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Infections in Long-Term Care Facilities: Prevention, Diagnosis, and Management
Dr. Mody is an Assistant Professor, Univerisity of Michigan Medical School, and Associate Director, Clinical Programs, at the Ann Arbor VA Geriatric Research Education and Clinical Center, Ann Arbor, Michigan.
Until recently, the vast majority of medical treatments took place in acute care facilities – not so anymore. In the last couple of decades, healthcare has changed considerably. Nowadays it is available in a variety of settings such as hospitals, sub−acute care, long−term care facilities (LCTFs) or nursing homes, rehabilitation, assisted living, home, and outpatient settings.
As healthcare costs have risen, you’d be right to guess that the average length of hospital stays has declined, while, of course, the intensity of illnesses in hospitals and ICU admissions have also risen. Along with this trend, outpatient services have also increased, as have home care and nursing home stays for older adults.(1) As a result, LTFCs and nursing homes are seeing sicker and more susceptible patients, so they must always be ready to deliver high−quality medical care to their residents.
There are several types of infections among LTCF residents, some of which can significantly increase their mortality rate. These infections are also responsible for a great number of transfers to acute care hospitals – in fact, a whopping 1.5 to 2.0 million infections are estimated to occur in the LTCF each year, which can result in billions of additional dollars in medical expenses.(2) Americans over the age of 65 account for a disproportionate number of patients in the hospital for infection−related illnesses.(3)
This article outlines some of the most common infections that occur in the LTCF, as well as offers some ideas and tips when searching for a good (read: clean!) long−term care facility for oneself or loved one.
Urinary Tract Infections
Urinary Tract Infections may be particularly dangerous because they can lead to bacteremia – bacteria in the blood stream – and may result in transferring the patient to a hospital temporarily. Asymptomatic bacteriuria may also result in overtreatment with antibiotics, which is not good for the immune system and can ultimately lead to a host of other problems.
Why are UTIs so common in LTCFs? Some of the risk factors for UTIs include diabetes, long−term stays in a facility, deterioration of the nerves that control the bladder muscles, and general functional/cognitive impairments associated with age. But a frequent cause seems to be the use urinary catheters in patients, both the short− and long−term.(5)(6)(7) Continual use of use of catheters significantly increases the chances of having asymptomatic bacteruria, having a real UTI, and having a UTI that’s resistant to antibiotics. In fact, one study found that 90% of patients with catheters suffered from bacteruria(8)(9), and about 50% of patients with catheters will suffer from a true, symptomatic UTI each year. And these infections are often resistant to antibiotics.
Doctors point out that patients with and without catheters should be watched for symptoms of UTIs, so that they may be diagnosed and treated as soon as possible. Patients without catheters will typically show at least a few of the following symptoms: fever or chills, increasing frequency of and/or pain associated with urination, pain around the area of the bladder, changes in the urine, and worsening of mental or functional status. Patients who have catheters will often have similar symptoms but may not notice increasing frequency or pain during urination.(10)
The use of leg bags to collect urine can also increase risk of infection, so their use is often discouraged in LTCFs these days. If they are used, it’s absolutely necessary that they be changed at least every four hours, rinsed with vinegar solution and dried in between uses, kept below the level of the bladder, and that an aseptic technique is used when disconnecting and reconnecting the parts.(2)(12)
Often, if a patient with a catheter shows signs of fever, confusion, or general worsening of condition, doctors at LTCF will assume a UTI and take the proper course of treatment (first obtaining a urine sample to confirm the presence of bacteria).
The Center for Disease Control (CDC) has published a list of guidelines for proper catheter care, which includes insertion only by trained personnel, avoiding unnecessary catheter changes, keeping patients well−hydrated, limiting frequent antibiotic use, and limiting the overall use of catheters in patients whenever possible.(11)(12)
Respiratory Tract Infections
The symptoms of pneumonia in LTCF patients are not always “textbook,” but there are certain things to look out for, which are fairly common indicators. Many (about 70%) of pneumonia patients will run a fever, and almost as many (61%) will have a new, or increased, cough. Altered mental status and increased rate of breathing may also be symptoms of pneumonia.(18) Ideally, chest x−rays, complete blood count and pulse oximetry (to measure hemoglobin level) are good diagnostic tools if the patient’s doctor suspects pneumonia.(19) Based on the severity of the patient’s symptoms, doctors will decide the best mode of treatment, or whether the patient should be transferred to an acute care facility.
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