Definitions of infection for surveillance in long-term care facilities

Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Association for Professionals in Infection Control and Epidemiology and Society for Healthcare Epidemiology of America

In 1997 the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in out-of-hospital settings. The following report represents the Consensus Panel's best assessment of requirements for a healthy and effective out-of-hospital-based infection control and epidemiology program. The recommendations fall into 5 categories: managing critical data and information; developing and recommending policies and procedures; intervening directly to prevent infections; educating and training of health care workers, patients, and nonmedical caregivers; and resources. The Consensus Panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee.

Prevention of influenza in long-term-care facilities. Long-Term-Care Committee of the Society for Healthcare Epidemiology of America

Influenza is a frequent cause of epidemic and endemic respiratory illness in long-term-care facilities (LTCFs), resulting in considerable morbidity and mortality. Detection of influenza outbreaks in this setting can be difficult, because the clinical presentation in older adults is atypical and other pathogens also cause influenza-like illness (ILI) during the influenza season. Use of the standard case definition for influenza has not been effective in detecting episodes in residents of LTCFs. Alternative case-definitions that reflect the atypical presentation of influenza in this population have been recommended but not validated. The use of rapid tests for the detection of influenza in conjunction with more sensitive case definitions of ILI may lead to the earlier detection of influenza outbreaks in LTCFs, earlier initiation of infection control measures, and reduction in transmission. The definition of outbreak, eg, the number of episodes of ILI or episodes of confirmed influenza A that would result in the initiation of antiviral chemoprophylaxis, remains controversial in this setting. The use of newer antivirals could limit the side effects seen in older adults in LTCFs. However, annual vaccination of residents and staff remains the most effective way to prevent the introduction of influenza A or influenza B into LTCFs. In addition, vaccination of LTCF residents reduces rates of illness and pneumonia due to influenza, as well as cardiopulmonary exacerbation, hospitalization, and death.

Nursing home-acquired pneumonia

Nursing Home-Acquired Pneumonia is a significant infection that is often seen in the long-term care setting. It is associated with substantial morbidity, healthcare expenditure, and mortality rates as high as 44%. Uniform diagnosis and therapeutic strategies have not been specifically established for pneumonia in the nursing home setting. This paper will update the long-term care provider with the unique features and challenges of pneumonia in this setting and review the approaches to the diagnosis and treatment of this important illness. The discussion will conclude with details regarding overall prevention of nursing home-acquired pneumonia and the critical role played by the nursing home medical director in this process.

Influenza vaccination in long-term-care facilities: structuring programs for success

OBJECTIVES

To determine which influenza vaccination program characteristics were associated with high resident vaccination rates in Canadian long-term-care facilities (LTCFs).

DESIGN

A cross-sectional survey consisting of a mailed questionnaire conducted in spring 1991.

PARTICIPANTS

All 1,520 Canadian LTCFs for the elderly with at least 25 beds.

RESULTS

The mean overall influenza vaccination rate in the 1,270 (84%) responding facilities was 79%. In multivariate analysis, the variables significantly associated with increased vaccination rates were: a single nonphysician staff person organizing the program, having more program aspects covered by written policies, the offering of vaccine to all residents, a policy of obtaining consent on admission that was durable for future years rather than repeating consent annually, and automatically administering vaccine to residents whose guardians could not be contacted for consent. Any encouragement to staff to be vaccinated had a significant impact on staff vaccination rates.

CONCLUSION

Well-organized influenza vaccination programs increase the influenza vaccination rates of residents in Canadian LTCFs. Facilities need to develop resident vaccination programs further and to focus on vaccinating staff.

Infected pressure ulcers in the long-term-care facility

Pressure ulcers occur with some frequency in the elderly, debilitated population in long-term-care facilities. Pressure ulcers cause morbidity and mortality and, by virtue of breaking the integumentary barrier, predispose to skin and soft-tissue infections. The latter often are deep and require lengthy medical and surgical therapy. Prevention depends on avoidance of pressure, as well as providing adequate nutrition and meticulous skin care.

