Chesley L. Richards Jr.
Donna Lewis
Introduction
Long-term care has been defined as “an array of health, personal care, and social services provided over a sustained period of time to persons with chronic conditions and with functional limitations” [1]. These services can be provided in the home, in community settings, or in institutions. In contrast to acute care facilities, long-term care facilities (LCTFs) typically are residential. Consequently, staffing and policies are oriented toward maintaining independence, maximizing resident and family satisfaction, and promoting socialization. The traditional LTCF resident is a cognitively or functionally impaired elderly adult. However, recent trends have seen increases in the proportion of LTCF residents who receive postacute care services (e.g., rehabilitation following a surgical operation or acute illness) or skilled nursing services (e.g., intravenous antimicrobials, parenteral or enteral nutrition, or aggressive wound care). This chapter will review LTCF characteristics, selected infections in LTCF residents and facilities, and infection control issues in LTCF.
Characteristics of LTCF Residents, Staff, and Clinicians
LTCF Characteristics
In the United States, >40% of adults will reside in an LTCF at some point during their life [2,3]. Of 1.6 million LTCF residents in 1999 in the United States, most were female (72%), age ≥75 (78%), widowed (57%), and residing in nursing homes in the Midwest and South (63%) [4]. Before LTCF admission, most residents came from a hospital (46%) or private residence (30%). LTCF residents are highly dependent on staff for activities of daily living (ADLs). Of 5 ADLs (bathing, dressing, eating, transferring, or toileting), most residents (74%) require assistance with ≥3 ADLs (Figure 28-1). The most common ADL requiring assistance is bathing (94%).
LTCF staffing is lower than staffing in acute care hospitals. Nationally, LTCFs have one-third the number of full- or part-time employees (1.9 million vs. 5.3 million) as acute care hospitals, even though there are more LTCFs than acute care hospitals (16,000 vs. 5,800) and >50% more LTCF beds (1.6 million vs. 987,000) [5]. Nursing staff includes registered nurses (RN) (7.6 full-time employees [FTEs] per 100 beds), licensed practical nurses (LPN) (10.6 FTEs per 100 beds), or nurse's aides (32.9 FTEs per 100 beds) [4]. These FTE distributions represent the entire staff, not just staffing per shift. Consequently, these data emphasize that nurse's aides provide the bulk of direct resident care in most LTCFs. Especially during evening/night shifts or on weekends, a typical 100-bed LTCF may have only one or two RNs or LPNs on duty. Improving the ratio of nursing staff to residents and expanding the presence of RNs has been proposed as important steps toward improving the quality of care in nursing homes [1].
P.472
|
Figure 28-1 Percent distribution of residents with dependencies in activities of daily living and number of dependences: United States, 1999. Vital Health Stat 2002; 13 (152). |
Direct medical care rarely is provided by physicians in the LTCF setting. The majority of physicians (77%) do not spend time caring for nursing home residents [6]. For physicians who provide nursing home care, the median effort is 2 hours per week, or approximately 4% of the physicians' overall practice. Very few physicians (3%) spend >5 hours per week providing medical care in nursing homes. Consequently, nonphysician clinicians provide much of the direct medical care in LTCFs. In a national survey of LTCFs, 63% reported having nurse practitioners with a median of two nurse practitioners per facility [7]. On-site nonphysician clinicians can reduce hospitalizations of LTCF residents and overall costs [8,9].
In addition to practicing clinicians, each nursing home is required to have a medical director who is responsible for providing “oversight and participate in drug utilization review and quality assurance programs and to work with attending physicians on appropriate drug therapies and medical care issues” [1]. Most medical directors are either internists or family physicians and on average spend 10–20 hours per month performing medical director responsibilities, which include infection control and resident safety. At a national level, the American Medical Director's Association (AMDA) is the primary professional organization for medical directors and provides training and certification for medical directors [10].
LTCFs often have consultant pharmacists on staff or available by contract who evaluate medication prescribing in the facility and provide consultation regarding drug therapy issues. In most LTCFs, consultant pharmacists perform mandatory medication reviews and provide feedback to the LTCF administrator and medical director. Consultant pharmacists may offer an important on-site perspective and expertise in improving the management of a wide range of medications, including antimicrobials, and should be seen as a potential resource for clinicians and medical directors regarding antimicrobial management [11]. During disease outbreaks in LTCFs, consultant pharmacists also may provide valuable resident and family counseling regarding medication side effects or support regarding the distribution of prophylactic antimicrobials (i.e., oseltamivir) [12].
