Hospital Infection Control

Nursing home or long-term care facility patients

What specific infection control measures are relevant to nursing homes and long-term care facilities?

Strausbaugh and Joseph have provided estimates of incidence, morbidity, and mortality of infections in the long-term care setting based on studies done in a variety of different settings (individual nursing homes, groups of homes, proprietary homes, and Veterans Affairs nursing homes) (See Table I).

Table I.

Estimates of infection and infection-related mortality in the long-term care facility
Incidence overall days 3-7 infections per 1000 resident care days
Lower respiratory tract infection 0.3-4.7 cases per 1000 resident care days
Urinary tract infection 0.19-2.3 cases per 1000 resident care days
Skin/soft tissue infection 0.1-2.1 cases per 1000 resident care days
Incidence of death related to infection in U.S. nursing homes yearly 0.04-0.71 deaths per 1000 resident care days
Estimated total infection-related deaths in U.S. nursing homes yearly 2,000-388,000

These estimates suggest that nursing home residents are at greater risk of developing infection than people living in the community who are admitted to the hospital. Placed into the congregative setting of the nursing home, elderly, fragile, and debilitated people are not only susceptible to typical endemic infections but also outbreaks of infectious diseases, most notably respiratory and gastrointestinal infection outbreaks.

Regardless of the type of facility, infection prevention and control is an integrated, responsive process that applies to all programs, services, and settings in the organization. It requires collaboration throughout the organization to develop, implement, and evaluate.

The general goals of an infection prevention and control program in the long-term care setting are to:

  • Minimize the risk of infection in individual residents to the extent that it is possible.

  • Reduce the risk of transmission of infectious agents among and between residents and healthcare workers.

  • Reduce risks of infections developing in residents related to the use of devices and procedures required in care.

These goals are achieved through the following methods:

  • Surveillance.

  • Ongoing analysis of surveillance data.

  • Education of staff regarding appropriate infection prevention procedures.

  • Monitoring adherence to infection prevention procedures by all departments and individuals of a facility.

  • Assigning at least one person to be responsible for the co-ordination of infection prevention and control activities and who should be provided with sufficient administrative support and authority to carry out the functions of an infection control co-ordinator.

  • Integrating the infection control program into the facility's quality management/improvement program.

Despite the mandate for maintaining an active infection control program in nursing homes there are multiple issues that limit the proper implementation of an infection control program in this setting that differ substantially from those in the hospital setting:

  • The employee assigned to do infection control has many other responsibilities and this limits the time available for prevention/surveillance activities.

  • There is a lack of training in infection control principles; most have "on the job" training.

  • Infection control is a mandated service but the resources assigned for this activity are limited in most facilities.

  • Diagnostic capability is limited making infection surveillance difficult.

  • The population served by a nursing home varies from people admitted for skilled care who will be discharged in a relatively short time to those who permanently live in the facility; the risk of infection may be quite different between these two groups.

  • Among the long-term care population in a given home the infection risk may vary significantly depending on functional impairment and the amount of care required by staff; this risk has yet to be quantified accurately.

  • There are no national benchmarks for infection incidence in long-term care facilities.

  • Lack of recognition by facility administrators of the importance of infection control.

  • Most of the infection control policies and procedures used in nursing homes are modifications of hospital policies and may not always be applicable; there is a lack of clinical trials to determine effective infection control procedures in the nursing home setting.

What are the conclusions of clinical trials or meta-analyses related to infection control in nursing homes and long-term care facilities?

A small number of prospective and retrospective studies using standardized surveillance definitions have identified considerable variation in incidence of infections between homes.

Variation in incidence of infection has not been adequately explained but it is plausible that it is due, in part, to variation in risk of infection among nursing home residents because of differences in functional status related to underlying co-morbidities. There continues to be difficulty in accounting for this variation in studies of infection in nursing home residents.

What are the consequences of ignoring infection prevention strategies in a nursing home or long-term care facility?

Given a background of mandates, regulations, and limitations, infection control practice tends to be limited in most long-term care facilities to infection surveillance with little effort to analyze data due to lack of expertise and lack of time.