Two nursing home outbreaks of respiratory infection with Legionella sainthelensi

OBJECTIVE

To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection.

DESIGN

Descriptive epidemiology and a case-control study.

SETTING

Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994.

SUBJECTS

Case-residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control-residents were defined as those who were in the homes during the outbreaks and were asymptomatic.

MEASUREMENTS

Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X-rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case-control study was done to assess possible risk factors for legionellosis.

RESULTS

Twenty-nine cases -- 17 in nursing home A; 12 in nursing home B - were identified. Four (14%) case-residents had documented pneumonia and four case-residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0-5.3)), eating pureed food (OR 4.6 (95% CI, 1.6-12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0-5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2-.9)) or to eat solid food (OR .3, (95% CI, .1-.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6-13.0, P = .01)).

CONCLUSION

This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes.

Regional data set of infection rates for long-term care facilities: description of a valuable benchmarking tool

BACKGROUND

Surveillance for nosocomial infections has been clearly established as a key element of all infection control programs. Surveillance programs in long-term care facilities (LTCFs) have been described, but published infection rates vary widely depending on the type of facility studied, nature of resident population, definitions used for LTCF-acquired infections, and type of data analysis. The aim of this initial study was to create a standardized regional data set of infection rates that could provide an external benchmark for interfacility comparison.

METHODS

The study included 6 LTCFs in close geographic proximity with similar patient populations. Surveillance in each facility was conducted by a licensed nurse supervised by an infectious diseases physician. Standard definitions for infections and uniform reporting forms were used. Data were pooled in an aggregate cumulative fashion, and data analysis was patterned after the National Nosocomial Infection Surveillance System.

RESULTS

The data set consisted of 328,065 resident-days of care during 30 months, with a total of 1252 infections for a pooled mean rate of 3.82 infections per 1000 resident-days of care. Infections for specific categories were 496 urinary tract infections (rate 1.51), 376 respiratory tract infections (rate 1.15), 88 gastroenteritis infections (rate 0.27), 283 skin and soft tissue infections (rate 0.86), 2 bloodstream infections (rate 0.06), and 3 unexplained febrile illnesses (rate 0. 09). Data analysis for comparison included interfacility means +/-2 standard deviations and percentiles of distribution.

CONCLUSIONS

A regional data set of infection rates for LTCFs allowed for meaningful interfacility comparison of overall and specific endemic rates and is a valuable benchmarking tool for participating facilities.

Infection control programs in skilled nursing long-term care facilities: an assessment, 1995

BACKGROUND

In 1989 the Health Care Financing Administration mandated that long-term care facilities (LTCFs) maintain infection control programs; however, few data are available to guide the design of these programs. The purpose of this study was to assess the current status of infection control programs in LTCFs by using methodology adapted from Phase I of the Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control.

METHODS

A descriptive study of infection control programs in skilled nursing LTCFs was undertaken in a representative sample of 136 New England skilled nursing LTCFs that have >/=25 beds, with use of a self-report Infection Surveillance and Control Questionnaire.

RESULTS

Nearly all (98%) the LTCFs reported having personnel responsible for infection control, with a median of 8 hours per week spent on infection control activities. Ninety percent of these persons were registered nurses; 52% had formal training in infection control. Twenty-five percent of the respondents reported that their infection control program was either "inactive" or nonexistent in 1988, and 60% rated their programs as either "moderately active" (43%) or "very active" (17%) during that year. By 1994, most LTCFs (67%) rated themselves as "very active," and only 3% as inactive or nonexistent. The mean scores on the questionnaire's surveillance and control indices were 23 (out of a possible 30) and 47 (out of a possible 60), respectively, which indicates medium infection surveillance and control activity. On the basis of the data provided by 72% of the respondents (n = 98), a crude estimate of 13.97 infections per 1000 resident-days was calculated, which is a higher rate than previously reported for LTCFs.

CONCLUSIONS

Findings from the study indicate that it is feasible to use methodology adapted from Phase I of the Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control to assess infection control programs in LTCFs; however, further research into the efficacy of nosocomial infection control in skilled nursing LTCFs is needed.

