February/March 2000
written by and for Long Term Care Infection Control Nurses

Broad Street Solutions
James Marx, RN, MS, CIC Editor
PO Box 16557
San Diego, CA 92176
(619)656-7887 Voice/FAX
jmarx@concentric.net
 
 
 
 
 
 
 
 

Every ten years the Centers for Disease Control and Prevention (CDC) holds an international conference on infection control and health-care related infections. This year there were several abstracts presented on the practice of infection control in the long term care setting. For a full copy of the abstracts go to http://www.decennial.org/abstract.html. The following report is a summary of the proceedings.
 

Impact of Multi-Resistant Bacteria on the Quality of Life in Older Adults in Long-Term Care Facilities
This study conducted by M Leob et al found that residents colonized with MRSA or VRE had no difference in their quality of life, as measured by Geriatric Depression Scale and Dysfunctional Behavior Rating. The authors concluded that because few precautions are used, the effect on the quality of life was minimal. EDITORS NOTE: This may be different in facilities that use prolonged contact isolation for colonized residents, something this paper did not study.

Using Resource Utilization Groups as a Predictor of the Incidence of Healthcare-Associated Infection Rates
This study by Steele et al. was conducted in NorthEastern New York State and involved 16 long term care facilities. They collected surveillance data using standardized methods and submitted the data to a central registry, along with RUG-II scores. In relation to the Behavioral RUG-II category, residents who were classified in the Clinically Complex or Special Care category had an increased risk of infection, 1.21 and 1.62 respectively. They study concluded that RUG-II scores could be used was a risk stratification tool. EDITORS NOTE: Many facilities may now use the RUG-III score. These scores are used for financial reimbursement and may have application for risk stratification in both infectious and non-infectious adverse events.

Influenza and Pneumococcal Vaccination Rates in Nursing Home, U.S. 1997
This study was conducted by the CDC and presented by AR Buikema et al. found that 28% of residents had received the pneumococcal vaccine and 64% had received the influenza vaccine in 1997. This is far below the Healthy People 2000 goal of 80%, and the Healthy People 2010 goal of 90%. They suggested yearly influenza vaccination campaigns, assessing vaccination status on admission, giving pneumococcal vaccination when the past history is unknown, using standing orders for vaccination, documentation of vaccinations in the medical record and an annual assessment of vaccine rates. EDITORS NOTE: The number of residents vaccinated is now part of the survey process and is required on the HCFA 672-Resident Census and Conditions of Residents form.

Outbreak of Influenza among vaccinated Residents in a Nursing Home
This study, done in France by C Sartor et al., presented an investigation of an influenza outbreak in 1998. The outbreak started as a cluster of pneumonia among residents and staff. Influenza effected 42% of the residents and 34% of the staff. There was one hospitalization and three deaths. The index case was a staff member. Although 91% of the residents had been vaccinated, only 16% showed influenza antibody. It was not clear what percent of the staff had been vaccinated. EDITORS NOTE: Vaccination among the staff is critical to prevent introducing influenza into the facility. Staff members typically have higher vaccine response rates than the residents.

Analysis of Antibiotic Use in a Long Term Care Facility
This study by B Coignard et al. was conducted by the CDC and Cook County, IL Bureau of Health Services. They reviewed antibiotic use and found that 130 of 232 (56%) of residents received antibiotics in a one year period. The median length of treatment was 11 days. Urinary tract infection accounted the most use, 26%. Cultures did not seem to influence therapy. The authors concluded a need to guide emperic therapy with improved use of microbiology laboratory data. EDITORS NOTE: Inappropriate antibiotic use has been linked with development of resistant bacteria such as MRSA and VRE.

Nosocomial Infection Surveillance in Eight Long Term Care Facilities
This study was done in Massachusetts by KE Sands et al. The study use antibiotic prescribing as the indication of an infection and found the urinary tract infection rate of 0.9-3.4 infections per 1000 resident-days, and respiratory tract infection rates of 0.7-2.0 infections per 1000 resident-days. EDITORS NOTE: This study may have missed residents who developed infection and died or were transferred before treatment was prescribed. In addition, antibiotic prescribing habits vary between physicians and may account for some variability in infection rates when using this method.

Comparison of Universal Gloving to Contact Isolation Precautions to prevent transmission of Multidrug-Resistant Bacteria in a Long-Term Care Facility
This study was done by the CDC again in conjunction with the Cook County, IL Bureau of Health Services by WE Trick. They studied two methods of isolation precautions for the control of MRSA, VRE, K. pneumoniae and E. coli. The first method used traditional contact precautions for residents identified with a resistant bacteria. The second method use contact precautions (except routine gown use) for all residents, regardless of the presence or absence of an antibiotic resistant bacteria (Universal Gloving). There was no difference in the evidence of person-to-person spread. EDITORS NOTE: The role of gowns to prevent person-to-person transmission of bacteria has been questioned before. The cost impact of universal gloving was not examined.

Relaxation of Contact Isolation and its impact on VRE
This study by T Garrison was conducted at the Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis, MO. The authors concluded that in an acute care setting, routine use of gowns when giving care to patients colonized with VRE did not reduce person-to-person transmission. EDITORS NOTE: Most LTC facilities do not routinely use gowns when entering the room of a resident colonized or infected with VRE. The CDC currently recommends that gowns should be used routinely.

No Change in VRE rates after elimination of Contact Precautions at a Veterans Affairs Medical Center
This study was done by GV Oda at the Veterans Affairs Palo Alto Health Care System in Palo Alto, CA. The facility used Standard Precautions and decided to eliminate Contact Precautions for VRE, as recommended by the CDC. They compared infection rates for two years and found no change in the infection rates for the two most common sites of VRE infection, the urine and blood. They suggested elimination of Contact Precautions for residents colonized or infected with VRE. EDITORS NOTE: Elimination of unnecessary isolation precautions may help decrease cost of resident care. This area needs further study. Some LTC facilities already do not use Contact Precautions for residents with VRE.