Avoiding the nightmare of drug-resistant pneumococcal pneumonia.

An outbreak in an Oklahoma nursing home gave long-term care facilities the impetus to develop new infection-control strategies

The first outbreak of multidrug-resistant pneumococcal pneumonia among adults in the United States was seen among residents of a nursing home in Oklahoma, and it underscored current fears about the growing problem of antibiotic resistance around the world. It was written up in an article, "An Outbreak of Multidrug-Resistant Pneumococcal Pneumonia and Bacteremia Among Unvaccinated Nursing Home Patients," in the June 25, 1998, issue of the New England Journal of Medicine. According to the article, pneumonia developed in 11 of 84 residents, three of whom died.

A single strain of multidrug-resistant Streptococcus pneumoniae was the cause. Only three of the residents were immunized against pneumococcus. After residents received the vaccine, and prophylactic antibiotics to allow time for the vaccine to become effective, there were no additional cases.

The NEJM study cited several factors as contributing to the outbreak, including the susceptibility of the nursing home population. The elderly have impaired immunity and are susceptible to infection because of altered throat flora and bacteria from their airways, as well as underlying diseases such as COPD and heart disease. Residents also have conditions that predispose them to aspiration, swallowing disorders and the need for feeding tubes. They also make frequent trips to and from acute care settings, allowing for the spread of the disease. Also, according to the NEJM article, clusters of pneumococcal disease may be underrecognized in nursing homes. Finally, the mortality for LTC-acquired pneumonia is much higher than for community-acquired pneumonia.

For these reasons, long-term care facilities should take steps to reduce the likelihood of pneumococcal and other infectious outbreaks in their facilities in two ways: by pursuing better standards of infection control and by making sure residents are vaccinated against pneumococcal disease.

The Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) offer a position paper, "Infection Prevention and Control in the Long-Term Care Facility," published in the December 1997 issue of the American Journal of Infection Control. It outlines several recommendations for "an active, effective, facility-wide infection-control program ...to help prevent the development and spread of infectious diseases."

Among its recommendations: a surveillance system based on systematic data collection to identify infections in residents; a system to detect and investigate institutional outbreaks; an isolation and precautions plan; infection-control policies and procedures; continuing education of staff; resident health and employee health programs focusing on vaccination; a system for antibiotic surveillance; and a mechanism for reporting suspected outbreaks to public health authorities.

I will discuss a few of these suggestions more thoroughly, particularly as they address issues brought up in the NEIM article.

Surveillance. The NE]M study notes that "there is no routine surveillance for respiratory infections in nursing homes, so unrecognized or unreported clusters of pneumococcal disease may be more common than currently believed." In addition, pneumonia can be difficult to diagnose in this setting because of the lack of x-ray facilities and the difficulty of getting good sputum specimens. If you are developing a surveillance program, remember that concurrent surveillance is preferred, as opposed to retrospective review of clinical records. These data can be used for planning infection-control efforts, detecting epidemics, directing continuing education, and identifying individual resident problems for intervention.

Infection control. Infection-control practices should be under the jurisdiction of one staff member assigned to be in charge of infection control, someone with the authority to intervene during an outbreak. That person should do periodic environmental surveillance, making rounds to check on infection-control practices being implemented throughout the facility. These include such nursing home divisions as dietary, physical therapy/rehabilitation and laundry areas. In laundry alone, for instance, you need to check on whether there are enough clean linens, whether they are transported in covered carts, whether they are segregated from dirty linens, whether dirty linen is bagged, whether staff washes hands after handling dirty linen, and the temperature of the wash cycle.

Looking at the general condition of the soiled utility room will tell you a lot: Is it organized and clean? Do you detect an odor? Is there an EPA-approved disinfectant available, a lot of soap and water, and protective equipment for staff cleaning bedpans and other disposable equipment? Are trashcans full of used paper towels from hand washing and bags used on dirty linens? The same degree of attention to detail must be paid to other areas of the facility as well, if infection control is to be effective.

Sick-day policies. The NEJM study was also very strong in its discussion of the possible transmission of this disease from two staff members. In the long-term care facility, there should be a policy that staff who are ill should be discouraged from working. If they are present in the workplace, employees with signs or symptoms of communicable diseases should not have contact with residents.

