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SHEA/APIC Guideline: Infection prevention and control in the long-term care facility PhilipW.Smith,MD,aGailBennett,RN,MSN,CIC,bSuzanneBradley,MD,cPaulDrinka,MD,dEbbingLautenbach,MD,e James Marx, RN, MS, CIC,f Lona Mody, MD,g Lindsay Nicolle, MD,h and Kurt Stevenson, MDi July 2008 Long-term care facilities (LTCFs) may be defined as of illness of nursing home residents has increased. institutions that provide health care to people who LTCF residents have a risk of developing health care- are unable to manage independently in the commu- associatedinfection(HAI)thatapproachesthatseenin nity.1 This care may be chronic care management or acutecarehospitalpatients.Agreatdealofinformation short-term rehabilitative services. The term nursing has been published concerning infections in the LTCF, homeisdefinedasafacilitylicensedwithanorganized and infectioncontrolprogramsarenearlyuniversalin professional staff and inpatient beds that provides that setting. This position paper reviews the literature continuous nursing and other services to patients oninfectionsandinfectioncontrolprogramsintheLTCF. who are not in the acute phase of an illness. There is Recommendationsaredevelopedforlong-termcare considerableoverlapbetween the 2 terms. (LTC) infection control programs based on interpreta- More than 1.5 million residents reside in United tionofcurrentlyavailableevidence.Therecommenda- States (US) nursing homes. In recent years, the acuity tions cover the structure and function of the infection control program, including surveillance, isolation precautions, outbreak control, resident care, and Professor of Infectious Diseases, Colleges of Medicine and Public employee health. Infection control resources are also Health, University of Nebraska Medical Center, Omaha, Nebraskaa; President,ICPAssociates, Inc,Rome, Georgiab; ProfessorofInternal presented. Medicine,DivisionsofInfectiousDiseasesandGeriatricMedicineVA Hospital infection control programs are well estab- AnnArborHealthcareSystem,andtheUniversityofMichiganMedical lished in the US. Virtuallyevery hospital has an infec- School,AnnArbor,Michiganc;ClinicalProfessor,InternalMedicine/Ger- tion control professional (ICP), and many larger iatrics,UniversityofWisconsin-Madison,andMedicalCollegeofWis- consin–Milwaukee, Wisconsind; Associate Professor of Medicine and hospitals have a consulting hospital epidemiologist. Epidemiology,AssociateHospitalEpidemiologist,HospitaloftheUni- The Study on the Efficacy of Nosocomial Infection versityofPennsylvania,andSeniorScholar,CenterforClinicalEpidemi- Control(SENIC)documentedtheeffectivenessofahos- ologyandBiostatistics,UniversityofPennsylvaniaSchoolofMedicine, pital infection control program that applies standard Philadelphia,Pennsylvaniae;InfectionPreventionist,BroadStreetSolu- tions,SanDiego,Californiaf;AssistantProfessor,DivisionsofGeriatric surveillance and controlmeasures.2 Medicine, University of Michigan Medical School, and Geriatric Re- The major elements leading to a HAI are the infec- search and Education Center, Veteran Affairs Ann Arbor Healthcare tious agent, a susceptible host, and a means of trans- System,AnnArbor,Michigang;Professor,InternalMedicineandMedical mission. These elements are present in LTCFs as well Microbiology, University of Manitoba, Winnipeg, Manitoba, Canadah; and AssociateProfessorofMedicine, Divisionof InfectiousDiseases, as in hospitals. It is not surprising, therefore, that DepartmentofInternalMedicine,TheOhioStateUniversityCollege almost as many HAIs occur annually in LTCFs as in ofMedicine,Columbus,Ohio.i hospitals in the US.3 AddresscorrespondencetoPhilipW.Smith,MD,SectionofInfectious The last 2 decades have seen increased recognition Disease, University of Nebraska Medical Center, 985400 Nebraska oftheproblemofinfectionsinLTCFs,withsubsequent MedicalCenter,Omaha,NE68198-5400E-mail:[email protected]. widespreaddevelopmentofLTCFinfectioncontrolpro- AmJInfectControl2008;36:504-35. grams and definition of the role of the ICP in LTCFs. 0196-6553/$34.00 An increasingly robust literature is devoted to LTC Copyright ª 2008 by the Association for Professionals in Infection infection control issues such as the descriptive epide- Control and Epidemiology, Inc, and Society for Healthcare miology of LTCF infections, the microbiology of LTCF Epidemiology. infections, outbreaks, control measures, and isolation. doi:10.1016/j.ajic.2008.06.001 Nevertheless,thereisasyetnoSENIC-equivalentstudy 504 Smith et al September 2008 505 documentingtheefficacyofinfectioncontrolinLTCFs, etc. Reworking those sources to a form applicable to and few controlled studies have analyzed the efficacy all LTCFs is beyondthe scope ofthisguideline. or cost-effectiveness of the specific control measures Any discussion of infection control issues must be in that setting. made in the context of the LTCFas a community. The Although hospitals and LTCFs both have closed LTCF is a home for residents, a home in which they populations of patients requiring nursing care, they usually reside for months or years; comfort and are quite different. They differ with regard to pay- infectioncontrolprinciples must both be addressed. ment systems, patient acuity, availability of labora- tory and x-ray, and nurse-to-patient ratios. More BACKGROUND fundamentally, the focus is different. The acute Demography and definitions care facility focus is on providing intensive care to a patient who is generally expected to recover or im- TheUSpopulationaged65to85yearsisincreasing prove, and high technology is integral to the process. rapidly, and the population aged 85 years and older is In LTCFs, the patient population may be very heter- expected to double by 2030.4 One of every 4 persons ogeneous. Most LTCFs carry out plans of care that who reach the age of 65 can be expected to spend have already been established in acute care or eval- part of his or her life in a nursing home; more people uate chronic conditions. The LTCF is functionally the occupy nursing home beds than acute care hospital home for the resident, who is usually elderly and in beds in the US.5 Approximately 1.5 million persons declining health and will often stay for years, hence in the US reside in a nursing home; there are 15,000 