Effective infection prevention and control measures in long-term care facilities in non-outbreak and outbreak settings: a systematic literature review
Antimicrobial Resistance & Infection Control volume 12, Article number: 113 (2023)
Healthcare-associated infections in long-term care are associated with substantial morbidity and mortality. While infection prevention and control (IPC) guidelines are well-defined in the acute care setting, evidence of effectiveness for long-term care facilities (LTCF) is missing. We therefore performed a systematic literature review to examine the effect of IPC measures in the long-term care setting.
We systematically searched PubMed and Cochrane libraries for articles evaluating the effect of IPC measures in the LTCF setting since 2017, as earlier reviews on this topic covered the timeframe up to this date. Cross-referenced studies from identified articles and from mentioned earlier reviews were also evaluated. We included randomized-controlled trials, quasi-experimental, observational studies, and outbreak reports. The included studies were analyzed regarding study design, type of intervention, description of intervention, outcomes and quality. We distinguished between non-outbreak and outbreak settings.
We included 74 studies, 34 (46%) in the non-outbreak setting and 40 (54%) in the outbreak setting. The most commonly studied interventions in the non-outbreak setting included the effect of hand hygiene (N = 10), oral hygiene (N = 6), antimicrobial stewardship (N = 4), vaccination of residents (N = 3), education (N = 2) as well as IPC bundles (N = 7). All but one study assessing hand hygiene interventions reported a reduction of infection rates. Further successful interventions were oral hygiene (N = 6) and vaccination of residents (N = 3). In outbreak settings, studies mostly focused on the effects of IPC bundles (N = 24) or mass testing (N = 11). In most of the studies evaluating an IPC bundle, containment of the outbreak was reported. Overall, only four articles (5.4%) were rated as high quality.
In the non-outbreak setting in LTCF, especially hand hygiene and oral hygiene have a beneficial effect on infection rates. In contrast, IPC bundles, as well as mass testing seem to be promising in an outbreak setting.
In the United States, there are 65,600 regulated long-term care facilities (LTCF). Around 70% of people turning 65 are expected to need long-term care at some point in their life, and 18% of the older persons will spend over a year in a nursing facility . Similar data exist for Europe, where approximately 3 million long-term care beds exist in nursing and residential care facilities in the 26 EU member states for which data are available in 2020 .
Healthcare-associated infections (HAI) are a major threat in acute and long-term care . Point prevalence studies from Switzerland demonstrated that between 2.0 and 4.4% of nursing home residents are affected by HAI . In combination, these numbers indicate that a large proportion of the population will sooner or later be affected by HAI in a long-term care institution and that there is an essential need for effective HAI preventive and control measures in these settings . The Covid-19 pandemic underlined the strong need for recommendations to prevent HAI in long-term care .
While infection prevention and control (IPC) measures and outcomes are well defined for acute care hospitals in the World Health Organization (WHO) core components for infection prevention , data are scarce for long-term care settings.
In a thorough review by Lee et al., published 2019 prior to the Covid-19 pandemic, the authors were unable to identify a set of measures that could be proposed for implementation of effective IPC measures . Up to this review, only a few high-quality studies were available .
In the current study, we aimed to both, update the findings by Lee et al. and complete by focusing on the Covid-19 pandemic in order to provide an overview of the current literature, identify existing research gaps and propose IPC measures and that could uniformly be recommended in long-term care. For the analysis, we differentiated between non-outbreak and outbreak settings.
The methods and results are reported according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement 2020 .
The population of interest was defined as residents and healthcare workers in adult LTCF. Interventions included any IPC measures in accordance with the WHO core components for infection prevention even if they were mainly developed for acute care settings . Furthermore, we included oral hygiene as IPC measure as it has been shown to have a beneficial effect on infection rates in other settings . No restrictions in terms of comparisons were made. Outcomes were defined as HAIs or HAI prevention measures, mortality or transmission events, as well as healthcare worker attributes such as IPC knowledge or adherence to measures.
In order to cover the most recent scientific evidence, with a specific focus on the Covid-19 pandemic, we performed an electronic search of PubMed and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms (((infection[Title/Abstract] OR infections[Title/Abstract]) AND (‘nursing home*’[Title/Abstract] OR ‘skilled nursing*’[Title/Abstract] OR ‘long-term care’[Title/Abstract])) AND (practice[Title/Abstract] OR control*[Title/Abstract] OR measure*[Title/Abstract] OR evaluate*[Title/Abstract] OR effect*[Title/Abstract] OR prevent*[Title/Abstract] OR program*[Title/Abstract] OR intervention*[Title/Abstract] OR outcome*[Title/Abstract])) NOT (surgery[Title/Abstract] OR cancer[Title/Abstract] OR ‘neoplasm’[Title/Abstract] OR ‘intensive care unit’[Title/Abstract] OR child[Title/Abstract] OR children[Title/Abstract] OR ‘operative’[Title/Abstract]). Thereby, we built on the search strategy used in the most comprehensive existing review , but extended the time frame from 2017 until the 4th of November, 2022. In addition, reference lists of reviewed articles were scanned and the results combined.
