SHEA/APIC Guideline: Infection prevention and control in the long-term care facility



## Background demography and definitions
The US population aged 65 to 85 years is increasing rapidly, and the population aged 85 years and older is expected to double by 2030. One of every 4 persons who reach the age of 65 can be expected to spend part of his or her life in a nursing home; more people occupy nursing home beds than acute care hospital beds in the US. Approximately 1.5 million persons in the US reside in a nursing home; there are 15,000 nursing homes in this country. Ninety percent of nursing home residents are over 65 years of age, and the mean age of residents is over 80 years.
A LTCF is a residential institution for providing nursing care and related services to residents. It may be attached to a hospital (swing-bed) or free standing; the latter is often called a nursing home. A resident is a person living in the LTCF and receiving care, analogous to the patient in a hospital.

## Scope of position paper
This position paper addresses all levels of care in the LTCF. The focus is specifically the LTCF, also known as the nursing home, caring for elderly or chronically ill residents. These recommendations generally also should apply to special extended care situations (such as institutions for the mentally retarded, psychiatric hospitals, pediatric LTCFs, and rehabilitation hospitals). However, other extended care facilities may have different populations (eg, the residents of institutions for the mentally retarded are much younger than nursing home residents), different disease risks (eg, hepatitis B in psychiatric hospitals), or different levels of acuity and technology (eg, higher acuity in long-term acute care facilities or LTACs). Thus, the recommendations may need to be adapted for these special extended care situations.
Changes from prior Guideline. This position paper is similar to the 1997 Society for Healthcare Epidemiology of America (SHEA)/Association for Professionals in Infection Control and Epidemiology (APIC) guideline, although the present version reflects an updating of research and experience in the field. Several important areas of discussion are new or changed.

## Infections in the long-term care facility epidemiology
In US LTCFs, 1.6 million to 3.8 million infections occur each year. In addition to infections that are largely endemic, such as urinary tract infections (UTIs) and lower respiratory tract infections (LRTIs), outbreaks of respiratory and gastrointestinal (GI) infections are also common.The overall infection rate in LTCFs for endemic infections ranges from 1.8 to 13.5 infections per 1000 resident-care days. For epidemics, good estimates are difficult to ascertain, but the literature suggests that several thousand outbreaks may occur in US LTCFs each year. The wide ranges of infections and resulting mortality and costs illustrate the challenge in understanding the epidemiology of infections and their impact in LTCFs. There are currently little data and no national surveillance systems for LTCF infections; the estimates have been calculated based on research studies and outbreak reports from the medical literature.
As a part of aging, the elderly have diminished immune response including both phenotypic and functional changes in Tcells.However, these changes are of limited clinical significance in healthy elderly. Consequently, immune dysfunction in elderly residents of LTCFs is primarily driven by the multiple factors that result in secondary immune dysfunction such as malnutrition, presence of multiple chronic diseases, and polypharmacy, especially with medications that diminish host defenses (eg, immunosuppressants).In addition, LTCF residents often have cognitive deficits that may complicate resident compliance with basic sanitary practices (such as handwashing and personal hygiene) or functional impairments such as fecal and urinary incontinence, immobility, and diminished cough reflex. The elderly nursing home resident is known to have a blunted febrile response to infections.This parallels other agerelated immunologic abnormalities. A notable fever in this population often signals a treatable infection, such as UTI or aspiration pneumonia.
While the use of urinary catheters in LTCF residents has decreased in recent years, utilization remains around 5%. In LTC residents, the use of invasive devices (eg, central venous catheters, mechanical ventilators, enteral feeding tubes) increases the likelihood of a device-associated infection. Of the over 15,000 LTCFs in the US in 2004, 42% provided infusion therapy, 22% had residents with peripherally-inserted central lines, and 46% provided parenteral nutrition. 14 Another challenge for preventing infections in LTCFs is the increasing acuity of residents, especially with the rapidly growing subpopulation of postacute residents. Postacute residents are hospitalized patients who are discharged to LTCFs to receive skilled nursing care or physical/occupational therapy. In the past, these patients, often frail, would have remained hospitalized, but, with increasing efforts to control hospital costs, these patients are now discharged to LTCFs. In addition to higher device utilization, these residents are more likely to receive antimicrobial therapy than long-stay LTCF residents.Much remains to be learned about resident and LTCF factors correlated with HAIs. There is evidence that institutional factors such as nurse turnover, staffing levels, prevalence of Medicare recipients, rates of hospital transfer for infection, intensity of medical services, and family visitation rates are associated with incidence of HAI in the LTC setting.The rate of deaths in LTCF residents with infections ranges from 0.04 to 0.71 per 1000 resident-days, with pneumonia being the leading cause of death. Infections are a leading reason for hospital transfer to LTCF residents, and the resulting hospital costs range from $673 million to $2 billion each year. LTCFs and acute care facilities differ in another key aspect: LTCFs are residential. As residences, LTCFs are required to provide socialization of residents through group activities. While these activities are important for promoting good physical and mental health, they may also increase communicable infectious disease exposure and transmission. Occupational and physical therapy activities, while vital toward restoring or maintaining physical and mental function, may increase risk for person-to-person transmission or exposure to contaminated environmental surfaces (eg, physical or occupational therapy equipment).

## Specific nosocomial infections in the long-term care facility

## Urinary tract infections
In most surveys, the leading infection in LTCFs is UTI,although with restrictive clinical definitions, symptomatic urinary infection is less frequent than respiratory infection.Bacteriuria is very common in residents of these facilities but, by itself, is not associated with adverse outcomes and does not affect survival.Bacteriuria and UTI are associated with increased functional impairment, particularly incontinence of urine or feces.The symptoms of UTI are dysuria and frequency (cystitis) or fever and flank pain (pyelonephritis). The elderly may present with atypical or nonlocalizing symptoms. Chronic genitourinary symptoms are also common but are not attributable to bacteriuria.Because the prevalence of bacteriuria is high, a positive urine culture, with or without pyuria, is not sufficient to diagnose urinary infection.Clinical findings for diagnosis of UTI in the noncatheterized resident must include some localization to the genitourinary tract.The diagnosis also requires a positive quantitative urine culture. This is obtained by the clean-catch voided technique, by in and out catheterization, or by aspiration through a catheter system sampling port. A negative test for pyuria or a negative urine culture obtained prior to initiation of antimicrobial therapy excludes urinary infection.
The prevalence of indwelling urethral catheters in the LTCF is 7% to 10%.Catheterization predisposes to clinical UTI, and the catheterized urinary tract is the most common source of bacteremia in LTCFs.Residents with long-term catheters often present with fever alone. Residents with indwelling urinary catheters in the LTCF are uniformly colonized with bacteria, largely attributable to biofilm on the catheter.These organisms are often more resistant to oral antibiotics than bacteria isolated from elderly persons in the community.Catheter-related bacteriuria is dynamic, and antimicrobial treatment only leads to increased antimicrobial resistance.Thus, it is inappropriate to screen asymptomatic catheterized residents for bacteriuria or to treat asymptomatic bacteriuria.Specimens collected through the catheter present for more than a few days reflect biofilm microbiology. For residents with chronic indwelling catheters and symptomatic infection, changing the catheter immediately prior to instituting antimicrobial therapy allows collection of a bladder specimen, which is a more accurate reflection of infecting organisms.Catheter replacement immediately prior to therapy is also associated with more rapid defervescence and lower risk of early symptomatic relapse posttherapy.Guidelines for prevention of catheter-associated UTIs in hospitalized patients 32 are generally applicable to catheterized residents in LTCFs. Recommended measures include limiting use of catheters, insertion of catheters aseptically by trained personnel, use of as small diameter a catheter as possible, handwashing before and after catheter manipulation, maintenance of a closed catheter system, avoiding irrigation unless the catheter is obstructed, keeping the collecting bag below the bladder, and maintaining good hydration in residents. Urinary catheters coated with antimicrobial materials have the potential to decrease UTIs but have not been studied in the LTCF setting. For some residents with impaired voiding, intermittent catheterization is an option, and clean technique is as safe as sterile technique.External catheters are also a risk factor for UTIs in male residents 34 but are significantly more comfortable and associated with fewer adverse effects, including symptomatic urinary infection, than an indwelling catheter.Local external care is required. The CDC guideline 32 briefly discusses care of condom catheters and suprapubic catheters, but no guideline for leg bags is available. Leg bags allow for improved ambulation of residents but probably increase the risk of UTI because opening of the system and reflux of urine from the bag to the bladder occur more frequently than with a standard closed system. Suggestions for care of leg bags include using aseptic technique when disconnecting and reconnecting, disinfecting connections with alcohol, changing bags at regular intervals, rinsing with diluted vinegar, and drying between uses. 36 A 1:3 dilution of white vinegar has been recommended for leg bag disinfection. 37

