Kent Crossley

Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: Results of a consensus conference

Establishing a clinical diagnosis of infection in residents of long-term-care facilities (LTCFs) is difficult. As a result, deciding when to initiate antibiotics can be particularly challenging. This article describes the establishment of minimum criteria for the initiation of antibiotics in residents of LTCFs. Experts in this area were invited to participate in a consensus conference. Using a modified delphi approach, a questionnaire and selected relevant articles were sent to participants who were asked to rank individual signs and symptoms with respect to their relative importance. Using the results of the weighting by participants, a modification of the nominal group process was used to achieve consensus. Criteria for initiating antibiotics for skin and soft-tissue infections, respiratory infections, urinary infections, and fever where the focus of infection is unknown were developed.

Clostridium difficile in Long-Term–Care Facilities for the Elderly

Antimicrobial agents are among the most frequently prescribed medications in long-term-care facilities (LTCFs). Therefore, it is not surprising that Clostridium difficile colonization and C. difficile-associated diarrhea (CDAD) occur commonly in elderly LTCF residents. C. difficile has been identified as the most common cause of non-epidemic acute diarrheal illness in nursing homes, and outbreaks of CDAD in LTCFs have also been recognized. This position paper reviews the epidemiology and clinical features of CDAD in elderly residents of LTCFs and, using available evidence, provides recommendations for the management of C. difficile in this setting.

Methylene Blue--a therapeutic dye for all seasons?

Abstract Since it was first synthesised in 1876, Methylene Blue (MB) has found uses in many different areas of clinical medicine, ranging from dementia to cancer chemotherapy. In addition, MB formed the basis of antimicrobial chemotherapy - particularly in the area of antimalarials – and eventually led to the discovery of the neuroleptic drug families. More recently, the photosensitising potential of MB and its congeners has been recognised, and these are being applied in various antimicrobial fields, especially that of blood disinfection. The range of activities of MB is due to the combination of its simple chemical structure and facility for oxidation-reduction reactions in situ.

Antimicrobial resistance in long-term-care facilities

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term-care facilities (LTCFs). Gram-negative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified.

Causes for hospitalization of nursing home residents: the role of infection

Little is known about specific clinical conditions that lead to hospitalization of nursing home patients. To explore this, the authors examined the hospitalizations of 128 nursing home residents and compared them with hospitalizations of 320 patients from the outpatient clinic. Hospitalized nursing home patients were older, were admitted to medical services more frequently, and had more nonspecific complaints on admission. Nursing home patients were hospitalized most frequently for diseases of the circulatory system (16 per cent), respiratory system (14 per cent), and genitourinary system (12 per cent); clinic patients, for diseases of the circulatory system (25 per cent) and nervous system (10 per cent), neoplasms (10 per cent), and signs and symptoms of ill‐defined conditions (10 per cent). The most frequent causes of hospitalization for all patients were diseases of the circulatory system (23 per cent), nervous system (10 per cent), and neoplasms (10 per cent). Among patients from the nursing home, infections caused substantially more admissions (27 per cent) than among patients originating from clinic (12 per cent; P < 0.001). These findings disclose an important opportunity to reduce health care costs and enhance quality of life in the nursing home, particularly through the treatment and control of infections.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

The association between staphylococcus aureus bacteremia and bacteriuria

The relationship between Staphylococcus aureus bacteremia and bacteriuria was studied over a five year period in three hospitals. In a Veterans Administration Hospital, 59 patients with Staph, aureus bacteremia had a urine culture within 48 hours of a positive blood culture. In 16 of 59 (27 per cent), greater than 10(5) Staph. aureus was recovered from the urine in pure culture. Six of these patients had apparent primary staphylococcal urinary tract infection. Clinical and laboratory parameters in the patients with staphylococcal bacteremia and bacteriuria were compared with those in 31 patients with staphylococcal bacteremia and sterile urine cultures. The two groups differed only in the more frequent occurrence of pyuria and proteinuria in the bacteriuric patients. In two other hospitals, staphylococcal bacteriuria occurred in 7 per cent of patients with Staph. aureus bacteremia and in 13 per cent of cases of staphylococcal endocarditis. Review of autopsy records for 33 patients who died within one month of their bacteremia failed to show a correlation between bacteriuria and the presence of renal abscess. Staphylococcal bacteriuria is a frequent and unexplained concomitant of Staph. aureus bactremia.

Tuberculosis prevention and control in long-term-care facilities for older adults.

In the United States, older adults comprise 22% of cases of tuberculous disease but only 12% of the population. Most cases of tuberculosis (TB) occur in community dwellers, but attack rates are highest among frail residents of long-term-care facilities. The detection and treatment of latent TB infection and TB disease can pose special challenges in older adults. Rapid recognition of possible disease, diagnosis, and implementation of airborne precautions are essential to prevent spread. It is the intent of this evidence-based guideline to assist healthcare providers in the prevention and control of TB, specifically in skilled nursing facilities for the elderly.

Acceptance of hepatitis B vaccine by hospital personnel

Personnel at high risk of acquiring hepatitis B in two university-affiliated teaching hospitals were offered immunization against this disease. Of the 1,193 employees, 454 (38%) requested immunization. Individuals who declined or deferred immunization were sent questionnaires requesting the reasons for their decisions. Responses to the questionnaire were received from 487 of 674 personnel (72%). Most respondents (greater than 90%) indicated that they: 1) were aware of being at risk of acquiring hepatitis B, and 2) recognized the potential danger of the disease. A majority of respondents (56%) indicated that they had decided not to be immunized because they wanted to wait until more was known about the vaccine. Concern about specific side effects (eg, Guillain-Barré syndrome or acquired immunodeficiency syndrome) was cited much less often as a reason for declining immunization. Nearly one-fifth of questionnaire respondents either did not know the date of their last tetanus-diphtheria immunization or had not received a booster within the past decade.

Vancomycin-resistant enterococci in long-term-care facilities

The Society for Healthcare Epidemiology of America (SHEA) Committee on Long-Term Care decided in 1996 that there was need to develop a position document about vancomycin-resistant enterococci (VRE) in long-term–care facilities (LTCFs). This document is intended to complement the two previous position statements from our committee that discuss antibiotic use and antibiotic resistance in LTCFs. It is designed to supplement Hospital Infection Control Practice Advisory Committee (HICPAC) recommendations and to provide realistic guidelines for the LTCF.