Infection Management for Geriatrics in Long Term Care Facilities

INFECTION MANAGEMENT FOR GERIATRICS IN LONG-TER M CAR E FA C I L I T I E S EDITED BY T H O M A S T. YO S H I K AWA Charles R. Drew University of Medicine and Science and Martin Luther King, Jr.–Charles R. Drew Medical Center Los Angeles, California JOSEPH G. OUSLANDER Emory University School of Medicine Atlanta, Georgia Marcel Dekker, Inc. New York • Basel TM Copyright © 2002 by Marcel Dekker, Inc. All Rights Reserved.

ISBN: 0-8247-0784-2 This book is printed on acid-free paper. Headquarters Marcel Dekker, Inc. 270 Madison Avenue, New York, NY 10016 tel: 212-696-9000; fax: 212-685-4540 Eastern Hemisphere Distribution Marcel Dekker AG Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland tel: 41-61-261-8482; fax: 41-61-261-8896 World Wide Web http://www.dekker.com The publisher offers discounts on this book when ordered in bulk quantities. For more in- formation, write to Special Sales/Professional Marketing at the headquarters address above. Copyright © 2002 by Marcel Dekker, Inc. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher. Current printing (last digit): 10 9 8 7 6 5 4 3 2 1 PRINTED IN THE UNITED STATES OF AMERICA

To our wives, Catherine Yoshikawa and Lynn Ouslander, for their love and support.



Preface With the increasing growth of the aging population—especially those aged 85 years and older—over the next 40 years, there will be a parallel demand for long- term care. Such a demand is inevitable, given the changes, diseases, disabilities, and socioeconomic factors associated with growing old. When such age-related factors in an older person create a need for care, services, and support that cannot be met by family and other caregivers, the need arises for long-term care outside the home environment. Although there are different types and venues for long- term care, nursing homes (nursing facilities) remain the dominant sites for pro- viding care for chronically and functionally disabled and cognitively impaired older persons. Thus, nursing homes serve as the prototype long-term care facility (LTCF) that manages chronically disabled elderly individuals. As more and more care is provided in LTCFs, inherent risks and problems arise when the population is very old, frail, and disabled. The population at risk resides in a closed institutional setting; the ratio of healthcare staff to residents may be suboptimal; and quick and easy access to diagnostic, therapeutic, and preventive interventions is limited. One of the most common risks (and compli- cations) of long-term care is infection. Infection (or presence of a fever) is often the reason an LTCF resident is sent to an emergency department or transferred to an acute care facility. However, the clinical diagnosis of an infection in a frail, elderly LTCF resident may be quite difficult, given the atypical clinical manifestations of infection in the very old, limited availability of a clinician on- site in the LTCF to examine the resident, and lack of quick access to diagnostic laboratory and radiological tests. Moreover, once a presumptive diagnosis of in- fection is made, the decision for an appropriate therapeutic approach may be v

vi Preface complex. Issues of advanced directives and/or desires of the resident/family re- garding the extent of diagnostic and therapeutic interventions must be consid- ered. Can the resident be treated in the LTCF or is transfer to an acute care fa- cility more appropriate? Does the LTCF have the resources and appropriately trained personnel to treat the resident within the LTCF? If treatment is initiated in the LTCF, what antibiotics and dosages should be used? In addition, other clinical infectious disease issues to be considered when caring for residents in an LTCF include the following: What are the most common infections in this setting? What is the role of an LTCF nurse in managing infections? What ethi- cal factors need to be considered? What should be done when an outbreak of an infection occurs? Are there drug-resistant pathogens in this setting, and how should these be managed? Infection Management for Geriatrics in Long-Term Care Facilities ad- dresses these and many other important questions and issues related to the diag- nosis, treatment, prevention, and control of infections in elderly residents of LTCFs. The book was written by internationally and nationally recognized ex- perts in the area of infections, geriatrics, and long-term care. The editors are clin- icians who have a long record of patient care, education and training, and research in the fields of geriatrics, gerontology, and long-term care. They are editor-in- chief and deputy editor, respectively, of the Journal of the American Geriatrics Society, the leading journal in the field of aging. The book is divided into three major sections. The first is devoted to the principles of aging, long-term care, and infection, with chapters discussing the de- mographics of long-term care; the differences between acute care and long-term care; epidemiology and special aspects of infections in long-term care; host resis- tance changes with aging; the interrelationship between aging, nutrition, and im- munity; altered clinical manifestations of infections with aging; ethical consider- ations in managing infections in this setting; the role of nursing in managing infections in LTCFs; principles of infection control in an LTCF; identification and management of outbreaks in an LTCF; and a rational approach to using antibiotics in residents of LTCFs. The second section focuses on the most common and im- portant infectious diseases problems encountered in LTCFs. These include uri- nary tract infection; influenza and other respiratory viruses; pneumonia and bron- chitis; tuberculosis; selected skin infections, i.e., herpes zoster, cellulitis, and scabies; infectious diarrhea; viral hepatitis; and vaccination. The third and final section addresses the problem of emerging drug-resistant pathogens in LTCFs, with detailed information on pathogenetic and molecular mechanisms for antibi- otic resistance; methicillin-resistant Staphylococcus aureus; glycopeptide (pri- marily vancomycin)-resistant enterococci; gram-negative bacteria; and selected fungi (e.g., Candida). An appendix is included with definitions of common infec- tions in a long-term care setting and guidelines for the evaluation of fever and in- fections in long-term care facilities.

Preface vii The book is formatted for easy and quick access to key information; there are numerous figures and tables that summarize important data; and the most rel- evant and up-to-date references are provided. Clinicians will find this book infor- mative, easy to read, and helpful in managing their LTCF residents with fever and infection. Infection Management for Geriatrics in Long-Term Care Facilities is an essential resource for all healthcare providers and administrators involved with the care of elderly residents in LTCFs. The editors would like to thank Ms. Patricia Thompson for retyping and preparing all the manuscripts in their final form. Thomas T. Yoshikawa Joseph G. Ouslander



Contents Preface v Contributors xiii I. Principles of Aging, Long-Term Care, and Infection 1 15 1. Demographics and Economics of Long-Term Care A. Jefferson Lesesne and Joseph G. Ouslander 27 2. Evaluation of Infections in Long-Term Care Facilities Versus 33 Acute Care Hospitals Andrew D. Weinberg 51 71 3. Epidemiology and Special Aspects of Infectious Diseases 79 in Aging ix Thomas T. Yoshikawa 4. Impact of Age and Chronic Illness-Related Immune Dysfunction on Risk of Infections Steven C. Castle 5. Nutrition and Infection Kevin P. High 6. Clinical Manifestations of Infections Dean C. Norman 7. Ethical Issues of Infectious Disease Interventions Elizabeth L. Cobbs

x Contents 8. Nursing Management of Infections 99 Donna L. Barton and Janet D. Register 115 9. Establishing an Infection Control Program 133 Janet Nau Franck, Elizabeth Owens Schwab, 155 and David W. Bentley 173 10. Epidemiologic Investigation of Infectious Disease Outbreaks 197 Chesley L. Richards, Jr., and William R. Jarvis 223 245 11. An Approach to Antimicrobial Therapy 257 Shobita Rajagopalan, Jay P. Rho, and Thomas T. Yoshikawa 283 305 II. Special Infectious Disease Problems 313 337 12. Urinary Tract Infection Lindsay E. Nicolle 363 13. Influenza and Other Respiratory Viruses Ghinwa Dumyati and Ann R. Falsey 14. Pneumonia and Bronchitis Joseph M. Mylotte 15. Tuberculosis Shobita Rajagopalan 16. Infected Pressure Ulcers Nigel Livesley and Anthony W. Chow 17. Herpes Zoster, Cellulitis, and Scabies Kenneth Schmader and Jack Twersky 18. Infectious Diarrhea Abbasi J. Akhtar 19. Hepatitis Darrell W. Harrington and Peter V. Barrett 20. Vaccinations Stefan Gravenstein III. Emerging and Drug-Resistant Pathogens 21. Pathogenesis and Molecular Mechanisms of Antibiotic Resistance Robert A. Bonomo

