Infection Prevention and Control in the Long-Term-Care Facility

Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review

BACKGROUND

Infection prevention and control (IPC) is a measure to prevent healthcare-associated infections in healthcare settings. There is limited evidence of the effectiveness of IPC programmes in long-term care facilities (LTCFs).

AIM

To review and analyse the effectiveness and the components of IPC programmes in LTCFs for older adults.

METHODS

Electronic databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched systematically for English-language articles assessing IPC interventions in LTCFs, published over the last decade (2007-2016). The components of IPC programmes were analysed based on the World Health Organization (WHO) manuals for improving IPC activities. Two reviewers independently assessed the quality of studies using the Cochrane risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies.

FINDINGS

Seventeen studies met the eligibility criteria; 10 studies were randomized trials (58.8%) and the others were non-randomized trials to examine the impact of IPC programmes on infection and/or performance outcomes of healthcare workers. None of the included studies implemented all of the WHO core components. Behavioural change strategies using education, monitoring and feedback were reported to be successful interventions for reducing the threat of healthcare-associated infections. Generally, studies using four or more elements of the WHO multi-modal strategy reported significant reductions in infection rates.

CONCLUSIONS

There is some evidence for the effectiveness of IPC interventions using education, monitoring, feedback and four or more elements of the WHO multi-modal strategy to control healthcare-associated infections in LTCFs.

Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities

Objectives:

To measure infection rates in a regional cohort of long-term-care facilities (LTCFs) using standard surveillance methods and to analyze different methods for interfacility comparisons.

Setting:

Seventeen LTCFs in Idaho.

Design:

Prospective, active surveillance for LTCF-acquired infections using standard definitions and case-finding methods was conducted from July 2001 to June 2002. All surveillance data were combined and individual facility performance was compared with the aggregate employing a variety of statistical and graphic methods.

Results:

The surveillance data set consisted of 472,019 resident-days of care with 1,717 total infections for a pooled mean rate of 3.64 infections per 1,000 resident-days. Specific infections included respiratory (828; rate, 1.75), skin and soft tissue (520; rate, 1.10), urinary tract (282; rate, 0.60), gastrointestinal (77; rate, 0.16), unexplained febrile illnesses (6; rate, 0.01), and bloodstream (4; rate, 0.01). Initially, methods adopted from the National Nosocomial Infections Surveillance System were used comparing individual rates with pooled means and percentiles of distribution. A more sensitive method appeared to be detecting statistically significant deviations (based on chi-square analysis) of the individual facility rates from the aggregate of all other facilities. One promising method employed statistical process control charts (U charts) adjusted to compare individual rates with aggregate monthly rates, providing simultaneous visual and statistical comparisons. Small multiples graphs were useful in providing images valid for rapid concurrent comparison of all facilities.

Conclusion:

Interfacility comparisons have been demonstrated to be valuable for hospital infection control programs, but have not been studied extensively in LTCFs.

Epidemiology and risk factors for faecal extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage derived from residents of seven nursing homes in western Shanghai, China

Nursing homes (NHs) have been implicated as significant reservoirs of antibiotic-resistant organisms causing severe infectious disease. We investigated the prevalence and molecular epidemiology of, and risk factors for, faecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). A multicentre cross-sectional study was conducted in seven NHs in Shanghai between March 2014 and May 2014. Antimicrobial susceptibility testing and polymerase chain reaction were used to detect genes coding for ESBLs and carbapenemases. NH records at individual-resident level and facility level were examined for potential risk factors. Four hundred and fifty-seven Enterobacteriaceae isolates were collected of which 183 (46·92%) were colonized by ESBL-E. CTX-M enzymes (198/200, 99%) predominated, with CTX-M-14 (84/200, 42%) the most common types. Two carbapenemase producers harboured blaKPC-2. Resistance rates to carbapenems, TZP, AK, FOS, CL and TGC were low. History of invasive procedures [odds ratio (OR) 2·384, 95% confidence interval (CI) 1·318-4·310, P = 0·004], narrow-spectrum cephalosporins (OR 1·635, 95% CI 1·045-2·558, P = 0·031) and broad-spectrum cephalosporins (OR 3·276, 95% CI 1·278-8·398, P = 0·014) were independently associated with ESBL-E carriage. In conclusion, NH residents have a very high prevalence of faecal carriage of ESBL-E. Continuous and active surveillance is important, as are prudent infection control measures and antibiotic use to prevent and control the spread of these antibiotic-resistant strains.