## Respiratory tract infections
Because of the impaired immunity of elderly persons, viral upper respiratory infections (URIs) that generally are mild in other populations may cause significant disease in the institutionalized elderly patient.Examples include influenza, respiratory syncytial virus (RSV), parainfluenza, coronavirus, rhinoviruses, adenoviruses, and recently discovered human metapneumovirus.Pneumonia. Pneumonia or lower respiratory tract infection (LRTI) is the second most common cause of infection among nursing home residents, with an incidence ranging from 0.3 to 2.5 episodes per 1000 resident care-days and is the leading cause of death from infections in this setting. Elderly LTCF residents are predisposed to pneumonia by virtue of decreased clearance of bacteria from the airways and altered throat flora, poor functional status, presence of feeding tubes, swallowing difficulties, and aspiration as well as inadequate oral care.Underlying diseases, such as chronic obstructive pulmonary disease and heart disease, further increase the risk of pneumonia in this population.The clinical presentation of pneumonia in the elderly often is atypical. While there is a paucity of typical respiratory symptoms, recent studies have shown that fever is present in 70%, new or increased cough in 61%, altered mental status in 38%, and increased respiratory rate above 30 per minute in 23% of residents with pneumonia.While acquiring a diagnostic sputum can be difficult, obtaining a chest radiograph is now more feasible than in the past. In general it is recommended that a pulse oximetry, chest radiograph, complete blood count with differential, and blood urea nitrogen should be obtained in residents with suspected pneumonia.Streptococcus pneumoniae appears to be the most common etiologic agent accounting for about 13% of all cases, 47,48 followed by Hemophilus influenzae (6.5%), Staphylococcus aureus (6.5%), Moraxella catarrhalis (4.5%), and aerobic gram-negative bacteria (13%).Legionella pneumoniae also is a concern in the LTCF. Colonization with methicillin-resistant S aureus (MRSA) and antibiotic-resistant, gram-negative bacteria further complicate diagnosis and management of pneumonia in LTCF residents.The mortality rate for LTCF-acquired pneumonia is significantly higher than for community-acquired pneumonia in the elderly population.Preinfection functional status, dementia, increased rate of respirations and pulse, and a change in mental status are considered to be poor prognostic factors. Several indices predictive of mortality have been developed and may be useful in managing residents with pneumonia.The CDC guideline for prevention of pneumonia 54 is oriented toward acute care hospitals but covers a number of points relevant to the LTCF, including respiratory therapy equipment, suctioning techniques, tracheostomy care, prevention of aspiration with enteral feedings, and immunizations. Examples of relevant recommendations for the LTCF include hand hygiene after contact with respiratory secretions, wearing gloves for suctioning, elevating the head of the bed 30 to 45 degrees during tube feeding and for at least 1 hour after to decrease aspiration, and vaccination of high-risk residents with pneumococcal vaccine.The evidence for the efficacy of pneumococcal vaccine in high-risk populations, including the elderly population, is debated.However, the vaccine is safe, relatively inexpensive, and recommended for routine use in individuals over the age of 65 years.Pneumococcal vaccination rates for a facility are now publicly reported at the Centers for Medicare and Medicaid Services (CMS).Influenza. Influenza is an acute respiratory disease signaled by the abrupt onset of fever, chills, myalgias, and headache along with sore throat and cough, although elderly LTCF residents may not have this typical presentation. The incubation period for influenza is approximately 1 to 2 days.It is a major threat to LTCF residents, who are among the high-risk groups deserving preventive measures.Influenza is very contagious, and outbreaks in LTCFs are common and often severe. Clinical attack rates range from 25% to 70%, and case fatality rates average over 10%.A killed virus vaccine is available but must be given annually. Influenza vaccine in the elderly is approximately 40% effective at preventing hospitalization for pneumonia and approximately 50% effective at preventing hospital deaths from pneumonia.Although concern has been expressed regarding the efficacy of the influenza vaccine in institutionalized elderly patients, most authors feel that the influenza vaccine is effective and indicated for all residents and caregivers.Recent surveys have shown an increased rate of influenza vaccination among LTCF residents, although significant variability exists.Influenza vaccination rates for a facility are now publicly reported at the Centers for Medicare and Medicaid (CMS) Web site http://www.medicare.gov/NHCompare/ home.asp. Staff immunization rates remain less impressive, with average immunization rates between 40% and 50% at best.
While viral cultures from nasopharynx remain the gold standard for diagnosis of influenza, several rapid diagnostic methods (rapid antigen tests) such as immunofluorescence or enzyme immunoassay have been developed. These tests detect both influenza A and B viral antigens from respiratory secretions. Amantadine-resistant influenza has caused LTCF outbreaks and hence amantadine is not recommended for influenza prophylaxis.Zanamivir and oseltamivir are effective against both influenza A and B and have been approved for prophylaxis and treatment of influenza A and B. Oseltamivir is administered orally and is excreted in the urine requiring dose adjustments for renal impairment. Zanamivir is given by oral inhalation, which is a problem in a noncooperative LTCF resident.
Rapid identification of cases in order to promptly initiate treatment and isolate them to prevent transmission remains the key to controlling influenza outbreaks. Other measures recommended during an outbreak of influenza include restricting admissions or visitors and cohorting of residents with influenza.Infected staff should not work.
Tuberculosis. Tuberculosis (TB) also has caused extensive outbreaks in LTCFs, generally traced to a single ambulatory resident. Large numbers of staff and residents may be involved, with a potential to spread in the community.Price and Rutala 77 found 8.1% of new employees and 6.4% of new residents to be positive by the purified protein derivative (PPD) of tuberculin method in their North Carolina survey, with significant 5-year skin test conversion rates in both groups.
The diagnosis of TB in the LTCF is problematic. Clinical signs (fever, cough, weight loss) are nonspecific. Chest radiographs, when obtained, often show characteristic pulmonary infiltrates (eg, cavities in the upper lung fields). Infection with TB usually causes a positive tuberculin skin test (TST), although occasional false positives and false negatives are seen. The specificity of the TST may be improved by an in vitro blood test of interferon release in response to TB peptides, such as the quantiferon test. The most specific diagnostic test is a sputum culture for TB, but a good specimen may be difficult to obtain. Recent advances in microbiology have facilitated the diagnosis of TB greatly. Diagnostics such as radiometric systems, polymerase chain reaction (PCR), as well as specific DNA probes help shorten the time for diagnosis of TB, although susceptibility testing requires several weeks.
Guidelines discussing standards for control of TB in institutions are available.There appears to be a consensus that TST of residents and personnel in the LTCF should be undertaken on a regular basis, although many LTCFs have inadequate TB screening programs.The cost-effectiveness of using a 2-step TST to survey for the booster effect is not demonstrable for all populations, but the 2-step skin test is recommended by the CDC for initial screening of employees and residents. For LTCF residents without any known contact with a case of known TB or other significant risk factors such as human immunodeficiency virus (HIV) or immunosuppression, induration of 10 mm or greater to PPD injection is considered positive. Induration of 5 mm or greater is considered positive in any individual with recent contact with a known case of TB or other significant risk factors such as immunosuppression or changes on chest x-ray consistent with old TB.There was a resurgence of TB in the US in the mid-1980s; multidrug-resistant cases of TB have been seen, and nosocomial spread within health care facilities is a concern. 84 In response to this, guidelines have been promulgated by the CDC that address surveillance (identification and reporting of all TB cases in the facility including residents and staff); containment (recommended treatment under directly observed therapy and appropriate respiratory isolation and ventilation control measures); assessment (monitoring of surveillance and containment activities); and ongoing education of residents, families, and staff.Since most LTCFs do not have a negative-pressure room, residents with suspected active TB should be transferred to an appropriate acute care facility for evaluation. There should be a referral agreement with that facility.