There are policies and procedures for isolation for certain resistant organisms or infections and these are often hospital policies that have been modified for the nursing home setting.

Obvious outbreaks (respiratory and GI) are identified but many outbreaks that occur more insidiously, e.g., respiratory syncytial virus (RSV), may not be identified. However, infection control and prevention in the nursing home setting will likely become a higher priority for administrators if public reporting of infections becomes widespread.

Summary of current controversies.

A major dilemma in the nursing home setting is that it is the home for an individual but at the same time it is the home for many others; one must balance what is good for the individual and what is good for all of the residents at the same time; e.g., one would not isolate a person with an infection in his own home from others in the home as one might do in the hospital setting; this also applies to the nursing home as the home of the resident; on the other hand, there are many vulnerable people in the nursing home who might be at considerable risk if infection spreads from one person to another in the absence of some type of procedure to prevent spread.

Although an all-inclusive program for infection control in a long-term care facility is desirable, the reality is that it is not feasible for most staff providing infection control coverage in a nursing home. There is just not enough time or resources for one person to do all this and do it reasonably well, especially since this person usually has many other duties in the nursing home.

Given that reality one has to develop a program that is feasible yet provides a safe environment for residents, staff, and visitors. This usually means that some of the infection control responsibilities will be shared with other members of the facility staff, e.g., there may be a facility employee who is responsible for employee health and resident health.

Therefore, in terms of feasibility one approach would be to focus on infection control activities that target areas that will be most beneficial to residents, staff, and visitors.

These areas might include surveillance of infection, analysis of infection data, monitoring for resistant organisms, monitoring antibiotic use, establishing and monitoring compliance with infection control policies and procedures, and inclusion of the infection control program in the facility process improvement activities.

Once the "target" focus areas have been determined, the next step is to develop methods to perform the activities in as efficient a manner as possible.

What is the structure and scope of an infection prevention program in a long-term care facility?

The Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) developed separate guidelines for infection control in the long-term care setting. Recently these societies have jointly published a guideline (see SHEA/APIC guideline) that outlines the elements of an infection control program in long-term care as follows:

Structure of the infection control program

  • Infection control committee.

  • Infection control professional (“preventionist”).

Development of infection control policies and procedures:

  • Standard precautions

  • Contact precautions.

  • Droplet precautions.

  • Hand hygiene.

  • Organism-specific precautions (resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended spectrum β-lactamase (ESBL)-producing gram-negative bacilli, scabies, Clostridium difficile).

  • Employee education.

Surveillance for infection

  • Utilize definitions of infection specific to long-term care.

  • Establish the endemic rate of infection overall and for specific infections.

  • Monitor for outbreaks.

  • Monitor occurrence of resistant organisms (MRSA, VRE, ESBL-producing gram-negative bacilli).

Monitoring antibiotic use ("antibiotic stewardship")

General procedures of importance to a facility

  • General maintenance.

  • Food preparation/storage.

  • Laundry and cleaning.

  • Collection and disposal of waste.

  • Disinfection/sanitation.

  • Cleaning of equipment.

Resident health (tuberculosis screening; immunization)

Employee health (tuberculosis screening; immunization; occupational exposures)

Miscellaneous

  • Performance improvement.

  • Resident safety.

  • Preparedness planning, e.g., pandemic influenza planning.

What national and international guidelines exist related to nursing homes or long-term care facilities?

The following outlines the structure and function of an infection prevention program in a long-term care facility or nursing home.

The goal of infection control procedures is to prevent transmission of infectious agents to residents and healthcare workers. These procedures traditionally have been referred to as isolation techniques. The reader is referred to the SHEA/APIC guideline and the Tables (more detail below) for a review of the history of isolation procedures that were first developed by the Centers for Disease Control and Prevention (CDC) in the early 1970s and have evolved considerably in the subsequent 4 decades.

The term “isolation” has been dropped in favor of the term “precautions”. All of the precautions used in the long-term care setting were originally developed in the hospital setting and have been modified to take into consideration the principle that the nursing home is the residents’ home.

The long-term care setting poses unique problems for preventing transmission of infectious agents that need to be considered when developing prevention procedures and policies:

  • Some residents are mobile and may be in contact with other residents frequently; lack of hand hygiene or incontinence is frequent and difficult to control.