Contents xi 383 22. Methicillin-Resistant Staphylococcus aureus 411 Larry J. Strausbaugh 429 449 23. Vancomycin (Glycopeptide)-Resistant Enterococci Lona Mody, Shelly A. McNeil, and Suzanne F. Bradley 473 477 24. Gram-Negative Bacteria 481 Vinod K. Dhawan 25. Candida and Other Fungi Carol A. Kauffman and Sara A. Hedderwick Appendix A: Definitions of Common Infections in Long-Term Care Facilities Appendix B: Guide to Evaluating Fever and Infection in a Long-Term Care Setting Index



Contributors Abbasi J. Akhtar, M.D., M.R.C.P. Department of Internal Medicine, Charles R. Drew University of Medicine and Science and Martin Luther King, Jr.–Charles R. Drew Medical Center, Los Angeles, California Peter V. Barrett, M.D. Department of Medicine, Harbor–UCLA Medical Center, Torrance, California Donna L. Barton, R.N., B.C., B.S.N., FACDONA/LTC Director of Nursing, Lake Eustis Care Center, Eustis, Florida David W. Bentley, M.D. Department of Internal Medicine, Saint Louis Uni- versity School of Medicine, and Geriatric Research, Education, and Clinical Cen- ter, St. Louis VA Medical Center, St. Louis, Missouri Robert A. Bonomo, M.D. Department of Medicine, Case Western Reserve University, Cleveland, Ohio Suzanne F. Bradley, M.D. Department of Internal Medicine, University of Michigan, and Divisions of Geriatric Medicine and Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Steven C. Castle, M.D. Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, and UCLA School of Medicine, Los An- geles, California xiii

xiv Contributors Anthony W. Chow, M.D., F.R.C.P.(C), F.A.C.P. Department of Medicine, University of British Columbia, and Division of Infectious Diseases, Vancouver Hospital Health Sciences Centre, Vancouver, British Columbia, Canada Elizabeth L. Cobbs, M.D. Department of Geriatrics and Extended Care, Wash- ington D.C. VA Medical Center, and George Washington University, Washing- ton, D.C. Vinod K. Dhawan, M.D., F.A.C.P., F.R.C.P.(C) Department of Medicine, Charles R. Drew University of Medicine and Science, and UCLA School of Medicine, Los Angeles, California Ghinwa Dumyati, M.D. Infectious Disease Unit, University of Rochester School of Medicine, and Rochester General Hospital, Rochester, New York Ann R. Falsey, M.D. Infectious Disease Unit, University of Rochester School of Medicine, and Rochester General Hospital, Rochester, New York Janet Nau Franck, R.N., M.B.A., C.I.C. Consulting Professionals, Inc., St. Louis, Missouri Stefan Gravenstein, M.D., M.P.H. Department of Medicine, Glennan Center for Geriatrics and Gerontology, Eastern Virginia Medical School, Norfolk, Virginia Darrell W. Harrington, M.D. Department of Medicine, Harbor–UCLA Medi- cal Center, Torrance, California Sara A. Hedderwick, M.R.C.P., D.T.M.&H Department of Infectious Dis- eases, Royal Victoria Hospital, Belfast, Northern Ireland Kevin P. High, M.D., M.Sc. Sections of Infectious Diseases and Hematol- ogy/Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina William R. Jarvis, M.D. Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia Carol A. Kauffman, M.D. Department of Internal Medicine, University of Michigan, and Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan A. Jefferson Lesesne, M.D. Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, Georgia

Contributors xv Nigel Livesley, M.D., F.R.C.P.(C) Department of Medicine, University of British Columbia, and Division of Infectious Diseases, Vancouver Hospital Health Sciences Centre, Vancouver, British Columbia, Canada Shelly A. McNeil, M.D., F.R.C.P.(C) Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada Lona Mody, M.D. Department of Internal Medicine, University of Michigan, and Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare Sys- tem, Ann Arbor, Michigan Joseph M. Mylotte, M.D. Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York Lindsay E. Nicolle, M.D., F.R.C.P.(C) Department of Internal Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada Dean C. Norman, M.D. Chief of Staff, VA Greater Los Angeles Healthcare System, and UCLA School of Medicine, Los Angeles, California Joseph G. Ouslander, M.D. Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Shobita Rajagopalan, M.D. Department of Internal Medicine, Charles R. Drew University of Medicine and Science and Martin Luther King, Jr.–Charles R. Drew Medical Center, Los Angeles, California Janet D. Register, B.S., ICP, R.N., B.S.N. Department of Infection Control, Leesburg Regional Medical Center, Leesburg, Florida Jay P. Rho, Pharm.D. Department of Pharmaceutical Sciences, University of Southern California University Hospital, Los Angeles, California Chesley L. Richards, Jr., M.D. Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Preven- tion, Atlanta, Georgia Kenneth Schmader, M.D. Department of Medicine, Duke University Medical Center, and Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina Elizabeth Owens Schwab, R.N., B.S.N., M.P.H. Center for Healthcare Qual- ity, BJC Health System, St. Louis, Missouri

xvi Contributors Larry J. Strausbaugh, M.D. Division of Hospital and Specialty Medicine, Portland VA Medical Center, and Department of Internal Medicine, Oregon Health Sciences University School of Medicine, Portland, Oregon Jack Twersky, M.D. Department of Medicine, Duke University Medical Cen- ter, and Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina Andrew D. Weinberg, M.D., F.A.C.P. Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Thomas T. Yoshikawa, M.D. Department of Internal Medicine, Charles R. Drew University of Medicine and Science and Martin Luther King, Jr.–Charles R. Drew Medical Center, Los Angeles, California

1 Demographics and Economics of Long-Term Care A. Jefferson Lesesne and Joseph G. Ouslander Emory University School of Medicine, Atlanta, Georgia I. INTRODUCTION Long-term care has been defined as “a set of health, personal care, and social ser- vices delivered over a sustained period of time to persons who have lost or never acquired some degree of functional capacity” (1). Long-term care includes a broad range of services for chronically disabled individuals over an extended period. Venues for care are predominantly nursing homes (nursing facilities), assisted liv- ing facilities, senior housing, and personal dwellings without much, if any, coor- dination among these sites. The nursing facility remains the most common insti- tutional setting for long-term care. In 1996 there were approximately 16,500 certified facilities with 1.8 million beds (2). This is nearly three times the number of acute care hospitals and twice the number of hospital beds. An aging society will create ever-increasing demands for services and costs associated with long- term care. This chapter will review the relevant demographic and economic fac- tors affecting nursing facilities, with a brief discussion of the assisted living facil- ity market. II. DEMAND FOR NURSING FACILITY CARE Three main factors contribute to the demand for nursing home care: (1) the num- ber of frail older adults with physical functional disabilities, mental health prob- lems, or both that preclude independent living or community-based care; (2) the available social support system; (3) available, accessible and affordable commu- 1

2 Lesesne and Ouslander Table 1 Factors Affecting the Need for Nursing Home Admission Characteristics of the individual Age, sex, race Marital status Living arrangements Degree of mobility Ability to perform basic and instrumental activities of daily living Urinary incontinence Behavior problems Mental status Memory impairment Mood disturbance Tendency for falls Clinical prognosis Income Payment eligibility Need for special services Characteristics of the support system Family capability Health and function of spouse (if married) Presence of responsible relative (usually adult child) Family structure of responsible relative Employment status of responsible relative Physician availability Amount of care currently received from family and others Community resources Formal community resources (See Table 2) Informal support systems Presence of long-term care institutions Characteristics of long-term care institutions Source: Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics, 3rd ed. New York, McGraw-Hill, 1994. nity-based long-term care resources (Table 1). 57% of people aged 65 and older report long-term care needs as measured by their need for assistance with activi- ties of daily living (ADLs). Among those aged 85 and older, 21% resided in nurs- ing facilities in 1995. In 1996, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) concluded in a consensus panel that moderate to severe dementia was prevalent in 2% of those aged 65 to 69, 4% of those aged 70 to 74, 8% of those aged 75 to 79, and 16% of those older than aged 85 (3). Another study concluded that 47% of people older than aged 85

Demographics and Economics 3 had some degree of dementia (4). Figure 1 depicts the projected increase in those with dementia over the next 50 years. The older, more cognitively impaired indi- vidual is more likely to need assistance with ADLs and, therefore, will need some form of long-term care. Much of the long-term care in the United States is carried out by family and friends, especially wives and daughters. A survey of informal caregivers indicated that nearly 75% are women, whereas 40% are spouses, and 35% are adult children (5). The average age of the informal caregiver is 60, with 70% of them not work- ing outside the home. Two-thirds of those who work outside the home reported conflicts with work and caregiving. Approximately 20% of men and 50% of women aged 75 and older live alone. About one-third of those who live alone have no children. The older population now tends to have fewer children and are more geographically disbursed than previous generations (Fig. 2). The significance of informal caregiving is evident by the fact that 50% of older adults with long-term care needs and no family support reside in nursing facilities, compared with 7% of those with family caregivers (6). The geriatric population will see unprecedented growth with the aging of the baby boomer generation, and this growth will greatly increase the likelihood of needing long-term care (Fig. 3). The number of Americans aged 65 and older is expected to increase by approximately 60 to 90 million by 2040. The 85 and older population—those most likely to need long-term care—will increase by 8 to 20 Figure 1 Projected number of persons with dementia in the U.S. population. (Based on prevalence estimates and projections from the National Institute on Aging and U.S. Bureau of the Census.)

