Incidence of health-care-associated infections in long-term care facilities in nine European countries: a 12-month, prospective, longitudinal cohort study

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 809 years (SD 146), including 960 (317%) men and 2069 (683%) women. 3763 HAIs were recorded, with at least one HAI identified in 1717 (57%) of 3029 residents. There were 1242 HAIs (95% CI 1186-1299) per 100 residents and 18 HAIs (09-33) per 1000 resident-days. 160 (43% [95% CI 39-54]) HAIs led to hospitalisation, and 154 (45% [25-48]) were associated with death. Respiratory tract infections (RTIs) were the most frequent type of infection (n=1080, 289% [95% CI 273-305]), including pneumonia (n=279, 73% [64-83]) and other lower RTIs (n=394, 107% [96-118]), followed by urinary tract infections (UTIs; n=743, 187% [172-203]). RTIs showed the highest incidence of mortality (n=85, 23% [95% CI 18-28] of all HAIs). Severe cases of COVID-19 (n=72, 19% [95% CI 15-24] of all HAIs) were less frequent than mild or moderate cases (n=615, 160% [149-171] of all HAIs). 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. Copyright (c) 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.