care facilities. Infection. 2009;37(3):216-21.

Stevenson CG, McArthur MA, Naus M, Abraham E, McGeer AJ. Prevention of influenza and pneumococcal pneumonia in Canadian long-term care facilities: how are we doing? Cmaj. 2001;164(10):1413-9.

Thomas RE. Pneumococcal Pneumonia and Invasive Pneumococcal Disease in Those 65 and Older: Rates of Detection, Risk Factors, Vaccine Effectiveness, Hospitalisation and Mortality. Geriatrics (Basel). 2021;6(1).

McConeghy KW, Davidson HE, Canaday DH, Han L, Saade E, Mor V, et al. Cluster- randomized trial of adjuvanted vs. non-adjuvanted trivalent influenza vaccine in 823 U.S. nursing homes. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2020.

Ino H. Vaccine mandate in long-term care facilities. Geriatr Gerontol Int. 2020;20(10):995-6.

Arnedo-Pena A, Juan-Cerdán JV, Romeu-Garcia M, Sorribes-Segura S, Tirado-Balaguer M, Gil-Fortuño M, et al. Vitamin D status and latent tuberculosis infection: conversion in nursing homes, Spain. Int J Tuberc Lung Dis. 2020;24(3):278-86.

Khan A, Rebhan A, Seminara D, Szerszen A. Enduring Challenge of Latent Tuberculosis in Older Nursing Home Residents: A Brief Review. J Clin Med Res. 2019;11(6):385-90.

Bouza E, Ancochea-Bermúdez J, Campins M, Eirós-Bouza JM, Fargas J, García Rojas A, et al. The situation of vaccines for the prevention of infections in adults: An opinion paper on the situation in Spain. ­Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia. 2019;32(4):333-64.

Sociedad Española de Geriatría y Gerontología. Recomendaciones de vacunación para adultos y mayores y calendarios vacunales 2019-2020. Available at https://www.segg.es/pdfViewer/web/viewer.asp?archivo=vacunacion2022-2023

Thomas RE. Reducing Morbidity and Mortality Rates from COVID-19, Influenza and Pneumococcal Illness in Nursing Homes and Long-Term Care Facilities by Vaccination and Comprehensive Infection Control Interventions. Geriatrics (Basel). 2021;6(2).

Boey L, Roelants M, Vandermeulen C. Increased vaccine uptake and less perceived barriers toward vaccination in long-term care facilities that use multi-intervention manual for influenza campaigns. Hum Vaccin Immunother. 2021;17(3):673-80.

Kenny E, McNamara Á, Noone C, Byrne M. Barriers to seasonal influenza vaccine uptake among health care workers in long-term care facilities: A cross-sectional analysis. Br J Health Psychol. 2020;25(3):519-39.

Bechini A, Lorini C, Zanobini P, Mandò Tacconi F, Boccalini S, Grazzini M, et al. Utility of Healthcare System-Based Interventions in Improving the Uptake of Influenza Vaccination in Healthcare Workers at Long-Term Care Facilities: A Systematic Review. Vaccines (Basel). 2020;8(2).

Tan HY, Lai E, Kunasekaran M, Chughtai AA, Trent M, Poulos CJ, et al. Prevalence and predictors of influenza vaccination among residents of long-term care facilities. Vaccine. 2019;37(43):6329-35.

Shireman TI, Ogarek J, Gozalo P, Zhang T, Mor V, Davidson HE, et al. Cost Benefit of High-Dose vs. Standard-Dose Influenza Vaccine in a Long-Term Care Population During an A/ H1N1-Predominant Influenza Season. Journal of the American Medical Directors Association. 2019;20(7):874-8.

Campbell J. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions. Int J Nurs Pract. 2019;25(3):e12730.

Shrotri M, Krutikov M, Palmer T, Giddings R, Azmi B, Subbarao S, et al. Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study. The Lancet Infectious diseases. 2021.

Munitz A, Yechezkel M, Dickstein Y, Yamin D, Gerlic M. BNT162b2 vaccination effectively prevents the rapid rise of SARS-CoV-2 variant B.1.1.7 in high-risk populations in Israel. Cell Rep Med. 2021;2(5):100264.

Mor V, Gutman R, Yang X, White EM, McConeghy KW, Feifer RA, et al. Short-term impact of nursing home SARS-CoV-2 vaccinations on new infections, hospitalizations, and deaths. Journal of the American Geriatrics Society. 2021.

McDonald CJ, Baik SH, Zheng Z, Amos L. A method for prioritizing risk groups for early SARS-CoV-2 Vaccination, By the Numbers. medRxiv. 2020.

García-Botella A, García-Lledó A, Gómez-Pavón J, González Del Castillo J, Hernández-Sampelayo T, Martín-Delgado MC, et al. Booster or additional vaccination doses in patients vaccinated against COVID-19. Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia. 2021.

Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother. 2011;9(5):286-309.

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2005;40(5):643-54.

Loeb M, Bentley DW, Bradley S, Crossley K, Garibaldi R, Gantz N, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infection control and hospital epidemiology. 2001; 22(2):120-4.