Infection Control Practices in Assisted Living Facilities: A Response to Hepatitis B Virus Infection Outbreaks

Background.

The medical needs of the approximately 1 million persons residing in assisted living facilities (ALFs) continually become more demanding. Moreover, the number of ALF residents is expected to double by 2030. ALFs are not subject to federal oversight; state regulations that govern ALF infection control are variable. In 2005, two outbreaks of acute hepatitis B virus (HBV) infection in ALFs in Virginia were associated with sharing fingerstick devices used in blood glucose monitoring.

Objective.

To characterize infection control practices, determine compliance with guidelines, and identify educational and policy needs in ALFs in Virginia.

Methods.

Following the outbreaks of HBV infection, educational packets were sent to ALFs in Virginia to inform them of infection control guidelines and recommendations regarding glucose monitoring. A follow-up survey consisting of on-site interviews was conducted in a random sample of ALFs. Differences among infection control practices, according to the size and ownership of the ALFs, were assessed.

Results.

Fifty of 155 ALFs in central Virginia were surveyed. Of the 45 ALFs that had used fingerstick devices, 7 (16%) had shared these devices (without cleaning) between residents. Sharing practices for glucose monitoring equipment did not differ by facility size or ownership. Of all 50 ALFs, 17 (34%) did not offer employees HBV vaccine. HBV vaccine was less frequently offered at ALFs that had fewer than 50 residents, compared with ALFs with at least 50 residents (P < .01), and HBV vaccine was less frequently offered at ALFs that were individually owned, compared with those that were not individually owned (P = .02).

Conclusions.

Despite outreach and long-standing recommendations, approximately 1 in 6 facilities shared fingerstick devices, and more than one-third of ALFs surveyed were considered noncompliant with federal guidelines (Occupational Safety and Health Administration Bloodborne Pathogens Standard). Public health and licensing agencies should work with ALFs to implement infection control measures and prevent disease transmission.

Geriatric Fever Score: a new decision rule for geriatric care

BACKGROUND

Evaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups.

MATERIALS AND METHODS

Consecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done.

RESULTS

Three hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets <150 10(3)/mm3) (LST). After assigning weights to each predictor, we developed a Geriatric Fever Score that stratifies patients into two mortality-risk and disposition groups: low (4.0%) (95% CI: 2.3-6.9%): a general ward or treatment in the ED then discharge and high (30.3%) (95% CI: 17.4-47.3%): consider the intensive care unit. The area under the curve for the rule was 0.73.

CONCLUSIONS

We found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

Antimicrobial prescribing in European nursing homes

OBJECTIVES

The aim of this study was to investigate antimicrobial prescribing in nursing homes in countries across Europe.

METHODS

Point prevalence studies were completed in April and November 2009 in 85 nursing homes in 15 European countries and two UK administrations.

RESULTS

A total of 10,388 and 9430 residents participated in April and November 2009, respectively. The mean prevalence of antimicrobial prescribing in the nursing homes was 6.5% in April and 5.0% in November. The most commonly prescribed antimicrobials were methenamine (17.5%), trimethoprim (11.4%) and co-amoxiclav (11.1%) in April and co-amoxiclav (12.2%), nitrofurantoin (12.2%) and methenamine (11.5%) in November. There was large variation in the overall mean antimicrobial prescribing in the selected nursing homes from each of the contributing countries, ranging from 1.4% in Germany and Latvia to 19.4% in Northern Ireland in April and 1.2% in Latvia to 13.4% in Finland in November. Furthermore, differences in prescribing were apparent within countries with the largest variation evident in nursing homes in Northern Ireland (21.5%) in April and Finland in November (30.1%).

