Principles of infection prevention and control in long-term care facilities

INTRODUCTION — 

Long-term care facilities (LTCFs) represent a diverse group of health care settings that serve individuals of all ages and provide variable degrees of care; LTCFs are increasingly addressing a broader range of acute care needs. LTCFs include nursing homes, skilled-nursing facilities providing postacute care, assisted living facilities, retirement homes, rehabilitation centers, long-term care hospitals, long-term psychiatric facilities, and institutions for individuals with intellectual disabilities. The Centers for Medicare & Medicaid Services Reform of Requirements for Long-Term Care Facilities Final Rule requires LTCFs to develop an infection prevention and control (IPC) program that includes an Antibiotic Stewardship Program and to designate at least one infection preventionist whose main focus is to oversee the IPC program [1].

For many residents, their LTCF is a home as well as a place of nursing, medical, and/or psychosocial care. Tensions may exist between restrictive IPC interventions and quality of life for residents [2]. In the context of the COVID-19 pandemic, many innovative strategies were devised to maintain quality of life for residents whilst reducing the transmission of COVID-19 [3].

General issues related to IPC in LTCFs will be reviewed here. Additional information on IPC specific to COVID-19 and causes of infection in LTCFs are discussed separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "Outbreaks in long-term care facilities: Detection and management".)

EPIDEMIOLOGY — 

In the United States, people aged 65 and over represented 17 percent of the population in 2020. That is expected to grow to 22 percent by 2040. A relatively small number of people (1.2 million) age 65 and older lived in nursing homes in 2019; the percentage increased with age, ranging from 1 percent for persons ages 65 to 74 and 2 percent for persons ages 75 to 84 to 8 percent for persons over age 85 [4].

The incidence of HAIs in LTCFs is comparable with that in acute care hospitals and ranges from 1.8 to 13.5 infections per 1000 resident-days [5,6]. A point prevalence study of over 1700 general nursing homes, residential homes, or mixed LTCFs in 27 European countries reported that 3.6 percent of residents had at least one HAI when evaluated on a single day in 2016 to 2017. The prevalence rate in individual countries ranged from 0.9 to 8.5 percent [7]. In a study from the Netherlands, prevalence fell from 5 percent in 2009 to 2 percent in 2019 [8]. Adverse clinical outcomes associated with infections, including high rates of morbidity and mortality, prolonged hospitalizations, and substantial health care costs are frequently reported [9]. In one study, infections contributed to 63 percent of deaths in LTCFs and were the primary reason for 25 to 50 percent of transfers to acute care hospitals [10].

COMPONENTS OF AN INFECTION PREVENTION AND CONTROL PROGRAM — 

The Association for Practitioners in Infection Control and the Society for Hospital Epidemiology have developed guidelines for infection prevention and control (IPC) in LTCFs [5]. Recommendations to 're-imagine a nursing home IPC program,' that include references to specific elements of the health care work system (people, tasks, tools, organization, the built environment and external environment), have recently been proposed [11].

A systematic review of economic evaluations of IPC in LTCFs using a "discounting approach" in Canada is being undertaken. The proposed protocol has been published in an effort to expand the evidence base of interventions in this setting [12].

Management and governance — Management structure and governance processes associated with IPC in LTCFs will differ dependent on the type of facility, the layout of the facility (including isolation facilities and adequate availability of sinks for handwashing), the risk factors among the residents, and available resources.

While the person in charge of the LTCF must have overall responsibility for the IPC program, each facility should have a designated IPC practitioner and multidisciplinary oversight group (including facility administrator, medical director, clinical staff, and local health department) [13].

It is important that the barriers to implementing an IPC program in LTCFs are examined and addressed. In a web-based survey of direct care providers and IPC professionals in British Columbia, barriers identified were giving a lower priority to IPC guidance over other tasks, limited supplies of personal protective equipment, hand hygiene products, and cleaning disinfection products, and deficits in IPC leadership, support, and training [14]. An examination of international perspectives identified a need for increased funding, transparency and accountability, building an evidence-based culture, and integrating family and friends as partners in health care [15].