4 Lesesne and Ouslander Figure 2 Frequency of seeing children among community-dwelling elderly who live alone. (Courtesy of Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics, 2nd ed. New York, McGraw-Hill, 1989.) Figure 3 Actual and projected growth of the U.S. geriatric population. (Courtesy of Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics, 3rd ed. New York, McGraw-Hill, 1994.)

Demographics and Economics 5 85 75 Black Female White Female Black Male White Male At Age 65 0 5 10 15 20 Years Remaining Figure 4 Life expectancy in the geriatric population. (Courtesy of Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics, 2nd ed. New York, McGraw-Hill, 1989.) million people by this date (7). A portion of the increase is the result of increased life expectancy. Men aged 65 could expect to live 15 years in 1995; by 2030, they can expect to live 18 years (Fig. 4). Some estimates project the number of people aged 65 and older with functional limitations to be approximately 20 to 30 million by 2040. These demographic shifts will substantially increase the need for nurs- ing facility care. Many community services are available to frail older adults. These services may delay or prevent nursing facility admission for some people (Table 2). They tend to be fragmented and, in many cases, are not reimbursable by most insurance or governmental funding sources. Additionally, there is poor integration of care in the acute and long-term care settings. The primary funding sources of Medicare and Medicaid have differing eligibility requirements and coverage rules that pre- vent integration. There is also a fear of financial loss on the part of commercial carriers, as there is no risk adjustment for chronically ill or disabled people. So- cial health maintenance organizations attempt to add community services and short-term nursing home care to a traditional health maintenance organization health plan. The Program for All-Inclusive Care for the Elderly (PACE) is de- signed for frail older adults, eligible for Medicaid, who are nursing home certifi- able. PACE attempts to help these individuals age in the community. Many states are also developing their own initiatives to provide better community care and de- lay nursing home admission. The number of such programs is increasing, but many frail elders will reach a point at which institutional care is the most appro- priate alternative. The growth in the number of assisted living facilities has had an impact on long-term care. There is no clear definition of what constitutes an assisted living

6 Lesesne and Ouslander facility; however, these venues provide some level of long-term care for their res- idents. A national study of assisted living facilities recently estimated that there were approximately 11,500 facilities with 650,000 beds providing services to 560,000 residents (8). This survey included facilities with at least 11 beds, pro- viding 24-hour oversight and serving at least two meals per day. The major dif- ference is that this industry is composed of more real estate developers and hotel managers than healthcare providers. Nursing home usage rates vary by age, sex, and race (Fig. 5). There are more whites than blacks and more women than men in nursing facilities. Nearly 25% of white women reside in a nursing home by age 85. Interestingly the number aged 65 and older who stay overnight in a nursing home fell by 8% from 1985 to 1995 Table 2 Example of Formal Community Services Available Outside of Nursing Homes Housing Outpatient centers Senior apartments Geriatric clinics Psychosocial counseling Residential care facilities Rehabilitation Assisted living Adult day care Foster care Day hospital Life care community Health promotion activities Home health Wellness programs Home health agencies Exercise classes Medicare-certified Family and patient education Private Nutrition consultation Visiting nurse association Meal programs Hospice Volunteer programs Homemaker Outreach Chore Screening clinics Home infusion therapies Mobile vans Durable medical equipment Discharge planning Case management Acute inpatient units Information and referral Geriatric Meals-on-Wheels Rehabilitation Transportation Psychiatric Emergency response system Alcohol/substance abuse Respite care Source: Ouslander JG., Osterweil D, Morley J. Medical Care in the Nursing Home, 2nd ed. New York, McGraw-Hill, 1997.

Demographics and Economics 7 Figure 5 Percent of population aged 65 and older in nursing homes by age, sex, and race. (Based on 1985 data from the National Center for Health Statistics.) (9). This decline may have resulted from a decline in disability rates of the elderly, increased use of home health services, and the growth in assisted living facilities. All of these tend to delay or prevent placement in a nursing facility. III. ECONOMICS OF LONG-TERM CARE Financing for long-term care in the United States is primarily provided through private funding and governmental assistance programs, including Medicare and Medicaid. Private funding can include personal resources and may include a com- ponent of long-term care insurance. There are also “Medigap” insurance policies to cover the copayment required by Medicare. Long-term care costs as a percent- age of personal health care expenditures have increased from 4% in 1960 to 11% in 1993 (3). Approximately $106 billion was spent on long-term care, including home care, in 1995. Medicare accounted for nearly 18% and Medicaid 38% (21% state Medicaid and 17% federal Medicaid) (Fig. 6). States are the major financiers of long-term care for older adults, whereas the federal government finances most acute care. Many Americans are unprepared for long-term care expenditures be- cause they believe it is a Medicare benefit.

8 Lesesne and Ouslander Figure 6 Expenditures on nursing home and home health care by source of funds, 1995. (From Health Care Financing Administration. Cited by National Academy on Aging, 1997.) A. Medicare Medicare is a governmental insurance program that covers the cost of acute hos- pitalization for those aged 65 and older, as well as some disabled individuals younger than age 65 and those requiring renal dialysis or transplant. In addition, it covers outpatient services and post-acute hospital care for up to 100 days after a 3-day hospitalization. Currently there are approximately 39 million beneficiaries and in 1997, the annual budget was $215 billion dollars. Sixty-nine percent of Medicare expenditures goes to hospitals, with another 25% covering physician services. Less than 5% goes to nursing home care. Medicare expenditures for home health increased nearly 10 times from 1987 to 1995 (10). In response, Congress and the President enacted the 1997 Balanced Budget Act that greatly reduced these payments and initiated a significant effort to reduce fraud and abuse. Many states have developed strategies to help their Medicaid recipients maximize their Medicare home health benefits in an effort to conserve state Medicaid dollars. Medicare also limits its funding for long-term

Demographics and Economics 9 care by only covering post-acute or “subacute” skilled care. Medicare provides post-acute skilled care for 100 days after an acute hospitalization of 3 or more days. To qualify, the patient must require daily skilled nursing care or rehabilita- tion services for the condition that was treated in the hospital (Table 3). Funding for post-acute care from Medicare is transitioning to a prospective payment sys- tem (PPS) based on resident problems identified in the Minimum Data Set (MDS). Under the PPS model, a capitated reimbursement is made to the nursing home for care of particular medical problems after an acute hospitalization. The reimburse- ment is calculated based on the MDS and then translated into resource utilization groups or “RUGS,” similar to the Medicare diagnostic related group (DRG) pay- ment system for acute hospitals. An important component is that all ancillary ser- vices (rehabilitation therapy, laboratory services, medications, etc.) are now bun- dled into one payment. This has profound implications for the relationship between nursing homes and physicians, because under PPS the nursing home bears the cost of physician-ordered laboratory tests, medications and therapies. B. Medicaid Medicaid is a federally sponsored, state-administered program to provide health insurance for the indigent. It covers both acute hospital care and outpatient ser- vices for those who qualify based on means testing. The long-term care compo- Table 3 Admission Criteria to Subacute Units Intravenous antibiotics Physical therapy six to seven times/week Occupational therapy five times/week Weaning oxygen with blood gas measurements three times/week Tracheal suctioning at least two times/shift Respiratory therapy treatment three times/day or more frequently Capillary blood glucose monitoring two times/day with insulin coverage Injectable medications every 8 hours or two times/day Wound care (sterile) day Tube feeding Laboratory test monitoring every 2 to 3 days Renal dialysis with monitoring Bladder training Pain management (parenteral) Skilled nursing observation of congestive heart, liver, or renal failure Physician visits at least weekly