Risk Factors for Infections in LTCFs
Resident Level
Resident-level risk factors for infection include immunologic senescence, malnutrition, chronic diseases, medications (e.g., immunosuppressants, central nervous system agents that diminish cough reflex), cognitive deficits that may complicate resident compliance with basic sanitary practices (e.g., hand hygiene), and functional impairments (e.g., fecal and urinary incontinence, immobility, diminished cough reflex) [13,14,15,16] (Table 28-1). Medical interventions also may increase risk for infection. Indeed, with the growth of subacute or postacute care, many LTCFs now have residents receiving medical interventions or therapy (e.g., central venous catheters, hemodialysis, parenteral antimicrobial or nutrition therapy, or mechanical ventilation) equivalent in complexity to interventions performed in many acute care hospitals.
|
TABLE 28-1 |
|
|
Facility Level
As residences, LTCFs typically promote activities and policies that foster socialization of residents through group
P.473
activities, both in and outside the nursing home. While these activities are important for promoting good physical and mental health for residents, they also may increase risk for exposure to and transmission of communicable infectious diseases [13,14,15,16]. While vital to restoring or maintaining physical and mental function, occupational and physical therapy activities may increase risk for person-to-person transmission or exposure to contaminated environmental surfaces (e.g., physical or occupational therapy equipment). In LTCFs, group bathing facilities or whirlpool therapy units may be potential sources of infection with waterborne pathogens. Finally, group dining is encouraged for nursing home residents. A common dining area may be used for all nursing home residents or for residents of a specific ward, hall, or wing in a large facility. Group dining may be an avenue for person-to-person transmission of infectious pathogens and for foodborne disease outbreaks [13,14,15,16]. Low rates of healthcare worker (HCW) immunization in LTCFs have been associated with outbreaks caused by vaccine-preventable respiratory pathogens (e.g., influenza, S. pneumoniae) [16,17,18,19]. Finally, specific institutional characteristics have been associated with disease outbreaks. In a study of outbreaks among New York LTCFs, institutional risk factors for respiratory or gastrointestinal infection outbreaks included larger homes (risk ratio 1.71 per 100 bed increase), nursing homes with a single nursing unit, or with multiple units but shared staff [20]. Risk for outbreaks was lower in LTCFs with paid employee sick leave.
Antimicrobial Resistant Pathogen Infections in LTCFs
The introduction or emergence of antimicrobial resident bacteria in LTCFs has resulted in both regional outbreaks of antimicrobial-resistant pathogen (ARP) infections and increasing prevalence of ARPs [21,22]. In addition to the individual and institutional risk factors for infection discussed previously, colonization with ARPs (e.g., methicillin-resistantStaphylococcus aureus (MRSA); vancomycin-resistant enterococcus (VRE), multidrug-resistant E. coli, Acinetobacter, Enterobacter, or Pseudomonas aeruginosa) increases the likelihood of both epidemics and high rates of endemic disease with ARPs in LTCFs [23]. Risk factors for the development of infection with multidrug-resistant pathogens include exposure to antimicrobials, lack of hand-washing sinks, and lower levels of registered nurse staffing [24].
Selected Infections
Evaluation of Fever and Infection in LTCF Residents
Recommendations outlining the minimum evaluation for infection in nursing home residents have been published [25]. For residents with suspected infection, the guideline recommends that nurse's aides measure vital signs (e.g., temperature, blood pressure, pulse, respiratory rate, presence of pain), identify residents with fever or suspected infection, and relay this information to licensed nursing staff. Next, the licensed nursing staff (e.g., LPN or RN) should perform an initial clinical assessment on residents with fever or suspected infection, and significant findings should be relayed to clinicians [25]. LTCFs should have training and procedures in place to ensure that residents with suspected infection are quickly identified by nursing staff and appropriate information relayed to clinicians.
