Articles
Incidence of health-care-associated infections in long-term care facilities in nine European countries: a 12-month, prospective, longitudinal cohort study
Enrico Ricchizzi, Elena Sasdelli, Anna Caterina Leucci, et al
Lancet Infect Dis Available online 16 June 2025
https://doi.org/10.1016/S1473-3099(25)00217-8
Summary
Background
The number of older people in need of long-term care is increasing, and health-care-associated infections (HAIs) are a major cause of morbidity and mortality for residents of long-term care facilities (LTCFs). This study, organised by the European Centre for Disease Prevention and Control (ECDC), provided data on the incidence of HAIs and related adverse outcomes in LTCFs in European countries, supplementing the available estimates from repeated point prevalence surveys conducted by the ECDC.
Methods
In this longitudinal, prospective cohort study, we analysed all HAIs collected in a convenience sample of residents from 65 LTCFs (including general nursing homes, residential homes, and mixed facilities) in nine EU or European Economic Area (EEA) countries (Belgium, Finland, France, Italy, Lithuania, Luxembourg, the Netherlands, Poland, and Spain) over 12 months. Eligible residents were those expected to stay in the LTCF for at least the entire study period. Data were collected with three questionnaires: an institutional questionnaire, a residents' questionnaire, and an HAI questionnaire. HAIs were defined according to standard ECDC criteria. The primary outcome was HAI incidence. Incidence measures, estimated using generalised estimating equation models to account for sample heterogeneity, were percentages of each type of HAI, numbers of HAIs per 100 LTCF residents (ratio), and numbers of HAIs per 1000 resident-days (incidence rate).
Findings
HAIs were analysed in 3029 residents of LTCFs between Jan 1–May 4, 2022, and Jan 1–May 12, 2023. The mean age of study participants was 80·9 years (SD 14·6), including 960 (31·7%) men and 2069 (68·3%) women. 3763 HAIs were recorded, with at least one HAI identified in 1717 (57%) of 3029 residents. There were 124·2 HAIs (95% CI 118·6–129·9) per 100 residents and 1·8 HAIs (0·9–3·3) per 1000 resident-days. 160 (4·3% [95% CI 3·9–5·4]) HAIs led to hospitalisation, and 154 (4·5% [2·5–4·8]) were associated with death. Respiratory tract infections (RTIs) were the most frequent type of infection (n=1080, 28·9% [95% CI 27·3–30·5]), including pneumonia (n=279, 7·3% [6·4–8·3]) and other lower RTIs (n=394, 10·7% [9·6–11·8]), followed by urinary tract infections (UTIs; n=743, 18·7% [17·2–20·3]). RTIs showed the highest incidence of mortality (n=85, 2·3% [95% CI 1·8–2·8] of all HAIs). Severe cases of COVID-19 (n=72, 1·9% [95% CI 1·5–2·4] of all HAIs) were less frequent than mild or moderate cases (n=615, 16·0% [14·9–17·1] of all HAIs).