## Skin and soft-tissue infections, infestations
Pressure ulcers (also termed decubitus ulcers) occur in up to 20% of residents in LTCFs and are associated with increased mortality.Infected pressure ulcers often are deep soft-tissue infections and may have underlying osteomyelitis; secondary bacteremic infections have a 50% mortality rate.They require costly and aggressive medical and surgical therapy. Once infected, pressure ulcer management requires a multidisciplinary approach with involvement of nursing, geriatrics and infectious disease specialists, surgery, and physical rehabilitation.
Medical factors predisposing to pressure ulcers have been delineatedand include immobility, pressure, friction, shear, moisture, incontinence, steroids, malnutrition, and infection. Reduced nursing time can also increase the risk of developing pressure ulcers. Several of these factors may be partially preventable (such as malnutrition and fecal incontinence). Prevention of pressure ulcers involves developing a plan for turning, positioning, eliminating focal pressure, reducing shearing forces, and keeping skin dry. Attention to nutrition, using disposable briefs and identifying residents at a high risk using prediction tools can also prevent new pressure ulcers.
The goals are to treat infection, promote wound healing, and prevent future ulcers. Many physical and chemical products are available for the purpose of skin protection, debridement, and packing, although controlled studies are lacking in the area of pressure ulcer prevention and healing.A variety of products may be used to relieve or distribute pressure (such as special mattresses, kinetic beds, or foam protectors) or to protect the skin (such as films for minimally draining stage II ulcers, hydrocolloids and foams for moderately draining wounds, alginates for heavily draining wounds). Negative-pressure wound therapy (vacuum dressings) using gentle suction to provide optimal moist environment is increasingly being used in treatment of complex pressure ulcers.Nursing measures such as regular turning are essential as well. A pressure ulcer flow sheet is a useful tool in detecting and monitoring pressure ulcers and in recording information such as ulcer location, depth, size, stage, and signs of inflammation as well as in timing of care measures. Infection control measures include diligent hand hygiene and glove usage.
Because all pressure ulcers, like the skin, are colonized with bacteria, antibiotic therapy is not appropriate for a positive surface swab culture without signs and symptoms of infection. Nonintact skin is more likely to be colonized with pathogens. True infection of a pressure ulcer (cellulitis, osteomyelitis, sepsis) is a serious condition, generally requiring broadspectrum parenteral antibiotics and surgical debridement in an acute care facility.
Cellulitis (infection of the skin and soft tissues) can occur either at the site of a previous skin break (pressure ulcer) or spontaneously. Skin infections generally are caused by group A streptococci or S aureus. Outbreaks of group A streptococcal infections have been described, presenting as cellulitis, pharyngitis, pneumonia, or septicemia.Scabies is a contagious skin infection caused by a mite. Lesions usually are very pruritic, burrow-like, and associated with erythema and excoriations, usually in interdigital spaces of the fingers, palms and wrists, axilla, waist, buttocks, and the perineal area. However, these typical findings may be absent in debilitated residents, leading to large, prolonged outbreaks in LTCFs.Diagnosis in an individual with a rash requires a high index of suspicion in order to recognize the need for diagnostic skin scrapings. The presence of a proven case should prompt a thorough search for secondary cases. A single treatment with permethrin or lindane usually is effective, but repeated treatment or treatment of all LTCF residents, personnel, and families occasionally is necessary.Ivermectin, an oral antihelminthic agent, is an effective, safe, and inexpensive option for treatment of scabies. However, it has not been approved by the FDA for this indication. Therapy of rashes without confirming the diagnosis of scabies unnecessarily exposes residents to the toxic effects of the topical agents. Because scabies can be transmitted by linen and clothing, the environment should be cleaned thoroughly. This includes cleaning inanimate surfaces, hot-cycle washing of washable items (clothing, sheets, towels, etc), and vacuuming the carpet.

## Other infections
Viral gastroenteritis (caused by rotavirus, enteroviruses, or noroviruses), 99,100 bacterial gastroenteritis (caused by Clostridium difficile, Bacillus cereus, Escherichia coli, Camplylobacter spp, C perfringens, or Salmonella spp), and parasites (such as Giardia lambia) are well-known causes of diarrhea outbreaks in LTCFs.The elderly are at increased risk of infectious gastroenteritis due to age-related decrease in gastric acid. In a population with a high prevalence of incontinence, the risk of cross infection is substantial. Person-to-person spread, particularly due to shared bathroom, dining, and rehabilitation facilities, plays a role in viral gastroenteritis and in Shigella spp and C difficile diarrhea.Foodborne disease outbreaks also are very common in this setting, 108 most often caused by Salmonella spp or S aureus. E coli O157:H7 and Giardia also may cause foodborne outbreaks, underscoring the importance of proper food preparation and storage.
Bacteremiain the LTCF, although rarely detected, may be primary or secondary to an infection at another site (pneumonia, UTI). The most common source of secondary bacteremia is the urinary tract, with E coli being the culprit in over 50% of cases.As the acuity of illness in LTCF residents has risen, the prevalence of IV devices and related bacteremic complications appears to have increased. The CDC guideline for prevention of IV infections is a useful resource and generally applicable to the LTCF.Relevant points include aseptic insertion of the IV cannula, daily inspection of the IV for complications such as phlebitis, and quality control of IV fluids and administration sets.
Conjunctivitis in the adult presents as ocular pain, redness, and discharge. In the LTCF, cases may be sporadic or outbreak-associated.Many cases are nonspecific or of viral origin; S aureus appears to be the most frequent bacterial isolate.Epidemic conjunctivitis may spread rapidly through the LTCF. Transmission may occur by contaminated eye drops or hand cross contamination. Gloves should be worn for contact with eyes or ocular secretions, with hand hygiene performed immediately after removing gloves.
Many additional infections have been encountered in the LTCF, including herpes zoster, herpes simplex, endocarditis, viral hepatitis, septic arthritis, and abdominal infections. There has been a resurgence of ''pediatric'' infections in the LTCF (eg, pertussis, RSV, and H influenzae respiratory tract infections), reflecting the decline of the host's immunologic memory with aging.

## Epidemic infections in the ltcf
Most LTCF HAIs are sporadic. Many are caused by colonizing organisms with relatively low virulence. Tissue invasion may be facilitated by the presence of a urinary catheter or chronic wound or following an aspiration event. Ongoing surveillance (see Surveillance section below) is required to detect epidemic clustering of transmissible, virulent infections. Outbreaks must be anticipated. Ideally, infection control surveillance and practices should be the responsibility of frontline staff as well as infection control staff.
An outbreak or transmission within the facility may occur explosively with many clinical cases appearing within a few days or may, for example, involve an unusual clustering of MRSA clinical isolates on a single nursing unit over several months. On the other hand, a case of MRSA infection may follow a prolonged period of asymptomatic nasal colonization after an aspiration event or development of a necrotic wound.Outbreaks in LTCFs accounted for a substantial proportion (15%) of reported epidemics. Clustering of URIs, diarrhea, skin and soft tissue infection, conjunctivitis, and antibiotic-resistant bacteriuria have been noted.Major outbreaks of infection have also been ascribed to E coli, 117 group A streptococci, 92,118 C difficile 104,119 respiratory viruses,Salmonella spp,Chlamydia pneumoniae,Legionella spp,and gastrointestinal viruses.Nursing homes accounted for 2% of all foodborne disease outbreaks reported to the CDC and 19% of outbreak-associated deaths.Transmissible gastrointestinal pathogens may be introduced to the facility by contaminated food or water or infected individuals. High rates of fecal incontinence, as well as gastric hypochlorhydria, make the nursing home ideal for secondary fecal-oral transmission.Other epidemics include scabies, hepatitis B, 127 group A streptococcal infections, viral conjunctivitis, and many other infections.
These outbreaks underscore the vulnerability of the elderly to infection, as well as the role of cross infection in residents with urinary catheters and open wounds or in those with incontinence who require serial contact care by staff.In addition, mobile residents with poor hygiene may interact directly.

## Antibiotic-resistant bacteria
Multidrug resistant organisms (MDROs) such as MRSA, vancomycin-resistant enterococci (VRE), drugresistant S pneumoniae, and multidrug-resistant gramnegative bacteria (eg, Pseudomonas aeruginosa, Acinetobacter spp and extended-spectrum b-lactamase (ESBL)-producing enterobacteriaceae) are increasingly important causes of colonization and infection in LTCFs.In this setting, infection with MDROs has been associated with increased morbidity, mortality, and cost,although the attributable morbidity, mortality, and cost of MDROs has not yet been fully defined. Indeed, LTCF residence has been frequently identified as a risk factor for antibiotic-resistant infection in hospitalized patients.Elderly and disabled residents are at increased risk for colonization with resistant organisms, and colonization may persist for long periods of time (ie, months to years).Within the LTCF, length of stay in the facility and accommodation in rooms with multiple beds have been identified as risk factors for transmission of MRSA.Both infected and colonized residents may serve as sources for the spread of MDROs in the LTCF.When MRSA becomes endemic within a facility, elimination is highly unlikely.LTCFs can expect infections with MDROs to be a continuing problem. Strategies for curbing the emergence and spread of antimicrobial resistance in LTCFs are discussed below in ''Antibiotic Stewardship'' and ''Isolation and Precautions'' sections.