Only limited diagnostic testing for febrile or potentially infected residents is available in most LTCFs. Laboratory testing usually is sent to a hospital or reference laboratory. The delay between obtaining specimens and actual laboratory processing and in getting reports back to clinicians in LTCFs may be substantial. This delay may lead to poor decisions regarding empiric or continued antimicrobial use. Medical directors should work with nursing home administrators, directors of nursing, and laboratory providers to both improve specimen collection and reporting of results. When possible, laboratory providers should provide a facility-specific antibiotic susceptibility testing profile (i.e., antibiogram) either for the individual facility or for a network of LTCFs. Using acute care facility antibiograms may be misleading, and the availability of a LTCF specific antibiogram may improve the initial selection of empiric antimicrobial therapy. Clinicians should re-evaluate residents on antimicrobial therapy at 48 to 72 hours with the goal of tailoring antimicrobial therapy to the clinical course, identified pathogens, and antimicrobial susceptibility profile. Residents who require diagnostic studies not available in the LTCF or who are unstable should be transferred to acute care hospitals for further evaluation and therapy unless they have advanced directives (e.g., “living wills”) for no hospitalization. Residents with presumed infections account for one-quarter of all hospital transfers from LTCFs [26].
The minimum recommended evaluation varies depending on the type of suspected infection [25]. First, LTCF residents may present atypically when developing infections. For example, altered mental status or a decline in oral intake without fever may be the initial presentation for pneumonia or urinary tract infection in some residents. In addition, residents with cognitive or speech impairment may not be able to communicate symptoms related to infection and may instead develop agitation or combativeness.
All residents with a presumed infection should have a complete blood count (CBC) performed. The presence of leukocytosis (white blood count [WBC] count ≥14,000 cells/mm3), even in the absence of a left shift, warrants further careful assessment for infection. Urinalysis and urine cultures are often overused in LTCFs and should be reserved for residents with symptoms of urinary tract infection without indwelling urinary catheters. In residents with chronic
P.474
indwelling urinary catheters, urinalysis and urine cultures should be obtained only for symptoms or signs referable to the urinary tract or for presumed sepsis. For residents with suspected pneumonia, especially with tachypnea (respiratory rate >25 breaths per minute), the minimum evaluation should include a chest radiograph and determination of oxygen saturation using pulse oximetry.
In addition to recommended tests, some laboratory tests may not be appropriate in LTCF residents. For example, properly collected sputum gram stain and culture can be very helpful in diagnosis and treatment of pneumonia. However, sputum studies should be obtained only if purulent sputum is available and if the sample can be transported to the clinical laboratory ≤2 hours of collection [25]. In most LTCFs, this will not be possible. In many LTCFs, blood cultures probably should not be obtained because of the high likelihood of contamination, low yield, and the recognition that residents with presumed sepsis or bacteremia probably should be transferred to acute care facilities for evaluation and management [25]. If blood cultures are obtained, LTCF medical directors should ensure that staff members (e.g., nurses) collecting the blood samples have been properly trained. Working with the hospital or commercial laboratory to monitor for probable contaminants in blood culture results (e.g., coagulase-negative Staphylococcus) may provide early clues when collection techniques are suboptimal. Similarly, surface cultures from infected wounds are not recommended because of the high likelihood of contamination and the low yield from these cultures.
Urinary Tract Infections (UTIs)
UTIs account for 25–30% of all bacterial infections in LTFC residents [4,7] and are among the most common bacterial infections in LTCF residents. Normally, the urinary bladder is sterile; however, in frail older adults, the bladder often becomes colonized with bacteria, typically from the gastrointestinal tract [27]. Determining whether bacteriuria represents colonization or true infection is both difficult and controversial. Accurate clinical diagnosis of symptomatic UTI in frail elderly LTCF residents may be difficult. In the institutionalized elderly, only 4–8% of residents with fever and bacteriuria have clinical findings consistent with UTI [28]. In residents with an indwelling urinary catheter, about 25% of individuals with fever and bacteriuria had UTI [28]. In cognitively impaired frail elderly people, eliciting symptoms or signs specific to the urinary tract (e.g., dysuria, frequency, flank pain) can be extraordinary difficult. Using more nonspecific symptoms (e.g., changes in mental status, decreased oral intake) can be misleading. In cognitively impaired elderly persons, new urinary incontinence should be considered as a potentially useful symptom or sign to indicate UTI, although further studies are needed to better define its sensitivity and specificity for predicting UTI.
