Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents.

One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.

Nursing home-associated bloodstream infection: A scoping review.

OBJECTIVE: To update a 2005 review of nursing home-associated bloodstream infection (NHABSI) regarding sources, organisms, antibiotic resistance, and outcome. METHODS: A scoping review of studies of NHABSI identified by searching Google Scholar and Medline with OVID for the period January 1, 2004, to June 30, 2021, was conducted. RESULTS: Overall, 6 studies of NHABSI were identified. Only 1 study was conducted with residents in North American facilities whereas in the 2005 review all studies were conducted in North America. Escherichia coli was the most common blood isolate, the urinary tract was the most common source of NHABSI; and the case-fatality rates ranged from 21% to 28%. These findings were comparable to those in the 2005 review. However, the proportion of NHABSI episodes due to antibiotic-resistant organisms increased substantially compared to the 2005 review. The most common antibiotic-resistant organisms were extended-spectrum ß-lactamase-producing E. coli and Klebsiella spp. The 2 studies that evaluated the relationship between appropriate empiric antibiotic therapy and outcome came to different conclusions. CONCLUSIONS: The only major difference between the 2 reviews in the epidemiology of NHABSI was the marked increase in antibiotic resistance among blood isolates. Despite the increased antibiotic resistance, the case fatality rates in the current review were comparable to those reported in the 2005 review. However, the impact of appropriate empiric antibiotic therapy on outcome of NHABSI remains unclear.

Risk adjustment for benchmarking nursing home infection surveillance data: A narrative review.

Until recently, there was no national surveillance system for monitoring infection occurrence in long-term care facilities (LTCF) in the United States. As a result, there are no national benchmarks for LTCF infection rates that can be utilized for quality improvement at the facility level. One of the major challenges in the reporting of health care-related infection data is accounting for nonmodifiable facility and patient characteristics that influence benchmarks for infection. The objectives of this paper are to review: (a) published infection rates in LTCF in the United States to assess the level of variability; (b) studies describing facility- and resident-level risk factors for infection that can be used in risk adjustment models; (c) published attempts to risk-adjust LTCF infection rates; and (d) efforts to develop models specifically for risk adjustment of infection rates in LTCF for benchmarking. It is anticipated that this review will stimulate further study of methods to risk-adjust LTCF infection rates for benchmarking that will facilitate research and public reporting.

Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review.

The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.

Nursing Home-Associated Pneumonia, Part II: Etiology and Treatment.

This is the second of 2 parts of a narrative review of nursing home-associated pneumonia (NHAP) that deals with etiology and treatment in the nursing home. In the 1980s and 1990s, the etiology of NHAP was considered to be similar to community-acquired pneumonia (CAP). This belief was reflected in CAP guidelines until 2005 when the designation healthcare-associated pneumonia or HCAP was introduced and nursing home residents were included in the HCAP category. Patients in the HCAP group were thought to be at high risk for pneumonia because of multidrug resistant organisms and required empiric broad-spectrum antibiotic therapy much like people with hospital-acquired infection. Subsequent studies of the etiology of NHAP using sophisticated diagnostic testing found limited evidence of resistant organisms such as methicillin-resistant Staphylococcus aureus or resistant gram-negative organisms or atypical organisms. In terms of management of NHAP in the nursing home there are several considerations that are discussed: hospitalization decision, initial oral or parenteral therapy, timing of switch to an oral regimen if parenteral therapy is initially prescribed, duration of therapy with an emphasis on shorter courses, and follow-up during therapy including the use of the "antibiotic time out" protocol. The oral and parenteral antibiotic regimens recommended for treatment of NHAP in this report are based on limited information because there are no randomized controlled trials to define the optimum regimen. In conclusion, most residents with pneumonia can be treated successfully in the nursing home. However, there is an urgent need for a specific NHAP diagnosis and treatment guideline that will give providers guidance in the management of this infection in the nursing home.

What is the Role of Nursing Homes in the Surviving Sepsis Campaign?

