SHEA/APIC Guideline: Infection prevention and control in the long-term care facility

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SHEA/APIC Guideline: Infection prevention and control in the long-SHEA/APIC Guideline: Infection prevention and control in the long-

term care facility term care facility

Philip W. Smith

University of Nebraska Medical Center

, [email protected]

Gail Bennett

ICP Associates, Inc

, [email protected]

Suzanne Bradley

University of Michigan Medical School

, [email protected]

Paul Drinka

University of Wisconsin-Madison

Ebbing Lautenbach

Hospital of the University of Pennsylvania

, [email protected]

See next page for additional authors

Follow this and additional works at: https://digitalcommons.unl.edu/veterans

Smith, Philip W.; Bennett, Gail; Bradley, Suzanne; Drinka, Paul; Lautenbach, Ebbing; Marx, James; Mody,

Lona; Nicolle, Lindsay; and Stevenson, Kurt, "SHEA/APIC Guideline: Infection prevention and control in the

long-term care facility" (2008).

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Authors Authors

Philip W. Smith, Gail Bennett, Suzanne Bradley, Paul Drinka, Ebbing Lautenbach, James Marx, Lona Mody,

Lindsay Nicolle, and Kurt Stevenson

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veterans/75

SHEA/APIC Guideline:

Infection prevention and control

in the long-term care facility

Philip W. Smith, MD,

Gail Bennett, RN, MSN, CIC,

Suzanne Bradl ey, MD,

Paul Drinka, MD,

Ebbing Lautenbach, MD,

James Marx, RN, MS, CIC,

Lona Mody, MD,

Lindsay Nicolle, MD,

and Kurt Stevenson, MD

July 2008

Long-term care facilities (LTCFs) may be deﬁned as

institutions that provide health care to people who

are unable to manage independently in the commu-

nity.

This care may be chronic care management or

short-term rehabilitative services. The term nursing

home is deﬁned as a facility licensed with an organized

professional staff and inpatient beds that provides

continuous nursing and other services to patients

who are not in the acute phase of an illness. There is

considerable overlap between the 2 terms.

More than 1.5 million residents reside in United

States (US) nursing homes. In recent years, the acuity

of illness of nursing home residents has increased.

LTCF residents have a risk of developing health care-

associated infection (HAI) that approaches that seen in

acute care hospital patients. A great deal of information

has been published concerning infections in the LTCF,

and infection control programs are nearly universal in

that setting. This position paper reviews the literature

on infections and infection control programs in the LTCF.

Recommendations are developed for long-term care

(LTC) infection control programs based on interpreta-

tion of currently available evidence. The recommenda-

tions cover the structure and function of the infection

control program, including surveillance, isolation

precautions, outbreak control, resident care, and

employee health. Infection control resources are also

presented.

Hospital infection control programs are well estab-

lished in the US. Virtually every hospital has an infec-

tion control professional (ICP), and many larger

hospitals have a consulting hospital epidemiologist.

The Study on the Efﬁcacy of Nosocomial Infection

Control (SENIC) documented the effectiveness of a hos-

pital infection control program that applies standard

surveillance and control measures.

The major elements leading to a HAI are the infec-

tious agent, a susceptible host, and a means of trans-

mission. These elements are present in LTCFs as well

as in hospitals. It is not surprising, therefore, that

almost as many HAIs occur annually in LTCFs as in

hospitals in the US.

The last 2 decades have seen increased recognition

of the problem of infections in LTCFs, with subsequen t

widespread development of LTCF infection control pro-

grams and deﬁnition of the role of the ICP in LTCFs.

An increasingly robust literature is devoted to LTC

infection control issues such as the descriptive epide-

miology of LTCF infections, the microbiology of LTCF

infections, outbreaks, control measures, and isolation.

Nevertheless, there is as yet no SENIC-equivalent study

Professor of Infectious Diseases, Colleges of Medicine and Public

Health, University of Nebraska Medical Center, Omaha, Nebraska

;

President, ICP Associates, Inc, Rome, Georgia

; Professor of Internal

Medicine, Divisions of Infectious Diseases and Geriatric Medicine VA

Ann Arbor Healthcare System, and the University of Michigan Medical

School, Ann Arbor, Michigan

; Clinical Professor, Internal Medicine/Ger-

iatrics, University of Wisconsin-Madison, and Medical College of Wis-

consin–Milwaukee, Wisconsin

; Associate Professor of Medicine and

Epidemiology, Associate Hospital Epidemiologist, Hospital of the Uni-

versity of Pennsylvania, and Senior Scholar, Center for Clinical Epidemi-

ology and Biostatistics, University of Pennsylvania School of Medicine,

Philadelphia, Pennsylvania

; Infection Preventionist, Broad Street Solu-

tions, San Diego, California

; Assistant Professor, Divisions of Geriatric

Medicine, University of Michigan Medical School, and Geriatric Re-

search and Education Center, Veteran Affairs Ann Arbor Healthcare

System, Ann Arbor, Michigan

; Professor, Internal Medicine and Medical

Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada

;

and Associate Professor of Medicine, Division of Infectious Diseases,

Department of Internal Medicine, The Ohio State University College

of Medicine, Columbus, Ohio.

Address correspondence to Philip W. Smith, MD, Section of Infectious

Disease, University of Nebraska Medical Center, 985400 Nebraska

Medical Center, Omaha, NE 68198-5400

E-mail: pwsmith@unmc.edu.

Am J Infect Control 2008;36:504-35.

0196-6553/$34.00

Control and Epidemiology, Inc, and Society for Healthcare

Epidemiology.

doi:10.1016/j.ajic.2008.06.001

504

American Journal of Infection Control, Volume 36, Issue 7, September 2008, Pages 504-535

This article is a U.S. government work, and is not subject to copyright in the United States.

documenting the efﬁcacy of infection control in LTCFs,

and few controlled studies have analyzed the efﬁcacy

or cost-effectiveness of the speciﬁc control measures

in that setting.

Although hospitals and LTCFs both have closed

populations of patients requiring nursing care, they

are quite different. They differ with regard to pay-

ment systems, patient acuity, availability of labora-

tory and x-ray, and nurse-to-patient ratios. More

fundamentally, the focus is different. The acute

care facility focus is on providing intensive care to

a patient who is generally expected to recover or im-

prove, and high technology is integral to the process.

In LTCFs, the patient population may be very heter-

ogeneous. Most LTCFs carry out plans of care that

have already been established in acute care or eval-

uate chronic conditions. The LTCF is functionally the

home for the resident, who is usually elderly and in

declining health and will often stay for years, hence

comfort, dignity, and rights are paramount. It is a

low-technology setting. Residents are often trans-

ferred between the acute care and the LTC setting,

adding an additional dynamic to transmission and

acquisition of HAIs.

Application of hospital infection control guidelines to

the LTCF is often unrealistic in view of the differences

noted above and the different infection control re-

sources. Standards and guidelines speciﬁc to the LTCF

setting are now commonly found. The problem of devel-

oping guidelines applicable to all LTCFs is compounded

by the varying levels ofnursing intensity (eg, skilled nurs-

ing facility vs assisted living), LTCF size, and access to

physician input and diagnostic testing.

This position paper provides basic infection control

recommendations that could be widely applied to

LTCFs with the expectation of minimizing HAIs in

LTC. The efﬁcacy of these measures in the LTCF, in

most cases, is not proven by prospective controlled

studies but is based on infection control logic, adapta-

tion of hospital experience, LTCF surveys, Cente rs for

Disease Control and Prevention (CDC) and other guide-

lines containing speciﬁc recommendations for LTCFs,

and ﬁeld experience. Every effort will be made to

address the unique concerns of LTCFs. Because facili-

ties differ, the infection risk factors speciﬁc to the

resident population, the nature of the facility, and the

resources available shoul d dictate the scope and focus

of the infection control program.

In a number of instances, speciﬁc hospital-oriented

guidelines have been publ ished and are referenced

(eg, guidelines for prevention of intravascular (IV)

device-associated infection). These guidelines are

relevant, at least in part, to the LTC setting but may be

adapted depending on facility size, resources, resident

acuity, local regulations, local infection control issues,

etc. Reworking those sources to a form applicable to

all LTCFs is beyond the scope of this guideline.

Any discussion of infection control issues must be

made in the context of the LTCF as a community. The

LTCF is a home for residents, a home in which they

usually reside for months or years; comfort and

infection control principles must both be addressed.

BACKGROUND

Demography and deﬁnitions

The US population aged 65 to 85 years is increasing

rapidly, and the population aged 85 years and older is

expected to double by 2030.

One of every 4 persons

who reach the age of 65 can be expected to spend

part of his or her life in a nursing home; more people

occupy nursing home beds than acute care hospital

beds in the US.

Approximately 1.5 million persons

in the US reside in a nursing home; there are 15,000

nursing homes in this country.

Ninety percent of nurs-

ing home residents are over 65 years of age, and the

mean age of residents is over 80 years.

A LTCF is a residential institution for providing nurs-

ing care and related services to residents. It may be

attached to a hospital (swing-bed) or free standing;

the latter is often called a nursing home. A resident is

a person living in the LTCF and receiving care, analo-

gous to the patient in a hospital.

Scope of position paper

This position paper addresses all levels of care in the

LTCF. The focus is speciﬁcally the LTCF, also known as

the nursing home, caring for elderly or chronically ill

residents. These recommendations generally also

should apply to special extended care situations

(such as institutions for the mentally retarded, psychi-

atric hospitals, pediatric LTCFs, and rehabilitation hos-

pitals). However, other extended care facilities may

have different populations (eg, the residents of institu-

tions for the mentally retarded are much younger than

nursing home residents), different disease risks

(eg, hepatitis B in psychiatric hospitals), or different

levels of acuity and technology (eg, higher acuity in

long-term acute care facilities or LTACs). Thus, the

recommendations may need to be adapted for these

special extended care situations.

Changes from prior Guideline. This position paper

is similar to the 1997 Society for Healthcare Epidemiol-

ogy of A merica (SHEA)/Association for Professionals in

Infection Control and Epidemiology (APIC) guideline,

although the present version reﬂects an updating of

research and experience in the ﬁeld. Several important

areas of discussion are new or changed.

Smith et al September 2008 505

INFECTIONS IN THE LONG-TERM CARE

FACILITY

Epidemiology

In US LTCFs, 1.6 million to 3.8 million infections

occur each year.

In addition to infections that are

largely endemic, such as urinary tract infections

(UTIs) and lower respiratory tract infections (LRTIs),

outbreaks of respiratory and gastrointestinal (GI) infec-

tions are also common.

The overall infection rate in

LTCFs for endemic infections ranges from 1.8 to 13.5

infections per 1000 resident-care days.

For epidemics,

good estimates are difﬁcult to ascertain, but the litera-

ture suggests that several thousand outbreaks may oc-

cur in US LTCFs each year.

8,9

The wide ranges of

infections and resulting mortality and costs illustrate

the challenge in understanding the epidemio logy of

infections and their impact in LTCFs. There are cur-

rently little data and no national surveillance systems

for LTCF infections; the estimates have been calculated

based on research studies and outb reak reports from

the medical literature.

As a part of aging, the elderly have diminished

immune response including both phenotypic and

functional changes in Tcells.

However, these changes

are of limited clinical signiﬁcance in healthy elderly.

Consequently, immune dysfunction in elderly resi-

dents of LTCFs is primarily driven by the multiple

factors that result in secondary immune dysfunction

such as malnutrition , presence of multiple chronic dis-

eases, and polypharmacy, especially with medications

that diminish host defenses (eg, immunosuppres-

sants).

11,12

In addition, LTCF residents often have cogni-

tive de ﬁcits that may complicate resident compliance

with basic sanitary practices (such as handwashing

and personal hygiene) or functional impairments

such as fecal and urinary incontinence, immobility,

and diminished cough reﬂex. The elderly nursing

home resident is known to have a blunted febrile

response to infections.

This parallels other age-

related immunologic abnormalities. A notable fever in

this population often signals a treatable infection,

such as UTI or aspiration pneumonia.

While the use of urinary catheters in LTCF residents

has decreased in recent years, utilization remains

around 5%. In LTC residents, the use of invasive devices

(eg, central venous catheters, mechanical ventilators,

enteral feeding tubes) increases the likelihood of a de-

vice-associated infection. Of the over 15,000 LTCFs in

the US in 2004, 42% provided infusion therapy, 22%

had residents with peripherally-inserted central lines,

and 46% provided parenteral nutrition.

Another

challenge for preventing infections in LTCFs is the in-

creasing acu ity of residents, especially with the rapidly

growing subpopulation of postacute residents. Posta-

cute residents are hospitalized patients who are

discharged to LTCFs to receive skilled nursing care or

physical/occupational therapy. In the past, these

patients, often frail, would have remained hospitalized,

but, with increasing efforts to control hospital costs,

these patients are now discharged to LTCFs. In addition

to higher device utilization, these residents are more

likely to receive antimicrobial therapy than long-stay

LTCF residents.

Much remains to be learned about resident and LTCF

factors correlated with HAIs. There is evidence that in-

stitutional factors such as nurse turnover, stafﬁng

levels, prevalence of Medicare recipients, rates of

hospital transfer for infection, intensity of medical

services, and family visitation rates are associated

with incidence of HAI in the LTC setting.

The rate of deaths in LTCF residents with infections

ranges from 0.04 to 0.71 per 1000 resident-days, with

pneumonia being the leading cause of death.

Infec-

tions are a leading reason for hospital transfer to

LTCF residents, and the resulting hospital costs range

from $673 million to $2 billion each year.

LTCFs and acute care facilities differ in another key

aspect: LTCFs are residential. As residences, LTCFs are

required to provide socialization of residents through

group activities. While these activities are important

for promoting good physical and mental health, they

may also increase communicable infectious disease

exposure and transmission. Occupati onal and physical

therapy activities, while vital toward restoring or main-

taining physical and mental function , may increase

risk for person-to-person transmission or exposure to

contaminated environmental surfaces (eg, physical or

occupational therapy equipment).

SPECIFIC NOSOCOMIAL INFECTIONS IN THE

LONG-TERM CARE FACILITY

Urinary tract infections

In most surveys, the leading infection in LTCFs is

UTI,

although with restrictive clinical deﬁnitions,

symptomatic urinary infection is less frequent t han

respiratory infection.