comfort, dignity, and rights are paramount. It is a nursinghomesinthiscountry.6Ninetypercentofnurs- low-technology setting. Residents are often trans- ing home residents are over 65 years of age, and the ferred between the acute care and the LTC setting, mean ageof residentsis over80 years. adding an additional dynamic to transmission and ALTCFisaresidentialinstitutionforprovidingnurs- acquisition of HAIs. ing care and related services to residents. It may be Applicationofhospitalinfectioncontrolguidelinesto attached to a hospital (swing-bed) or free standing; the LTCF is often unrealistic in view of the differences the latter is often called a nursing home. A resident is noted above and the different infection control re- a person living in the LTCF and receiving care, analo- sources. Standards and guidelines specific to the LTCF goustothe patient ina hospital. settingarenowcommonlyfound.Theproblemofdevel- opingguidelinesapplicabletoallLTCFsiscompounded bythevaryinglevelsofnursingintensity(eg,skillednurs- Scope of position paper ing facility vs assisted living), LTCF size, and access to physicianinputanddiagnostictesting. Thispositionpaperaddressesalllevelsofcareinthe Thispositionpaperprovidesbasicinfectioncontrol LTCF. The focus is specifically the LTCF, also known as recommendations that could be widely applied to the nursing home, caring for elderly or chronically ill LTCFs with the expectation of minimizing HAIs in residents. These recommendations generally also LTC. The efficacy of these measures in the LTCF, in should apply to special extended care situations most cases, is not proven by prospective controlled (suchasinstitutions forthementallyretarded,psychi- studiesbutisbasedoninfectioncontrollogic,adapta- atrichospitals, pediatricLTCFs, and rehabilitation hos- tion of hospital experience, LTCF surveys, Centers for pitals). However, other extended care facilities may DiseaseControlandPrevention(CDC)andotherguide- havedifferentpopulations(eg,theresidentsofinstitu- lines containing specific recommendations for LTCFs, tionsforthementallyretardedaremuchyoungerthan and field experience. Every effort will be made to nursing home residents), different disease risks address the unique concerns of LTCFs. Because facili- (eg, hepatitis B in psychiatric hospitals), or different ties differ, the infection risk factors specific to the levels of acuity and technology (eg, higher acuity in resident population, the nature of the facility, and the long-term acute care facilities or LTACs). Thus, the resourcesavailableshoulddictatethescopeandfocus recommendations may need to be adapted for these of the infectioncontrolprogram. special extendedcaresituations. In a numberof instances, specifichospital-oriented Changes from prior Guideline. This position paper guidelines have been published and are referenced issimilartothe1997SocietyforHealthcareEpidemiol- (eg, guidelines for prevention of intravascular (IV) ogyofAmerica(SHEA)/AssociationforProfessionalsin device-associated infection). These guidelines are Infection Control and Epidemiology (APIC) guideline,7 relevant,at least inpart, tothe LTC setting but maybe although the present version reflects an updating of adapted depending on facilitysize, resources, resident researchandexperienceinthefield.Severalimportant acuity, local regulations, local infection control issues, areasofdiscussion areneworchanged. 506 Vol. 36 No. 7 Smith et al INFECTIONS IN THE LONG-TERM CARE growing subpopulation of postacute residents. Posta- FACILITY cute residents are hospitalized patients who are discharged to LTCFs to receive skilled nursing care or Epidemiology physical/occupational therapy. In the past, these In US LTCFs, 1.6 million to 3.8 million infections patients,oftenfrail,wouldhaveremainedhospitalized, occur each year.8 In addition to infections that are but, with increasing efforts to control hospital costs, largely endemic, such as urinary tract infections thesepatientsarenowdischargedtoLTCFs.Inaddition (UTIs) and lower respiratory tract infections (LRTIs), to higher device utilization, these residents are more outbreaksofrespiratoryandgastrointestinal(GI)infec- likely to receive antimicrobial therapy than long-stay tions are also common.9 The overall infection rate in LTCF residents.15 LTCFs for endemic infections ranges from 1.8 to 13.5 MuchremainstobelearnedaboutresidentandLTCF infectionsper1000resident-caredays.8Forepidemics, factorscorrelatedwithHAIs.Thereisevidencethatin- good estimates aredifficult toascertain,butthe litera- stitutional factors such as nurse turnover, staffing turesuggeststhatseveralthousandoutbreaksmayoc- levels, prevalence of Medicare recipients, rates of cur in US LTCFs each year.8,9 The wide ranges of hospital transfer for infection, intensity of medical infections and resulting mortality and costs illustrate services, and family visitation rates are associated the challenge in understanding the epidemiology of with incidenceof HAI in the LTC setting.16 infections and their impact in LTCFs. There are cur- The rateofdeaths in LTCF residents with infections rently little data and no national surveillance systems ranges from 0.04 to 0.71 per 1000 resident-days, with forLTCFinfections;theestimateshavebeencalculated pneumonia being the leading cause of death.8 Infec- based on research studies and outbreak reports from tions are a leading reason for hospital transfer to the medical literature. LTCF residents, and the resulting hospital costs range As a part of aging, the elderly have diminished from$673 million to$2 billioneachyear.8 immune response including both phenotypic and LTCFs and acute care facilities differ in another key functionalchangesinTcells.10However,thesechanges aspect: LTCFs are residential. As residences, LTCFs are are of limited clinical significance in healthy elderly. required to provide socialization of residents through Consequently, immune dysfunction in elderly resi- group activities. While these activities are important dents of LTCFs is primarily driven by the multiple for promoting good physical and mental health, they factors that result in secondary immune dysfunction may also increase communicable infectious disease suchasmalnutrition,presenceofmultiplechronicdis- exposureandtransmission.Occupationalandphysical eases,and