INFECTION CONTROL IN LONG TERM CARE FACILITIES

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INFECTION CONTROL IN LONG TERM CARE
FACILITIES

• Bob Sharbaugh, Ph.D., CIC

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The Nursing Home What makes it different?
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Nursing Home Population

• There are more than 1.5 million residents in LTC
  facilities
• There are approximately 19,000 nursing homes in
  the US
• 20 of the elderly population in the US over age
  85 resides in the nursing home

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Nursing Home Population

• One of every 4 persons gt 65 yo will spend some
  time as a nursing home resident
• 90 of nursing home residents are over age 65
• The mean age of NH residents is over age 80
• Aging of the baby boomers will create a nursing
  home crisis around 2010

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Predisposition to Nosocomial Infections

• NH resident has an average of 3.3 underlying
  conditions
• Increased severity of illness in NHs since
  implementation of DRGs in hospitals
• Increased technology used in the NH
• (e.g. peritoneal dialysis, central venous
  catheters, transfusions, ventilators

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Magnitude of the Nosocomial
Infection
Problem in LTC

• 1.5 million NIs per year
• Prevalence rates found 2.7 - 32.7
• Incidence rates found 2.6 - 7.1
  infections/1000 resident days

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Major Factors Predisposing to Nosocomial
Infection

• Environmental Factors
• -- GU instrumentation
• -- Indwelling vascular lines
• -- Respiratory therapy

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Major Factors Predisposing to Nosocomial
Infection

• Biologic Factors
• Age Paraplegia
• Diabetes Malnutrition
• Neoplasia Steroids
• Alcoholism CRI
• Emphysema CHF
• Sickle cell anemia COPD

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Major Anatomical Sites Involved With NI in LTCFs

• Urinary Tract
• Upper/Lower Respiratory Tract
• Skin and Soft Tissue
• Conjunctivitis
• Cellulitis

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Urinary Tract Infections

• Leading nosocomial infection in LTCFs
• 20-50 incidence in non-catheterized patients
• 30 of septicemias 2o to UTI
• High incidence in females

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Urinary Tract Infections

• Risk Factors
• -- Indwelling/external catheters
• -- Incontinence
• -- Dehydration
• -- Poor patient hygiene
• -- Duration of catheterization
• -- Gender
• -- Degree of debilitation

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Respiratory Tract Infections

• Pneumonia
• Risk factors include
• Aspiration (number one cause) --
  feeding tubes
• -- GI disease -- achlorhydria
• -- depressed gag reflex
• -- confusion

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Respiratory Tract Infections

• Influenza
• Major threat in LTC
• Outbreaks common
• Over 40,000 excess deaths/year
  
  
  
  
  95 over the age of 65
• Vaccinate annually (genetic drift)

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Skin and Soft Tissue Infections

• Pressure ulcers
• Risk factors include
• -- immobility
• -- incontinence
• -- malnutrition
• -- altered level of consciousness
• AHCPR Clinical Practice Guidelines
• 1-800-358-9295

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Skin and Soft Tissue Infections

• Cellulitis
• -- closed infection
• -- absence of CS data
• Scabies (the itch mite)
• -- NH outbreaks common
• -- skin to skin transmission
• -- pruritic lesions
• -- Elemite (5 permethrin)
• -- Skin scrapings needed to diagnose

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Other Infections of Nosocomial Concern

• Gastroenteritis
• -- Usually viral in nature
• Bacteremia
• -- Relatively rare in LTCFs
• Conjunctivitis

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Antibiotic Resistant Organisms in LTC

• Methicillin-resistant Staphylococcus aureus
  (MRSA)
• Vancomycin-resistant Enterococci (VRE)
• Extended spectrum Beta Lactamase Gram
  negative bacteria (ESBLs)

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Methicillin-Resistant Staphylococcus aureus
(MRSA)

• Resistant to
• -- Methicillin, Nafcillin, Oxacillin
• Resistance due to genetic alteration in
  penicillin binding protein (PBP)
• Transmitted by Direct Contact
• No More Virulent Than MSSA
• Susceptible to common disinfectants
• Vancomycin the drug of choice

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RESISTANCE OF S. AUREUS TO B-LACTAM
ANTIBIOTICSTHROUGH THE PRODUCTIONS OF
PENICILLIN BINDING PROTEINS (PBPs)
Bacterial Cell Wall
MSSA
PBP
methicillin
Genetic mutation
Bacterial Cell Wall
MRSA
PBP
methicillin
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VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE)