Juthani-Mehta M, Quagliarello V, Perrelli E, Towle V, Van Ness PH, Tinetti M. Clinical features to identify urinary tract infection in nursing home residents: a cohort study. Journal of the American Geriatrics Society. 2009;57(6):963-70.

Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ (Clinical research ed). 2005;331(7518):669.

Mitchell SL, Shaffer ML, Loeb MB, Givens JL, Habtemariam D, Kiely DK, et al. Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia. JAMA internal medicine. 2014;174(10):1660-7.

Dufour AB, Shaffer ML, D’Agata EM, Habtemariam D, Mitchell SL. Survival After Suspected Urinary Tract Infection in Individuals with Advanced Dementia. Journal of the American Geriatrics Society. 2015;63(12):2472-7.

Monette J, Miller MA, Monette M, Laurier C, Boivin JF, Sourial N, et al. Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities. Journal of the American Geriatrics Society. 2007;55(8):1231-5.

Pettersson E, Vernby A, Mölstad S, Lundborg CS. Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial. The Journal of antimicrobial chemotherapy. 2011;66(11):2659-66.

Zabarsky TF, Sethi AK, Donskey CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. American journal of infection control. 2008;36(7):476-80.

Nicolle LE. Antimicrobial stewardship in long term care facilities: what is effective? Antimicrobial resistance and infection control. 2014;3(1):6.

Centers for Medicare & Medicaid Services (CMS) H. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Final rule. Fed Regist. 2016;81(192):68688-872.

Rummukainen ML, Jakobsson A, Matsinen M, Järvenpää S, Nissinen A, Karppi P, et al. Reduction in inappropriate prevention of urinary tract infections in long-term care facilities. American journal of infection control. 2012;40(8):711-4.

Crnich CJ, Jump R, Trautner B, Sloane PD, Mody L. Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs & aging. 2015;32(9):699-716.

Agarwal M, Dick AW, Sorbero M, Mody L, Stone PW. Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018. Journal of the American Medical Directors Association. 2020;21(1):97-103.

Checovich MM, Barlow S, Shult P, Reisdorf E, Temte JL. Evaluation of Viruses Associated With Acute Respiratory Infections in Long-Term Care Facilities Using a Novel Method: Wisconsin, 2016‒2019. Journal of the American Medical Directors Association. 2020;21(1):29-33.

Childs A, Zullo AR, Joyce NR, McConeghy KW, van Aalst R, Moyo P, et al. The burden of respiratory infections among older adults in long-term care: a systematic review. BMC geriatrics. 2019;19(1):210.

Carnahan JL, Shearn AJ, Lieb KM, Unroe KT. Pneumonia Management in Nursing Homes: Findings from a CMS Demonstration Project. J Gen Intern Med. 2021;36(2):570-2.

Rios P, Radhakrishnan A, Williams C, Ramkissoon N, Pham B, Cormack GV, et al. Preventing the transmission of COVID-19 and other coronaviruses in older adults aged 60 years and above living in long-term care: a rapid review. Syst Rev. 2020;9(1):218.

Kain DC, McCreight LJ, Johnstone J. Dealing with coronavirus disease 2019 (COVID-19) outbreaks in long-term care homes: A protocol for room moving and cohorting. Infection control and hospital epidemiology. 2020:1-2.

Dosa D, Jump RLP, LaPlante K, Gravenstein S. Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines for a Population at Highest Risk. Journal of the American Medical Directors Association. 2020;21(5):569-71.

Bosco E, van Aalst R, McConeghy KW, Silva J, Moyo P, Eliot MN, et al. Estimated Cardiorespiratory Hospitalizations Attributable to Influenza and Respiratory Syncytial Virus Among Long-term Care Facility Residents. JAMA Netw Open. 2021;4(6):e2111806.

Liao RS, Appelgate DM, Pelz RK. An outbreak of severe respiratory tract infection due to human metapneumovirus in a long-term care facility for the elderly in Oregon. J Clin Virol. 2012;53(2):171-3.

Poscia A, Collamati A, Carfì A, Topinkova E, Richter T, Denkinger M, et al. Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study. Eur J Public Health. 2017;27(6):1016-20.

Black CL, Williams WW, Arbeloa I, Kordic N, Yang L, MaCurdy T, et al. Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 2006-2014. Journal of the American Medical Directors Association. 2017;18(8):735.e1-.e14.

Omura T, Matsuyama M, Nishioka S, Sagawa S, Seto M, Naoe M. Association Between the Swallowing Reflex and the Incidence of Aspiration Pneumonia in Patients with Dysphagia Admitted to Long-term Care Wards. Arch Phys Med Rehabil. 2021.

Cristino S, Legnani PP, Leoni E. Plan for the control of Legionella infections in long- term care facilities: role of environmental monitoring. Int J Hyg Environ Health. 2012;215(3):279-85.

Machado M, Valerio M, Álvarez-Uría A, Olmedo M, Veintimilla C, Padilla B, et al. Invasive pulmonary aspergillosis in the COVID-19 era: An expected new entity. Mycoses. 2021;64(2):132-43.

Guinea J, Torres-Narbona M, Gijón P, Muñoz P, Pozo F, Peláez T, et al. Pulmonary aspergillosis in patients with chronic obstructive pulmonary disease: incidence, risk factors, and outcome. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2010;16(7):870-7.

World Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Geneva: World Health Organization. Copyright © World Health Organization 2014.; 2014.

Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. Journal of public health medicine. 2001;23(4):346-8.

Lynch RM, Goring R. Practical Steps to Improve Air Flow in Long-Term Care Resident Rooms to Reduce COVID-19 Infection Risk. Journal of the American Medical Directors Association. 2020;21(7):893-4.

Reddy M, Heidarinejad M, Stephens B, Rubinstein I. Adequate indoor air quality in nursing homes: An unmet medical need. Sci Total Environ. 2021;765:144273.

Barker KA, Whitney EA, Blake S, Berkelman RL. A Review of Guidelines for the Primary Prevention of Legionellosis in Long-Term Care Facilities. Journal of the American Medical Directors Association. 2015;16(10):832-6.

Nisbet LC, Cobbledick AM, Smith TE, Bryant PA, Lawrence J. Opportunistic influenza vaccination in the home: broadening access in isolated times. Arch Dis Child. 2020.

Frentzel E, Jump RLP, Archbald-Pannone L, Nace DA, Schweon SJ, Gaur S, et al. Recommendations for Mandatory Influenza Vaccinations for Health Care Personnel From AMDA’s Infection Advisory Subcommittee. Journal of the American Medical Directors Association. 2020;21(1):25-8.e2.

Menéndez Colino R, Merello de Miguel A, Argentina F, Barcons Marqués M, Chaparro Jiménez B, López Hernández P, et al. [Evolution of COVID-19 at nursing homes from the second wave to vaccination. Description of a coordination program between Primary Care, Geriatrics and Public Health.]. Rev Esp Salud Publica. 2021;95.

McConaghy M, Sartaj M, Conway BR, Aldeyab MA. An assessment of the impact of the vaccination program on coronavirus disease 2019 (COVID-19) outbreaks in care homes in Northern Ireland-A pilot study. Infection control and hospital epidemiology. 2021:1-2.

Stephens LM, Varga SM. Considerations for a Respiratory Syncytial Virus Vaccine Targeting an Elderly Population. Vaccines (Basel). 2021;9(6).

Rubin MS, Nivin B, Ackelsberg J. Effect of timing of amantadine chemoprophylaxis on severity of outbreaks of influenza a in adult long-term care facilities. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2008;47(1):47-52.

Dolamore MJ. Influenza prophylaxis in the long-term care facility: a case-control study of the risk factors for adverse drug reactions to amantadine. Curr Ther Res Clin Exp. 2003;64(9):753-63.

Stewart RJ, Flannery B, Chung JR, Gaglani M, Reis M, Zimmerman RK, et al. Influenza Antiviral Prescribing for Outpatients With an Acute Respiratory Illness and at High Risk for Influenza-Associated Complications During 5 Influenza Seasons-United States, 2011-2016. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2018;66(7):1035-41.

Havers FP, Campbell AP, Uyeki TM, Fry AM. Commentary: A Historical Review of Centers for Disease Control and Prevention Antiviral Treatment and Postexposure Chemoprophylaxis Guidance for Human Infections With Novel Influenza A Viruses Associated With Severe Human Disease. The Journal of infectious diseases. 2017;216(suppl_4):S575-s80.

Dobson J, Whitley RJ, Pocock S, Monto AS. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. Lancet (London, England). 2015;385(9979):1729-37.

McGeer A, Green KA, Plevneshi A, Shigayeva A, Siddiqi N, Raboud J, et al. Antiviral therapy and outcomes of influenza requiring hospitalization in Ontario, Canada. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2007;45(12):1568-75.

Bouza E, Brenes FJ, Díez Domingo J, Eiros Bouza JM, González J, Gracia D, et al. The situation of infection in the elderly in Spain: a multidisciplinary opinion document. Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia. 2020;33(5):327-49.

Henig O, Kaye KS. Bacterial Pneumonia in Older Adults. Infectious disease clinics of North America. 2017;31(4):689-713.

Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. The Cochrane database of systematic reviews. 2013;2013(1):Cd000422.

Bonten MJ, Huijts SM, Bolkenbaas M, Webber C, Patterson S, Gault S, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. The New England journal of medicine. 2015;372(12):1114-25.

Jump RLP, Crnich CJ, Mody L, Bradley SF, Nicolle LE, Yoshikawa TT. Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management. Journal of the American Geriatrics Society. 2018;66(4):789-803.

Yogo N, Gahm G, Knepper BC, Burman WJ, Mehler PS, Jenkins TC. Clinical Characteristics, Diagnostic Evaluation, and Antibiotic Prescribing Patterns for Skin Infections in Nursing Homes. Frontiers in medicine. 2016;3:30.

LeBlanc K, Woo KY, VanDenKerkhof E, Woodbury MG. Skin tear prevalence and incidence in the long-term care population: a prospective study. J Wound Care. 2020;29(Sup7):S16-s22.

Abizanda Pea. Vacunación y políticas de prevención y manjeo de infecciones en el medio residencial.. ratado de medicina geriátrica 2nd Edition. Fundamentos de la atención sanitaria a los mayores. Elsevier España 2020:1019-27.