polypharmacy,especiallywithmedications therapyactivities,whilevitaltowardrestoringormain- that diminish host defenses (eg, immunosuppres- taining physical and mental function, may increase sants).11,12Inaddition,LTCFresidentsoftenhavecogni- risk for person-to-person transmission or exposure to tive deficits that may complicate resident compliance contaminated environmental surfaces (eg, physical or with basic sanitary practices (such as handwashing occupational therapyequipment). and personal hygiene) or functional impairments such as fecal and urinary incontinence, immobility, SPECIFIC NOSOCOMIAL INFECTIONS IN THE and diminished cough reflex. The elderly nursing LONG-TERM CARE FACILITY home resident is known to have a blunted febrile Urinary tract infections response to infections.13 This parallels other age- relatedimmunologic abnormalities.A notablefever in In most surveys, the leading infection in LTCFs is this population often signals a treatable infection, UTI,17 although with restrictive clinical definitions, such as UTI oraspirationpneumonia. symptomatic urinary infection is less frequent than WhiletheuseofurinarycathetersinLTCFresidents respiratory infection.18 Bacteriuria is verycommon in has decreased in recent years, utilization remains residents of these facilities but, by itself, is not associ- around5%.InLTCresidents,theuseofinvasivedevices ated with adverse outcomes and does not affect sur- (eg, central venous catheters, mechanical ventilators, vival.19,20 Bacteriuria and UTI are associated with enteralfeedingtubes)increasesthelikelihoodofade- increased functional impairment, particularly inconti- vice-associated infection. Of the over 15,000 LTCFs in nence ofurine orfeces.21,22 the US in 2004, 42% provided infusion therapy, 22% The symptoms of UTI are dysuria and frequency had residents with peripherally-inserted central lines, (cystitis) or fever and flank pain (pyelonephritis). The and 46% provided parenteral nutrition.14 Another elderly may present with atypical or nonlocalizing challenge for preventing infections in LTCFs is the in- symptoms. Chronic genitourinary symptoms are also creasingacuityofresidents,especiallywiththerapidly common but are not attributable to bacteriuria.20,21 Smith et al September 2008 507 Becausetheprevalenceofbacteriuriaishigh,apositive effects, including symptomatic urinary infection, than urine culture, with or without pyuria, is not sufficient an indwelling catheter.35 Local external care is re- to diagnose urinary infection.20 Clinical findings for quired. The CDC guideline32 briefly discusses care of diagnosis of UTI in the noncatheterized resident must condom catheters and suprapubic catheters, but no include some localization to the genitourinary tract.23 guideline for leg bags is available. Leg bags allow for The diagnosis also requires a positive quantitative improved ambulation of residents but probably urine culture. This is obtained by the clean-catch increasetheriskofUTIbecauseopeningofthesystem voided technique, by in and out catheterization, or by and reflux of urine from the bag to the bladder occur aspiration through a catheter system sampling port. more frequently than with a standard closed system. A negative test for pyuria or a negative urine culture Suggestions for care of leg bags include using aseptic obtained prior to initiation of antimicrobial therapy technique when disconnecting and reconnecting, dis- excludes urinary infection. infecting connections with alcohol, changing bags at The prevalence of indwelling urethral catheters in regularintervals,rinsingwithdilutedvinegar,anddry- the LTCF is 7% to 10%.24-26 Catheterization predis- ingbetweenuses.36A1:3dilutionofwhitevinegarhas posestoclinicalUTI,andthecatheterizedurinarytract been recommended forlegbag disinfection.37 isthemostcommonsourceofbacteremiainLTCFs.17,19 Residents with long-term catheters often present with Respiratory tract infections fever alone. Residents with indwelling urinary cathe- tersintheLTCFareuniformlycolonizedwithbacteria, Because of the impaired immunity of elderly per- largelyattributable to biofilm on the catheter.27 These sons,viralupperrespiratoryinfections(URIs)thatgen- organisms are often more resistant to oral antibiotics erally are mild in other populations may cause thanbacteriaisolatedfromelderlypersonsinthecom- significant disease in the institutionalized elderly munity.28,29 Catheter-related bacteriuria is dynamic, patient.38,39 Examples include influenza, respiratory andantimicrobialtreatmentonlyleadstoincreasedan- syncytial virus (RSV), parainfluenza, coronavirus, rhi- timicrobial resistance.30 Thus, it is inappropriate to noviruses, adenoviruses, and recently discovered hu- screen asymptomatic catheterized residents for bacte- man metapneumovirus.40 riuria or to treat asymptomatic bacteriuria.20 Speci- Pneumonia. Pneumonia or lower respiratory tract mens collected through the catheter present for more infection (LRTI) is the second most common cause of than a few days reflect biofilm microbiology. For resi- infectionamongnursinghomeresidents,withaninci- dents with chronic indwelling catheters and sympto- dence ranging from 0.3 to 2.5 episodes per 1000 resi- matic infection, changing the catheter immediately dent care-days and is the leading cause of death from priortoinstitutingantimicrobialtherapyallowscollec- infectionsinthissetting.ElderlyLTCFresidentsarepre- tion of a bladder specimen, which is a more accurate disposed to pneumonia by virtue of decreased clear- reflection of infecting organisms.31 Catheter replace- ance of bacteria from the airways and altered throat ment immediately prior to therapy is also associated flora,poorfunctionalstatus,presenceoffeedingtubes, withmorerapiddefervescenceandlowerriskofearly swallowingdifficulties,andaspirationaswellasinade- symptomatic relapseposttherapy.31 quate oral care.41-43 Underlying diseases, such as Guidelines for prevention of catheter-associated chronic obstructive pulmonary disease and heart dis- UTIsinhospitalizedpatients32aregenerallyapplicable ease, further increase the risk of pneumonia in this tocatheterizedresidentsinLTCFs.Recommendedmea- population.44 The clinical presentation of pneumonia sures include limiting use of catheters, insertion of intheelderlyoftenisatypical.Whilethereisapaucity catheters aseptically by trained personnel, use of as of typical respiratory symptoms, recent studies have small diameter a catheter as possible, handwashing shown that fever is present in 70%, new or increased before and after catheter manipulation, maintenance cough in 61%, altered mental status in 38%, and in- of a closed catheter system, avoiding irrigation unless creased respiratory rate above 30 per minute in 23% the catheter is obstructed, keeping the collecting bag of residentswith pneumonia.45 below the bladder, and maintaining good hydration in While acquiring a diagnostic sputum can be diffi- residents. Urinary catheters coated with antimicrobial cult,obtainingachestradiographisnowmorefeasible materials have the potential to decrease UTIs but than in the past. In general it is recommended that a havenotbeenstudiedintheLTCFsetting.Forsomeres- pulse oximetry, chest radiograph, complete blood identswithimpairedvoiding,intermittentcatheteriza- countwithdifferential,andbloodureanitrogenshould tion is an option, and clean technique is as safe as be obtainedin residentswith suspectedpneumonia.46 sterile technique.33 External catheters are also a risk Streptococcuspneumoniaeappearstobethemostcom- factorforUTIsinmaleresidents34butaresignificantly mon etiologic agent accounting for about 13% of all more comfortable and associated with fewer adverse cases,47,48 followed by Hemophilus influenzae (6.5%), 508 Vol. 36 No. 7 Smith et al Staphylococcus aureus (6.5%), Moraxella catarrhalis is effective and indicated for all residents and care- (4.5%), and aerobic gram-negative bacteria (13%).44 givers.63-68 Recent surveys have shown an increased Legionella pneumoniae also is a concern in the LTCF. rate of influenza vaccination among LTCF residents, Colonization with methicillin-resistant S aureus although significant variability exists.69,70 Influenza (MRSA)andantibiotic-resistant,gram-negativebacteria vaccination rates for a facility are now publicly further complicate diagnosis and management of reported at the Centers for Medicare and Medicaid pneumoniain LTCF residents.49,50 (CMS) Web site http://www.medicare.gov/NHCompare/ The mortality rate for LTCF-acquired pneumonia is home.asp. Staff immunization rates remain less significantly higher than for community-acquired impressive, with average immunization rates between pneumonia in the elderly population.51 Preinfection 40% and 50% atbest. functional status, dementia, increased rate of respira- While viral cultures from nasopharynx remain the tionsandpulse,andachangeinmentalstatusarecon- gold standard for diagnosis of influenza, several rapid sidered to be poor prognostic factors. Several indices diagnosticmethods(rapidantigentests)suchasimmu- predictive of mortality have been developed and nofluorescence or enzyme immunoassay have been may be useful in managing residents with developed. These tests detect both influenza A and B pneumonia.45,52,53 viral antigens from respiratory secretions. Amanta- TheCDCguidelineforpreventionofpneumonia54is dine-resistant influenza has caused LTCF outbreaks orientedtowardacutecarehospitalsbutcoversanum- and hence amantadine is not recommended for influ- berofpointsrelevanttotheLTCF,includingrespiratory enza prophylaxis.71 Zanamivir and oseltamivir are therapy equipment, suctioning techniques, tracheos- effective against both influenza A and B and have tomy care, prevention of aspiration with enteral feed- beenapprovedforprophylaxisandtreatmentofinflu- ings, and immunizations. Examples of relevant enzaAandB.Oseltamivirisadministeredorallyandis recommendations for the LTCF include hand hygiene excretedintheurinerequiringdoseadjustmentsforre- after contact with respiratory secretions, wearing nalimpairment.Zanamivirisgivenbyoralinhalation, gloves for suctioning, elevating the head of the bed whichisaprobleminanoncooperativeLTCFresident. 30 to 45 degrees during tube feeding and for at least Rapid identification of cases in order to promptly 1hour after to decrease aspiration, and vaccination initiatetreatmentandisolatethemtopreventtransmis- of high-risk residents with pneumococcal vaccine.54 sion remains the key to controlling influenza out- Theevidencefortheefficacyofpneumococcalvaccine breaks. Other measures recommended during an inhigh-riskpopulations,includingtheelderlypopula- outbreak of influenza include restricting admissions tion,isdebated.55,56However,thevaccineissafe,rela- or visitors and cohorting of residents with influ- tively inexpensive, and recommended for routine use enza.60,72,73 Infected staffshould not work. in individuals over the age of 65 years.56,57 Pneumo- Tuberculosis. Tuberculosis (TB) also has caused ex- coccal vaccination ratesfora facilityarenow publicly tensiveoutbreaksinLTCFs,generallytracedtoasingle reported at the Centers for Medicare and Medicaid ambulatory resident. Large numbers of staff and resi- Services (CMS).58 dents may be involved, with a potential to spread in Influenza. Influenza is an acute respiratory disease the community.74-76 Price and Rutala77 found 8.1% of signaled by the abrupt onset of fever, chills, myalgias, newemployeesand6.4%ofnewresidentstobepositive and headache along with sore throat and cough, by the purified protein derivative (PPD) of tuberculin althoughelderlyLTCFresidentsmaynothavethistyp- methodintheirNorthCarolinasurvey,withsignificant ical presentation. The incubation period for influenza 5-yearskintestconversionratesinbothgroups. is approximately 1 to 2 days.59 It is a major threat to ThediagnosisofTBintheLTCFisproblematic.Clin- LTCF residents, who are among the high-risk groups ical signs (fever, cough, weight loss) are nonspecific. deservingpreventivemeasures.60Influenzaisverycon- Chestradiographs,whenobtained,oftenshowcharac- tagious,andoutbreaksinLTCFsarecommonandoften teristic pulmonary infiltrates (eg, cavities in the upper severe. Clinical attack rates range from 25% to 70%, lungfields).InfectionwithTBusuallycausesapositive and case fatality ratesaverageover 10%.61-64 tuberculin skin test (TST), although occasional false Akilledvirusvaccineisavailablebutmustbegiven positives and false negatives are seen. The specificity annually. Influenza vaccine in the elderly is approxi- of the TST may be improved by an in vitro blood test mately 40% effective