INFECTIONS
This summary and its accompanying materials are provided
primarily for the use of front-line caregivers in the longterm care facility, and for reference use by nursing home
medical directors and the Quality Improvement
Organizations (QIOs) that partner with them under the
Nursing Home Quality Initiative (NHQI) by the Centers for
Medicare and Medicaid Services (CMS). It is not intended
to be complete, to represent a thorough, academic approach
to the subject for general use by physician, or to imitate a
peer-reviewed medical journal article. It is limited to those
eight infection topics chosen by CMS for NHQI.
Infections
epidemics. The most common outbreaks are
of respiratory, gastrointestinal tract, and skin
infestations.
The
common
endemic
infections are in the urinary tract, and skin
or soft tissue. The overall burden of
infection in LTCFs ranges from an incidence
of three to seven infections per 1000
resident-care-days.
Residents of long-term care facilities
(LTCFs) have a high prevalence of
infections, which are a major cause of
morbidity, mortality, hospital transfers, and
a source of considerable expense. The
literature indicates that there is concern
about management of infections in LTCFs
and whether it is optimal.
The diagnosis, treatment, and surveillance of
infection in the nursing home setting is
made more difficult in this elderly
population by a number of factors. Residents
may have various degrees of immune
compromise, from aging alone, due to
difficulties with nutrition, or due to coexisting disease. This may result in atypical
manifestations
and
presentations
of
infection. Limited staffing, lack of rapid
access to physician attention, and lack of
onsite availability of laboratory and imaging
support may contribute to these difficulties.
The variability among LTCFs in their
patient populations may determine different
service needs and solutions. One example is
tuberculosis, which is a larger problem in
areas having a high rate of tuberculosis in
the general community, but may be only a
potential problem in other areas, and thus
The aging population of America represents
an increasing public health priority. Citizens
living to “old-old” age (i.e., greater than 85
years) comprise the most rapidly growing
segment. The trends to smaller families and
continuing geographical mobility with
dispersal of family members point to
increasing need for long-term care services
in the future. Currently there are 1.7 million
residents of LTCFs, and this number is
expected to triple by 2030.
Residents in LTCFs are at increased risk of
infections, because they are undergoing
physiologic aging, have a greater number of
comorbidities, and they live in an
institutional environment. Each factor makes
them especially more susceptible during
Infections
1
Prevention
the frequency of surveillance screening
would differ.
Prevention of infections in long-term care
facilities begins with thorough maintenance
of an active lifestyle, proper nutrition, and
appropriate management of underlying
diseases,
sanitation,
hygiene,
and
compulsive attention to good hand washing
by all staff, adherence to accepted food
handling procedures, and maintenance of
ventilation
and
plumbing
systems.
Education of staff, as well as residents and
visitors, is helpful in avoiding transmission
of known illnesses, especially those spread
by airborne droplets (chicken pox,
tuberculosis, measles, influenza) and by
direct
contact
(staphylococcus
and
streptococcus diseases, especially multiantibiotic resistant organisms, and chronic
hand carriage of gram-negative organisms).
Employee health policies that provide paid
leave during illness with a contagious
disease, identification of employees with
chronic conditions, such as dermatitis or
infections,
and
recognition
and
immunization of those not immune to
chicken pox help to prevent spread of
illnesses between staff, residents, and
visitors. In addition, special emphasis is
warranted in encouraging all staff to obtain
annual immunization against influenza.
There is strong support in the literature
showing
that
adequate
influenza
immunization of nursing home staff is
effective in preventing influenza outbreaks.
The increasing problem of the general use of
empirical antibiotic treatment in the
community and the resultant rise of
antibiotic resistant organisms in the long
term care setting (and elsewhere) further
complicate the issue of infection in this
setting.
Frequently
mentioned
as
contributing to antibiotic resistance is the
empiric treatment for common infections
such as indwelling catheter-associated UTIs,
decubitus ulcers, and pneumonia. Current
guidelines and literature on these conditions
address the problem of resistance help to
minimize it if followed.
Infections represent up to 50% of the
reasons for transfers to hospitals, comprising
up to 300,000 admissions per year, and costs
are estimated to approach $2 billion each
year. Direct costs for antimicrobial therapies
alone are estimated between $40 and $140
million per year. There is concern that the
public health cost in terms of increased
antibiotic resistance may be huge, and the
decrease in quality of life, morbidity, and
premature mortality for the residents of
LTCFs is unmeasured.