Bacteriuria is very common in

residents of these facilities but, by itself, is not associ-

ated with adverse outcomes and does not affect sur-

vival.

19,20

Bacteriuria and UTI are associated with

increased functional impairment, particularly inconti-

nence of urine or feces.

21,22

The symptoms of UTI are dysuria and frequency

(cystitis) or fever and ﬂank pain (pyelonephritis). The

elderly may present with atypical or nonlocalizing

symptoms. Chronic genitourinary symptoms are also

common but are not attributable to bacteriuria.

20,21

506 Vol. 3 6 No. 7 Smith et al

Because the prevalence of bacteriuria is high, a positive

urine culture, with or without pyuria, is not sufﬁcient

to diagnose urinary infection.

Clinical ﬁndings for

diagnosis of UTI in the noncatheterized resident must

include some localization to the genitourinary tract.

The diagnosis also requires a positive quantitative

urine culture. This is obtained by the clean-catch

voided technique, by in and out catheterization, or by

aspiration through a catheter system sampling port.

A negative test for pyuria or a negative urine culture

obtained prior to initiation of antimicrobial therapy

excludes urinary infection.

The prevalence of indwelling urethral catheters in

the LTCF is 7% to 10%.

24-26

Catheterization predis-

poses to clinical UTI, and the catheterized urinary tract

is the most common source of bacteremia in LTCFs.

17,19

Residents with long-term catheters often present with

fever alone. Residents with indwelling urinary cathe-

ters in the LTCF are uniformly colonized with bacteria,

largely attributable to bioﬁlm on the catheter.

These

organisms are often more resistant to oral antibiotics

than bacteria isolated from elderly persons in the com-

munity.

28,29

Catheter-related bacteriuria is dynamic,

and antimicrobial treatment only leads to increased an-

timicrobial resistance.

Thus, it is inappropriate to

screen asymptomatic catheterized residents for bacte-

riuria or to treat asymptomatic bacteriuria.

Speci-

mens collected through the catheter present for more

than a few days reﬂect bioﬁlm microbiology. For resi-

dents with chronic indwelling catheters and sympto-

matic infection, changing the catheter immediately

prior to instituting antimicrobial therapy allows colle c-

tion of a bladder specimen, which is a more accurate

reﬂection of infecting organisms.

Catheter replace-

ment immediately prior to therapy is also associated

with more rapid defervescence and lower risk of early

symptomatic relapse posttherapy.

Guidelines for prevention of cathete r-associated

UTIs in hospitalized patients

are generally applicable

to catheterized residents in LTCFs. Recommended mea-

sures include limiting use of catheters, insertion of

catheters aseptically by trained personnel, use of as

small diameter a catheter as possible, handwashing

before and after cathete r manipulation, maintenance

of a closed catheter system, avoiding irrigation unless

the catheter is obstructed, keeping the collecting bag

below the bladder, and maintaining good hydration in

residents. Urinary catheters coated with antimicrobial

materials have the potential to decrease UTIs but

have not been studied in the LTCF setting. For some res-

idents with impaired voiding, intermittent catheteriza-

tion is an option, and clean technique is as safe as

sterile technique.

External catheters are also a risk

factor for UTIs in male residents

but are signiﬁcantly

more comfortable and associated with fewer adverse

effects, including symptomatic urinary infection, than

an indwelling catheter.

Local external care is re-

quired. The CDC guideline

brieﬂy discusses care of

condom catheters and suprapubic catheters, but no

guideline for leg bags is available. Leg bags allow for

improved ambulation of residents but probably

increase the risk of UTI because opening of the system

and reﬂux of urine from the bag to the bladder occur

more frequently than with a standard closed system.

Suggestions for care of leg bags include using aseptic

technique when disconnecting and reconnecting, dis-

infecting connections with alcohol, changing bags at

regular intervals, rinsing with diluted vinegar, and dry-

ing between uses.

A 1:3 dilution of white vinegar has

been recommended for leg bag disinfection.

Respiratory tract infections

Because of the impaired immunity of elder ly per-

sons, viral upper respiratory infections (URIs) that gen-

erally are mild in other populations may cause

signiﬁcant disease in the institutionalized elderly

patient.

38,39

Examples include inﬂuenza, respiratory

syncytial virus (RSV), parainﬂuenza, coronavirus, rhi-

noviruses, adenoviruses, and recently discovered hu-

man metapneumovirus.

Pneumonia. Pneumonia or lower respiratory tract

infection (LRTI) is the second most common cause of

infection among nursing home residents, with an inci-

dence ranging from 0.3 to 2.5 episodes per 1000 resi-

dent care-days and is the leading cause of death from

infections in this setting. Elderly LTCF residents are pre-

disposed to pneumonia by virtue of decreased clear-

ance of bacteria from the airways and altered throat

ﬂora, poor functional status, presence of feeding tubes,

swallowing difﬁculties, and aspiration as well as inade-

quate oral care.

41-43

Underlying diseases, such as

chronic obstructive pulmonary disease and hear t dis-

ease, further increase the risk of pneumonia in this

population.

The clinical presentation of pneumonia

in the elderly often is atypical. While there is a paucity

of typical respiratory symptoms, recent studies have

shown that fever is present in 70%, new or increased

cough in 61%, altered mental status in 38%, and in-

creased respiratory rate above 30 per minute in 23%

of residents with pneumonia.

While acquiring a diagnostic sputum can be difﬁ-

cult, obtaining a chest radiograph is now more feasible

than in the past. In general it is recommended that a

pulse oximetry, chest radiograph, complete blood

count with differential, and blood urea nitrogen should

be obtained in residents with suspected pneumonia.

Streptococcus pneumoniae appears to be the most com-

mon etiologic agent accounting for about 13% of all

cases,

47,48

followed by Hemophilus inﬂuenzae (6.5%),

Smith et al September 2008 507

Staphylococcus aureus (6.5%), Moraxella catarrhalis

(4.5%), and aerobic gram-negative bacteria (13%).

Legionella pneumoniae also is a concern in the LTCF.

Colonization with methicillin-resistant S aureus

(MRSA) and antibiotic-resistant, gram-negative bacteria

further complicate diagnosis and management of

pneumonia in LTCF residents.

49,50

The mortality rate for LTCF-acquired pneumonia is

signiﬁcantly higher than for community-acquired

pneumonia in the elderly population.

Preinfection

functional status, dementia, increased rate of respira-

tions and pulse, and a change in mental status are con-

sidered to be poor prognostic factors. Several indices

predictive of mortality have been developed and

may be useful in managing residents with

pneumonia.

45,52,53

The CDC guideline for prevention of pneumonia

oriented toward acute care hospitals but covers a num-

ber of points relevant to the LTCF, including respiratory

therapy equipment, suctioning techniques, tracheos-

tomy care, prevention of aspiration with enteral feed-

ings, and immunizations. Examples of relevant

recommendations for the LTCF include hand hygiene

after contact with respiratory secretions, wearing

gloves for suctioning, elevating the head of the bed

30 to 45 degrees during tube feeding and for at least

1 hour after to decrease aspiration, and vaccination

of high-risk residents with pneumococcal vaccine.

The evidence for the efﬁcacy of pneumococcal vaccine

in high-risk populations, including the elderly popula-

tion, is debated.

55,56

However, the vaccine is safe, rela-

tively inexpensive, and recommended for routine use

in individuals over the age of 65 years.

56,57

Pneumo-

coccal vaccination rates for a facility are now publicly

reported at the Centers for Medicare and Medicaid

Services (CMS).

Inﬂuenza. Inﬂuenza is an acute respiratory disease

signaled by the abrupt onset of fever, chills, myalgias,

and headache along with sore throat and cough,

although elderly LTCF residents may not have this typ-

ical presentation. The incubation period for inﬂuenza

is approximately 1 to 2 days.

It is a major threat to

LTCF residents, who are among the high -risk groups

deserving preventive measures.

Inﬂuenza is very con-

tagious, and outbreaks in LTCFs are common and often

severe. Clinical attack rates range from 25% to 70%,

and case fatality rates average over 10%.

61-64

A killed virus vaccine is available but must be given

annually. Inﬂuenza vaccine in the elderly is approxi-

mately 40% effective at preventing hospitalization for

pneumonia and approximately 50% effective at pre-

venting hospital deaths from pneumonia.

Although

concern has been expressed regarding the efﬁcacy of

the inﬂuenza vaccine in institutionalized elderly

patients, most authors feel that the inﬂuenza vaccine

is effective and indicated for all residents and care-

givers.

63-68

Recent surveys have shown an increased

rate of inﬂuenza vaccination among LTCF residents,

although signiﬁcant variability exists.

69,70

Inﬂuenza

vaccination rates for a facility are now publicly

reported at the Centers for Medicare and Medicaid

(CMS) Web site http://www.medicare.gov/NHCompare/

home.asp. Staff immunization rates remain less

impressive, with average immunization rates between

40% and 50% at best.

While viral cultures from nasopharynx remain the

gold standard for diagnosis of inﬂuenza, several rapid

diagnostic methods (rapid antigen tests) such as immu-

noﬂuorescence or enzyme immunoassay have been

developed. These tests detect both inﬂuenza A and B

viral antigens from respiratory secretions. Amanta-

dine-resistant inﬂuenza has caused LTCF outbreaks

and hence amantadine is not recommended for inﬂu-

enza prophylaxis.

Zanamivir and oseltamivir are

effective against both inﬂuenza A and B and have

been approved for prophylaxis and treatment of inﬂu-

enza A and B. Oseltamivir is administered orally and is

excreted in the urine requiring dose adjustments for re-

nal impairment. Zanamivir is given by oral inhalation,

which is a problem in a noncooperative LTCF resident.

Rapid identiﬁcation of cases in order to promptly

initiate treatment and isolate them to prevent transmis-

sion remains the key to controlling inﬂuenza out-

breaks. Other measures recommended during an

outbreak of inﬂuenza include restricting admi ssions

or visitors and cohorting of residents with inﬂu-

enza.

60,72,73

Infected staff should not work.

Tuberculosis. Tuberculosis (TB) also has caused ex-

tensive outbreaks in LTCFs, generally traced to a single

ambulatory resident. Large numbers of staff and resi-

dents may be involved, with a potential to sp read in

the community.

74-76

Price and Rutala

found 8.1% of

new employees and 6.4% of new residents to be positive

by the puriﬁed protein derivative (PPD) of tuberculin

method in their North Carolina survey, with signiﬁcant

5-year skin test conversion rates in both groups.

The diagnosis of TB in the LTCF is problematic. Clin-

ical signs (fever, cough, weight loss) are nonspeciﬁc.

Chest radiographs, when obtained, often show charac-

teristic pulmonary inﬁltrates (eg, cavities in the upper

lung ﬁelds). Infection with TB usually causes a positive

tuberculin skin test (TST), although occasional false

positives and false negatives are seen. The speciﬁcity

of the TST may be improved by an in vitro blood test

of interf eron release in response to TB peptides, such

as the quantiferon test. The most speciﬁc diagnostic

test is a sputum culture for TB, but a good specimen

may be difﬁcult to obtain. Recent advances in microbi-

ology have facilitated the diagnosis of TB greatly. Diag-

nostics such as radiometric systems, polymerase chain

508

Vol . 36 No. 7 Smith et al

reaction (PCR), as well as speciﬁc DNA probes help

shorten the time for diagnosis of TB, although suscep-

tibility testing requires several weeks.

Guidelines discussi ng standards for control of TB in

institutions are available.

78-81

There appears to be a con-

sensus that TST of residents and personnel in the LTCF

should be undertaken on a regular basis, although

many LTCFs have inadequate TB screening programs.

The cost-effectiveness of using a 2-step TST to survey

for the booster effect is not demonstrable for all popula-

tions, but the 2-step skin test is recommended by the

CDC for initial screening of employees and residents.

For LTCF residents without any known contact with

a case of known TB or other signiﬁcant risk factors

such as human immunodeﬁciency virus (HIV) or

immunosuppression, induration of 10 mm or greater

to PPD injection is considered positive. Induration of

5 mm or greater is considered positive in any individual

with recent contact with a known case of TB or other sig-

niﬁcant risk factors such as immunosuppression or

changes on chest x-ray consistent with old TB.

There was a resurgence of TB in the US in the mid-

1980s; multidrug-resistant cases of TB have been seen,

and nosocomial spread within health care facilities is a

concern.

In response to this, guidelines have been

promulgated by the CDC that address surveillance

(identiﬁcation and reporting of all TB cases in the facil-

ity including residents and staff); containment (recom-

mended treatment under directly observed therapy

and appropriate respiratory isolation and ventilation

control measures); assessment (monitoring of surveil-

lance and containment activities); and ongoing educa-

tion of residents, families, and staff.

Since most

LTCFs do not have a negative-pressure room, residents

with suspect ed active TB should be transferred to an

appropriate acute care facility for evaluation. There

should be a referral agreement with that facility.

Skin and soft-ti ssue infections, infestations

Pressure ulcers (also termed decubitus ulcers) occur

in up to 20% of residents in LTCFs and are associated

with increased mortality.

86-88

Infected pressure ulcers

often are deep soft-tissue infections and may have

underlying osteomyelitis; secondary bacteremic infec-

tions have a 50% mortality rate.

They require costly

and aggressive medical and surgical therapy. Once

infected, pressure ulcer management requires a multi-

disciplinary approach with involvement of nursing,

geriatrics and infectious disease specialists, surgery,

and physical rehabilitation.

Medical factors predisposing to pressure ulcers have

been delineated

and include immobility, pressure,

friction, shear, moisture, incontinence, steroids, malnu-

trition, and infection. Reduced nursing time can also

increase the risk of developing pressure ulcers. Several

of these factors may be partially preventable (such as

malnutrition and fecal inco ntinence). Prevention of

pressure ulcers involves developing a plan for turning,

positioning, eliminating focal pressure, reducing shear-

ing forces, and keeping skin dry. Attention to nutrition,

using disposable briefs and identifying residents at a

high risk using prediction tools can also prevent new

pressure ulcers.

