Infections in Long-Term Care Facilities: Prevention, Diagnosis, and Management

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

The most common infections to occur in LTCFs are Urinary Tract Infections (UTIs). The frequency with which UTIs occur is typically between 0 and 2.3 times for every 1,000 days a person spends in a LTCF, which is actually a fairly high rate of occurrence.(4) In fact, the Centers for Medicare and Medicaid (CMS) use the frequency with which UTIs are reported as an indicator of the quality of a given facility. It’s also estimated that about 50% of all LTCF residents suffer from bacteruria (bacteria in the urine) without showing symptoms.(2)

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.

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.

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

Because older individuals often have weakened immune systems, respiratory tract infections are also common in LTCFs. Infections that wouldn’t necessarily cause a big problem in the general population can cause serious illness in an elderly person.(14) Two of the most common types of respiratory illnesses are bacterial pneumonia and influenza,(15) both discussed below.

Bacterial Pneumonia
Though pneumonia is the second most common type of infection in LTCFs, it is also the leading cause for mortality in LTCFs. Patients in these settings are particularly prone to pneumonia because their bodies may no longer be able to clear bacteria from the lungs as effectively, or patients may have feeding tubes, poor oral health, suffer from chronic obstructive pulmonary disease (COPD) or heart disease, all of which can increase susceptibility to pneumonia.(16)(17) Unfortunately, the mortality rate in LCTF residents suffering from pneumonia is significantly higher than elderly people in the general population.(20)

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.

Preventing Pneumonia
Making sure patients receive influenza and pneumococcal (a common cause of pneumonia) vaccinations is generally recommended in the elderly population.(22) In addition, caretakers at LTCFs should make sure to wash their hands thoroughly after interacting with a sick patient, wear gloves if suctioning the nose/mouth, and be sure to elevate the patient’s head after tube feeding for at least an hour, so that the patient doesn’t aspirate (inhale liquid).(21)