Joint Commission standards for long-term care infection control: putting together the process element. Joint Commission on Accreditation of Healthcare Organizations

Infection control in long-term care is being recognized more and more as the essential entity it has always been. As a surveyor for the long-term care program of the Joint Commission on Accreditation of Healthcare Organizations, I have noted that some confusion exists in the field as to what aspects of an infection control program are to be surveyed at specific standards. The standards are designed to allow flexibility to ensure that infection control programs meet the specific needs of the resident population and that these programs can continue to evolve. This article attempts to provide some clarity for the infection control professionals who are preparing for Joint Commission survey.

Antimicrobial prescribing in long-term care facilities: prospective evaluation of potential antimicrobial use and cost indicators

BACKGROUND

Few studies exist regarding methods of monitoring antimicrobial prescribing in the long-term care setting.

METHODS

Data were collected monthly in 4 long-term care facilities (LTCFs) for 20 to 26 months. The data included incidence (No. of antimicrobial courses started per 1000 resident care days) of antimicrobial use, antimicrobial utilization ratio (ratio of the number of antimicrobial-days to the number of resident care days), cost of antimicrobial-day, and cost of therapy per resident care day. In one facility, physician-specific data were also collected.

RESULTS

Seasonal variation in the incidence of antimicrobial use was identified, with the highest rates occurring in the winter months. Significant differences in the mean incidence of antimicrobial use, mean antimicrobial utilization ratio, mean cost per antimicrobial-day, and mean cost per resident care day were identified among the 4 LTCFs during the study period. A significant correlation existed between incidence of antimicrobial use or antimicrobial utilization ratio and the overall infection rate or site-specific rates when the data from all 4 LTCFs were aggregated for analysis. Monthly variation in cost per antimicrobial-day was best explained by the monthly variation in prescribing of high-cost (>$15 per day) agents. With these same parameters for use and cost, considerable variation in prescribing and cost of therapy was noted among 7 physicians in the same facility.

CONCLUSIONS

The parameters evaluated detected significant differences in prescribing and cost of antimicrobials among 4 LTCFs. If these findings are verified in larger studies, these parameters may be useful for monitoring trends in prescribing and for interfacility comparisons after adjustment for case-mix differences.

Provider practice patterns in nursing home-acquired pneumonia

OBJECTIVE

To describe provider practice patterns in the diagnosis and treatment of Nursing Home-Acquired Pneumonia (NHAP) and to document associations with cure, mortality, and transfer.

DESIGN

A retrospective cohort.

SETTING

Six nursing homes in Seattle, Washington.

PARTICIPANTS

A total of 94 patients, 65 years of age or older (mean 83 +/- SD 9), in whom the diagnosis of pneumonia was documented in the nursing home medical record between July 1, 1994, and June 6, 1995.

MEASUREMENTS

Multivariate logistic regression was used to assess the relationship between descriptive, diagnostic, or therapeutic measures and three outcomes, cure, 30-day mortality, and hospital transfer.

RESULTS

Ninety-four episodes of pneumonia were identified. Allowing for more than one outcome per patient, there were 71 (75.5%) cures, 16 (17%) deaths, and nine (9.6%) transfers. Eighty-five percent of patients identified as having NHAP by their providers had chest X-rays (CXRs), and 69% had physical examinations. Sputum examination was ordered in 5%, blood cultures in 6%, and white blood cell counts in 33% of patients. In multivariate analysis, patients with functional decline were more likely to die (Odds Ratio (OR) 36.5 (95% CI 6.1, 220)). Cognitive decline was a risk factor for mortality (OR 6.8 l (CI 1.8, 26)) and transfer (OR 7.5 (CI 1.2, 46)). Those patients receiving only oral antibiotics (OR 3.2 (CI 1.1, 9.7)) were more likely to be cured. Length of therapy >1 week was also associated with cure (OR 2.9 (CI 1.0, 8.6)). Providers with Certificate of Added Qualifications (CAQ) in Geriatric Medicine were more likely to achieve cure (OR 3.1 (CI 1.0, 9.0)).