• Group D Streptococci
• E. faecalis E. faecium
• Common members of the GI flora
• High degree of antibiotic resistance
• Usually sensitive to vancomycin
• Transmission of resistant strains associated with
  both direct and indirect contact

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Extended Spectrum Beta LactamaseGram Negative
Bacilli (ESBLs)

• Members of the Enterobacteriaceae
• Klebsiella, E. coli, Proteus, Citrobacter,
  
  
  
  
  Serratia
• Resistant to cephalosporins and
• aminoglycosides
• Contact Precautions

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Control Strategies for Antibiotic Resistant
Organisms in LTC

• Do not deny entry of colonized residents into LTC
• Decolonization neither required nor generally
  recommended
• Do not restrict colonized residents from social
  activities unless transmission has been documented

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Control Strategies for Antibiotic Resistant
Organisms in LTC

• Request notification of colonization prior to
  admission
• Monitor all CS reports for evidence of
• AROs
• Handwashing minimize use of invasive devices
  appropriate barrier precautions
• Private room vs. cohorting vs. prudent patient
  placement

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ISOLATION PRACTICES

• Standard Precautions
• -- A synthesis of Universal Precautions and
  Body Substance Isolation
• -- Applies to all patients
• -- Major components include handwashing
  barrier technique, and sharps precautions

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ISOLATION PRACTICES

• Transmission Based Precautions
• -- Airborne (TB, measles, Varicella)
• -- Droplet (influenza, strep throat)
• -- Contact (AROs, lice, scabies, C. difficile)

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THE INFECTION CONTROL PROGRAM

• FEDERAL (HCFA) REGULATIONS (CONDITIONS OF
  PARTICIPATION)
• STATE REGULATIONS
• JCAHO STANDARDS
• OSHA REGULATIONS

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HCFA CONDITIONS OF PARTICIPATION FOR LONG TERM
CARE

• INFECTION CONTROL
• F440-A 483.65 INFECTION CONTROL
• A) INFECTION CONTROL PROGRAM
• (B) PREVENTING SPREAD OF INFECTION
• (C) LINENS

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INFECTION CONTROL COMMITTEE

• FREQUENCY OF MEETINGS
• COMBINED WITH OTHER MEETINGS
• CHAIRMAN - ICP VS. MEDICAL DIRECTOR

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EDUCATIONAL ACTIVITIES

• ORIENTATION
• ANNUAL PROGRAMS
• PROBLEM-ORIENTED TEACHING

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EXPOSURE CONTROL PLAN

• BLOODBORNE PATHOGENS
• -- Standard Precautions
• -- Personal Protective Equipment
• -- Regulated (Infectious) waste
• -- Laundry
• -- Hepatitis B immunization
• -- Post-exposure prophylaxis
• -- Education and training

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EXPOSURE CONTROL PLAN

• TUBERCULOSIS
• Hierarchy of Control Measures
• -- Administrative Controls
• employee/resident screening
• -- Engineering Controls
• -- Respiratory Controls

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ADMINISTRATIVE CONTROLS EMPLOYEE/RESIDENT
SCREENING

• PPD TUBERCULIN SKIN TEST
• -- Administration schedule
• -- Interpretation
• -- Cut Points
• -- 2-step methodology
• CHEST RADIOGRAPHY

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ENGINEERING CONTROLS

• ISOLATION ROOM
• NEGATIVE PRESSURE
• 6 AIR CHANGES PER HOUR
• DIRECT EXHAUST TO OUTSIDE
• NOT USUALLY APPLICABLE TO LTCFs

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RESPIRATORY PROTECTION

• N 95 respirator (mask)
• make available in various sizes
• surgical mask for patient transport

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Infection Prevention and Control in the Long
Term Care Facility

• APIC/SHEA Position Paper
• Smith, P. Rusnak, P. American Journal of
  Infection Control, December, 1997.

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INFECTION CONTROL WEB SITES

• APIC http//www.apic.org
• AHCPR http//text.nlm.nih.gov/ftrs/dbaccess/ahcp
  r
• CDC http//www.cdc.gov/cdc.html
• EPA Disinfectants http//www.ace.orst.edu/info/n
  ain
• FDA Sterilants www.fda.gov/cdrh/ode/germlab.html
  
• JCAHO www.jcaho.org
• OSHA httpwww.osha-slc.gov/OCIS/standards_related
  .html