  • The long-term care facility is considered the resident’s home.

  • Residents frequently congregate for eating or other activities.

  • Hospitalization of residents may lead to acquisition or transmission of antibiotic resistant organisms (AROs).

  • There are residents who are in the facility short-term for skilled care (rehabilitation) before returning to their usual living situation as well as long-term residents. These two groups may have different risks for infection as well as differences in rates of carriage of resistant organisms.

Precautions

These procedures are the same as in the hospital for the most part except that the use of private rooms is limited in the long-term care setting and policies need to be adjusted for that situation. A complete discussion of these various types of precautions can be found in another section of this site; below is a brief summary.

Standard precautions

The basic principle is that all residents may be colonized with a resistant organism or blood borne pathogen; therefore, the healthcare worker needs to apply this principle in the care of all residents during each interaction.

  • Gloves are to be worn when exposure to body fluids is likely.

  • Hand hygiene is a critical component even if gloves are worn.

  • Masks, eye protection, and gowns should be worn during procedures or patient care activities likely to generate splashes of blood, body fluids, secretions, or excretions or other care activities that may expose the healthcare worker to contamination with one or more of these substances.

  • Care should be taken to avoid sharps injuries.

Contact precautions

For patients with known or suspected epidemiologically important infections or colonization with resistant organisms transmitted by direct or indirect contact with residents or the environment e.g., wound infections, colonization with MRSA, VRE, resistant gram-negative bacilli, RSV infection, skin infections (herpes zoster), C. difficile infection or other types of infectious diarrhea, excessive wound drainage and fecal incontinence:

  • Gloves and gowns must be worn when caring for a resident.

  • Discard personal protective equipment before leaving the room.

  • Hand hygiene is a critical step after care is completed.

  • A private room is also recommended but this is difficult to do in the long-term care setting.

  • Residents may leave their room if the infection site can be covered effectively to minimize contamination.

  • Residents who require skilled care (physical and occupational therapy) represent a challenge; they should continue to receive skilled care either in their room or after other residents have completed therapy; environmental contamination in the therapy area needs to be minimized.

Droplet precautions

Prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain airborne over long distances, special air handling and ventilation are not required. Infectious agents for which droplet precautions are indicated include Bordetella pertussis, influenza virus, adenovirus, rhinovirus, Neisseria meningitides, and group A Streptococcus (for the first 24 hours of antimicrobial therapy).

  • A private room is preferred but is difficult to provide in long-term care settings.

  • Standard precautions apply.

  • Healthcare workers wear a mask (not a respirator) when entering the room and if coming into close contact with the resident who is infectious.

  • Hand hygiene is required after completing care.

  • If the resident needs to leave the room, a mask should be worn by the resident if tolerated.

Hand hygiene

Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings.

This includes hand washing with either plain or antiseptic-containing soap and water, or the use of alcohol-based products (gels, rinses, and foams) that do not require the use of water.

If there is no visible soiling, alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience.

When dealing with C. difficile infection, hand washing with either plain or antiseptic-containing soap and water is recommended over alcohol-based products because spores are not killed by alcohol products; the mechanical action of washing with soap and water washes off the spores.

Effectiveness of hand hygiene can be reduced by the type and length of fingernails; artificial nails or nail extenders should not be worn by healthcare workers who have direct contact with residents.

Policies and procedures for antibiotic resistant organisms

There are two aspects to dealing with resistant organisms in long-term care: (1) monitoring or surveillance (see the section on threshold testing below); and (2) having effective policies to deal with resistant organisms that apply to the long-term care setting.

State regulatory bodies have developed policies for various resistant organisms that are specific to the long-term care setting; the reader should check with their state health department to determine if such policies are available and can be applied to their facility.

Several examples of specific policies are given below along with policy templates that can be utilized by facilities as needed.

The Healthcare Infection Control Practices Advisory Committee (HICPAC) of CDC has published a guideline for “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006” that primarily focuses on the hospital setting but readers will find useful background information on this topic.