The goals are to treat infection, promote wound

healing, and prevent future ulcers. Many physical and

chemical products are available for the purpose of

skin protection, debridement, and packing, although

controlled studies are lacking in the area of pressure

ulcer prevention and healing.

A variety of products

may be used to relieve or distribute pressure (such as

special mattresses, kinetic beds, or foam protectors)

or to protect the skin (such as ﬁlms for minimally

draining stage II ulcers, hydrocolloids and foams for

moderately draining wounds, alginates for heavily

draining wounds). Negative-pressure wound therapy

(vacuum dressings) using gentle suction to provide

optimal moist environment is increasingly being used

in treatment of complex pressure ulcers.

Nursing

measures such as regular turning are essential as

well. A pressure ulcer ﬂow sheet is a useful tool in

detecting and monitoring pressure ulcers and in

recording information such as ulcer location, depth,

size, stage, and signs of inﬂammation as well as in tim-

ing of care measures. Infection control measures

include diligent hand hygiene and glove usage.

Because all pressure ulcers, like the skin, are colo-

nized with bacteria, antibiotic therapy is not appropri-

ate for a positive surface swab culture without signs

and symptoms of infection. Nonintact skin is more

likely to be colonized with pathogens. True infection

of a pressure ulcer (cellulitis, osteomyelitis, se psis) is

a serious condition, generally requiring broad-

spectrum parenteral antibiotics and surgical debride-

ment in an acute care facility.

Cellulitis (infection of the skin and soft tissues) can

occur either at the site of a previous skin break (pres-

sure ulcer) or spontaneously. Skin infections generally

are caused by group A streptococci or S aureus. Out-

breaks of group A streptococcal infections have been

described, presenting as cellulitis, pharyngitis, pneu-

monia, or septicemia.

91-93

Scabies is a contagious skin infection caused by a

mite. Lesions usually are very pruritic, burrow-like,

and associated with erythema and excoriations,

usually in interdigital spaces of the ﬁngers, palms and

wrists, axilla, waist, buttocks, and the perineal area.

However, these typical ﬁndings may be absent in debil-

itated residents, leading to large, prolonged outbreaks in

LTCFs.

94-96

Diagnosis in an individual with a rash

Smith et al September 2008 509

requires a high index of suspicion in order to recognize

the need for diagnostic skin scrapings. The presence of a

proven case should prompt a thorough search for sec-

ondary cases. A single treatment with permethrin or lin-

dane usually is effective, but repeated treatment or

treatment of all LTCF residents, personnel, and families

occasionally is necessary.

97,98

Ivermectin, an oral anti-

helminthic agent, is an effective, safe, and inexpensive

option for treatment of scabies. However, it has not

been approved by the FDA for this indication. Therapy

of rashes without conﬁrming the diagnosis of scabies

unnecessarily exposes residents to the toxic effects of

the topical agents. Because scabies can be transmitted

by linen and clothing, the environment should be

cleaned thoroughly. This includes cleaning inanimate

surfaces, hot-cycle washing of washable items (clothing,

sheets, towels, etc), and vacuuming the carpet.

Other infections

Viral gastroenteritis (caused by rotavirus, enterovi-

ruses, or noroviruses),

99,100

bacterial gastroenteritis

(caused by Clostridium difﬁcile, Bacillus cereus, Esche-

richia coli, Camplylobacter spp, C perfringens, or Salmo-

nella spp), and parasites (such as Giardia lambia)are

well-known causes of diarrhea outbreaks in LTCFs.

101-106

The elderly are at increased risk of infectious gastro-

enteritis due to age-related decrease in gastric acid. In a

population with a high prevalence of incontinence, the

risk of cross infection is substantial. Person-to-person

spread, particularly due to shared bathroom, dining,

and rehabilitation facilities, plays a role in viral gastro-

enteritis and in Shigella spp and C difﬁcile diarrhea.

107

Foodborne disease outbreaks also are very common

in this setting,

108

most often caused by Salmonella

spp or S aureus. E coli O157:H7 and Giardia a lso may

cause foodborne outbreaks, underscoring the impor-

tance of proper food preparation and storage.

Bacteremia

109-111

in the LTCF, although rarely

detected, may be primary or secondary to an infection

at another site (pneumonia, UTI). The most common

source of secondary bacteremia is the urinary tract,

with E coli being the culprit in over 50% of cases.

109,111

As the acuity of illness in LTCF residents has risen, the

prevalence of IV devices and related bacteremic compli-

cations appears to have increased. The CDC guideline

for prevention of IV infections is a useful resource and

generally applicable to the LTCF.

112

Relevant points

include aseptic insertion of the IV cannula, daily inspec-

tion of the IV for complications such as phlebitis, and

quality control of IV ﬂuids and administration sets.

Conjunctivitis in the adult presents as ocular pain,

redness, and discharge. In the LTCF, cases may be

sporadic or outbreak-associated.

113

Many cases are

nonspeciﬁc or of viral origin; S aureus appears to be

the most frequent bacterial isolate.

114

Epidemic

conjunctivitis may spread rapidly through the LTCF.

Transmission may occur by contaminated eye drops

or hand cross contamination. Gloves should be

worn for contact with eyes or ocular secretions, with

hand hygiene performed immed iately after removing

gloves.

Many additional infections have been encountered in

the LTCF, including herpes zoster, herpes simplex, endo-

carditis, viral hepatitis, septic arthritis, and abdominal

infections. There has been a resurgence of ‘‘pediatric’’

infections in the LTCF (eg, pertussis, RSV, and H inﬂuen-

zae respiratory tract infections), reﬂecting the decline of

the host’s immunologic memory with aging.

Epidemic infections in the LTCF

Most LTCF HAIs are sporadic. Many are caused by

colonizing organisms with relatively low virulence. Tis-

sue invasion may be facilitated by the presence of a uri-

nary catheter or chronic wound or following an

aspiration event. Ongoing surveillance (see Surveil-

lance section below) is required to detect epidemic

clustering of transmissible, virulent infections. Out-

breaks must be anticipated. Ideally, infection control

surveillance and practices should be the responsibility

of frontline staff as well as infection control staff.

An outb reak or transmission within the facility may

occur explosively with many clinical cases appearing

within a few days or may, for example, involve an

unusual clustering of MRSA clinical isolates on a single

nursing unit over several months. On the other hand, a

case of MRSA infection may follow a prolonged period

of asymptomatic nasal colonization after an aspiration

event or development of a necrotic wound.

115

Outbreaks in LTCFs accounted for a substantial pro-

portion (15%) of reported epidemics

116

(Table 1). Clus-

tering of URIs, diarrhea, skin and soft tissue infection,

conjunctivitis, and antibiotic-resistant bacteriuria

have been noted.

Major outbreaks of infection have

also been ascribed to E coli,

117

group A strepto-

cocci,

92,118

C difﬁcile

104,119

respiratory viruses,

Salmo-

nella spp,

120

Chlamydia pneumoniae,

121,122

Legionella

spp,

123

and gastrointestinal viruses.

124

Nursing homes

accounted for 2% of all foodborne disease outbreaks

reported to the CDC (1975-1987) and 19% of

outbreak-associated deaths.

125

Transmissible gastroin-

testinal pathogens may be introduced to the facility

by contaminated food or water or infected individuals.

High rates of fecal incontinence, as well as gastric

hypochlorhydria, make the nursing home ideal for sec-

ondary fecal-oral transmission.

126

Other epidemics

include scabies, hepatitis B,

127

group A streptococcal

infections, viral conjunctivitis, and many other

infections.

510

Vol . 36 No. 7 Smith et al

These outbreaks underscore the vulnerability of the

elderly to infection, as well as the role of cross infection

in residents with urinary catheters and open wounds or

in those with incontinence who require serial contact

care by staff.

120

In addition, mobile residents with

poor hygiene may interact directly.

Antibiotic-resistant bacteria

Multidrug resistant organisms (MDROs) such as

MRSA, vancomycin-resistant enterococci (VRE), drug-

resistant S pneumoniae, and multidrug-resistant gram-

negative bacteria (eg, Pseudomonas aeruginosa,

Acinetobacter spp and extended-spectrum b-lactamase

(ESBL)-producing enterobacteriaceae) are increasingly

important causes of colonization and infection in

LTCFs.

128-137

In this setting, in fection with MDROs

has been associated with increased morbidity, mortal-

ity, and cost,

138,139

although the attributable morbidity,

mortality, and cost of MDROs has not yet been fully

deﬁned. Indeed, LTCF residence has been frequently

identiﬁed as a risk factor for antibiotic-resistant infec-

tion in hospitalized patients.

140,141

Elderly and disabled residents are at increased risk

for colonization with resistant organisms, and coloni-

zation may persist for long periods of time (ie, months

to years).

133,142-146

Within the LTCF, length of stay in

the facility and accommodation in rooms with multiple

beds have been identiﬁed as risk factors for transmis-

sion of MRSA.

147

Both infected and colonized residents

may serve as sources for the spread of MDROs in the

LTCF.

135,148

When MRSA becomes endemic within

a facility, elimination is highly unlikely.

148

LTCFs can

expect infections with MDROs to be a continuing prob-

lem. Strategies for curbing the emergence and spread

of antimicrobial resistance in LTCFs are discussed

below in ‘‘Antibiotic Stewardship’’ and ‘‘Isolation and

Precautions’’ sections.

THE INFECTION CONTROL PROGRAM

Evolution of programs

The 1980s saw a dramatic increase in LTCF infection

control activities, stimulated by federal and state regu-

lations. Several studie s provide insight into the extent

of program development. A 1981 survey of Utah

LTCFs

113

noted that all facilities had regular infection

control meetings, but none performed systematic sur-

veillance for infections or conducted regular infection

control training. All LTCFs had policies regarding the

maintenance and care of urinary catheters, although

the policies were not uniform. Price et al

149

surveyed

12 North Carolina LTCFs in 1985 and found that,

although all 12 had a designated ICP, none of the

ICPs had received special training in this area. Also

noted were deﬁciencies in isolation facilities, particu-

larly an insufﬁcient number of sinks and recirculated,

inadequately ﬁltered air.

In a 1985 survey of Minnesota LTCFs, Crossley

et al

150

found that the majority had an infection control

committee (ICC) and a designated ICP, although sub-

stantial deﬁciencies in resident and employee health

programs occurred. For instance, only 61% offered

the inﬂuenza vaccine to residents, and one third did

not screen new employees for a history of infectious

disease problems. A 1988 Maryland survey

151

found

that one third of nursing homes still performed routine

environmental cultures, and many lacked proper isola-

tion policies. In 1990, a survey of Connecticut LTCFs

found that most ICPs had received some training in

infection control.

152,153

Most LTCFs performed surveil-

lance at least weekly, and most used written criter ia to

determine HAIs.

More recent regional surveys of facilities from Mary-

land and New England in the mid-1990s and Michigan

in 2005 noted increasing gains in time spent in infec-

tion control activities from 1994 to 2005.

69,154

In New

England, 98% of facilities had a person designated to

do infection control, 90% were registered nurses, and

52% had formal training.

154

In the 1990s, an average

of 9 to 12 hours per week was spen t on infection con-

trol; 50% to 54% of that time was spent on surveillance

activities.

154

Seventy-eight to 97% percent of the LTCFs

reported a systematic surveillance system.

Formal

deﬁnitions were used by 95% of respondents; 81%

used the McGeer criteria, and 59% calculated infection

rates.

154

All facilities reportedly used Universal Precau-

tions in caring for their residents.

154

By 2005, 50% of responding facilities in Michigan

had a full-time ICP.

The mean time spen t on infec tion

Table 1. Common long-term care facility epidemics

Respiratory:

Inﬂuenza

Tuberculosis

S pneumoniae

Chlamydia pneumoniae

Legionella spp

Other respiratory viruses (Parainﬂuenza, RSV)

Gastrointestinal: (may be foodborne)

Viral gastroenteritis (Norovirus, etc)

Clostridium difﬁcile

Salmonellosis

E coli 0157:H7 colitis

Other infections:

Methicillin-resistant Staphylococcus aureus (MRSA)

Vancomycin-resistant Enterococcus (VRE)

Group A Streptococcus

Scabies

Conjunctivitis

Smith et al September 2008 511

control activities by the infection control staff varied

from 40 hours per week for full-time ICPs to 15 hours

per week for part-time staff.

However, part-time

ICPs did not necessarily supervise smaller facilities

with fewer subacute care beds or give fewer in-services

than full-time staff.

Despite these improvements, the number of ICPs per

nursing home bed is 4-fold fewer than the number of

ICPs available in acute care hospitals.

155

LTCF-based

ICPs are more likely to assume noninfection control

functions than acute care ICPs regardless of bed size;

in one survey, 98% of LTCF ICPs had other duties,

156

while in a Michigan survey, 50% of 34 LTCFs had full-

time ICPs.

Many of these noninfe ction control func-

tions include employee health, staff education and

development, and quality improvement.

155

In addition,

LTCF ICPs are still less likely to receive additional for-

mal training in infection control (8%) compared with

95% of acute care ICPs.

155

The results of this study

from Maryland led to a state proposal that at least

one ICP from each LTCF be formally trained in infection

control.

155

From these surveys, one can develop a composite

picture of the LTCF ICP as a nurse who still has not nec-

essarily received formal training in infection con-

trol.

154,155

Many ICPs still work part-tim e on infection

control activities regardless of the number of beds or

patient acuity.

69,155

While the time spent on infection

control activities appears to have increased signiﬁ-

cantly from 36 to 48 hours per month in the 1990s to

90 to 160 hours per month in 2005, the ICP continues

to have other duties such as general duty nursing, nurs-

ing supervision, in-service education, employee

health, and quality assurance.

34,69,154

Regulatory aspects

LTCFs are covered by federal and state regulations as

well as voluntary agency standards such as those writ-

ten by The Joint Commission (TJC).

157

Skilled nursing

facilities are required by the Omn ibus Budget Reconcil-

iation Act of 1987 (OBRA) to have an infection control

program.

158

CMS has published requirements for

LTCFs

159

that apply to LTCFs accepting Medicare and/

or Medicaid residents. CMS regulations address the

need for a comprehensive infection control program

that includes surveillance of infections; implementa-

tion of methods for preventing the spread of infections

including use of appropriate isolation measures,

employee health protocols, hand hygiene practices;

and appropriate handling, processing, and storage of

linens.

