Multidrug-resistant gram-negative bacteria in a long-term care facility: prevalence and risk factors

OBJECTIVES: To quantify the prevalence, risk factors, and mode of transmission associated with colonization by multidrug-resistant gram-negative bacteria (MDRGN) in the long-term care (LTC) setting.
DESIGN: Cross-sectional.
SETTING: Four nursing units in a 648-bed LTC facility in Boston, Massachusetts.
PARTICIPANTS: Eighty-four long-term care residents.
MEASUREMENTS: Nasal and rectal swabs were obtained to determine colonization with MDRGN; if present, molecular typing was performed. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) was also determined. Demographic and clinical characteristics were obtained from the medical record. Multivariable analysis was used to identify factors independently associated with MDRGN colonization.
RESULTS: A total of 51%, 28%, and 4% subjects were colonized with MDRGN, MRSA, and VRE, respectively. After multivariable adjustment, advanced dementia (adjusted odds ratio (AOR)=2.9, 95% confidence interval (CI)=1.2–7.35, P =.02) and nonambulatory status (AOR=5.7, 95% CI=1.1–28.9, P =.04) were the only independent risk factors for harboring MDRGN. Molecular typing indicated person-to-person transmission.
CONCLUSION: Colonization with MDRGN is common in the LTC setting. A diagnosis of advanced dementia is a major risk factor for harboring MDRGN.     

Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

OBJECTIVES: To describe patterns of antimicrobial use for respiratory tract infections (RTIs) in older residents of long‐term care facilities (LTCFs). DESIGN: Data from a prospective, randomized, controlled study of the effect of vitamin E supplementation on RTIs conducted from April 1998 through August 2001 were analyzed. SETTING: Thirty‐three LTCFs in the greater Boston area. PARTICIPANTS: Six hundred seventeen subjects aged 65 and older residing in LTCFs. MEASUREMENTS: RTIs, categorized as acute bronchitis, pneumonia, common cold, influenza‐like illness, pharyngitis, and sinusitis, were studied for appropriateness of antimicrobial use, type of antibiotics used, and factors associated with their use. For cases in which drug treatment was administered, antibiotic use was rated as appropriate (when an effective drug was used), inappropriate (when a more‐effective drug was indicated), or unjustified (when use of any antimicrobial was not indicated). RESULTS: Of 752 documented episodes of RTI, overall treatment was appropriate in 79% of episodes, inappropriate in 2%, and unjustified in 19%. For acute bronchitis, treatment was appropriate in 35% and unjustified in 65% of cases. For pneumonia, treatment was appropriate in 87% of episodes. Of the most commonly used antimicrobials, macrolide use was unjustified in 43% of cases. No statistically significant differences in the patterns of antibiotic use were observed when stratified according to age, sex, race, or comorbid conditions, including diabetes mellitus, dementia, and chronic kidney disease. CONCLUSION: Antimicrobials were unjustifiably used for one‐fifth of RTIs and more than two‐thirds of cases of acute bronchitis, suggesting a need for programs to improve antibiotic prescribing at LTCFs.     

Burden of Clostridium difficile-associated diarrhea in a long-term care facility

OBJECTIVES: To describe the incidence and prevalence of Clostridium difficile-associated diarrhea (CDAD) in a long-term care facility (LTCF). DESIGN: Retrospective review of CDAD cases between July 2001 and December 2003. SETTING: Two hundred two-bed LTCF affiliated with an academic medical center in Baltimore, Maryland. PARTICIPANTS: All residents of the facility during July 2001 to December 2003. MEASUREMENTS: Clinical and laboratory-confirmed cases of CDAD. RESULTS: Incidence of CDAD ranged from 0 to 2.62 cases per 1,000 resident days. The highest rates were observed in residents of subacute units, whereas incidence was much lower on traditional nursing home units. Prevalence of CDAD at admission was greater on units (subacute and rehabilitative) where the majority of patients were admitted from hospital settings than on those where the majority of patients were admitted from the community (nursing home units). Recurrent disease occurred in 21.7% of patients with CDAD. CONCLUSION: CDAD remains a problem in the long-term care setting, and importation from the acute care setting accounts for a large proportion of the C. difficile seen LTCFs. As the population continues to age, issues of disease and infection in long-term care are expected to increase. New prevention and control strategies are needed to control the spread of CDAD in LTCFs.     

Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel

The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.     