SHEA collaborated with HICPAC (2008) and published a position paper on metrics to be used to monitor multidrug-resistant organisms in healthcare facilities; although this document pertains primarily to hospitals, the metrics could be modified for use in long-term care.

Methicillin-resistant Staphylococcus aureus

  • APIC Guide to Elimination of MRSA (2009) in the long-term care facility.

  • MRSA policy for long-term care template - see Table II

  • Surveillance forms for MRSA - see Table III (weekly prevalence) and Table IV (line listing form).

Table II.

MRSA policy for long-term care template

Table III.

Surveillance forms for MRSA: weekly prevalence

Table IV.

Surveillance forms for MRSA: line listing form

Vancomycin-resistant enterococci

  • New York State Department of Health supplemental guideline for care of patients with VRE in hospitals, long-term care facilities, and home care (this provides useful information on which to base a policy for VRE - see NYS DOH Revised 2008)

  • Surveillance forms for VRE - see Table V (weekly prevalence) and Table VI (line listing form)—these forms are similar to the MRSA forms.

Table V.

Surveillance forms for VRE: weekly prevalence

Table VI.

Surveillance forms for VRE: line listing form

ESBL gram-negative bacilli-policy is the same as for VRE as these organisms tend to colonize the GI tract predominately; Standard precautions should suffice much of the time.

See the Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline for “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006”.

Policies and procedures for miscellaneous infections

Similar to resistant organisms, state regulatory agencies have often developed policies to deal with the infections listed below.

Clostridium difficile

  • Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA): this provides an extensive background on this infection including issues related to surveillance, diagnosis, treatment, control, and prevention; it is geared to hospitals primarily but has much useful information.

  • SHEA published a position paper specifically dealing with C. difficile in the long-term care setting in 2002.

  • A CDC work group developed recommendations for surveillance for C. difficile in 2007; this is an important publication in that it attempts to standardize the definitions for surveillance; however, these definitions may not be applicable to long-term care facilities.

  • C. difficile policy for long-term care template - see Table VII.

  • C. difficile line listing form - see Table VIII.

Table VII.

C. difficile policy for long-term care template

Table VIII.

C. difficile line listing form

Tuberculosis

The literature includes:

  • SHEA position paper on tuberculosis (TB) prevention and control in long-term care facilities.

  • In 2005 the CDC published new guidelines for preventing transmission of TB in healthcare settings. This provides an extensive review of the literature, recommendations for TB control, supportive documentation, and references. Some, but not all, of the recommendations are applicable to long-term care. In the long-term care setting the focus is on employees, providers, and volunteers in terms of TB control.

  • TB policy for long-term care template – see Table IX

Table IX.

TB policy for long-term care template

Scabies —see Table X

Table X.

Scabies: Diagnosis and Management in the Long Term Care Facility

Influenza/other respiratory viruses - see Table XI

Table XI.

Influenza/other respiratory viruses - Prevention and Control of Influenza

Shingles - see Table XII

Table XII.

Shingles - Prevention and control in long-term care facilities

Surveillance for infection

A long-term care facility is required by federal law to monitor residents for the presence of infections in order to minimize the occurrence of infection as well as to identify and control outbreaks. Unfortunately, there are no published benchmarks for infection occurrence in long-term care as there has been for hospitals for several decades provided by CDC. However, beginning in 2012 the CDC established a voluntary program for collecting data on infections caused by resistant organisms and C. difficile.

The SHEA/APIC guideline for infection control in long-term care facilities provides a detailed discussion of the common infections and infection outbreaks occurring in this setting and this will not be discussed in this section. The reader is referred to this excellent review for this information.

Infection surveillance in any setting, including the long-term care facility, involves proper collection of infection occurrence, maintaining proper recording of infections, and, most importantly, analysis of infection data in order to identify problems or outbreaks. The SHEA/APIC guideline identified seven components of an infection surveillance program in long-term care:

Assessing the population

This refers to the extent of surveillance that one might conduct in a facility: focused surveillance on an apparent high-risk group for infection or surveillance for the entire facility. In reality, most long-term care facilities are doing surveillance on all residents. The caveat is that facilities often have residents with varying risks of infection as previously mentioned.