160,161

For example, the LTCF is required to estab-

lish and maintain an infection control program

designed to provide a safe, sanitary, and comfortable

environment and to help prevent the development

and transmission of disease and infection. Interpretive

guidelines for surveyors further discuss deﬁnitions of

infection, risk assessment, outbreak management and

control, measures for preventing speciﬁc infections,

staff orientation, antibiotic monitoring, sanitation,

and assessment of compliance with infection control

policies.

161

Because the LTCF is an employer of health care

workers (HCWs), it must comply with federal and/or

state OSHA regulations. For infection con trol, those

regulations

162,163

deal primari ly with protection of

workers from exposure to bloodborne pathogens

such as HIV, hepatitis B virus (HBV), and hepatitis C

virus (HCV) and from TB exposure.

Adherence of

LTCFs to infection control regulations is an OSHA

priority.

Other standards that apply to LTCFs include the fed-

eral minimum requirements for design, construction,

and equipment

164

and TJC LTC Standards.

165

The

2007 TJC Standards for LTC require a written infection

control plan based on an assessment of risk; establish-

ment of priorities, goals, and strategies; and an evalua-

tion of the effectiveness of the interventions. The

Standards also deal with managing an inﬂux of

patients with an infectious disease as well as leader-

ship’s involvement in the program.

165

In addition,

many states have statutory requirements for LTCFs

that vary widely.

On October 7, 2005, CMS published a ﬁnal rule

requiring LTCFs to offer annually to each resident

immunization against inﬂuenza and to offer lifetime

immunization against pneumococcal disease. LTCFs

are required to ensure that each resident or legal repre-

sentative receive education on the beneﬁts and poten-

tial side effects of the immunizations prior to their

being administered.

The LTCF administrative staff

should be knowledgeable about the federal, state, and

local regulations governing infection control in order

to implement and maintain a program in compliance

with these regulations. The LTCF ICP ideally should

be involved in the formation and revision of regula-

tions, through local and national infection control

and long-term care organizations, to help assure the

scientiﬁc validity of the regulations.

Experts in infection control in Canada have called

for 1 full-time formally trained ICP per 150 to

250 long-term beds.

166

The Consensus Panel from

SHEA and APIC has recommended that nonhospital fa-

cilities including LTCFs provide adequate resources in

terms of personnel, education, and materials to ICPs

to fulﬁll their functions.

167

While most of the current

information has been derived from facilities serving

older populations in North America, reports from LTCFs

in Europe and Australia and those serving pediatric

populations are increasing.

168-171

512 Vol. 3 6 No. 7 Smith et al

Infection control program elements

The structure and components of an infection con-

trol program are shown in Tables 2 and 3, respectively.

Several authors have discussed the components of an

infection control program in the LTCF.

34,36,166,167,172-177

These components generally are drawn from regula-

tory requirements, current nursing home practices,

and extrapolations from hospital programs. The lim-

ited resources of most LTCFs affect the type and extent

of programs developed.

173

Most authors feel that an in-

fection control program should include some form of

surveillance for infections, an epidemic control

program, education of employees in infection control

methods, policy and procedure formation and review,

an employee health program, a resident health

program, and monitoring of resident care practices.

The program also may be involved in quality improve-

ment, patient safety, environmental review, antibiotic

monitoring, product review and evaluation, litigation

prevention, resident safety, preparedness planning ,

and reporting of diseases to public health authorities.

The ICP

An ICP is an essential component of an effective in-

fection control program and is the person designated

by the facility to be responsible for infection control

(see Table 2 ), The ICP usually is a staff nurse, a back-

ground that is helpful for resident assessment and

chart review. The ICP most commonly is a registered

nurse. Because of size and stafﬁng limitations, the

vast majority of LTCF ICPs have other duties, such as

assistant director of nursing, charge nurse, in-service

coordinator, employee health, or performance

improvement. The number of LTCF beds justifying a

full-time ICP is unknown and usually depends on the

acuity level of residents and the level of care provided.

A LTCF with more than 250 to 300 beds may need a full-

time ICP. Th e LTCF ICP, like the hospital ICP, requires

speciﬁc training in infection control; well-deﬁned sup-

port from administration; and the ability to interact

tactfully with personnel, physicians, and residents.

APIC and the Community and Hospital Infection

Control Association-Canada (CHICA-Canada) have

developed professional and practice standards for

infection control and epid emiology that address educa-

tion including qualiﬁcations and professional develop-

ment for the ICP.

178

These standards may not represent

the current education and qualiﬁcations of ICPs in

many LTCFs, but they serve as a benchmark for which

LTC ICPs and their facilities can strive.

The qualiﬁcations include 3 criteria for entering the

profession. The ICP:

Has knowledge and experience in areas of resident

care practices, microbiology, asepsis, disinfection/

sterilization, adult education, infectious diseases,

communication, program administration, and

epidemiology;

has a baccalaureate degree (the minimum educa-

tional preparation for the role); and

attends a basic infection control training course

within the ﬁrst year of entering the profession.

The criteria for professional development include

the ICP maintaining current knowledge and skills in

the area of infection prevention, control, and epidemi-

ology. The professional development standards include

5 criter ia. The ICP:

Table 2. Long-term care facility infection control program: structure

Leadership Expertise/training Role(s)

Infection Control Committee/Oversight Committee

Core members Administration, Nursing Representative, Medical Director, ICP Identiﬁes areas of risk

Ad hoc members Food Service, Maintenance, Housekeeping, Laundry Services,

Clinical Services, Resident Activities, Employee Health

Establishes priorities

Plans strategies to achieve goals

Implements plans

Develops policies/procedures

Allocates resources

Assesses program efﬁcacy at least annually

Infection Control Professional

ICP Qualiﬁcation via education, experience, certiﬁcation Surveillance

Data collection and analysis

Implementation of policies, procedures

Education

Reporting to oversight group/ICC

Communication to public health

Communication to other agencies

Communication to other facilities

Smith et al September 2008 513

Becomes cer tiﬁed in infection control within 5 years

of entry into the profession and maintains

certiﬁcation;

advances knowledge and skills through continuing

education;

pursues formal education in health care

epidemiology;

maintains a knowledge base of current infection pre-

vention and control information through peer net-

working, Internet access, published literature,

and/or professional meetings; and

advances the ﬁeld of infection prevention and con-

trol and epidemiology through support of related

research.

The inf ection control oversight committee

The regulatory requirement for a formal LTCF ICC

was dropped by OBRA at the federal level, but some

states still require them.

174

The ICP should be familiar

with state regulations. This committee frequently has

been less active than the corresponding ICC in the hos-

pital setting, in part because of decreased physician

availability. A small working group (the infection

control oversight committee) consisting of the ICP,

the administrator, the medical director, and the nursing

supervisor or their des ignee may efﬁciently make most

of the infection control decisions (Table 2). The ICC

functions may be merged wit h the performance im-

provement or patient safety programs, but infection

control must remain identiﬁable as a distinct program.

Whatever group is selected to oversee the infection

control program, it should meet regularly to review

infection control data, review policies, and monitor

program goals and activities. Written records of meet-

ings should be kept.

The LTCF administrative staff should support the ICP

with appropriate educational opportunities and

resources, including expert consultation in infectious

diseases and infection control as needed. The partici-

pation of an infectious diseases (ID) physician or other

health care professional with training or experience in

infection control should be available on at least a con-

sultative basis. Information may be obtained from

SHEA (www.shea-online.org or 703-684-1006). The

local health department may have useful information,

and local ICPs are another valuable source of informa-

tion, available from the APIC at www.apic.org.

Educational opportunities for ICPs

Courses are available for ICPs and health care epi-

demiologists. SHEA offers jointly spo nsored courses

in health care epi demiology and infectio n control

for individuals with different levels of experience.

The SHEA/CDC course is for physicians and others

with advanced training who wish to increase their

expertise in infection control. The SHEA/Infectious

Diseases Society of America (IDSA)/Johns Hopkins

University School of Medi cine of America course is

designed primarily for ID physicians in training. Sim-

ilar courses are offered in Europe through SHEA and

the European Society for Clinical Microbiology and In-

fectious Diseases (www.shea-online.org or 703-684-

1006). APIC offers a training course for hospital and

LTCF infection control professionals (www.apic.org

or 202-789-1890). The Nebraska Infection Control

Network offers regular 2-day basic training courses

speciﬁcally for LTCF ICPs (www.nicn.org), and other

local courses are available.

Table 3. Long-term care facility infection control

program: elements

Elements Examples

Infection control activities

Establish and implement

routine infection control

policies and procedures

Hand hygiene

Standard precautions

Organism-speciﬁc isolation

Employee education

Infection identiﬁcation Develop case deﬁnitions

Establish endemic rates

Establish outbreak thresholds

Identiﬁcation, investigation,

and control of outbreaks

Organism-speciﬁc infection control

policies and procedures

Inﬂuenza

Scabies

MDROs (eg, MRSA)

Disease reporting Public health authorities

Receiving institutions

LTCF staff

Antibiotic stewardship Review of antimicrobial use

Monitoring of patient care practices Aspiration precautions

Pressure ulcer prevention

Invasive device care and use

Facility management issues General maintenance

Plumbing/ventilation

Food preparation/storage

Laundry collection/cleaning

Infectious waste collection/

disposal

Environment

Housekeeping/cleaning

Disinfection/sanitation

Equipment cleaning

Product evaluation Single use devices

Resident health program TB screening

Immunization program

Employee health program TB screening

Immunizations

Occupational exposures

Other program elements

Performance improvement Serve on PI committee

Resident safety Study preventable adverse events

Preparedness planning Develop pandemic inﬂuenza

preparedness plan

514 Vol. 3 6 No. 7 Smith et al

Surveillance

Infection surveillance in the LTCF involves the sys-

tematic collection, consolidation, and analysis of data

on HAIs. Standardization of surveillance is desirable.

To facilitate standardization, resources that include

practice guidance for surveillance identifying seven

recommended steps are available. These steps are

(1) assessing the population, (2) selecting the outcome

or process for surveillance, (3) using surveillance

deﬁnitions, (4) collecting surveillance data, (5) calculat-

ing and analyzing infection rates, (6) applying risk

stratiﬁcation methodology, and (7) reporting and using

surveillance information.

179

Assessing the population. Infection surveillance

may either include all residents in a facility (total house

surveillance) or be targeted at speciﬁc subpopulations.

Although facility-wide surveillance is useful for calcu-

lating baseline rates and detecting outbreaks, a more

focused analysis could include examination of infec-

tion rates in residents who are at risk for certain kinds

of infection (such as aspiration pneumonia in residents

receiving tube feedings or bloodstream infection

among residents with indwelling vascular catheters).

Focused surveillance should target infections that are

preventable; that occur frequently; and that are associ-

ated with signiﬁcant morbidity, mortality, and cost.

Facility-wide surveillance is useful for establishing an

infection control ‘‘presence’’ in the LTCF and may be

required as a part of local or state regulatory programs.

To establish baseline infection rates, track progress,

determine trends, and detect outbreaks, site-speciﬁc

rates should be calculated (eg, central line infections

per 1000 central line-days). Routine analysis should

try to explain the variation in site-speciﬁc rates. For

example, a change in the rate might be related to a

change in t he resident population. Focused or high-

risk resident surveillance may permit conservation of

resources, although in many small institutions whole

house surveillance is feasi ble.

Selecting the outcome measures. Traditionally

surveillance in the LTCF refers to collection of data on

outcome measures such as HAIs that occur within the

institution (eg, incidence of UTI or central line-

associated bacteremia). These surveillance data are

used primarily to guide control activities, to plan

educational programs, and to detect epidemics, but

surveillance also may detect infections that require

therapeutic act ion.

Process measures (eg, surveillance of infection

control practices) should also be part of the infection

control and quality improvement programs and may

be very helpful in identifying areas for improvement

in practice and for monitoring compliance with regula-

tory aspects of the infection control program.

Examples of process measures include observation of

hand hygiene compl iance, observation of correct cath-

eter care technique, antibiotic utilization studies, time-

liness in administering and reading TB skin tests, and

administration of hepatitis B immunization to new em-

ployees within 10 working days of hire.

Using surveillance deﬁnitions. Surveillance

requires objective, valid deﬁnitions of infec tions. Most

hospital surveillance deﬁnitions are based on the

National Nosocomial Infections Surveillance System

(NNIS) criteria,

180

but no such standard exists for

long-term care. NNIS (now the National Healthcare

Safety Network [NHSN]) deﬁnitions depend heavily

on laboratory data and recorded clinical observations.

In the LTCF, radiology and microbiology data are less

available, and written physician notes and nursing

assessments in the medical record usually are brief.

Timely detection of HAI in the LTCF often depends on

recognition of clues to infection by nurses’ aides and

reporting of these ﬁndings to the licensed nursing

staff.

181

Positive cultures do not necessarily signify

infection.

Modiﬁed LTCF-speciﬁc surveillance criteria were

developed by a Canadian consensus conference. These

deﬁnitions were designed in light of some of the

unique limitations of nursing home surveillance men-

tioned previously. They are used widely, although

they have not yet been validated in the ﬁeld.

Collecting surveillance data. Published LTCF sur-

veys have been either incidence or prevalence studies.

Prevalence studies detect the number of existing (old

and new) cases in a popul ation at a given time, whereas

incidence studies ﬁnd new cases during a deﬁned time

period. The latter is preferred because more concur-

rent information can be collected by an incidence

study if data are collected with regularity.

The surveillance process consists of collecting

data on individual case s and determining whether

or not a HAI is present by comparing collected

data to standard written deﬁnitions (criteria) of infec-

tions. One recommended data collection method in

the LTCF is ‘‘walking rounds.’’

182

This is a means

of collecting concurrent and prospective infection

data that are necessary to make infection control de-

cisions. Surveillance should be done on a timely ba-

sis, probably at least weekly.

183

During rounds, the

ICP may use house reports from nursing staff, chart

reviews, laboratory or radiology reports, treatment

reviews, antibiotic usage data, and clinical observa-

tions as sources of information.