Urinalysis (UA) in healthy, young adults is very useful in detecting UTIs. However, the presence of pyuria, either by direct microscopy (e.g., ≥5 WBCs on high powered field) or dipstick (e.g., positive leukocyte esterase) is less helpful in frail elderly. For example, in 214 chronically incontinent asymptomatic nursing home residents, 45% had pyuria, and 43% had bacteriuria. Of those who had pyuria, 59% had bacteriuria [29]. In a study of newly catheterized hospitalized patients of all ages (mean age = 60 years), the positive predictive value of pyuria was 32% [30]. Use of pyuria or bacteriuria as indicators of UTI in frail elderly patients without clinical symptoms is not recommended.
In LTCFs, chronic urinary catheters are used to manage patients who have neurogenic bladders or obstruction to urinary drainage. The presence of a urinary catheter increases risk for UTI dramatically. Consequently, primary prevention strategies in LTCF have focused on improved incontinence management and removal of catheters. Unfortunately, physicians may not always be aware that residents have urinary catheters, even when these catheters are considered inappropriate [31]. An alternative for residents who truly have a long-term indication for a urinary catheter, use of an antimicrobial- or silver-impregnated catheter may be beneficial [32]. Compared to standard urinary catheters, trials of antimicrobial- (e.g., nitrofurazone, minocycline-rifampin) and silver-impregnated catheters have demonstrated substantial reductions (30 to 70%) in bacteriuria and UTIs [33]. A recent decision analysis suggests that despite a higher catheter cost, use of silver impregnated catheters would probably be cost saving at a population level in addition to preventing UTIs [34].
Respiratory Tract Infections
Respiratory tract infection outbreaks in LTCFs are relatively common. In five Canadian LTCFs, 16 outbreaks over 3 years involving 480/1,313 residents were reported [35]. The outbreaks occurred year round, and the most common symptoms among residents during these outbreaks were cough (83%), fever (40%), and coryza (45%). A minority of residents developed pneumonia (15%). The most common pathogens were influenza, parainfluenza, or respiratory syncytial viruses; Legionella spp; or Chlamydia pneumoniae. Approximately 12% of residents were transferred to hospitals, and 8% died.
Influenza
The most important cause of respiratory tract disease outbreaks in LTCFs is influenza. Outbreaks of influenza A or B usually occur from early October to April but may sometimes extend into summer [36]. Of the 20,000 deaths from influenza each year, 90% occur in persons ≥65 years. Primary risk factors are lack of influenza vaccination among residents and HCWs. Ventilation and
P.475
architectural issues also may play a role. In a report of an outbreak of influenza A affecting 68 residents, the LTCF had four separate buildings, one of which was newly constructed [37]. Interestingly, the attack rate in the new building was significantly lower than in the other buildings. Key differences in the new building included (1) a ventilation system that did not recirculate air, (2) more public space per resident, and (3) no office space in the building serving the entire facility. Even widespread use of immunization, the cornerstone of influenza prevention, may be insufficient to prevent some LTCF outbreaks. Especially in older residents, influenza vaccine effectiveness may be diminished, increasing the risk for influenza outbreaks. These failures may be secondary to poor immunologic response to the vaccine in this elderly population. In a LTCF with high rates (>85%) of resident influenza vaccination, outbreaks involving 172 residents were reported despite a match between the vaccine strain and outbreak strain [38]. Although influenza vaccination may not completely prevent clinical disease, clinical presentation often is ameliorated, especially if the match between influenza strains circulating in the LTCF and the vaccine strain is good.
Other Respiratory Viruses
In addition to influenza, infections with parainfluenza virus, respiratory syncytial virus, adenoviruses, and rhinoviruses can cause respiratory tract disease in LTCF residents. Parainfluenza virus type 3 was associated with an outbreak of respiratory disease on a 50 bed-nursing unit of a large Wisconsin LTCF. The attack rate was 50% and resulted in 16% mortality within 9 days of symptom onset [39]. In contrast, a study of 30-day mortality suggested that non-influenza viruses have lower mortality than influenza viruses with mortality ranging from 6.1% (influenza B) and 5.4% (influenza A) to virtually nil for (RSV) and rhinoviruses [40]. The key observations from reports on respiratory tract outbreaks are that early identification of the infectious agents, institution of appropriate treatment or prophylaxis, and aggressive use of infection control precautions, especially isolation of residents and improved HCW compliance with hand hygiene recommendations, are critical to minimize serious morbidity and deaths.
Streptococcus Pneumoniae
Although not a common cause of outbreaks in LTCFs, Streptococcus pneumoniae is the most common pathogen identified in endemic respiratory tract disease in LTCF residents, is an important cause of invasive disease, and is increasingly resistant to antimicrobials. The incidence of invasive S. pneumoniae in LTCF residents is 4 times higher than in community living elderly individuals [41]. In a review of 26 S. pneumoniae outbreaks since 1990, the majority occurred in elderly patients in LTCFs or hospitals [42]. The most common serotypes identified in these outbreaks were 23F, 14, and 4, all of which are included in current formulations of the pneumococcal vaccine. Outbreaks of S. pneumoniae pneumonia and bacteremia in Oklahoma, Massachusetts, and Maryland LTCFs were associated with low pneumococcal vaccination rates [43]. An LTCF outbreak of S. pneumoniae pneumonia in Massachusetts was associated with a 20% case-fatality rate. Antecedent infection with human parainfluenza virus was associated with increased risk of S. pneumoniae infection [44].
Legionnaire's Disease
Legionnaire's disease, caused by Legionella pneumophilia, remains an important consideration during respiratory tract disease outbreaks. Outbreaks in both LTCFs and hospitals generally are associated with contaminated water systems. L. pneumophilia may persist in healthcare facility water systems despite the use of a variety of interventions [45]. To identify these outbreaks earlier, LTCF clinicians and staff should maintain a high index of suspicion for Legionnaires's disease and obtain the proper laboratory support for microbiologic testing to identify L. pneumophila.
Nursing Home–Acquired Pneumonia
Pneumonia probably is the most serious common infection in LTCFs with regard to morbidity and mortality [46]. Independent risk factors for LTCF-acquired pneumonia include poor functional status, chronic lung disease, difficulty swallowing, presence of a tracheostomy, increasing age, and male gender. Aspiration of oropharyngeal contents is the usual mechanism, especially in frail, cognitively impaired or neurologically compromised residents. Diagnosis should include chest radiography and assessment of oxygenation (e.g., pulse oximetry) at a minimum but etiologic diagnosis often is lacking. Prevention interventions such as improving oral hygiene, swallowing evaluations, and dietary interventions (e.g., thickening of liquids) have had limited evaluation and success. Elevation of the head of the bed in a resident with high risk for aspiration may be beneficial but also may increase risk for other adverse events (e.g., falls). Influenza and pneumococcal vaccination are recommended to reduce risk for pneumonia.
Gastrointestinal Infections
Diarrhea in LTCF residents is common and may be due to both infectious and noninfectious causes. Diarrheal or gastrointestinal outbreaks in LTCFs are potentially explosive, have high attack rates once established, and can result in severe dehydration and death. Outbreaks can affect both residents and staff, causing severe disruption in the LTCF. The usual modes of transmission are through person-to-person transmission or, less commonly, foodborne transmission. The most common outbreaks are
P.476
due to norovirus or rotavirus. Outbreaks due to bacterial pathogens are less commonly reported.