We included randomized controlled trials, observational studies (cohort and case–control studies) and quasi-experimental studies (before-after studies) in non-outbreak settings and outbreak reports. Studies were included if they were published in English and reported results from an infection prevention intervention in adult LTCFs.
Article types such as review papers, letters, editorials, expert opinions, ecological studies and study protocols were excluded, as were studies from pediatric long-term-care settings.
Four main authors (NB, DF, SPK, and JM) screened searched titles and abstracts of each reference identified by the search. If the study met the eligibility criteria, the full-text article was reviewed independently for definitive inclusion by two authors each. In case of disagreement or in unclear cases, a third author made the decision about final inclusion.
Study data were extracted by the same authors (NB, DF, SPK, and JM), including setting, study design, main topic, type of intervention, and outcomes, using a standardized data collection form. An intervention was rated as successful when a statistically significant effect in the primary outcome was observed.
Included studies were further classified into non-outbreak versus outbreak settings.
To assess methodological quality and risk of bias, we used the Cochrane risk-of-bias (RoB) 2.0 tool for randomized controlled trials, and the Newcastle Ottawa Quality Assessment Scale for Cohort studies and case–control studies [11, 12]. Each included study was assessed by one author and classified as high, medium, or low quality.
If the judgement in all key domains was ‘low risk of bias’ for RCT or achieved one star within every category for observational studies, the study was determined to be high quality. If the judgement in one or more key domains was ‘unclear’ or had ‘some risk of bias’ in the RoB 2.0 tool or achieved most but not all stars in the Newcastle–Ottawa-Scale, the study was evaluated to be medium quality. If the study was assessed to be at high risk of bias in one or more key domains for RCTs or failed to meet most of the stars for observational studies, the quality-summary was deemed to be low in quality. Single-arm trials and outbreak reports were classified as low quality.
In order to avoid duplication and for better readability, most results are either presented in the detailed tables or in the main text.
The literature search yielded 8675 references (Fig. 1). After the screening of titles and abstracts, we selected 150 studies for full-text screening. Seventy-four studies met the inclusion criteria and were included [13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86] (Tables 1, 2).
Details for study type, study quality, place of study, and type of intervention are summarized in Table 3.
Type of intervention and setting
The most frequent interventions from the non-outbreak setting were hand hygiene (N = 10) [21,22,23,24,25,26,27,28,29,30], an IPC bundle with several measures included (N = 7) [18, 31,32,33,34,35,36], oral hygiene (N = 6) [38,39,40,41,42,43], antimicrobial stewardship (N = 4) [13,14,15,16] as well as vaccination of residents (N = 3) [44,45,46]. Interestingly, studies from Asia mainly concentrated on oral health (N = 4) [38, 39, 41, 43] and hand hygiene (N = 3) [22, 23, 28], whereas studies from North America drew their attention towards antimicrobial stewardship [13,14,15,16] and hand hygiene [21, 24, 25, 30] (each N = 4). An overview on the results of the included studies in non-outbreak settings is shown in Fig. 2.
The majority of studies in the outbreak setting concentrated on an IPC bundle (N = 24) [47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70] and on mass testing/surveillance (N = 11) [71,72,73,74,75,76,77,78,79,80,81].
Hand hygiene alone was evaluated in ten studies [21,22,23,24,25,26,27,28,29,30], all conducted in non-outbreak settings. Nine of ten articles showed a successful intervention with reduced infection rates and lower prevalence of multi drug resistant organisms (MDRO) [21,22,23, 25,26,27,28,29,30].
No study evaluated hand hygiene alone in an outbreak setting.
Four studies in non-outbreak-settings on antimicrobial stewardship which also measured the infection rates were included in our review [13,14,15,16]. Three could demonstrate a reduction of C.difficile infections through antimicrobial stewardship [14,15,16], while one retrospective quasi-experimental study showed no decrease of MDRO-incidence or C.difficile infections .
In an outbreak setting no studies on this topic were undertaken so far.
Two studies assessed the effect of education in IPC measures [19, 20]. Both were executed in a non-outbreak setting. One RCT found no difference of methicillin-resistant Staphylococcus aureus (MRSA) prevalence in groups with IPC education . The other study recorded a successful outcome with a significant improvement of knowledge after education .
No studies were conducted to evaluate the effect of education alone in an outbreak setting.
One RCT assessed decolonization measures as main intervention in a non-outbreak setting  and found a reduction of MRSA prevalence after decolonization measures were implemented. No study evaluated decolonization measures in an outbreak setting.
One high-quality study from the USA evaluated the effect of isolation precautions alone with no significant difference in MDRO prevalence with/without isolation precautions .
We included three studies on vaccination in a non-outbreak setting [44,45,46]. A high-quality trial from Japan showed a significant reduction in cases of pneumonia in residents of 23 LTCF after the 23-valent pneumococcal vaccine was introduced . Two studies were conducted in the non-outbreak setting with COVID-19 vaccination and showed a significant reduction in COVID-19 cases, COVID-19 related hospitalization and mortality [44, 45]. In outbreak settings, COVID-19 vaccination of residents significantly reduced outbreaks, COVID-19 cases, COVID-19 related hospitalization, and mortality in 3 of 4 studies. One study, executed in the turn of the year 2021 to 2022 showed no reduction in COVID-19 cases, but a reduced case fatality after vaccination .