Recently, there have been several publications advocating for an expansive role for nursing homes (NHs) in the Surviving Sepsis Campaign (SSC). The rationale for this effort is the problem of high rates of 30-day readmissions from NHs and a disproportionate percentage of residents with a diagnosis of sepsis in emergency departments. This article provides a brief history of the SSC and the evolution of the definition of sepsis and of the timing of interventions that make up a "sepsis bundle." Screening tools for sepsis that may be used in the NH setting are discussed. It is emphasized that there is no gold standard for the diagnosis of sepsis, and this limits the ability to identify a screening tool with high sensitivity. Three recent publications that discuss the recognition and management of sepsis in the NH are reviewed, although there is very little published information about this problem. Despite the lack of information about sepsis in NHs, several states have developed protocols for identification and management of sepsis in NHs but there are no results of the impact of these efforts on hospitalization or readmission rates or resident outcome. Based on the review of this information, the ability of NH providers and staff to identify residents with possible sepsis is unclear given no effective screening tool and the recent change in the definition of sepsis that focuses on a point late in the continuum from infection to sepsis with organ dysfunction. Also, NH capability to perform, in a timely fashion, interventions recommended in a sepsis bundle such as insertion of an intravenous catheter, performing blood cultures, administering antibiotics, and fluid resuscitation will likely vary considerably. There is a need for more intensive study of sepsis in the NH setting to identify screening tools with better sensitivity and identification of interventions suitable for the NH setting and that have an impact on various outcomes.

Nursing Home-Associated Pneumonia, Part I: Diagnosis.

Pneumonia is 1 of the 3 most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting. In regard to pneumonia in the nursing home setting, practitioners are focused primarily on identifying residents with this infection and choosing a treatment regimen. In this article, the diagnosis of this infection is addressed. Based on published studies and clinical experience, "bedside criteria" for the diagnosis of nursing home-associated pneumonia (NHAP) are proposed that are based primarily on objective respiratory signs and symptoms that can be readily identified by staff. It is also stressed that factors predisposing to aspiration should be identified because there is a risk for aspiration pneumonitis. A previously published decision tool to distinguish between aspiration pneumonia and aspiration pneumonitis is discussed. Because providers are often not present when there is a change in status of a resident, nursing staff are crucial to the diagnosis of NHAP. However, there is variability in staff experience and the ability to obtain and communicate clinical findings to assist providers in making decisions about diagnosis. To deal with this issue, templates have been developed to help staff collect the appropriate information before contacting the provider. The most important diagnostic test in a resident with suspected pneumonia is a chest radiograph. However, studies done more than a decade ago demonstrated considerable variability in radiologists' interpretation of chest radiographs of residents performed in the nursing home. Radiologic techniques have improved considerably with utilization of digital technology, but there have been no recent studies to determine if interpretation of these radiographs is more consistent. An alternative to radiographs is lung ultrasonography, which has been found to be more accurate than chest radiographs in identifying pneumonia in adults; however, this method has not been studied in the nursing home setting. Host biomarkers such as serum C-reactive protein and procalcitonin levels have been studied in adults with pneumonia to distinguish between bacterial and nonbacterial infection, but there has been limited study in NHAP and the findings are conflicting. Lastly, it is stressed that the provider should carefully document the clinical findings and testing that result in a diagnosis of pneumonia to enhance surveillance for infection as well as antimicrobial stewardship activities.

Will Maintenance of Oral Hygiene in Nursing Home Residents Prevent Pneumonia?

This article is an evaluation of the literature on oral hygiene as a risk factor for nursing home-associated pneumonia (NHAP) and with interventions to improve oral hygiene and reduce the incidence of NHAP. The background for this article is that studies that have evaluated interventions to improve oral hygiene and prevent NHAP have conflicting results. To try to understand the reason for these results, the objective was to examine risk factor and intervention studies and determine their methodological validity. Review of studies evaluating oral hygiene status as a risk factor for NHAP found multiple methodological problems, resulting in limited evidence to support this association. Studies of intervention methods, whether finding benefit or not in preventing NHAP, all had methodological limitations. Therefore, it is unclear whether oral hygiene is a risk factor for NHAP and whether improving oral hygiene decreases the incidence of this infection. A recommendation is made that future studies should carefully define the etiology of suspected NHAP using molecular techniques when evaluating methods to prevent this infection because viral pneumonia and aspiration pneumonitis may mimic bacterial pneumonia even though, at times, there may be coinfection with bacteria. In this latter situation, improving oral hygiene may not prevent pneumonia. Therefore, viral infection and pneumonitis with or without bacterial coinfection need to be excluded so that the focus is on prevention of bacterial pneumonia.