For example, residents admitted for skilled care may have a different risk for infection than long-term residents and as a result, rather than combining these two groups for surveillance purposes, it may be more appropriate to collect surveillance data separately on these two groups. This point is not stressed in existing guidelines.

Selection of outcome measures

In most cases this should be site-specific infection rates (urinary tract infection (UTI), pneumonia, upper respiratory tract infection, and C. difficile). Rates should be expressed as the number of new cases per 1000 resident care days per month (incidence).

For resistant organisms one might choose to collect prevalence data, e.g., the number of residents known to be colonized with MRSA, VRE, and ESBL-producing organisms weekly by unit with no denominator.

Surveillance definitions

Definitions of infection specifically designed for use in the long-term care facility were developed by a Canadian consensus committee in the late 1980s and are often referred to as the “McGeer criteria” after the lead author of the group that developed the definitions.

These definitions have two important characteristics that distinguish them from those used in the hospital setting:

  • Diagnostic testing is not required.

  • Physician diagnosis is not required.

Unfortunately, more than 2 decades after these definitions were published and widely adopted they have yet to be validated. In 2010 a committee of experts was convened to revise these definitions. After an extensive review of the literature, the revised definitions were published in 2012. Substantive changes were made only to the definitions for urinary tract infection and respiratory tract infection. Definitions for norovirus and C. difficile infection were added.

Table XIII

Revised McGeer definitions

is a copy of the revised McGeer definitions in a format that is useful for surveillance.

Collecting surveillance data

This is one of the more difficult tasks for the person responsible for infection control in the long-term care setting. Many times the responsible person may be using methods developed in the hospital setting such as reviewing all orders for antibiotics and/or reviewing culture results. These methods are time consuming and many infections in long-term care are likely to be missed because:

  • Cultures are done infrequently except for urine cultures.

  • Physician-documented evidence of infection is often lacking as many times decisions regarding antibiotic therapy are made by phone and after hours.

The following are suggestions for doing infection surveillance:

Identifying new infections:

  • The SHEA/APIC guideline suggests using “walking rounds” to collect data, e.g., weekly, in order to collect data on a timely basis—the argument against this is that it is time consuming.

  • Unit staff collects data on infection occurrence by completing a surveillance form (using the form in Table XIII) when an infection is suspected; these forms can be collected by the infection control professional and reviewed with further evaluation only if there is a question regarding validity. This method saves time and also makes staff an active participant in the infection control program. This also reduces the reliance on physician documentation.

Monitoring prevalence of resistant organisms:

  • The SHEA/APIC guideline does not discuss this in any detail.

  • Monitoring prevalence of resistant organisms on a weekly basis by unit can be done with minimal effort.

  • For example, each unit is responsible for maintaining a weekly count of all residents known to be colonized with MRSA, VRE, or ESBL-producing Escherichia coli or Klebsiella pneumoniae.

  • This count should be done on the same day each week and the information forwarded to the infection control professional.

  • The infection control professional monitors prevalence by completing a form for each of the resistant organisms separately (see Table XIV for a copy of the collection tool for MRSA).

Table XIV.

Collection tool for MRSA

The underlying concept for this type of prevalence surveillance is “colonization pressure”. This concept assumes that the more residents who are colonized or infected with a resistant organism, the more likely transmission will occur, and the greater the risk for infection to develop.

The key issue is defining what level of prevalence is higher than expected (see analysis of surveillance data below).

Analysis of surveillance data

This is the most difficult aspect of surveillance because infection control professionals in the long-term care setting are not instructed how to do it using a method that they can understand and utilize quickly and easily, and that is valid.

The SHEA/APIC guideline does not provide guidance on this issue to any great extent.

Incidence of infection for the common infections should be calculated on a monthly basis using resident care days as the denominator (cases per 1000 resident days).

Prevalence data should be on a weekly basis with no denominator necessary (this assumes that the resident characteristics on a specific unit are not changing significantly over time).

Methods for analysis

One cannot just determine the incidence per month of a given infection or the weekly prevalence of a resistant organism. There must be a method applied that will analyze the data and detect significant changes from baseline over time. Keep in mind that the baseline infection rate is equal to the average and equal to the endemic rate. These terms are interchangeable.

