AMDA-Dedicated to Long Term Care Medicine (formerly the American Medical Directors Association) recently updated its “Common Infections in the Long-Term Care Setting Clinical Practice Guideline.”1 Survey organizations consider these guidelines to be a source of authoritative guidance (as well as evidence-based and expert-endorsed) for LTC practitioners and the interdisciplinary team. A more comprehensive discussion on infection prevention and control is available in that publication and a summary is available at the National Guideline Clearinghouse (www.guideline.gov). Electronic or hard copies of the guideline are available from AMDA for a fee.
TRANSMISSION OF INFECTION
Staff, residents and family members need to realize that communal living and consequent “hands-on,” close-contact care facilitates explosive outbreaks of viral pathogens that also sicken staff (norovirus, influenza and other potentially lethal respiratory viruses). This situation also leads to the more gradual transmission of Multidrug-resistant Organisms (MDRO) including Methicillin-resistant Staphylococcus aureus (MRSA) and quinolone-resistant gram-negative bacteria.
Explosive outbreaks require rapid identification and establishment of control measures that, unfortunately, limit resident activities. Clinical outbreaks of gastrointestinal or respiratory illness may manifest on nights or weekends. Weekly tabulation of new cases by the infection preventionist might not always adequately identify explosive outbreaks with high attack rates. Therefore, frontline staff should be trained to rapidly identify these situations, initiate a line listing and report to supervisors. The early application of isolation precautions is a crucial step in containment.
AMDA-Dedicated to Long Term Care Medicine, the professional association of medical directors, attending physicians and others practicing in the long-term care continuum, is dedicated to excellence in patient care and provides education, advocacy, information and professional development to promote the delivery of quality long-term care medicine. For more information, go to www.AMDA.com.
Transmission may also present as a more extended clustering of MDRO/MRSA on a single nursing unit. The identification of clustering in “time and space” requires analysis of a clinical bacteriology database-something that many nursing facility staff may not be trained to analyze. According to the AMDA guideline, while LTC facilities have to maintain records of patients treated for infection, such records are of limited use for the prevention of infection. Aggregate data analysis that provides information about patterns of specific infections within the facility is much more useful. It is this type of analysis that can prompt the facility to modify and improve the control (and prevention) of infections.
Infection prevention is the responsibility of all staff. The infection prevention program should be embedded into all aspects of facility practice with efforts to minimizing effects on resident autonomy. The consistent application of hand hygiene is a cornerstone of prevention, which should be performed by staff between resident contacts and by or for residents when they leave their rooms. The use of alcohol-based hand hygiene products has been associated with lower rates of MRSA.
Facilities are required to prohibit employees with transmissible infectious diseases or infected skin lesions from having direct contact with residents and residents’ food because staff can be the source of outbreaks and lethal resident illness. Implement active screening programs to identify infected staff and visitors, especially during community outbreaks of viral respiratory or gastrointestinal illness. This screening is a foremost component of programs to prevent the introduction of pandemic influenza and other infectious diseases into LTC facilities. In addition, staff should be trained to monitor themselves for signs and symptoms of transmissible infection and to exclude themselves from work, and/or report to employee health or nursing staff for further evaluation.
Standard precautions are the cornerstone of efforts to prevent transmission. Known MDRO carriers are only the “tip of the iceberg” of all carriers. In other words, any resident can be a carrier and as that possibility exists, the intensity of the standard precautions should be based on that possibility. The 2007 CDC [Centers for Disease Control and Prevention] Isolation Guideline recommends gloves (and possibly a gown appropriate to the task) for direct contact with potentially contaminated intact skin regardless of MDRO carrier status (p. 79).2 Residents with potentially contaminated intact skin include those with uncontained secretions or excretions, incontinence and/or poor or absent hygiene. The Isolation Guideline also recommends contact precautions in the presence of uncontained drainage from an abscess or pressure ulcer regardless of MDRO status (pps. 94, 106).2 In many facilities nursing assistants wear gloves/gowns when providing personal hygiene, toileting and incontinence care regardless of MDRO carrier status. These tasks may not only contaminate staff hands but also their forearms and torso.
Universal respiratory hygiene and cough etiquette are also standard. All infectious respiratory secretions should be contained with 3-6 foot “spatial separation,” tissues, or masks. Standard precautions are quite extensive.
True “isolation” with transmission-based precautions (contact, droplet) requires restricting the resident to the room. This can lead to social isolation and interfere with rehabilitation and assessments. Failure to meet the psychosocial needs of an isolated resident can lead to undesirable psychosocial consequences and functional decline for residents in addition to survey violations.
Contact and/or droplet precautions are necessary: (1) during outbreaks such as influenza, viral respiratory infections, and norovirus; and with (2) MDRO-colonized or infected residents implicated in transmission or at high risk to transmit such as a MRSA-infected resident with poor hygiene, uncontained secretions, excretions; or a VRE-infected resident with uncontained diarrhea and/or incontinence. The surveyor guidance states: “Transmission-based precautions are employed for residents who are actively infected with MDRO.” (p. 21)3 The CDC MDRO guideline states: “Consider the individual patient’s clinical situation and prevalence or incidence of MDRO when deciding whether to implement or modify contact precautions in addition to standard precautions for a patient infected or colonized with a target MDRO.” (pps. 37-38) 4 In the case of sporadic MDRO colonization, the level of precautions should be based on an assessment of the staff and resident’s ability to contain secretions during activities, especially out of room.
Full-blown transmission-based precautions are not required for all MDRO carriers. LTC facilities may modify contact precautions for MDRO-colonized residents to allow participation in group activities (pps. 38, 44, 73-4).4 Body fluids and wound drainage must be contained, and the resident must perform good hand hygiene. Covering wounds and open areas, ensuring resident hand hygiene, clean clothes, equipment, supervision, environmental cleaning as well as using gloves and gowns during “contact care” can avoid isolation.