Maelegheer K, Dumitrescu I, Verpaelst N, Masson H, Broucke C, Braekeveld P, et al. Infection prevention and control challenges in Flemish homecare nursing: a pilot study. Br J Community Nurs. 2020;25(3):114-21.

McNeil JC, Fritz SA. Prevention Strategies for Recurrent Community-Associated Staphylococcus aureus Skin and Soft Tissue Infections. Curr Infect Dis Rep. 2019;21(4):12.

Hine JL, de Lusignan S, Burleigh D, Pathirannehelage S, McGovern A, Gatenby P, et al. Association between glycaemic control and common infections in people with Type 2 diabetes: a cohort study. Diabet Med. 2017;34(4):551-7.

Wasson NJ, Varley CD, Schwab P, Fu R, Winthrop KL. “Serious skin & soft tissue infections in rheumatoid arthritis patients taking anti-tumor necrosis factor alpha drugs: a nested case-control study”. BMC Infect Dis. 2013;13:533.

Morrison SM, Blaesing CR, Millar EV, Chukwuma U, Schlett CD, Wilkins KJ, et al. Evaluation of methicillin-resistant Staphylococcus aureus skin and soft-tissue infection prevention strategies at a military training center. Infection control and hospital epidemiology. 2013;34(8):841-3.

Millar EV, Schlett CD, Law NN, Whitman TJ, Ellis MW, Tribble DR, et al. Opportunities and Obstacles in the Prevention of Skin and Soft-Tissue Infections Among Military Personnel. Mil Med. 2019;184(Suppl 2):35-43.

Laboral. JdASGdSPyCDGdSPyOFSdVyS. Recomendaciones para la prevención de la transmisión de microorganismos multirresistentes durante la atención a residentes colonizados/ infectados en centros residenciales. 2017:75.

Ye C, Zhu W, Yu J, Li Z, Fu Y, Lan Y, et al. Viral pathogens among elderly people with acute respiratory infections in Shanghai, China: Preliminary results from a laboratory-based surveillance, 2012-2015. Journal of medical virology. 2017;89(10):1700-6.

Kestler M, Muñoz P, Mateos M, Adrados D, Bouza E. Respiratory syncytial virus burden among adults during flu season: an underestimated pathology. The Journal of hospital infection. 2018;100(4):463-8.

Falsey AR, McElhaney JE, Beran J, van Essen GA, Duval X, Esen M, et al. Respiratory syncytial virus and other respiratory viral infections in older adults with moderate to severe influenza-like illness. The Journal of infectious diseases. 2014;209(12):1873-81.

Sloss EM, Solomon DH, Shekelle PG, Young RT, Saliba D, MacLean CH, et al. Selecting target conditions for quality of care improvement in vulnerable older adults. Journal of the American Geriatrics Society. 2000;48(4):363-9.

Pu Y, Dolar V, Gucwa AL. A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities. BMC geriatrics. 2016;16:148.

Grosholz JM, Blake S, Daugherty JD, Ayers E, Omer SB, Polivka-West L, et al. Accuracy of influenza vaccination rate estimates in United States nursing home residents. Epidemiology and infection. 2015;143(12):2588-95.

Hutt E, Reznickova N, Morgenstern N, Frederickson E, Kramer AM. Improving care for nursing home-acquired pneumonia in a managed care environment. The American journal of managed care. 2004;10(10):681-6.

Daugherty JD, Blake SC, Grosholz JM, Omer SB, Polivka-West L, Howard DH. Influenza vaccination rates and beliefs about vaccination among nursing home employees. American journal of infection control. 2015;43(2):100-6.

Hsieh VC, Hsieh ML, Chiang JH, Chien A, Hsieh MS. Emergency Department Visits and Disease Burden Attributable to Ambulatory Care Sensitive Conditions in Elderly Adults. Scientific reports. 2019;9(1):3811.

Warshaw G, Mehdizadeh S, Applebaum RA. Infections in nursing homes: assessing quality of care. The journals of gerontology Series A, Biological sciences and medical sciences. 2001;56(2):M120-3.

Trautner BW, Greene MT, Krein SL, Wald HL, Saint S, Rolle AJ, et al. Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infection control and hospital epidemiology. 2017;38(1):83-8.

Giri S, Chenn LM, Romero-Ortuno R. Nursing homes during the COVID-19 pandemic: a scoping review of challenges and responses. Eur Geriatr Med. 2021:1-10.

Wang Z. Use the Environment to Prevent and Control COVID-19 in Senior-Living Facilities: An Analysis of the Guidelines Used in China. Herd. 2021;14(1):130-40.

Sanchez GV, Biedron C, Fink LR, Hatfield KM, Polistico JMF, Meyer MP, et al. Initial and Repeated Point Prevalence Surveys to Inform SARS-CoV-2 Infection Prevention in 26 Skilled Nursing Facilities - Detroit, Michigan, March-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(27):882-6.

Blain H, Rolland Y, Schols J, Cherubini A, Miot S, O’Neill D, et al. August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19. Eur Geriatr Med. 2020;11(6):899-913.

Collison M, Beiting KJ, Walker J, Huisingh-Scheetz M, Pisano J, Chia S, et al. Three- Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association. 2020;21(11):1560-2.

