It may be difficult or impossible to determine whether an infection is present or, if an infection is present, the site and specific etiologic agent.
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Clinical presentations differ from those in younger, less-impaired populations, because of chronic symptoms of comorbid illness, impaired communication, or aging-associated blunting of the temperature response. Diagnostic tests may not be obtained, because patients cannot cooperate e. When microbiological tests are obtained, the interpretation of positive results is frequently problematic.
Finally, measurements of outcomes and goals of interventions may differ from those in other populations table 2. For example, for permanent residents, length of stay is not a useful measure of effectiveness of an intervention but maintenance of functional status likely is. Mortality will sometimes be a humane outcome, such as in the severely functionally impaired demented person who develops pneumonia [ 8 ].
Thus, infection prevention in the long-term care facility must be viewed within a framework of baseline medical and functional compromise of patients, diagnostic imprecision, and outcome measures relevant to this population.
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The infection-control program is the organizational structure within which infection prevention is standardized and implemented. Over the past 2 decades, there has been substantial progress in the implementation and practice of infection-control programs within long-term care facilities [ 11 , 12 ]. This was driven in part by regulatory requirements [ 11 ] and in part by the increasing appreciation of the frequency of infections in these facilities.
Consensus definitions for surveillance of infection in long-term care facilities have been developed and are widely used [ 14 ]. Guidelines identifying minimal essential criteria for infection control in health care settings outside the acute care hospital, including long-term care facilities, conclude that the fundamental components of surveillance, policy development, employee health, and education are similar for long-term care facilities and for other health care-delivery programs [ 15 ].
There are, however, several differences characterizing infection-control programs in acute and long-term care facilities [ 13 ]. In general, long-term care facilities have fewer resources in personnel, expertise, and diagnostic or support services. Persons responsible for infection control usually have multiple other responsibilities and may not have a level of training equivalent to that of practitioners in acute care facilities.
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Access to computers and secretarial support is limited. On-site laboratory or diagnostic imaging is infrequent, and diagnostic microbiological testing may not be available. There is less access to medical expertise for assessing and monitoring unstable patients because physician reimbursement practices usually restrict the frequency of physician attendance for patients in these facilities. The medical record is less complete and may not be useful for identification of infection.
Finally, a major limitation for infection-control programs in long-term care facilities is the limited evidence to support the effectiveness of such programs or individual components of programs [ 13 ]. Although the Study on the Efficacy of Nosocomial Infection Control SENIC study has documented the effectiveness of infection-control programs in acute care facilities, similar evidence of program benefits to support commitment of resources in the long-term care facility is not available.
In fact, a recent study was unable to show a decrease in endemic infection rates in nursing homes in which a program stressing hand washing, infection-control education, and environmental cleaning was undertaken, compared with rates in nursing homes used as controls [ 16 ]. Thus, there is an important need for further evaluation of infection-control programs in these settings, to ensure optimal effectiveness and cost-efficiency. As mentioned earlier, the major determinants of endemic infection in residents of long-term care facilities are the associated comorbid conditions and impairment of functional status.
For instance, asymptomatic bacteriuria is highly associated with the presence of bowel and bladder incontinence and dementia [ 6 ]. Although it might be feasible to decrease the occurrence of infection by limiting use of condom catheters or chronic indwelling catheters, these devices are appropriate and useful in the care of some patients [ 5 ]. Pneumonia, the only infection contributing significantly to mortality [ 1 ], is associated with poor or deteriorating health status, chronic obstructive lung disease, tracheostomy, and aspiration [ 7 ].
In general, these characteristics are not modifiable, and no studies have yet documented that alternate feeding strategies decrease the frequency or morbidity of pneumonia. Whereas pneumococcal vaccination is recommended for all nursing home residents, the impact of this intervention in altering overall morbidity and mortality in the institutionalized population is still unclear. Colonization and infection with anti-microbial-resistant organisms such as methicillin-resistant S.
Infected pressure ulcers can be prevented by optimal nursing care. However, most residents of long-term care facilities who have pressure ulcers acquire these in other facilities before transfer to long-term care [ 10 ]. Thus, many questions remain about prevention strategies for endemic infection, and the feasibility of prevention of most of these infections is uncertain. Several randomized comparative clinical trials relevant to specific aspects of care of residents of long-term care facilities have been reported [ 18—20 ].
These not only provide information about the specific intervention evaluated but also serve as examples of the feasibility and usefulness of such trials. The role of malnutrition in infection is not well studied in this population, although it is frequently thought that these patients are malnourished and therefore at risk for infection. In one study, a randomized trial of supplementation with vitamin A did not decrease the frequency of infection in a group of residents in a long-term care facility [ 18 ].
Routine changes of gastric or jejunal feeding tubes did not decrease the occurrence of infection, compared with changes as circumstances required. In fact, routine changes were associated with an increased frequency of the feeding tube falling out [ 19 ]. Finally, residents with neurogenic bladders and voiding managed by intermittent catheterization had a similar frequency of urinary infection whether a clean or sterile catheterization technique was used [ 20 ].