A few case reports illustrate key aspects of diarrheal or gastroenteritis outbreaks in LTCFs. In a 250-bed LTCF in Tennessee, 14% of residents developed gastroenteritis due toSalmonella hadar [47]. Among the 244 HCWs, the attack rate was 27% in laundry workers while only 3% in nursing staff and 4% in kitchen staff. Although the index case was probably a member of the kitchen staff, the high attack rate among the laundry staff was probably secondary to inconsistent use of gloves and lack of protective clothing while handling of increased volumes of soiled linen during the outbreak. In an Australian LTCF, 25 residents developed gastroenteritis caused by Clostridium perfringens due to contamination of pureed food [48]. Apparently, after the food was liquified, it was not reheated and subsequently became contaminated. Consequently, the authors recommended that pureed food be reheated to 70°C to inactivate potential contaminating pathogens before consumption. In Virginia LTCFs during one year, caliciviruses were responsible for eight different reported outbreaks [49]. In a Maryland LTCF with 121 residents, 51% of residents and 47% of the staff developed gastroenteritis due to a calicivirus over a four-month period [50]. The index case in the outbreak was a nurse who continued to work for two additional days after becoming ill. The outbreak illustrates the need to exclude ill employees in a timely fashion by providing sick leave and not expecting staff to take annual or vacation leave for illnesses. In a norovirus outbreak in an LTCF, the majority (57%) of residents developed acute gastroenteritis following exposure to an ill LTCF resident, the index case [51]. In the residents, prominent symptoms included vomiting (90%), diarrhea (70%), and fever (12%). Four residents required hospitalization, and three died. Many HCWs (35%) also developed gastroenteritis. Based on molecular typing, the outbreak appeared to occur among debilitated residents and their nurses, implying that the outbreak was propagated through LTCF staff rather than ambulatory residents. Cohorting of ill patients and strict adherence to infection control practices, such as hand hygiene, glove use, and barrier precautions, stopped the outbreak.
Skin Infections
Skin infections in LTCF residents usually are caused by fungi or bacteria, easily treated, and self-limited. However, LTCF residents have several risk factors that may promote both more serious infections and skin infection outbreaks. These risk factors include poor nutritional status, presence of surgical wounds or pressure ulcers, skin maceration or wetness due to contact with feces or urine, and the use of common bathing facilities. Examples of LTCF skin infection outbreaks due to bacteria include S. pyogenes–associated cellulitis,Pseudomonas aeruginosa associated with a contaminated whirlpool bath, and group A streptococcus or ARPs causing infections of pressure ulcers. In addition to bacterial skin infections, scabies is an important parasitic skin infection that not infrequently causes outbreaks in LTCFs. Transmission of scabies may occur by contact with mite-contaminated inanimate objects (e.g., bed linens) or direct person-to-person contact. Outbreaks of scabies in three Norwegian LTCF lasted for five months and involved 27 patients or HCWs [52]. Initial treatments with permethrin were not successful; however, benzyl benzoate was effective. Ultimately, >600 residents and staff were treated. A key observation from these outbreaks was the need for simultaneous treatment of residents and staff and disinfection of bedding, clothing, and the environment. As with other outbreaks, early identification is optimal for management of scabies outbreaks and occasionally may require dermatological consultation or skin biopsy for diagnosis.
Infections with ARPs
Both endemic and epidemic infections in LTCFs occur due to ARPs [15]. Important ARPs include MRSA; VRE, or multidrug-resistant gram-negative rods such as E. coli, Acinetobacter, Enterobacter, or Pseudomonas aeruginosa [23,53]. Widespread colonization of residents in LTCFs with ARPs provides a potential reservoir for subsequent transmission and outbreaks. In Chicago, a citywide outbreak of multidrug-resistant Klebsiella pneumoniae and Escherichia coli demonstrated that LTCFs were important ARP reservoirs [54]. Furthermore, in a single Chicago skilled nursing facility, 43% of residents were colonized with ≥1 ARP [55]. Recent studies have demonstrated success in reducing VRE colonization or infection and may offer important intervention strategies for the future [56,57]. These studies have documented the importance of resident active surveillance cultures, isolation, HCW hand hygiene, and decreased inappropriate antimicrobial use.
In addition to cross-transmission, widespread antimicrobial use is a potential risk factor for the development of antimicrobial resistance within LTCFs. In Maryland, 54% of LTCF residents received ≥1 course of antimicrobial therapy [58]. In four New York LTCFs, the percentage of patient-days during which antimicrobials were given ranged from 2.7% to 6.8% [59]. In a Veterans Affairs LTCF, the majority (54%) of patient febrile episodes resulted in the initiation of antimicrobial therapy, with upper respiratory tract illnesses, bronchitis/pneumonia, or UTIs accounting for the majority of indications [60]. Following diagnostic evaluation, 39% of patients continued to receive antimicrobials despite negative laboratory and radiographic studies for bacterial infections. In general, previous studies have found substantial inappropriate use of antimicrobials in LTCF residents, ranging from 25–75% [61]. In addition to increasing the risk of ARP colonization or infection, inappropriate antimicrobial use
P.477
adds to patient care costs and may place the patient at risk for adverse medication reactions [59,61].