Analysis and reporting of surveillance data. Analysis

of absolute numbers of infections is misl eading;

calculation of rates provides the most accurate informa-

tion. Rates are generally calculated by using 1000 resi-

dent-days as the denominator. In the past, average

Smith et al September 2008 515

daily census has sometimes been used as the denomin-

ator, but resident-days more clearly reﬂect resident risk.

Infection control data, including rates, then need to be

displayed and distributed to appropriate committees and

personnel (including administration) and used in planning

infection control efforts . The data should lead to speciﬁc

interventions such as education and control programs .

To compare rates within a facility or to other facili-

ties, the method of calculation must be identical (in-

cluding the denominator). Even when calculation

methods are consistent, infection rates may differ

between facilities because of different deﬁnitions of

infection or differences in resident risk factors and dis-

ease severity, and thus comparisons may not be valid.

Comparison of infection rates between facilities, for

public reporting or other purposes, requires control

of deﬁnitions and collection methods, severity adjust-

ing and data validation.

184

The use of a regional data

set may allow for more meaningful intrafacility

comparison of infection rates.

185

This may also allow

for interfacility comparisons of infection rates across

a corporation or geographic area.

Analysis and reporting of infection data usually are

done monthly, quarterly, and annually to detect trends.

This process is facilitated by an individual infection

report form, samples of which have been pub-

lished.

36,186,187

The statistics used in analysis of data

need not be complex. Computerization for sorting

and analysis of data may be timesaving for larger pro-

grams, and software for use on a personal computer is

available. Graphs and charts facilitate presentation and

understanding of infection control data and also may

be facilitated by computer programs. The commer-

cially available programs may help with analysis of

surveillance data, but manual data collection is still

usually necessary.

The feasibility of routine surveillance in LTCFs has

been demonstrated, and data have been used to pro-

vide a basis for continuing education.

188

Surveillance

needs to be simple and pragmatic, particularly because

the LTCF ICP may be able to spend only a few hours per

week on infection control act ivities.

181

Outbreak control

Outbreak surveillance and control should be consid-

ered a high priority for ICPs. The leading causes of LTCF

outbreaks are discussed above and listed in Table 1.

When the number of cases exceeds the normal base-

line, an outbreak within the facility should be consid-

ered. The ICP is advised, and required by CMS, to

monitor resident and staff illnesses, since healthy per-

sonnel may acquire and transmit virulent pathogens.

For many, the word outbreak means a dramatic

clustering of cases of an infectious disease in a

geographic area over a relatively short period of

time. However, the threshold for declaring an out-

break and initiating control measures may be

much lower. For example, we know that inﬂuenza

may cause explosive outbreaks in nursing homes.

Public health ofﬁcials have, therefore, set low thresh-

olds for identifying an outbreak if inﬂuenza is sus-

pected so that outbreak control strategies can be

implemented to avoid hig h attack rates. The CDC

recommends deﬁning a nursing home outbreak of

inﬂuenza as a single laboratory-conﬁrmed case or

a sudden increase of acute febrile respiratory illness

over the normal background rate.

189

Special out-

break control measures may, therefore, be appropri-

ate if there is evidence of transmission of an

epidemiologically important pathogen within the fa-

cility rather than waiting for a fully evolved clinical

outbreak.

For TB, an outbreak investigation should be trig-

gered by a single active case. TB outbreaks are often

caused by a single case and may infect large numbers

of residents and staff by the airborne route before

detection.

74,190

In addition, a single infection caused

by Legionella spp, scabies, Salmonella spp, or other GI

pathogens associated with outbreaks should trigger

an evaluation. A single case of Legionella spp may sig-

nal colonization of the water supply.

123

The approach to investigating an outbreak includes

(1) determining that an outbreak has occurred, (2) de-

veloping a case deﬁnition, (3) case ﬁnding, (4) analyz-

ing the outbreak, (5) formulating a hypothesis

regarding mechanism of transmission, (6) designating

control measures, and (7) evaluating control measures.

A CDC SHEA publication is available to guide investiga-

tion of outbreaks.

191

Given the fact that inﬂuenza and norovirus

outbreaks are relatively common, clinical case deﬁni-

tions should be developed in advance and placed in

preexisting policies and procedures. To facilitate rapid

implementation of control measures, the charge nurses

should be empowered by preexisting policies to rapidly

isolate and/or cohort infected individual s and to curtail

contact between residents and staff on units in an out-

break situation .

The LTCF may have difﬁculty responding to an

epidemic with appropriate measures (such as mass

vaccination or administration of antivirals during an

inﬂuenza outbreak) if consent needs to be obtained

on short notice from a resident’s decision maker or pri-

mary physician. One way to circumvent this problem is

to develop preexisting policies and procedures

approved by the medical staff and to obtain consent

for vaccination and outbreak control measures at the

time of admission from the resident or their power of

attorney/medical decision maker.

516

Vol . 36 No. 7 Smith et al

Isolation and precautions: Importance and

evolution

Prevention of transmission of signiﬁcant pathogens

to patients and HCWs is the major goal of isolation

within health care systems. There are very limited

data on the impact of isolation and infecti on control

precautions, however, on the transmission of patho-

gens within LTCFs. The high prevalence of risk factors

for infection among LTCF residents, the high coloniza-

tion rate of MDROs in skilled care units, and the fre-

quent reports of LTCF infectious disease outbreaks

support the need for appropriate infection control in

that setting.

136

A unique infection control challenge

for the LTCF is the mobile resident, who may be con-

fused or incontinent and serves as a possible vector

for infectious diseases.

The presence of MDROs in the LTCF has implications

beyond the individual facility. Because residents of

LTCFs are hospitalized frequently, they can transfer

pathogens between LTCFs and receiving hospitals;

transfer of patients colo nized with MDROs between

hospitals and LTCFs has been well documented.

192,193

On the other hand, LTCF residents remain in the facility

for extended periods of time, and the LTCF is function-

ally their home. An atmosphere of community is fos-

tered, and residents share common eating and living

areas and participate in various activities. Thus, the

psychosocial consequences of isolation measures

must be carefully balanced against the infection con-

trol beneﬁts.

Isolation recommendations from the CDC have been

available since 1970 but have speciﬁcally been targeted

towards acute care settings. ICPs in the LTCF have thus

been required to adapt these practices to their individ-

ual settings. Traditionally, 2 types of systems for imple-

menting barrier precautions in the hospital were

promoted. A Category-Speciﬁc System listed 7 cat e-

gories of isolation or precautions based on means of

disease transmission: strict isolation, contact isolation,

respiratory isolation, TB isolation, enteric precautions,

drainage and secretion precautions, and blood and

body ﬂuid precautions. Modiﬁcations of this approach

have been promoted since 1970 with a reﬁned Cate-

gory-Speciﬁc System in the 1983 recommenda-

tions.

194,195

A Disease-Speciﬁc System listed all

relevant contagious diseases and the recommended

barrier method. In general, the Category-Speciﬁc

System was simpler to use, but the Disease-Speciﬁc

System consumed fewer resources because precau-

tions were tailored to the speciﬁc disease. In the 1983

guideline, blood precautions were expanded to include

body ﬂuids.

195

In response to the HIV/AIDS epidemic,

the concept of Universal Precautions was introduced

to protect HCWs from all bloodborne exposures.

196,197

These recommendations became adopted by OSHA

and have thus been applicable to all health care set-

tings including LTCFs.

163,198

In this system, all bloo d

and certain body ﬂuids are considered potentially in-

fectious. Education, provision of needle-disposal units,

provision of protective equipment (such as gloves,

gowns, and protective eye wear), and monitoring

compliance were part of Universal Precautions,

although it alone was not considered a complete isola-

tion system.

CDC isolation guidelines released in 1996 integrated

earlier isolation systems by introducing transmission-

based precautions.

199

Standard Precautions replaced

Universal Precautions and were to be applied to all

patients. Standard Precautions emphasize hand

hygiene, gloves (when touching body ﬂuids), masks,

eye protection, and gowns (when contamination of

clothing is likely), as well as avoidance of needlestick

and other sharps injuries. More speciﬁc isolation was

recommended for patients with documented or sus-

pected contagious pathogens. These include Airborne

Precautions (eg, for varicella, measles, and TB), Droplet

Precautions (eg, for inﬂu enza and other respiratory in-

fections), and Contact Precautions (eg, for MRSA,VRE,

and C difﬁcile diarrhea).

CDC and HICPAC have recently released 2 infection

control guidelines that have application in this regard

to LTCFs. The ﬁrst one released focuses speciﬁcally

on the management of MDROs in health care settings,

and the second is an update to previously recommen-

ded general isolation precautions from 1996 guide-

lines.

200,201

Respiratory hygiene/cough etiquette and

safe injection practices were added as new elements

of Standard Precautions. Most LTCFs do not have nega-

tive-pressure rooms for Airbor ne Precautions, and

residents with suspected TB should be transferred to

facilities where such units exist.

Isolation and precautions: MDROs

The majority of the infection control literature on

MDROs in the LTCF has focused on MRSA, but these

guidelines may also apply if a facility recognizes signif-

icant problems with other MDROs such as VRE or anti-

biotic-resistant, gram-negative bacilli. Barrier

precautions are important in preventing cross infection

with known resistant microorganisms, but approaches

to isolation of LTCF patients colonized or infected with

MDROs vary substantially across facilities.

69,156

Most LTCFs employ at least some type of isolation for

MDROs.

202,203

It was found that 90.5% of facilities ac-

cepting patients with MRSA stated that they followed

Contact Precautions despite only 39.7% placing them

in private rooms.

202

In another survey, most LTCFs in

Smith et al September 2008 517

Nebraska were aware of and often screened for MRSA

and employed some precautions in dealing with these

residents (eg, single room, cohorting, contact isolation,

or placing the resident with MDRO in the same room

as a low-risk roommate).

203

Another study demon-

strated no difference in transmission of MDROs in a

skilled care unit between contact isolation precautions

and routine glove use.

204

The authors suggested that

universal glove use may be preferable to contact isola-

tion because it reduces social isolation for LTCF resi-

dents where their health care facility is also their

home. Others have suggested a ‘‘modiﬁed’’ contact iso-

lation protocol as often more appropriate in the LTCF

setting.

205

Clearly, additional evidence-based studies

deﬁning the speciﬁc isolation needs within LTCF are

needed.

General guidelines for control of MRSA

148

and

VRE

206

are published but emphasize hospital settings.

These guidelines serve as an appropriate starting point

for adapting an LTCF approach. There are many reports

of aggressive infection control measures containing

MDROs in the hospital setting.

200

However, data in

the LTCF are very limited, and implementation of isola-

tion procedures identical to those found in a hospital

may result in undesirable social and psychological con-

sequences and functional decline for residents.

207

SHEA position papers on antimicrobial resistance and

infection control speciﬁc ally address the LTCF

208,209

and discuss prescreening admissions for resistant bac-

teria, surveillance for resistant bacteria, and endemic

resistance.

The recent HICPAC isolation guidelines attempt to

address some of the speciﬁc needs and concerns of

the LTCF.

200,201

The principles in both documents can

be adopted for use in the LTCF setting. The MDRO doc-

ument discusses general control interventions such as

administrative suppor t, education of HCWs, surveil-

lance, and judicious use of antimicrobial agents

(see Antibiotic stewardship section below) that are

applicable in the LTCF setting. LTCFs are encouraged

to identify experts who can provide consultation for

analyzing surveillance data and devising effective

infection control strategies to control MDROs. The de-

velopment of laboratory protocols for storing bacterial

isolates for molecular typing when needed to under-

stand the epidemiology of transmission is recommen-

ded. When the LTCF laboratory has contracted with

an off-site laboratory, the facility will need to develop

an arrangement for storing and testing isolates.

The guid elines

200,201

recommend continuing the

use of transmission-based isolation precautions. In

LTCFs, it is advised to consider the individual resident’s

clinical situation when deciding whether to implement

or modify the use of Contact Precautions in addition to

Standard Precautions if colonized or infected with a

MDRO. Standard Precautions are sufﬁcient for rela-

tively healthy and independent residents, ensuring

that gloves and gowns are used for contact with uncon-

trolled secretions, pressure ulcers, draining wounds,

stool, and ostomy tubes/bags.

Contact Precautions are indicated for residents with

MDROs who are ill and totally dependent upon HCWs

for activities of daily living or whose secretions or

drainage cannot be contained. Single rooms for these

residents are recommended if available. The cohorting

of MDRO residents is acceptable if single rooms are not

available. If cohorting is not possible, then placing

residents with MDRO with residents who are low risk

for acquisition or with anticipated short lengths of

stay is advised. While ‘‘low risk for acquisition’’ of an

MDRO has not be en ofﬁcially deﬁned, one source sug-

gested that it should include residents who are not

immunosuppressed; not on antibiotics; and free of

open wounds, drains, and indwelling urinary cathe-

ters.

209

Case-by-case decisions, as needed, can be

made regarding the best precautions to use for each

resident with a MDRO. With Contact Precautions, wear-

ing a gown and gloves for all interactions that may

involve contact with the resident and their environ-

ment is advised, and eye protection is recommended

when there is risk of splash or spray of respiratory or

other body ﬂuids.

Recommendations for minimizing antibiotic resis-

tance also include using appropriate barrier precau-

tions for MDROs, maintaining a line listing of

residents infected or colonized with MDROs, and not

attempting eradication of MDROs from colonized resi-

dents.

208

It is not recommended that the LTCF refuse

MRSA or VRE cases but develop an institutional strat-

egy for control of the resistant organisms based on

local considerations.

133,148,208,210

In summary, elements of routine MDRO control for

the LTCF include monitoring MRSA and VRE culture

results, commun icating MDRO data to health care pro-

viders, including routine communication about

MDROs at in-services, assessing compliance with isola-

tion precautions and hand hygiene, monitoring antimi-

crobial usage, notifying receiving or transmitting

facilities of the presence of a MDRO, designating resi-

dents previously known to be infected or colonized

with MDROs, and instituting adequate environmental

cleaning. If a MDRO problem exists in a LTCF and is

not controlled with these basic infection control

practices, then additional control measures are indi-

cated. These include consultation from experts, inten-

siﬁcation of education, increased efforts to control

antimicrobial use, active surveillance cultures, point-

prevalence cultu ring of targeted units, intensiﬁcation

of isolation with compliance assessment, and monitor-

ing environmental cleaning.