Thus, observations from these studies have been uniformly negative with respect to effectiveness of the intervention in preventing endemic infection. Outbreaks of infection are common in long-term care facilities, and a wide variety have been reported table 3 [ 1 ]. The most important organism, in terms of frequency and morbidity, is influenza A virus; gastrointestinal infections caused by Escherichia coli O, Salmonella species, and caliciviruses and skin infestations with scabies are other important and relatively common problems.
Effective outbreak management requires prior planning for an outbreak event, with issues unique to the most common and important pathogens specifically addressed [ 13 , 15 ]. Effective implementation of control programs should limit the occurrence and extent of outbreaks. An important element is ongoing surveillance to support early identification of outbreaks. Because limited laboratory testing is frequently the norm, decision points identifying clinical situations in which laboratory testing must be obtained are essential.
These will vary with the institutional characteristics and resources but should include prompt identification of potential clusters of influenza and other respiratory illness, gastroenteritis, and skin infection. Restrictions in patient activity and visitor restrictions must also be addressed, and considerations relevant to resources, leadership, and authority must be delineated.
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Appropriate liaison with public health personnel and laboratories is essential. All long-term care facilities must have ongoing programs to minimize the impact of influenza epidemics. Key features of these programs include yearly influenza vaccination for both patients and staff, clinical and laboratory surveillance for early identification of potential influenza cases, and guidelines for provision of prophylaxis or treatment of cases once influenza is recognized in the facility.
Both E. In one reported outbreak caused by E. The impact of an outbreak of this magnitude on a facility is substantial. Gastrointestinal outbreaks can be prevented with appropriate food-handling practices and appropriate hand washing and glove use in patient care, particularly with handling contaminated linen and patient excreta. Outbreaks caused by caliciviruses, such as the Norwalk agent, may cause disease in a high proportion of both patients and staff but have been associated with low mortality.
Effective interventions to prevent or limit calicivirus outbreaks are not well established, because the explosive nature suggests transmission by routes other than contact. Policies must identify criteria for specimens from residents with diarrhea or gastroenteritis to be forwarded to the laboratory for stool culture or electron microscopy, so that outbreaks are rapidly identified and interventions promptly initiated.
Scabies outbreaks have repeatedly occurred in long-term care facilities [ 1 ]. A common theme in these outbreaks is failure of early recognition of the index case as scabies.
Both staff members and other residents subsequently become infected. Thus, each facility needs a policy specific for scabies that addresses the diagnosis of rashes, rapid treatment of infected residents, and management of contaminated linen.
A high rate of colonization with antimicrobial-resistant organisms has been reported in many nursing homes. This is not, however, a universal observation, and some nursing homes have not yet experienced this problem. The epidemiology of methicillin-resistant S. Patients generally acquire methicillin-resistant S.
Transmission from resident to resident within the long-term care facility is infrequent, although occasional outbreaks have been described. In the case of methicillin-resistant S. Although methicillin-resistant S. The use of intensive barrier and isolation precautions has not been shown to be more beneficial than gloving or hand washing in limiting the frequency of colonization or infection [ 24 , 25 ].
In selected circumstances, such as a patient with extensive skin lesions colonized with methicillin-resistant S. Most efforts at decolonization of patients infected by methicillin-resistant S.
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Thus, recommendations for general screening or intense isolation for residents colonized with these resistant organisms in the long-term care facility cannot be justified on the basis of current evidence. There is also no evidence to support nonadmission of residents to the long-term care facility on the basis of being colonized or infected by resistant organisms.
In fact, available evidence is consistent with prevention of acquisition in acute care facilities being the most effective strategy to decrease the prevalence of colonization by methicillin-resistant S. Ciprofloxacin-resistant gram-negative organisms are reported to be increasing in frequency in some facilities. In this case, the intensity of use of quinolone antimicrobials in the long-term care facility appears to be an important variable [ 26 ]. Antimicrobial use is an important issue relevant to antimicrobial resistance in long-term care facilities.
There is intense use of antimicrobials in these facilities and, as in any other population, a substantial proportion of this is inappropriate use [ 8 ].
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Many factors drive this inappropriate use. The most important is diagnostic uncertainty, which means that most antibiotic use is empirical. Recommendations for improving antimicrobial use have included development of a formulary and continuing review of anti-microbial use and prevalence of antimicrobial resistance in cultures obtained from patients with suspected infection [ 13 ].
However, to address the large problem of intense antimicrobial use in long-term care facilities, relevant clinical trials that define the utility of diagnostic testing as well as outcomes with different empirical therapies and, in fact, with no antimicrobial therapy are needed. Although recommendations for ongoing monitoring of antimicrobial use in long-term care facilities have been made, the extent to which these have been implemented and their utility are currently unknown. The spectrum of care delivered to patients in long-term care facilities is changing, as it is throughout the health care system.
Some facilities are moving toward a patient mix that may be more consistent with acute care, with patients with multiple invasive devices, including those on respirators, undergoing dialysis, or with central catheters in place.
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