CONCLUSIONS

This is the first study to investigate antimicrobial prescribing in nursing homes in a large number of European countries. The findings suggest that there is considerable variation in antimicrobial prescribing in nursing homes across and within European countries. Nursing homes provide a significant service to the European community and must be supported in order to optimize antimicrobial use and limit the development of antimicrobial resistance.

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

OBJECTIVE

To investigate the effectiveness of a multifaceted hand hygiene program involving the use of pocket-sized containers of antiseptic gel in long-term care facilities (LTCFs) with elderly residents.

METHODS

In this clustered randomized controlled trial, Hong Kong LTCFs for elderly persons were recruited via snowball sampling. Staff hand hygiene adherence was directly observed, and residents' infections necessitating hospitalization were recorded. After a 3-month preintervention period, LTCFs were randomized to receive pocket-sized containers of alcohol-based gel, reminder materials, and education for all HCWs (treatment group) or to receive basic life support education and workshops for all healthcare workers (HCWs) (control group). A 2-week intervention period (April 1-15, 2007) was followed by 7 months of postintervention observations.

RESULTS

In the 3 treatment LTCFs, adherence to hand rubbing increased from 5 (1.5%) of 333 to 233 (15.9%) of 1,465 hand hygiene opportunities (P = .001)and total hand hygiene adherence increased from 86 (25.8%) of 333 to 488 (33.3%) of 1,465 opportunities (P = .01)after intervention; the 3 control LTCFs showed no significant change. In the treatment group, the incidence of serious infections decreased from 31 cases in 21,862 resident-days (1.42 cases per 1,000 resident-days) to 33 cases in 50,441 resident-days (0.65 cases per 1,000 resident-days) (P = .002), whereas in the control group, it increased from 16 cases in 32,726 resident-days (0.49 cases per 1,000 resident-days) to 85 cases in 81,177 resident-days (1.05 cases per 1,000 resident-days) (P = .004]). In the treatment group, the incidence of pneumonia decreased from 0.91 to 0.28 cases per 1,000 resident-days (P = .001) and the death rate due to infection decreased from 0.37 to 0.10 deaths per 1,000 resident-days (P = .01); the control group revealed no significant change.

CONCLUSIONS

A hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.

Healthcare associated infection in care homes for older people in Scotland: results from a pilot survey

The prevalence of infection in Scottish care homes is currently unknown. The aim of this survey was to estimate the prevalence of infection within a small sample of care homes for older people and to develop and test a methodology for point prevalence surveys which would allow local care home staff to monitor infection in care homes for older people that employ trained nurses.

The pilot survey was undertaken by Health Protection Scotland (HPS) in collaboration with the Care Commission and two volunteer service providers. Data collection within 18 volunteer care homes was undertaken between 6 April 2009 and 1 May 2009. A total of 922 residents from 18 care homes were included. On the day of survey, 87 infections were identified in 86 residents. The prevalence of infection was 9.3%. The most common infections types were urinary tract infections and respiratory tract infections.

The results from this small survey of volunteer care homes have provided valuable insight into the previously unmeasured prevalence of infection in Scottish care homes for older people.

It is hoped that the rollout of a larger scale survey that includes a representative sample of all Scottish care homes can be implemented.

