Causes of infection in long-term care facilities
- Michael J Richards, MD, FRACP
Michael J Richards, MD, FRACP
- The Royal Melbourne Hospital
- Victoria, Australia
- Rhonda L Stuart, MBBS, FRACP, PhD
Rhonda L Stuart, MBBS, FRACP, PhD
- Infectious Diseases Physician, Medical Director Infection Control
- Monash Health
Long-term care facilities (LTCFs) provide a unique environment for facilitating transmission of infection between residents [1-4]. Types of infections and important pathogens in LTCFs will be reviewed here.
Infection control strategies in LTCFs are discussed separately. (See "Principles of infection control in long-term care facilities".)
TYPES OF INFECTIONS
Important types of infection in long-term care facilities (LTCFs) include respiratory tract infection, gastrointestinal infection, urinary tract infection, and skin and soft tissue infection . Together, these infections represent 94 percent of infections seen in LTCFs [2,3,6,7].
Respiratory tract infection
Pneumonia — Mortality due to pneumonia is higher among residents of LTCFs than adults in the community. In addition, an episode of pneumonia in a LTCF resident is associated with increased mortality that persists for up to two years . Predisposing factors include underlying obstructive pulmonary disease, left heart failure, and risk of aspiration [9,10]. Aspiration pneumonia is common in the presence of risk factors including stroke, neuromuscular disorders, or impaired consciousness.
Pneumonia in LTCFs may be caused by pathogens associated with community-acquired pneumonia or hospital-acquired pneumonia. The microbiology depends on whether residents have recently been in an acute care facility and their length of stay in the LTCF. Streptococcus pneumoniae is the most common pathogen [11,12]. Atypical pathogens such as Mycoplasma pneumoniae are less common in LTCFs than the general community.
- High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:149.
- Heudorf U, Boehlcke K, Schade M. Healthcare-associated infections in long-term care facilities (HALT) in Frankfurt am Main, Germany, January to March 2011. Euro Surveill 2012; 17.
- Cotter M, Donlon S, Roche F, et al. Healthcare-associated infection in Irish long-term care facilities: results from the First National Prevalence Study. J Hosp Infect 2012; 80:212.
- Smith PW, Bennett G, Bradley S, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol 2008; 29:785.
- Montoya A, Mody L. Common infections in nursing homes: a review of current issues and challenges. Aging health 2011; 7:889.
- Pop-Vicas A, Mitchell SL, Kandel R, et al. Multidrug-resistant gram-negative bacteria in a long-term care facility: prevalence and risk factors. J Am Geriatr Soc 2008; 56:1276.
- Engelhart ST, Hanses-Derendorf L, Exner M, Kramer MH. Prospective surveillance for healthcare-associated infections in German nursing home residents. J Hosp Infect 2005; 60:46.
- Vergis EN, Brennen C, Wagener M, Muder RR. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival. Arch Intern Med 2001; 161:2378.
- Medina-Walpole AM, Katz PR. Nursing home-acquired pneumonia. J Am Geriatr Soc 1999; 47:1005.
- Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 2003; 124:328.
- Polverino E, Dambrava P, Cillóniz C, et al. Nursing home-acquired pneumonia: a 10 year single-centre experience. Thorax 2010; 65:354.
- Polverino E, Torres A, Menendez R, et al. Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case-control study. Thorax 2013; 68:1007.
- Ewig S, Klapdor B, Pletz MW, et al. Nursing-home-acquired pneumonia in Germany: an 8-year prospective multicentre study. Thorax 2012; 67:132.
- Carusone SC, Loeb M, Lohfeld L. Pneumonia care and the nursing home: a qualitative descriptive study of resident and family member perspectives. BMC Geriatr 2006; 6:2.
- Fukuyama H, Yamashiro S, Tamaki H, Kishaba T. A prospective comparison of nursing- and healthcare-associated pneumonia (NHCAP) with community-acquired pneumonia (CAP). J Infect Chemother 2013; 19:719.
- Pop-Vicas A, Gravenstein S. Influenza in the elderly: a mini-review. Gerontology 2011; 57:397.
- Centers for Disease Control and Prevention. Prevention strategies for seasonal influenza in healthcare settings. http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm (Accessed on March 24, 2015).
- Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000; 355:93.
- Pearson ML, Bridges CB, Harper SA, et al. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1.
- Stead WW, Lofgren JP, Warren E, Thomas C. Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med 1985; 312:1483.
- Stead WW, To T, Harrison RW, Abraham JH 3rd. Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann Intern Med 1987; 107:843.
- Stead WW. Isoniazid prophylaxis. Ann Intern Med 1981; 95:393.
- Thrupp L, Bradley S, Smith P, et al. Tuberculosis prevention and control in long-term-care facilities for older adults. Infect Control Hosp Epidemiol 2004; 25:1097.
- Verma G, Chuck AW, Jacobs P. Tuberculosis screening for long-term care: a cost-effectiveness analysis. Int J Tuberc Lung Dis 2013; 17:1170.
- Smith BM, Schwartzman K, Bartlett G, Menzies D. Adverse events associated with treatment of latent tuberculosis in the general population. CMAJ 2011; 183:E173.
- Chan-Yeung M, Chan FH, Cheung AH, et al. Prevalence of tuberculous infection and active tuberculosis in old age homes in Hong Kong. J Am Geriatr Soc 2006; 54:1334.
- Borgdorff MW, Nagelkerke NJ, de Haas PE, van Soolingen D. Transmission of Mycobacterium tuberculosis depending on the age and sex of source cases. Am J Epidemiol 2001; 154:934.
- Naglie G, McArthur M, Simor A, et al. Tuberculosis surveillance practices in long-term care institutions. Infect Control Hosp Epidemiol 1995; 16:148.
