Antimicrobial-resistant bacteria in long-term care facilities: infection control considerations.

Abstract

With the emergence of two cases of infections with vancomycin-resistant Staphylococcus aureus in 2002, the infection control community has once again focused intense interest on the prevention and control of antimicrobial-resistant Grampositive bacteria. 1 Developing and implementing prevention and control programs for antimicrobial-resistant pathogens in long-term care facilities (LTCFs) is especially challenging. A comprehensive approach should not only promote wise use of antimicrobial agents but also improve the prevention and diagnosis of infections and the prevention of transmission of antimicrobial-resistant pathogens. This article will review barriers and challenges for infection control in LTCFs, risk factors for infections in LTCF, and opportunities for improving infection prevention and control. INFECTION CONTROL CHALLENGES IN LTCF More than 40% of adults in the United States will spend some time in LTCFs before they die; the majority (53%) of residents in LTCFs will spend 1 year. 2,3 As LTCFs become an increasingly important site of medical care and drug prescribing for the elderly, prevention and control of infectious diseases in LTCFs will become both increasingly important and challenging. The residential nature of LTCFs promotes socialization of residents through group activities, both in and outside the LTCF. Although these activities are key to promoting good physical and mental health for residents, they may increase the risk of exposure to infectious diseases, including those caused by antimicrobial-resistant bacteria. Group settings for eating and physical therapy, vital to the maintenance of resident independence and functional status, may increase risk for person-toperson transmission, or exposure to potential fomites, such as equipment used in physical or occupational therapy. The evaluation and management of infectious diseases in LTCFs is also complicated. The availability of clinicians to evaluate febrile residents may be limited, and diagnostic studies, including microbiologic cultures, are generally less available than in acute-care facilities. Consequently, nursing assistants usually perform the initial resident assessment, and licensed nurses relay important findings to clinicians, usually by telephone. 4 In LTCFs, antimicrobials for the empiric treatment of suspected infection often are prescribed without on-site clinician evaluation or diagnostic testing. 5,6 When diagnostic testing is performed, only limited tests are available in most LTCFs. This, together with outsourcing of most laboratory work, may lead to suboptimal timeliness of reporting and, in some situations, inaccurate or misleading results. When residents are acutely ill or diagnostic testing is not available in LTCFs, residents often are transferred to the emergency departments of acute-care hospitals. Not surprisingly, evaluation and management of infection accounts for approximately one quarter of resident transfers from LTCFs to hospitals. 7