Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference.

Establishing a clinical diagnosis of infection in residents of long-term-care facilities (LTCFs) is difficult. As a result, deciding when to initiate antibiotics can be particularly challenging. This article describes the establishment of minimum criteria for the initiation of antibiotics in residents of LTCFs. Experts in this area were invited to participate in a consensus conference. Using a modified delphi approach, a questionnaire and selected relevant articles were sent to participants who were asked to rank individual signs and symptoms with respect to their relative importance. Using the results of the weighting by participants, a modification of the nominal group process was used to achieve consensus. Criteria for initiating antibiotics for skin and soft-tissue infections, respiratory infections, urinary infections, and fever where the focus of infection is unknown were developed.

Practice guideline for evaluation of fever and infection in long-term care facilities.

The elderly population (i.e., persons aged > or = 65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that >40% of persons aged > or = 65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infection-control measures are not available in the LTCF.

Infection control in subacute care.

Little or no published data are available regarding infections or infection control measures in subacute care units in the United States. Infection-control measures designed for long-term care facilities should, in general, suffice for subacute care units. When developing an infection-control program for a subacute unit, one must be continuously cognizant of the objectives of care rendered by such a unit to ensure that policies and procedures are consistent with those objectives.

Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee.

There is intense antimicrobial use in long-term-care facilities (LTCFs), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and the virtual absence of relevant clinical trials. This position paper recommends approaches to management of common infections in LTCF patients and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the position paper acknowledges the unique aspects of provision of care in the LTCF.

The sequelae of hospitalization for ischemic stroke among older adults.

OBJECTIVES: To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality. DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups. SETTING: In-person and telephone interviews were conducted. PARTICIPANTS: A total of 6071 noninstitutionalized respondents 70 years old or older at baseline. MEASUREMENTS: Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression. RESULTS: The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression-adjusted mean number of instrumental activities of daily living and lower body function limitations at follow-up. CONCLUSION: Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed.

The risk of hospitalization for ischemic stroke among older adults.

OBJECTIVES: The purpose of this study was to identify risk factors for stroke and to estimate their relative importance in a large, nationally representative sample of very old men and women. METHODS: The study was designed as a secondary analysis of the Longitudinal Study on Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984 to 1991. Participants were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for ischemic stroke was defined as having one or more episodes with a primary discharge diagnosis containing ICD-9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Multivariable proportional hazards regression was used to estimate the risks associated with previously identified epidemiologic factors. RESULTS: Five hundred and three persons (8.3%) had at least one primary discharge diagnosis of ischemic stroke. In descending order of importance-based on the partial r statistics associated with their adjusted hazards ratios (AHRs), the salient risk factors were having a previous history of stroke (AHR = 2.86), age (AHR = 1.04 per year), diabetes (AHR = 1.78), male gender (AHR = 1.42), lower body limitations (AHR = 1.09 per limitation), arthritis (AHR = 0.74), hypertension (AHR = 1.29), and poverty (AHR = 1.33). CONCLUSION: Patients presenting with the high risk factors identified in this study should be considered for further evaluation and monitoring. Current protocols for the therapeutic management of these higher risk patients should be considered, and compliance should be encouraged.

Humoral and cellular immune responses following vaccination with purified recombinant hemagglutinin from influenza A (H3N2) virus.

Adults were immunized with either baculovirus-expressed, purified recombinant hemagglutinin (rHA) from influenza A/Beijing/32/92 (H3N2) virus or saline placebo and evaluated for humoral and in vitro cellular immune responses. Compared with responses in placebo recipients, vaccinees had greater postvaccination H3(Beijing/32) HA (H3)-specific lymphoproliferation and interleukin (IL)-2, IL-10, and interferon-gamma (IFN-gamma) production. Mean increases in the production of IL-10 (> or = 20-fold) and IL-2 (10-fold) were relatively greater than that of IFN-gamma (4-fold) or IL-4 (no change). Serum H3 antibodies were induced in 80% of rHA recipients, and the rise in antibody titer was significantly correlated with changes in IL-2, IL-10, and IFN-gamma concentrations. Vaccination with rHA only minimally enhanced anti-influenza virus cytotoxic T lymphocyte activity. These data demonstrate that rHA immunization of adults elicits a significant recall response by memory B and T lymphocytes and suggest that the cytokine response to vaccination has a T helper cell type 0-like profile.