Other important components of an IPC program include written IPC policies (including those related to environmental cleaning) and procedures as well as protocols for detecting, treating, containing, and preventing transmission of potential pathogens.

Standard and isolation precautions — Standard precautions that should be employed at all times with all residents include hand hygiene, the use of appropriate personal protective equipment, the safe use and disposal of sharps, routine environmental cleaning, reprocessing of reusable medical equipment and instruments, respiratory hygiene and cough etiquette, aseptic management, waste management and appropriate handling of linen.

Hand hygiene is the single most important IPC intervention; a review found in all but one study (n=6) assessing hand hygiene intervention, a reduction in infections was reported [16]. Hand hygiene refers to either handwashing with soap and water or the use of alcohol-based gels or foams that do not require the use of water. Hand hygiene should be performed by staff and visitors before and after each contact with a resident or their surroundings, before aseptic procedures, and after contact with blood or body fluids.

Transmission-based precautions (contact, droplet, and airborne) for certain pathogens are summarized in the table (table 1). Further education and research is needed to determine if and when isolation should be used in LTCFs to best decrease risk of multi-drug resistant organism (MDRO) transmission. One United States national-wide study showed isolation was used for few MDRO-infected residents (12.8 percent) and of the nursing homes reporting MDRO infection in the past year, 31 percent used isolation at least once among MDRO-infected residents [17].

Issues related to precautions are discussed further separately. (See "Infection prevention: Precautions for preventing transmission of infection".)

Some LTCFs lack private rooms or rooms with appropriate ventilation. Cohorting of residents with the same organisms is sometimes acceptable if single rooms are not available [5].

In an effort to contain the spread of MDROs in nursing homes, the CDC recommends enhanced barrier precautions, that is the use of gown and gloves during high-contact resident care activities (eg, bathing/showering) that provide opportunities for transfer of MDROs to staff hands and clothing. These precautions apply to all residents with any of the following:

●Infection or colonization with an MDRO when contact precautions do not otherwise apply

●Wounds and/or indwelling medical devices (eg, central line, urinary catheter) [18,19]

Visitors and volunteers may also be a source of infection transmission. The Centers for Disease Prevention and Control recommendations about management of visitor access include hand hygiene, use of personal protective equipment while visiting residents on precautions, and limited movement within the facility. Visitors with respiratory symptoms should be asked not to visit, but if visitation occurs, they should wear masks and avoid contact with other residents [20].

Outbreak management — Outbreaks may be defined as an unusual increase in illness above baseline levels; outbreak surveillance and control should be a high priority.

Common causes of outbreaks in LTCFs include respiratory and gastrointestinal infections.

Details regarding outbreak management in LTCFs are found separately. (See "Outbreaks in long-term care facilities: Detection and management".)

Resident and staff health and safety — Infection protection and management for residents and staff include promoting immunization and antiviral prophylaxis. While the LTCF has a duty of care to staff, staff also have a responsibility to protect themselves and to not put others at risk.

Resident — On admission, each resident should have a complete history, review of immunization history, and physical examination [5]. The most important vaccines for older adult residents of LTCFs are COVID-19, influenza vaccine, pneumococcal vaccine, and tetanus-diphtheria toxoid vaccination [5,21].

●Influenza – Influenza vaccine, although less effective in LTCF residents, should be given annually. (See "Seasonal influenza vaccination in adults".)

Higher vaccination rates among both residents and staff of LTCFs have been associated with lower rates of influenza outbreaks [22]. However, vaccines are known to be less effective in older individuals and those with comorbidities. Thus, other measures need to be implemented to decrease the likelihood of residents in LTCFs contracting influenza [23].

