Double, Double, Toil and Trouble Infections Still Spreading in Long-Term–Care Facilities

The rapid shift in the delivery of healthcare from acute care settings to chronic care settings has continued unabated.1 Provision of care to an increasingly frail and elderly population in long-term–care facilities (LTCFs) is, not unexpectedly, associated with infection. In hospitals, guidelines and processes for detection, diagnosis, treatment, and control of infections have evolved during approximately the past 40 years. In contrast, infection control research in LTCFs began in the 1980s, conducted by investigators from a few institutions based primarily in North America.2 In 2005, basic questions remain regarding the prevalence of infection and the most effective means of diagnosis and treatment. In addition, it is difficult to judge the efficacy, or lack thereof, of infection control measures used in LTCFs. The Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) have called for active surveillance for collection and review of infection control data in LTCFs analogous to that done in hospitals.3,4 Unfortunately, no specific processes have been defined and widely varying infection rates generated by different methods in individual LTCFs have made interfacility comparisons difficult. In this issue of Infection Control and Hospital Epidemiology, Stevenson et al. propose a standardized surveillance program that was prospectively validated in 17 regional skilled nursing facilities.5 Infection control professionals experienced in infection surveillance were trained to use uniform infection definitions, based on the McGeer criteria, data collection, and reporting methods.6 Surveillance data were compiled from ward rounds and review of records, temperature charts, antibiotic orders, laboratory data, culture data, and radiographic studies. Residents’ functional status, diagnoses, and treatments were obtained from the Minimum Data Set.7 Data were adjusted for acuity using resource utilization groups, version III (RUG-III), case-mix indices.8 Of submitted reports, 93.9% were correctly identified as infection, and the authors found less variability in infection rates between facilities with this process. Infection rates and threshold data for each month could be generated for each facility to account for the seasonal variability of some infections. In addition, individual facility data could be compared against aggregate data for all facilities per month or by percentiles in a manner used by the National Nosocomial Infections Surveillance (NNIS) System.9 Using these data as a benchmark, the authors propose that LTCFs would be able to compare their infection rates with those in other facilities. Such data would assist in determining whether infection control strategies require re-evaluation or greater resource allocation. Ultimately, the authors hope that a network of LTCFs could enter their own data into a central repository similar to the NNIS System. The Centers for Medicare & Medicaid Services has been considered using such data for public performance reporting, and the Department of Veterans Affairs is considering using its nationwide computerized patient database to begin to address the prevalence of infection and antibiotic resistance in its LTCFs. This is an important study in that the clinically based McGeer criteria are validated as effective and accurate in the detection of infection when used by facilities with personnel experienced in infection detection. However, even with highly trained infection control personnel, more than