Rational approach to the antibiotic treatment of pneumonia in the elderly.

The incidence of pneumonia is highest among the aged compared with other adult populations, and causes significant morbidity and mortality among this group. Most episodes of pneumonia are caused by aspiration of oropharyngeal flora into the lungs and failure of lung defence mechanisms to eliminate the aspirated bacteria. Studies in elderly patients have shown a high rate of oropharyngeal carriage of Gram-negative bacilli and polymicrobial/mixed flora pneumonias, especially in debilitated elderly patients in nursing homes or hospitals. This information is helpful to practitioners in prescribing empirical antibiotic therapy for elderly patients with pneumonia. Because of the many additional concerns which must be considered in the rational selection of an antibiotic regimen, e.g. route of administration, compliance, drug pharmacokinetics and pharmacodynamics, drug toxicity, and drug-disease interactions, it is also helpful for practitioners to become familiar with a small number of the large group of available antibiotics. Based on these considerations and the presumed bacteriology of pneumonia in the elderly in the 3 clinical settings (community, nursing home and hospital), a limited number of antibiotics are recommended for empirical antibiotic regimens for elderly patients with pneumonia. In particular, beta-lactamase inhibitors and cotrimoxazole (trimethoprim-sulfamethoxazole) are recommended, with ciprofloxacin as an alternative agent. There is a limited role for third-generation cephalosporins and extended-spectrum penicillins. Aminoglycosides are only recommended for patients with pneumonia in the intensive care unit on mechanical ventilation. Monotherapy (single agent) should be used whenever possible.

Disposition of intramuscular cefonicid in elderly patients.

OBJECTIVE: To examine the disposition of intramuscular (IM) cefonicid in elderly patients with bacterial pneumonia. DESIGN: Pharmacokinetic study. SETTING: A 620-bed university-affiliated long-term care institution with its own 39-bed acute care unit. PATIENTS: Nine consecutive elderly patients with bacterial pneumonia treated with IM cefonicid. MEASUREMENTS: Blood samples were collected on the seventh day of therapy over a 24-hour period and analyzed by high performance liquid chromatography. Pharmacokinetics parameters (volume of distribution, half-life, and clearance) and protein binding were calculated. Clinical outcome of IM cefonicid therapy was also noted. RESULTS: The estimated creatinine clearance (CIcr) ranged from 32 to 145 mL/min. Peak cefonicid serum concentrations occurred at 0.5-1.5 hours, with a mean value of 118 +/- 41 micrograms/mL. Cefonicid concentrations declined monoexponentially to 57 +/- 16 micrograms/mL at 12 hours and 28 +/- 14 micrograms/mL at 24 hours. The mean apparent distribution volume was 0.2 +/- 0.07 L/kg, and the mean apparent total clearance was 15 +/- 12 mL/min. The half-life ranged from 3.1 to 38 hours. A linear correlation was noted between Clcr and cefonicid clearance (r = 0.99). CONCLUSIONS: Cefonicid absorption was variable among these patients, and the serum half-life was longer than previous values noted in younger patients with similar degree of renal dysfunction. Pharmacokinetic and clinical outcome data from our study group indicate the potential role of IM cefonicid in treating elderly patients with bacterial pneumonia.

Methicillin-resistant Staphylococcus aureus: a questionnaire survey of 75 long-term care facilities in western New York.