Control charts can be utilized to evaluate surveillance data and are useful and valid. However, this method is based on data entered into computer software to construct control charts. If this is available, it can be quite useful in monitoring trends in infection occurrence or in prevalence of resistant organisms.

Infection control professionals in nursing homes without access to computer software to utilize control charts have another option. There is an approach available that utilizes the principles of control charts but does not require a computer or software and only requires pencil, paper, and a calculator and some additional information.

This method is referred to as “threshold testing” and is described in more detail in the following section.

Threshold testing methodology

The first objective of the threshold testing method is to define the “endemic”, “baseline”, or “average” infection rate.

Each facility has an “endemic” or “baseline” or “average” incidence of infection (number of new infections per 1000 resident care days per month) overall and for each specific infection (e.g., UTI, pneumonia, etc).

Each facility has a baseline prevalence of resistant organisms (e.g., average number of residents colonized with MRSA per week [for the entire facility or by unit]).

The baseline should be determined using data collected for a 1-year period to be valid. An example of how this is done is shown in Table XV.

Table XV.

Calculating the Endemic Rate of Infection
  • Note that there is no denominator.

  • The endemic level is determined by summing the number of monthly occurrences of a specific infection for a calendar year and dividing by 12.

  • To calculate the endemic weekly prevalence of a resistant organism the weekly prevalence is summed up for a calendar year and divided by 52.

A caveat is dealing with an outbreak situation. In Table XV there is an example of how to handle an outbreak in terms of calculating the endemic level. In short, the month (or months) when an outbreak occurred should not be included in summing up the data.

Threshold testing is a statistical method to evaluate infection occurrence as it relates to the endemic level. There are two assumptions underlying the threshold testing method:

  • Resident care days are not changing (therefore, no denominator is required).

  • Case-mix is not variable over time.

Based on these assumptions one can calculate the “threshold level of concern” for a given endemic rate of infection or prevalence of resistant organisms. In other words, how high above the endemic level the rate of infection or prevalence of resistant organisms is before one is concerned that a significant increase has occurred that requires investigation.

Fortunately, these statistical calculations have been done for us and a threshold table is provided in Table XVI.

Table XVI.

Threshold Numbers for Various Endemic Levels of Infection
  • In this table increasing levels of the endemic rate are listed in the first column.

  • The threshold number is listed in the next 3 columns.

  • The threshold number is the number of infections or residents with colonization with a resistant organism expected for a specific endemic level and probability level as calculated from the binomial distribution.

  • For example, at an endemic level of two (infections per month or two residents colonized per week) one would expect with a probability of 10% (0.10) that as many as four infections or residents colonized would occur by chance alone, or with a probability of 5% (0.05) that as many as five infections or residents colonized per week would occur by chance alone in a given month or week, or with a probability of 1% (0.01) that as many as six infections or residents colonized would occur by chance alone.

  • It is recommended to utilize the 0.01 probability column.

  • Therefore, for an infection or colonization prevalence with an endemic level of two per month, the likelihood that six infections per month or residents colonized per week would occur is 1%, a significant increase from the endemic level or baseline, and an investigation is required.

In summary the threshold method consists of the following:

  • Determine the yearly endemic level of each specific infection or prevalence of resistant organism colonization for the facility.

  • The threshold level of concern for each type of infection or prevalence of resistant organism is determined using the probability level = 0 .01.

  • When the threshold level is reached or exceeded in any given month (for infection) or week (for resistant organism), this represents a “significant” event and requires investigation; that is, the likelihood of reaching or exceeding the threshold is 1% or less by chance alone.

  • The infection control professional is responsible for doing an investigation when the threshold is met or exceeded. He/she should submit the findings of the investigation to the administrator and director of nursing. All findings of the investigation should be submitted to the appropriate regulatory agency if required.

  • Threshold levels should be re-evaluated on a yearly basis.

Risk stratification

This refers to variation in risk of infection among residents in a long-term care facility.

Although this concept has biological plausibility, i.e., the more chronically ill or debilitated someone is, the higher the risk of infection, there is presently no method to accurately determine the risk of infection at the individual level or facility level.