Cost effect of managing methicillin-resistant Staphylococcus aureus in a long-term care facility

OBJECTIVES: The purpose of this study was to measure the total consumption of resources involved in the care of a long-term care facility (LTCF) resident infected with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: A retrospective cohort study. SETTING: A 375-bed LTCF that provides two levels of care. PARTICIPANTS: Ninety LTCF residents infected with Staphylococcus aureus (mean age +/- standard deviation for methicillin-sensitive Staphylococcus aureus (MSSA) patients = 85 +/- 8.8, for MRSA patients = 82 +/- 9.5, P =.127; 49 MSSA and 41 MRSA patients). Inclusion criteria consisted of identification of a positive S. aureus culture in addition to symptoms/signs consistent with infection. Patients colonized with S. aureus were excluded. MEASUREMENTS: A standardized data collection tool was used to conduct chart and database review throughout the defined infection period. The type of information collected included demographic, infection characterization, antibiotic regimen, resource assessment, and cost data. The cost data were further categorized into total pharmaceutical, infection management, physician care, nursing care, and total infection cost. RESULTS: One hundred eleven cases were identified, with 90 cases eligible for evaluation. No difference in population demographics was noted between groups. A significantly higher number of patients in the MRSA group had an indwelling device (P <.001), pressure ulcer(s) (P =.028), or diabetes mellitus (P =.007). There was a significantly higher number of patients with congestive heart failure in the MSSA group (P =.047), but no difference existed in the primary infection site (P =.297) or the incidence of patients with more than two comorbidities (P =.509). The infection characterization variables included were also similar between groups. The most prevalent infection site was the urinary tract (48%) followed by skin/skin structure (38%). Because the majority of patients (82%) developed infection at least 30 days after their LTCF admission, the infections may be considered to have been largely LTCF acquired. The median infection management cost of an MRSA infection was six times greater than that of a MSSA infection (P <.001), whereas the median associated nursing care cost was two times greater (P =.001). The median overall infection cost associated with MRSA was 1.95 times greater than that of MSSA (median (range): MSSA 1,332 US dollars (268-7,265 US dollars) vs MRSA 2,607 US dollars (849-8,895 US dollars), P <.001). Nursing care cost constituted the major portion of the overall infection cost in both groups (MSSA 51%, MRSA 48%). Evaluation of antimicrobial management revealed that infected residents were treated with a wide array of combination therapies (65% of patients received combination therapy). CONCLUSIONS: The management of a resident infected with MRSA was much more costly to the LTCF than that of an MSSA-infected patient. The general care of the patient and not the specific antibiotic regimen influenced the large difference in cost between groups. The approach to the antibiotic management of these patients was variable. A more streamlined approach to infection management that facilitates a faster cure rate may dramatically lower resource consumption and improve patient outcomes.     

Patterns of antimicrobial use and antimicrobial resistance among healthy children in Bolivia

Summary
objective   To determine the incidence of antimicrobial-resistant, nonpathogenic Escherichia coli among healthy children aged 6–72 months in Camiri town and a rural village, Javillo, in south-eastern Bolivia.
method   A community-based survey: stool samples were obtained from 296 healthy children selected by modified cluster sampling in Camiri and all 25 eligible children in Javillo. E. coli isolates were tested for antimicrobial susceptibility according to the standard disc diffusion method. By a questionnaire survey of 12 pharmacies and by using simulated patients, we investigated the antimicrobial availability and the usage patterns in Camiri town.
results   In Camiri, over 90%, and in Javillo over 70% of children carried E. coli resistant to ampicillin, trimethoprim-sulphamethoxazole (TMP/SMX) or tetracycline. Overall, 63% of children carried E. coli with multiple resistance to ampicillin, TMP/SMX, tetracycline and chloramphenicol. In the simulated patients study, antimicrobials were dispensed inappropriately for 92% of adults and 40% of children with watery diarrhoea, and were under-prescribed for males with urethral discharge (67%) or females with fever and dysuria (58%). The dose and/or duration of antimicrobials dispensed was almost always too low.
conclusion  Our study showed a disturbingly high prevalence of carriage of nonpathogenic E. coli resistant to antimicrobials. The prevalence of resistance to ampicillin and TMP/SMX was higher than that previously reported in developing countries. The existence of a large reservoir of resistance genes in healthy individuals in developing countries represents a threat to the success of antimicrobial therapy throughout the world. Programmes to improve rational and effective drug use in developing countries are urgently needed.     

Increasing influenza immunization for long-term care facility staff using quality improvement

OBJECTIVES: To improve staff immunization rates for influenza in long-term care facilities (LTCFs).
DESIGN: A quality improvement project.
SETTING: LTCFs ranging in size from 50 to 2,000 beds.
PARTICIPANTS: Staff members at facilities.
MEASUREMENTS: Change in staff influenza immunization rate.
RESULTS: Of the 13 nursing homes involved, 11 improved their staff influenza immunization rates; nine improved more than 10%, and six improved to a rate greater than 55%, a level that corresponds to substantial protection against outbreaks. Staff education was essential but insufficient. Direct encouragement and dramatic informative endeavors helped, as did financial incentives, competitions, and requiring unambiguously worded consents for refusals. Paying staff members $150 each achieved improvement rapidly.
CONCLUSION: Quality improvement increased staff immunization rates at LTCFs, which reduces the risk of an influenza outbreak. Based on the insights learned about effective changes, the project developed a change package for use by other LTCFs.     