OBJECTIVES: To determine the frequency of recognition of methicillin-resistant Staphylococcus aureus (MRSA) as an infection control problem and its prevalence among long-term care facilities, and to evaluate whether certain long-term care facility characteristics such as bed size, ownership, level of infection control activity, and frequency of resident transfers to acute care hospitals are related to the recognition or prevalence of MRSA in this setting. DESIGN: Questionnaire survey. SETTING: Seventy-five long-term care facilities in the 8 counties of western New York. RESULTS: Seventy-five of 81 (92.6%) long-term care facilities returned a completed questionnaire. Seventy-nine percent were considered to have a "limited" level of infection control activity (part-time infection control practitioner who spent less than 10 hours a week on infection control activities). The larger the long-term care facility, the more time was spent on infection control activities (p = .01). Seventy-two percent of the long-term care facilities screened new admissions for MRSA by reviewing culture reports; 69% of the long-term care facilities had a specific infection control policy for MRSA. Sixteen of the 75 (21%) facilities felt they had an infection control problem with MRSA. By univariate analysis, the only characteristic significantly associated with this recognition was use of nurse practitioners or physician assistants by a facility (p < .05). Eighty-one percent of the 75 long-term care facilities had identified one or more patients with MRSA in the year prior to the survey. By univariate analysis, the only characteristics that were significantly associated with the number of residents with MRSA were the monthly average number of residents transferred to acute care facilities (p = .034) and facility bed size (p = .022); there was also a trend toward increasing intensity of infection control activities (p = .085). However, facility bed size and the average number of resident transfers per month to acute care facilities were strongly associated (p = .0002). By stepwise logistic regression analysis, only bed size was an independent predictor of the number of residents with MRSA. Many long-term care facilities had tried to eradicate MRSA; ciprofloxacin was most commonly used to eradicate MRSA. CONCLUSIONS: The vast majority of the 75 long-term care facilities in the 8 counties of western New York have identified patients with MRSA, although only a minority (21%) of them actually believed that an infection control problem existed. Facility size (a surrogate for the monthly average number of resident transfers to acute care facilities) seems to be an important factor in determining the number of residents with MRSA in long-term care facilities in our geographic region. The major longitudinal studies of MRSA in such facilities have so far been done only in Veterans Affairs facilities. Further studies are needed in freestanding long-term care facilities, the largest group of long-term care facilities in the United States, to determine the epidemiology of MRSA in this setting and to develop practical and valid infection control methods for residents with MRSA.

Vaccinations.

Tetanus-diphtheria toxoid, influenza virus vaccines, and pneumococcal vaccine are recommended for older persons in the United States by the Centers for Disease Control. But most high-risk older persons remain unvaccinated, despite experiencing relatively high rates of tetanus, influenza-related complications, and pneumococcal disease, and having available effective, safe, and low-cost vaccines. Strategies for improving these vaccination rates require an intensive approach focused on (1) identifying older persons with high-risk conditions, (2) improving the delivery of vaccines, (3) improving the acceptance of vaccines by older persons, and (4) establishing mandatory immunization programs.

Streptococcus pyogenes outbreak in a long-term care facility.

BACKGROUND: Although outbreaks involving Streptococcus pyogenes have been uncommon among the elderly population, recent reports suggest that this organism is an important nosocomial pathogen among institutionalized older patients and carries significant morbidity and mortality. An outbreak of S. pyogenes, type M12, T12, occurred in a large long-term care institution serving the ill and chronically disabled. The outbreak involved 14 residents of the intermediate care facility and lasted for 4 months. METHODS: A prospective epidemiologic investigation was initiated at the onset of the outbreak. Pertinent clinical and demographic information regarding both residents and personnel was obtained by interview, review of medical and surveillance records, and examination of patients for lesions. Cultures were obtained within 24 hours of symptom onset from those with characteristic clinical symptoms. Unpaired convalescent sera were tested for group A streptococcal extracellular antigens by a rapid hemagglutination slide test. Control measures included active surveillance of residents and staff for suspicious clinical syndromes, transfer of high-risk patients, elimination of a common seating area, and improved handwashing and hygiene measures. RESULTS: The attack rate was 7.5%, with 64.3% of these patients residing on one unit. S. pyogenes was isolated from eight residents, 5 residents had a characteristic syndrome and an elevated streptozyme hemagglutination titer of 400, and 1 resident died within hours of having cellulitis of the groin. Clinical syndromes included cellulitis, pharyngitis, bronchitis, pneumonia, and septicemia. Seven residents required acute care; two residents died within 3 weeks of the onset, yielding a case fatality rate of 14.3%. CONCLUSIONS: The major means of transmission appeared to be direct contact between residents, although transmission from an infected staff member may have accounted for some cases. The hypothesis of long-term colonization was supported by the extended times between infections. The severity of illness and the apparent transmission through direct contact between residents warrants (1) early detection of infected lesions, (2) recognition of invasive illness, (3) prompt effective treatment, and (4) surveillance for S. pyogenes infections among residents and personnel.