at preventing hospitalization for of interferon release in response to TB peptides, such pneumonia and approximately 50% effective at pre- as the quantiferon test. The most specific diagnostic venting hospital deaths from pneumonia.65 Although test is a sputum culture for TB, but a good specimen concern has been expressed regarding the efficacy of maybedifficulttoobtain.Recentadvancesinmicrobi- the influenza vaccine in institutionalized elderly ologyhavefacilitatedthediagnosisofTBgreatly.Diag- patients, most authors feel that the influenza vaccine nosticssuchasradiometricsystems,polymerasechain Smith et al September 2008 509 reaction (PCR), as well as specific DNA probes help increasetheriskofdevelopingpressureulcers.Several shortenthetimefordiagnosisofTB,althoughsuscep- of these factors may be partially preventable (such as tibility testing requires severalweeks. malnutrition and fecal incontinence). Prevention of GuidelinesdiscussingstandardsforcontrolofTBin pressureulcersinvolvesdevelopingaplanforturning, institutionsareavailable.78-81Thereappearstobeacon- positioning,eliminatingfocalpressure,reducingshear- sensusthatTSTofresidentsandpersonnelintheLTCF ingforces,andkeepingskindry.Attentiontonutrition, should be undertaken on a regular basis, although using disposable briefs and identifying residents at a manyLTCFshaveinadequateTBscreeningprograms.82 high risk using prediction tools can also prevent new The cost-effectiveness of using a 2-step TST to survey pressureulcers. fortheboostereffectisnotdemonstrableforallpopula- The goals are to treat infection, promote wound tions, but the 2-step skin test is recommended by the healing, and prevent future ulcers. Many physical and CDC for initial screening of employees and residents. chemical products are available for the purpose of For LTCF residents without any known contact with skin protection, debridement, and packing, although a case of known TB or other significant risk factors controlled studies are lacking in the area of pressure such as human immunodeficiency virus (HIV) or ulcer prevention and healing.89 A variety of products immunosuppression, induration of 10mm or greater may be used to relieve or distribute pressure (such as to PPD injection is considered positive. Induration of special mattresses, kinetic beds, or foam protectors) 5mmorgreaterisconsideredpositiveinanyindividual or to protect the skin (such as films for minimally withrecentcontactwithaknowncaseofTBorothersig- draining stage II ulcers, hydrocolloids and foams for nificant risk factors such as immunosuppression or moderately draining wounds, alginates for heavily changesonchestx-rayconsistentwitholdTB.83 draining wounds). Negative-pressure wound therapy Therewasa resurgence ofTB in the USin the mid- (vacuum dressings) using gentle suction to provide 1980s;multidrug-resistantcasesofTBhavebeenseen, optimal moist environment is increasingly being used andnosocomialspreadwithinhealthcarefacilitiesisa in treatment of complex pressure ulcers.90 Nursing concern.84 In response to this, guidelines have been measures such as regular turning are essential as promulgated by the CDC that address surveillance well. A pressure ulcer flow sheet is a useful tool in (identificationandreportingofallTBcasesinthefacil- detecting and monitoring pressure ulcers and in ityincludingresidentsandstaff);containment(recom- recording information such as ulcer location, depth, mended treatment under directly observed therapy size,stage,andsignsofinflammationaswellasintim- and appropriate respiratory isolation and ventilation ing of care measures. Infection control measures control measures); assessment (monitoring of surveil- include diligent hand hygieneand glove usage. lance and containmentactivities);and ongoing educa- Because all pressure ulcers, like the skin, are colo- tion of residents, families, and staff.85 Since most nizedwithbacteria,antibiotictherapyisnotappropri- LTCFsdonothaveanegative-pressureroom,residents ate for a positive surface swab culture without signs with suspected active TB should be transferred to an and symptoms of infection. Nonintact skin is more appropriate acute care facility for evaluation. There likely to be colonized with pathogens. True infection should be a referralagreementwith that facility. of a pressure ulcer (cellulitis, osteomyelitis, sepsis) is a serious condition, generally requiring broad- spectrum parenteral antibiotics and surgical debride- Skin and soft-tissue infections, infestations ment inan acute carefacility. Pressure ulcers(also termed decubitus ulcers) occur Cellulitis (infection of the skin and soft tissues) can in up to 20% of residents in LTCFs and are associated occur either at the site of a previous skin break (pres- with increased mortality.86-88 Infected pressure ulcers sureulcer)orspontaneously.Skininfectionsgenerally often are deep soft-tissue infections and may have are caused by group A streptococci or S aureus. Out- underlyingosteomyelitis;secondarybacteremicinfec- breaks of group A streptococcal infections have been tions havea 50% mortalityrate.88 Theyrequire costly described, presenting as cellulitis, pharyngitis, pneu- and aggressive medical and surgical therapy. Once monia, orsepticemia.91-93 infected,pressureulcermanagementrequiresamulti- Scabies is a contagious skin infection caused by a disciplinary approach with involvement of nursing, mite. Lesions usually are very pruritic, burrow-like, geriatrics and infectious disease specialists, surgery, and associated with erythema and excoriations, and physicalrehabilitation. usually in interdigital spaces of the fingers, palms and Medicalfactorspredisposingtopressureulcershave wrists, axilla, waist, buttocks, and the perineal area. been delineated86 and include immobility, pressure, However,thesetypicalfindingsmaybeabsentindebil- friction,shear,moisture,incontinence,steroids,malnu- itatedresidents,leadingtolarge,prolongedoutbreaksin trition, and infection. Reduced nursing time can also LTCFs.94-96 Diagnosis in an individual with a rash 510 Vol. 36 No. 7 Smith et al requiresahighindexofsuspicioninordertorecognize the most frequent bacterial isolate.114 Epidemic theneedfordiagnosticskinscrapings.Thepresenceofa conjunctivitis may spread rapidly through the LTCF. provencaseshouldprompta