It is well known that there is significant variation in incidence of infection when comparisons are made among facilities after standardizing surveillance methods.

Assuming that errors of surveillance are excluded, the variation in infection occurrence may be related to differences in risk for infection among long-term care facilities.

This is an important area for further research and needs to be considered before requiring public reporting of facility infection rates.

Reporting/utilizing surveillance data

Once data analysis is done the findings need to be disseminated/reported to the appropriate individuals in the facility who require this information (administrator and director of nursing) and to the appropriate committees as established in the chain of command for the facility.

Accountability regarding the proper administration of the infection control program ultimately resides with the facility administrator who needs to be kept updated on surveillance data as well as all investigations of excess infection or outbreaks.

Periodic reports to facility staff are also important, especially when an investigation is required.

What other consensus group statements exist and what do key leaders advise?

Antibiotic use in long-term care

SHEA has published 2 position papers about antibiotic use in long-term care that provide an excellent review of the studies done in this regard up to 1999. The general opinion about antibiotic therapy in long-term care based on published studies is that antibiotic therapy in the long-term care setting is often inappropriate.

However, almost all of the studies on which this opinion is based are more than 20 years old and their relevance in the 21st century is debatable. Studies of appropriate antibiotic therapy in the long-term care setting are difficult at best to interpret because of the frequent lack of provider documentation and the lack of cultures or other diagnostic testing. Recent prospective studies have suggested that nearly 50% of antibiotics prescribed in nursing homes are unnecessary.

The SHEA/APIC guideline on infection control in long-term care has a brief section on “Antibiotic Stewardship”, the latest terminology that avoids the use of “inappropriate”.

The guideline recommends approaches used in the hospital setting with regard to antibiotic stewardship.

Minimum criteria for starting antibiotic therapy in the long-term care setting were developed by a panel of experts. A practice guideline for evaluation of fever and infection in residents of long-term care facilities has also been published.

There has been no published evidence that these criteria have had an effect on the prescribing of antibiotics in long-term care.

These criteria were meant to be used as an aide to prescribing antibiotics and not for judging appropriateness of antibiotic therapy.

Because of the concern about excessive antibiotic prescribing in long-term care there has been increased interest and promotion of antibiotic stewardship in this setting. The rationale for antibiotic stewardship in long-term care is as follows:

  1. There is excessive antibiotic use and significant variability in antibiotic prescribing among nursing homes.

  2. There is increasing antibiotic resistance in long-term care.

  3. There is increasing adverse events related to antibiotic prescribing in long-term care including drug reactions and C. difficile infection.

Based on this rationale the goals of antibiotic stewardship in all healthcare facilities are:

  1. To ensure the timely administration of an effective antibiotic regimen to someone [residents] with a disease process that would benefit from such treatment.

  2. To minimize the intensity and duration of antibiotic treatment consistent with effective care.

  3. Mitigate the unintended consequences of antibiotic therapy: C. difficile infection, development of resistance, adverse reactions.

How do you do antibiotic stewardship [AS] in long-term care?

Several studies have been published evaluating various methods to perform AS in LTC; none are practical or sustainable for most facilities based on these reviews.

CDC has published core elements for antibiotic stewardship in long-term care that can be used as a starting point to establish a program. There are seven elements: leadership commitment, accountability, drug expertise, action [includes process and outcome measures], tracking [metrics], reporting, and education. (see CDC core elements).

Two of the most important components of a successful stewardship program are the action and tracking components. It has been suggested that a successful stewardship program must be able to measure antibiotic use to be able to detect a change in use with an intervention and measure an outcome related to the change in antibiotic use.

However, metrics for antibiotic use have not been emphasized in any guideline or publication related to antibiotic stewardship in long-term care. In addition, studies of stewardship programs done in long-term care facilities have not evaluated outcomes of interventions utilized to change prescribing.

There have been several studies of metrics for antibiotic use and cost that are specific for long-term care. A facility should choose one of these metrics for monitoring use.