CONCLUSIONS

Most patients with NHAP had diagnostic CXRs and physical examinations. In multivariate analysis, death was more likely to occur in patients with cognitive or functional decline. Cure was associated with the use of oral antibiotics alone and with care by providers with CAQ in Geriatric Medicine.

Infection prevention and control in the long-term-care facility. SHEA Long-Term-Care Committee and APIC Guidelines Committee

More than 1.5 million residents reside in US nursing homes. In recent years, the acuity of illness of nursing home residents has increased. Long-term-care facility residents have a risk of developing nosocomial infection that is similar to acute-care hospital patients. A great deal of information has been published concerning infections in the long-term-care facility, and infection control programs are nearly universal. This position paper reviews the literature on infections and infection control program in the long-term-care facility, covering such topics as tuberculosis, bloodborne pathogens, epidemics, isolation systems, immunization, and antibiotic-resistant bacteria. Recommendations are developed for long-term-care infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation, outbreak control, resident care, and employee health. Infection control resources also are presented.

Surveillance of colonization and infection with Staphylococcus aureus susceptible or resistant to methicillin in a community skilled-nursing facility

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen in acute care hospitals and long-term care facilities. Few studies have been reported in private skilled nursing facilities (SNFs) not experiencing outbreaks of infections caused by MRSA.

METHODS

From a 149-bed SNF with no outbreaks, we report a 1-year prospective surveillance study of S. aureus colonization and infection, with focus on S. aureus phenotypes, both methicillin susceptible (MS) and methicillin resistant (MR). Nasal and stool or rectal screening cultures were done on admission, and all patients underwent screening on at least a quarterly basis for 1 year.

RESULTS

Overall, 35% of patients were colonized at least once with S. aureus, (72% MS, 25% MR, and 3% mixed phenotypes), 94% of the MRSA were ciprofloxacin resistant. Nasal colonization with any S. aureus was more frequent, but 13% of patients had positive results only in rectal specimens. Twenty-one percent of the newly admitted and 15% of continuing patients acquired colonization during their stay in the SNE Colonization was transient or persistent, persisted longer in the nares compared with colonization in rectal specimens, and was more stable for methicillin-susceptible S. aureus. Nine percent of patients had development of infection with S. aureus. There was no indication that MRSA colonization led to more infections than methicillin-susceptible S. aureus. Of the 13 infected patients in whom cultures had previously been obtained, seven (54%) had been colonized by the same phenotype strains.

CONCLUSIONS

In this private SNF, endemic S. aureus infections occur at a low frequency, reflecting a moderate level of colonization with S. aureus. However, a trend showing gradual increases in frequencies of colonization and infection is of concern and suggests that in this SNF, future intervention could become warranted.

Pneumonia in elders

In spite of the availability of potent antibiotics and sophisticated diagnostic techniques, pneumonia continues to be a serious problem among elders. Respiratory infections occur frequently and often are complex. Management is complicated by atypical clinical presentations and altered metabolism of pharmacologic agents. Community-acquired pneumonia and nosocomial pneumonia are caused by different organisms but can have similar clinical presentations. Current therapeutic measures and appropriateness of hospitalization are discussed. Via synthesis and application of this material, nurses can maximize positive outcomes by identifying symptoms, individualizing care, and implementing effective preventive education in the acute care setting, as well as in the community.

Surveillance in acute care and nonacute care settings: current issues and concepts

Infection surveillance programs should be designed to meet the needs of a given health care organization. Opportunities to learn how to design epidemiologically sound surveillance programs are not readily available. This report describes the results of small-group discussions held with infection control professionals from various health care settings. Facilitators coached participants through a series of discussions to generate ideas about scientific surveillance for specific patient populations. Key strategies were identified, and suggestions for surveillance studies were given. Before these strategies can be widely recommended, reports of actual application are needed.