Infection Control in LTCFs
Developing and implementing infection prevention and control programs in LTCFs is especially challenging. A comprehensive approach should include preventing infections through vaccinations, improving the diagnostic approach to infections and antimicrobial use and implementing effective infection control strategies [62].
Infection Control Program
Several reviews, guidelines, and position statements for infection control in LTCFs have been published previously [61,63,64]. In addition, guidelines from the Centers for Disease Control and Prevention for many aspects of infection control are available through the Internet (www.cdc.gov/ncidod/dhqp). The key components of a well-organized infection control program in LTCFs include (1) a well-trained infection control professional (ICP) to head the program, (2) an infection control committee, (3) a written and widely disseminated infection control plan, and (4) sufficient administrative support to undertake core infection control functions.
The two most important aspects of an LTCF infection control program are that the ICP is trained in infection control and that the LTCF administrator provides support and resources for the program. In a survey of LTCFs in the northeastern United States, most ICPs were registered nurses (90%) who performed infection control duties on a part-time basis (median = 8 hours per week) [65]. However, only half (52%) had formal training in infection control, and most had additional clinical or administrative nursing duties. These sobering statistics point out the difficulty faced in obtaining significant resources for LTCF infection control. However, the second component of the program, an infection control committee, can be instrumental in assisting the ICP in developing the infection control program. In smaller LTCFs, the committee may consist of the ICP, nursing director, medical director, and administrator. In larger LTCFs, the infection control committee also might include consultant pharmacists, an infectious disease expert, representatives from physical therapy or rehabilitation, and environmental services. In addition, the formation of teams including both geriatric clinicians, ICPs, and nursing staff may be especially beneficial in outbreak management [66]. To address resource limitations, LTCFs can seek to develop alliances with acute care hospitals, other LTCFs in the region, or have a corporate infection control program in a multifacility corporate chain. In some LTCFs, the infection control committee or its functions may be part of the facility's overall quality management or improvement committee. In this setting, it is important to maintain a distinct focus, expertise, and resource commitment on infection control.
Immunization
Currently, LTCF residents should have yearly influenza vaccination and pneumococcal vaccination at least once after age 65, and LTCF HCWs should strongly consider receiving annual influenza vaccination [36,67,68]. Overall vaccination rates among LTCF residents for influenza vaccine (64%) and pneumococcal vaccine (28%) are suboptimal, and many LTCFs have inadequate policies addressing routine vaccination [69]. Preventing influenza and pneumococcal infections through an active immunization program is important not only for preventing these infections but also for limiting empiric antimicrobial use and avoiding post-influenza secondary bacterial infection. The components of a well-organized immunization program include a written facility policy and plan on immunization, an implementation manual, training for staff members including physicians on the immunization plan, collecting and recording baseline vaccination rates for current residents, and then initiation of vaccination of both current residents and new arrivals [69]. To monitor for outbreaks and institute timely control measures, LTCF infection control personnel should include active surveillance for acute febrile respiratory tract illnesses as part of the overall infection control plan. Furthermore, LTCF personnel should develop the surveillance system in conjunction with local and state health departments to enhance communication and ensure compliance with public health requirements [69]. Recently, implementation of standing orders for influenza and pneumococcal vaccination in LTCFs has been proposed as an effective intervention to increase vaccination rates [70].
Antimicrobial Prescribing
Decreasing inappropriate antimicrobial use in LTCFs should be an important component of an effective infection control program. Categories of inappropriate use include continued antimicrobial exposure despite no clinical evidence of infection, antimicrobial therapy with agents to which organisms from appropriate clinical cultures were not susceptible, and use of antimicrobials in residents with known allergies to the agent or with significant drug-drug interactions. Inappropriate use of an antimicrobial agent adds to patient care costs, may place the patient at risk for adverse medication reactions, and increases the risk of infections with ARPs.