Another aspect of antibiotic prescribing in long-term care that has been identified as problematic is duration of treatment. In the largest population-based study of antibiotic use in long-term care facilities published to date [2016], 50% of antibiotic courses were found to be > 1 week with no correlation with resident characteristics or type of infection treated in > 600 homes in the province of Ontario, Canada. Therefore, it may be useful to focus on reducing the duration of antibiotic therapy that extends beyond 7 days.

In terms of outcome measures related to interventions to change antibiotic prescribing one should consider monitoring the incidence of C. difficile infection because of its direct relationship to this therapy.

How can the infection control professional apply this information in the individual facility?

The infection control professional will be part of a multidisciplinary group involved with an antibiotic stewardship program in long-term care.

A key member of the stewardship effort is the pharmacy provider for a facility.

Nursing staff is also a key component of the program because they provide initial information about suspected infection to providers. They require education and the ability to communicate accurate clinical information.

In terms of metrics one possible way of collecting data on prescribing would be to have nursing staff document when an antibiotic is started. This metric can be transmitted to the infection control practitioner who can calculate the rate of use as the # antibiotic starts per 1000 resident care days. An alternative metric that has been utilized in several studies is days of therapy per 10,000 resident care days. This latter parameter would require information from the pharmacy provider on days of therapy.

These metrics can be trended for the whole facility, by unit, or by physician.

A caveat is that, if possible, this calculation should be confined to residents on long-term status.

Residents admitted for skilled care (physical and occupational therapy) should be excluded and calculations done separately for this group.

There are no national benchmarks for antibiotic use in the long-term care setting.

The infection control professional can utilize published data as an initial benchmark, e.g. Daneman 2013.

It would also be useful to monitor the proportion of total antibiotic cost for each class of antibiotics on a quarterly basis. For example, a previous study of 11 nursing homes in one region found that about 42% of the total cost of antibiotics during a one year period (2003) was for quinolones followed by 7.5% for nitrofurantoin, 5% for trimethoprim/sulfa, 5% for cephalexin, and 5% for broad-spectrum oral cephalosporins. This information can be used to target interventions for improvement.

Another focus of attention in the long-term care setting has been the diagnosis of urinary tract infection that is complicated by the frequent occurrence of asymptomatic bacteriuria.

How can this information be used to evaluate appropriateness of antibiotic therapy?

Measuring antibiotic use allows one to obtain a quantitative measure that can be monitored over time.

It also allows one to focus on high use areas of a facility, high use antibiotics, or unusual use.

For example, if quinolones represent the most common antibiotics prescribed or represent the highest proportion of the total cost of antibiotics, the focus could be on evaluating documentation of the presence of infection, duration of treatment, and outcome when a quinolone is prescribed.

Feedback to providers is critical in attempting to alter prescribing practices. A caveat in this regard is that family members of residents often pressure physicians to prescribe antibiotics even if the practitioner recognizes that no bacterial infection is present. This is all too often the reason for antibiotic therapy and is difficult to document.

In summary, measuring antibiotic use in the long-term care setting can be done using the methods outlined above. This will likely identify areas of concern that can be focused on by the antibiotic stewardship team.

Antibiotic resistance in long-term care

There has been concern regarding the increase in long-term care residents colonized or infected with antibiotic resistant organisms. CDC has listed the following resistant organisms of concern for long-term care: MRSA, VRE, ESBL-producing E. coli and Klebsiella, multidrug resistant Acinetobacter and Ps. Aeruginosa, and carbapenem-resistant Enterobacteriaceae.

Antibiotic resistance in long-term care settings is most often related to 3 factors. The most important factor is people transferred to a facility from other healthcare facilities who are colonized/infected with a resistant organism.

A second factor is unnecessary or prolonged use of antibiotic therapy in nursing home residents—resistance often is only observed in urine cultures; e.g., quinolone resistance is common in urinary isolates.

A third factor is transmission of resistant organisms from resident-to-resident in a facility. This has not been well-studied and the extent to which this factor is important in the overall problem of resistance in long-term care remains to be determined.

Based on this analysis it is important that staff are well-versed in standard precautions and other precautions as necessary to limit transmission.

In addition, monitoring the longitudinal trend in occurrence of colonization/infection with resistant organisms [as outlined above in the surveillance section] is key to limiting transmission.

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