Infections and antibiotic resistance in nursing homes

Infections occur frequently in nursing home residents. The most common infections are pneumonia, urinary tract infection, and skin and soft tissue infection. Aging-associated physiologic and pathologic changes, functional disability, institutionalization, and invasive devices all contribute to the high occurrence of infection. Antimicrobial agent use in nursing homes is intense and usually empiric. All of these factors contribute to the increasing frequency of antimicrobial agent-resistant organisms in nursing homes. Programs that will limit the emergence and impact of antimicrobial resistance and infections in nursing homes need to be developed.

Febrile urinary infection in the institutionalized elderly

PURPOSE

Bacteriuria is common among institutionalized elderly populations, but the contribution of urinary infection to febrile morbidity is unknown because of difficulties in clinical ascertainment. This study was undertaken to febrile morbidity using both clinical and serologic criteria.

METHODS

Episodes of fever in residents of two long-term care institutions were identified prospectively for 2 years. Serum and urine specimens were obtained initially and at 4 weeks. The proportion of episodes attributable to urinary infection was determined by both standard clinical criteria proposed for use in these populations and serum antibody response to uropathogens.

RESULTS

For 372 fewer episodes, 211 met clinical criteria for infection: 147 (40%) of the respiratory tract; 26 (7%) of the genitourinary tract; 25 (6%) of the gastrointestinal tract; and 13 (3%) of skin and soft tissue. Of the remaining 161 fever episodes, 2 (1%) were noninfectious and 159 (43%) were of unknown origin. The prevalence of bacteriuria for residents with nongenitourinary sources of fever varied from 32% to 75%. An antibody response meeting serologic criteria for urinary infection occurred in 26 (8.3%) of 314 episodes with paired sera obtained; 10 (43%) of 23 identified clinically as genitourinary infection, 14 (11%) of 132 unknown, 1 (4%) of 25 gastrointestinal, and 1 (0.8%) of 122 respiratory. The positive predictive value of bacteriuria for febrile urinary infection identified by clinical criteria was was 11% (95% confidence interval [CI] 4%, 18%) and identified by serologic criteria was 12% (95% CI 7%, 17%).

CONCLUSIONS

Urinary infection contributes to less than 10% of episodes of clinically significant fever in this high-prevalence bacteriuric population. A restrictive clinical definition for genitourinary infection has poor sensitivity and specificity compared with serologic criteria for identification of fever of urinary source, and bacteriuria has a low predictive value for identifying febrile urinary infection.

Approach to fever and infection in the nursing home

OBJECTIVE

To summarize current information on the scope, epidemiology, clinical manifestations, diagnostic approach, and general management of infectious diseases in nursing home residents, as well as the specific treatment of common infections occurring in the nursing home setting.

DESIGN

Survey and literature review of the diagnostic and therapeutic problems of nursing home residents with infections.

CONCLUSIONS

Older persons residing in nursing homes as well as other types of long-term care facilities are at increased risk for infections. Moreover, infection is the most frequent reason for patients to be transferred from nursing homes to an acute-care facility. The most common infections that are acquired in nursing homes are urinary tract infection (cystitis pyelonephritis), respiratory infections (pneumonia, bronchitis), and skin/soft tissue infections (infected pressure ulcers, cellulitis). Most serious infections in this setting are caused by bacteria; however, influenza and other respiratory viruses as well as herpes zoster may cause significant morbidity in older nursing home residents. Mycobacterium tuberculosis infects nursing home residents at a higher rate than it infects older community dwellers. Infections in older nursing home residents may manifest clinically, with atypical symptoms and signs, including the absence of fever. Rapid diagnostic evaluation and early therapeutic intervention are essential for minimizing the high mortality and morbidity associated with infections in this older population; most nursing home residents with serious infections should be considered for hospitalization.

Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia

OBJECTIVE

To determine factors associated with success or failure of oral antibiotic treatment for nursing home-acquired pneumonia (NHAP).

DESIGN

Retrospective study of outcomes for all identifiable NHAP cases in 1991.

SETTING

The Nursing Home Services Program of St. Paul Ramsey Medical Center and 31 metropolitan St. Paul, Minnesota, community nursing homes.