The Nursing Home Quality Initiative
highlights increasing awareness and concern
for this public health priority, and
recognizes the need for increased prevention
and control of infections in long-term care
facilities. A renewed focus of attention
toward improvement of the quality of care
delivered in LTCFs, begun with the
Omnibus Budget Reconciliation Act in 1987
and continued during the recent six years of
work by the Quality Improvement
Organizations under CMS, is evidenced in
the choice of quality measures reported
under this new initiative.
Infections
Primary prevention includes the proper
treatment of underlying diseases (i.e.,
congestive heart failure, chronic obstructive
pulmonary disease, stroke, diabetes, etc.)
and avoidance of invasive devices such as
urinary tract catheters when possible. In
addition, oral and dental care may be an
important strategy for prevention of
infectious complications of aspiration
pneumonia.
2
Bibliography
Direct prevention of certain infections for
residents is provided through immunization
of both residents and staff, illustrated by use
of pneumococcal and influenza vaccines, but
also tetanus/diphtheria inoculation. Annual
national targets for the 65 years and older
population have been set for influenza and
pneumococcal immunizations, leading to the
2010 goal of 90% coverage. Unfortunately,
both influenza and pneumococcal vaccines
remain underutilized, with the 2000 targets
of 80% coverage for each not achieved.
Nationally, only 38% coverage was
achieved for pneumococcal immunization
and 65% for influenza. Evidence of the
efficacy of annual influenza immunizations
in reduction of infection, morbidity, and
mortality is compelling, and cannot be
overstressed.
A bibliography with complete citations and
annotations on infections in the nursing
home environment has been developed for
this Quality Initiative. Guidelines and
articles accompanying this text are
mentioned under the categories presented
below.
In addition, review of materials presented at
a conference by the Emory University
Center for Health in Aging in March 2001 at
Alpharetta, Georgia, contributed to this
summary commentary. In the search for
materials useful for LTCFs in addressing the
subject of infections and infection control,
the major criteria were usefulness and
applicability in the nursing home
environment by the nurses and nurses’ aides
actually doing the work. While academic
completeness and erudition are laudable, and
ongoing investigation produces the evidence
base supporting advances in care practices,
those faced with the limits and demands of
the LTCF environment require a focus on
the actual "how to" instruction and basic
understanding of the task and its elements.
Another strategy for prevention is the early
detection for intervention of outbreaks of
infections, as well as identification of other
infections in their asymptomatic stage in
order to delay or prevent symptoms and
morbidity. In this elderly population,
declining physical responses such as ability
to mount a fever or increase the white blood
cell count in the face of infecting organisms
makes recognition of the presence of
infection difficult.
Infection Control
The importance of infection control is
widely recognized in LTCFs, where the
group living situation increases the exposure
and risk of outbreaks. There is extensive
regulation addressing this important aspect
of long-term care delivery, and a cadre of
professionals with its body of literature has
emerged. However, it is well known that
LTCFs are chronically understaffed, and the
infection control professionals have many
other duties and responsibilities. In addition,
as many as half of those performing
infection control duties have not had specific
training, and most spend only about eight
Because it is difficult to establish a clinical
diagnosis of infection in residents of LTCFs,
deciding when to initiate antibiotics is a
challenge for practitioners. An article by
Loeb et al. (2001), “Development of
Minimum Criteria for the Initiation of
Antibiotics in Residents of Long-Term Care
Facilities: Results of a Consensus
Conference,” provides useful guidance.
Criteria for initiating antibiotics for skin and
soft-tissue,
respiratory
and
urinary
infections, and fever where the focus of
infection is unknown are included.
Infections
3
Fever
hours per week on those infection control
issues. Furthermore, many of those efforts
focus on data collection, without a direct
link to intervention measures. Lastly, much
of the work in infection control has been
done in hospitals and is not directly
applicable or appropriate to the nursing
home environment.
On the importance and role of fever as a
marker of infection, a guideline is provided
by Norman (1992) from the Clinics in
Geriatric Medicine: “Infections in Elderly
Persons: An Altered Presentation.” It
addresses the special
and unique
characteristics of infections in the elderly as
noted above and provides direct information
useful in the LTCF. Lindsay highlights the
diagnosis, treatment, and prevention of fever
in nursing home patients, and discusses
typical and atypical febrile responses and
their infectious and noninfectious sources.
Also included is the Practice Guideline for
Evaluation of Fever and Infection in LTC
Facilities, a recently published set of
standards from the Infectious Diseases
Society of America. They provide a
practical approach to evaluation of potential
infection and assistance in early recognition
and treatment by nursing home personnel.