●Pneumococcal pneumonia – Pneumococcal vaccine should be given at age 65 or on admission to the LTCF if the resident is over 65 years, unless the resident has been recently immunized. (See "Pneumococcal vaccination in adults".)

●Tetanus-diphtheria toxoid vaccination should be offered every 10 years. (See "Tetanus-diphtheria toxoid vaccination in adults".)

●Issues related to zoster vaccine are discussed separately. (See "Vaccination for the prevention of shingles (herpes zoster) in adults".)

Staff — Staff in LTCFs should have an assessment of immunization status at the start of employment. Annual influenza vaccination for staff in LTCFs is particularly important [5]. Increased vaccination coverage among staff has been shown to reduce the probability of infection in residents of LTCFs [24]. Issues related to immunizations for staff are discussed separately. (See "Immunizations for health care providers".)

Education on precautions to reduce the risk of transmission of bloodborne pathogens should be offered, and there should be an established mechanism for access to appropriate postexposure prophylaxis in the setting of bodily fluid exposure [5]. (See "Prevention of hepatitis B virus and hepatitis C virus infection among health care providers".)

Surveillance for infection — Surveillance is important for detection of outbreaks, changes in infection rates, and other issues requiring IPC intervention (including the need for additional training or staff education) [25,26]. The components of a surveillance system include a mechanism for data collection, a schedule and procedure for evaluation of data, dissemination of results, and mechanisms for action and follow-up. Monitoring of disease patterns over time may provide information on the effectiveness of changes in IPC practices and policies.

The scope of surveillance depends on the type of facility and available resources. Facility-wide surveillance provides information on the burden of infection and detects outbreaks, whereas targeted surveillance focuses on preventable infections with significant morbidity, requires fewer resources than facility-wide surveillance, and can be used to monitor targeted interventions to improve resident safety. Each facility should have a specific surveillance plan that includes the type of surveillance to be undertaken, the form of data collection, and the frequency of data reporting.

Surveillance data can be collected via periodic review of charts, laboratory reports, and other records. In addition, regular conversations with residents and nursing staff and clinical observations are important components of surveillance data collection [5,27]. Surveillance of adherence to IPC measures (such as hand hygiene compliance, catheter care, and resident and staff immunization rates) is also an important IPC component.

The frequency of data review depends upon the size and the nature of the LTCF. Larger facilities should examine data at least weekly, while smaller facilities can use a biweekly or monthly interval. As an example, a facility managing residents on ventilators has substantially different needs for surveillance than one with residents predominantly with dementia. (See "Outbreaks in long-term care facilities: Detection and management".)

Calculating crude infection rates (number of cases divided by resident census) is useful for identifying outbreaks within a LTCF, while calculation of risk-adjusted infection rates is most accurate for comparison of infection rates between facilities. It may be useful to express infection rates in terms of specific exposure (for example, calculation of infection associated with urinary catheter should use the number catheter-days) rather than an overall census denominator. One method for interfacility comparison of infection rates created a standardized regional data set to provide an external benchmark for interfacility comparisons [28].

Norway has developed an automated national register-based surveillance system for outbreaks in LTCFs. This has proved substantially more sensitive than traditional methods. In the pandemic, three times more SARS-CoV-2 clusters were identified than with previous methods [29].

Education and training — Training of staff is critical to effective IPC in LTCFs. The recent COVID-19 pandemic brought to light the lack of preparedness of the aged care sector for emergencies and an urgent need to improve IPC in this sector. Program planning and implementation as a statewide response to this need has recently been published [30].

Training should be formal and informal, sufficiently frequent to address needs arising from staff turnover, and should be readily understandable by all staff. Orientation for staff should include hand hygiene, modes of transmission of infection, assessment of residents for infection, and environmental cleaning. In addition, staff should know to report significant communicable symptoms (including cough, rash, or diarrhea) and that they should not have contact with residents while potentially infectious. Train-the-trainers, a standardized training approach to train IPC practitioners to promote hand hygiene, has been widely adopted internationally and well received [31]. Written procedures and guidelines should be developed addressing these topics.