518

Vol . 36 No. 7 Smith et al

Isolation and precautions: Bloodborne

pathogen i ssues

LTCFs may be asked to provide care for persons with

hepatitis C, hepatitis B, HIV, and acquired immunodeﬁ-

ciency syndrome (AIDS), especially for individuals with

advanced disease who are too ill to reside at home but

do not require acute hospital care. Earlier guidelines for

dealing with HI V infection in the health care setting are

incorporated widely in hospitals but also apply in the

LTCF.

197,199

The standard approaches to protecting

HCWs and other patients from transmission of blood-

borne pathogens have essentially not changed since

these earlier recommendations. In the current isolation

guidelines,

201

Standard Precautions are still promoted

as the main method for preventing exposure to blood

and body ﬂuids for all patient interactions. These in-

clude the routine use of hand hygiene, gloves, gowns,

masks, and eye protection, depending upon the antici-

pated exposures.

The guideline also discusses in detail safe work prac-

tices to prevent exposures to bloodborne pathogens,

including prevention of needlesticks and other shar-

p-related injuries; prevention of mucous membrane

contact; safe injection practices; and precautions during

aerosol-generating procedures. Infection control

personnel at all LTCFs should carefully review these

guidelines and develop a plan for implementation

within their facilities. As in hospitals, it is known that

needlestick injuries do occur in the LTCF and usually

are related to needle recapping.

21 1

Plans for regular

education of all staff and for compliance with OSHA

standards should be in place, and LTCFs should ensure

the availability to hepatitis B vaccination and postexpo-

sure prophylaxis for HIV or hepatitis B for all employees

in accordance with the most recent guidelines.

212

Hand hygiene

Hand hygiene likely remains the most important

infection control measure in the LTCF as well as in

the hospital. Unfortunately, poor compliance with

hand hygiene recommendations has been noted in

LTCFs, as in other settings.

213,214

Health care provider

hand contamination is usually transient and amenable

to hand hygiene,

215

frequent hand hygiene would be

expected to lower LTCF infection rates,

203,216

and the

availability of alcohol-based hand sanitizer dispensers

enhances access to hand sanitizing agents.

CDC and HICPAC published a comprehensive hand

hygiene guideline.

217

Other published guidelines for

hand hygiene and choice of antiseptic agents are also

applicable.

218,219

They recommend the use of bar or

liquid soap when hands are visibly dirty or contami-

nated with proteinaceous material or visibly soiled

with blood or other body ﬂuids. If hands are not visibly

soiled, then the routine use of an alcohol-based hand

rub is recommended in the LTCF. Hands should always

be decontaminated after the removal of gloves. Hand

hygiene with an antiseptic agent or alcohol-based

hand rub is recommended before donning sterile

gloves for performing invasive procedures such as

placement of an intravenous or urinary catheter.

Hand hygiene compliance should be monitored by

the facility.

Resident health

Resident health programs are recommended for pre-

vention of infections,

but comprehensive programs

often are lacking in LTCFs.

149

One of the major functions

of a resident health program is the immunization of the

elderly resident.

59,220,221

The elderly are underserved in

terms of immunization to tetanus,

222

as well as pneumo-

coccal and inﬂuenza vaccines.

223

They should receive

pneumococcal vaccine at age 65, when they are rela-

tively immunologically responsive, rather than at age

80 to 85 when entering the LTCF.

Standing orders for

inﬂuenza and pneumococcal vaccination are associated

with improved vaccination rates.

224

Residents should

receive a TB skin test on admission and undergo chest

radiograph if TST positive or symptomatic.

Other resident care practices that should be

addressed include resident hand hygiene, oral hygiene,

prevention of aspiration, skin care, and prevention of

UTIs. Clinical trials in LTCFs have reported no decrease

in infections with routine vitamin or mineral supple-

mentation.

225,226

However, optimal care of comorbid

illnesses and good nutrition are principles of care irre-

spective of impact on infections.

Employee health

Published information on infection control in hospi-

tal personnel is available.

227-229

Employee infection

prevention considerations in the LTCF are somewhat

different than in the hospital, but the published litera-

ture and guidelines generally apply to the LTCFs as well

as hospitals. Because of congregate living conditions in

most LTCFs, there are some notable differences inc lud-

ing an increased risk of exposure to residents with her-

pes zoster, scabies, conjunctivitis, inﬂuenza, TB, and

viral gastroenteritis. The pediatric LTCF offers addi-

tional challenges to the prevention of infection includ-

ing childhood diseases, such as varicella, measles,

mumps, and rubella.

Regulations concerning protection of employees

from bloodborne pathogens apply to the LTCF.

163,196

The LTCF should be able to provide timely chemopro-

phylaxis to employees who may have blood/body

ﬂuid exposure to residents known to have HIV.

212

Smith et al September 2008 519

Employee health policies and procedures should ad-

dress postexposure follow-up or prophylaxis for cer-

tain infections, such as hepatitis B, hepatitis C, TB,

scabies, and HIV.

Primary employee vaccination considerations

should include inﬂuenza, hepatitis B, tetanus/diphthe-

ria, and pertussis. Varicella, measles, mumps, rubella,

and hepatitis A are of greater concern in the pediatric

LTCF setting. Inﬂuenza vaccine campaigns should

require signed declination statements by employees

who decline vaccination.

230

Adult vaccination information can be found at http://

www.immunize.org/. Vaccination should include hepa-

titis B to protect from this bloodborne pathogen. Vari-

cella vaccine is appropriate if an employee is not

immune. Hepatitis A vaccine may be appropriate in

certain circumstances, especially in behavioral health

and developmental disability facilities. Vaccine Infor-

mation Sheets (VIS) should be given to all adult vacci-

nees as required by the National Childhood Vaccine

Injury Act (42 U.S.C. §300aa-26). Anaphylaxis or any

other adverse event requiring medical attention within

30 days after receipt of a vaccine must be reported to

the Vaccine Adverse Events Reporting System (VAERS),

a requirement of the National Vaccine Injury Compen-

sation Program (www.vaers.org/pdf/vaers_form.pdf).

Initial assessment of employees and education in

infection control also are important, as is a reasonable

sick-leave policy.

150

Ill employees may cause signiﬁ-

cant outbreaks in the LTCF.

124

Initial screening should

include TB, also required by some states.

231,232

LTCFs

are required to prohibit employees with communicable

diseases or infected skin lesions from direct contact

with residents and to prohibit employees with poten-

tially infectious skin lesions from contact with resi-

dents’ food.

159

Education. The value of education of the LTCF ICP

has long been recognized, and surveys of personnel

conﬁrm this need.

233

The importance of ICP education

is accen tuated by the great turnover in LTCF personnel.

While the beneﬁts of ICP training are widely assumed,

one study analyzed the effects of a 2-day, intensive

basic training program on 266 ICPs.

234,235

Trainees

not only demonstrated an increase in postcourse

knowledge but, at 3- and 12-month follow-up, had a

signiﬁcant increase in implementation of key infection

control practices. Practices included performance of

surveillance, using infection deﬁnitions, calculating

infection rates, and giving employees and residents

TST and inﬂuenza vaccine.

The role of education in infection prevention in the

LTCF extends well beyond the ICP. One of the most im-

portant roles of the ICP is education of LTCF personnel

in basic infection control principles. It is recommended

that the ICP routinely assess the e ducational needs of

staff, residents, and families and develop educational

objectives and strategies to meet those needs; collabo-

rate in the development, delivery, and evaluation of

educational programs or tools that relate to infection

prevention, control, and epidemiology; and continu-

ously evaluate the effectiveness of educational pro-

grams and learner outcomes.

Education should focus on new personnel and certi-

ﬁed nursing assistants.

186

Priority for training should

be directed toward orientation, OSHA-mandated pro-

grams, problem-oriented teaching, and other programs

required by regulations. Surveillance data are an excel-

lent starting point for infecti on control training, and

compliance rounds provide an opportunity for the

ICP to provide timely, informal education to personnel.

Infection control content shoul d include information

on disease transmission, hand hygiene, barrier precau-

tions, and basic hygiene.

234

In addition, all individuals

with direct resident care responsibility need education

in early problem and symptom recognition. The teach-

ing methods used need to be sensitive to language,

cultural background, and educational level. A coordi-

nated, effective educational program will result in

improved infection control activities.

235

An tib iotic stewardship

Antibiotic-resistant bacteria pose a signiﬁcant

hazard in the LTCF, and this resistance has been

strongly associated with antibiotic use.

136,236-240

Anti-

microbials are among the most frequently prescribed

medications in the LTCF.

241

Antibiotics are given to approximately 7% to 10% of

residents in LTCFs, frequently for lengthy periods of

time.

242-244

A study of 22 LTCFs noted an incidence of

antibiotic prescriptions of 2.9 to 13.9 antibiotic courses

per 1000 resident-days.

245

Several studies have ques-

tioned the appropriateness of this practice.

242-244

A common problem is the failure to distinguish infec-

tion and colonization (such as a positive swab cultu re

of a pressure ulcer or a urine culture showing bacteri-

uria without signs or symptoms of infection) and the

treatment of the colonization with antibiotics. In addi-

tion, antibiotics often are prescribed over the tele-

phone in this setting.

246

There also appears to be

signiﬁcant variability in antibiotic prescribing patterns

in the LTCF.

247

Several reviews and guidelines for infection control

efforts to curb antibiotic resistance in health care set-

tings (including LTCFs) have been published .

167,173,200

These guidelines stress the importance of having an

ICP trained in infection control and LTCF administrative

support and resources for the infection control pro-

gram.

237

The CDC has published a 12-step program

for preventing antimicrobial resistance among LTCF

520

Vol . 36 No. 7 Smith et al

residents that addresses the broad areas of preventing

infection (eg, resident vaccination), diagnosis/treat-

ment of infection, using antibiotics wisely, and pre-

venting transmission (www.cdc.gov). A LTCF antibiotic

review program is recommended

173

and is often found

in LTCFs.

248,249

Recent guidelines have addressed the development

of antimicrobial stewardship programs in hospi-

tals.

250

Using this guideline as a starting point, LTCFs

are encouraged to include antimicrobial stewardship

in the LTCF infection control program and discuss ap-

propriate choices for various clinical situations.

241

A recent survey revealed that fewer than one third

of LTCFs surveyed had any such antibiotic use proto-

cols in place.

251

Minimum criteria for initiation of an-

tibiotic therapy have been proposed to improve

antimicrobial prescribing in LTCFs

252

and may be of

assistance in developing antibiotic appropriateness

criteria.

Approximately two thirds of LTCF professionals

identiﬁed a clear need for greater education regarding

judicious antibiotic use in LTCFs.

251

Education and

development of antibiotic guidelines have improved

antimicrobial usage in the LTCF setting in several

studies.

253,254

Other aspects of the program

Policies and procedures. An important aspect of in-

fection control programs is the development and up-

dating of infection control policies and procedures.

Because practices change, they should be reviewed

on a scheduled basis. Review of the Bloodborne Patho-

gens Exposure Control Plan is required to be done

annually.

163

Resources are available on the writing of policies

and procedures in general

255,256

dietetic service

policies,

255

laundry policies,

257

physical therapy poli-

cies,

255,258,259

and handwashing.

217-219

Respiratory

therapy issues may be relevant to the LTCF, including

cleaning of humidiﬁers, respiratory therapy equip-

ment, suctioning technique, and tracheotomy care.

Pharmacy and medication issues include use of multi-

dose medication vials and resident speciﬁc creams and

ointments.

A policy and procedure on hand hygiene are criti-

cally important to have available for staff.

217

The policy

details speciﬁc ind ications for hand hygiene, including

when coming on duty; whenever hands are soiled;

after personal use of toilet; after blowing or wiping

nose; after contact with resident blood or body secre-

tions; before performing any invasive procedures on

a resident; after leaving an isolation room; after han-

dling items such as dressings, bedpans, cathete rs, or

urinals; after removing gloves; before eating; and on

completion of duty. The corresponding procedure

should list explicit steps in the hand hygiene process.

A 15-second handwash is usually recommended.

36,219

Alcohol-based hand rubs should be made available

and used by staff, especially when hand washing facil-

ities are inadequate or inaccessible. Hand hygiene

compliance should be monitored.

217

Facility management. Environmen tal control in the

facility is an important consideration. Routine environ-

mental cultures are not cost-effective and do not usu-

ally generate information relevant to clinical

infections. However, periodic environmental compli-

ance rounds are recommended.

186,258

Sources are

available suggesting speciﬁc environmental measures

such as dishwasher and laundry cleaning tempera-

tures,

186,258,260

although limited data exist.

A related area of concern is sterilization, disinfection,

and asepsis, including the evaluation of cleaning

methods, such as monitoring reuse of disposable

equipment. Resources are available.

261,262

An infection

control program should also monitor basic hygiene (eg,

respiratory etiquette) and compliance with proper in-

fection control techniques. Staff, residents, and fami-

lies may all be the source of HAIs if there is a

breakdown in basic hygiene.

Selection of proper disinfectants and antiseptics

requires infection control expertise. Reading the man-

ufacturer’s label directions and following the required

dilution and contact time instructions are recommen-

ded. Infection control input will also be needed on

additional and new products that affect infection

prevention, such as urinary catheter systems, gloves,

and disposable diapers. Quality, efﬁcacy, and cost

issues need to be weighed in product selection.

263

Waste management is the important in the LTCF.

Medical and biohazardous waste issues are controver-

sial; Environmental Protection Agency (EPA) regula-

tions, OSHA regulations, and CDC recommendations

may conﬂict.

264

Local health department regulations

should also be checked. Several resources are available

on medical waste issues relevant to the

LTCF.

162,255,258,260,264,265

Disease reporting. Another important function of

the infection control program is disease reporting to

public health authorities. State and local health depart-

ments will provide a list of reportable diseases and

other public health resources.

Performance improvement/resident safety. The in-

creased emphasis on quality indicators in health care is

becoming evident in LTC. There are important differ-

ences in deﬁnitions of infection published for LTCF sur-

veillance (see Surveillance section above) and those in

the long-term care Minimum Data Set (MDS) manual.