In-depth information and an extensive
bibliography for QIO reference are included.
The updated guideline referenced by the
Society of Hospital Epidemiologists of
America
(SHEA)
Long-Term
Care
Committee and Association for Practitioners
in Infection Control (APIC) Guidelines
Committee, entitled “Infection Prevention
and Control in the Long-Term Care
Facility,” reviews the literature on infections
and infection control programs in LTCFs. It
covers such topics as tuberculosis, bloodborne pathogens, epidemics, isolation
systems, immunization, and antibioticresistant bacteria, and is an excellent
resource.
Articles are included that review risk factors
for infection in LTCFs and provide the
components of an infection control program
(Nicolle and Garibaldi, 1995), and
summarize interventions that may prevent
infections, identify outbreaks early, and
minimize prevalence of resistant organisms
(Nicolle, 2000). A source of information on
the multiple antibiotic-resistant unusual
organisms (Strasbaugh et al., 1996) and a
nurses’ aide-centered prospective study on
intensive surveillance (Jackson et al., 1993)
should assist in management of these
difficult problems. The latter is especially
useful in that it provides insights on how the
frontline certified nurse-assistant (CNA)
staff view symptoms of infection and their
dependence on simple signs such as fever.
Infections
Infections in LTCFs
Specific types of infections in LTCFs are
highlighted.
Pulmonary
infections
(pneumonia, recurrent lung-aspirations,
other respiratory infections), urinary tract
infections, wound infections and septicemia,
are included:
Pulmonary Infections
Pneumonia
A LTCF-oriented guideline from the
Institute for Clinical Systems Improvement
provides an analytic framework to assist
practitioners in LTCFs in evaluating and
treating residents with community-acquired
pneumonia and understanding the rationale
for treatment choices. Two articles by
Mulder (1998, 2000) are included. A review
4
of the literature on pneumonia in LTCFs
thoroughly covers risk factors, etiology,
clinical presentation, treatment, and
prevention. The second is included for its
completeness and bibliography as a
reference source for QIO use in this project.
chronic aspiration in the etiology of
nocosomial pneumonia. Two-thirds of the
patients in their study were found to have a
history of recurrent aspiration and were
more likely to require tube or assisted oral
feedings. Pick et al. (1996), identified tube
feeding, presence of a hyperextended neck
contraction, malnutrition, and the use of
benzodiazepines and anticholinergics as risk
factors for aspiration in their study published
in the Journal of the American Geriatric
Society. An overview of the disorders that
place the LTCF resident at risk for
aspiration, as well as a discussion of
evaluation, treatment, and prevention is
provided by Teofilo and Lee-Chiong (1998)
in the Annals of Long-Term Care. Lastly,
the American Speech-Language-Hearing
Association (2000) provides as a desk
reference, guidelines for the use of
instrumentation in the assessment, diagnosis,
management, and treatment of patients with
dysphasia.
The article by Fried et al. (1995) covers the
factors associated with the decision to treat
or transfer the patient to the hospital. It
shows that the time of day the attending
physician is contacted by LTCF staff is a
major determinant of the decision to
transfer, and that no difference in survival
was demonstrated between treatment in the
LTCF or hospital location for cases with
mild to moderate pneumonia. Additional
publications on this subject indicate that
those with severe pneumonia do better on
intravenous antibiotics, which have usually
mandated hospital transfer, but some LTCFs
do now have the capability of offering such
therapy, along with good nursing monitoring
of the patient. Lastly, an editorial from the
Journal of the American Geriatrics Society
(Zimmer,
1997)
emphasizes
an
individualized approach to the LTCF
resident with pneumonia and provides the
opposing view by favoring hospitalization
for treatment.
Other Respiratory Infections
Tuberculosis
Screening for tuberculosis at admission has
long been practiced, even mandated, in
LTCFs; but there is increasing concern that
annual screening is not being performed, or
is inadequate to identify residents with reactivated TB who might pose a risk to other
residents and staff. Two references for the
prevention and control of tuberculosis are
included. Bentley (1990) summarized
recommendations for prevention and control
of TB from the DHHS Advisory Committee
for the Elimination of Tuberculosis, and
reviews an outbreak in a large, wellrespected LTCF, thus underscoring the
importance of careful TB surveillance for
this serious and extremely contagious
disease. He points out that the current
estimated incidence of TB in LTCF
residents was 39.2 per 100,000 person years,
“Prevention and Control of VaccinePreventable Diseases in Long-Term Care
Facilities” is a comprehensive supplement
from the American Medical Directors
Association Journal (2000), which provides
a "plug-in" process and complete
instructions for LTCFs to implement an
immunization program and surveillance for
influenza and pneumococcal disease. It is an
excellent reference for use by both the
LTCF and its supporting QIO.