10 Lesesne and Ouslander nent of Medicaid covers nursing home care on a means-tested basis. This program insures 41 million people (10% elderly) at an annual cost of $160 billion. Sixty- nine percent of expenditures go to nursing homes, with 17% to hospitals and 3% to physician services. Each state administers the program differently, so there is substantial variability is terms of benefits covered. Virtually all nursing home care is paid for out-of-pocket or by Medicaid, which has led to a phenomenon known as “spend down” (Figs. 7 and 8). Individ- uals and families will deplete a person’s assets until they can pass the means test Figure 7 Top: Sources of overall health care expenditures for the geriatric population. Bottom: Per capita health care expenditures by type of care and source for the geriatric pop- ulation. Based on 1984 data. (Courtesy of Kane RL, Ouslander JG, Abrass IB, Essentials of Clinical Geriatrics, 2nd ed. New York, McGraw-Hill, 1989.)

Demographics and Economics 11 Figure 8 Proportions of Medicare, Medicaid, and out-of-pocket expenditures used for different types of care by the geriatric population. Based on data from the United States Special Committee on Aging, 1986. (From Ref. 1.)

12 Lesesne and Ouslander for Medicaid funding for long-term care. Since nursing home care can cost as much as $40,000 to $60,000 per year, it does not take older adults very long to qualify for Medicaid. As a result, Medicaid has become, in effect, the payer of last resort for institutional long-term care. This has inspired many state Medicaid agencies to develop and work with programs that prevent or delay the need for in- stitutional care. C. Private Funding Private long-term care insurance only covered 6% of nursing home and home-care costs in 1995 (6). The number of policies sold has recently seen a dramatic in- crease from 800,000 in 1987 to nearly 5 million in 1996. A wide range of cover- age is available through these policies; however, most provide some type of home care component to avoid or delay nursing home coverage. Several states have pro- moted the purchase of long-term care insurance by providing a mechanism to pro- tect assets from Medicaid eligibility requirements equal to the amount of long- term care coverage. IV. EVOLVING CHANGES IN LONG-TERM CARE The long-term care industry has seen substantial growth of post-acute care in the United States over the last decade. As the population ages and hospital lengths of stay are shortened, more medically complex patients with greater nursing home care needs are being discharged from hospitals to nursing facilities. Often they are not functionally able or medically stable enough to return home. Subacute units in nursing facilities have become the place for residents to convalesce before their ultimate discharge. For these units to succeed, there needs to be adequate reim- bursement, availability of skilled nurses, and quality medical care, as well as ad- equate ancillary services. Regulations to set standards for staffing ratios would most likely improve quality of care in nursing homes (11). Nursing homes would also benefit from a survey process that provides education and is outcomes based, rather than a punitive process to identify misconduct. Additionally, unfunded government mandates are difficult to implement, and they drain resources. Improved reim- bursement will help ensure adequate staffing of nurses and therapists, as well as improve the availability of ancillary services. Improving nursing education and professional opportunities will also assist in attracting and retaining quality staff. This is true for physicians, nurse practitioners, and physician assistants. Innova- tive programs are essential to improving job satisfaction and quality of care pro- vided by nursing aides, since they provide more than 90% of hands-on care in nursing homes.

Demographics and Economics 13 Reimbursements that are adjusted for risk and complexity will help provide quality care in the most appropriate setting. The RUGs system is a step in this di- rection. Outcome monitoring based on quality indicators will also provide the ap- propriate incentives for quality care in the nursing home (12). Integrated care sys- tems composed of hospitals, primary care providers, long-term care facilities, and community-based partners will also improve quality and have financial implica- tions. These systems must have shared visions, goals, and financial incentives to provide good care. They also implement care standards as well as develop much needed information systems. All of these features will reduce practice variability and medical errors, and improve the quality of care. REFERENCES 1. Kane RA, Kane RL. Long-Term Care: Principles, Programs, and Policies. New York, Springer, 1987. 2. American Association of Retired Persons: Across the States 1998. Profiles of Long- Term Care Systems, 3rd ed. Washington, DC, 1998. 3. Stone RI. Long-Term Care for the Elderly with Disabilities: Current Policy, Emerg- ing Trends, and Implications for the Twenty-First Century. Milbank Memorial Fund, 2000. 4. Costa PT, Williams TF, Albert MS. Recognition and Initial Assessment of Alzheimer’s Disease and Related Dementias. Clinical Practice Guideline No. 19, AHCPR Publication No. 97–0702. Washington, DC, Agency for Health Care Policy and Research, 1996. 5. The Assistant Secretary for Planning and Evaluation and the Administration on Ag- ing: Informal Caregiving. Compassion in Action. Washington, DC, 1998. 6. National Academy on Aging. Facts on Long-Term Care. Washington, DC, 1997. Available at http://geron.org/NAA/ltc.html 7. U.S. Bureau of the Census. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050: Current Population Reports, P25–1130. Washington, DC, U.S. Government Printing Office, 1996. 8. Hawes C, Rose M, Phillips CD, Iannacchione V. A National Study of Assisted Liv- ing for the Frail Elderly: Results of a National Telephone Survey of Facilities. Beach- wood, Ohio, Menorah Park Center for the Aging, 1999. 9. Bishop CE. Where are the missing elders? The decline in nursing home use, 1985 and 1995. Health Affairs 1999; 18(4):146–155. 10. Kenney G, Rajan S, Soscia S. State spending for Medicare and Medicaid home care programs. Health Affairs 1998; 17(1):201–212. 11. Wunderlich GS, Kohler PO (eds). Improving the Quality of Long-Term Care: A Re- port of the Institute of Medicine. Washington, DC, National Academy Press, 2001. National Academy of Sciences. 12. Zimmerman DR, Karon SL, Arling G. Development and testing of nursing home quality indicators. Health Care Financing Rev 1995; 16:107–127.



2 Evaluation of Infections in Long-Term Care Facilities Versus Acute Care Hospitals Andrew D. Weinberg Emory University School of Medicine, Atlanta, Georgia I. LONG-TERM CARE FACILITY VERSUS ACUTE CARE HOSPITAL In general, evaluation and management of acute care infections remains one of the greatest challenges to staff and healthcare practitioners in institutional long-term care facilities (LTCFs). The general goals and objectives, staffing patterns, avail- able resources for diagnostic testing, and primary role of physicians and nursing staff are different between an acute care hospital and an LTCF, as indicated in Table 1. Thus, the approach to evaluating infections in LTCFs will also be differ- ent between an acute care hospital and an LTCF. The differences in the evaluation of infections in the hospital setting include the infrequent presence of physicians in the LTCFs, the inability to obtain timely and accurate laboratory and radiolog- ical data, and the limited nursing assessment that occurs at the LTCF, which is subsequently transmitted to the healthcare practitioner via telephone. II. HOW INSTITUTIONAL LTCFS DIFFER IN INFECTION EVALUATION A. Staffing and Resources The majority of care in an LTCF is provided by licensed nursing staff (licensed practical nurses [LPNs] and registered nurses [RNs]). The staffing ratios in facil- 15