Preventive measures related to transmission via the hands and uniforms of staff, shared equipment, and the environment can be targeted without compromising resident autonomy as these measures involve staff efforts only and require no restrictions on resident activity. Facilities should clearly delineate between nursing and housekeeping tasks for infection control and prevention duties to ensure the tasks are performed when needed to keep tasks from “falling through the cracks.”
All frequently touched surfaces (e.g., handrails, bedrails, doorknobs, faucet handles) and shared equipment (e.g., lifts, blood pressure cuffs) should be decontaminated between resident contacts or on a routine cleaning/disinfecting schedule. During norovirus outbreaks, decontamination of frequently touched surfaces may be required three times per day.
Two studies in the United Kingdom found that staff influenza vaccination programs were associated with a 40% reduction in mortality among residents. Facilities should implement an influenza immunization program for residents, staff and volunteers. Patients and staff should be urged to receive annual immunization. In March 2011, AMDA updated its Immunization Position Statement to read, “AMDA supports a mandatory annual influenza vaccination for every long-term healthcare worker who has direct patient contact unless a medical contraindication or religious objection exists.”
Residents should also be offered immunization against Pneumococcus, diphtheria, tetanus and pertussis (for those under age 65 and in those older than 65 years if they come in close contact with infants). Practitioners should also consider zoster vaccines for individual residents to prevent shingles. Staff who may have contact with blood or bodily fluids containing blood must be offered Hepatitis B vaccination.
USE OF ANTIBIOTICS
It is important to develop specific indications for starting antibiotics rather than starting antibiotics for vague indications. The Loeb minimum criteria for the initiation of antibiotics in residents of LTC may be used as a starting point.5,6 These criteria require signs or symptoms localized to the urinary tract to diagnose urinary tract infections (UTI) in residents without catheters. UTIs are overdiagnosed as a cause of nonspecific status changes such as falls or increased confusion. This leads to unnecessary antibiotic use that will promote the proliferation of MDROs. A resident with a positive urine culture who is eating and drinking poorly because of a bacterial pneumonia or adverse drug reaction may be diagnosed with UTI. Falsely attributing the status change to UTI may result in failure to detect the real problem. For example, a positive urine culture in the absence of urinary symptoms or signs (i.e., new onset dysuria, frequency or urgency) really does not determine whether a resident’s nonspecific status change is caused by a UTI.
Develop protocols to monitor for an evolving condition if no specific indication for antibiotics exists. Protocols could include monitoring intake, change in function, behavior, cognition, pulse oximetry, vital signs and weight. Residents and families might be reassured when antibiotics are withheld knowing that the resident is being formally monitored for an evolving (or change of) condition.
When initiating antibiotic therapy, it is important to obtain cultures, if possible, because of the increased prevalence of MDRO. Cultures should generally be obtained only in the presence of signs or symptoms of infection. LTC staff should not treat on the basis of a culture result if the patient has no clinical signs or symptoms supporting an infection. In the Surveyor Guidance State Operations Manual, there is listed as an example under “Severity Level 3 Considerations: Actual Harm That Is Not Immediate Jeopardy,” a situation in which a facility routinely obtained urine cultures of asymptomatic patients with indwelling catheters and put patients with positive cultures on antibiotics.3 This practice resulted in two patients who acquired antibiotic-related colitis and experienced significant weight loss.
ANALYSIS OF SURVEILLANCE DATA
Facilities should use standard definitions of infection, track events per 1,000 resident days, and specifically track device-associated infections since a significant proportion of these infections are considered to be reasonably preventable. An excess rate of urosepsis in residents with urinary catheters requires review of appropriate catheter indications, aseptic insertion and emptying of collection bags, and prevention of catheter trauma or obstruction.
The surveyor guidance emphasizes analysis of surveillance data to detect trends and patterns and to correct the causes of excessive infection rates and antibiotic resistance. Analysis may include correlating infection rates with the use of hand hygiene products or correlating utilization of a specific antibiotic class with resistance to that antibiotic.
Discourage unnecessary antibiotic utilization by determining if antibiotics are initiated according to preexisting criteria and if appropriate modification occurred following the return of cultures. This should be followed by practitioner feedback. Antibiotic utilization is mentioned four times in the surveyor guidance.
A more complete description of the management of infection is available in the recently updated AMDA “Clinical Practice Guideline: Common Infections.” For more information, go to www.amda.com/infections.
Paul Drinka, MD, CMD, AGSF, is Clinical Professor of Internal Medicine/Geriatrics, University of Wisconsin, Madison, Medical College of Wisconsin, Milwaukee. For more information, email
Jacqueline Vance, RNC, CDONA/LTC, is Director of Clinical Affairs and Industry Relations AMDA-Dedicated to Long Term Care Medicine. For more information, email
firstname.lastname@example.org or visit
Christopher J. Crnich, MD, MS, is Assistant Professor of Medicine, Division of Infectious Diseases, UWSMPH Staff Physician and Hospital Epidemiologist, Middleton VA Hospital. For more information, email
- American Medical Directors Association. Common Infections in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD:AMDA 2011.
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007. Available at: www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.
- State Operations Manual. Appendix PP – Guidance to Surveyors for Long Term Care Facilities. CMS: Interpretive Guidance F-Tag 441. Available at: https://www.cms.gov/manuals/…/som107ap_pp_guidelines_ltcf.pdf
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings. 2006. Centers for Disease Control and Prevention: Atlanta. Available at: www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf.
- 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. Infection Control and Hospital Epidemiology. 2001; 22:120-24.
- Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. British Medical Journal 2005; 331:669-72.
Long-Term Living 2011 June;60(6):22-26
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