Paananen J, Rannikko J, Harju M, Pirhonen J. The impact of Covid-19-related distancing on the well-being of nursing home residents and their family members: a qualitative study. Int J Nurs Stud Adv. 2021;3:100031.

McGilton KS, Escrig-Pinol A, Gordon A, Chu CH, Zúñiga F, Sanchez MG, et al. Uncovering the Devaluation of Nursing Home Staff During COVID-19: Are We Fuelling the Next Health Care Crisis? Journal of the American Medical Directors Association. 2020;21(7):962-5.

Senczyszyn A, Lion KM, Szcześniak D, Trypka E, Mazurek J, Ciułkowicz M, et al. Mental Health Impact of SARS-COV-2 Pandemic on Long-Term Care Facility Personnel in Poland. Journal of the American Medical Directors Association. 2020;21(11):1576-7.

Kuzuya M, Aita K, Katayama Y, Katsuya T, Nishikawa M, Hirahara S, et al. The Japan Geriatrics Society consensus statement “recommendations for older persons to receive the best medical and long-term care during the COVID-19 outbreak-considering the timing of advance care planning implementation”. Geriatr Gerontol Int. 2020;20(12):1112-9.

Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C, et al. Quality indicators for the management of medical conditions in nursing home residents. Journal of the American Medical Directors Association. 2005;6(3 Suppl):S36-48.

Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C, et al. Quality indicators for the management of medical conditions in nursing home residents. Journal of the American Medical Directors Association. 2004;5(5):297-309.

Menéndez R, et al. Neumonía adquirida en la comunidad. Normativa de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). ­Actualización 2020 Community- Acquired Pneumonia Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines 2020 Update. 2020:10.

González-Castillo J, Martín-Sánchez FJ, Llinares P, Menéndez R, Mujal A, Navas E, et al. Guidelines for the management of community-acquired pneumonia in the elderly patient. Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia. 2014;27(1):69-86.

Tappen RM, Newman D, Huckfeldt P, Yang Z, Engstrom G, Wolf DG, et al. Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program. Journal of the American Medical Directors Association. 2018;19(10):907-13.e1.

Durazzo M, Campion D, Fagoonee S, Pellicano R. Gastrointestinal tract disorders in the elderly. Minerva Med. 2017;108(6):575-91.

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-15.

Eusebi LH, Rabitti S, Artesiani ML, Gelli D, Montagnani M, Zagari RM, et al. Proton pump inhibitors: Risks of long-term use. J Gastroenterol Hepatol. 2017;32(7):1295-302.

Šubelj M, Učakar V. An outbreak of acute gastroenteritis associated with group A Rotavirus in long-term care facility in Slovenia. Wien Klin Wochenschr. 2015;127(11-12):415-20.

Utsumi M, Makimoto K, Quroshi N, Ashida N. Types of infectious outbreaks and their impact in elderly care facilities: a review of the literature. Age and ageing. 2010;39(3):299-305.

Taslim H. Clostridium difficile infection in the elderly. Acta Med Indones. 2009;41(3):148-51.

Greig JD, Lee MB. Enteric outbreaks in long-term care facilities and recommendations for prevention: a review. Epidemiology and infection. 2009;137(2):145-55.

Bermejo Boixareu C, Tutor-Ureta P, Ramos Martínez A. [Updated review of Clostridium difficile infection in elderly]. Rev Esp Geriatr Gerontol. 2020;55(4):225-35.

Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, et al. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. Journal of the American Medical Directors Association. 2020;21(1):55-61.e2.

Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Clostridioides difficile recurrence across a national cohort of veterans in outpatient, acute, and long-term care settings. Am J Health Syst Pharm. 2019;76(9):581-90.

Novakova E, Kotlebova N, Gryndlerova A, Novak M, Vladarova M, Wilcox M, et al. An Outbreak of Clostridium (Clostridioides) difficile Infections within an Acute and Long-Term Care Wards Due to Moxifloxacin-Resistant PCR Ribotype 176 Genotyped as PCR Ribotype 027 by a Commercial Assay. J Clin Med. 2020;9(11).

Marincu I, Bratosin F, Vidican I, Cerbu B, Turaiche M, Tirnea L, et al. Predictive Factors for the First Recurrence of Clostridioides difficile Infection in the Elderly from Western Romania. Medicina (Kaunas). 2020;56(9).

Grace E, Chahine EB. Updates on Clostridioides (Clostridium) difficile Infection With Emphasis on Long-Term Care. Sr Care Pharm. 2019;34(1):29-42.

Endres BT, Dotson KM, Poblete K, McPherson J, Lancaster C, Bassères E, et al. Environmental transmission of Clostridioides difficile ribotype 027 at a long-term care facility; an outbreak investigation guided by whole genome sequencing. Infection control and hospital epidemiology. 2018;39(11):1322-9.

Donskey CJ, Sunkesula VCK, Stone ND, Gould CV, McDonald LC, Samore M, et al. Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents. Infection control and hospital epidemiology. 2018;39(8):909-16.