## The infection control program

## Evolution of programs
The 1980s saw a dramatic increase in LTCF infection control activities, stimulated by federal and state regulations. Several studies provide insight into the extent of program development. A 1981 survey of Utah LTCFs 113 noted that all facilities had regular infection control meetings, but none performed systematic surveillance for infections or conducted regular infection control training. All LTCFs had policies regarding the maintenance and care of urinary catheters, although the policies were not uniform. Price et al 149 surveyed 12 North Carolina LTCFs in 1985 and found that, although all 12 had a designated ICP, none of the ICPs had received special training in this area. Also noted were deficiencies in isolation facilities, particularly an insufficient number of sinks and recirculated, inadequately filtered air.
In a 1985 survey of Minnesota LTCFs, Crossley et al 150 found that the majority had an infection control committee (ICC) and a designated ICP, although substantial deficiencies in resident and employee health programs occurred. For instance, only 61% offered the influenza vaccine to residents, and one third did not screen new employees for a history of infectious disease problems. A 1988 Maryland surveyfound that one third of nursing homes still performed routine environmental cultures, and many lacked proper isolation policies. In 1990, a survey of Connecticut LTCFs found that most ICPs had received some training in infection control.Most LTCFs performed surveillance at least weekly, and most used written criteria to determine HAIs. More recent regional surveys of facilities from Maryland and New England in the mid-1990s and Michigan in 2005 noted increasing gains in time spent in infection control activities from 1994 to 2005.In New England, 98% of facilities had a person designated to do infection control, 90% were registered nurses, and 52% had formal training.In the 1990s, an average of 9 to 12 hours per week was spent on infection control; 50% to 54% of that time was spent on surveillance activities.Seventy-eight to 97% percent of the LTCFs reported a systematic surveillance system.Formal definitions were used by 95% of respondents; 81% used the McGeer criteria, and 59% calculated infection rates.All facilities reportedly used Universal Precautions in caring for their residents.By 2005, 50% of responding facilities in Michigan had a full-time ICP.The mean time spent on infectionHowever, part-time ICPs did not necessarily supervise smaller facilities with fewer subacute care beds or give fewer in-services than full-time staff. Despite these improvements, the number of ICPs per nursing home bed is 4-fold fewer than the number of ICPs available in acute care hospitals.LTCF-based ICPs are more likely to assume noninfection control functions than acute care ICPs regardless of bed size; in one survey, 98% of LTCF ICPs had other duties,while in a Michigan survey, 50% of 34 LTCFs had fulltime ICPs.Many of these noninfection control functions include employee health, staff education and development, and quality improvement.In addition, LTCF ICPs are still less likely to receive additional formal training in infection control (8%) compared with 95% of acute care ICPs.The results of this study from Maryland led to a state proposal that at least one ICP from each LTCF be formally trained in infection control.From these surveys, one can develop a composite picture of the LTCF ICP as a nurse who still has not necessarily received formal training in infection control.Many ICPs still work part-time on infection control activities regardless of the number of beds or patient acuity.While the time spent on infection control activities appears to have increased significantly from 36 to 48 hours per month in the 1990s to 90 to 160 hours per month in 2005, the ICP continues to have other duties such as general duty nursing, nursing supervision, in-service education, employee health, and quality assurance.Regulatory aspects LTCFs are covered by federal and state regulations as well as voluntary agency standards such as those written by The Joint Commission (TJC).Skilled nursing facilities are required by the Omnibus Budget Reconciliation Act of 1987 (OBRA) to have an infection control program.CMS has published requirements for LTCFs 159 that apply to LTCFs accepting Medicare and/ or Medicaid residents. CMS regulations address the need for a comprehensive infection control program that includes surveillance of infections; implementation of methods for preventing the spread of infections including use of appropriate isolation measures, employee health protocols, hand hygiene practices; and appropriate handling, processing, and storage of linens.For example, the LTCF is required to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Interpretive guidelines for surveyors further discuss definitions of infection, risk assessment, outbreak management and control, measures for preventing specific infections, staff orientation, antibiotic monitoring, sanitation, and assessment of compliance with infection control policies.Because the LTCF is an employer of health care workers (HCWs), it must comply with federal and/or state OSHA regulations. For infection control, those regulations 162,163 deal primarily with protection of workers from exposure to bloodborne pathogens such as HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) and from TB exposure.Adherence of LTCFs to infection control regulations is an OSHA priority.
Other standards that apply to LTCFs include the federal minimum requirements for design, construction, and equipmentand TJC LTC Standards.The 2007 TJC Standards for LTC require a written infection control plan based on an assessment of risk; establishment of priorities, goals, and strategies; and an evaluation of the effectiveness of the interventions. The Standards also deal with managing an influx of patients with an infectious disease as well as leadership's involvement in the program.In addition, many states have statutory requirements for LTCFs that vary widely. On October 7, 2005, CMS published a final rule requiring LTCFs to offer annually to each resident immunization against influenza and to offer lifetime immunization against pneumococcal disease. LTCFs are required to ensure that each resident or legal representative receive education on the benefits and potential side effects of the immunizations prior to their being administered.The LTCF administrative staff should be knowledgeable about the federal, state, and local regulations governing infection control in order to implement and maintain a program in compliance with these regulations. The LTCF ICP ideally should be involved in the formation and revision of regulations, through local and national infection control and long-term care organizations, to help assure the scientific validity of the regulations.
Experts in infection control in Canada have called for 1 full-time formally trained ICP per 150 to 250 long-term beds.The Consensus Panel from SHEA and APIC has recommended that nonhospital facilities including LTCFs provide adequate resources in terms of personnel, education, and materials to ICPs to fulfill their functions.While most of the current information has been derived from facilities serving older populations in North America, reports from LTCFs in Europe and Australia and those serving pediatric populations are increasing.Infection control program elements
The structure and components of an infection control program are shown in, respectively. Several authors have discussed the components of an infection control program in the LTCF.These components generally are drawn from regulatory requirements, current nursing home practices, and extrapolations from hospital programs. The limited resources of most LTCFs affect the type and extent of programs developed.Most authors feel that an infection control program should include some form of surveillance for infections, an epidemic control program, education of employees in infection control methods, policy and procedure formation and review, an employee health program, a resident health program, and monitoring of resident care practices. The program also may be involved in quality improvement, patient safety, environmental review, antibiotic monitoring, product review and evaluation, litigation prevention, resident safety, preparedness planning, and reporting of diseases to public health authorities.

## The icp
An ICP is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control (see, The ICP usually is a staff nurse, a background that is helpful for resident assessment and chart review. The ICP most commonly is a registered nurse. Because of size and staffing limitations, the vast majority of LTCF ICPs have other duties, such as assistant director of nursing, charge nurse, in-service coordinator, employee health, or performance improvement. The number of LTCF beds justifying a full-time ICP is unknown and usually depends on the acuity level of residents and the level of care provided. A LTCF with more than 250 to 300 beds may need a fulltime ICP. The LTCF ICP, like the hospital ICP, requires specific training in infection control; well-defined support from administration; and the ability to interact tactfully with personnel, physicians, and residents.
APIC and the Community and Hospital Infection Control Association-Canada (CHICA-Canada) have developed professional and practice standards for infection control and epidemiology that address education including qualifications and professional development for the ICP.These standards may not represent the current education and qualifications of ICPs in many LTCFs, but they serve as a benchmark for which LTC ICPs and their facilities can strive.
The qualifications include 3 criteria for entering the profession. The ICP: d Has knowledge and experience in areas of resident care practices, microbiology, asepsis, disinfection/ sterilization, adult education, infectious diseases, communication, program administration, and epidemiology; d has a baccalaureate degree (the minimum educational preparation for the role); and d attends a basic infection control training course within the first year of entering the profession.
The criteria for professional development include the ICP maintaining current knowledge and skills in the area of infection prevention, control, and epidemiology. The professional development standards include 5 criteria. The ICP:

## The infection control oversight committee
The regulatory requirement for a formal LTCF ICC was dropped by OBRA at the federal level, but some states still require them.The ICP should be familiar with state regulations. This committee frequently has been less active than the corresponding ICC in the hospital setting, in part because of decreased physician availability. A small working group (the infection control oversight committee) consisting of the ICP, the administrator, the medical director, and the nursing supervisor or their designee may efficiently make most of the infection control decisions. The ICC functions may be merged with the performance improvement or patient safety programs, but infection control must remain identifiable as a distinct program. Whatever group is selected to oversee the infection control program, it should meet regularly to review infection control data, review policies, and monitor program goals and activities. Written records of meetings should be kept.
The LTCF administrative staff should support the ICP with appropriate educational opportunities and resources, including expert consultation in infectious diseases and infection control as needed. The participation of an infectious diseases (ID) physician or other health care professional with training or experience in infection control should be available on at least a consultative basis. Information may be obtained from SHEA (www.shea-online.org or 703-684-1006). The local health department may have useful information, and local ICPs are another valuable source of information, available from the APIC at www.apic.org.