Six studies evaluated the effect of improved oral hygiene on overall infection rates, all from a non-outbreak setting [38,39,40,41,42,43]. All studies found a reduction of infections (mainly cases of pneumonia) with the intervention.
No publication on the effect of oral hygiene in an outbreak setting was recorded.
We found no study on mass testing in a non-outbreak setting. All studies that analyzed the effect of mass testing were performed in an outbreak setting during an early stage of the COVID-19 pandemic [72,73,74,75,76,77,78,79,80,81] and mostly resulted in the isolation of residents and quarantine of HCWs who tested positive. All of them found a significant number of asymptomatic HCWs and residents with a range of asymptomatic carriers from around 3% up to 43% in different studies.
Half of the included studies (21% in non-outbreak-setting [18, 31,32,33,34,35,36] and 60% in outbreak setting [47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70]) focused on several topics simultaneously within an IPC bundle. In the non-outbreak setting one cRCT study evaluated a bundle of education of health care workers (HCW), surface cleaning, and feedback on HAI rates and could not observe a significant reduction in infection rates .
Furthermore, a large RCT in 104 long-term care facilities in Switzerland showed no effect of MRSA decolonization and different isolation precautions (standard vs. contact precautions) on MRSA prevalence .
In contrast, four studies could demonstrate a reduction of MDRO prevalence through a multicomponent intervention that included barrier precautions, active surveillance of MDRO and infections, as well as staff education and hand hygiene promotion [18, 33, 35, 36]. Koo et al. could at least show an improvement in knowledge for trained topics through an IPC bundle that included education while not evaluating infection rates . Twenty-four of 31 included studies on IPC bundles were performed in an outbreak setting [47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70]. The included studies contained cohort and case–control studies, as well as outbreak reports. A median of 5 measures were included in an IPC bundle (range 2 to 8) with isolation/precautions (N = 24, 19.7%), surveillance (N = 13, 10.7%) and hand hygiene (N = 9, 8.2%) being the most represented interventions included in the bundles. All outbreak reports showed containment of the outbreaks.
When we differentiated by the transmission route, we found 15 studies where the transmission occurred mainly by respiratory droplets (SARS-CoV-2, Group A streptococci, Influenza-like illnesses) [47, 48, 50, 54,55,56, 58,59,60,61, 63, 65,66,67,68] and 8 studies with transmission via direct and/or indirect contact (gastroenteritis, MDRO, Norovirus etc.) [49, 51, 53, 57, 62, 64, 69, 70]. The bundles in these two categories varied slightly. The ones for pathogens transmitted through the respiratory route concentrated on wearing masks and repetitive testing, whereas those for direct or indirect contact transmissions focused more on environmental cleaning measures and contact precautions.
In the non-outbreak setting we found two articles focusing on the effect of vaccination on SARS-CoV-2 infection rates [44, 45]. Both found a positive effect of the vaccination on infection incidence in nursing home residents and staff as well as a reduced mortality in residents.
In 22/40 (55%) studies from the outbreak setting, SARS-CoV-2 was the main pathogen [48, 50, 59, 60, 63, 65, 66, 71,72,73,74,75,76,77,78,79,80,81,82,83,84,85]. Vaccination was also highly effective in reducing infections in this setting [82,83,84,85]. 7 articles reported the effect of an IPC bundle [48, 50, 59, 60, 63, 65, 66], whereas mass testing was the main IPC measure in 11 articles [71,72,73,74,75,76,77,78,79,80,81] (see also paragraph on mass testing above) and vaccination was evaluated in four studies [82,83,84,85]. As already mentioned above, most of the included studies from the outbreak setting documented a successful containment of the outbreak. This was also true for COVID-19.
Other WHO core components
Other WHO core components for infection prevention, such as IPC programs per se, IPC guidelines, monitoring of IPC practices, reduction of workload, optimized staffing and bed occupancy rates as well as the environment, materials and equipment alone were not evaluated in the studies that were identified by our search.
The quality of included studies was generally low (Additional file 1: Tables S2a, S2b, S2c). Only four (5%) studies were classified as high quality [31, 33, 37, 46]; all of these were RCTs. Other RCTs were medium (N = 10) [15, 17, 19, 26, 27, 32, 34, 35, 42, 43] or low (N = 4) in quality [18, 22, 28, 38]. In contrast, the included cohort studies were medium-quality [21, 24, 41, 53, 82] or low-quality studies (N = 5) [29, 36, 39, 44, 77]. The case–control studies were classified as medium (N = 4) [47, 52, 54, 68] or low quality (N = 2) [57, 69]. All outbreak reports were classified as low quality per definition (N = 16) [48,49,50,51, 55, 56, 58,59,60,61,62,63,64,65, 67, 70].