Table 1. Clinical and demographic characteristics of the study population
| Empty Cell | Empty Cell | Belgium | Finland | France | Italy | Lithuania | Luxembourg | Netherlands | Poland | Spain | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|
| LTCFs | 4 | 15 | 10 | 24 | 5 | 2 | 3 | 1 | 1 | 65 | |
| LTCF residents | 260 | 344 | 702 | 395 | 368 | 153 | 275 | 269 | 263 | 3029 | |
| Age, years | 81·2 (11·0) | 84·9 (7·4) | 87·1 (8·7) | 85·0 (10·0) | 61·3 (14·8) | 59·3 (22·6) | 83·3 (10·0) | 84·1 (10·2) | 87·5 (8·5) | 80·9 (14·6) | |
| Sex | |||||||||||
| Female | 174 (67%) | 235 (68%) | 516 (74%) | 278 (70%) | 188 (51%) | 73 (48%) | 179 (65%) | 210 (78%) | 216 (82%) | 2069 (68%) | |
| Male | 86 (33%) | 109 (32%) | 186 (26%) | 117 (30%) | 180 (49%) | 80 (52%) | 96 (35%) | 59 (22%) | 47 (18%) | 960 (32%) | |
| Disorientation | |||||||||||
| Mild | 52 (20%) | 71 (21%) | 102 (15%) | 105 (27%) | 41 (11%) | 28 (18%) | 53 (19%) | 49 (18%) | 41 (16%) | 542 (18%) | |
| Moderate | 49 (19%) | 111 (32%) | 143 (20%) | 65 (16%) | 67 (18%) | 19 (12%) | 55 (20%) | 80 (30%) | 51 (19%) | 640 (21%) | |
| Severe | 45 (17%) | 135 (39%) | 345 (49%) | 77 (19%) | 57 (15%) | 13 (8%) | 50 (18%) | 101 (38%) | 156 (59%) | 979 (32%) | |
| Missing data | 0 | 6 (2%) | 2 (<1%) | 1 (<1%) | 0 | 1 (<1%) | 6 (2%) | 4 (1%) | 0 | 20 (<1%) | |
| Mobility | |||||||||||
| Ambulant | 178 (68%) | 166 (48%) | 397 (57%) | 131 (33%) | 312 (85%) | 118 (77%) | 139 (51%) | 27 (10%) | 163 (62%) | 1631 (54%) | |
| Wheelchair | 75 (29%) | 93 (27%) | 201 (29%) | 250 (63%) | 34 (9%) | 35 (23%) | 124 (45%) | 117 (43%) | 85 (32%) | 1014 (33%) | |
| Bedridden | 7 (2·7%) | 85 (25%) | 102 (15%) | 14 (4%) | 22 (6%) | 0 | 9 (3%) | 117 (43%) | 15 (6%) | 371 (12%) | |
| Missing data | 0 | 0 | 2 (<1%) | 0 | 0 | 0 | 3 (1%) | 8 (3%) | 0 | 13 (<1%) | |
| Incontinence | 168 (64%) | 283 (82%) | 517 (74%) | 279 (71%) | 127 (35%) | 53 (35%) | 144 (52%) | 247 (92%) | 207 (79%) | 2025 (67%) | |
| Missing | 0 | 0 | 5 (<1%) | 0 | 0 | 0 | 22 (8%) | 10 (4%) | 0 | 37 (1%) | |
| Urinary catheter | 10 (4%) | 22 (6·4) | 11 (2%) | 24 (6%) | 3 (<1%) | 9 (6%) | 35 (13%) | 39 (14%) | 4 (2%) | 153 (5%) | |
| Missing data | 0 | 0 | 6 (<1%)) | 0 | 0 | 0 | 6 (2%) | 27 (10%) | 0 | 39 (1%) | |
| Vascular catheter | 1 (<1%) | 1 (<1%) | 2 (<1%) | 7 (2%) | 0 | 0 | 1 (<1%) | 18 (7%) | 2 (<1%) | 32 (1%) | |
| Missing data | 0 | 0 | 6 (<1%) | 0 | 0 | 0 | 7 (3%) | 32 (12%) | 0 | 45 (1%) | |
| Charlson Comorbidity Index | 2·8 (2·4) | 2·5 (2·3) | 3·5 (2·8) | 2·9 (2·2) | 3·1 (3·1) | 1·3 (2·0) | 1·2 (1·4) | 3·4 (2·5) | 2·8 (3·0) | 2·9 (2·7) | |
Table 2. Ratios of hospitalisations per 100 residents at 7 days and 30 days after HAI onset, by HAI type
| Empty Cell | 7-day hospitalisations | 30-day hospitalisations | ||||
|---|---|---|---|---|---|---|
| Empty Cell | n | Crude ratio | Estimated ratio (95% CI) | n | Crude ratio | Estimated ratio (95% CI) |
| RTIs | 158 | 5·2 | 4·4 (3·9–5·5) | 202 | 6·7 | 5·1 (4·3–5·7) |
| UTIs | 110 | 3·6 | 2·6 (2·1–3·7) | 133 | 4·4 | 2·9 (2·3–3·6) |
| Skin and soft-tissue infections | 72 | 2·1 | 1·6 (1·2–2·2) | 86 | 2·8 | 1·9 (1·4–2·4) |
| COVID-19 | 57 | 1·9 | 1·6 (1·2–2·0) | 72 | 2·4 | 2·0 (1·6–2·5) |
| Gastrointestinal infections | 35 | 1·2 | 0·9 (0·6–1·2) | 38 | 1·3 | 1·0 (0·7–1·3) |
| Eye, ear, nose, and mouth infections | 26 | 0·9 | 0·7 (0·4–1·0) | 32 | 1·1 | 0·8 (0·6–1·2) |
| Other infections* | 19 | 0·6 | 0·5 (0·3–0·8) | 21 | 0·7 | 0·6 (0·4–0·9) |
| Surgical site infections | 10 | 0·3 | 0·3 (0·1–0·5) | 10 | 0·3 | 0·3 (0·1–0·5) |
| Bloodstream infections | 10 | 0·3 | 0·3 (0·2–0·5) | 11 | 0·4 | 0·3 (0·1–0·5) |
| Unexplained febrile episodes | 4 | 0·1 | 0·1 (0·0–0·3) | 4 | 0·1 | 0·1 (0·0–0·3) |
| All | 501 | 16·5 | 14·1 (10·9–18·1) | 609 | 20·1 | 18·8 (13·6–22·3) |
*Includes HAIs that did not meet any specific case definitions used in the study.
Table 3. Ratio of deaths per 100 residents at 7 days and 30 days after HAI onset, by HAI type
| Empty Cell | 7-day deaths | 30-day deaths | ||||
|---|---|---|---|---|---|---|
| Empty Cell | n | Crude ratio* | Estimated ratio (95% CI) | n | Crude ratio* | Estimated ratio (95% CI) |
| RTIs | 51 | 1·7 | 1·7 (1·3–2·2) | 96 | 3·2 | 3·2 (2·6–3·9) |
| UTIs | 9 | 0·3 | 0·3 (0·2–0·6) | 30 | 1·0 | 1·0 (0·7–1·4) |
| COVID-19 | 5 | 0·2 | 0·2 (0·1–0·4) | 16 | 0·5 | 0·5 (0·3–0·9) |
| Gastrointestinal infections | 5 | 0·2 | 0·2 (0·1–0·4) | 7 | 0·2 | 0·2 (0·1–0·5) |
| Skin and soft-tissue infections | 4 | 0·1 | 0·1 (0·1–0·4) | 18 | 0·6 | 0·6 (0·4–0·9) |
| Eye, ear, nose, and mouth infections | 4 | 0·1 | 0·1 (0·1–0·4) | 8 | 0·3 | 0·3 (0·1–0·5) |
| Unexplained febrile episodes | 4 | 0·1 | 0·1 (0·1–0·4) | 6 | 0·2 | 0·2 (0·1–0·4) |
| Other infections† | 2 | 0·1 | 0·1 (0·0–0·3) | 7 | 0·2 | 0·2 (0·1–0·5) |
| Bloodstream infections | 1 | 0·0 | 0·0 (0·0–0·2) | 2 | 0·1 | 0·1 (0·0–0·3) |
| All | 85 | 2·8 | 2·0 (1·8–3·1) | 190 | 6·3 | 7·0 (4·6–8·3) |
*11 values missing.
†Includes HAIs that did not meet any specific case definitions used in the study.
Interpretation
This study shows the high incidence of HAIs among LTCF residents in EU or EEA countries, with more than one in two residents experiencing at least one HAI, and with RTIs and UTIs accounting for almost half of all observed HAIs.
Funding
European Centre for Disease Prevention and Control.