thoroughsearchforsec- Transmission may occur by contaminated eye drops ondarycases.Asingletreatmentwithpermethrinorlin- or hand cross contamination. Gloves should be dane usually is effective, but repeated treatment or worn for contact with eyes or ocular secretions, with treatmentofallLTCFresidents,personnel,andfamilies hand hygiene performed immediately after removing occasionallyisnecessary.97,98Ivermectin,anoralanti- gloves. helminthicagent,isaneffective,safe,andinexpensive Manyadditionalinfectionshavebeenencounteredin option for treatment of scabies. However, it has not theLTCF,includingherpeszoster,herpessimplex,endo- beenapprovedbytheFDAforthisindication.Therapy carditis, viral hepatitis, septic arthritis, and abdominal of rashes without confirming the diagnosis of scabies infections.Therehasbeenaresurgenceof‘‘pediatric’’ unnecessarily exposes residents to the toxic effects of infectionsintheLTCF(eg,pertussis,RSV,andHinfluen- the topical agents. Because scabies can be transmitted zaerespiratorytractinfections),reflectingthedeclineof by linen and clothing, the environment should be thehost’simmunologicmemorywithaging. cleaned thoroughly. This includes cleaning inanimate surfaces,hot-cyclewashingofwashableitems(clothing, Epidemic infections in theLTCF sheets,towels,etc),andvacuumingthecarpet. Most LTCF HAIs are sporadic. Many are caused by colonizingorganismswithrelativelylowvirulence.Tis- Other infections sueinvasionmaybefacilitatedbythepresenceofauri- Viral gastroenteritis (caused by rotavirus, enterovi- nary catheter or chronic wound or following an ruses, or noroviruses),99,100 bacterial gastroenteritis aspiration event. Ongoing surveillance (see Surveil- (caused by Clostridium difficile, Bacillus cereus, Esche- lance section below) is required to detect epidemic richiacoli,Camplylobacterspp,Cperfringens,orSalmo- clustering of transmissible, virulent infections. Out- nella spp), and parasites (such as Giardia lambia) are breaks must be anticipated. Ideally, infection control well-knowncausesofdiarrheaoutbreaksinLTCFs.101-106 surveillanceandpracticesshouldbetheresponsibility Theelderlyareatincreasedriskofinfectiousgastro- of frontline staffas wellas infectioncontrolstaff. enteritisduetoage-relateddecreaseingastricacid.Ina Anoutbreakortransmissionwithinthefacilitymay populationwithahighprevalenceofincontinence,the occur explosively with many clinical cases appearing risk of cross infection is substantial. Person-to-person within a few days or may, for example, involve an spread, particularly due to shared bathroom, dining, unusualclusteringofMRSAclinicalisolatesonasingle andrehabilitationfacilities,playsaroleinviralgastro- nursingunitoverseveralmonths.Ontheotherhand,a enteritis and in Shigella spp and C difficile diarrhea.107 caseofMRSAinfectionmayfollowaprolongedperiod Foodborne disease outbreaks also are very common ofasymptomaticnasalcolonizationafteranaspiration in this setting,108 most often caused by Salmonella eventordevelopmentofanecroticwound.115 spp or S aureus. E coli O157:H7 and Giardia also may OutbreaksinLTCFsaccountedforasubstantialpro- cause foodborne outbreaks, underscoring the impor- portion(15%)ofreportedepidemics116(Table1).Clus- tanceof properfoodpreparation and storage. tering of URIs, diarrhea, skin and soft tissue infection, Bacteremia109-111 in the LTCF, although rarely conjunctivitis, and antibiotic-resistant bacteriuria detected,maybeprimaryorsecondarytoaninfection have been noted.9 Major outbreaks of infection have at another site (pneumonia, UTI). The most common also been ascribed to E coli,117 group A strepto- source of secondary bacteremia is the urinary tract, cocci,92,118Cdifficile104,119respiratoryviruses,38Salmo- withEcolibeingtheculpritinover50%ofcases.109,111 nella spp,120 Chlamydia pneumoniae,121,122 Legionella AstheacuityofillnessinLTCFresidentshasrisen,the spp,123 and gastrointestinal viruses.124 Nursing homes prevalenceofIVdevicesandrelatedbacteremiccompli- accounted for 2% of all foodborne disease outbreaks cations appears to have increased. The CDC guideline reported to the CDC (1975-1987) and 19% of forpreventionofIVinfectionsisausefulresourceand outbreak-associated deaths.125Transmissiblegastroin- generally applicable to the LTCF.112 Relevant points testinal pathogens may be introduced to the facility includeasepticinsertionoftheIVcannula,dailyinspec- bycontaminatedfoodorwaterorinfectedindividuals. tion of the IV for complications such as phlebitis, and High rates of fecal incontinence, as well as gastric qualitycontrolofIVfluidsandadministrationsets. hypochlorhydria,makethenursinghomeidealforsec- Conjunctivitis in the adult presents as ocular pain, ondary fecal-oral transmission.126 Other epidemics redness, and discharge. In the LTCF, cases may be include scabies, hepatitis B,127 group A streptococcal sporadic or outbreak-associated.113 Many cases are infections, viral conjunctivitis, and many other nonspecific or of viral origin; S aureus appears to be infections. Smith et al September 2008 511 Table 1. Common long-term care facility epidemics of antimicrobial resistance in LTCFs are discussed below in ‘‘Antibiotic Stewardship’’ and ‘‘Isolation and Respiratory: Precautions’’sections. Influenza Tuberculosis Spneumoniae THE INFECTION CONTROL PROGRAM Chlamydiapneumoniae Evolution of programs Legionellaspp Otherrespiratoryviruses(Parainfluenza,RSV) The1980ssawadramaticincreaseinLTCFinfection Gastrointestinal:(maybefoodborne) Viralgastroenteritis(Norovirus,etc) controlactivities,stimulatedbyfederalandstateregu- Clostridiumdifficile lations. Several studies provide insight into the extent Salmonellosis of program development. A 1981 survey of Utah Ecoli0157:H7colitis LTCFs113 noted that all facilities had regular infection Otherinfections: control meetings, but none performed systematic sur- Methicillin-resistantStaphylococcusaureus(MRSA) Vancomycin-resistantEnterococcus(VRE) veillance for infections or conducted regular infection GroupAStreptococcus control training. All LTCFs had policies regarding the Scabies maintenance and care of urinary catheters, although Conjunctivitis the policies were not uniform. Price et al149 surveyed 12 North Carolina LTCFs in 1985 and found that, although all 12 had a designated ICP, none of the ICPs had received special training