Long Term Care facilities present unique infection prevention risks. Communal living environments, in general, provide an excellent breeding ground for bacteria and viruses with closed ventilation systems, regular use of common bathing facilities and shared dining areas. Residents with dementia and other conditions may have a limited ability to perform proper hand hygiene and cough etiquette, and often have increased dependence on staff to provide ADL care. In addition, each resident brings their own unique microbiome to the facility, developed over the years based on their unique medical history, diet and environmental factors.
The Infection Preventionist’s Role
The effective Infection Preventionist (IP) must learn to be an excellent steward of antibiotic use and develop clear lines of communication with prescribing practitioners to help prevent the development or spread of multi-drug resistant organisms (MDROs) and promote judicious use of antibiotics, including the use of the most narrow-spectrum antibiotic needed based on disease process and culture reports. Differing sources report that somewhere between 60-80% of all long-term care residents will have a course of antibiotics within the first 6 months of their stay. Based on chart review and nationally recognized clinical criteria, more than 50% of these antibiotic courses may have been unnecessary. It is the IP’s duty to monitor and guide evaluation and treatment decisions to prevent adverse outcomes.
The IP should be proficient in standards of care for the prevention, assessment and management of the most common infectious diseases generally found in Long Term Care which include:
- Urinary Tract Infections (UTIs)
- Pneumonia and other Respiratory Infections
- Skin and Soft Tissue Infections (SSTI)
- Gastrointestinal infections including Clostridioides difficile (C.Diff)
Many residents come to LTC already colonized with asymptomatic bacteriuria. They commonly remain symptom free, but if you were to perform a surveillance culture, they would often demonstrate greater than 100K colony counts. This may lead you to believe they have an infection; however, they demonstrate no symptoms. Should these residents be treated? The answer is a resounding NO according to guidance from the National Institute of Health. In addition, the effective IP must be diligent in monitoring to ensure that antibiotics are not prescribed for symptoms such as altered mental status, which is not recognized as a symptom of UTI based on either NHSN or McGeer’s criteria. The role of staff in UTI prevention cannot be overstated. Proper perineal care is critical to prevent development of UTI. Staff competency should be completed on hire and routinely thereafter, especially if the IP recognizes a trend of similar organisms within a specific care area in the facility or a significant increase in UTI’s over a period of time.
Pneumonia and other Respiratory Infections
Residents, especially those being admitted from acute care facilities, often have multiple exposures to respiratory microbes that promote the development of infection. In addition, many LTC residents have medical conditions that decrease their ability to swallow safely or cough effectively, both natural mechanisms which help keep a healthy respiratory system infection free. Currently, relevant infections in the community (or, in the case of COVID-19, the world) also will guide the IP’s recommendations for treating and/or isolating residents with respiratory symptoms. A resident with dementia may not perform respiratory hygiene/cough etiquette or hand hygiene effectively without staff intervention. Add wandering behaviors to the mix and you have a recipe for rapid spread through units and even entire facilities. The use of masks for source control, isolation precautions and the judicious use of antibiotics, when necessary, can help mitigate the spread of respiratory bacteria and viruses.
Skin and Soft Tissue Infections
The skin serves as the body’s primary barrier to the entry of microbes. The aging process, poor fluid intake, pressure ulcers, skin tears, and other problems which can decrease the effectiveness of this barrier, all place LTC residents at risk. The general condition of a resident’s skin is critical. Dry skin can serve as a portal of entry for pathogens. Regular use of moisturizers, gentle cleansing agents with proper rinsing, and staff using caution when providing care can all help improve the overall health of the resident’s skin. If there is an actual alteration to the integrity of the skin, such as a pressure ulcer, skin tear or vascular process such as ulceration or dermatitis, it is imperative that staff monitor for and report any changes to the skin so treatment can be initiated. Rapid detection of skin changes and initiation of topical treatment can often prevent the need for systemic antibiotics, which helps maintain the resident’s microbiome.
Gastrointestinal Infections including Clostridium difficile (C.Diff)
Clarity on the resident’s medical history is critical to determining the risk of C.Diff infection. Over the course of their lifetime, how many courses of antibiotics have they had? What were the antibiotics? Obtaining a full medical history may be unattainable, but the IP should presume that the resident’s normal gut flora has been exposed to and altered in some way by antibiotics over their lifetime. A history of C.Diff infection will place a resident at higher risk for repeat infection, and symptoms of diarrhea must be addressed promptly to prevent spread. Reducing exposure to antibiotics and to C. difficile spores are the cornerstones of CDI prevention. (Infectious Diseases in Older Adults of Long-term Care Facilities: Update on Approach to Diagnosis and Management – PMC (nih.gov)). Staff must be educated that the use of alcohol based hand sanitizer is not effective with gastrointestinal infections, including C.Diff, and hand washing must be performed. There can be no sharing of toileting facilities, and the resident’s hands must be washed. Environmental surfaces must be cleaned thoroughly and disinfected, and the IP should check with the housekeeping department to ensure that cleaning products are sporicidal.
Development of a strong, open line of communication with your Medical Director and other medical staff will be critical for the effective IP. Monitoring and tracking the current microbiome within the facility through culture reports can give you an idea of what is already present in your facility, and the careful selection of appropriate antibiotics based on specificity and infectious process will help keep your residents safe from adverse effects of antibiotic use. And, of course, having the buy in of all staff members in your infection prevention and antibiotic stewardship plan is critical. From the frontline nurses to clinical team leadership, the staff development nurse and the QAPI team, each member of the IDT will play a role in promoting and managing an effective IPC program.
Join Proactive on April 19th for the next webinar in our Proficient Infection Preventionist Series: Infectious Diseases Common in Post Acute Settings. Access earlier sessions of this series on demand at: https://www.proactivemedicalreview.com/the-proficient-infection-preventionist/
Contact Proactive for assistance in driving IPC program quality or for consulting services related to Directed Plans of Correction.