Antimicrobial Stewardship in Long-Term Care: Metrics and Risk Adjustment.

An antimicrobial stewardship program (ASP) has been recommended for long-term care facilities because of the increasing problem of antibiotic resistance in this setting to improve prescribing and decrease adverse events. Recommendations have been made for the components of such a program, but there is little evidence to support any specific methodology at the present time. The recommendations make minimal reference to metrics, an essential component of any ASP, to monitor the results of interventions. This article focuses on the role of antibiotic use metrics as part of an ASP for long-term care. Studies specifically focused on development of antibiotic use metrics for long-term care are reviewed. It is stressed that these metrics should be considered as an integral part of an ASP in long-term care. In order to develop benchmarks for antibiotic use for long-term care, there must be appropriate risk adjustment for interfacility comparisons and quality improvement. Studies that have focused on resident functional status as a risk factor for infection and antibiotic use are reviewed. Recommendations for the potentially most useful and feasible metrics for long-term care are provided along with recommendations for future research.

Surveillance for Clostridium difficile infection in nursing homes.

OBJECTIVES: To define the time of onset of Clostridium difficile infection (CDI) in the community nursing home setting. DESIGN: Retrospective. SETTING: Four community nursing homes. PARTICIPANTS: Residents with incident CDI identified from infection control surveillance records. MEASUREMENTS: Cases were divided into two groups depending on the time of onset of infection: within 30 days of admission after hospitalization or more than 30 days after admission to a nursing home after hospitalization. RESULTS: Of 75 incident CDI cases, 52 (69%) developed within 30 days of admission and 23 (31%) more than 30 days after admission. Of the 52 cases that developed within 30 days, 68% were in residents admitted for subacute care. The mean number of days ± standard deviation to CDI was 10.5 ± 2.5 in those who developed infection within 30 days; 75% of these cases developed within 15 days of admission. CONCLUSIONS: The majority of CDI in the study nursing homes developed within 30 days of admission; this group may be analogous to community-onset, hospital-associated CDI as defined in the Centers for Disease Control and Prevention (CDC) surveillance definitions. Therefore, the proposed CDC surveillance definitions may overestimate the incidence of nursing home-associated CDI.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients.

INTRODUCTION: Dental plaque biofilms are colonized by respiratory pathogens in mechanically-ventilated intensive care unit patients. Thus, improvements in oral hygiene in these patients may prevent ventilator-associated pneumonia. The goal of this study was to determine the minimum frequency (once or twice a day) for 0.12% chlorhexidine gluconate application necessary to reduce oral colonization by pathogens in 175 intubated patients in a trauma intensive care unit. METHODS: A randomized, double-blind, placebo-controlled clinical trial tested oral topical 0.12% chlorhexidine gluconate or placebo (vehicle alone), applied once or twice a day by staff nurses. Quantitation of colonization of the oral cavity by respiratory pathogens (teeth/denture/buccal mucosa) was measured. RESULTS: Subjects were recruited from 1 March, 2004 until 30 November, 2007. While 175 subjects were randomized, microbiologic baseline data was available for 146 subjects, with 115 subjects having full outcome assessment after at least 48 hours. Chlorhexidine reduced the number of Staphylococcus aureus, but not the total number of enterics, Pseudomonas or Acinetobacter in the dental plaque of test subjects. A non-significant reduction in pneumonia rate was noted in groups treated with chlorhexidine compared with the placebo group (OR = 0.54, 95% CI: 0.23 to 1.25, P = 0.15). No evidence for resistance to chlorhexidine was noted, and no adverse events were observed. No differences were noted in microbiologic or clinical outcomes between treatment arms. CONCLUSIONS: While decontamination of the oral cavity with chlorhexidine did not reduce the total number of potential respiratory pathogens, it did reduce the number of S. aureus in dental plaque of trauma intensive care patients.