In this systematic review, which also covers the SARS-CoV-2 pandemic, we identified 74 studies of different quality evaluating the effect of infection prevention and control measures in long-term care facilities in outbreak or non-outbreak settings, respectively. Hand hygiene, staff education measures, antimicrobial stewardship, vaccination and oral care seem to be consistently effective in preventing healthcare-associated infections or transmission events in long-term care settings. However, studies were mostly of low quality and highly heterogeneous with regard to setting, intervention measures, populations, and outcomes. Therefore, deriving standard of care recommendations or guidelines for LTCFs based on these data remains difficult.
Our current systematic review covers data from non-outbreak and outbreak settings, especially during the SARS-CoV-2 pandemic, from a variety of countries worldwide. With a large increase in new publications during the COVID-19 pandemic, our study provides an update on the currently available literature on the effectiveness of different infection prevention measures in LTCFs in comparison to previous reviews. This allowed us to draw a more accurate picture of the current evidence on this topic.
For non-outbreak publications, our results regarding the effectiveness of different measures as well as the difficult comparability of the studies are in line with earlier well-made systematic reviews [7, 87]. In comparison to Lee et al., we identified relatively good quality data on the importance of hand hygiene, antimicrobial stewardship, vaccination and oral hygiene in addition to the already known beneficial effects of education, monitoring and multi-modal strategies. Of note, Lee et al. did not evaluate any antimicrobial stewardship interventions in their review . While Uchida et al. focused solely on therapeutic measures  we also analyzed studies on educational measures and focused more on the effect of the type of intervention. This allowed us to identify the particular contribution of various measures to a given outcome.
In contrast to others authors [7, 87,88,89,90], we included articles from the non-outbreak setting as well as from the outbreak-setting. While one review on IPC measures in the outbreak setting was conducted before COVID-19 , the others were published during the pandemic [88, 89].
For the outbreak setting, mainly for studies on SARS-CoV-2, our review indicates that reasonably good data exist for the effectiveness of vaccination, mass testing, and IPC bundles, whereas no statement can be made about other single or combination of measures [71, 72]. Since outbreaks in general and virus-related outbreaks in particular are often self-limiting , it remains difficult to assess and put into context the added value of such transiently applied outbreak control measures. Whether an outbreak could be contained because of the IPC bundle or because of the temporary nature of outbreaks is impossible to discriminate in studies without control group.
It is to be expected that a combination of different measures produces an additive or synergistic effect, although, in our review, combinations of different measures were mostly applied in outbreak settings, with a difficult to evaluate outcome for the reasons mentioned above. Therefore, an additive or synergistic effect cannot be proven in our dataset.
Although education is often part of a bundle of measures, there is very little data on the importance of education alone. However, this should not limit the importance of education, which is extremely important in this context where health care workers are often insufficiently trained in medical and infection prevention and control.
Strengths and limitations
Our study has several limitations. First, generalizability is hampered in that we only included studies published in English and most studies in our review were performed in North America and Europe. As long-term settings vary widely within and across countries, settings and thus effectiveness of interventions may differ across institutions. Second, publication bias may have played a role in that ineffective IPC interventions may not be published, especially in outbreak settings. Furthermore, due to the heterogeneity and the low quality of studies, we were unable to compare effect sizes, let alone to meta-analyze effects across studies, even within similar settings or types of interventions. Last, we did not extend our search beyond PubMed and The Cochrane Central Register of Controlled Trials (CENTRAL), but given the quality and heterogeneity of identified studies, we are confident that searching further databases would not have led to more refined results. Another limitation of our study is the fact that LTC institutions provide medical and nursing care for different and rather heterogeneous resident populations in different countries. Thus, an identical measure could have a different clinical outcome based on the cognitive and or functional status of the persons living in the LTCF. This also applies to common geriatric syndromes such as frailty and/or malnutrition including urinary or stool incontinence. In addition the way how and by whom medical care is provided may have some impact upon the outcomes documented in our selected studies.
Strengths of our study are the inclusion of studies conducted in both non-outbreak and outbreak settings, including the COVID-19 pandemic and outbreaks of other pathogens, the inclusion of antimicrobial stewardship as a topic and the updated search until November 2022. Through this, we were able to recognize a large amount of studies with IPC measures not included in other reviews.
Conclusion and outlook
In conclusion, although we were able to find a good amount of data on IPC measures in the LTCF setting, interpretability and generalizability of these data remains difficult. Especially for outbreak settings, reports of successful control measures often do not add more value than do single case reports in the individual patient care setting. Given that the population at risk for healthcare-associated infections in these settings is large and constantly growing, coordinated action is imperative. In order to move a step forward and to complete the picture, well executed studies on this topic are desperately needed. These include a systematic evaluation of clearly defined single interventions or intervention bundles using high-quality (cluster-)-randomized controlled trials in well-defined settings and patient populations with useful outcome measures. These, due to the special needs of this population, do not only include HAIs, but also other measures such as quality of life, which sometimes might be favored over restrictive measures for infection prevention. In addition, IPC intervention trials and or measures across a clearly defined resident population and interventions that control for geriatric syndromes are urgently needed. Such efforts are only possible if sufficient funding for large, concerted, multi-national initiatives is available.
In general, it can be discussed whether reducing nosocomial infections is of high priority for the long-term-care setting or whether the focus should rather be on maintaining quality of life. Data on the influence of IPC measures on quality of life in long-term-care facilities are scarce or non-existing. From the COVID-19 pandemic, we assume that certain factors, such as visitor restriction, isolation measures and wearing masks for example, had an impact on the well-being of APH residents.