A quality improvement program to enhance after-hours telephone communication between nurses and physicians in a long-term care facility

OBJECTIVES: To determine whether satisfaction of on-site nurses with after-hours telephone communication with off-site physicians improved in one long-term care (LTC) facility after a nurse-oriented intervention.
DESIGN: Longitudinal quality improvement study.
SETTING: Extended Care and Rehabilitation Center (ECRC), Durham Veterans Affairs Medical Center.
PARTICIPANTS: Eighteen registered nurses.
INTERVENTION: Communicating Health Assessments by Telephone (Project CHAT), a program of individualized training sessions and decision support tools to aid LTC nurses with symptom assessment and communication of health information over the telephone.
MEASUREMENTS: Nurses completed six satisfaction surveys (three surveys in the 3 months before Project CHAT and three surveys in the 3 months after Project CHAT).
RESULTS: The nurses' average satisfaction scores increased on several items, including those that assessed whether the nurse was pretty sure what pieces of information the physician was going to ask for ( P =.04), felt that the amount of patient information the physician asked for seemed reasonable ( P =.03), felt prepared to answer the questions the physician asked ( P =.01), and felt that the process of gathering patient information for the physician was easy ( P =.01). The percentage of calls that resulted in immediate evaluation by a physician (on-site or in the emergency department) increased from 2.0% in the period before Project CHAT to 8.6% in the period after Project CHAT ( P =.01).
CONCLUSION: Nurses' satisfaction with several aspects of after-hours telephone medicine improved after an inexpensive, education-based intervention in one LTC facility. Further research is needed to determine how similar interventions might affect other quality measures, including patient outcomes.     

Antibiotic and infection tracking in Minnesota long-term care facilities

OBJECTIVES: To describe current systems used to track infections, antibiotic use, and antibiotic-resistant infections in Minnesota long-term care facilities (LTCFs). DESIGN: Self-administered multiple-choice survey assessing the methods, frequency, content, and dissemination of information used to track infections and antibiotic use. SETTING: Licensed Minnesota LTCFs providing skilled nursing care to geriatric residents as of June 2005. PARTICIPANTS: Surveys addressed to the director of nursing at 393 eligible LTCFs. MEASUREMENTS: Responses to survey questions, assessed by percentage of all responders. Of the 345 surveys returned, the majority had a system to track infections (94.1%), antibiotics prescribed (80.6%), and antibiotic-resistant infections (86.2%). Most facilities used only a nonelectronic format to track antibiotic use (73.4%) and antibiotic-resistant infections (72.4%). Respondents collected information on antibiotic susceptibility results from cultures of blood (49.0%), urine (53.0%), sputum (50.0%), or wounds (50.0%). One third of attending clinicians were routinely informed of trends in facility antibiotic use. In 42% of facilities, less than 5 hours per month of paid time for an infection control practitioner was provided. Two-thirds of responders (64.2%) described their systems as not or somewhat effective at optimizing appropriate antibiotic use in their facilities. CONCLUSION: Most facilities in Minnesota have a system in place to track infections, antibiotic use, and antibiotic resistance. These systems may not collect or disseminate information effectively enough to identify or address the development of antibiotic resistance. Paid infection control practitioner time is limited.     

A prospective evaluation of the Charlson Comorbidity Index for use in long-term care patients

OBJECTIVES: Because of the high prevalence of coexisting medical conditions in frail older adults, clinical investigators often need to adjust for comorbidity when assessing the effect of long-term care (LTC) on patient outcomes.This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting 3-year mortality and functional decline in the LTC setting and compared its prognostic value to that of two data-derived comorbidity indices. DESIGN: Longitudinal cohort study. SETTING: Eighty-eight residential care facilities from Quebec, Canada. PARTICIPANTS: Two hundred ninety-one dependent older adults aged 65 and older. MEASUREMENTS: Subjects' functional abilities were assessed at baseline and 3 years later with the revised version of the Functional Autonomy Measurement System(SMAF). Comorbidity data and the exact date of death for those who had died were collected retrospectively from the subjects' medical files. Subjects were classified as functional decliners if they died or gained 5 points or more on the SMAF between the two assessments. RESULTS: Multivariate Cox and logistic regressions were used to derive two new comorbidity indices, one for predicting mortality and the other for identifying functional decliners. Although the CCI performed well in predicting these two outcomes, its performance was generally inferior to that of the two newly proposed indices. CONCLUSIONS: Findings suggest that the CCI can be improved upon when used to measure comorbidity in LTC patients.     

