SHEA/APIC Guideline: Infection prevention and control in the long

32 Pages·2012·0.44 MB·English

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: