Implementing Long-Term Care Infection Control Guidelines Into Practice: A Case-Based Approach
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Infections result in significant morbidity and mortality among residents of long-term care facilities (LTCFs). The prevalence of antimicrobial-resistant organisms is increasing along with the medical complexity of residents in this setting. However, given the heterogeneity of LTCFs and diversity of residents, the management and prevention of infections and antimicrobial resistance is often not straightforward. In addition, infection prevention methods must be balanced with other clinical goals and the optimization of residents’ functional status, comfort, and quality of life. This article aims to
apply the Society for Healthcare Epidemiology of America (SHEA) and Association for Professionals in Infection Control and Epidemiology (APIC) guidelines to real-world scenarios using a case-based approach and present key points for wider dissemination to clinical practitioners. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[2]:28-33)
Introduction
More and more often, healthcare in the United States is delivered outside of the acute care setting. Today, outpatient clinics, ambulatory surgical centers, rehabilitation units, and long-term care facilities (LTCFs) are sites of care that continue to grow in importance.1,2 Not unexpectedly, infection rates also are increasing at these ancillary sites. Approximately 1.5-2 million infections occur each year in LTCFs, a rate that is similar to acute care hospitals. Infections among LTCF residents are associated with increased mortality and morbidity, and frequently result in transfers to acute care hospitals. Hospitalization of older adults can result in serious adverse consequences including delirium, pressure ulcers, adverse drug events, decline in functional status, and the acquisition of antimicrobial-resistant infections.3
Many infections in LTCFs are caused by multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacilli (R-GNB). For every older adult infected with an MDRO, many more are asymptomatically colonized with these organisms.3,4 These asymptomatic carriers are at increased risk of symptomatic infections. Perhaps even more important, carriers serve as reservoirs for MDRO transmission within LTCFs, as well as in acute care hospitals.
The LTCF environment presents unique challenges to implementing an effective infection prevention program. Most notably, LTCF residents are a highly vulnerable population with enhanced susceptibility to infections, in large part due to an increased prevalence of underlying risk factors. These factors include the presence of multiple comorbid conditions, an increased severity of illness, functional and cognitive impairment (predisposing to aspiration and pressure ulcers), incontinence and resultant need for indwelling catheter use, and the institutional environment itself.3 Most infections found among these residents are thought to be endogenous in nature, often resulting from the resident’s own flora. The high level of medical complexity frequently results in polypharmacy and the need for urgent transfers to the acute care hospital. The combination of these factors results in a vulnerable resident highly prone to infections and subsequent transmission of resistant pathogens. Compounding these host factors are suboptimal full-time equivalents for registered nurses, nursing aides, and therapists, along with high staff turnover. Despite these challenges, significant progress has been made in the past two decades to advance research and inform policy in this area.
The Society for Healthcare Epidemiology of America (SHEA) and Association for Professionals in Infection Control and Epidemiology (APIC) recently updated their LTC infection prevention guidelines.1,2 Too often, guidelines are written but not translated to clinical practice.
1. Smith PW, Bennett G, Bradley S, et al; SHEA/APIC guideline: Infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol 2008;29:785-814.
2. Smith PW, Bennett G, Bradley S, et al; Society for Healthcare Epidemiology of America (SHEA); Association for Professionals in Infection Control and Epidemiology (APIC). SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. Am J Infect Control 2008;36:504-535.
3. Mody L. Infection control issues in older adults. Clin Geriatr Med 2007;23:499-514, vi.
4. Pop-Vicas A, Mitchell SL, Kandel R, et al. Multidrug-resistant gram-negative bacteria in a long-term care facility: Prevalence and risk factors. J Am Geriatr Soc 2008;56:1276-1280. Published Online: June 28, 2008.
5. Heffner JE, Alberts WM, Irwin R, Wunderink R. Translating guidelines into clinical practice : Recommendations to the American College of Chest Physicians. Chest 2000;118(2 suppl):70S-73S.
6. Stevenson KB, Moore J, Colwell H, Sleeper B. Standardized infection surveillance in long-term care: Interfacility comparisons from a regional cohort of facilities. Infect Control Hosp Epidemiol 2005;26:231-238.
7. Boscia JA, Abrutyn E, Kaye D. Asymptomatic bacteriuria in elderly persons: Treat or do not treat? Ann Intern Med 1987;106:764-766.
8. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987;83:27-33.
9. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:1-7.
10. High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:149-171.
11. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: Results of a consensus conference. Infect Control Hosp Epidemiol 2001;22:120-124.
12. Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:2058-2064.
13. Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis. 2002;35:1205-1211.
14. Naughton BJ, Mylotte JM, Tayara A. Outcome of nursing home-acquired pneumonia: Derivation and application of a practical model to predict 30 day mortality. J Am Geriatr Soc 2000;48:1292-1299.
15. Marrie TJ. Pneumonia in the long-term-care facility. Infect Control Hosp Epidemiol 2002;23:159-164.
16. Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR Recomm Rep 1997;46:1-79.
17. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 1997;46(RR-8):1-24.
18. Watson L, Wilson BJ, Waugh N. Pneumococcal polysaccharide vaccine: A systematic review of clinical effectiveness in adults. Vaccine 2002;20:2166-2173.
19. Ammerlaan HS, Kluytmans JA, Wertheim HF, et al. Eradication of methicillin-resistant Staphylococcus aureus carriage: A systematic review. Clin Infect Dis 2009;48:922-930.
20. Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: Expanding the armamentarium for infection control and prevention. Clin Infect Dis 2008;46:274-281.
21. Mody L, Kauffman CA, McNeil SA, et al. Mupirocin-based decolonization of Staphylococcus aureus carriers in residents of 2 long-term care facilities: A randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003;37:1467-1474.
22. Robicsek A, Beaumont JL, Thomson RB Jr, et al. Topical therapy for methicillin-resistant Staphylococcus aureus colonization: Impact on infection risk. Infect Control Hosp Epidemiol 2009;30:623-632.
23. McConeghy KW, Mikolich DJ, LaPlante KL. Agents for the decolonization of methicillin-resistant Staphylococcus aureus. Pharmacotherapy 2009;29:263-280.
24. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality [published correction appears in N Engl J Med 2006;354(20):2200]. N Engl J Med 2005;353:2442-2449. Published Online: December 1, 2005.
25. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006;12:409-415.
26. Simor AE, Bradley SF, Strausbaugh LJ, et al; SHEA Long-Term-Care Committee. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002;23:696-703.
27. Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S81-92.
28. Lautenbach E, Woeltje K, eds. Practical Handbook for Healthcare Epidemiologists. 2nd ed. Thorofare, NJ: Slack Incorporated; 2004.
29. Mayhall CG, ed. Hospital Epidemiology and Infection Control. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
30. Yoshikawa TT, Ouslander JG, eds. Infection Management for Geriatrics in Long-Term Care Facilities. 2nd ed. New York, NY: Informa HealthCare; 2006.
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