Vaccination. Another important, but too-often-overlooked, section of the APIC/SHEA position paper describes the need for a resident health program, a vital part of infection control in a long-term care facility. This program should include a protocol to screen for vaccinations during admission and to make sure unprotected residents are vaccinated. According to the NEJM article, the wider use of vaccine is important to prevent institutional outbreaks of drug-resistant S. pneumoniae infection. It is shocking to observe how overlooked this inexpensive and accessible vaccine is. Indeed, the entire outbreak in Oklahoma was preventable. And according to the NEJM article, revaccination has not been found to cause adverse effects if people who might have been vaccinated before, but can't remember for sure, are given the vaccine again. The pneumococcal vaccine should be considered for those residents who are eligible, along with influenza, diphtheria and tetanus vaccinations and TB testing.

Judicious use of antibiotics. The APIC/SHEA position paper devotes one entire section to the problem of antibiotic resistance and monitoring. It is suggested that the infection-control practitioner monitor all infectious diseases to identify any significant antibiotic-resistant bacteria such as MRSA and VRE. The facility should also have a policy on drug- resistant bacteria that details how to deal with colonized or infected residents, including admissions policies, isolation and surveillance. In addition, the facility should encourage prudent antimicrobial prescribing. This should include a review of antibiotic appropriateness in consultation with the resident's physician.

Indeed, the judicious use of antibiotics is vital to preventing the emergence of more multidrug-resistant disease. The NEJM study notes that infections in nursing homes have generally responded to empiric treatment, without microbiologic confirmation of their cause. But the article added that drug-resistant strains have made selection of empiric treatment for pneumonia more difficult and may soon make such therapy less effective, and thus clusters of infection in nursing homes may be seen more frequently.

According to NEJM, the optimal strategy for controlling drug-resistant pneumococcal outbreaks in long-term care still needs to be determined. But the resources are out there, from APIC, CDC and others, to begin now to practice infection control, avoid inappropriate use of antibiotics, and make sure residents are protected against disease by offering the pneumococcal vaccine to all eligible residents and to those being newly admitted to long-term care facilities.

Some background on pneumococcal infection

The family of pneumococcal infections includes pneumonia (with the infection in the respiratory tract), meningitis (in the brain and spinal cord), otitis media (in the middle ear), and bacteremia (in the blood). These infections account for more deaths each year in the U.S. than any other vaccine-preventable bacterial disease, with some 40,000 mortalities. Most of these deaths occur among the elderly, with the death rate for bacteremia in this population standing at 40% of the infected. The costs of treating pneumococcal diseases, together with flu and other vaccine-preventable diseases, is an estimated $10 billion a year, with 90% of those costs occurring at the hospital level. Pneumococcal disease has traditionally been treated with antibiotics, but the emergence of drug-resistant bacteria is making this a problematic procedure.

CDC offers infection-control help to long-term care facilities

The Centers for Disease Control and Prevention (CDC) in Atlanta offers guidelines for preventing infections, but they are primarily geared to acute care settings. However many of the points they make are relevant to the long-term care setting as well. These include care of respiratory equipment, suctioning techniques, care of tracheotomy tubes, prevention of aspiration with enteral feedings, and so on.

In addition, the CDC Web site has a list of resources for infection control in long-term care facilities that includes the state health department, infection-control practitioners at similar institutions and the area chapter of the Association for Professionals in Infection Control and Epidemiology (APIC). The latter is available by calling [phone].

The CDC list also refers nursing homes to two articles: McGeer, Campbell and Emori's "Definitions of Infections for Surveillance in Long-Term. Care Facilities," and Smith and Rusnak's "APIC Guidelines for Infection Prevention and Control in the Long-Term Care Facility," pages 191-215 of the American Journal of Infection Control, 1991, Volume '19.

According to its Web site as of July 27, 1998, the CDC- is also developing guidelines analogous to those for preventing nosocomial infections in hospitals that will help prevent infections in other institutional settings, including nursing homes. CDC has worked with FDA to produce videotapes on safe food handling in nursing homes, where it says that food-borne infections are most likely to have serious effects. Similar efforts, says CDC, are needed to promote the appropriate use of antimicrobial drugs and infection-control procedures in nursing homes.

The CDC recommends that all persons 65 and over receive pneumococcal vaccine, but only 30% of this population has been vaccinated. And in nursing homes where pneumococcal outbreaks have been reported, less than 5% of residents have been vaccinated.

Janet Franck, RN, MBA, CIC, has researched, taught and published on a variety of infection-control topics for more than 24 years. As an infection-control consultant, she promotes up-to-date infection-control practices to healthcare facilities nationwide.