[Repeated prevalence investigations of nursing home-associated infections as a tool to assess the hygienic quality of care]

The rate of healthcare-associated infections can be regarded as an important outcome parameter of the hygienic quality of care in nursing homes. Our study aimed to evaluate the applicability of repeated prevalence investigations as a tool for surveillance of healthcare-associated infections in nursing homes. From December 2006 to September 2007 a total of five prevalence investigations were conducted in four nursing homes each (n=2,369 residents). Initially, defined structural and procedural parameters of the hygienic quality of the four nursing homes were evaluated based on a detailed inspection and a checklist including 40 parameters. The results showed a uniformly high level of the hygienic quality with only minor variation (mean 84%, range 75%-93% of parameters fulfilled). In total, the prevalence of healthcare-associated infections was 6.8%, with a marked increase with higher categories of dependency (3.5%, 4.0%, 8.5%, and 12.3%, respectively, in the categories 0, I, II, and III of the German grading of skilled nursing care). Respiratory tract (4.1%), skin/soft tissue (1.5%), and urinary tract infections were the most prevalent healthcare-associated infections. Respiratory tract infections showed a marked seasonal pattern. During the second prevalence investigation (February 2007), an outbreak of upper respiratory tract infections occurred in one of the nursing homes (attack rate, 17%). The crude prevalence rates showed considerable differences between the four nursing homes; however, after adjusting for the different categories of dependency, the standardized infection rates (SIR) were largely comparable (excluding the outbreak). After inclusion of the outbreak, the SIR of the specific nursing home was significantly higher compared to all other nursing homes. In conclusion, our study shows that repeated prevalence investigations can be an easy to use tool for surveillance of healthcare-associated infections as a surrogate parameter of the hygienic quality in nursing homes. This implies a knowledge of the seasonality of specific infections and a risk adjustment according to the categories of dependency. The primary intention of surveillance should be the identification of hygienic problems. However, the resources should preferentially be focused on hygienic structures and processes.

Epidemiology of antimicrobial resistance among gram-negative organisms recovered from patients in a multistate network of long-term care facilities

We identified 1,805 gram-negative organisms in cultures of urine samples obtained over a 10-month period from residents of 63 long-term care facilities. The prevalence of fluoroquinolone resistance in Escherichia coli was 51% (446 of 874 isolates), whereas the prevalences of ceftazidime and imipenem resistance in Klebsiella species were 26% and 6% (84 and 19 of 323 isolates), respectively. The prevalence of resistance varied significantly by facility type, size, and geographic location.

Clinical features to identify urinary tract infection in nursing home residents: a cohort study

OBJECTIVES

To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI).

DESIGN

Prospective, observational cohort study from 2005 to 2007.

SETTING

Five New Haven, Connecticut area nursing homes.

PARTICIPANTS

Five hundred fifty-one nursing home residents each followed for 1 year for the development of clinically suspected UTI.

MEASUREMENTS

The combined outcome of bacteriuria (>100,000 colony forming units from urine culture) plus pyuria (>10 white blood cells from urinalysis).

RESULTS

After 178,914 person-days of follow-up, 228 participants had 399 episodes of clinically suspected UTI with a urinalysis and urine culture performed; 147 episodes (36.8%) had bacteriuria plus pyuria. The clinical features associated with bacteriuria plus pyuria were dysuria (relative risk (RR)=1.58, 95% confidence interval (CI)=1.10-2.03), change in character of urine (RR=1.42, 95% CI=1.07-1.79), and change in mental status (RR=1.38, 95% CI=1.03-1.74).

CONCLUSION

Dysuria, change in character of urine, and change in mental status were significantly associated with the combined outcome of bacteriuria plus pyuria. Absence of these clinical features identified residents at low risk of having bacteriuria plus pyuria (25.5%), whereas presence of dysuria plus one or both of the other clinical features identified residents at high risk of having bacteriuria plus pyuria (63.2%). Diagnostic uncertainty still remains for the vast majority of residents who meet only one clinical feature. If validated in future cohorts, these clinical features with bacteriuria plus pyuria may serve as an evidence-based clinical definition of UTI to assist in management decisions.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long‐term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one‐half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on‐site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies

BACKGROUND

As part of routine diabetes care, capillary blood is typically sampled using a finger-stick device and then tested using a handheld blood glucose meter. In settings where multiple persons require assistance with blood glucose monitoring, opportunities for bloodborne pathogen transmission may exist.

METHODS

Reports of hepatitis B virus (HBV) infection outbreaks in the United States that have been attributed to blood glucose monitoring practices were reviewed and summarized.