Mallia G, Van Toen J, Rousseau J, Jacob L, Boerlin P, Greer A, et al. Examining the epidemiology and microbiology of Clostridium difficile carriage in elderly patients and residents of a healthcare facility in southern Ontario, Canada. The Journal of hospital infection. 2018;99(4):461-8.

Guh AY, Mu Y, Baggs J, Winston LG, Bamberg W, Lyons C, et al. Trends in incidence of long-term-care facility onset Clostridium difficile infections in 10 US geographic locations during 2011-2015. American journal of infection control. 2018;46(7):840-2.

Asempa TE, Nicolau DP. Clostridium difficile infection in the elderly: an update on management. Clinical interventions in aging. 2017;12:1799-809.

König E, Medwed M, Pux C, Uhlmann M, Schippinger W, Krause R, et al. Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria. Antibiotics (Basel). 2021;10(5).

Engelhart ST, Hanses-Derendorf L, Exner M, Kramer MH. Prospective surveillance for healthcare-associated infections in German nursing home residents. The Journal of hospital infection. 2005;60(1):46-50.

McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, et al. Definitions of infection for surveillance in long-term care facilities. American journal of infection control. 1991;19(1):1-7.

Nicolle LE. Infection prevention issues in long-term care. Current opinion in infectious diseases. 2014;27(4):363-9.

Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019;68(10):1611-5.

Stevenson KB, Moore J, Colwell H, Sleeper B. Standardized infection surveillance in long-term care: interfacility comparisons from a regional cohort of facilities. Infection control and hospital epidemiology. 2005;26(3):231-8.

Pigrau C. [Nocosomial urinary tract infections]. Enfermedades infecciosas y microbiologia clinica. 2013;31(9):614-24.

Bagchi S, Watkins J, Norrick B, Scalise E, Pollock DA, Allen-Bridson K. Accuracy of catheter-associated urinary tract infections reported to the National Healthcare Safety Network, January 2010 through July 2018. American journal of infection control. 2020;48(2):207-11.

Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2010;50(5):625-63.

Anthony D, Alosoumi D, Safari R. Prevalence of pressure ulcers in long-term care: a global review. J Wound Care. 2019;28(11):702-9.

Igarashi A, Yamamoto-Mitani N, Gushiken Y, Takai Y, Tanaka M, Okamoto Y. Prevalence and incidence of pressure ulcers in Japanese long-term-care hospitals. Arch Gerontol Geriatr. 2013;56(1):220-6.

Ahn H, Cowan L, Garvan C, Lyon D, Stechmiller J. Risk Factors for Pressure Ulcers Including Suspected Deep Tissue Injury in Nursing Home Facility Residents: Analysis of National Minimum Data Set 3.0. Adv Skin Wound Care. 2016;29(4):178-90; quiz E1.

Lee YJ, Kim JY, Dong CB, Park OK. Developing risk-adjusted quality indicators for pressure ulcers in long-term care hospitals in the Republic of Korea. Int Wound J. 2019;16 Suppl 1(Suppl 1):43-50.

Ayello EA. CMS MDS 3.0 Section M Skin Conditions in Long-term Care: Pressure Ulcers, Skin Tears, and Moisture-Associated Skin Damage Data Update. Adv Skin Wound Care. 2017;30(9):415-29.

Bates-Jensen BM, Cadogan M, Osterweil D, Levy-Storms L, Jorge J, Al-Samarrai N, et al. The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes? Journal of the American Geriatrics Society. 2003;51(9):1203-12.

Stotts NA, Rodeheaver GT. Revision of the PUSH Tool using an expanded database. Pressure Ulcer Scale for Healing. Adv Wound Care. 1997;10(5):107-10.

Maklebust J. PUSH Tool reality check: audience response. Pressure Ulcer Scale for Healing. Adv Wound Care. 1997;10(5):102-6.

Thomas DR, Rodeheaver GT, Bartolucci AA, Franz RA, Sussman C, Ferrell BA, et al. Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force. Adv Wound Care. 1997;10(5):96-101.

Sussman C. Presenting a draft pressure ulcer scale to monitor healing. Adv Wound Care. 1997;10(5):92.

Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Adv Wound Care. 1997;10(5):65-73.

Pfingsten-Würzburg S, Pieper DH, Bautsch W, Probst-Kepper M. Prevalence and molecular epidemiology of meticillin-resistant Staphylococcus aureus in nursing home residents in northern Germany. The Journal of hospital infection. 2011;78(2):108-12.

Greenland K, Rijnders MI, Mulders M, Haenen A, Spalburg E, van de Kassteele J, et al. Low prevalence of methicillin-resistant Staphylococcus aureus in Dutch nursing homes. Journal of the American Geriatrics Society. 2011;59(4):768-9.

Reynolds C, Quan V, Kim D, Peterson E, Dunn J, Whealon M, et al. Methicillin- resistant Staphylococcus aureus (MRSA) carriage in 10 nursing homes in Orange County, California. Infection control and hospital epidemiology. 2011;32(1):91-3.

Rooney PJ, O’Leary MC, Loughrey AC, McCalmont M, Smyth B, Donaghy P, et al. Nursing homes as a reservoir of extended-spectrum beta-lactamase (ESBL)-producing ciprofloxacin-resistant Escherichia coli. The Journal of antimicrobial chemotherapy. 2009;64(3):635-41.