Pharmacodynamics of vancomycin at simulated epithelial lining fluid concentrations against methicillin-resistant Staphylococcus aureus (MRSA): implications for dosing in MRSA pneumonia.

Little is known regarding killing activity of vancomycin against methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) in pneumonia since the extent of vancomycin penetration into epithelial lining fluid (ELF) has not been definitively established. We evaluated the impact of the extent of ELF penetration on bacterial killing and resistance by simulating a range of vancomycin exposures (24-h free drug area under the concentration-time curve [fAUC24]/MIC) using an in vitro pharmacodynamic model and population-based mathematical modeling. A high-dose, 1.5-g-every-12-h vancomycin regimen according to American Thoracic Society/Infectious Diseases Society of America guidelines (trough concentration, 15 mg/liter) with simulated ELF/plasma penetration of 0, 20, 40, 60, 80, or 100% (fAUC24/MIC of 0, 70, 140, 210, 280, or 350) was evaluated against two agr-functional, group II MRSA clinical isolates obtained from patients with a bloodstream infection (MIC = 1.0 mg/liter) at a high inoculum of 10(8) CFU/ml. Despite high vancomycin exposures and 100% penetration, all regimens up to a fAUC24/MIC of 350 did not achieve bactericidal activity. At regimens of < or = 60% penetration (fAUC24/MIC < or = 210), stasis and regrowth occurred, amplifying the development of intermediately resistant subpopulations. Regimens simulating > or = 80% penetration (fAUC24/MIC > or = 280) suppressed development of resistance. Resistant mutants amplified by suboptimal vancomycin exposure displayed reduced rates of autolysis (Triton X-100) at 72 h. Bacterial growth and death were well characterized by a Hill-type model (r2 > or = 0.984) and a population pharmacodynamic model with a resistant and susceptible subpopulation (r2 > or = 0.965). Due to the emergence of vancomycin-intermediate resistance at a fAUC24/MIC of < or = 210, exceeding this exposure breakpoint in ELF may help to guide optimal dosage regimens in the treatment of MRSA pneumonia.

"Never events": not every hospital-acquired infection is preventable.

Medicare stopped reimbursing United States hospitals for several complications or comorbidities developed during hospitalizations effective 1 October 2008. The Centers for Medicare and Medicaid Services selected high-cost or high-frequency events from the National Quality Forum's list of "never events" for inclusion in this reimbursement change. Several of these complications and/or comorbidities are nosocomial infections, a significant proportion of which are not likely to be preventable. Attempts to eliminate these events may have unwanted clinical and economic outcomes, and compliance with coding and billing requirements will have a significant effect on research conducted using administrative databases. Although this reimbursement change is a step toward reducing the rate of preventable adverse events, its current form does not provide guidance with regard to how hospitals may hope to reduce the rate of these infections, and it uses individual case-based rather than process-based or population-based outcome measures, which makes benchmarking and goalsetting difficult.

Loss of vancomycin bactericidal activity against accessory gene regulator (agr) dysfunctional Staphylococcus aureus under conditions of high bacterial density.

The impact of accessory gene regulator (agr) dysfunction and high bacterial density on vancomycin killing and resistance was evaluated among 10 clinical methicillin-resistant Staphylococcus aureus bloodstream isolates using time kill experiments. Under conditions of high inocula and agr dysfunction, vancomycin activity was markedly attenuated, amplifying resistant mutants by 72 h.

Nursing home-associated pneumonia.

Nursing home-associated pneumonia (NHAP) is associated with considerable morbidity and mortality. The etiology of NHAP continues to be debated and has influenced treatment guideline recommendations. Diagnosis may not be straightforward but at least one respiratory symptom usually is present and the presence of hypoxemia is a key finding. Treatment recommendations vary depending on the organisms believed the predominant cause of NHAP. Pneumococcal and influenza vaccination remain the most important methods for prevention of NHAP at present.