October 27, 2009

Nursing Home Infections

Lona Mody, M.D., M.Sc.
Millions of infections occur in nursing homes each year, costing billions of dollars.
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. 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. Americans over the age of 65 account for a disproportionate number of patients in the hospital for infection−related illnesses.

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. 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.

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. 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, 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.

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.

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.

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. Two of the most common types of respiratory illnesses are bacterial pneumonia and influenza, 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. Unfortunately, the mortality rate in LCTF residents suffering from pneumonia is significantly higher than elderly people in the general population.

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. 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. 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. 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).

Influenza (flu)
Like pneumonia , influenza symptoms may not be always be typical in LTCF patients, but common symptoms tend to include sudden onset of fever, chills, headache, muscle pain, sore throat, and cough. The flu is a real threat to LTCF patients and when it does hit, outbreaks can be severe – not only is the flu highly contagious but LTCF patients are already at higher risk than the general population. The fatality rate for flu in LTCF patients is estimated at about 10%.

The good news is that influenza vaccines are reasonably effective at preventing hospitalization and mortality from the flu.2 Flu vaccines are generally recommended for both patients and staff at LTCFs, though the rate of vaccination for staff is still considerably lower than it is for patients.

Diagnosis and Treatment
Though there are some newer methods to diagnosing influenza, the gold standard is still to take and analyze a culture from the nasopharynx (the area at the back of the throat).

The good news is that influenza vaccines are reasonably effective at preventing hospitalization and mortality from the flu.

The antiviral drugs Zanamivir (Relenza) and oseltamivir (Tamiflu) are effective at preventing and fighting both influenza A and B strains in LTCF patients. Zanamivir is taken by inhalation, which can be tricky with uncooperative patients; oseltamivir is administered orally and might be better received.

They key to fighting the flu in LTCFs is quick diagnosis and treatment of the disease, as well as isolating patients to control further spread of the disease. Visitors are also often restricted during outbreaks. Some facilities allow staff to stay home without penalty if they become affected with the flu, to prevent further spread between patients.

Skin and Other Infections

Because many LTCF residents are not as mobile as they once were, pressure ulcers may develop from staying in once position for too long. These ulcers can present a big problem, occurring in about 20% of all residents, and actually increasing the risk of mortality. Some infections become very deep and can affect the underlying soft tissue or even bone; those that lead to bacteria in the blood stream are linked to a 50% rate of mortality.

Risk Factors
Certain factors are thought to predispose some individuals to developing skin ulcers, such as reduced mobility; pressure, friction, and moisture around certain areas of the body; incontinence; steroids; malnutrition and infection. Some of these factors can be managed or eliminated, like malnutrition and incontinence. But it is also important for the facility to take care in turning patients at certain intervals, eliminating pressure in certain spots, keeping patients’ skin clean and dry, giving patients disposable briefs, and making sure patients are well−nourished.

Managing Ulcers
Taking care with patients’ overall health in order to prevent ulcers from happening at all is key. There are special mattresses available in some LTCFs which distribute pressure on the body more evenly, so help avoid ulcers all together. And, as always, all staff who interact with patients who have ulcers should take good care to wash hands and use gloves as much as possible.

Often an ulcer flow sheet will help monitor ulcers once they do occur, tracking ulcer location, depth, size, stage and signs of inflammation, as well as the timing of treatment measures. Once an ulcer has been diagnosed, treating the infection and preventing future ones tends to require an all−around approach, sometimes involving geriatric and infectious disease specialists, nurses, surgeons and physical rehabilitation. Pressure ulcers are a serious condition, and often require broad spectrum antibiotics and surgical removal of the affected skin.

Another concern in LTCFs is scabies, a skin infection that is caused by mite bites. The lesions that occur as a result are burrow−like, and very itchy and red. They usually occur between the fingers, palms, and wrists, underarms, waste, buttocks, and perineal area. However, these symptoms may not always occur so typically in LTCF patients, so outbreaks can be large and prolonged as a result.

Diagnosis and Treatment
Skin scrapings can be done to confirm a suspected case of scabies. Doctors recommend that secondary causes are also considered, as rashes can be caused by contact dermatitis, drug rash, hives, herpes, and eczema.

Once a case is confirmed, treatment with the topical drugs permethrin and lindane, or the oral drug ivermectin is usually very effective. Sometimes repeated treatment, as well as treatment of all LTCF residents, staff and family members, is required to crush the outbreak completely. (The topical drugs are somewhat toxic, so it’s very important that scabies cases are confirmed officially before beginning treatment.)

It’s also important to note that scabies can be transmitted between residents via linen and clothing, so it is crucial that LTCF staff clean these materials thoroughly in hot−wash cycles, clean carpets completely, and disinfect all other surfaces as needed.

Other Infections
Gastroenteritis is another common ailment in LTCF residents and it can be disabling. The disease can be viral, bacterial, or parasitic in nature, and therefore spread around the facility fairly quickly, leading to serious problems and ultimately to hospital transfers. Food−borne outbreaks from E. coli, Salmonella, or other microbes can also be of concern, so proper food preparation is extremely important in these facilities.

Bacteremia (again, bacteria in the blood stream) is not detected often but can be a concern. It usually exists as a secondary infection to others, like UTIs, pneumonia, and skin and other infections of the soft tissues. Urinary tract infections are the most common type of infections leading to secondary bacteremia, with E. coli accounting for about 50% of these instances.

Since more illnesses are now treated in LTCFs, experts expect intravenous (IV) catheter−related infections to rise, so, as always, it is particularly important that facility staff practice good hygiene when inserting catheters and caring for catheterized patients.

Editors' Note:
Choosing a Long−Term Care Facility

Given the risks of infection in long−term care facilities outlined here, families choosing one should take into account the facility's infection prevention and control practices. Naturally, there are other considerations as well. The AARP magazine has a good article outlining the factors everyone should consider when looking for long−term care. Cost and location are often foremost on families' minds, but as this discussion of infection suggests, there are concerns related to infection prevention and control that can have a big impact the health and well−being of residents. Even though these safety measures are less obvious than décor, activities and food quality, they need to be given careful thought when searching for long−term care. Ask for the most recent state inspection survey to see what kinds of problems state inspectors have found. And do spend time in the facility yourself, dropping in unannounced, using restrooms, and noting the overall cleanliness of the rooms. Time spent in advance can save lots of time and trouble later.

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