This is especially important for UTIs. In addition,

CMS provides a Web site called Nursing Home

Smith et al September 2008 521

Compare,

which posts information to the public on

nursing home quality measures, inspections, stafﬁng,

and other data for individual LTCFs. For instance, UTI

in the CMS MDS requires a physician diagnosis in the

chart and a positive urine culture.

266

This deﬁnition

has been found to be inaccurate compared with stan-

dard de ﬁnitions such as the McGeer deﬁnition,

which

requires a com bination of symptoms and signs.

267

A quality assessment and assurance committee is

required.

159

Infection control is the prototype quality

improvement or performance improvement (PI) pro-

gram, and many of the techniques used in infection

control are directly applicable to PI, such as data collec-

tion, data analysis, and intervention.

268,269

The tradi-

tional performance improvement process focuses on

adverse events and assesses functions of the

system.

270,271

In the course of performing infection

surveillance, there is ample opportunity to monitor

compliance with infection control policies and proce-

dures and to provide informal infection control educa-

tion to address observed problems.

Examples of appropriate quality indicators for PI

study include resident immun ization with inﬂuenza

and pneumoccoccal vaccines,

272

employee vaccination

for inﬂuenza,

273

number of employee TSTconversions,

and employee hand hygiene compliance. A national fo-

cus on patient safety and prevention of adverse events

has relevance to the LTC setting as well.

274

Preparedness planning. The ICP will frequently

play a key role in LTCF preparedness planning. Th e

planning is currently focused on pandemic inﬂuenza

but should prepare the LTCF for dealing with a variety

of disaster scenarios. Issues to be considered include

surge capacity, medication availability and rationing,

stockpiling, staff shortages during an inﬂuenza pan-

demic, and communication with public health author-

ities for planning purposes.

275,276

It appears that the

LTCF ICP will play an important role in preparedness

and that about half of LTCFs have a pandemic inﬂuenza

plan.

277

RESOURCES

Having appropriate job-related resources is essential

to good performance in the role of infection prevention

and control. A few resources for the ICP are listed

below:

1 Smith PW, editor. Infection control in long-term care

facilities. 2nd ed. Albany, NY: Delmar Publishers, Inc

(800-347-7707); 1994. Cost, $38.95.

2 APIC infection connection: long-term care facilities

newsletter. Available from the As sociation for Profes-

sionals in Infection Control and Epidemiology (202-

296-2742). Cost for nonmem bers, $15.

3 Strausbaugh LJ, Joseph C. Epidemiology and preven-

tion of infections in residents of long-term care facil-

ities. In: Mayhall CG, editor. Hospital epidemiology

and infection control. Baltimore, MD: Williams &

Wilkins (800-6380672); 2004. Cost, $199.

4 Heymann DL, editor. Control of communicable dis-

eases manual. 18th ed. Washington, DC: American

Public Health Association; 2004. Cost, $33.00.

5 Horan-Murphy E, Barnard B, Chenoweth C, Friedman

C, Hazuka B, Russell B, et al. APIC/CHICA-

Canada infection control and epidemiology: profes-

sional and practice standards. Am J Infect Control

1999;27:47-51.

6 McGeer A, et al. Deﬁnitions of infection for surveil-

lance in long-term care facilities. Am J Infect Control

1991;19:1-7.

7 APIC text of infection control and epid emiology.

Washington, DC: Association for Professionals in

Infection Control and Epidemiology, Inc.; 2005.

8 Nicolle LE, Garibaldi RA. Infection control in long-

term care facilities. Infect Control Hosp Epidemiol

1995;16:348-53.

RECOMMENDATIONS

See Table 4 for scoring scheme.

A. Infection control program

1 An active, effective, facility-wide infection control

program should be established in the LTCF. The pur-

pose of the program is to help prevent the develop-

ment and spread of infectious diseases (Category IC).

Comment: The elements of a program generally

include the following:

a. Surveillance—Systematic data collection to iden-

tify infections in residents

b. Outbreak Control—A system for detection, inves-

tigation, and control of epidemi c infectious diseases

in the LTCF

c. Isolation—An isolation and precautions system to

reduce the risk of transmission of infectious agents

d. Policies and procedures—Relevant to infection

control (see Table 2)

e. Education—Continuing education in infection

prevention and control

f. Resident health program

g. Employee health program

h. Antibiotic stewardship—A system for antibiotic

review and control

i. Disease reporting to public health authorities

j. Facility man agement, including environmental

control, waste management, product evaluation

and disinfection, sterilization and asepsis

522

Vol . 36 No. 7 Smith et al

k. Performance improvement/resident safety

l. Preparedness planning

2 The infection control program must be in compli-

ance with federal, state, and local regulations (Cate-

gory IC).

B. Infection control administrative structure

1 Oversight of the infection control program should be

deﬁned and should include participation of the ICP,

administration, nursing staff, and physician staff

(Category II).

Comment: A committee, traditionally the ICC

(infection control committee), may oversee the

infection control program for the facility. ICC

members often include the ICP; the medical direc-

tor; and representatives from nursing, administra-

tion, and pharmacy. Participation of other

departments, such as dietary, housekeeping, and

physical therapy, should be considered on an ad

hoc basis. Administrative structures other than

an ICC may provide oversight to the infection con-

trol program. One example is an infection control

oversight committee, a small group consisting of

the LTCF administrator, the ICP, and the medical di-

rector. Alternatively, the performance improve-

ment committee or patient safety committee and

the ICC may be combined, but it is important to

maintain the identity of the infection control pro-

gram. The duties of the ICC should be delegated

appropriately if no formal ICC exists.

2 Formal delegation of infection control oversight

should be made in writing (Category II).

3 The infection control oversight committee should

meet on a regular basis and have a mechanism for

emergent meetings as neede d (Category II).

4 This committee should maintain written minutes

with identiﬁcation of problems and plans for action

(Category II).

5 The effectiveness of the infection control program

should be evaluated by the administration on at least

an annual basis (Category II).

6 Policies and procedures for investigating, control-

ling, and preventing infection transmission in the

facility should be established (Category IC).

Comment: Other functions include (a) review of

infection control data, (b) approval of policies

and procedures, (c) monitoring program activities,

and (d) recommending policy to the facility

administration.

7 Consultation should be available as needed including

with an infectious disease physician or other profes-

sional with expertise in infection control (Category II).

C. ICP

1 One person, the ICP, should be assigned the respon-

sibility of directing infection control activities in the

LTCF. The ICP should be someone familiar with LTCF

resident care problems (Category IC).

2 The ICP should have a written job description of in-

fection control duties (Category II).

3 The ICP is responsible for implementing, monitor-

ing, and evaluating the infection control program

for the LTCF (Category II).

4 The ICP should be guaranteed sufﬁcient time and the

support of the administration to effectively direct the

infection control program (Category II).

5 The ICP (or another appropriate individual, such as

the medical director) should have written authority

to institute infection control measures in emergency

situations (Category IB).

6 The ICP should have a sufﬁcient infection control

knowledge base to carry out responsibilities appro-

priately (Category II).

Comment: A background in infectious diseases,

microbiology, geriatrics, and educational methods

is advisable. Management and teaching skills also

are helpful. Continuing education is essential for

the ICP (eg, meetings, courses, journals).

7 The ICP should know the federal, state, and local reg-

ulations dealing with infection control in the LTCF

(Category II).

8 The ICP should communicate with relevant facility

committees and personnel within the facility, ICPs

from transferring facilities, and public health author-

ities to ensure appropriate isolation and collection of

surveillance information (Category II).

Table 4. Categorization of recommendations

In this document, as in a number of published HICPAC, SHEA, and APIC

guidelines, each recommendation is categorized on the basis of existing

scientiﬁc evidence, theoretical rationale, applicability, and national or

state regulations. The following categorization scheme is applied in this

guideline:

Category IA. Strongly recommended for implementation and strongly

supported by well-designed experimental, clinical, or epidemiologic

studies.

Category IB. Strongly recommended for implementation and supported

by some experimental,clinical, or epidemiologic studies and by strong

theoretical rationale.

Category IC. Required for implementation, as mandated by federal or

state regulation or standard.

Category II. Recommended for implementation and supported by

suggestive clinical or epidemiologic studies or by theoretical rationale.

No Recommendation. Unresolved issue. Practices for which insufﬁcient

evidence or no consensus regarding efﬁcacy exists.

Smith et al September 2008 523

9 No recommendation on number of ICPs per 100 LTCF

beds.

D. Surveillance

1 The LTCF should have a system for ongoing collec-

tion of data on infections in the institution (Category

IC).

2 A documented surveillance procedure should be

used, including written deﬁnitions of infections

(Category IB).

Comment: Concurrent surveillance is preferable to

retrospective surveillance. The frequency of

surveillance for HAIs in the LTCF should be based

on factors such as acuity level of the resident

population. Surveillance at least once a week

generally is needed to collect timely data. Surveil-

lance data should be collected from communica-

tion with staff; this may be during walking

rounds in the LTCF. Medical progress notes in the

chart, laboratory or radiology reports, nursing

notes, treatment records, medication records,

physical assessments, environmental observa-

tions, and follow-up information from transfers

to acute care hospitals provide clues to the pres-

ence of infections.

3 The ICP should review surveillance data frequently

and recommend infection control measures, as

appropriate, in response to identiﬁed problems

(Category IB).

Comment: Analysis of surveillance data should

include at least the following elements on each

infection to detect clusters and trends: resident

identiﬁer, type of infection, date of onset, location

in the facility, and appropriate laboratory

information.

4 Infection rates should be calculated periodically,

recorded, analyzed, and reported to the administra-

tion and the infection control oversight committee

(Category IB).

Comment: Infection rates usually are calculated

monthly, quarterly, and annually. HAI rates are

calculated preferably as infections per 1000 resi-

dent-days. A standard infection report form facili-

tates reporting of surveillance information. Tables,

graphs, and charts may be used and facilitate edu-

cation of personnel.

5 Surveillance data should be used for planning infec-

tion control efforts, detecting epidemics, directing

continuing education, and identifying individual res-

ident problems for intervention (Category IB).

Comment: In addition to collection of baseline

infection rates, the ICP should perform problem-

focused studies. Examples of special studies are

evaluation of UTIs in catheterized residents, a

study of the occurrence of inﬂuenza in vaccinated

versus unvaccinated residents, or the prevalence

of pressure ulcers in bed-bound residents.

6 In addition to the above outcome measures, surveil-

lance should also include analysis of process mea-

sures relevant to infection control (Category II).

Comment: Examples include monitoring hand hy-

giene compliance, observation of aseptic tech-

nique, and measuring HCW inﬂuenza vaccination

rates.

E. O utbreak control

1 Surveillance data should be used to detec t and

prevent outbreaks in the LTCF (Category IB/IC).

Comment: The occurrence of even a single veriﬁed

case of a highly transmissible disease (such as

infectious TB, inﬂuenza, scabies, Salmonella, and

norovirus) in the LTCF should prompt notiﬁcation

of appropriate individuals (such as the medical

director or administrator), consideration of an

outbreak, and institution of control measures.

After the institution of isolation precautions,

assessment of exposed residents and personnel

should be made in a timely fashion to detect other

cases.

2 The facility should deﬁne authority for intervention

during an outbreak (Category IB).

Comment: The LTCF should have a preexisting

protocol for dealing with infectious disease epi-

demics, including the authority to relocate resi-

dents, conﬁne residents to their rooms, restrict

visitors, obtain cultures, isolate, and administer

relevant prophylaxis or treatment (such as antivi-

rals during an inﬂuenza outbreak).

3 In order to facilitate response to an outbreak, con-

sent for appropriate diagnostic or therapeutic mea-

sures should be obtained from the resident or

medical decision maker and the resident’s primary

physician on admission to the facility (Category II).

4 Obtaining cultures of the environment or from

asymptomatic personnel is not recommended

except as targeted by an epidemiologic investigation

(Category II).

5 A TB control program should focus on detection of

active cases in residents and staff and isolation or

transfer of residents with known or suspected pul-

monary TB disease (Category IC).

524

Vol . 36 No. 7 Smith et al

Comment: TB control programs are mandated by

OSHA. A case of TB in residents or staff that was

or may have been acquired in the facility should

lead to clinical evaluation and TB testing of resi-

dents and employees.

F. The facility

1 Hand hygiene facilities and supplies should be avail-

able and conveniently located for residents and staff

(Category IA).

2 Clean and soiled utility areas should be functionally

separate and clearly designated (Category IC).

3 Appropriate ventilation and air ﬁltration should be

addressed by the LTCF (Category IC).

Comment: If the LTCF provides care for residents

or accepts residents with a diagnosis of active

TB, the airborne infection isolation (AII) require-

ment should be met. If these requirements cannot

be met, a system for transfer of cases to an appro-

priate institution that provides AII should be part

of the overall infection control plan.

4 Housekeeping in the facility should be performed on

a routine and consistent basis to provide for a safe

and sanitary environment (Category IC).

Comment: Cleaning schedules should be kept for

all areas in the LTCF. Cleaning products should

be approved and labeled appropriately; man ufac-

turer’s (or other authoritative) recommendations

for use and dilution should be followed.

5 Measures should be instituted to correct unsafe and

unsanitary practices (Category II).

Comment: Environmental cleanliness may be

monitored by walking rounds with a checklist for

each area of the LTCF. Nursing interventions may

be monitored by direct observation during such

rounds.

6 Areas in the LTCF with unique infection control con-

cerns (eg, laundry, kitchen, rehabilitation) should

have the appropriate policies and procedures devel-

oped (Category II).

Comment: Laundry policies and procedures

should address the following: proper bagging of

linen at the site of use, transporting linen in appro-

priate carts, cleaning of the carts on a regular basis,

separation of clean and soiled linen, washing tem-

peratures or use of an appropriate chemical mix for

low-temperature washing, covering of clean linen,

protection of personnel handling soiled laundry,

and hand hygiene after contact with soiled linen.