Recurrent Lung Aspiration
McDonald et al. (1992), highlight in the
Journal of Infection Control the role of
Infections
5
compared to the incidence of 21.5 per
100,000 person years among elderly persons
living in the community. The observed rate
of tuberculosis for employees of LTCFs was
3.0 times the rate expected in employed
adults of similar age, race, and sex.
Rajagopalan and Yoshikawa outline the
epidemiology and clinical features of TB in
the elderly and point out that the often subtle
clinical manifestations present diagnostic
challenges. The use of the familiar two-step
testing in older persons is emphasized.
discussed in Falsey (1991). These types of
infections often occur as "outbreaks" or
case-clusters in nursing homes. In addition,
Heath et al. (1997) present two fatal LTCF
cases of Haemophilus Influenzae Type B
infection transmitted within the facility. This
vaccine-preventable disease, usually seen in
young children, may be under-recognized in
the elderly.
Urinary Tract Infection
The position paper developed by the SHEA
Long-Term Care Committee (Nicolle, 2001)
is included to assist LTCFs, as well as
physicians and QIOs, in dealing with this
common and difficult problem. It is a "must"
for understanding and managing UTI in this
setting. In addition, the current CDC
guideline covering epidemiology, control,
and prevention of catheter-associated UTI,
with an extensive bibliography, provides an
authoritative reference. The University of
Michigan Health System guideline on UTI
diagnosis, management, treatment, and
follow-up provides a helpful clinical
algorithm.
An excellent "in-service" TB training is
provided in the nurse-conducted review of
tuberculosis by Schultz et al. (2001),
concerning new converters in LTCF
settings. A classic paper on significance of
the PPD in the elderly by Stead and To
(1987) is based on a study of almost 50,000
residents. They specify that conversion with
an increase of at least 12mm or more from
those with previously documented negative
PPDs indicated occurrence of infection. If
not treated at that time, 7.6% of women and
12.7% of men developed active disease.
They point out that as many as 25% of those
clinically ill with TB may show no reaction
to 5 units of tuberculin. In their experience,
61% of cases of (active) tuberculosis in
nursing homes developed among previous
reactors to tuberculin, assumed to be the
result of old infection.
Viral Hepatitis
A study by Marcus and Tur-Kaspa (1997)
offers a review of the epidemiology,
manifestations, and prevention of hepatitis
in elders and deals with all known types,
including A, B, C, D, and G. It points out
that age is not necessarily an exclusion
criterion for anti-viral treatment. Chien et al.
(1999) found anti-HCV was surprisingly
high in a study of three LTCFs and
recommends that all new patients admitted
be
screened
for
anti-HCV.
The
comprehensive CDC guideline on Hepatitis
C virus is also included for QIO and
clinician reference for its extensive
bibliography.
Influenza
The Centers for Disease Control and
Prevention guideline, “Prevention and
Control of Influenza 2002,” is presented as
the current and definitive treatise on
prevention and treatment of influenza and
control or outbreaks in LTCFs.
Other Unusual Respiratory Infections
Viral infections including respiratory
syncytial,
parainfluenza,
rhinovirus,
coronavirus, and adenovirus in LTCFs are
Infections
6
LTCF setting. Muder et al. (1992) provide
an excellent reference, showing that the
urinary tract source accounted for 55% of
bacteremia, while respiratory tract (11%)
and soft tissue (9%) infections were the
other major sources. In this study, mortality
was significantly associated with the
respiratory tract infection bacteremia.
Wound Infections
Two cases of peri-stomal wound infection
associated with bacteremia in the same
LTCF caused by the nocosomial pathogen,
Group A streptococcus, presumably spread
by a nurse with Group A streptococcal
pharyngitis, are presented by Tsai and
Bradley (1992). This highlights the fact that
wound infections with common pathogens
can result in serious consequences, including
spread within the nursing home. Prompt
identification and treatment of both carriers,
and residents with infected wounds, is
important to prevent spread of disease.
References
Bentley DW. Tuberculosis in long-term care
facilities. Infection Control and Hospital
Epidemiology. 1990; 11: 42-46.
Chien NT, Dundoo G, Horani MH, et al.