Visitors and volunteers require appropriate IPC training, too. Whilst a study evaluating knowledge of volunteers before and after a training program (established when critical shortcomings were identified in one institution) showed substantial improvements, real life observance and sustainability should also ideally be monitored [32].

An online compendium of IPC resources may be developed including IPC tools, international resources, and educational slide blocks [33]. Standardized patient assessment tools have been developed to facilitate remote IPC assessment in LTCFs and to evaluate knowledge and practices. These tools may be used proactively or in response to outbreaks [34].

Antimicrobial stewardship — Antimicrobial stewardship (AMS) in LTCFs should be tailored to the facility and may include guidelines for antibiotic use in the setting of suspected urinary and respiratory tract infections, antimicrobial restrictions, audit and feedback on antimicrobial prescribing, and education for medical staff, nursing staff, residents, and family members [5,35-40]. The CDC has provided guidance for initiating or expanding antimicrobial stewardship strategies in LTCFs on its website; implementing strategies from each of the outlined core elements (leadership commitment, accountability, drug expertise, action, tracking, reporting, and education) is considered necessary to implementing a successful antimicrobial stewardship program.

Use of antimicrobials in LTCFs is common [41,42]. In some circumstances, antimicrobials are administered for inappropriate indications and for protracted periods; examples include urinary tract colonization associated with catheter use and pressure sores that are not infected [41-44]. Challenges to appropriate antimicrobial prescribing in LTCFs include limited access to laboratory and radiograph support and off-site clinicians resulting in assessments based on phone call advice.

The Built Environment — Awareness of the importance of the "Built Environment" increased through the COVID-19 pandemic, with the understanding of the relative importance of airborne transmission over fomites in the spread of this infection. Substantial changes in the built environment were undertaken in many facilities, such as considering improving ventilation, spatial separation, and physical barriers [45]. The CDC developed and released recommendations for ventilation systems for nursing homes during the COVID-19 pandemic; the extent of implementation, however, may not be complete and often is associated with practical barriers to complete adoption, with ongoing aerosolized spread occurring [46].

Bundled interventions — In certain circumstances, a "bundled" approach to addressing a particular IPC issue may be warranted in LTCFs, particularly in the setting of an outbreak.

As an example, one investigation described a bundled intervention for reducing infection due to K. pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae [47]; interventions included screening for rectal colonization, contact isolation, daily chlorhexidine bathing, and staff education. In another study, universal decolonization with chlorhexidine bathing and intranasal povidone iodine, coupled with audits and staff training in wound care and device management, was associated with a reduction in infection-related hospitalizations and colonization with multidrug-resistant organisms [48].

ADDITIONAL RESOURCES — 

The United States Centers for Disease Control and Prevention (CDC) website is a useful resource for infection prevention and control (IPC) and antimicrobial stewardship fact sheets, articles, and presentations.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Infection control".)

SUMMARY AND RECOMMENDATIONS

●Types of long-term care facilities – Long-term care facilities (LTCFs) include nursing homes, skilled-nursing facilities providing postacute care, assisted living facilities, retirement homes, rehabilitation centers, long-term care hospitals, long-term psychiatric facilities, and institutions for individuals with intellectual disabilities. (See 'Introduction' above.)

●Epidemiology – Residents of LTCFs are at risk for infections circulating in the community as well as health care-associated infections. (See 'Epidemiology' above.)

●Components of an IPC program – LTCFs as part of their infection prevention and control (IPC) program must consider management and governance, standard and isolation precautions, outbreak management, resident and staff health and safety, surveillance of infections, education and training, antimicrobial stewardship, the built environment, and bundled interventions. (See 'Components of an infection prevention and control program' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Rhonda L Stuart, MBBS, FRACP, PhD, who contributed to an earlier version of this topic review.