PARTICIPANTS

Nursing home (NH) cohort: 124 patients (mean age 85.2 years) with a new respiratory symptom and new infiltrate on portable chest X-ray for whom oral antibiotics were prescribed. Hospital cohort: 74 NH patients (mean age 84.3 years) admitted to hospital with new X-ray infiltrate and pneumonia diagnosis. Supportive care status patients were excluded. Forty-three physician/nurse practitioner (MD/NP) teams were represented.

MEASUREMENTS

Nursing home cohort: Outcomes of hospitalization within 14 days or 30-day mortality. A discriminant model was applied to predict outcome and discriminant rule performance was analyzed. Hospital cohort: 30-day mortality.

RESULTS

Of 198 episodes of NH pneumonia, 63% were treated in the facility; 30.6% (38) failed NH treatment. Thirty-day mortality was 13%. There was no examination by the MD or NP for 59% of NH-treated episodes. The hospital cohort had a higher mean pulse (P < .05) but a similar frequency of feeding dependence. Hospital cohort mortality was 17.6%. The NH treatment failure group had significantly higher proportions of pulse > 90/min, temperature > 100.5 degrees F, respirations > 30/min, feeding dependence, and mechanically altered diets. A discriminant model using these factors was significant (P = .002). The NH treatment failure rate was 11% for no factors present, 23% for two or fewer factors, and 59.5% for three or more (likelihood ratio 3.1). Thirty-two percent of the hospital cohort had zero or one factor present and were alive at 30 days.

CONCLUSION

The majority of NHAP episodes were treated successfully with oral antibiotics, but 31% failed treatment in the NH. Patients with a mechanically altered diet or requiring feeding assistance by staff had significantly higher failure rates. Feeding dependence and need for a mechanically altered diet as well as abnormal vital signs are associated with oral antibiotic treatment failure. These factors should be considered in treatment decisions for NHAP.

Assessment of infection control programs in Maryland skilled-nursing long-term care facilities

BACKGROUND

Nosocomial infections cause substantial morbidity and mortality among residents in long-term care facilities (LTCFs). Although infection control programs now exist in many LTCFs in the United States, little has been published regarding the effectiveness of these programs. The 1976 Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control (SENIC) established the effectiveness of infection control programs in acute care facilities. However, a limitation of that study was the exclusion of LTCFs.

METHODS

The purpose of this pilot study was to assess infection control programs in LTCFs through the use of an Infection Surveillance and Control Questionnaire adapted from SENIC. The sample consisted of 123 skilled-nursing LTCFs in the State of Maryland. The questionnaire was completed by the person responsible for infection control activities in each LTCF.

RESULTS

Results of the study show the following: (1) an upward trend in infection control activity in Maryland LTCFs, with the majority having medium activity, and (2) an estimated overall prevalence rate of infection of 4% on the basis of total resident census.

CONCLUSION

The findings indicated that the Infection Surveillance and Control Questionnaire is a reliable instrument to assess infection control programs in LTCFs. A nationwide study is planned to examine the relationship between infection control activity and the risk of nosocomial infection among skilled-nursing LTCFs throughout the United States.

Infection control programs for long-term care

1. Many infection control concerns are the same for both hospitals and long-term care facilities (LTCFs), but some are unique to LTCFs. The unique concerns seem to be in the area of "caring." 2. The Association for Practitioners in Infection Control (APIC) offers many educational opportunities for infection control practitioners (ICPs) in LTCFs. 3. The APIC Guideline for Infection Prevention and Control in the Long-Term Care Facility and interpretive assistance for implementing the Guideline in a variety of LTCF settings are available for ICPs.

Gross hematuria in residents of long-term-care facilities

PURPOSE

To describe the epidemiology and characteristics of gross hematuria in elderly residents of nursing homes and to identify the associations of gross hematuria with urinary infection and the potential contribution of urinary infection to morbidity.