RESULTS

Since 1990, state and local health departments investigated 18 HBV infection outbreaks, 15 (83%) in the past 10 years, that were associated with the improper use of blood glucose monitoring equipment. At least 147 persons acquired HBV infection during these outbreaks, 6 (4.1%) of whom died from complications of acute HBV infection. Outbreaks appear to have become more frequent in the past decade, primarily affecting long-term care residents with diabetes. Each outbreak was attributed to glucose monitoring practices that exposed HBV-susceptible persons to blood-contaminated equipment that was previously used on HBV-infected persons. The predominant unsafe practices were the use of spring-loaded finger-stick devices on multiple persons and the sharing of blood glucose testing meters without cleaning and disinfection between uses.

CONCLUSION

Hepatitis B virus infection outbreaks associated with blood glucose monitoring have occurred with increasing regularity in the Unites States and may represent a growing but under-recognized problem. Advances in technology, such as the development of blood glucose testing meters that can withstand frequent disinfection and noninvasive glucose monitoring methods, will likely prove useful in improving patient safety.

Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing home residents

OBJECTIVES

To prospectively evaluate nursing home residents with suspected urinary tract infection (UTI) to determine whether they met the McGeer, Loeb, or revised Loeb consensus-based criteria and whether any set of criteria was associated with laboratory evidence of UTI, namely bacteriuria (>100,000 colony forming units) plus pyuria (>10 white blood cells).

DESIGN

Prospective cohort study.

SETTING

Three New Haven-area nursing homes.

PARTICIPANTS

Of 611 residents screened, 457 were eligible, 362 consented, and 340 enrolled.

MEASUREMENTS

Participants underwent prospective surveillance from May 2005 to April 2006 for the development of suspected UTI (defined as a participant's physician or nurse clinically suspecting UTI). One hundred participants with suspected UTI and a urinalysis and urine culture performed were included in the analyses.

RESULTS

Participants were identified who met the criteria of McGeer, Loeb, revised Loeb, and laboratory evidence of UTI. Using laboratory evidence of UTI as the outcome, the McGeer criteria demonstrated 30% sensitivity, 82% specificity, 57% positive predictive value (PPV), and 61% negative predictive value (NPV); the Loeb criteria showed 19% sensitivity, 89% specificity, 57% PPV, and 59% NPV; and the revised Loeb criteria demonstrated 30% sensitivity, 79% specificity, 52% PPV, and 60% NPV.

CONCLUSION

All of the consensus-based criteria have similar test characteristics. The diagnostic accuracy of UTI criteria in nursing home residents could be improved, and the data suggest that evidence-based clinical criteria associated with laboratory evidence of UTI need to be identified and validated.

Infection control in pediatric extended care facilities

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools. Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.

Longitudinal trends in antimicrobial susceptibilities across long-term-care facilities: emergence of fluoroquinolone resistance

BACKGROUND

Antibiotic resistance in the longterm-care facility (LTCF) setting is of increasing concern due to both the increased morbidity and mortality related to infections in this debilitated population and the potential for transfer of resistant organisms to other healthcare settings. Longitudinal trends in antibiotic resistance in LTCFs have not been well described.

DESIGN

Correlational longitudinal survey study.

SETTING

Four LTCFs in Pennsylvania.

SUBJECTS

All clinical cultures of residents of the participating LTCFs (700 total beds) from 1998 through 2003. We assessed the annual prevalence of resistance to various antimicrobials of interest for the following organisms: Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and enterococcus species.

RESULTS

A total of 4,954 clinical isolates were obtained during the study. A high prevalence of antimicrobial resistance was noted for many organism-drug combinations. This was especially true for fluoroquinolone susceptibility among the Enterobacteriaceae (susceptibility range, 51.3% to 92.2%). In addition, the prevalence of resistance to various agents differed significantly across study sites. Finally, significant increasing trends in resistance were noted over time and were most pronounced for fluoroquinolone susceptibility among the Enterobacteriaceae.