16 Weinberg Table 1 Differences Between Acute Care Facility and Long-Term Care Facility Parameter Acute care facility Long-term care facility Patient population Young and old Predominantly old Setting High technology Home-like Goals Acute disease treatment Comfort, support Length of stay Days, weeks Months, years Physician role Primary Secondary, limited Infection definition Clinical ϩ tests Clinical ϩ limited tests Resources for infection Broad Variable and often limited control Broad Limited to none Isolation capability Adapted from: Yoshikawa TT, Norman DC: Infection control in long-term care. Clin Geriatr Med 1995;11:467–480. ities may range from one licensed nurse per 20 residents to as high as one to 40 residents, depending on the shift. Certified nursing assistants (CNAs) provide the majority of hands-on care, including grooming, washing, ambulation, feeding, dressing, and overall supervision. The CNA staffing ratios may range from one CNA per 8 to 15 residents, again depending on the particular shift. In the major- ity of LTCFs, physicians are physically present in the facility for a limited num- ber of hours per week and are only required by state or federal regulations to visit, on average, every 30 to 60 days after the first 90 days of residency in the facility. Thus, the vast majority of changes in a resident’s baseline condition and responses to acute medical illnesses are managed by telephone or fax transmissions from the RN to LPN to the primary or cross-covering physician of record, a nurse practi- tioner (NP), or a physician assistant (PA) (1–3). Often limited technical resources are available for the evaluation of infec- tions in the LTCF setting, especially on evenings, nights, weekends, and holiday shifts. Practice guidelines for the evaluation of fever and infection in the long-term care setting have been recently published (4), but the majority of triage for an acute illness is done by telephone exchange with the nursing staff, often without the benefit of laboratory data at the time of the first contact. The availability of specialty consultations is virtually nonexistent onsite. Referrals to infectious dis- ease specialists outside the nursing facility are difficult to arrange and involve sig- nificant nonreimbursable transportation costs. In general, staff and healthcare practitioners rely on the clinical history and symptoms and signs of illness rather than on advanced diagnostic testing. The CNAs are the first line of detection, as they interact closely with the residents and customarily can detect small changes in mental status or functional decline that could signal an underlying infection. The CNAs then report these observations to the licensed nurse on duty. The nurse is then expected to obtain vital signs and per-

Long-Term Care and Acute Care Facilities 17 form a nursing assessment so that this information, along with any recent, perti- nent history, can be given to the practitioner when he or she is contacted. Infection remains one of the most common causes of death among LTCF residents and a frequent reason for transfer to the acute care setting and subsequent hospitalization (5–7). Those LTCF residents who are at greatest risk for develop- ing clinical infections are more likely to require higher levels of nursing care, have significant functional disability, or have more indwelling catheters (3,8). Infec- tions of the urinary tract, pulmonary system, and skin remain the most common sites of infection in the LTCF setting. B. Recognition of Infection Recognition of infection in this population may be hindered by the atypical pre- sentation of these illnesses in cognitively impaired individuals who may not be able to effectively communicate to their caregivers when they feel ill (9,10). Cer- tified nursing assistants or licensed nursing staff may be able to detect infections by subtle declines in cognitive or physical functioning or by the presence of new or increasing confusion. One of the universal indicators of infection is the presence of fever. How- ever, it is now known that the basal body temperatures in the frail older adult may be lower than the well-established mean value of 37°C or 98.6°F (11). Thus, fever as a marker for infection in the LTCF resident is not the most sensitive of indica- tors. Also, “fever” can be defined somewhat differently from facility to facility, so it is important to be aware of the current definition used in each facility, especially when implementing evaluation and treatment protocols for infection. Addition- ally, temperatures may be obtained from different sites of measurement, includ- ing oral, rectal, axillary, or tympanic, and all are not necessarily equally as accu- rate (12). (See also Chapter 6, Clinical Manifestations of Infections.) The routine use of acetaminophen can mask the presence of fever, and its rou- tine use should be discouraged until the source of fever is identified or the evalua- tion of an infection is in progress (13). Once the presence of a new fever is docu- mented, the source of this temperature elevation should be sought. The particular areas to assess for potential sources of infection include the oropharynx, conjunc- tiva, skin (whole body evaluation), chest, heart, abdomen, perineum, perirectal area, and the central nervous system (14). Several groups have outlined general guidelines for the evaluation of suspected infections; however, these recommen- dations represent a consensus of opinion of individuals representing various long- term care organizations involved but have not been validated to date (15–17). Concurrent dehydration can also pose a risk to the outcome of infections in this population. In one study of 40 febrile LTCF residents (5), 24 (60%) had evi- dence of hypernatremia, increased blood urea nitrogen to serum creatinine ratio, or both. Studies have shown that not one specific physical finding was deemed to

18 Weinberg be of any particular value in diagnosing dehydration (5,18), and that laboratory data remain the most objective and easily attainable information on the state of hydration. C. The Initial Evaluation of Suspected Infection The initial assessment is usually completed by the nurse on duty in the facility af- ter being notified of a change in status by the CNA. The nurse then reports the findings via telephone to the NP, PA, or attending physician (4). (See Appendix B for a summary of guidelines for evaluation of fever and infection in LTCF [4]) The NP, PA, or physician may then order additional laboratory or radiological tests, initiate treatment, or order the resident transferred to an acute care setting for further evaluation. Initial laboratory data obtained usually consists of a urinalysis with culture if an infection in the genitourinary tract is suspected, a chest X-ray if a pulmonary process is suspected, and a complete blood count with differential to determine the severity of the problem (Fig. 1). “Stat” laboratory and radiological tests are available, but several hours or even a full day may elapse until the results are relayed back to the ordering healthcare practitioner. If an epidemic is suspected in the facility (usually defined as 10% or more of the resident population ill at the same time), nursing staff should alert the di- rector of nursing who, in turn, must notify the medical director. The infection con- trol nurse should also be contacted so that ongoing monitoring can be carried out. Nursing staff should be briefed or inserviced (as time permits) on the relevant por- tions of the infection control policies for the facility that would pertain to this out- break. Overall evaluation and treatment in the LTCF setting must take into con- sideration the resident’s wishes (or a legal guardian or next of kin if the resident is incompetent to make medical decisions), the cost of evaluation, and the effect of treatment on the quality of life given the wishes of the resident/family. Tests should be ordered if the results will cause the clinician to change or reassess the current treatment and improve overall management or the comfort of the resident. The need for specific laboratory tests should be based on the clinical presentation of each resident. Protocols to aid the staff in their approach to suspected infections should be developed and distributed, and inservice education should be provided to all three shifts. The ability to obtain adequate culture specimens may be problematic in the LTCF setting. The prevalence of asymptomatic bacteriuria may run as high as 50% of all noncatheterized female residents of LTCFs and does not usually re- quire treatment with antibiotics (19). This may confound the interpretation of cul- ture results. When such cultures are indicated, it is possible to collect adequate specimens in both men and women without catherization (4). Blood and sputum cultures are extremely difficult to obtain in the LTCF setting. Obtaining adequate

Long-Term Care and Acute Care Facilities 19 Suspected Infection Functional decline Change in mental status Fever Onset of viral, urinary tract, respiratory or diarrheal symptoms Evidence of unexplained discomfort (crying, moaning, agitation) Significant decrease in food/fluid intake Nurse/Certified nursing assistant obtains vital signs (Temperature, pulse, respiratory rate, and blood pressure) Perform nursing assessment Review chart and document all assessments Call practitioner to relay information and recent medical history Note any current advance directives Practitioner assesses stability via telephone or by visit Unstable Unstable Stable Advance directive limits intervention No advance directive Call family Call family Call family Comfort measures Transfer to acute care facility Order laboratory or other tests Order treatment if clinically indicated Follow-up with family Follow-up with family Follow-up with family Document in chart rationale Document in chart rationale Document all medical orders and goals and goals for transfer and test results Adjust treatment as indicated Establish Continuous Quality Improvement (CQI) process for ongoing review and analysis of cases when resident is transferred to an acute care facility Figure 1 Recommended clinical evaluation for suspected infections in long-term care residents. specimens for sputum cultures in the LTCF setting is made difficult by the tech- nical difficulties associated with the procedure in frail, cognitively impaired resi- dents and the lack of specific training on the part of the staff. Additionally, con- tracted laboratories rarely can provide this service to LTCFs. Blood cultures obtained within 24 hours of presentation have been associated with improved sur-