- Macarthur C, Enarson DA, Fanning EA, et al. Tuberculosis among institutionalized elderly in Alberta, Canada. Int J Epidemiol 1992; 21:1175.
- Marchand RS, Tousignant P. [Tuberculosis in aged persons residing in Quebec facilities: are screening and chemoprophylaxis indicated?]. Can J Public Health 1995; 86:238.
- Hutton MD, Cauthen GM, Bloch AB. Results of a 29-state survey of tuberculosis in nursing homes and correctional facilities. Public Health Rep 1993; 108:305.
- Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005; 54:1.
- Jacobson C, Strausbaugh LJ. Incidence and impact of infection in a nursing home care unit. Am J Infect Control 1990; 18:151.
- Kirk MD, Fullerton KE, Hall GV, et al. Surveillance for outbreaks of gastroenteritis in long-term care facilities, Australia, 2002-2008. Clin Infect Dis 2010; 51:907.
- Frenzen PD. Deaths due to unknown foodborne agents. Emerg Infect Dis 2004; 10:1536.
- Simor AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: a review. J Am Geriatr Soc 2010; 58:1556.
- Makris AT, Gelone S. Clostridium difficile in the long-term care setting. J Am Med Dir Assoc 2007; 8:290.
- Nicolle LE, SHEA Long-Term-Care-Committee. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol 2001; 22:167.
- Wang L, Lansing B. Attributable rates of infections due to indwelling device use in skilled nursing facilities. SHEA Meeting Presentation, April 4, 2011.
- Wong ES, Hooton TM. Guideline for prevention of catheter-associated urinary tract infections. Infect Control 1981; 2:125.
- Nicolle LE. The chronic indwelling catheter and urinary infection in long-term-care facility residents. Infect Control Hosp Epidemiol 2001; 22:316.
- McNulty C, Freeman E, Smith G, et al. Prevalence of urinary catheterization in UK nursing homes. J Hosp Infect 2003; 55:119.
- Estes SA, Estes J. Therapy of scabies: nursing homes, hospitals, and the homeless. Semin Dermatol 1993; 12:26.
- Boustcha E, Nicolle LE. Conjunctivitis in a long-term care facility. Infect Control Hosp Epidemiol 1995; 16:210.
- Schwartz B, Elliott JA, Butler JC, et al. Clusters of invasive group A streptococcal infections in family, hospital, and nursing home settings. Clin Infect Dis 1992; 15:277.
- Harkness GA, Bentley DW, Mottley M, Lee J. Streptococcus pyogenes outbreak in a long-term care facility. Am J Infect Control 1992; 20:142.
- Thigpen MC, Richards CL Jr, Lynfield R, et al. Invasive group A streptococcal infection in older adults in long-term care facilities and the community, United States, 1998-2003. Emerg Infect Dis 2007; 13:1852.
- Jordan HT, Richards CL Jr, Burton DC, et al. Group a streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures. Clin Infect Dis 2007; 45:742.
- Jasuja S, Thompson ND, Peters PJ, et al. Investigation of hepatitis B virus and human immunodeficiency virus transmission among severely mentally ill residents at a long term care facility. PLoS One 2012; 7:e43252.
- Stone ND, Lewis DR, Johnson TM 2nd, et al. Methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in residents of Veterans Affairs long-term care facilities: role of antimicrobial exposure and MRSA acquisition. Infect Control Hosp Epidemiol 2012; 33:551.
- Manzur A, Gudiol F. Methicillin-resistant Staphylococcus aureus in long-term-care facilities. Clin Microbiol Infect 2009; 15 Suppl 7:26.
- Garazi M, Edwards B, Caccavale D, et al. Nursing homes as reservoirs of MRSA: myth or reality? J Am Med Dir Assoc 2009; 10:414.
- Elizaga ML, Weinstein RA, Hayden MK. Patients in long-term care facilities: a reservoir for vancomycin-resistant enterococci. Clin Infect Dis 2002; 34:441.
- Benenson S, Cohen MJ, Block C, et al. Vancomycin-resistant enterococci in long-term care facilities. Infect Control Hosp Epidemiol 2009; 30:786.
- O'Fallon E, Kandel R, Schreiber R, D'Agata EM. Acquisition of multidrug-resistant gram-negative bacteria: incidence and risk factors within a long-term care population. Infect Control Hosp Epidemiol 2010; 31:1148.
- Tinelli M, Cataldo MA, Mantengoli E, et al. Epidemiology and genetic characteristics of extended-spectrum β-lactamase-producing Gram-negative bacteria causing urinary tract infections in long-term care facilities. J Antimicrob Chemother 2012; 67:2982.
- Lin MY, Lyles-Banks RD, Lolans K, et al. The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2013; 57:1246.
- Prabaker K, Lin MY, McNally M, et al. Transfer from high-acuity long-term care facilities is associated with carriage of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae: a multihospital study. Infect Control Hosp Epidemiol 2012; 33:1193.
- Markham K, Rao A, Mody L, et al. Prevalence of resistant gram negative bacilli in nursing homes. J Am Geriatr Soc 2003; 51:S59.
- TYPES OF INFECTIONS
- Respiratory tract infection
- - Pneumonia
- - Influenza
- - Tuberculosis
- Diarrheal disease
- Urinary tract infection
- Skin and soft tissue infection
- - Pressure ulcers
- - Scabies
- - Tinea infection
- Group A streptococcal infection
- Bloodborne and sexually transmitted pathogens
- ANTIMICROBIAL-RESISTANT ORGANISMS
- Methicillin-resistant S. aureus
- Vancomycin-resistant Enterococcus
- Drug-resistant gram-negative organisms