Infection control in the nursing home: the physician's role.

Infection control in the nursing home or long-term care facility is an increasingly complex activity. The high rates (approximately 15%) and special risks (group activities, crowding) for nosocomial infection demand special attention by attending physicians. Some specific responsibilities include: recognition of infection; knowledge and use of basic infection control principles; appropriate antibiotic use; review of immunizations; facilitation of communications among office, hospital, and long-term care facility; and involvement with infection control program(s).

Risk factors for nosocomial pneumonia in the elderly.

PURPOSE: Pneumonia is now the second most frequent hospital-acquired infection in acute-care facilities, and recent studies indicate that the incidence rate for nosocomial pneumonia in long-term-care facilities is of similar magnitude. The mortality rate is high, especially in the elderly. With prevention of this complication as an overall priority, this study was designed to determine the risk factors associated with nosocomial pneumonia in the elderly in both acute-care and long-term-care settings. PATIENTS AND METHODS: An epidemiologic case-control study was undertaken to compare patients or residents who developed radiographically confirmed pneumonia with control subjects who did not have and did not develop respiratory infection. Thirty-three cases were identified in the acute-care setting during the 18-week period, and 27 cases were identified in the long-term-care setting. Two matched controls were chosen for each case. Data collection involved review of the medical record and verification by medical personnel while the cases or controls were still institutionalized. Risk factor variables were analyzed using an odds ratio and 95% confidence interval calculation for matched triplets, and chi-square analysis. Selected risk factors were entered into a backward stepwise logistic regression to determine the best combination of risk factors for each setting. RESULTS: In the acute-care setting, current neurologic disease, current renal disease, deteriorating health, altered level of consciousness, disorientation, dependent bathing, dependent bowel function, dependent feeding, aspiration, difficulty with oropharyngeal secretions, and presence of a nasogastric tube were significant risk factors. In the long-term-care setting, deteriorating health, malnourishment, recent weight change, altered level of consciousness, disorientation, aspiration, difficulty with oropharyngeal secretions, suctioning, presence of a nasogastric or gastric tube, upper respiratory infection, inhalation therapy, increased confusion, and increased agitation were determined to be significant. Current pulmonary disease, previous infection, and antibiotic therapy were found not to be associated with the onset of nosocomial pneumonia. Through logistic regression, the best models for prediction of nosocomial pneumonia in the elderly were identified. In the acute-care setting, difficulty with oropharyngeal secretions and presence of a nasogastric tube were the best predictors. In the long-term-care setting, difficulty with oropharyngeal secretions, deteriorating health, and occurrence of an unusual event were the best combination of predictors. CONCLUSION: These data confirm prior findi

Seizure with ciprofloxacin and theophylline combined therapy.

Ciprofloxacin has been reported to cause theophylline toxicity by inhibiting theophylline metabolism. A 93-year-old woman without a known seizure history, while on ciprofloxacin and theophylline combined therapy, experienced a grand mal seizure. Her serum theophylline concentration at the time was 20 micrograms/mL. On previous occasion of theophylline toxicity, she had a serum theophylline concentration of 27 micrograms/ml but the patient did not experience any seizure. Several reports suggest that the combination of theophylline and ciprofloxacin has an additive inhibitory effect on gamma-aminobutyric acid (GABA) sites. Inhibition of the binding of GABA to its receptor sites has been related to the convulsant effects of other drugs. The seizure in our patient may have been caused by altered pharmacokinetics and pharmacodynamics brought about by combined therapy of theophylline and ciprofloxacin.