20 Weinberg vival in community-acquired pneumonias with sepsis (20), but there are no simi- lar studies in the LTCF setting and thus are not generally recommended (4). Pulse oximetry can be useful in assessing arterial oxygen partial pressures and is relatively inexpensive and easy to use in the LTCF setting. It can be a pre- dictor of impending respiratory failure requiring hospital admission (21). Assess- ment of the resident for impending respiratory failure can also be done at the bedside using a rate greater than 25 breaths per minute and confirmed by pulse oximetry indicating an oxygen saturation of less than 90%, as suggested in the re- cent modification of the Pneumonia Prognosis Index in nursing home residents (22). Because respiratory therapy services are generally not available in LTCFs, pulse oximetry measurements by nursing staff can be very helpful in treating res- idents suspected of having pneumonia. D. Subacute Care Infection Control There are few articles in the literature regarding infection control practices in sub- acute (postacute care; PAC) units (23), and there is no mention of PAC units as a special setting in either the position paper on infection prevention and control in LTCFs from the Association for Professionals in Infection Control and Epidemi- ology or the Society for Healthcare Epidemiology of America (24). Postacute Care units are a specified number of Medicare-certified beds within an LTCF de- signed to provide more advanced medical, nursing, and rehabilitative services to post-hospitalized older adults for a period not exceeding 100 days per calendar year under Medicare Part A. The ability to administer intravenous antibiotics is a commonly provided service (25). Many individual patients are admitted to PAC units for completion of an- timicrobial therapy for already diagnosed and partially treated infections, such as chronic osteomyelitis or endocarditis. Some deconditioned patients in these units may develop pneumonia because of their overall poor medical condition or from aspiration (e.g., after a stroke). The subsequent antibiotic administration, which can be accomplished in most LTCFs with PAC units (25), will usually cover the majority of nosocomial infections one might expect to encounter. The LTCF facility medical director (or PAC unit medical director) can be in- volved in the screening of high-acuity patients with known infections before their acceptance into the unit (26). This allows the stability of the patient’s infection to be assessed, as well as anticipated equipment and medical needs (e.g., the presence of central lines, specialty mattresses, stage IV pressure ulcer management). There have been recent changes to reimbursement for subacute services in PAC units involving a prospective payment system (PPS); a fixed per diem reim- bursement to the facility based on functional and medical needs is provided. This PPS payment is required to cover all nursing and ancillary services, including the

Long-Term Care and Acute Care Facilities 21 cost of X-rays, laboratory tests, medications, and intravenous administration of antibiotics performed in the facility. As the evaluation and treatment of compli- cated infections that develop after admission to a PAC unit will be borne by the facility under PPS, it has the potential to affect the assessment or treatment of acute infections in this setting. III. WHEN TO TRANSFER LTCF RESIDENTS TO AN ACUTE CARE SETTING An ongoing issue is appropriate use of the emergency department (ED) as a re- source for the evaluation of suspected infections in LTCF residents. Some studies have suggested that such transfers are overutilized and deem them inappropriate (27,28). The expense and inconvenience to the resident is considerable when such transfers are not properly used. The reasons for and frequency of transfers of LTCF residents to EDs for evaluation vary considerably by practice and location (Table 2) (27,29). The ability to adequately evaluate, monitor, and safely treat an LTCF resident is often the key question confronting the practitioner. Also, the in- ability to obtain necessary radiological or laboratory testing, the nursing assess- ment of the resident’s stability, and family recommendation will all affect the practitioner’s final decision on whether to transfer an individual. Most common bacterial pathogens seen in the LTCF setting can be treated with broad-spectrum oral antimicrobial therapy (30,31), but some practitioners, for a variety of reasons Table 2 Reasons to Transfer an LTCF Resident to an Emergency Department for Suspected Infection in Absence of Advance Directives • Abrupt change in vital signs or mental status associated with suspected infection • Inability to maintain adequate hydration and nutrition • In nurse’s judgment, the resident is not stable and practitioner not able to make onsite evaluation • Infections that are not responding to initiated treatment • Need for intravenous antibiotics or other necessary treatment that cannot be administered at the facility • Inability to obtain critical laboratory or radiological studies in the LTCF setting in a timely manner • Required infection control measures cannot be adequately implemented in the facility • Family concerns that adequate care is not being provided in the facility and requests transfer for more aggressive intervention LTCF ϭ Long-term care facility. A suggested algorithm for evaluation of a suspected infection in the LTCF is shown in Figure 1.

22 Weinberg including potential legal liability, may routinely order the transfer of all “acutely” ill residents to the local ED for “evaluation.” The ideal solution for those frail LTCF residents whose benefit/risk ratio for transfer and potential hospitalization is low is to discuss these issues in ad- vance with the individual or a legal representative and specify guidance to the practitioner in the form of an advance directive. However, use of advance di- rectives before the onset of a crisis is relatively low. Advance directives re- questing “comfort care only” or “do not hospitalize” may facilitate the manage- ment of the LTCF resident with a suspected infection. However, studies examining advance directives in regard to the evaluation of suspected infections do not exist. Antibiotic treatment appears to be provided less often to residents with urinary, respiratory, or skin infections who have advance directives speci- fying “comfort care only” (32). Developing and implementing protocols to ensure that LTCF nursing staff can obtain and communicate adequate baseline information and assessments of the resident is critical for the practitioner to proceed with an organized and logi- cal evaluation of a potential infection. Because much, if not all, of the initial in- formation is transferred from the facility to the practitioner by telephone, this step may be considered the critical ink in the flow of information. More complete pro- tocols for effective communication between nurses and physicians regarding res- ident assessment have been published (33), and one is available by the American Medical Directors Association (34). Following the resident’s advance directives and consulting with the legal representative can certainly give the practitioner direction as to the desired degree of evaluation or intervention and whether transfer to an ED is appropriate. If trans- fer is not desired, then appropriate laboratory, radiological, or specimen collection can be ordered to complete the evaluation at the LTCF site. Follow-up on any or- dered tests and the response to prescribed treatment must be an ongoing process between the facility and the practitioner. Any pending laboratory or radiological results or recent family decisions as to the desired intervention should be con- veyed to the “on call” practitioner for the night or weekend to avoid confusion and unwanted or unnecessary interventions. Facilities should develop Continuous Quality Improvement projects to re- view the entire evaluation and transfer process of residents to monitor the efficacy of current policies and procedures. Information on transfers and hospital admis- sions should be collected to assess whether there are procedures that can be im- plemented or current policies modified to improve the efficiency of the system in use. The facility medical director should be involved in the development, imple- mentation, and review of all protocols to assure efficiency of assessments and in- formation control procedures in collaboration with the infection control nurse and director of nursing. Data should also be collected on antibiotic resistance patterns, if possible (35).

Long-Term Care and Acute Care Facilities 23 IV. SUMMARY The evaluation and treatment of infections in LTCFs is significantly different from acute care hospitals in many ways, including the availability of onsite as- sessment by physicians, specialty consultants, and diagnostic technologies. Al- though the vast majority of the more common clinical infections and their mani- festations can be diagnosed and treated in the LTCF setting, there are instances when the severity of the illness or the treatment required may necessitate transfer to an acute care facility. Keeping this in perspective, advance directives and fam- ily discussions should be used to avoid undesired hospital transfers or aggressive treatments whenever possible. The medical director should be extensively in- volved in the development, review, and implementation of all infection control and treatment protocols. REFERENCES 1. Evans JM, Chutka DS, Fleming KC, Tangalos EG, Vittone J, Heathman JH. Medical care of nursing home residents. Mayo Clin Proc 1995; 70:694–702. 2. Ouslander JG, Osterweil D. Physician evaluation and management of nursing home residents. Ann Intern Med 1994; 121:584–592. 3. Smith PW, Rusnak PG. Infection prevention and control in the long-term care facil- ity. Infect Control Hosp Epidemiol 1997; 18:831–849. 4. Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for the evaluation of fever and infection in long-term care facilities. J Am Geriatr Soc 2001; 49:210–222. 5. Weinberg AD, Pals JK, Levesque PG, Beal LF, Cunningham TJ, Minaker KL. De- hydration and death during febrile episodes in the nursing home. J Am Geriatr Soc 1994; 42:968–971. 6. Irvine PW, Van Buren N, Crossley K. Causes for hospitalization of nursing home res- idents: The role of infection. J Am Geriatr Soc 1984; 32:103–107. 7. Weinberg AD, Engingro PF, Miller RL, Weinberg LL, Parker CL. Death in the nurs- ing home: Senescence, infection and other causes. J Gerontolog Nurs 1989; 15(4): 12–16. 8. Nicolle LE, Garibaldi RA. Infection control in long-term care facilities. Infect Con- trol Hosp Epidemiol 1995; 16:348–353. 9. Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age Ageing 1987; 16:201–207. 10. Samily AH. Clinical manifestations of disease in the elderly. Med Clin North Am 1983; 67:333–344. 11. Castle SC, Norman DC, Yeh M, Miller D, Yoshikawa TT. Fever response in elderly nursing home residents. Are the older truly colder? J Am Geriatr Soc 1991; 39: 853–857. 12. Darowski A, Najim Z, Weinberg JR. The febrile response to mild infections in elderly hospital residents. Age Ageing 1991; 20:193–198.