Murphy CR, Quan V, Kim D, Peterson E, Whealon M, Tan G, et al. Nursing home characteristics associated with methicillin-resistant Staphylococcus aureus (MRSA) Burden and Transmission. BMC Infect Dis. 2012;12:269.

Rodríguez-Villodres Á, Martín-Gandul C, Peñalva G, Guisado-Gil AB, Crespo-Rivas JC, Pachón-Ibáñez ME, et al. Prevalence and Risk Factors for Multidrug-Resistant Organisms Colonization in Long-Term Care Facilities Around the World: A Review. Antibiotics (Basel). 2021;10(6).

O’Fallon E, Schreiber R, Kandel R, D’Agata EM. Multidrug-resistant gram-negative bacteria at a long-term care facility: assessment of residents, healthcare workers, and inanimate surfaces. Infection control and hospital epidemiology. 2009;30(12):1172-9.

Peters C, Schablon A, Bollongino K, Maaß M, Kaß D, Dulon M, et al. Multiresistant pathogens in geriatric nursing - infection control in residential facilities for geriatric nursing in Germany. GMS hygiene and infection control. 2014;9(3):Doc22.

Huebner C, Roggelin M, Flessa S. Economic burden of multidrug-resistant bacteria in nursing homes in Germany: a cost analysis based on empirical data. BMJ open. 2016;6(2):e008458.

Ruscher C, Schaumann R, Mielke M. [The challenge of infections and multiresistant bacteria among the elderly living in long-term care facilities]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2012;55(11-12):1444-52.

Tacconelli E, Mazzaferri F, de Smet AM, Bragantini D, Eggimann P, Huttner BD, et al. ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2019;25(7):807-17.

House TW. NATIONAL STRATEGY FOR COMBATING ANTIBIOTICRESISTANT BACTERIA. 2014:37.

Lim CJ, Kong DC, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clinical interventions in aging. 2014;9:165-77.

Centers for Diseases Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. 2019.

Palms DL, Kabbani S, Bell JM, Anttila A, Hicks LA, Stone ND. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes Enrolled in the National Healthcare Safety Network. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019;69(7):1235-8.

Norman DC, Yoshikawa TT. Fever in the elderly. Infectious disease clinics of North America. 1996;10(1):93-9.

Norman DC, Grahn D, Yoshikawa TT. Fever and aging. Journal of the American Geriatrics Society. 1985;33(12):859-63.

Outzen M. Management of fever in older adults. Journal of gerontological nursing. 2009;35(5):17-23; quiz 4-5.

Montoya A, Cassone M, Mody L. Infections in Nursing Homes: Epidemiology and Prevention Programs. Clinics in geriatric medicine. 2016;32(3):585-607.

Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infection control and hospital epidemiology. 2008;29(9):785-814.

Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2008;20(1):22-30.

Fuentes. V ea. Recomendaciones para la Prevención de la Transmisión de Microorganismos Multirresistentes durante la Atención a Residentes Colonizados/Infectados en Centros Residenciales. 2017:75.

World Health Organization. Hand hygiene in outpatient and home-based care and long- term care facilities: a guide to the application of the WHO multimodal hand hygiene improvement strategy and the “My Five Moments For Hand Hygiene” approach. 2012.

Torres A, El-Ebiary M, Riquelme R, Ruiz M, Celis R. Community-acquired pneumonia in the elderly. Semin Respir Infect. 1999;14(2):173-83.

Torres OH, Gil E, Comas MT, Saez ME, Clotet S, Ramirez HD, et al. [Impact of a multidimensional intervention in elderly patients with community-acquired pneumonia: IMIEPCAP clinical trial]. Rev Esp Geriatr Gerontol. 2016;51(1):37-43.

Füri J, Widmer A, Bornand D, Berger C, Huttner B, Bielicki JA. The potential negative impact of antibiotic pack on antibiotic stewardship in primary care in Switzerland: a modelling study. Antimicrobial resistance and infection control. 2020;9(1):60.

Giry M, Pulcini C, Rabaud C, Boivin JM, Mauffrey V, Birgé J. Acceptability of antibiotic stewardship measures in primary care. Med Mal Infect. 2016;46(6):276-84.

Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, et al. Primary care physicians’ attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ open. 2020;10(7):e034983.

Zetts RM, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary Care Physicians’ Attitudes and Perceptions Towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey. Open Forum Infect Dis. 2020;7(7):ofaa244.

Badalona Serveis Assistencials. PROA atención Primaria 2021.

Aronow WS. Clinical causes of death of 2372 older persons in a nursing home during 15-year follow-up. Journal of the American Medical Directors Association. 2000;1(3):95-6.

Braggion M, Pellizzari M, Basso C, Girardi P, Zabeo V, Lamattina MR, et al. Overall mortality and causes of death in newly admitted nursing home residents. Aging Clin Exp Res. 2020;32(2):275-80.

Envejecimiento en Red - EnR. Un perfil de las personas mayores en España, 2019 Indicadores estadísticos básicos. 2019:38.

