Current approaches to infection control.

Reducing the incidence and spread of infection in nursing homes can be easier and more effective these days.

Infection control practices in the long term care setting have intensified during the past four or five years. During that time, more articles and books were published on this subject than in the last 15 years. We probably have the federal government to thank for this. Nursing homes have, until recently, been notoriously negligent in this area for a variety of reasons.

The main one is that those assigned to perform infection control surveillance had received no training in epidemiology and microbiology. At most, some would contact their referral hospital for help, but many hospital personnel -- with some exceptions -- did not understand nursing homes' intrinsic problems, nor did they care. Reference laboratories, meanwhile, were reluctant to give in-service programs or to make an effort to employ individuals cognizant of nursing home practices.

But times are changing for nursing homes. They are admitting a diverse population of residents which may require more invasive procedures and more nursing management. Nursing home personnel must develop better surveillance techniques to monitor these residents for the possibility of disseminated disease.

There are two types of infection control surveillance programs that nursing homes can perform. One is total surveillance, a technique with which most nursing homes are familiar, and the other -- and more meaningful -- approach is called surveillance by objectives. This focuses on specific infections and tries to reduce or eliminate them. The problem, though, is to develop a system allowing efficient and cost-effective detection.

Nursing homes have to be able to recognize clusters and increases of infections. One of the ways that this can be performed is to work with a reference laboratory very closely. Laboratories can develop epidemiology reports that can show a nursing home what types of infections are developing, the organisms involved, and the anatomical sites where these organisms are being cultured. An added measure would be to keep track of where in the facility the organisms are being isolated. Graphs can be obtained and examined by the infection control committee to see where the problems lie and determine what measures must be taken to lower the infection rate.

The laboratory must help the facility learn how to obtain the data from each of the wards, how to compile it and how to use it as an inservice tool for education.

For example, the data in Figure 1 were compiled over time to show that methicillin-susceptible Staphylococcus aureus was being overshadowed by methicillin-resistant Staphylococcus aureus (MRSA). This indicates that health care costs will increase, because treating MRSA-infected residents is more expensive than treating those who are susceptible to methicillin. In Figure 2, the observation that enteric organisms are being isolated from urine (Escherichia coli, Proteus mirabilis and Enterococcus faecalis) probably indicates endogenous (auto) infection, and that nursing personnel must be made aware that good perineal cleansing is a prerequisite to reduce urinary tract infections.

Effective surveillance also requires that the nurses be skilled in monitoring residents for signs and symptoms of infection. For example, tuberculosis is once again a growing concern. Even though all residents upon admission should undergo a two-step Mantoux test, they must be watched continually for the signs of TB -- not always an easy matter with the elderly. Chronic respiratory distress with sputum production may be the only recognizable signs in this population. X-rays showing lesions would, of course, be confirmatory, but timely ordering of these will depend largely on nurses understanding symptoms.

Fortunately, with the resources available today, an effective infection control system can be very easy to develop in a nursing home setting if one has the basic element, i.e., a person dedicated to performing such a task. This individual should make an effort to establish good relations with the local hospital's infection control department as an information resource, and to reach out to reference laboratories to provide the other types of assistance described above. The nursing home's "infection control specialist" can also obtain much helpful information from the Association of Practitioners in Infection Control, 505 E. Hawley Street, Mundelein, IL 60060-2458.

Nursing home care is more of a challenge today than ever before. More and more reference laboratories are trying to obtain their business. As a result, nursing homes now have a choice. The job has to be done, so it is only logical that steps should be taken to develop an infection control protocol that is reasonable, cost-effective, and in compliance with federal and state government standards.

Raymond B. Otero, MD, is Professor of Biology at Eastern Kentucky University, Richmond, KY, and Technical Director of the Microbiology Laboratory for SmithKline-Beecham Laboratories, Lexington, KY. He is also Consultant to the Infection Control Committees at Good Samaritan Hospital, Humana Hospital, Tanbark Nursing Home, Shriners Hospital, Cardinal Hill Hospital, and Kenwood House, where he also serves on the medical staff.