Point Prevalence Surveillance Protocol for Antimicrobial Use and Antimicrobial Resistant Organisms within Selected Canadian Long-Term Care Facilities
Questionnaire des résidents
Antimicrobial resistance (AMR) refers to the ability of microorganisms to withstand attack by antimicrobial drugs, such as antibiotics, that were originally effective in treating infections caused by these microorganisms. Antimicrobial resistance is considered a serious threat to public health because it erodes the efficacy of these agents in treating and preventing a wide range of infectious diseases in humans. Numerous studies have shown that resistant infections contribute to increased hospitalization rates, greater disease severity, increased health care costs, and higher mortality.
Currently there is a gap in AMR surveillance in Canadian long-term care facilities. With an aging population, a third of seniors aged 85 and over, living in care facilities focused in providing specialized care to senior’s, and residents of long term care facilities (LTCF) are at a higher risk of infection. Enhanced surveillance in this population is needed.
Residents of long-term care facilities have a higher risk of infection than the general population. Risk factors for infection in residents of LTCFs include a higher likelihood of immunocompromised status, co-morbidities, invasive devices and decreased mobility. With close-confined living quarters and an aging population, long -term care facilities may have a frequency of infection comparable to rates observed in acute care facilities.
The emergence of infections caused by antibiotic-resistant pathogens is a growing concern and has now become a major health issue in LTCFs. Studies have shown that many residents enter LTCFs colonized with antibiotic-resistant organisms that were acquired in acute care. Various resident and facility factors, unique to LTCFs, contribute to persistent colonization. Residents of some LTCFs may have a high frequency of colonization with antimicrobial-resistant organisms, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, multi-drug resistant pneumococci, and extended spectrum β-lactamase-producing gram-negative organisms.
The Canadian Antimicrobial Resistance Surveillance System (CARSS) was established as the national focal point for surveillance of antimicrobial resistance (AMR) and antimicrobial use (AMU) in Canada in order to address the global concerns of AMR. CARSS currently works closely with internal stakeholders within the Public Health Agency of Canada (PHAC) and the National Microbiology Laboratory (NML), as well as provincial and territorial (P/T) stakeholders in order to provide a comprehensive report of the impact of AMU and AMR across Canada. Despite the ongoing efforts in capturing the true burden of AMU and AMR within the country, there are still many gaps to address.
Currently there is a lack of information on the true burden of AMU and AMR in non-acute health care facilities including long term care facilities. Antimicrobials are the most commonly prescribed medications in these facilities and with high rates of colonization there can be misdiagnosis of infections leading to misuse of antibiotics. Certain P/T’s have conducted pilot studies to get an estimate of the burden of AMR and AMU in LTCFs; however, there is no available information at the national level. The aim of this project is to identify the burden of top priority antimicrobial resistant organisms and antibiotic use in Canadian LTCFs by conducting a point prevalence survey on the burden of antibiotic resistance, colonization and use in participating facilities. The findings of this project may be used to inform policy, stewardship and research initiatives, introducing further research questions and advising guidelines.
The primary objective is to assess the prevalence of infections caused by antimicrobial resistant organisms (AROs) identified as a priority for surveillance by PHAC in a number of LTCFs identified by Infection Prevention and Control Canada (IPAC-Canada).
The specific objectives for this surveillance project include the following:
- To assess the prevalence at one pre-determined point in time of antimicrobial resistant organisms in residents residing in Canadian long-term care facilities;
- To describe the epidemiology of selected antimicrobial resistant organisms in Canadian long-term care facilities participating in the prevalence survey;
- To determine the prevalence of antimicrobial use in Canadian long-term care facilities participating in the survey at a pre-determined point of time. Information on antimicrobial use will be collected on all residents enrolled in this study whether or not they are found to have be infected or colonized with antimicrobial resistant organisms.
- Resident population and data collection
Residents will be identified at each long-term care facility by the facility census at a pre-determined time set by each facility on any day occurring between April 1 - 30, 2017. Patients admitted after the predetermined start time on that day will not be included in the survey. Residents cannot be enrolled more than once during the surveillance period. Data collection will begin 24 hours after the census (the day after) to allow sufficient time to complete medical/nursing entries in the resident’s
- Resident population
- Documented infection or colonization caused by one of the antimicrobial resistant organisms under surveillance (Please see Annex 1; case definitions);
- All residents using at least one systemic antibiotic on the specified date and time. Note: Residents receiving chronic ambulatory care on a regular basis in an acute care hospital should be included.
- Residents not living full-time in the long-term care facilities;
- Residents not living full-time in the long-term care facilities;
- Collected information
Information may be obtained from resident’s charts, nurses’ logs, laboratory reports, or as seen appropriate by the participating facility. The data will be entered in a questionnaire by LTCF staff and will be validated by PHAC.
a. Institutional questionnaire:
The institutional questionnaire will include information on the total number of residents as per the LTCF census on the day of the prevalence, the total number of eligible residents to be surveyed, total number of resident’s rooms, staffing, and stewardship indicators.
b. Resident questionnaire:
Demographic data will be collected on all eligible residents, including age, gender, and date of first admission to the facility. Information on the resident’s room and information on additional precautions/isolation will also be recorded.
The point prevalence study will provide an estimate of the burden of AMR in LTCFs. The analysis will consist of estimating the prevalence of AMR at a national level and regional level. Prevalence rates may be further stratified by risk factors and organisms. In addition, the frequency of antimicrobial use will be assessed and descriptive analyses will be provided.
The main activity in this project is data collection on all eligible residents at the specified point in time. Residents will be identified by the LTCF census on date selected for the point prevalence. From that time, the LTCF participating in the point prevalence surveillance project will have two weeks to complete the data collection. The workload will involve the following:
- Identifying residents by the inclusion and exclusion criteria and assigning each a random patient identifying number. A unique identifier linked to each participating resident will only identify residents at the site and will not be transmitted to PHAC.
- Completing the institutional questionnaire;
- Review resident chart and complete a questionnaire for all eligible residents;
- At completion of the data collection process for all residents, any paper survey forms will be sent via courier or by facsimile to PHAC and a copy kept on site. Data entry and database design will be the responsibility of PHAC/IPAC. At the completion of data analysis, each participating site will receive an analysis of their individual data and project report.
This surveillance project is observational and does not involve any alteration in resident care. Surveillance for hospital acquired infections (HAI) is a routine component of quality assurance and resident care in Canadian health care institutions and therefore informed consent will not be required. Research ethics board (REB) approval is not required by PHAC. However, individual LTCFs may seek institutional REB approval according to local facility policy. A unique identifier linked to each participating resident will only identify residents at the site and will not be transmitted to PHAC. All data will be strictly confidential.
 An antimicrobial is a natural, semisynthetic or synthetic substance that is capable of killing or inhibiting the growth of microbes. The term antimicrobial will be used throughout this document to refer to antibiotics, antivirals, antifungals and antiparasitics.
 Living arrangements of seniors. Census in briefs. 2011 Analytical products, Statistics Canada. https://www12.statcan.gc.ca/census-recensement/2011/as-sa/98-312-x/98-312-x2011003_4-eng.cfm
Moro, M. L., & Gagliotti, C. (2013). Antimicrobial resistance and stewardship in long-term care settings. Future Microbiology, 8(8), 1011-1025. doi: 10.1086/314010
 Nicolle, L. (2000). Infection Control in Long-Term Care Facilities. Clinical Infectious Diseases, 31 (3): 752-756.doi:10.2217/fmb.13.75