In the meantime, using the available low-quality evidence and extrapolating infection prevention and control measures from acute to long-term care with some common sense seem to be useful approaches. Thereby, the most essential basic IPC measures from the acute care setting, such as standard hygiene measures with hand hygiene and personal protective equipment when needed, combined with a good education for HCW and a functioning surveillance system might be the cornerstones of a successful IPC program in long-term care. Given that LTCFs are very heterogeneous with ever changing activities, defining the needs of every single institution is challenging. However, a standardized IPC program that every institution could adapt to its temporary needs may be a reasonable approach with a high acceptance on the part of the residents, HCW, and IPC team.
Availability of data and materials
The dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.
Cassini A, Plachouras D, Eckmanns T, Abu Sin M, Blank HP, Ducomble T, et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study. Harbarth S, editor. PLOS Med. 2016;13(10):e1002150.
Héquet D, Kessler S, Rettenmund G, Lemmenmeier E, Qalla-Widmer L, Gardiol C, et al. Healthcare-associated infections and antibiotic use in long-term care residents from two geographical regions in Switzerland. J Hosp Infect. 2021;117:172–8.
Storr J, Twyman A, Zingg W, Damani N, Kilpatrick C, Reilly J, et al. Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations. Antimicrob Resist Infect Control. 2017;6:6.
Lee MH, Lee GA, Lee SH, Park YH. Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review. J Hosp Infect. 2019;102(4):377–93.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3):e1003583.
World Health Organization. Improving infection prevention and control at the health facility: interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention and control programmes. World Health Organization; 2018. Report No.: WHO/HIS/SDS/2018.10. https://apps.who.int/iris/handle/10665/279788. Cited 4 Jan 2023.
Wolfensberger A, Clack L, von Felten S, Faes Hesse M, Saleschus D, Meier MT, et al. Prevention of non-ventilator-associated hospital-acquired pneumonia in Switzerland: a type 2 hybrid effectiveness-implementation trial. Lancet Infect Dis. 2023;23(7):836–46.
Risk of bias tools - Current version of RoB 2. https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob-2. Cited 28 Dec 2022.
Ottawa Hospital Research Institute. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Cited 4 Jan 2023.
Chahine EB, Cook RO, Carrion T, Sarkissian RJ. Impact of the antimicrobial Stewardship mandate on multidrug-resistant organisms and Clostridioides difficile infection among long-term care facility residents. Sr Care Pharm. 2022;37(8):345–56.
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. J Am Med Dir Assoc. 2020;21(1):55-61.e2.
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 Intern Med. 2020;180(7):944–51.
Salem-Schatz S, Griswold P, Kandel R, Benjamin-Bothwell S, DeMaria AJ, McElroy N, et al. A statewide program to improve management of suspected urinary tract infection in long-term care. J Am Geriatr Soc. 2020;68(1):62–9.
Mody L, Kauffman CA, McNeil SA, Galecki AT, Bradley SF. Mupirocin-based decolonization of Staphylococcus aureus carriers in residents of 2 long-term care facilities: a randomized, double-blind, placebo-controlled trial. Clin Infect Dis Off Publ Infect Dis Soc Am. 2003;37(11):1467–74.
Peterson LR, Boehm S, Beaumont JL, Patel PA, Schora DM, Peterson KE, et al. Reduction of methicillin-resistant Staphylococcus aureus infection in long-term care is possible while maintaining patient socialization: a prospective randomized clinical trial. Am J Infect Control. 2016;44(12):1622–7.
Baldwin NS, Gilpin DF, Tunney MM, Kearney MP, Crymble L, Cardwell C, et al. Cluster randomised controlled trial of an infection control education and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people. J Hosp Infect. 2010;76(1):36–41.
Freeman-Jobson JH, Rogers JL, Ward-Smith P. Effect of an education presentation on the knowledge and awareness of urinary tract infection among non-licensed and licensed health care workers in long-term care facilities. Urol Nurs. 2016;36(2):67–71.
Fendler EJ, Ali Y, Hammond BS, Lyons MK, Kelley MB, Vowell NA. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Infect Control. 2002;30(4):226–33.
Ho M, Seto W, Wong L, Wong T. Effectiveness of multifaceted hand hygiene interventions in long-term care facilities in Hong Kong: a cluster-randomized controlled trial. Infect Control Hosp Epidemiol. 2012;33(8):761–7.
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. J Microbiol Immunol Infect Wei Mian Yu Gan Ran Za Zhi. 2019;52(2):345–51.
Mody L, McNeil SA, Sun R, Bradley SE, Kauffman CA. Introduction of a waterless alcohol-based hand rub in a long-term-care facility. Infect Control Hosp Epidemiol. 2003;24(3):165–71.
Schweon SJ, Edmonds SL, Kirk J, Rowland DY, Acosta C. Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility. Am J Infect Control. 2013;41(1):39–44.