24 Weinberg 13. Weinberg AD, Pals JK, McClinchey-Berroth R. The source of fever and the effect of acetaminophen use on time to diagnosis in febrile long-term care residents. Nurs Home Med 1996; 4:340–347. 14. Yoshikawa TT, Norman DC. Approach to fever and infection in the nursing home. J Am Geriatr Soc 1996; 44:74–82. 15. Smith PW. Consensus Conference Participants. Consensus conference on nosoco- mial infections in long-term care facilities. Am J Infect Control 1987; 15:97–100. 16. Zimmer JG, Bentley DW, Valenti WM, Watson NM. Systemic antibiotic use in nurs- ing homes. A quality assessment. J Am Geriatr Soc 1986; 34:703–710. 17. AMDA. Clinical Practice Guideline: Altered mental states (E. Tangalos, Chairman). Columbia, MD, American Medical Directors Association, 1998. 18. Gross C, Lindquist RP, Wolley AC, Granieri R, Allard K, Webster B. Clinical indi- cators of dehydration severity in elderly patients. J Emerg Med 1992; 10:267–274. 19. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993; 14:220–225. 20. Arbo MDJ, Snydman DR. Influence of blood culture results on antibiotic choice in treatment of bacteremia. Arch Intern Med 1994; 154:2641–2645. 21. Bartlett JG, Mundy LM. Current concepts: Community-acquired pneumonia. N Engl J Med 1997; 336:243–250. 22. Mylotte JM, Naughton B, Saludades C, Maszarovics Z. Validation and application of the pneumonia prognosis index to nursing home residents with pneumonia. J Am Geriatr Soc 1998; 46:1538–1544. 23. Mylotte JM, Bentley DW. Infection control in subacute care. Clin Geriatr Med 2000; 16(4):805–816. 24. Friedman C, Barnette M, Buck AS, Ham R, Harris JA, Hoffman P, Johnson D, Ma- nian F, Nicolle L, Pearson ML, Perl TM, Solomon SL. Special communication: Re- quirements for infrastructure and essential activities of infection control and epi- demiology in out-of-hospital settings: A Consensus Panel report. Am J Infect Control 1999; 27:418–430. 25. Weinberg AD, Pals JK, Wei JY. The utilization of intravenous therapy programs in community long-term care nursing facilities. J Nutr Health Aging 1997; 1:161–166. 26. Weinberg AD. The medical director’s role in screening high-acuity admissions to subacute units. Ann Long Term Care 2000; 8(2):72–78. 27. Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department. Outcomes and policy implications. Acad Emerg Med 1997; 4:908–915. 28. Rubenstein LZ, Ouslander JG, Wieland D. Dynamics and clinical implications of the nursing home-hospital interface. Clin Geriatr Med 1988; 4:471–491. 29. Teresi JA, Holmes D, Bloom HG, Monaco C, Rosen S. Factors differentiating trans- fers from long-term care facilities with high and low transfer rates. Gerontologist 1991; 31:795–806. 30. Fried TR, Gillick MR, Lipsitz LA. Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc 1997; 45:302–306. 31. Thompson RS, Hall NK, Szpiech M, Reisenberg LA. Treatment and outcomes of pneumonia in the elderly. J Am Board Fam Pract 1997; 10:82–87.

Long-Term Care and Acute Care Facilities 25 32. Mott PD, Barker WH. Treatment decisions for infections occurring in nursing home residents. J Am Geriatr Soc 1988; 36:820–824. 33. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing Home, 2nd edi- tion. New York, McGraw-Hill, 1997. 34. AMDA. Protocols for physician notification: Assessing patients and collecting data on nursing facility patients: A guide for nurses on effective communication with physicians. Columbia, MD, American Medical Directors Association, 2000:1–33. 35. Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 1996; 9:1–17.



3 Epidemiology and Special Aspects of Infectious Diseases in Aging Thomas T. Yoshikawa Charles R. Drew University of Medicine and Science and Martin Luther King, Jr.–Charles R. Drew Medical Center, Los Angeles, California I. EPIDEMIOLOGY OF INFECTIOUS DISEASES A. Pre-Antibiotic Era Infectious diseases have assumed an important role in the evolution of the human race and the history of mankind. Survival of man during the prehistoric era de- pended on avoiding predators. Subsequently, the ushering in of civilization brought new threats for survival. Infectious diseases became the major cause of death and disability until the mid-20th century. Outbreaks such as smallpox, plague, cholera, typhoid fever, diphtheria, tuberculosis, and typhus fever have been responsible for the deaths of millions of people (1). As recently as 1918, an international epidemic of “Spanish flu” (strain of influenza virus) accounted for 21 million deaths in all parts of the world, including approximately 550,000 deaths in the United States (2). In addition, certain infections resulted in death and often caused severe disabilities, deformities, and functional incapacities, such as mumps, measles, scarlet fever, rheumatic fever, pertussis, poliomyelitis, and syphilis (1). Not surprisingly, childhood mortality was very high. It is for this rea- son that, up until the mid-1900s, life expectancy was relatively limited (approxi- mately 47 years in the United States) (3). B. Germ Theory and Its Impact Until the acceptance of microbes as causes of infections, the fundamental doctrine that explained the cause or causes of diseases was the doctrine of humoral pathol- 27

28 Yoshikawa ogy, that is, man’s health and temperament were affected by four body fluids or humors: blood, phlegm, black bile, and yellow bile (4). In the early 1800s, the con- cept of contagions and contagiousness, that is, diseases could be communicable and transmitted to others, laid the foundation for the establishment of the age of bacteriology and germ theory of medicine. In the mid- to late-1800s, discoveries by Louis Pasteur (pasteurization; microorganisms were the cause of disease; vac- cines for anthrax, rabies, and swine erysipelas), Joseph Lister (antisepsis), and Robert Koch (cause of tuberculosis; tuberculin skin test) led to the eventual ac- ceptance of the microbial cause of infections, hence, the “germ theory” of medicine (4). The clinical impact of the germ theory was the development and implemen- tation of antisepsis, antibiotics, vaccination, sanitation, and public health measures. These practices and processes reduced deaths and complications from infectious diseases in industrialized nations beginning in the latter half of the 20th century and resulted in the increase in life expectancy observed during the past 50 years in such nations, including the United States. However, in less developed parts of the world, infections continue to be the primary cause of mortality, accounting for one-third of all deaths worldwide. The World Health Organization estimates that 50,000 deaths occur each day in the world from infectious diseases (4). With the increase in life expectancy, the population of aging adults has grown rapidly, including those requiring long-term care (see Chapter 1.) Heart disease, cancer, and stroke have become the leading causes of death in both young and older adults (5). However, infections remain an important cause of morbidity and mortality in the elderly population, especially the very old and frail elderly (6). Currently, there is no evidence that aging is associated with greater vulnera- bility to all infectious diseases. The available data indicate that select infections are especially important in the elderly person because of their higher frequency (incidence, prevalence) and/or poor outcomes (higher morbidity, mortality, or both). These infections are listed in Table 1 (7). Table 1 Important Infections in the Geriatric Population Urinary tract infection Respiratory tract infection (pneumonia and bronchitis) Tuberculosis Skin and soft tissue infections (e.g., infected pressure ulcer, herpes zoster) Intra-abdominal infections (diverticulitis, cholecystitis, appendicitis) Bacterial meningitis Infective endocarditis

