Infection control in long-term care

Infections have proven to be one of long-term care’s most troubling problems; a significant source of illness and death, many consequences of infections are far-reaching and costly.¹ Infections account for up to half of all transfers from LTC facilities to hospitals, and result in an estimated 150,000 to 200,000 hospital admissions annually, at an estimated cost of $673 million to $2 billion annually.² When an LTC patient is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40 percent.² The death rate for LTC patients with infections ranges from 0.04 to 0.71 per 1,000 resident days, with pneumonia the leading cause of death.³

Federal regulations require every LTC facility to establish an infection prevention program based on current standards of practice to identify, investigate, control and prevent infections within the facility. Facilities must also designate a person to coordinate infection prevention and control activities in the facility, which may or may not be a trained infection preventionist. Although facilities are no longer federally required to have an infection control committee, some states still require such a committee. Facilities without an infection prevention and control committee still need a process or system in place to address infection prevention needs and analyze surveillance data.

Older adults residing in LTC facilities are particularly prone to developing infection because of factors that result in impaired defenses and increased risk of exposure to microbes. Consistent implementation of a comprehensive infection control program has been shown to reduce rates of infection in LTC facilities.⁴ When treating infections in the LTC setting it is imperative that staff members have defined roles in the treatment process and that facilities have clear procedures in place to effectively treat infections. If antibiotic therapy is being considered as a treatment, cultures should be obtained because of the prevalence of increased antibiotic resistance in the LTC setting. Generally cultures should only be obtained in the presence of signs or symptoms of infection. LTC staff should not treat the symptoms based solely on the culture results, especially if the patient has no clinical signs or symptoms supporting an infection.

Before starting antibiotics, a determination must be made to ensure that the infected patient isn’t treated with antibiotics without a reliable clinical picture. The facility’s medical director should have a process in place to establish minimum criteria for starting antibiotic treatment. Facilities should abide by, with development help from the medical director, specific indications for starting antibiotics.

These indications on when to treat infection with antibiotics are especially important because of the increase in multidisease-resistant organisms. If antibiotic resistance occurs in facilities, a more intense audit of antibiotic use by the infection prevention nurse or the director of nursing service is necessary and should then be shared with the facility’s medical director.

To assist with creating and implementing these important prevention and care plans, the American Medical Directors Association (AMDA) has developed a Clinical Practice Guideline, Common Infections in the Long Term Care Setting. This guideline focuses on management of the four most common sites of infections occurring in the LTC setting: urinary tract, respiratory system, gastrointestinal system and skin. The guideline also discusses infection prevention in LTC facilities.

Jacqueline Vance, RNC, CDONA/LTC is the Director of Clinical Affairs at AMDA—Dedicated to Long Term Care. She can be reached at jvance@amda.com. Perry Gwen Meyers is AMDA’s Marketing & Communications Coordinator. Contact her at pmeyers@amda.com.

AMDA—Dedicated to Long Term Care is the national professional association of medical directors, attending physicians and other professionals practicing LTC medicine and committed to the continuous improvement of patient care. 

REFERENCES

1. Tsan L, Langberg R, Davis C, et al. Nursing home-associated infections in Department of Veterans Affairs community living centers. American Journal of Infection Control 2010;38:461-6.

2. Centers for Medicare and Medicaid Services, Center for Medicaid and State Operations/Survey and Certification Group Nursing HomesIssuance of Revisions to Interpretive Guidance at F Tag 441, as Part of Appendix PP, State Operations Manual (SOM), and Training Materials (Ref. S&C-09-54). August 14, 2009.

3. Smith PW, Bennett G, Bradley S, et al. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. American Journal of Infection Control 2008;36: 504-35.

4. Makris AT, Morgan L, Gaber DJ, et al. Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. American Journal of Infection Control 2000;28:3-7.