## Educational opportunities for icps

## Surveillance
Infection surveillance in the LTCF involves the systematic collection, consolidation, and analysis of data on HAIs. Standardization of surveillance is desirable. To facilitate standardization, resources that include practice guidance for surveillance identifying seven recommended steps are available. These steps are (1) assessing the population, (2) selecting the outcome or process for surveillance, (3) using surveillance definitions, (4) collecting surveillance data, (5) calculating and analyzing infection rates, (6) applying risk stratification methodology, and (7) reporting and using surveillance information.Assessing the population. Infection surveillance may either include all residents in a facility (total house surveillance) or be targeted at specific subpopulations. Although facility-wide surveillance is useful for calculating baseline rates and detecting outbreaks, a more focused analysis could include examination of infection rates in residents who are at risk for certain kinds of infection (such as aspiration pneumonia in residents receiving tube feedings or bloodstream infection among residents with indwelling vascular catheters). Focused surveillance should target infections that are preventable; that occur frequently; and that are associated with significant morbidity, mortality, and cost. Facility-wide surveillance is useful for establishing an infection control ''presence'' in the LTCF and may be required as a part of local or state regulatory programs.
To establish baseline infection rates, track progress, determine trends, and detect outbreaks, site-specific rates should be calculated (eg, central line infections per 1000 central line-days). Routine analysis should try to explain the variation in site-specific rates. For example, a change in the rate might be related to a change in the resident population. Focused or highrisk resident surveillance may permit conservation of resources, although in many small institutions whole house surveillance is feasible.
Selecting the outcome measures. Traditionally surveillance in the LTCF refers to collection of data on outcome measures such as HAIs that occur within the institution (eg, incidence of UTI or central lineassociated bacteremia). These surveillance data are used primarily to guide control activities, to plan educational programs, and to detect epidemics, but surveillance also may detect infections that require therapeutic action.
Process measures (eg, surveillance of infection control practices) should also be part of the infection control and quality improvement programs and may be very helpful in identifying areas for improvement in practice and for monitoring compliance with regulatory aspects of the infection control program.
Examples of process measures include observation of hand hygiene compliance, observation of correct catheter care technique, antibiotic utilization studies, timeliness in administering and reading TB skin tests, and administration of hepatitis B immunization to new employees within 10 working days of hire.
Using surveillance definitions. Surveillance requires objective, valid definitions of infections. Most hospital surveillance definitions are based on the National Nosocomial Infections Surveillance System (NNIS) criteria,but no such standard exists for long-term care. NNIS (now the National Healthcare Safety Network [NHSN]) definitions depend heavily on laboratory data and recorded clinical observations. In the LTCF, radiology and microbiology data are less available, and written physician notes and nursing assessments in the medical record usually are brief. Timely detection of HAI in the LTCF often depends on recognition of clues to infection by nurses' aides and reporting of these findings to the licensed nursing staff.Positive cultures do not necessarily signify infection.
Modified LTCF-specific surveillance criteria were developed by a Canadian consensus conference. These definitions were designed in light of some of the unique limitations of nursing home surveillance mentioned previously. They are used widely, although they have not yet been validated in the field.Collecting surveillance data. Published LTCF surveys have been either incidence or prevalence studies. Prevalence studies detect the number of existing (old and new) cases in a population at a given time, whereas incidence studies find new cases during a defined time period. The latter is preferred because more concurrent information can be collected by an incidence study if data are collected with regularity.
The surveillance process consists of collecting data on individual cases and determining whether or not a HAI is present by comparing collected data to standard written definitions (criteria) of infections. One recommended data collection method in the LTCF is ''walking rounds.'' 182 This is a means of collecting concurrent and prospective infection data that are necessary to make infection control decisions. Surveillance should be done on a timely basis, probably at least weekly.During rounds, the ICP may use house reports from nursing staff, chart reviews, laboratory or radiology reports, treatment reviews, antibiotic usage data, and clinical observations as sources of information.
Analysis and reporting of surveillance data. Analysis of absolute numbers of infections is misleading; calculation of rates provides the most accurate information. Rates are generally calculated by using 1000 resident-days as the denominator. In the past, average daily census has sometimes been used as the denominator, but resident-days more clearly reflect resident risk.
Infection control data, including rates, then need to be displayed and distributed to appropriate committees and personnel (including administration) and used in planning infection control efforts. The data should lead to specific interventions such as education and control programs.
To compare rates within a facility or to other facilities, the method of calculation must be identical (including the denominator). Even when calculation methods are consistent, infection rates may differ between facilities because of different definitions of infection or differences in resident risk factors and disease severity, and thus comparisons may not be valid. Comparison of infection rates between facilities, for public reporting or other purposes, requires control of definitions and collection methods, severity adjusting and data validation.The use of a regional data set may allow for more meaningful intrafacility comparison of infection rates.This may also allow for interfacility comparisons of infection rates across a corporation or geographic area.Analysis and reporting of infection data usually are done monthly, quarterly, and annually to detect trends. This process is facilitated by an individual infection report form, samples of which have been published.The statistics used in analysis of data need not be complex. Computerization for sorting and analysis of data may be timesaving for larger programs, and software for use on a personal computer is available. Graphs and charts facilitate presentation and understanding of infection control data and also may be facilitated by computer programs. The commercially available programs may help with analysis of surveillance data, but manual data collection is still usually necessary.
The feasibility of routine surveillance in LTCFs has been demonstrated, and data have been used to provide a basis for continuing education.Surveillance needs to be simple and pragmatic, particularly because the LTCF ICP may be able to spend only a few hours per week on infection control activities.

## Outbreak control
Outbreak surveillance and control should be considered a high priority for ICPs. The leading causes of LTCF outbreaks are discussed above and listed in. When the number of cases exceeds the normal baseline, an outbreak within the facility should be considered. The ICP is advised, and required by CMS, to monitor resident and staff illnesses, since healthy personnel may acquire and transmit virulent pathogens.
For many, the word outbreak means a dramatic clustering of cases of an infectious disease in a geographic area over a relatively short period of time. However, the threshold for declaring an outbreak and initiating control measures may be much lower. For example, we know that influenza may cause explosive outbreaks in nursing homes.Public health officials have, therefore, set low thresholds for identifying an outbreak if influenza is suspected so that outbreak control strategies can be implemented to avoid high attack rates. The CDC recommends defining a nursing home outbreak of influenza as a single laboratory-confirmed case or a sudden increase of acute febrile respiratory illness over the normal background rate.Special outbreak control measures may, therefore, be appropriate if there is evidence of transmission of an epidemiologically important pathogen within the facility rather than waiting for a fully evolved clinical outbreak.
For TB, an outbreak investigation should be triggered by a single active case. TB outbreaks are often caused by a single case and may infect large numbers of residents and staff by the airborne route before detection.In addition, a single infection caused by Legionella spp, scabies, Salmonella spp, or other GI pathogens associated with outbreaks should trigger an evaluation. A single case of Legionella spp may signal colonization of the water supply.The approach to investigating an outbreak includes (1) determining that an outbreak has occurred, (2) developing a case definition, (3) case finding, (4) analyzing the outbreak, (5) formulating a hypothesis regarding mechanism of transmission, (6) designating control measures, and (7) evaluating control measures. A CDC SHEA publication is available to guide investigation of outbreaks.Given the fact that influenza and norovirus outbreaks are relatively common, clinical case definitions should be developed in advance and placed in preexisting policies and procedures. To facilitate rapid implementation of control measures, the charge nurses should be empowered by preexisting policies to rapidly isolate and/or cohort infected individuals and to curtail contact between residents and staff on units in an outbreak situation.
The LTCF may have difficulty responding to an epidemic with appropriate measures (such as mass vaccination or administration of antivirals during an influenza outbreak) if consent needs to be obtained on short notice from a resident's decision maker or primary physician. One way to circumvent this problem is to develop preexisting policies and procedures approved by the medical staff and to obtain consent for vaccination and outbreak control measures at the time of admission from the resident or their power of attorney/medical decision maker.

