Comment

Infections in long-term care: burden affirmed, action needed

Philipp Kohler, Allison McGeer

Lancet Infect Dis Available online 16 June 2025

https://doi.org/10.1016/S1473-3099(25)00287-7

In The Lancet Infectious Diseases, Enrico Ricchizzi and colleagues report the results of a year-long study of the incidence of health-care-associated infections (HAIs) in long-term care facilities (LTCFs) in nine European countries.¹ Using prospective surveillance data from more than 3000 residents in 65 LTCFs, the authors show that 57% of residents had at least one HAI during the 12-month observation period, with respiratory tract infections (RTIs) and urinary tract infections (UTIs) being most common, and with an overall case fatality rate of 4·5% (95% CI 2·5–4·8). An important limitation of the study is the question of generalisability, as LTCFs have diverse characteristics and functions in different countries, and although large, the sample in this study was a convenience sample. Nevertheless, these data shed important light on a highly relevant topic within a health-care setting that is often neglected. Implementation of surveillance programmes and research projects in long-term care is substantially impeded by the unfamiliarity of LTCF owners and staff with the topic, time constraints, and disproportionately high costs.² Thus, Ricchizzi and colleagues are to be commended all the more for this international prospective surveillance study, which adds considerably to our understanding of the epidemiology and burden of HAIs in LTCFs.

An average of one in two LTCF residents with any infection is not unexpected. However, the 4·5% case fatality rate emphasises the extreme frailty of this population and severity of the identified infections. 85 deaths were caused by RTIs, corresponding to a case fatality rate of 2·3% (95% CI 1·8–2·8) among those with an HAI. Mild upper RTIs might have been missed because residents were unable to report symptoms or because such infections were not recorded. Some RTIs might also have been caused by undiagnosed SARS-CoV-2 infections, which constitute a substantial new infection risk in this setting. We do not know to what extent antimicrobial resistance contributed to the high burden of infection, as the authors did not report any pathogen-specific infection data apart from for COVID-19. However, we do know that LTCFs in general constitute a high-risk setting for the acquisition and dissemination of resistant pathogens.

The question of how we can best prevent infections in LTCFs is obviously important. A 2023 systematic review³ documented that, although the overall quality of available evidence is low, several preventive measures have been shown to be effective. For example, data from randomised trials show the positive effect of hand-hygiene interventions on incidence of infection.³ Additionally, improved oral hygiene decreased the incidence of pneumonia—of note because the respiratory tract was the most common infection site in the study by Ricchizzi and colleagues.³ Vaccination of LTCF residents against respiratory pathogens such as pneumococci,³ influenza,⁴ and SARS-CoV-2⁵ is clearly of benefit, and vaccination of health-care workers and rapid implementation of outbreak-control measures could add additional protection against influenza.3, 6 Bundle interventions have also been shown to result in a reduction in catheter-associated UTIs,⁷although urinary catheters are not often used in LTCFs (only 153 [5%] of 3029 residents in the study by Ricchizzi and colleagues), and most UTIs are probably not catheter-related. Various antimicrobial stewardship interventions have been shown to lower the risk for Clostridioides difficile infection in this population,³ and interventions to prevent transmission have been shown to reduce the prevalence of meticillin-resistant Staphylococcus aureus,³ carbapenemase-producing Enterobacterales,⁸ and Candida auris.⁹

The demographic forecast for most Western countries is unambiguous. In Europe, 14% of the population is expected to be in need of long-term care by 2070.¹⁰ Given the growing importance of this patient population, as well as the substantial morbidity and mortality associated with HAIs in the LTCF setting, there is no question that further action is required. First, there is a need for ongoing surveillance of infections, work to validate surveillance definitions, and more epidemiological data (eg, pathogen-specific burden, contribution of outbreak vs sporadic infections, and added burden of antimicrobial resistance). Second, preventive measures known to be effective against HAIs in LTCFs should be implemented universally and reinforced where necessary. Third, pragmatic high-quality studies evaluating the effect and cost-effectiveness of specific interventions to reduce the burden of HAIs in LTCFs are needed. As an important learning point from the COVID-19 pandemic, the implications of preventive, diagnostic, and therapeutic measures on the physical, mental, and social wellbeing of LTCF residents have to be factored in when planning or implementing such studies. Finally, awareness must be increased among health-care providers, policy makers, funding bodies, and the general public about the substantial impact of HAIs on long-term care.

It has been said that the value of a society is measured by how well it treats its most vulnerable members. Long-term care residents are, indeed, among the most vulnerable members of our society. We look forward to what we hope will be a new focus on preventing infections in LTCFs.