CONCLUSIONS

The prevalence of antimicrobial resistance has increased significantly in LTCFs, although trends have varied substantially across different institutions. These trends have been particularly pronounced for fluoroquinolone resistance among the Enterobacteriaceae. These findings demonstrate that antimicrobial resistance is widespread and increasing in LTCFs, highlighting the need for future studies to more clearly elucidate the risk factors for, and potential interventions against, emerging resistance in these settings.

Infections and Functional Impairment in Nursing Home Residents: A Reciprocal Relationship

OBJECTIVES

To determine the relationship between infections and functional impairment in nursing home residents.

DESIGN

Prospective cohort study (follow-up period, 6 months).

SETTING

Thirty-nine nursing homes in western Switzerland.

PARTICIPANTS

A total of 1,324 residents aged 65 and older (mean age 85.7; 76.6% female) who agreed to participate, or their proxies, by oral informed consent.

MEASUREMENTS

Functional status measured every 3 months. Two different outcomes were used: (a) functional decline defined as death or decreased function at follow-up and (b) functional status score using a standardized measure.

RESULTS

At the end of follow-up, mortality was 14.6%, not different for those with and without infection (16.2% vs 13.1%, P=.11). During both 3-month periods, subjects with infection had higher odds of functional decline, even after adjustment for baseline characteristics and occurrence of a new illness (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.2-2.2, P=.002, and AOR=1.5, 95% CI=1.1-2.0, P=.008, respectively). The odds of decline increased in a stepwise fashion in patients with zero, one, and two or more infections. The analyses predicting functional status score (restricted to subjects who survived) gave similar results. A survival analysis predicting time to first infection confirmed a stepwise greater likelihood of infection in subjects with moderate and severe impairment at baseline than in subjects with no or mild functional impairment at baseline.

CONCLUSION

Infections appear to be both a cause and a consequence of functional impairment in nursing home residents. Further studies should be undertaken to investigate whether effective infection control programs can also contribute to preventing functional decline, an important component of these residents' quality of life.

Infection control in British nursing homes

Infection control in British nursing homes is different from that in U.S. nursing homes in seveal ways. Most British nursing homes, for example, do not have a designated on-site infection control nurse, and several agencies are responsible for regulatory oversight. This article discusses the state of infection control in British nursing homes.

Management of antibiotic-resistant bacteria

Optimizing the management of antibiotic resistance is an important strategy in improving outcomes for infectious diseases in older persons. Strategies that manage antibiotic resistance must take into account all clinical settings, because resistant pathogens previously seen only in acute care facilities are becoming increasingly common in long-term care facilities. Recently, modest improvement in therapeutic options for the treatment of infections due to resistant pathogens has become available because of the development of newer antibiotics. Some of these drugs are briefly discussed in this review, but the best strategy is to limit the potential for the development of resistance and transmission of these pathogens. This can best be accomplished by minimizing misuse of antibiotics and maximizing adherence to basic hygiene standards.

Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel

The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.

Nosocomial infections in geriatric long-term-care and rehabilitation facilities: exploration in the development of a risk index for epidemiological surveillance

OBJECTIVE

To compute a risk index for nosocomial infection (NI) surveillance in geriatric long-term-care facilities (LTCFs) and rehabilitation facilities.

DESIGN

Analysis of data collected during the French national prevalence survey on NIs conducted in 1996. Risk indices were constructed based on the patient case-mix defined according to risk factors for NIs identified in the elderly.

SETTING

248 geriatric units in 77 hospitals located in northern France.

PARTICIPANTS

All hospital inpatients on the day of the survey were included.

RESULTS

Data from 11,254 patients were recorded. The overall rate of infected patients was 9.9%. Urinary tract, respiratory tract, and skin were the most common infection sites in both rehabilitation facilities and LTCFs. Eleven risk indices, categorizing patients in 3 to 7 levels of increasing NI risk, ranging from 2.7% to 36.2%, were obtained. Indices offered risk adjustment according to NI rate stratification and clinical relevance of risk factors such as indwelling devices, open bedsores, swallowing disorders, sphincter incontinence, lack of mobility, immunodeficiency, or rehabilitation activity.