PATIENTS AND METHODS

This was a prospective, descriptive study of episodes of gross hematuria identified by the nursing staffs at two long-term-care facilities over 2 years. Episodes were characterized with respect to patient variables, presence of bacteriuria, duration of hematuria, therapeutic interventions, and genitourinary investigations. Clinical and serologic criteria were used to identify invasive infection.

RESULTS

The incidence of gross hematuria was 31/100,000 resident days. Bacteriuria was present in 58 (74%) of 78 episodes with evaluable cultures. Fifty-two (61%) episodes lasted more than 24 hours, 25 (29%) were temporally associated with fever, and antimicrobials were given for 53 (61%) episodes. Gross hematuria occurred more frequently in men than in women and was more frequently associated with fever in men. Twenty-four (28%) episodes occurred in subjects with indwelling catheters, 30 (34%) in subjects with known genitourinary abnormalities, 26 (30%) in subjects with no genitourinary investigations, and 4 (4.6%) in subjects with genitourinary investigations but no abnormalities identified. No adverse clinical outcomes were identified in patients in whom antimicrobial therapy was not initiated. The maximal estimated incidence of invasive urinary infection associated with hematuria was 5.8/100,000 resident days, and of bacterial hemorrhagic cystitis, 6.3/100,000 resident days.

CONCLUSIONS

These data suggest that underlying genitourinary abnormalities are present in most elderly institutionalized subjects with gross hematuria when genitourinary investigations are performed. Although bacteriuria is usually present, urinary infection, by itself, is an infrequent cause of gross hematuria. Afebrile hematuria without irritative symptoms probably does not require antimicrobial therapy. A standard approach to this clinical problem in the institutionalized elderly should be developed to optimize patient management and appropriate use of antimicrobial therapy.

Urinary immunoreactive interleukin-1 alpha and interleukin-6 in bacteriuric institutionalized elderly subjects

Urinary immunoreactive interleukin-1 alpha and interleukin-6 levels were measured in specimens obtained from elderly institutionalized subjects, including 67 asymptomatic subjects (51 of whom were bacteriuric), 34 with fever from nonurinary sources, 15 with bacteriuria and 9 with symptomatic urinary infection. For bacteriuric subjects urinary interleukin-1 alpha and interleukin-6 levels were measurable in 18 (35%) and 22 (43%) asymptomatic subjects, respectively, 9 (60%) and 8 (53%) with nonurinary sources of fever, respectively, and 6 (67%) and 7 (78%) with urinary infection, respectively. For subjects without bacteriuria 1 of 16 (6.3%) who were asymptomatic and 5 (25%) with nonurinary sources of fever had measurable urinary interleukin-1 alpha, and 2 (13%) and 1 (5.3%), respectively, had measurable interleukin-6. Presence of interleukin-1 alpha or interleukin-6 was significantly associated with bacteriuria for asymptomatic and symptomatic subjects. Interleukin-1 alpha or interleukin-6 quantitative levels were lower in subjects without than with bacteriuria. Quantitative levels of interleukin-6 tended to decrease for bacteriuric subjects with symptomatic infection between acute and convalescent specimens. These observations suggest that interleukin-1 alpha and interleukin-6 are produced in association with bacteriuria in some elderly subjects. Variation in local cytokine production with time and the clinical significance of these observations require further study.

A retrospective study of nosocomial pneumonia at a long-term care facility

BACKGROUND

Results of a passive surveillance system (pneumonia confirmed by x-ray examination) suggested that in 1989 a total of 187 cases of nosocomial pneumonia had occurred at the Canandaigua Veterans Administration Medical Center among 250 long-term care patients.

METHODS

A retrospective study was undertaken to validate cases and to enumerate risk factors. A chart review showed that 136 of 187 cases (72%) met predetermined criteria for nosocomial pneumonia.

RESULTS

Three nursing units characterized as at high risk had a pneumonia rate of 1.90 per 1000 patient days, as compared with a rate of 0.70 cases per 1000 patient days on the two other units. There were no differences in age, mean white blood cell count, or clinical symptoms between high- and average-risk patients. Two thirds of all patients had a history of chronic aspiration. High-risk patients were more likely to be confined to bed, to have a debilitating neurologic disease, and to require tube feedings. Twenty percent of patients on high-risk units died of nosocomial pneumonia or with nosocomial pneumonia as a contributory factor.

