Vaccinate
The leading cause of bacterial pneumonia is Streptococcus pneumoniae. It can often be prevented by vaccination with the pneumococcal vaccine (Pneumovax). This vaccine should be given at least once after the age of 65. The vaccine can be billed to Medicare. As you may know, the survey process now asks for the number of residents vaccinated for pneumococcal pneumonia (HCFA Form 672). Therefore you need a method to track who has been vaccinated. For information on vaccination call the National Institute on Aging at 800-222-2225, and ask for their packet, "Pneumonia Prevention:Its Worth A Shot."

Identify aspiration risk
Bedside assessment of swallowing is essential to identify those residents who are at risk of aspiration. A modified barium swallow study can also be used. Evaluation by a qualified person, such as speech therapist is often an essential component of a good aspiration risk assessment. Identifying those at risk and dietary modifications may be necessary. Evaluation by the dietitian is also essential, as is monitoring foods and liquids brought in by well meaning facility members.

Positioning
Maintaining a 30-45 degree elevation of the head during tube feeding will help reduce reflux to stomach contents into the respiratory tract. This position should be maintained for at least one hour after the feeding has been completed. Ideally, the resident should be sitting up while eating.

Clean equipment
Residents with tracheostomy are often colonized with bacteria. The presence of a foreign body, such as tracheostomy cannula, creates an environment for bacterial growth. Aseptic, regular cleaning of the tracheostomy equipment is essential. Most facilities now use disposable inner cannulas. In-line suction systems are preferred to the open suction systems. Respiratory equipment which is reused on the same resident needs to be cleaned and dried between uses. This is important for small volume or hand held nebulizers. These items should be rinsed and air dried between uses at a minimum. They should not be stored with liquid in the chamber between uses.

Common Bacterial Infections

While infections can be caused by a virus or fungus, bacteria remain the most common cause of infection on the skilled nursing facility. This article will review the most common sites of infection and identify the bacteria that are most frequently implicated to be the cause of infection.

Urinary Tract Infections
Usually the most frequent infection in a skilled nursing facility, urinary tract infections (UTI) are also the cause of frequent antibiotic use. Antibiotics for residents who have a positive urine culture and no clinical signs of infections have caused concern. Between 40-60% of elderly women have bacteruria without clinical signs of infection. The diagnosis of a UTI should include clinical signs of infection and a urine culture with no more than 2 organisms. Three of more organisms in a urine culture suggest a contaminated specimen was obtained and needs to be repeated. Lactobacillus and diptheroids are usually not pathogens.

Potential pathogens include:
Echerichia coli (E. coli), Proteus mirabilis, Enterococcus sp., and Pseudomonas sp.

Wound Infections
All wounds are colonized with bacteria. Obtaining a good specimen remains a challenge. Some have suggested that swab cultures are not a adequate diagnostic tool. If swab culture are obtained, the wound bed should be cleansed with normal saline before the specimen id obtained. If anaerobic organisms are suspected, a special transport container need to be obtained for the laboratory.

Potential pathogens for skin infections include:
Staphylococcus aureus, beta-hemolytic streptococci, Pseudomonas aeruginosa, Enterococcus sp. and Bacteroides (anaerobic).

Respiratory Tract Infections
Sputum specimens are not a reliable method to confirm the diagnosis of a respiratory tract infection. Most upper respiratory tract infections are caused by viruses. The diagnosis should be based on clinical signs of infection and chest x-ray. If a sputum specimen is sent, the report should show few epithelial cells and many white blood cells.

Potential Pathogens are:
Staphylococcus aureus, Streptococcus pneumoniae, beta-hemolytic streptococcus, Pseudomonas aeruginosa