CONCLUSION

The optimal index should be tailored to the strategy selected for NI surveillance in geriatric facilities in view of available financial and human resources.

The role of the laboratory in infection prevention and control programs in long-term-care facilities for the elderly

Hospital infection prevention and control programs rely extensively on diagnostic microbiology laboratory testing. However, specimens for microbiological evaluation are less likely to be obtained from elderly residents of long-term-care facilities (LTCFs). In this article, issues regarding laboratory utilization and the potential role of the microbiology laboratory in infection prevention and control programs in LTCFs are reviewed. The role of the laboratory in infection surveillance, in the management of antimicrobial resistance, and in outbreak investigation are highlighted.

The chronic indwelling catheter and urinary infection in long-term-care facility residents

From 5% to 10% of residents of long-term-care facilities have urinary drainage managed with chronic indwelling catheters. These residents are always bacteriuric, usually with a complex microbiological flora of two to five organisms and a biofilm on the catheter that may contribute to obstruction. Residents with chronic indwelling catheters have increased morbidity from urinary infection compared to bacteriuric residents without chronic catheters. The most effective means to prevent infection is limitation of chronic indwelling catheter use. While appropriate catheter care and infection control precautions are recommended in managing these patients, the impact of these practices on the occurrence of urinary infection or prevention of symptomatic episodes has not been evaluated. Symptomatic infection can likely be prevented by attention to catheter care, including early recognition and replacement of obstructed catheters and prevention of catheter trauma. Appropriate use of prophylactic antimicrobial therapy prior to invasive genitourinary procedures is also necessary. Asymptomatic bacteriuria should not be treated. When symptomatic episodes occur, patients should be evaluated clinically and microbiologically and treated with appropriate antimicrobial therapy. Further technological advances in catheter material and urine drainage will be needed to have a substantial impact on the frequency of urinary infection with chronic catheter use.

Practice guideline for evaluation of fever and infection in long-term care facilities

The elderly population (i.e., persons aged > or = 65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that >40% of persons aged > or = 65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infection-control measures are not available in the LTCF.

Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee

There is intense antimicrobial use in long-term-care facilities (LTCFs), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and the virtual absence of relevant clinical trials. This position paper recommends approaches to management of common infections in LTCF patients and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the position paper acknowledges the unique aspects of provision of care in the LTCF.

Evidence of delays in transferring patients with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus to long-term-care facilities

This retrospective case-control study examined whether there was a difference in length of time awaiting long-term-care placement for patients identified as having methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus compared to controls. Thirty-nine patients with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus waited for placement an average of 61 days longer than controls (P<.0002). The average number of requests for placement was 2.5 compared to 1.7 for controls (P=.015).

Nosocomial infection in long-term care facilities. A survey in a Brazilian psychiatric hospital

Nosocomial infection among male patients in a public psychiatric hospital was studied and the definitions for use in long-term care facilities were employed for diagnosis. The overall nosocomial infection rate was 6.7 per 1,000 day inpatients; 55.6% of these infections were identified in the respiratory tract, 50% of them being respiratory viral diseases; 38.9% of the nosocomial infections involved the eyes, ears, nose, throat and mouth, and 5.6% involved the skin and soft tissues. The epidemiological characteristics and the main clinical alterations of these inpatients were also identified.

Infection control programs in long-term-care facilities: structure and process

Due to the rapid transfer of patients from the acute-care setting, the intensity of nursing care among residents in long-term-care facilities (LTCFs) has increased, transforming today's LTCFs into subacute healthcare facilities. Given the increased risk of infection among residents in LTCFs and the associated morbidity and mortality, evaluation of infection control programs in skilled nursing LTCFs is warranted. This article addresses the current structure and process of infection control programs in skilled nursing LTCFs.