Symptom experience of dying long-term care residents

OBJECTIVES: To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents.
DESIGN: After-death interviews.
SETTING: Stratified random sample of 230 long-term care facilities in four states.
PARTICIPANTS: Staff (n=674) and family (n=446) caregivers for dying residents.
MEASUREMENTS: Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment.
RESULTS: Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=−0.043–0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care.
CONCLUSION: In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life.     

The last 48 hours of life in long-term care: a focused chart audit

OBJECTIVES: As a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end-of-life care for patients in long-term care (LTC) settings to develop an educational strategy for physicians. DESIGN: A chart audit, focusing on the last 48 hours of life of residents dying in LTC facilities. SETTING: Five LTC facilities in a city in Canada. PARTICIPANTS: Residents who died in the LTC facilities in a 12-month period. Those who died suddenly (i.e., with no palliation period) or in a hospital were excluded. MEASUREMENTS: Symptoms highlighted in the literature as commonly found in the terminally ill and the matching treatments were recorded on an audit form created by the authors. Included were pain, dyspnea, noisy breathing, delirium, dysphagia, fever, and myoclonus. RESULTS: One hundred eighty-five charts were reviewed. A large number of patients were cognitively impaired. Cancer was the final diagnosis in 14% of cases. Respiratory symptoms were the most prevalent symptom, with dyspnea being first and noisy breathing third. Pain was second, with a prevalence similar to that found in studies of cancer patients. Dyspnea was not treated in 23% of the patients with this symptom; opioids were used in only 27% of cases with dyspnea. Ninety-nine percent of patients who experienced pain were treated for it. Less than one-third of patients with noisy breathing were treated. Delirium was not treated in 38% of the cases, and no anti-dopaminergic medications were administered. Nurses were primarily responsible for documenting end-of-life issues, supporting the families of the dying residents, and communicating with other team members. CONCLUSION: The focused chart audit identified the high prevalence of cognitive impairment in the patient population, which complicates symptom management. Respiratory symptoms predominated in the last 48 hours of life. This symptom profile differs from that of cancer patients, who, according to the literature, have more pain and less respiratory trouble. Management of symptoms was variable. Nurses played a crucial role in the care of dying residents through their documentation and communication of end-of-life issues. Appropriate palliative care education can provide knowledge and skills to all health-care professionals, including physicians, and assist them in the control of symptoms and improvement of quality of life for patients dying in LTC facilities.     

Interactive video specialty consultations in long-term care

Objectives: To assess provider and resident satisfaction with and outcomes of specialist physician consultations provided via interactive video to residents of a long-term care (LTC) center.
Design: Cross-sectional survey.
Setting: Two Veterans Affairs Medical Centers (VAMC) and a state LTC center.
Participants: Physicians (n=12) at the VAMC and nurses (n=30) and residents (n=62) at the LTC center.
Intervention: Interactive video conferencing to provide physician specialty visits to residents at the LTC center.
Measurements: Satisfaction ratings and record review to determine changes in treatment plan and follow-up care.
Results: Data were collected on 76 individual consultations in six clinics. The most frequent outcome was a change in treatment plan with the resident remaining at the LTC setting (n=29, 38%) or no change in treatment (n=26, 34%). Physicians' ratings were 78% good to excellent for usefulness in developing a diagnosis, 87% good to excellent for usefulness in developing a treatment plan, 79% good to excellent for quality of transmission, and 86% good to excellent satisfaction with the consult format. Overall, 72% of residents were satisfied with the consult format, and 92% felt that it was easier to obtain medical care via telemedicine. Nurses felt that the telemedicine clinics were a good use of their time and skills (100%).
Conclusion: There was a high rate of physician, patient, and nurse satisfaction with interactive video conferencing. Care delivered to residents of LTC settings via video conferencing offers a number of potential advantages, including avoidance of travel for patient and provider and potentially greater continuity of care.     

Tetanus immunity in long-term care facilities

OBJECTIVES: To investigate the correlates of tetanus immunity in the elderly residing in a long-term care facility in Hawaii. DESIGN: Cross-sectional. SETTING: A nursing home in Honolulu, Hawaii. PARTICIPANTS: Sixty subjects aged 65 and older: 30 men and 30 women. MEASUREMENTS: The interview included demographic information, immunization history, military service information, and other potential risk factors for tetanus. Serum tetanus antibody titers were measured. RESULTS: The data showed that 76.7% (46/60) had adequate tetanus titers. This is in stark contrast to previous studies, which have reported immunity rates of 27% to 46% in similar populations. There were significant associations between immunity and prior history of military service. There were no significant associations between immunity and past history of immunization, education, socioeconomic status, or sex. CONCLUSION: History of immunization from patients, families, or medical charts may be unreliable indicators of tetanus immunity. Recognizing patterns of and barriers to immunization could have important consequences for public health policy in long-term care institutions.