Epidemiology of Infectious Diseases 29 In the very old and frail elderly, such as residents in long-term care facili- ties (LTCFs), the susceptibility to and mortality from infections greatly increase. Pneumonia, urinary tract infection, and skin/soft tissue infections, such as celluli- tis and infected pressure ulcers, are the most common infections found in residents of LTCFs (8,9). Moreover, within a closed institutional setting and environment, other types of infections become prominent. These include a variety of infectious diarrheas (see Chapter 18), scabies (see Chapter 17), viral hepatitis (see Chapter 19), and infections caused by multidrug-resistant bacteria (see Chapters 22, 23, and 24). II. SPECIAL ASPECTS OF INFECTIONS IN THE ELDERLY A. Clinical Manifestations Infection is now well known to be an important cause of morbidity and mortal- ity in elderly persons. However, the clinical diagnosis of infectious disease in older patients is often difficult and overlooked. The clinical manifestations of in- fections in the frail elderly LTCF resident may be atypical or absent (see Chap- ter 6). Fever may not be detectable in older persons with serious infections (10). In frail LTCF residents, studies have shown that baseline body temperatures may be subnormal, and febrile responses to an infection may occur but go un- recognized because the “fever” fails to reach a predetermined criterion (e.g., 101°F [38°C]). In such cases, a change in body temperature of at least 2°F from baseline should be interpreted as a possible “febrile” response (11). It also has been proposed that the absolute criterion for fever be lowered in frail elderly persons, that is, 99°F (37.2°C) for oral temperature and 99.5°F (37.5°F) for rec- tal temperature (12). B. Increased Susceptibility to Infections The increased susceptibility of older people to select infections may be a multi- factorial process. A “normal” process of aging is the phenomenon of immune dys- regulation or dysfunction (see Chapter 4). It is most likely the interrelationships between age-related immune dysregulation and age-associated chronic diseases that affect immune processes that place the older, frail LTCF resident at high risk for infectious diseases (13). In addition, other factors such as nutrition (see Chap- ter 5) and chronic use of antibiotics (see Chapter 11) have an impact on the risk, severity, and types of infections found in the geriatric population. The risk or severity of an infection can be simply illustrated in an equation that includes in- nate microbial factors (virulence), quantity of exposure to microorganisms, and

30 Yoshikawa host resistance: Infection (risk/severity) Ϸ ᎏvirulenhcoesᎏtϫreisnisotcaunᎏlcuem size This relationship states that infection risk or severity is directly proportional to the virulence of the pathogen and quantity of organisms, and inversely proportional to the integrity of host resistance (14). Certainly, frail LTCF residents are being exposed more to highly virulent organisms by virtue of several pathogens having resistance to multiple antibiotics (e.g., methicillin-resistant Staphylococcus aureus [MRSA], van- comycin-resistant enterococci [VRE]). The quantity of microorganisms to which these residents are exposed can be enormous, especially when they experience as- piration pneumonia, intra-abdominal infections, and infected skin/soft tissues (e.g., pressure ulcers). In addition, the age-related changes in immune function and the immune dysregulation associated with underlying chronic diseases reduce the elderly LTCF resident’s resistance to infection. C. Antimicrobial Therapy Chapter 11 provides an in-depth discussion of the principles and approach to pre- scribing antibiotics for elderly patients with suspected or confirmed infections. Nevertheless, it is important to consider the age-related changes in pharmacoki- netics and pharmacodynamics whenever any drug is prescribed to an elderly pa- tient. Dose adjustments and the pharmacological properties of a drug must be carefully determined because of the age-associated alterations in volume of dis- tribution, reductions in renal function, and potential sensitivity of select organs to certain drugs. Moreover, because the vast majority of older patients are taking some type of prescribed or over-the-counter medication, potential drug interac- tions as well as adverse side effects, must be carefully evaluated before and during administration of an antibiotic (e.g., divalent ion-containing antacids may affect the absorption of many quinolones). Adverse drug events occur more often in the elderly and increase with the number of drugs prescribed (15). It is impera- tive, therefore, that careful monitoring for adverse events in elderly patients or res- idents be performed regularly during administration of antibiotics or any other drug. Because elderly persons may not exhibit typical manifestations of drug side effects as described by the drug information packet, it is important to be aware that unexplained changes in cognitive function, behavior, or physical capacity may be attributable to medications. However, close monitoring is especially difficult in LTCFs because of the high level of disability and inability to communicate in many of the residents in these institutions, the limited number of visits made by physicians and other health providers, and lack of immediate availability of labo- ratory tests in such facilities. Given these limitations, prescribing antibiotics to

Epidemiology of Infectious Diseases 31 LTCF residents will require careful thought, appropriate indications, and judi- cious selection. REFERENCES 1. Lyons AS, Petrucelli RJ. Medicine: An Illustrated History. New York, Harry N. Abrams, 1978. 2. Crosby AW. Epidemic and Peace, 1918, Part IV. Wesport, CT, Greenwood Press, 1976. 3. U.S. Department of Health and Human Services (DHHS), Public Health Service, Na- tional Center for Health Statistics: Health United States 1985. DHHS Publication No. (PHS) 86-1232. Hyattsville, MD, DHHS, 1986. 4. Kupersmith C. Three Centuries for Infectious Disease. An Illustrated History of Re- search and Treatment. Greenwich, CT, Greenwich Press, 1998. 5. National Center for Health Statistics. Leading causes of death and number of deaths according to age: United States, 1980 and 1993. In: Health United States, 1995. De- partment of Health and Human Services (DHHS) Publication No. (PHS) 96-1232. Hyattsville, MD, DHHS, 1996. 6. Yoshikawa TT. Geriatric infectious diseases: An emerging problem. J Am Geriatr Soc 1983; 31:34–39. 7. Yoshikawa TT: Important infections in elderly persons. West J Med 1981; 135: 441–445. 8. Yoshikawa TT, Norman DC. Fever in the elderly. Clin Infect Dis 2000; 31:148–151. 9. Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infection in long-term care facilities. Clin Infect Dis 2000; 31:640–653. 10. Norman DC. Fever in the elderly. Clin Infect Dis 2000; 31:148–151. 11. Castle SC, Yeh M, Toledo S, Norman DC. Lowering the temperature criterion im- proves detection of infections in nursing home residents. Aging Immunol Infect Dis 1993; 4:67–76. 12. Norman DC, Yoshikawa TT. Fever in the elderly. Infect Dis Clin North Am 1996; 10:93–99. 13. Castle SC. Clinical relevance of age-related immune dysfunction. Clin Infect Dis 2000; 31:578–585. 14. Yoshikawa TT, Norman DC. Aging and Clinical Practice: Infectious Diseases. Diag- nosis and Treatment. New York, Igaku-Shoin, 1987. 15. Wong FS, Rho JP. Drug dosing and life-threatening drug reactions in the critically ill patient. In: Yoshikawa TT, Norman DC (eds). Acute Emergencies and Critical Care of the Geriatric Patient. New York, Marcel Dekker, Inc., 2000:31–47.



4 Impact of Age and Chronic Illness- Related Immune Dysfunction on Risk of Infections Steven C. Castle VA Greater Los Angeles Healthcare System, and UCLA School of Medicine, Los Angeles, California I. INTRODUCTION The increased risk and severity of infections in the elderly population is well doc- umented, and immunosenescence, the state of dysregulated immune function with aging, is felt to be a significant contributor to this increased risk. However, of more clinical relevance is the even higher risk of nosocomial infections in long- term care facilities (LTCFs). Surveillance of LTCF-acquired infections by the Na- tional Nosocomial Infections Surveillance system has reported a high incidence of 3.82 infections per 1000 resident-days of care, but with significant variability (1). Data vary widely depending on the type of facility, nature of the residents, defini- tions used for infections, and type of data analysis. Prevalence rates of infection range from 1.6% to 32.7%, and overall incidence rates range from 1.8 to 13.5 in- fections per 1000 resident-days of care, with equal variability for specific infec- tions such as urinary tract infection or pneumonia. The questions that are raised from these data are: (1) What resident or facility factors contribute to this wide variability of incidence of infections? (2) Can anything be done to reduce the risk of infection by treatment of residents? (3) What impact could changes in infection control policy have on infection rate for a given facility? If the goal is to prevent serious infections in the elderly, it appears the field of geriatric immunology/infectious disease is faced with the tremendous challenge of studying a very diverse population of chronically ill individuals in addition to the study of the very healthy elderly. Grouping individuals by disease severity or 33