CONCLUSIONS

Facility-associated pneumonia is an important cause of morbidity and mortality in long-term care facilities.

Infections and infection risks in home care settings

OBJECTIVES

To describe the characteristics of home healthcare clients with respect to infection risks and the presence of infections.

DESIGN

Descriptive survey of client charts using a point prevalence design.

SETTING

A private San Francisco, California, Bay area home care agency.

PARTICIPANTS

A random sample of 175 clients (28%) was taken from the active client list for a single day; demographic data and clinical data from the last visit prior to the selection day were collected from each chart.

RESULTS

The clients were predominantly elderly (mean = 68.6) with an average of 3.6 co-morbid conditions; 12% had an invasive device. Over 20% had an infection on the day surveyed. Five percent had an infection that occurred during home care delivery.

CONCLUSIONS

A substantial proportion of home health clients have infections, and they represent persons with a number of the risks associated with infections. Guidelines for defining and monitoring infections in home care need to be developed. Hospital-based surveillance methods are not altogether appropriate in this setting; redesigning methods such as targeted surveillance, monitoring rehospitalization, or immunization practices are discussed as potential ways to measure quality of care in the home setting.

The use of oral fluoroquinolones in nursing home patients

The approach to management of patients with presumed infection in the nursing home is influenced by the limited availability of diagnostic tests and support staff. Although antibiotics are most often prescribed in the absence of laboratory data, many studies indicate that empirical therapy for nursing home infections is relatively successful. With the scrutiny on containment of healthcare costs, therapy of nursing home patients has been changing and will continue to shift toward treatment within nursing homes without transfer to a hospital. Better oral antimicrobial agents with a wide spectrum of activity, such as the fluoroquinolones, will play a major role in the treatment of many infections acquired in the nursing home. Because of the favourable characteristics of the fluoroquinolone agents, they should be useful for elderly patients who develop infections in nursing homes. They have excellent in vitro activity against Gram-negative bacteria which are often multidrug-resistant and are common in nursing home patients. Studies indicate that absorption of orally administered fluoroquinolones is very efficient in the elderly and these drugs are well tolerated. Numerous clinical trials have documented good efficacy of the fluoroquinolones in the treatment of elderly patients for the most common infections in the nursing home, including urinary tract infections, respiratory tract infections and skin infections.

Surveillance and control of infections in long-term care: the Canadian experience

In 1980, the Laboratory Centre for Disease Control, Health Protection Branch, Department of National Health and Welfare Canada, established the Bureau of Infection Control in response to a growing need for an infection control resource at the national level. Until that time, there had been no federal programs in Canada for surveillance and control of infections in health care facilities. Initial efforts in the development of infection control programs focused on acute care facilities. In 1985, a specific need was identified to develop better surveillance and control of infections in long-term care facilities. Several national initiatives have been undertaken to meet this need, including the preparation and publication of an infection control guideline specifically for long-term care facilities, a national survey of Canadian long-term facilities, and the stimulation of research to evaluate new criteria for nosocomial infections in a selected number of Canadian long-term care facilities.

Current status of nosocomial infection control in extended care facilities

The 1980s saw the birth and growth of the distinct field of infection control in the extended care facility (ECF). Major advances in the field during the last decade have been surveys documenting the magnitude of the problem of ECF nosocomial infections, descriptive studies of ECF nosocomial infections, descriptive studies of ECF epidemics, development of ECF infection control programs, and recognition of the unique problems of the ECF infection control program. As the field matures, areas that should receive additional attention during the upcoming decade include: analysis of the risk factors and consequences of ECF nosocomial infections; analysis of resident and institutional variables that predict nosocomial infection; and studies on the efficacy of both infection control programs and specific infection control measures. ECF infection control programs have benefited a great deal from hospital infection control, but ECF infection control problems are quite different and demand unique solutions.