Teesing GR, Richardus JH, Nieboer D, Petrignani M, Erasmus V, Verduijn-Leenman A, et al. The effect of a hand hygiene intervention on infections in residents of nursing homes: a cluster randomized controlled trial. Antimicrob Resist Infect Control. 2021;10(1):80.
Temime L, Cohen N, Ait-Bouziad K, Denormandie P, Dab W, Hocine MN. Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: a cluster randomized trial. Am J Infect Control. 2018;46(2):173–9.
Yeung WK, Tam WSW, Wong TW. Clustered randomized controlled trial of a hand hygiene intervention involving pocket-sized containers of alcohol-based hand rub for the control of infections in long-term care facilities. Infect Control Hosp Epidemiol. 2011;32(1):67–76.
Banks M, Phillips AB. Evaluating the effect of automated hand hygiene technology on compliance and C. difficile rates in a long-term acute care hospital. Am J Infect Control. 2021;49(6):727–32.
Sassi HP, Sifuentes LY, Koenig DW, Nichols E, Clark-Greuel J, Wong LF, et al. Control of the spread of viruses in a long-term care facility using hygiene protocols. Am J Infect Control. 2015;43(7):702–6.
Bellini C, Petignat C, Masserey E, Büla C, Burnand B, Rousson V, et al. Universal screening and decolonization for control of MRSA in nursing homes: a cluster randomized controlled study. Infect Control Hosp Epidemiol. 2015;36(4):401–8.
Koo E, McNamara S, Lansing B, Olmsted RN, Rye RA, Fitzgerald T, et al. Making infection prevention education interactive can enhance knowledge and improve outcomes: results from the Targeted Infection Prevention (TIP) Study. Am J Infect Control. 2016;44(11):1241–6.
Mody L, Krein SL, Saint SK, Min LC, Montoya A, Lansing B, et al. A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial. JAMA Intern Med. 2015;175(5):714.
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. J Am Med Dir Assoc. 2017;18(8):707–12.
Mody L, Gontjes KJ, Cassone M, Gibson KE, Lansing BJ, Mantey J, et al. Effectiveness of a multicomponent intervention to reduce multidrug-resistant organisms in nursing homes: a cluster randomized clinical trial. JAMA Netw Open. 2021;4(7):e2116555.
Ben-David D, Masarwa S, Fallach N, Temkin E, Solter E, Carmeli Y, et al. Success of a national intervention in controlling carbapenem-resistant enterobacteriaceae in israel’s long-term care facilities. Clin Infect Dis Off Publ Infect Dis Soc Am. 2019;68(6):964–71.
Trick WE, Weinstein RA, DeMarais PL, Tomaska W, Nathan C, McAllister SK, et al. Comparison of routine glove use and contact-isolation precautions to prevent transmission of multidrug-resistant bacteria in a long-term care facility. J Am Geriatr Soc. 2004;52(12):2003–9.
Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(2):191–5.
Ishikawa A, Yoneyama T, Hirota K, Miyake Y, Miyatake K. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res. 2008;87(6):594–8.
Kullberg E, Sjögren P, Forsell M, Hoogstraate J, Herbst B, Johansson O. Dental hygiene education for nursing staff in a nursing home for older people. J Adv Nurs. 2010;66(6):1273–9.
Maeda K, Akagi J. Oral care may reduce pneumonia in the tube-fed elderly: a preliminary study. Dysphagia. 2014;29(5):616–21.
Quagliarello V, Juthani-Mehta M, Ginter S, Towle V, Allore H, Tinetti M. Pilot testing of intervention protocols to prevent pneumonia in nursing home residents. J Am Geriatr Soc. 2009;57(7):1226–31.
Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50(3):430–3.
Cabezas C, Coma E, Mora-Fernandez N, Li X, Martinez-Marcos M, Fina F, et al. Associations of BNT162b2 vaccination with SARS-CoV-2 infection and hospital admission and death with covid-19 in nursing homes and healthcare workers in Catalonia: prospective cohort study. BMJ. 2021;18(374):n1868.
Goldin S, Adler L, Azuri J, Mendel L, Haviv S, Maimon N. BNT162b2 mRNA COVID-19 (Comirnaty) vaccine effectiveness in elderly patients who live in long-term care facilities: a nationwide cohort. Gerontology. 2022;8:1–8.
Maruyama T, Taguchi O, Niederman MS, Morser J, Kobayashi H, Kobayashi T, et al. Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and improving survival in nursing home residents: double blind, randomised and placebo controlled trial. BMJ. 2010;8(340):c1004.
Ahmed SS, Diebold KE, Brandvold JM, Ewaidah SS, Black S, Ogundimu A, et al. The role of wound care in 2 group a Streptococcal outbreaks in a Chicago skilled nursing facility, 2015–2016. Open Forum Infect Dis. 2018;5(7):ofy145.
Al Hamad H, Malkawi MMM, Al Ajmi JAAA, Al-Mutawa MNJH, Doiphode SH, Sathian B. Investigation of a COVID-19 outbreak and its successful containment in a long term care facility in Qatar. Front Public Health. 2021;9:779410.
Barret AS, Jourdan-da Silva N, Ambert-Balay K, Delmas G, Bone A, Thiolet JM, et al. Surveillance for outbreaks of gastroenteritis in elderly long-term care facilities in France, November 2010 to May 2012. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2014;19(29):20859.