## Isolation and precautions: importance and evolution
Prevention of transmission of significant pathogens to patients and HCWs is the major goal of isolation within health care systems. There are very limited data on the impact of isolation and infection control precautions, however, on the transmission of pathogens within LTCFs. The high prevalence of risk factors for infection among LTCF residents, the high colonization rate of MDROs in skilled care units, and the frequent reports of LTCF infectious disease outbreaks support the need for appropriate infection control in that setting.A unique infection control challenge for the LTCF is the mobile resident, who may be confused or incontinent and serves as a possible vector for infectious diseases. The presence of MDROs in the LTCF has implications beyond the individual facility. Because residents of LTCFs are hospitalized frequently, they can transfer pathogens between LTCFs and receiving hospitals; transfer of patients colonized with MDROs between hospitals and LTCFs has been well documented.On the other hand, LTCF residents remain in the facility for extended periods of time, and the LTCF is functionally their home. An atmosphere of community is fostered, and residents share common eating and living areas and participate in various activities. Thus, the psychosocial consequences of isolation measures must be carefully balanced against the infection control benefits.
Isolation recommendations from the CDC have been available since 1970 but have specifically been targeted towards acute care settings. ICPs in the LTCF have thus been required to adapt these practices to their individual settings. Traditionally, 2 types of systems for implementing barrier precautions in the hospital were promoted. A Category-Specific System listed 7 categories of isolation or precautions based on means of disease transmission: strict isolation, contact isolation, respiratory isolation, TB isolation, enteric precautions, drainage and secretion precautions, and blood and body fluid precautions. Modifications of this approach have been promoted since 1970 with a refined Category-Specific System in the 1983 recommendations.A Disease-Specific System listed all relevant contagious diseases and the recommended barrier method. In general, the Category-Specific System was simpler to use, but the Disease-Specific System consumed fewer resources because precautions were tailored to the specific disease. In the 1983 guideline, blood precautions were expanded to include body fluids.In response to the HIV/AIDS epidemic, the concept of Universal Precautions was introduced to protect HCWs from all bloodborne exposures.These recommendations became adopted by OSHA and have thus been applicable to all health care settings including LTCFs.In this system, all blood and certain body fluids are considered potentially infectious. Education, provision of needle-disposal units, provision of protective equipment (such as gloves, gowns, and protective eye wear), and monitoring compliance were part of Universal Precautions, although it alone was not considered a complete isolation system.
CDC isolation guidelines released in 1996 integrated earlier isolation systems by introducing transmissionbased precautions.Standard Precautions replaced Universal Precautions and were to be applied to all patients. Standard Precautions emphasize hand hygiene, gloves (when touching body fluids), masks, eye protection, and gowns (when contamination of clothing is likely), as well as avoidance of needlestick and other sharps injuries. More specific isolation was recommended for patients with documented or suspected contagious pathogens. These include Airborne Precautions (eg, for varicella, measles, and TB), Droplet Precautions (eg, for influenza and other respiratory infections), and Contact Precautions (eg, for MRSA,VRE, and C difficile diarrhea).
CDC and HICPAC have recently released 2 infection control guidelines that have application in this regard to LTCFs. The first one released focuses specifically on the management of MDROs in health care settings, and the second is an update to previously recommended general isolation precautions from 1996 guidelines.Respiratory hygiene/cough etiquette and safe injection practices were added as new elements of Standard Precautions. Most LTCFs do not have negative-pressure rooms for Airborne Precautions, and residents with suspected TB should be transferred to facilities where such units exist.

## Isolation and precautions: mdros
The majority of the infection control literature on MDROs in the LTCF has focused on MRSA, but these guidelines may also apply if a facility recognizes significant problems with other MDROs such as VRE or antibiotic-resistant, gram-negative bacilli. Barrier precautions are important in preventing cross infection with known resistant microorganisms, but approaches to isolation of LTCF patients colonized or infected with MDROs vary substantially across facilities.Most LTCFs employ at least some type of isolation for MDROs.It was found that 90.5% of facilities accepting patients with MRSA stated that they followed Contact Precautions despite only 39.7% placing them in private rooms.In another survey, most LTCFs in Nebraska were aware of and often screened for MRSA and employed some precautions in dealing with these residents (eg, single room, cohorting, contact isolation, or placing the resident with MDRO in the same room as a low-risk roommate).Another study demonstrated no difference in transmission of MDROs in a skilled care unit between contact isolation precautions and routine glove use.The authors suggested that universal glove use may be preferable to contact isolation because it reduces social isolation for LTCF residents where their health care facility is also their home. Others have suggested a ''modified'' contact isolation protocol as often more appropriate in the LTCF setting.Clearly, additional evidence-based studies defining the specific isolation needs within LTCF are needed.
General guidelines for control of MRSA 148 and VRE 206 are published but emphasize hospital settings. These guidelines serve as an appropriate starting point for adapting an LTCF approach. There are many reports of aggressive infection control measures containing MDROs in the hospital setting.However, data in the LTCF are very limited, and implementation of isolation procedures identical to those found in a hospital may result in undesirable social and psychological consequences and functional decline for residents.SHEA position papers on antimicrobial resistance and infection control specifically address the LTCFand discuss prescreening admissions for resistant bacteria, surveillance for resistant bacteria, and endemic resistance.
The recent HICPAC isolation guidelines attempt to address some of the specific needs and concerns of the LTCF.The principles in both documents can be adopted for use in the LTCF setting. The MDRO document discusses general control interventions such as administrative support, education of HCWs, surveillance, and judicious use of antimicrobial agents (see Antibiotic stewardship section below) that are applicable in the LTCF setting. LTCFs are encouraged to identify experts who can provide consultation for analyzing surveillance data and devising effective infection control strategies to control MDROs. The development of laboratory protocols for storing bacterial isolates for molecular typing when needed to understand the epidemiology of transmission is recommended. When the LTCF laboratory has contracted with an off-site laboratory, the facility will need to develop an arrangement for storing and testing isolates.
The guidelinesrecommend continuing the use of transmission-based isolation precautions. In LTCFs, it is advised to consider the individual resident's clinical situation when deciding whether to implement or modify the use of Contact Precautions in addition to Standard Precautions if colonized or infected with a MDRO. Standard Precautions are sufficient for relatively healthy and independent residents, ensuring that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool, and ostomy tubes/bags. Contact Precautions are indicated for residents with MDROs who are ill and totally dependent upon HCWs for activities of daily living or whose secretions or drainage cannot be contained. Single rooms for these residents are recommended if available. The cohorting of MDRO residents is acceptable if single rooms are not available. If cohorting is not possible, then placing residents with MDRO with residents who are low risk for acquisition or with anticipated short lengths of stay is advised. While ''low risk for acquisition'' of an MDRO has not been officially defined, one source suggested that it should include residents who are not immunosuppressed; not on antibiotics; and free of open wounds, drains, and indwelling urinary catheters.Case-by-case decisions, as needed, can be made regarding the best precautions to use for each resident with a MDRO. With Contact Precautions, wearing a gown and gloves for all interactions that may involve contact with the resident and their environment is advised, and eye protection is recommended when there is risk of splash or spray of respiratory or other body fluids.
Recommendations for minimizing antibiotic resistance also include using appropriate barrier precautions for MDROs, maintaining a line listing of residents infected or colonized with MDROs, and not attempting eradication of MDROs from colonized residents.It is not recommended that the LTCF refuse MRSA or VRE cases but develop an institutional strategy for control of the resistant organisms based on local considerations.In summary, elements of routine MDRO control for the LTCF include monitoring MRSA and VRE culture results, communicating MDRO data to health care providers, including routine communication about MDROs at in-services, assessing compliance with isolation precautions and hand hygiene, monitoring antimicrobial usage, notifying receiving or transmitting facilities of the presence of a MDRO, designating residents previously known to be infected or colonized with MDROs, and instituting adequate environmental cleaning. If a MDRO problem exists in a LTCF and is not controlled with these basic infection control practices, then additional control measures are indicated. These include consultation from experts, intensification of education, increased efforts to control antimicrobial use, active surveillance cultures, pointprevalence culturing of targeted units, intensification of isolation with compliance assessment, and monitoring environmental cleaning.

## Isolation and precautions: bloodborne pathogen issues
LTCFs may be asked to provide care for persons with hepatitis C, hepatitis B, HIV, and acquired immunodeficiency syndrome (AIDS), especially for individuals with advanced disease who are too ill to reside at home but do not require acute hospital care. Earlier guidelines for dealing with HIV infection in the health care setting are incorporated widely in hospitals but also apply in the LTCF.The standard approaches to protecting HCWs and other patients from transmission of bloodborne pathogens have essentially not changed since these earlier recommendations. In the current isolation guidelines,Standard Precautions are still promoted as the main method for preventing exposure to blood and body fluids for all patient interactions. These include the routine use of hand hygiene, gloves, gowns, masks, and eye protection, depending upon the anticipated exposures.
The guideline also discusses in detail safe work practices to prevent exposures to bloodborne pathogens, including prevention of needlesticks and other sharp-related injuries; prevention of mucous membrane contact; safe injection practices; and precautions during aerosol-generating procedures. Infection control personnel at all LTCFs should carefully review these guidelines and develop a plan for implementation within their facilities. As in hospitals, it is known that needlestick injuries do occur in the LTCF and usually are related to needle recapping.Plans for regular education of all staff and for compliance with OSHA standards should be in place, and LTCFs should ensure the availability to hepatitis B vaccination and postexposure prophylaxis for HIV or hepatitis B for all employees in accordance with the most recent guidelines.

## Hand hygiene
Hand hygiene likely remains the most important infection control measure in the LTCF as well as in the hospital. Unfortunately, poor compliance with hand hygiene recommendations has been noted in LTCFs, as in other settings.Health care provider hand contamination is usually transient and amenable to hand hygiene, 215 frequent hand hygiene would be expected to lower LTCF infection rates,and the availability of alcohol-based hand sanitizer dispensers enhances access to hand sanitizing agents.
CDC and HICPAC published a comprehensive hand hygiene guideline.Other published guidelines for hand hygiene and choice of antiseptic agents are also applicable.They recommend the use of bar or liquid soap when hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or other body fluids. If hands are not visibly soiled, then the routine use of an alcohol-based hand rub is recommended in the LTCF. Hands should always be decontaminated after the removal of gloves. Hand hygiene with an antiseptic agent or alcohol-based hand rub is recommended before donning sterile gloves for performing invasive procedures such as placement of an intravenous or urinary catheter. Hand hygiene compliance should be monitored by the facility.