Adequate supplies of clean linen should be avail-

able. Laundry regulations should be addressed if

the facility does its own laundry. Dietetic servi ce

area policies and procedures should address the

following: handling of uncooked foods, cooking

of food, cleaning of food preparation areas, food

storage, cooking and refrigeration temperatures,

cleaning of ice machines, hand hygiene indica-

tions, and employee health. Food and drink should

be limited to speciﬁc areas. Policies and procedures

covering infection control aspects of physical ther-

apy (including cleaning of hydrotherapy tanks)

should be developed. It should include cleaning

and disinfection of hydrotherapy equipment,

hand hygiene indications, and cleaning of exercise

equipment. If pets are allowed, the LTCF should

have a policy deﬁning access, containment, clean-

liness, and vaccination of pets.

7 Policies and procedures for disposal of infectious

medical waste (including waste categorization, pack-

aging, storage, collection, transport, and disposal)

should be developed in accordance with federal,

state, and local regulations (Category IC).

Comment: Examples of speciﬁc issues include

types of waste disposal bags, cleaning of waste

transportation carts, and types of waste storage

containers. Policies for sharps disposal should be

developed.

G. Isolation and precautions

1 Isolation and precautions policies and procedures

should be developed, evaluated, and updated in

accordance with most recent CDC/HICPAC guidance

(Category IC).

2 Regular education programs should be developed to

reinforce understanding and compliance (Category IC).

3 Compliance with these infection control practices

(eg, hand hygiene, isolation) should be monitored

(Category IC).

4 Any isolation and precautions system used should

include implementation of Standard Precautions

for all residents (eg, wearing of gloves, masks, eye

protection, and gowns wh en contamination or

splashing with blood or body ﬂuids is likely) (Cate-

gory IC).

5 Any isolation and precautions system should include

the implementation of transmission-based precau-

tions (Contact Precautions, Droplet Precautions, or

Airborne Precautions) in accordance with current

CDC/HICPAC guidance (Category IB/IC).

6 The LTCF should have a policy dealing with MDROs

(such as MRSA or VRE) that is compatible with cur-

rent national standards (such as the HICPAC isolation

and MDRO guidelines) and appropriate to the LTCF

setting (Category IB).

Smith et al September 2008 525

Comment: This policy should deal with issues

such as acceptance of colonized or infected

patients into the facility, inquiring about coloniza-

tion of admissions with MDROs, and isolation of

residents with MDROs. Denial of admission to

the LTCF solely on the basis of colonization or

infection with a resistant organism is not appropri-

ate. HICPAC recommends intensiﬁcation of con-

tainment measures for MDROs if ongoing

transmission is occurring.

7 The individual resident’s clinical situation should be

considered when deciding whether to implement or

modify the use of Contact Precautions in addition to

Standard Precautions if colonized or infected with a

MDRO (Category IB/IC).

Comment. Routine glove use is an example of a

form of modiﬁed Contact Precautions, but it has

not been validated in the LTCF setting.

8 A program of safe work practices to prevent HCW

exposure should be developed in accordance with

CDC/HICPAC and OSHA guidance. Used needles and

syringes should not be manually recapped, broken,

or bent. Self-capping needles should be used. They

should be disposed of, with all sharps, in a punc-

ture-resistant, leak-proof container (Category IC).

9 Gloves are indicated for contact with blood or body

ﬂuids, contaminated items, mucous membranes, or

nonintact skin (Category IC).

10 Policies should be developed to deal with spills and

personnel exposure to blood or body ﬂuids.

Employees should know how to respond to an

exposure (eg, immediately washing the skin in the

event of a blood exposure). Postexposure prophy-

laxis should be readily available (Category IC).

11 Residents with suspected TB should be placed in a

negative-pressure room or transferred to a facility

with such a room (Category IC).

H. Asepsis and hand hygiene

1 Routine hand hygiene should be encouraged. Hands

should be washed after any patient contact but espe-

cially after contact with body ﬂuids, after removing

gloves, when soiled, and when otherwise indicated

(Category IA). Unless hands are visibly soiled, use

of alcohol-based hand gels is encouraged (Category

IA/IC).

2 A hand hygiene policy and procedure should be

developed by the LTCF in accordance with current

CDC/HICPAC guidance with a program of ongoing

hand hygiene education (Category IB/IC).

3 Hand hygiene compliance should be monitored (Cat-

egory IC).

4 Policies and procedures for disinfection and steriliza-

tion should be developed (Category IB).

Comment: These policies and procedures should

address issues such as sterile supplies, reuse of

disposable items, disinfection of equipment

(such as thermometers), and cleaning of noncriti-

cal items. All items, other than disposables, should

be cleaned, disinfected, or sterilized, following

published guidelines and manufacturers’ recom-

mendations. The ICP should identi fy those resi-

dent care procedures that require aseptic

technique.

I. Resident care

1 Resident rooms should have an accessible sink, with

soap, water, towels, and toilet facilities (Category II).

Comment: Provision should be made for maintain-

ing adequate resident personal hygiene and for

instructing residents in hygiene and hand hygiene

as appropriate to their functional status.

2 A resident skin care program should be developed to

maintain the skin as a barrier to infection (Category

II).

Comment: Resident skin care should include the

following: routine frequent turning for those

unable to do so themselves, keeping the residents

clean and dry, inspecting all residents’ skin on a

routine basis, ensuring appropriate nutrition,

treating pressure ulcers, and providing prompt

care for any other breaks in skin integrity. Turning

schedules and pressure ulcer assessment forms

may be useful.

3 A program to prevent UTIs should be developed,

including the following:

Routine urinalysis or urine culture to screen for

bacteriuria or pyuria is not recommended (Cate-

gory IA).

Residents with impaired bladder emptying man-

aged with intermittent catheterization should be

managed with a clean technique (Category IA).

s Policies for catheter use should address cathe-

ter insertion, closed drainage systems, mainte-

nance of urinary ﬂow, and indications for

changing the catheter (Category IB).

s Irrigation of indwelling catheters with saline or

antiseptics is not routinely recommended (Cate-

gory IB).

If leg bags are used, the LTCF should develop pol-

icies and procedures for aseptic connection,

cleaning, and storage of leg bags (Category II).

Adequate hydration should be maintained (Cate-

gory II).

526

Vol . 36 No. 7 Smith et al

Comment: Men with incontinence should have

voiding managed by a condom catheter rather

than ind welling catheter, where possible. Resi-

dents with chronic indwelling catheters should

have the catheter replaced and a specimen

collected immediately prior to initiating antimi-

crobial therapy for symptomatic infection.

4 A program to minimize the risk of pneumonia in the

LTCF should address the following: reducing the po-

tential for aspiration, minimizing atelectasis, and

caring for respiratory therapy equipment (Category

II).

Comment: Pneumonia prevention guidelines are

available, and many of the suggested measures

are applicable to the LTCF.

5 Policies and procedures should be developed for

prevention of infections associated with nasogastric

and gastrostomy feeding tubes, including the follow-

ing: preparation, storage, refrigeration, and adminis-

tration of feeding solutions and care of percutaneous

feeding tube skin sites (Category II).

6 Policies and procedures should be developed for pre-

vention of IV infections, including central lines, if

these devices are used (Category IB).

Comment: Policies should address indications for

IV therapy, the type of dressing used to cover the

IV exit site, cannula insertion, site maintenance,

and chan ging ﬂuids or tubing.

J. Resident heal th program

1 A resident health program should be implemented

(Category II).

There should be explicit and accessible documen-

tation of program components in the resident rec-

ord (Category II).

2 At admission, each resident should have a complete

history (including important past and present infec-

tious diseases), immunization status evaluation,

and recent physical examination (Category II).

3 All newly admitted residents should receive TB

screening unless a physician’s statement is obtained

that the resident had a past positive TST (Category IA/

IC).

Comment: A 2-step booster TST is often recom-

mended in this setting.

4 When new or active TB is suggested by a positive

skin-test result, or symptoms are consistent with

active TB, a chest radiograph and medical evaluation

should be obtained (Category II).

5 Follow-up TST for TB should be performed periodi-

cally or after discovery of a new case of TB in a

resident or staff member (Category IB). No recom-

mendation on frequency of routine follow-up TSTs

for residents.

6 Each resident should receive current vaccinations for

tetanus, diphtheria, inﬂuenza, pertussis, pneumo-

coccal pneumonia, and any other vaccines recom-

mended by the ACIP (Category IB/IC).

7 Each resident should receive the inﬂuenza vaccine

annually in the fall, unless medically contraindicated

(Category IC).

Comment: Facilities should obtain resident con-

sent at admission for yearly inﬂuenza vaccination

and use standing orders for yearly inﬂuenza

vaccination.

8 Policies and procedures addressing visitors should be

developed to limit introduction of community infec-

tions (such as inﬂuenza) into the LTCF (Category II).

K. Employee health program

1 All new employees should have a baseline health

assessment, including immunization status and his-

tory of relevant past or present infectious diseases

(Category 1B/IC).

Comment: The past history of infectious diseases

should address contagious diseases such as chi ck-

enpox, measles, hepatitis, furunculosis, and bacte-

rial diarrhea. Screening cultures of new employees

are rarely indicated.

2 All new employees should receive TSTunless there is

written documentation that the empl oyee had a pos-

itive reaction to a tuberculin test. When new or active

TB is suggested by a positive TST result or by symp-

toms, a chest radiograph and medical evaluation

should be obtained (Categ ory 1A/IC).

Comment: A 2-step booster TST technique is

recommended when indicated. Only empl oyees

who have active pulmonary TB should be

restricted from work.

3 Follow-up skin testing of staff who are TST negative

should be performed periodically based on the

facility’s annual risk assessment or after discovery

of a new case of TB in a resident or staff member

(Category 1A/IC).

Comment: The intradermal Mantoux method or

licensed blood test should be used. The frequency

of testing depends on the regional prevalence of

TB; the facility’s annual risk assessment; and fed-

eral, state, or local regulations.

4 All employees should have current immunizations as

recommended for HCWs by the Advisory Committee

Smith et al September 2008 527

on Immunization Practices (ACIP), with documenta-

tion in the employee record (Category 1A/IC).

5 Employees with blood or body ﬂuid contact should

be offered HBV immunization within 10 working

days of hire and after training has been completed

(Category 1C).

Comment: Refusal of this vaccine should be docu-

mented, using the OSHA-required Declination

Statement for Hepatitis B vaccine.

6 Employees should be offered the inﬂuenza vaccine

annually (Category 1A/1C).

Comment: A vaccine declination statement may be

signed by eac h employee who declines inﬂuenza

vaccination.

7 Each employee should be taught basic use of per-

sonal protective equipment and hand hygiene and

to consider blood and all body ﬂuids as potentially

infectious (Category 1C).

8 Employees with signs or symptoms of communicable

diseases (eg, cough, rash, diarrhea) should not have

contact with the residents or their food (Category 1B).

9 All employees should be educated to report any sig-

niﬁcant infectious illnesses to their supervisor and

the staff member responsible for employee health

(Category 1B).

Comment: Each employee record should include

factors affecting immune status (such as steroid

therapy, diabetes, HIV infection), history of com-

municable diseases, illnesses, and incidents such

as exposures to con tagious diseases, needl esticks,

injuries, and accidents.

10 The LTCF should develop protocols for managing

employee illnesses and exposures (such as blood-

borne pathogens like HIV and hepatitis B and C, as

well as TB, scabies, or gastroenteritis) (Category

1B/IC).

Comment: An employee absentee policy that dis-

courages the employee from working while ill

should be developed.

L. Education

1 Infection control education should be provided at the

initiation of employment and regularly thereafter.

Training should include all staff, especially those

providing direct resident care (Category IC).

2 All programs should be documented with the date,

topic, names of attendees, and evaluations (Category

IC).

Comment: Program topics should be timely and

relevant to infection prevention and control. Basic

hygiene, hand hygiene, respiratory etiquette,

transmission of infectious diseases, occupational

health, prevention of TB and bloodborne patho-

gens, Standard and Transmission-based Precau-

tions, infection control standards, and the

susceptibility of residents to infectious diseases

are topics that should be included. The ICP may

recommend topics. Surveillance data are of inter-

est to staff and may be included as appropriate.

The educators should evaluate the educational

program and outcomes and use that information

to modify future programs.

M. Po licies and procedures

1 Infection control policies and procedures dealing with

relevant aspects of infection control such as hand hy-

giene, disinfection, and isolation precautions should

be in place and compatible with current regulations

and infection control knowledge (Category IC).

2 Infection control policies and procedures should be

approved, reviewed, and revised on a regular basis

(Category IC).

Comment: The ICP should assist in the develop-

ment and updating of infection-related policies

and procedures.

3 Employees should be made aware of infection

control policies and procedures (Category IC).

Comment: The ICP should develop a system for

monitoring staff compliance with infection

control policies and procedures.

N. Antibiotic stewardship

1 Infection control programs in LTCFs should be

encouraged to include a component of antimicrobial

stewardship (Category IB).

Comment: The LTCF should encourage judicious

use of antimicrobials with guidelines based in

part on local susceptibility patter ns. Antibiotic

utilization and appropriateness may be monitored,

and these data used for interventions (eg, educa-

tion, antibiotic restrictions).

2 The ICP should monitor antibiotic susceptibility

results from cultures to detect clinically sign iﬁcant

antibiotic-resistant bacteria (such as MRSA or VRE)

in the institution. Changes in antibiotic-susceptibil-

ity trends should be communicated to appropriate

individuals and committees (Category IB).

O. Miscellaneous aspects

1 There should be a system for reporting notiﬁable dis-

eases to proper public health ofﬁcials (Category 1C).

528

Vol . 36 No. 7 Smith et al

2 The infection control program should collaborate

with the performance improvement (PI) program, if

a formal program exists (Category II).

Comment: Infection control is an important com-

ponent of PI, and the epidemiological techniques

used in in fection control will assist the PI program.

3 The ICP should be involved with the review and

selection of new products that have infection control

implications (Category II).

4 The ICP should be involved with LTCF inﬂuenza

pandemic preparedness planning (Category II).

5 Infection control activities should address relevant

resident safety issues (Category II).

P. R e g u l a t i o n s

1 The infection control program must be in compli-

ance with federal, state, and local regulations (Cate-

gory IC).

2 The infection control program should reﬂect

national, evidence-based standards of practice for

infection prevention and control (Category IC).

The authors gratefully acknowledge the expert contribution of Chesley Richards, MD,

of the CDC, and the editorial assistance of Elaine Litton of the University of Nebraska

Medical Center.

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