Bernadou A, Bouges S, Catroux M, Rigaux JC, Laland C, Levêque N, et al. High impact of COVID-19 outbreak in a nursing home in the Nouvelle-Aquitaine region, France, March to April 2020. BMC Infect Dis. 2021;21(1):198.
Bruins MJ, Koning Ter Heege AH, van den Bos-Kromhout MI, Bettenbroek R, van der Lubben M, Debast SB. VIM-carbapenemase-producing Escherichia coli in a residential care home in The Netherlands. J Hosp Infect. 2020;104(1):20–6.
Calles DL, Collier MG, Khudyakov Y, Mixson-Hayden T, VanderBusch L, Weninger S, et al. Hepatitis C virus transmission in a skilled nursing facility, North Dakota, 2013. Am J Infect Control. 2017;45(2):126–32.
Domínguez-Berjón MF, Hernando-Briongos P, Miguel-Arroyo PJ, Echevarría JE, Casas I. Adenovirus transmission in a nursing home: analysis of an epidemic outbreak of keratoconjunctivitis. Gerontology. 2007;53(5):250–4.
Dooling KL, Crist MB, Nguyen DB, Bass J, Lorentzson L, Toews KA, et al. Investigation of a prolonged Group A Streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009–2012. Clin Infect Dis Off Publ Infect Dis Soc Am. 2013;57(11):1562–7.
Gaillat J, Dennetière G, Raffin-Bru E, Valette M, Blanc MC. Summer influenza outbreak in a home for the elderly: application of preventive measures. J Hosp Infect. 2008;70(3):272–7.
Hand J, Rose EB, Salinas A, Lu X, Sakthivel SK, Schneider E, et al. Severe respiratory illness outbreak associated with human coronavirus NL63 in a long-term care facility. Emerg Infect Dis. 2018;24(10):1964–6.
Kanayama A, Kawahara R, Yamagishi T, Goto K, Kobaru Y, Takano M, et al. Successful control of an outbreak of GES-5 extended-spectrum β-lactamase-producing Pseudomonas aeruginosa in a long-term care facility in Japan. J Hosp Infect. 2016;93(1):35–41.
Mahmud SM, Thompson LH, Nowicki DL, Plourde PJ. Outbreaks of influenza-like illness in long-term care facilities in Winnipeg, Canada. Influenza Other Respir Viruses. 2013;7(6):1055–61.
McMichael TM, Clark S, Pogosjans S, Kay M, Lewis J, Baer A, et al. COVID-19 in a long-term care facility—King County, Washington, February 27–March 9, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):339–42.
Murti M, Goetz M, Saunders A, Sunil V, Guthrie JL, Eshaghi A, et al. Investigation of a severe SARS-CoV-2 outbreak in a long-term care home early in the pandemic. CMAJ Can Med Assoc J J Assoc Med Can. 2021;193(19):E681–8.
Nanduri SA, Metcalf BJ, Arwady MA, Edens C, Lavin MA, Morgan J, et al. Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strain. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2019;25(2):248.e1-248.e7.
Nicolay N, Boulet L, Le Bourhis-Zaimi M, Badjadj-Kab L, Henry L, Erouart S, et al. The role of dependency in a norovirus outbreak in a nursing home. Eur Geriatr Med. 2018;9(6):837–44.
Psevdos G, Papamanoli A, Barrett N, Bailey L, Thorne M, Ford F, et al. Halting a SARS-CoV-2 outbreak in a US Veterans Affairs nursing home. Am J Infect Control. 2021;49(1):115–9.
Sáez-López E, Marques R, Rodrigues N, Oleastro M, Andrade H, Mexía R, et al. Lessons learned from a prolonged norovirus GII.P16-GII.4 Sydney 2012 variant outbreak in a long-term care facility in Portugal, 2017. Infect Control Hosp Epidemiol. 2019;40(10):1164–9.
Shrader CD, Assadzandi S, Pilkerton CS, Ashcraft AM. Responding to a COVID-19 outbreak at a long-term care facility. J Appl Gerontol Off J South Gerontol Soc. 2021;40(1):14–7.
Telford CT, Bystrom C, Fox T, Holland DP, Wiggins-Benn S, Mandani A, et al. COVID-19 infection prevention and control adherence in long-term care facilities, Atlanta, Georgia. J Am Geriatr Soc. 2021;69(3):581–6.
Thigpen MC, Thomas DM, Gloss D, Park SY, Khan AJ, Fogelman VL, et al. Nursing home outbreak of invasive group a streptococcal infections caused by 2 distinct strains. Infect Control Hosp Epidemiol. 2007;28(1):68–74.
Van Dort M, Walden C, Walker ES, Reynolds SA, Levy F, Sarubbi FA. An outbreak of infections caused by non-typeable Haemophilus influenzae in an extended care facility. J Hosp Infect. 2007;66(1):59–64.
Van Esch G, Van Broeck J, Delmée M, Catry B. Surveillance of Clostridium difficile infections in a long-term care psychogeriatric facility: outbreak analysis and policy improvement. Arch Public Health Arch Belg Sante Publique. 2015;73(1):18.