## Resident health
Resident health programs are recommended for prevention of infections, 7 but comprehensive programs often are lacking in LTCFs.One of the major functions of a resident health program is the immunization of the elderly resident.The elderly are underserved in terms of immunization to tetanus, 222 as well as pneumococcal and influenza vaccines.They should receive pneumococcal vaccine at age 65, when they are relatively immunologically responsive, rather than at age 80 to 85 when entering the LTCF.Standing orders for influenza and pneumococcal vaccination are associated with improved vaccination rates.Residents should receive a TB skin test on admission and undergo chest radiograph if TST positive or symptomatic.Other resident care practices that should be addressed include resident hand hygiene, oral hygiene, prevention of aspiration, skin care, and prevention of UTIs. Clinical trials in LTCFs have reported no decrease in infections with routine vitamin or mineral supplementation.However, optimal care of comorbid illnesses and good nutrition are principles of care irrespective of impact on infections.

## Employee health
Published information on infection control in hospital personnel is available.Employee infection prevention considerations in the LTCF are somewhat different than in the hospital, but the published literature and guidelines generally apply to the LTCFs as well as hospitals. Because of congregate living conditions in most LTCFs, there are some notable differences including an increased risk of exposure to residents with herpes zoster, scabies, conjunctivitis, influenza, TB, and viral gastroenteritis. The pediatric LTCF offers additional challenges to the prevention of infection including childhood diseases, such as varicella, measles, mumps, and rubella.
Regulations concerning protection of employees from bloodborne pathogens apply to the LTCF.The LTCF should be able to provide timely chemoprophylaxis to employees who may have blood/body fluid exposure to residents known to have HIV.Employee health policies and procedures should address postexposure follow-up or prophylaxis for certain infections, such as hepatitis B, hepatitis C, TB, scabies, and HIV.
Primary employee vaccination considerations should include influenza, hepatitis B, tetanus/diphtheria, and pertussis. Varicella, measles, mumps, rubella, and hepatitis A are of greater concern in the pediatric LTCF setting. Influenza vaccine campaigns should require signed declination statements by employees who decline vaccination.Adult vaccination information can be found at http:// www.immunize.org/. Vaccination should include hepatitis B to protect from this bloodborne pathogen. Varicella vaccine is appropriate if an employee is not immune. Hepatitis A vaccine may be appropriate in certain circumstances, especially in behavioral health and developmental disability facilities. Vaccine Information Sheets (VIS) should be given to all adult vaccinees as required by the National Childhood Vaccine Injury Act (42 U.S.C. 300aa-26). Anaphylaxis or any other adverse event requiring medical attention within 30 days after receipt of a vaccine must be reported to the Vaccine Adverse Events Reporting System (VAERS), a requirement of the National Vaccine Injury Compensation Program (www.vaers.org/pdf/vaers_form.pdf).
Initial assessment of employees and education in infection control also are important, as is a reasonable sick-leave policy.Ill employees may cause significant outbreaks in the LTCF.Initial screening should include TB, also required by some states.LTCFs are required to prohibit employees with communicable diseases or infected skin lesions from direct contact with residents and to prohibit employees with potentially infectious skin lesions from contact with residents' food.Education. The value of education of the LTCF ICP has long been recognized, and surveys of personnel confirm this need.The importance of ICP education is accentuated by the great turnover in LTCF personnel. While the benefits of ICP training are widely assumed, one study analyzed the effects of a 2-day, intensive basic training program on 266 ICPs.Trainees not only demonstrated an increase in postcourse knowledge but, at 3-and 12-month follow-up, had a significant increase in implementation of key infection control practices. Practices included performance of surveillance, using infection definitions, calculating infection rates, and giving employees and residents TST and influenza vaccine.
The role of education in infection prevention in the LTCF extends well beyond the ICP. One of the most important roles of the ICP is education of LTCF personnel in basic infection control principles. It is recommended that the ICP routinely assess the educational needs of staff, residents, and families and develop educational objectives and strategies to meet those needs; collaborate in the development, delivery, and evaluation of educational programs or tools that relate to infection prevention, control, and epidemiology; and continuously evaluate the effectiveness of educational programs and learner outcomes.
Education should focus on new personnel and certified nursing assistants.Priority for training should be directed toward orientation, OSHA-mandated programs, problem-oriented teaching, and other programs required by regulations. Surveillance data are an excellent starting point for infection control training, and compliance rounds provide an opportunity for the ICP to provide timely, informal education to personnel. Infection control content should include information on disease transmission, hand hygiene, barrier precautions, and basic hygiene.In addition, all individuals with direct resident care responsibility need education in early problem and symptom recognition. The teaching methods used need to be sensitive to language, cultural background, and educational level. A coordinated, effective educational program will result in improved infection control activities.

## Antibiotic stewardship
Antibiotic-resistant bacteria pose a significant hazard in the LTCF, and this resistance has been strongly associated with antibiotic use.Antimicrobials are among the most frequently prescribed medications in the LTCF.Antibiotics are given to approximately 7% to 10% of residents in LTCFs, frequently for lengthy periods of time.A study of 22 LTCFs noted an incidence of antibiotic prescriptions of 2.9 to 13.9 antibiotic courses per 1000 resident-days.Several studies have questioned the appropriateness of this practice.A common problem is the failure to distinguish infection and colonization (such as a positive swab culture of a pressure ulcer or a urine culture showing bacteriuria without signs or symptoms of infection) and the treatment of the colonization with antibiotics. In addition, antibiotics often are prescribed over the telephone in this setting.There also appears to be significant variability in antibiotic prescribing patterns in the LTCF.Several reviews and guidelines for infection control efforts to curb antibiotic resistance in health care settings (including LTCFs) have been published.These guidelines stress the importance of having an ICP trained in infection control and LTCF administrative support and resources for the infection control program.The CDC has published a 12-step program for preventing antimicrobial resistance among LTCF residents that addresses the broad areas of preventing infection (eg, resident vaccination), diagnosis/treatment of infection, using antibiotics wisely, and preventing transmission (www.cdc.gov). A LTCF antibiotic review program is recommendedand is often found in LTCFs.Recent guidelines have addressed the development of antimicrobial stewardship programs in hospitals.Using this guideline as a starting point, LTCFs are encouraged to include antimicrobial stewardship in the LTCF infection control program and discuss appropriate choices for various clinical situations.A recent survey revealed that fewer than one third of LTCFs surveyed had any such antibiotic use protocols in place.Minimum criteria for initiation of antibiotic therapy have been proposed to improve antimicrobial prescribing in LTCFs 252 and may be of assistance in developing antibiotic appropriateness criteria.
Approximately two thirds of LTCF professionals identified a clear need for greater education regarding judicious antibiotic use in LTCFs.Education and development of antibiotic guidelines have improved antimicrobial usage in the LTCF setting in several studies.Other aspects of the program Policies and procedures. An important aspect of infection control programs is the development and updating of infection control policies and procedures. Because practices change, they should be reviewed on a scheduled basis. Review of the Bloodborne Pathogens Exposure Control Plan is required to be done annually.Resources are available on the writing of policies and procedures in general 255,256 dietetic service policies, 255 laundry policies, 257 physical therapy policies,and handwashing.Respiratory therapy issues may be relevant to the LTCF, including cleaning of humidifiers, respiratory therapy equipment, suctioning technique, and tracheotomy care.Pharmacy and medication issues include use of multidose medication vials and resident specific creams and ointments.
A policy and procedure on hand hygiene are critically important to have available for staff.The policy details specific indications for hand hygiene, including when coming on duty; whenever hands are soiled; after personal use of toilet; after blowing or wiping nose; after contact with resident blood or body secretions; before performing any invasive procedures on a resident; after leaving an isolation room; after handling items such as dressings, bedpans, catheters, or urinals; after removing gloves; before eating; and on completion of duty. The corresponding procedure should list explicit steps in the hand hygiene process. A 15-second handwash is usually recommended.Alcohol-based hand rubs should be made available and used by staff, especially when handwashing facilities are inadequate or inaccessible. Hand hygiene compliance should be monitored.Facility management. Environmental control in the facility is an important consideration. Routine environmental cultures are not cost-effective and do not usually generate information relevant to clinical infections. However, periodic environmental compliance rounds are recommended.Sources are available suggesting specific environmental measures such as dishwasher and laundry cleaning temperatures,although limited data exist.
A related area of concern is sterilization, disinfection, and asepsis, including the evaluation of cleaning methods, such as monitoring reuse of disposable equipment. Resources are available.An infection control program should also monitor basic hygiene (eg, respiratory etiquette) and compliance with proper infection control techniques. Staff, residents, and families may all be the source of HAIs if there is a breakdown in basic hygiene.
Selection of proper disinfectants and antiseptics requires infection control expertise. Reading the manufacturer's label directions and following the required dilution and contact time instructions are recommended. Infection control input will also be needed on additional and new products that affect infection prevention, such as urinary catheter systems, gloves, and disposable diapers. Quality, efficacy, and cost issues need to be weighed in product selection.Waste management is the important in the LTCF. Medical and biohazardous waste issues are controversial; Environmental Protection Agency (EPA) regulations, OSHA regulations, and CDC recommendations may conflict.Local health department regulations should also be checked. Several resources are available on medical waste issues relevant to the LTCF. 162,Disease reporting. Another important function of the infection control program is disease reporting to public health authorities. State and local health departments will provide a list of reportable diseases and other public health resources.
Performance improvement/resident safety. The increased emphasis on quality indicators in health care is becoming evident in LTC. There are important differences in definitions of infection published for LTCF surveillance (see Surveillance section above) and those in the long-term care Minimum Data Set (MDS) manual. This is especially important for UTIs. In addition, CMS provides a Web site called Nursing Home Compare,which posts information to the public on nursing home quality measures, inspections, staffing, and other data for individual LTCFs. For instance, UTI in the CMS MDS requires a physician diagnosis in the chart and a positive urine culture.This definition has been found to be inaccurate compared with standard definitions such as the McGeer definition,which requires a combination of symptoms and signs.A quality assessment and assurance committee is required.Infection control is the prototype quality improvement or performance improvement (PI) program, and many of the techniques used in infection control are directly applicable to PI, such as data collection, data analysis, and intervention.The traditional performance improvement process focuses on adverse events and assesses functions of the system.In the course of performing infection surveillance, there is ample opportunity to monitor compliance with infection control policies and procedures and to provide informal infection control education to address observed problems.
Examples of appropriate quality indicators for PI study include resident immunization with influenza and pneumoccoccal vaccines, 272 employee vaccination for influenza,number of employee TSTconversions, and employee hand hygiene compliance. A national focus on patient safety and prevention of adverse events has relevance to the LTC setting as well.Preparedness planning. The ICP will frequently play a key role in LTCF preparedness planning. The planning is currently focused on pandemic influenza but should prepare the LTCF for dealing with a variety of disaster scenarios. Issues to be considered include surge capacity, medication availability and rationing, stockpiling, staff shortages during an influenza pandemic, and communication with public health authorities for planning purposes.It appears that the LTCF ICP will play an important role in preparedness and that about half of LTCFs have a pandemic influenza plan.