Seroprevalence of viral hepatitis in an older
nursing home population. Journal of the
American Geriatric Society 1999; 47: 11101113.
The common problem of infections in
pressure ulcers is dealt with under that
separate topic. A guideline, “Treatment of
Pressure Ulcers,” from the U.S. Department
of Health and Human Services, Public
Health Service, AHCPR, is included to
cover the management of bacterial
colonization and infection, as well as
education
and
quality improvement
concerning pressure ulcers in the LTCF
environment.
Falsey AR. Noninfluenza respiratory virus
infection in long-term care facilities.
Infection
Control
and
Hospital
Epidemiology 1991; 12: 602-608.
Fried TR, Gillick MR, and Lipsitz LA.
Factors associated with hospitalization and
outcome of elderly long-term care patients
with pneumonia. Journal of General
Internal Medicine 1995; 10: 246-250.
Septicemia
Llewelyn and Cohen's (2001) reference
covering general considerations in the
diagnosis of septicemia and the importance
of appropriate microbiological diagnosis,
markers of infection, and literature-based
recommendations is provided for LTCF
Medical Directors use. A review of clusters
of Group A Streptococcal infection in
LTCFs is presented to underscore the
importance of this contagious and dramatic
illness presenting with a toxic-shock-like
syndrome. Studies by Leibovici et al. (1993)
and Richardson et al. (1995) deal with this
problem of septicemia and highlight the
status of the urinary tract infection,
especially those associated with urinary
incontinence or indwelling catheter use, as
the most frequent source of septicemia in the
Infections
Health TC, Hewitt MC, Jalaludin B, et al.
Invasive Haemophilus influenzae type b
disease in elderly nursing home residents:
Two related cases. Emerging Infectious
Diseases 1997; 3(2): 179-182.
Jackson MM, Schafer K. Identifying clues to
infections in nursing home residents: The
role of the nurses’ aide. Journal of
Gerontological Nursing 1993; Jul: 33-42.
Leibovici L, Pitlik SD, Konisberger H, and
Drucker M. Bloodstream infections in
7
patients older than eighty years. Age and
Ageing 1993; 22: 431-442.
Nicolle LE. Infection control in long-term
care facilities. Clinical Infectious Diseases
2000; 31: 752-756.
Llewelyn M and Cohen J. Diagnosis of
infection in sepsis. Intensive Care Medicine
2001; 27: S10-S32.
Nicolle LE and Garibaldi RA. Infection
control in long-term-care facilities. Infection
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16: 348-353.
Lindsay JM, Greenough WB, Zelesnick LB,
and Kuhn KE. Fever in the nursing home
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159-164.
Nicolle LE and the SHEA Long-Term Care
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initiation of antibiotics in residents of longterm-care facilities: Results of a consensus
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Epidemiology Feb 2001; 120 (2): 210-124.
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presentation. Clinics in Geriatric Medicine
1992; 8(4): 713-719.
Marcus EL, Tur-Kaspa R. Viral hepatitis in
older adults. Journal of the American
Geriatric Society 1997; 45: 755-763.
Pick N, McDonald A, Bennett N, et al.
Pulmonary aspiration in a long-term care
setting: Clinical and laboratory observations
and an analysis of risk factors. Journal of
the American Geriatric Society 1996; 44:
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McDonald AM, Dietsche L, Litsche M, et
al. A retrospective study of nosocomial
pneumonia at a long-term care facility.
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Rajagopalan S and Yoshikawa TT.
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Richardson JP and Hricz L. Risk factors for
the development of bacteremia in nursing
home patients. Archives of Family Medicine
1995; 4: 785-789.
Muder RR, Brennen C, Wagener MM, et al.
Bacteremia in a long-term-care facility: A
five-year prospective study of 163
consecutive cases. Clinical Infectious
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Infections
Schultz M, Hernández JM, Hernández NE,
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Schwartz B, Elliott JA, Butler JC, et al.
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et al. Interventions to improve the quality of
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Strausbaugh LJ, Crossley KB, Nurse BA,
Thrupp LD, and the SHEA Long-Term-Care
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long-term-care facilities. Infection Control
and Hospital Epidemiology 1996; 17: 129140.
Stead WW and To T. The significance of the
tuberculin skin test in elderly persons.
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Infections
MO-02-01-NHI December 2002
This material was prepared by Primaris under contract
with the Centers for Medicare & Medicaid Services (CMS).
The contents presented do not necessarily reflect CMS policy.
Version 12/20/2002
9