In an effort to improve antimicrobial prescribing, minimum criteria for the initiation of antimicrobial therapy in LTCF residents have been proposed [71] (Table 28-2). These recommendations were not meant as strict management guidelines for clinically complex residents, and the residents' overall status must be considered by the clinician. The recommendations are useful in attempting to provide
P.478
a rationale and guide for empiric antimicrobial therapy in otherwise stable residents. The guideline was based on expert opinion and remains to be tested in clinical trials. An important action that would potentially make a significant impact on antimicrobial prescribing in nursing homes is re-evaluation of residents with suspected infection after 48–72 hours of initial empiric antimicrobial therapy. For those residents in whom the clinical course (e.g., afebrile, no change in baseline functional status) and diagnostic study results (e.g., normal WBC count, negative culture results) do not suggest infection, clinicians should consider discontinuing antimicrobial therapy.
|
TABLE 28-2 |
||||||||||
|
Hand Hygiene
Improved adherence to hand hygiene (i.e., hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of pathogens (e.g., MRSA), and to reduce overall infection rates. CDC has published guidelines to promote improved hand hygiene in healthcare settings including LTCFs [72]. In addition to traditional hand washing with soap and water, CDC recommends use of alcohol-based handrubs by HCWs for patient care because they address some of the obstacles that HCWs face in maintaining hand hygiene. When HCWs' hands are visibly soiled, they should wash with soap and water. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70–80%, prevent cross-contamination, and protect patients and HCWs from infection. Handrubs should be used before and after each patient contact, just as gloves should be changed before and after each patient contact. Alcohol-based handrubs should be applied to the palm of one hand and hands rubbed together, covering all surfaces of hands and fingers, until hands are dry. Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, save time, and cause less skin irritation than soap and water.
When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color, and effect of dryness on hands. CDC recommends that healthcare facilities develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based handrub used/1,000 patient-days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of HCW hand hygiene when outbreaks of infection occur.
Infection Control Precautions
Infection control precautions are recommended, effective, and widely used in hospitalized patients who are colonized or infected with selected ARPs [73]. However, national guidelines for the use of infection control precautions in LTCF residents are used variably. Although use of active surveillance cultures and contact precautions in colonized
P.479
LTCF residents has been shown to reduce infections for some ARPs (e.g., VRE), widespread use of contact precautions has not occurred and would be challenging to implement in many LTCFs [56]. While also not widely used to date, universal glove use for contact with LTCF residents also may be effective [74]. However, simply having LTCF staff comply with standard precautions is likely to have an enormous impact in reducing ARP transmission. Often with bed-bound residents, HCWs are the usual vectors for transmission of pathogens. Because good hand hygiene is vital to reduce cross-transmission, LTCFs should consider the use of newly developed waterless alcohol-based hand hygiene agents to promote hand hygiene. Decisions about isolation of LTCF residents colonized or infected with ARPs must be considered on an individual resident and facility basis and must incorporate both an assessment of risk for cross-transmission and the impact on the resident's social and psychological health [61,62,63,64]. In addition to national guidelines, many state or local health departments have developed guidelines regarding the use of contact precautions or isolation of residents in LTCFs in that state or local jurisdiction. The LTCF medical director should be knowledgeable about these guidelines when making decisions regarding use of infection control precautions or isolating residents.
Conclusions
Infections in LTCF residents are an important public health concern, can result in serious illnesses and death in LTCF residents, and can be disruptive to LTCF staff. The major risk factors include the chronically ill population, the potential for cross-transmission during group activities and resident-HCW interactions, and the widespread empiric use of antimicrobial therapy. LTCFs can attempt to prevent or control ARP infections by ensuring that residents receive appropriate immunizations, supporting appropriate clinician evaluation for suspected infection, promoting good hand hygiene and appropriate empiric antimicrobial prescribing, and ensuring that the LTCF has a well-staffed and organized infection control program. Over the next several decades, the population of elderly LTCF residents will dramatically increase; resources for infection control programs in LTCF will be an important investment in improving the quality of care in this increasingly important healthcare setting. Likewise, the development of new knowledge regarding the epidemiology, prevention, and outcomes of infections in the LTCF residents is needed to make scientifically sound decisions regarding the use of limited infection control resources in LTCFs [75].
References
P.480