## Resources
Having appropriate job-related resources is essential to good performance in the role of infection prevention and control. A few resources for the ICP are listed below:

## Recommendations
Seefor scoring scheme. Comment: The elements of a program generally include the following: a. Surveillance-Systematic data collection to identify infections in residents b. Outbreak Control-A system for detection, investigation, and control of epidemic infectious diseases in the LTCF c. Isolation-An isolation and precautions system to reduce the risk of transmission of infectious agents d. Policies and procedures-Relevant to infection control (seeComment: Men with incontinence should have voiding managed by a condom catheter rather than indwelling catheter, where possible. Residents with chronic indwelling catheters should have the catheter replaced and a specimen collected immediately prior to initiating antimicrobial therapy for symptomatic infection.
4 A program to minimize the risk of pneumonia in the LTCF should address the following: reducing the potential for aspiration, minimizing atelectasis, and caring for respiratory therapy equipment (Category II).
Comment: Pneumonia prevention guidelines are available, and many of the suggested measures are applicable to the LTCF.
5 Policies and procedures should be developed for prevention of infections associated with nasogastric and gastrostomy feeding tubes, including the following: preparation, storage, refrigeration, and administration of feeding solutions and care of percutaneous feeding tube skin sites (Category II). 6 Policies and procedures should be developed for prevention of IV infections, including central lines, if these devices are used (Category IB).
Comment: Policies should address indications for IV therapy, the type of dressing used to cover the IV exit site, cannula insertion, site maintenance, and changing fluids or tubing.

## J. resident health program
1 A resident health program should be implemented (Category II). d There should be explicit and accessible documentation of program components in the resident record (Category II). 2 At admission, each resident should have a complete history (including important past and present infectious diseases), immunization status evaluation, and recent physical examination (Category II). 3 All newly admitted residents should receive TB screening unless a physician's statement is obtained that the resident had a past positive TST (Category IA/ IC).
Comment: A 2-step booster TST is often recommended in this setting.
4 When new or active TB is suggested by a positive skin-test result, or symptoms are consistent with active TB, a chest radiograph and medical evaluation should be obtained (Category II). 5 Follow-up TST for TB should be performed periodically or after discovery of a new case of TB in a resident or staff member (Category IB). No recommendation on frequency of routine follow-up TSTs for residents. 6 Each resident should receive current vaccinations for tetanus, diphtheria, influenza, pertussis, pneumococcal pneumonia, and any other vaccines recommended by the ACIP (Category IB/IC). 7 Each resident should receive the influenza vaccine annually in the fall, unless medically contraindicated (Category IC).
Comment: Facilities should obtain resident consent at admission for yearly influenza vaccination and use standing orders for yearly influenza vaccination.
8 Policies and procedures addressing visitors should be developed to limit introduction of community infections (such as influenza) into the LTCF (Category II). 3 Follow-up skin testing of staff who are TST negative should be performed periodically based on the facility's annual risk assessment or after discovery of a new case of TB in a resident or staff member (Category 1A/IC).

## K. employee health program
Comment: The intradermal Mantoux method or licensed blood test should be used. The frequency of testing depends on the regional prevalence of TB; the facility's annual risk assessment; and federal, state, or local regulations. All employees should have current immunizations as recommended for HCWs by the Advisory Committee on Immunization Practices (ACIP), with documentation in the employee record (Category 1A/IC). 5 Employees with blood or body fluid contact should be offered HBV immunization within 10 working days of hire and after training has been completed (Category 1C).
Comment: Refusal of this vaccine should be documented, using the OSHA-required Declination Statement for Hepatitis B vaccine.
6 Employees should be offered the influenza vaccine annually (Category 1A/1C).
Comment: A vaccine declination statement may be signed by each employee who declines influenza vaccination.
7 Each employee should be taught basic use of personal protective equipment and hand hygiene and to consider blood and all body fluids as potentially infectious (Category 1C). 8 Employees with signs or symptoms of communicable diseases (eg, cough, rash, diarrhea) should not have contact with the residents or their food (Category 1B). 9 All employees should be educated to report any significant infectious illnesses to their supervisor and the staff member responsible for employee health (Category 1B).
Comment: Each employee record should include factors affecting immune status (such as steroid therapy, diabetes, HIV infection), history of communicable diseases, illnesses, and incidents such as exposures to contagious diseases, needlesticks, injuries, and accidents.
10 The LTCF should develop protocols for managing employee illnesses and exposures (such as bloodborne pathogens like HIV and hepatitis B and C, as well as TB, scabies, or gastroenteritis) (Category 1B/IC).
Comment: An employee absentee policy that discourages the employee from working while ill should be developed.

## L. education
1 Infection control education should be provided at the initiation of employment and regularly thereafter. Training should include all staff, especially those providing direct resident care (Category IC). 2 All programs should be documented with the date, topic, names of attendees, and evaluations (Category IC).
Comment: Program topics should be timely and relevant to infection prevention and control. Basic hygiene, hand hygiene, respiratory etiquette, transmission of infectious diseases, occupational health, prevention of TB and bloodborne pathogens, Standard and Transmission-based Precautions, infection control standards, and the susceptibility of residents to infectious diseases are topics that should be included. The ICP may recommend topics. Surveillance data are of interest to staff and may be included as appropriate.
The educators should evaluate the educational program and outcomes and use that information to modify future programs. Comment: The LTCF should encourage judicious use of antimicrobials with guidelines based in part on local susceptibility patterns. Antibiotic utilization and appropriateness may be monitored, and these data used for interventions (eg, education, antibiotic restrictions).

## M. policies and procedures
2 The ICP should monitor antibiotic susceptibility results from cultures to detect clinically significant antibiotic-resistant bacteria (such as MRSA or VRE) in the institution. Changes in antibiotic-susceptibility trends should be communicated to appropriate individuals and committees (Category IB).

## O. miscellaneous aspects
1 There should be a system for reporting notifiable diseases to proper public health officials (Category 1C).
2 The infection control program should collaborate with the performance improvement (PI) program, if a formal program exists (Category II).
Comment: Infection control is an important component of PI, and the epidemiological techniques used in infection control will assist the PI program.
3 The ICP should be involved with the review and selection of new products that have infection control implications (Category II). 4 The ICP should be involved with LTCF influenza pandemic preparedness planning (Category II). 5 Infection control activities should address relevant resident safety issues (Category II).

## P. regulations
1 The infection control program must be in compliance with federal, state, and local regulations (Category IC). 2 The infection control program should reflect national, evidence-based standards of practice for infection prevention and control (Category IC).