Campos-Dompedro JR, JM. RC. Mortalidad en centros residenciales para mayores dependientes: estudio de variables asociadas. . Tesis doctoral T38413 Disertación 2016 Available at: Universidad complutense de Madrid Servicio de tesis doctorales y publicaciones académicas https://ucmonworldcatorg/. 2016.

van Dijk PT, Mehr DR, Ooms ME, Madsen R, Petroski G, Frijters DH, et al. Comorbidity and 1-year mortality risks in nursing home residents. Journal of the American Geriatrics Society. 2005;53(4):660-5.

Nace DA, Hanlon JT, Crnich CJ, Drinka PJ, Schweon SJ, Anderson G, et al. A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents. JAMA internal medicine. 2020;180(7):944-51.

Mody L, Greene MT, Meddings J, Krein SL, McNamara SE, Trautner BW, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents. JAMA internal medicine. 2017;177(8):1154-62.

Lai CC, Lu MC, Tang HJ, Chen YH, Wu YH, Chiang HT, et al. Implementation of a national quality improvement program to enhance hand hygiene in nursing homes in Taiwan. Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi. 2019;52(2):345-51.

Romøren M, Gjelstad S, Lindbæk M. A structured training program for health workers in intravenous treatment with fluids and antibiotics in nursing homes: A modified stepped- wedge cluster-randomised trial to reduce hospital admissions. PloS one. 2017;12(9):e0182619.

Simmons S, Schnelle J, Slagle J, Sathe NA, Stevenson D, Carlo M, et al. AHRQ Comparative Effectiveness Technical Briefs. Resident Safety Practices in Nursing Home Settings. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.

Low LF, Fletcher J, Goodenough B, Jeon YH, Etherton-Beer C, MacAndrew M, et al. A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes. PloS one. 2015;10(11):e0140711.

McConeghy KW, Baier R, McGrath KP, Baer CJ, Mor V. Implementing a Pilot Trial of an Infection Control Program in Nursing Homes: Results of a Matched Cluster Randomized Trial. Journal of the American Medical Directors Association. 2017;18(8):707-12.

Stone PW, Herzig CTA, Agarwal M, Pogorzelska-Maziarz M, Dick AW. Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study. Inquiry : a journal of medical care organization, provision and financing. 2018;55:46958018778636.

Dick AW, Bell JM, Stone ND, Chastain AM, Sorbero M, Stone PW. Nursing home adoption of the National Healthcare Safety Network Long-term Care Facility Component. American journal of infection control. 2019;47(1):59-64.

Wagner LM, McDonald SM, Castle NG. Impact of voluntary accreditation on short-stay rehabilitative measures in U.S. nursing homes. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses. 2013;38(4):167-77.

Gastmeier P, Behnke M, Reichardt C, Geffers C. [Quality management for preventing healthcare-acquired infections. The importance of surveillance]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2011;54(2):207-12.

Gudiol F. [Prudent use of antibiotics and suggestions for improvement in long-term-care facilities]. Enfermedades infecciosas y microbiologia clinica. 2010;28 Suppl 4:32-5.

European Centre for Disease Prevention and Control (ECD). Protocol for point prevalence surveys of healthcare-associated infections and antimicrobial use in European log- term care facilties. Version 2.1. 2015:60.

Fu CJ, Agarwal M, Dick AW, Bell JM, Stone ND, Chastain AM, et al. Self-reported National Healthcare Safety Network knowledge and enrollment: A national survey of nursing homes. American journal of infection control. 2020;48(2):212-5.

Stone PW, Chastain AM, Dorritie R, Tark A, Dick AW, Bell JM, et al. The expansion of National Healthcare Safety Network enrollment and reporting in nursing homes: Lessons learned from a national qualitative study. American journal of infection control. 2019;47(6):615-22.

Mukamel DB, Ye Z, Glance LG, Li Y. Does mandating nursing home participation in quality reporting make a difference? Evidence from Massachusetts. Medical care. 2015;53(8):713-9.

Sánchez Ferrín P, Fontecha Gómez BJ. [Infection epidemiology in gerontology centers]. Rev Esp Geriatr Gerontol. 2011;46(2):61-2.

Comas-Herrera A, Fernandez JL, Hancock R, Hatton C, Knapp M, McDaid D, et al. COVID-19: Implications for the Support of People with Social Care Needs in England. J Aging Soc Policy. 2020;32(4-5):365-72.

Scientific Societies that endorse this document (in alphabetical order):

• General Council of Official Colleges of Pharmacists

• General Nursing Council of Spain   

• Spanish Association of Vaccinology (AEV)

• Spanish Society of Chemotherapy (SEQ)

• Spanish Society of Clinical, Family and Community Pharmacy (SEFAC)

• Spanish Society of Family and Community Medicine (semFYC)

• Spanish Society of General and Family Doctors (SEMG)

• Spanish Society of Geriatrics and Gerontology (SEGG)

• Spanish Society for Infectious Diseases and Clinical Microbiology (SEIMC)

• Spanish Society of Internal Medicine (SEMI)

• Spanish Society of Preventive Medicine, Public Health and Hygiene (SEMPSPH)

• Spanish Society of Primary Care Physicians (SEMERGEN)

This article is published jointly under the publication and copyright agreement with the SEMERGEN journal ‘Medicina de Familia’.