in this area. Also Theseoutbreaksunderscorethevulnerabilityofthe noted were deficiencies in isolation facilities, particu- elderlytoinfection,aswellastheroleofcrossinfection larly an insufficient numberof sinks and recirculated, inresidentswithurinarycathetersandopenwoundsor inadequately filteredair. in those with incontinence who require serial contact In a 1985 survey of Minnesota LTCFs, Crossley care by staff.120 In addition, mobile residents with etal150foundthatthemajorityhadaninfectioncontrol poor hygienemayinteractdirectly. committee (ICC) and a designated ICP, although sub- stantial deficiencies in resident and employee health programs occurred. For instance, only 61% offered Antibiotic-resistant bacteria the influenza vaccine to residents, and one third did Multidrug resistant organisms (MDROs) such as not screen new employees for a history of infectious MRSA, vancomycin-resistant enterococci (VRE), drug- disease problems. A 1988 Maryland survey151 found resistant S pneumoniae, and multidrug-resistant gram- thatonethirdofnursinghomesstillperformedroutine negative bacteria (eg, Pseudomonas aeruginosa, environmentalcultures,andmanylackedproperisola- Acinetobactersppandextended-spectrumb-lactamase tion policies. In 1990, a survey of Connecticut LTCFs (ESBL)-producing enterobacteriaceae) are increasingly found that most ICPs had received some training in important causes of colonization and infection in infectioncontrol.152,153MostLTCFsperformedsurveil- LTCFs.128-137 In this setting, infection with MDROs lanceatleastweekly,andmostusedwrittencriteriato has been associated with increased morbidity, mortal- determine HAIs. ity,andcost,138,139althoughtheattributablemorbidity, MorerecentregionalsurveysoffacilitiesfromMary- mortality, and cost of MDROs has not yet been fully landandNewEnglandinthemid-1990sandMichigan defined. Indeed, LTCF residence has been frequently in 2005 noted increasing gains in time spent in infec- identified as a risk factor forantibiotic-resistant infec- tion controlactivities from1994 to2005.69,154 In New tion in hospitalized patients.140,141 England, 98% of facilities had a person designated to Elderly and disabled residents are at increased risk do infection control, 90% were registered nurses, and for colonization with resistant organisms, and coloni- 52% had formal training.154 In the 1990s, an average zationmaypersistforlongperiodsoftime(ie,months of9to12hoursperweekwasspentoninfectioncon- to years).133,142-146 Within the LTCF, length of stay in trol;50%to54%ofthattimewasspentonsurveillance thefacilityandaccommodationinroomswithmultiple activities.154Seventy-eightto97%percentoftheLTCFs beds have been identified as risk factors for transmis- reported a systematic surveillance system.69 Formal sionofMRSA.147Bothinfectedandcolonizedresidents definitions were used by 95% of respondents; 81% may serve as sources for the spread of MDROs in the usedtheMcGeercriteria,and59%calculatedinfection LTCF.135,148 When MRSA becomes endemic within rates.154AllfacilitiesreportedlyusedUniversalPrecau- a facility, elimination is highly unlikely.148 LTCFs can tionsin caringfortheir residents.154 expectinfectionswithMDROstobeacontinuingprob- By 2005, 50% of responding facilities in Michigan lem. Strategies for curbing the emergence and spread hadafull-timeICP.69Themeantimespentoninfection 512 Vol. 36 No. 7 Smith et al control activities by the infection control staff varied andtransmissionofdiseaseandinfection.Interpretive from 40hours per week forfull-time ICPs to 15hours guidelines for surveyors further discuss definitions of per week for part-time staff.69 However, part-time infection, risk assessment, outbreak management and ICPs did not necessarily supervise smaller facilities control, measures for preventing specific infections, withfewersubacutecarebedsorgivefewerin-services staff orientation, antibiotic monitoring, sanitation, than full-timestaff. and assessment of compliance with infection control Despitetheseimprovements,thenumberofICPsper policies.161 nursing home bed is 4-fold fewer than the number of Because the LTCF is an employer of health care ICPs available in acute care hospitals.155 LTCF-based workers (HCWs), it must comply with federal and/or ICPs are more likely to assume noninfection control state OSHA regulations. For infection control, those functions than acute care ICPs regardless of bed size; regulations162,163 deal primarily with protection of in one survey, 98% of LTCF ICPs had other duties,156 workers from exposure to bloodborne pathogens while in a Michigan survey, 50% of 34 LTCFs had full- such as HIV, hepatitis B virus (HBV), and hepatitis C time ICPs.69 Many of these noninfection control func- virus (HCV) and from TB exposure.85 Adherence of tions include employee health, staff education and LTCFs to infection control regulations is an OSHA development,andqualityimprovement.155Inaddition, priority. LTCF ICPs are still less likely to receive additional for- OtherstandardsthatapplytoLTCFsincludethefed- mal training in infection control (8%) compared with eral minimum requirements for design, construction, 95% of acute care ICPs.155 The results of this study and equipment164 and TJC LTC Standards.165 The from Maryland led to a state proposal that at least 2007 TJC Standards forLTC require a written infection oneICPfromeachLTCFbeformallytrainedininfection controlplanbasedonanassessmentofrisk;establish- control.155 mentofpriorities,goals,andstrategies;andanevalua- From these surveys, one can develop a composite tion of the effectiveness of the interventions. The pictureoftheLTCFICPasanursewhostillhasnotnec- Standards also deal with managing an influx of essarily received formal training in infection con- patients with an infectious disease as well as leader- trol.154,155 Many ICPs still work part-time on infection ship’s involvement in the program.165 In addition, control activities regardless of the number of beds or many states have statutory requirements for LTCFs patient acuity.69,155 While the time spent on infection that varywidely. control activities appears to have increased signifi- On October 7, 2005, CMS published a final rule cantly from 36 to 48hours per month in the 1990s to requiring LTCFs to offer annually to each resident 90 to160hoursper month in2005, the