Weterings V, Zhou K, Rossen JW, van Stenis D, Thewessen E, Kluytmans J, et al. An outbreak of colistin-resistant Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae in the Netherlands (July to December 2013), with inter-institutional spread. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol. 2015;34(8):1647–55.
Kennelly SP, Dyer AH, Noonan C, Martin R, Kennelly SM, Martin A, et al. Asymptomatic carriage rates and case fatality of SARS-CoV-2 infection in residents and staff in Irish nursing homes. Age Ageing. 2021;50(1):49–54.
Blackman C, Farber S, Feifer RA, Mor V, White EM. An illustration of SARS-CoV-2 dissemination within a skilled nursing facility using heat maps. J Am Geriatr Soc. 2020;68(10):2174–8.
Dora AV, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L, et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for Veterans—Los Angeles, California, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(21):651–5.
Eckardt P, Guran R, Hennemyre J, Arikupurathu R, Poveda J, Miller N, et al. Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. Am J Infect Control. 2020;48(12):1552–5.
Graham NSN, Junghans C, Downes R, Sendall C, Lai H, McKirdy A, et al. SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes. J Infect. 2020;81(3):411–9.
Louie JK, Scott HM, DuBois A, Sturtz N, Lu W, Stoltey J, et al. Lessons from mass-testing for coronavirus disease 2019 in long-term care facilities for the elderly in San Francisco. Clin Infect Dis Off Publ Infect Dis Soc Am. 2021;72(11):2018–20.
Patel MC, Chaisson LH, Borgetti S, Burdsall D, Chugh RK, Hoff CR, et al. Asymptomatic SARS-CoV-2 infection and COVID-19 mortality during an outbreak investigation in a skilled nursing facility. Clin Infect Dis Off Publ Infect Dis Soc Am. 2020;71(11):2920–6.
Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A, et al. Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. JAMA Intern Med. 2020;180(8):1101–5.
Sacco G, Foucault G, Briere O, Annweiler C. COVID-19 in seniors: findings and lessons from mass screening in a nursing home. Maturitas. 2020;141:46–52.
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.
Zollner-Schwetz I, König E, Krause R, Pux C, Laubreiter L, Schippinger W. Analysis of COVID-19 outbreaks in 3 long-term care facilities in Graz, Austria. Am J Infect Control. 2021;49(11):1350–3.
Giddings R, Krutikov M, Palmer T, Fuller C, Azmi B, Shrotri M, et al. Changes in COVID-19 outbreak severity and duration in long-term care facilities following vaccine introduction, England, November 2020 to June 2021. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2021;26(46):2100995.
Martinot M, Carnein S, Kempf C, Gantner P, Gallais F, Fafi-Kremer S. Outbreak of SARS-CoV-2 infection in a long-term care facility after COVID-19 BNT162b2 mRNA vaccination. Clin Microbiol Infect. 2021;27(10):1537–9.
Mazagatos C, Monge S, Olmedo C, Vega L, Gallego P, Martín-Merino E, et al. Effectiveness of mRNA COVID-19 vaccines in preventing SARS-CoV-2 infections and COVID-19 hospitalisations and deaths in elderly long-term care facility residents, Spain, weeks 53 2020 to 13 2021. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2021;26(24):2100452.
van Ewijk CE, Hazelhorst EI, Hahné SJM, Knol MJ. COVID-19 outbreak in an elderly care home: very low vaccine effectiveness and late impact of booster vaccination campaign. Vaccine. 2022;40:6664–9.
Cheng HY, Chen WC, Chou YJ, Huang ASE, Huang WT. Containing influenza outbreaks with antiviral use in long-term care facilities in Taiwan, 2008–2014. Influenza Other Respir Viruses. 2018;12(2):287–92.
Uchida M, Pogorzelska-Maziarz M, Smith PW, Larson E. Infection prevention in long-term care: a systematic review of randomized and nonrandomized trials. J Am Geriatr Soc. 2013;61(4):602–14.
Frazer K, Mitchell L, Stokes D, Lacey E, Crowley E, Kelleher CC. A rapid systematic review of measures to protect older people in long-term care facilities from COVID-19. BMJ Open. 2021;11(10):e047012.
Abbas M, Robalo Nunes T, Martischang R, Zingg W, Iten A, Pittet D, et al. Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers. Antimicrob Resist Infect Control. 2021;10(1):7.
Lee MH, Lee GA, Lee SH, Park YH. A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: back to basics of infection control. PLoS ONE. 2020;15(3):e0229911.
Blumberg S, Funk S, Pulliam JRC. Detecting differential transmissibilities that affect the size of self-limited outbreaks. PLoS Pathog. 2014;10(10):e1004452.
PK was supported by the Swiss National Sciences Foundation (Grant Number PZ00P3_179919).
Ethics approval and consent to participate
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Bloch, N., Männer, J., Gardiol, C. et al. Effective infection prevention and control measures in long-term care facilities in non-outbreak and outbreak settings: a systematic literature review. Antimicrob Resist Infect Control 12, 113 (2023). https://doi.org/10.1186/s13756-023-01318-9