Antimicrobial resistance in long-term-care facilities.

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term-care facilities (LTCFs). Gram-negative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified.

Implications of methicillin-resistant Staphylococcus aureus on nursing home practice.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is being isolated with increasingly frequency from nursing home patients. There is a limited choice of antibiotics available to treat infections caused by the organism. Control measures for nursing homes have not been well established. METHODS: Using the key words "methicillin," "homes for the aged," and "long-term care," and also using the text term "MRSA," the MEDLINE files were searched from 1966 to 1989 using a CD ROM system. Articles occurring subsequent to this search, until the manuscript was submitted, were accessed using a monthly update from the MEDLINE database using the same key words. RESULTS: MRSA prevalence rates as high as 34 percent have been reported from long-term care settings. Risk factors for developing MRSA include being sick, debilitated, and functionally impaired. Frequent use of antibiotics and invasive devices, such as catheters, are also identified risk factors. The implication of MRSA colonization on patient outcomes is not clear. Vancomycin remains the drug of choice for treating MRSA infections. Control measures include surveillance of new and established cases and the introduction of isolation procedures. Patients colonized with MRSA should not be refused admission to a nursing home because of their MRSA status. CONCLUSIONS: MRSA in nursing homes will continue to increase. There are resulting implications for patient care, health care costs, and admission and discharge policies. Research should first establish what effect MRSA colonization has on clinical outcomes in this setting and, if necessary, go on to develop clinical and cost effective methods of prevention and control.

Bacillus species isolates from cerebrospinal fluid in patients without shunts.

Of 849 CSF cultures done at Hartford Hospital, nine were positive for nonanthrax Bacillus species. Differentiation of true nonanthrax Bacillus species infection from contamination requires careful consideration of the clinical findings, the clinical course, and the laboratory data. In seven patients the nonanthrax Bacillus species represented contamination. In two patients the nonanthrax Bacillus species represented true infection. In one of these infected patients, nonanthrax Bacillus species complicated a cranial gun shot wound. Bacillus cereus meningitis developed in the second patient, a premature infant, following sepsis from a contaminated IV catheter. Nonanthrax Bacillus species, especially B cereus, can be resistant to penicillins and cephalosporins when nonanthrax Bacillus species infections are being treated, susceptibility testing should always be performed.

Infections in the elderly.

Elderly patients appear to be predisposed to serious infections because of coexisting chronic or acute diseases that disrupt integumental barriers, impair clearance mechanisms, or compromise cellular responses to infection. The severely disabled elderly are particularly at high risk, because they are often unable to care for their personal hygiene and are malnourished, immobile, incontinent, or institutionalized. Senescence of the immune system per se does not appear to be a major predisposing factor for infection in this population. Infections in the elderly frequently present with non-specific signs and symptoms. Clues of focal infection are often absent or obscured by underlying chronic conditions. Once a site of infection is identified, clinicians should initiate therapy with broad-spectrum antibiotics to treat the array of most likely potential pathogens. Strategies to prevent infection include programs to help the elderly maintain active, non-institutionalized life-styles and the appropriate use of available vaccines.