ICPcontinues immunization against influenza and to offer lifetime tohaveotherdutiessuchasgeneraldutynursing,nurs- immunization against pneumococcal disease. LTCFs ing supervision, in-service education, employee arerequiredtoensurethateachresidentorlegalrepre- health,and qualityassurance.34,69,154 sentativereceiveeducationonthebenefitsandpoten- tial side effects of the immunizations prior to their being administered.58 The LTCF administrative staff Regulatory aspects should be knowledgeable about the federal, state, and LTCFsarecoveredbyfederalandstateregulationsas local regulations governing infection control in order wellasvoluntaryagencystandardssuchasthosewrit- to implement and maintain a program in compliance ten by The Joint Commission (TJC).157 Skilled nursing with these regulations. The LTCF ICP ideally should facilitiesarerequiredbytheOmnibusBudgetReconcil- be involved in the formation and revision of regula- iation Actof1987 (OBRA)tohave an infectioncontrol tions, through local and national infection control program.158 CMS has published requirements for and long-term care organizations, to help assure the LTCFs159 that apply to LTCFs accepting Medicare and/ scientific validityof the regulations. or Medicaid residents. CMS regulations address the Experts in infection control in Canada have called need for a comprehensive infection control program for 1 full-time formally trained ICP per 150 to that includes surveillance of infections; implementa- 250 long-term beds.166 The Consensus Panel from tionofmethodsforpreventingthespreadofinfections SHEAandAPIChasrecommendedthatnonhospitalfa- including use of appropriate isolation measures, cilities including LTCFs provide adequate resources in employee health protocols, hand hygiene practices; terms of personnel, education, and materials to ICPs and appropriate handling, processing, and storage of to fulfill their functions.167 While most of the current linens.160,161Forexample,theLTCFisrequiredtoestab- information has been derived from facilities serving lish and maintain an infection control program olderpopulationsinNorthAmerica,reportsfromLTCFs designed to provide a safe, sanitary, and comfortable in Europe and Australia and those serving pediatric environment and to help prevent the development populations areincreasing.168-171 Smith et al September 2008 513 Table 2. Long-term care facility infection control program: structure Leadership Expertise/training Role(s) InfectionControlCommittee/OversightCommittee Coremembers Administration,NursingRepresentative,MedicalDirector,ICP Identifiesareasofrisk Establishespriorities Adhocmembers Food Service, Maintenance, Housekeeping, Laundry Services, Plansstrategiestoachievegoals ClinicalServices,ResidentActivities,EmployeeHealth Implementsplans Developspolicies/procedures Allocatesresources Assessesprogramefficacyatleastannually InfectionControlProfessional ICP Qualificationviaeducation,experience,certification Surveillance Datacollectionandanalysis Implementationofpolicies,procedures Education Reportingtooversightgroup/ICC Communicationtopublichealth Communicationtootheragencies Communicationtootherfacilities Infection control program elements improvement. The number of LTCF beds justifying a full-time ICP is unknown and usually depends on the The structure and components of an infection con- acuitylevelofresidentsandthelevelofcareprovided. trolprogramareshowninTables2and3,respectively. ALTCFwithmorethan250to300bedsmayneedafull- Several authors have discussed the components of an time ICP. The LTCF ICP, like the hospital ICP, requires infectioncontrolprogramintheLTCF.34,36,166,167,172-177 specifictrainingininfectioncontrol;well-definedsup- These components generally are drawn from regula- port from administration; and the ability to interact tory requirements, current nursing home practices, tactfully with personnel,physicians, and residents. and extrapolations from hospital programs. The lim- APIC and the Community and Hospital Infection itedresourcesofmostLTCFsaffectthetypeandextent Control Association-Canada (CHICA-Canada) have ofprogramsdeveloped.173Mostauthorsfeelthatanin- developed professional and practice standards for fection control program should include some form of infectioncontrolandepidemiologythataddresseduca- surveillance for infections, an epidemic control tionincludingqualificationsandprofessionaldevelop- program, education of employees in infection control mentfortheICP.178Thesestandardsmaynotrepresent methods, policy and procedure formation and review, the current education and qualifications of ICPs in an employee health program, a resident health manyLTCFs,buttheyserveasabenchmarkforwhich program, and monitoring of resident care practices. LTC ICPs and their facilities canstrive. Theprogramalsomaybeinvolvedinqualityimprove- Thequalificationsinclude3criteriaforenteringthe ment, patient safety, environmental review, antibiotic profession. The ICP: monitoring, product review and evaluation, litigation prevention, resident safety, preparedness planning, d Has knowledge and experience in areas of resident and reportingofdiseases topublichealth authorities. care practices, microbiology, asepsis, disinfection/ sterilization, adult education, infectious diseases, The ICP communication, program administration, and epidemiology; AnICPisanessentialcomponentofaneffectivein- d has a baccalaureate degree (the minimum educa- fection control program and is the person designated tionalpreparation forthe role); and by the facility to be responsible for infection control d attends a basic infection control training course (see Table 2), The ICP usually is a staff nurse, a back- within the first yearofentering the profession. ground that is helpful for resident assessment and chart review. The ICP most commonly is a registered The criteria for professional development include nurse. Because of size and staffing limitations, the the ICP maintaining current knowledge and skills in vast majority of LTCF ICPs have other duties, such as theareaofinfectionprevention,control,andepidemi- assistant director of nursing, charge nurse, in-service ology.Theprofessionaldevelopmentstandardsinclude coordinator, employee health, or performance 5 criteria. The ICP:

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