The staff developer needs to promote staff education on the benefits of vaccination. Why are healthcare workers resistant to taking vaccines? The most common answer I hear to this question is fear of needle sticks.  There is also a lot of resistance to TB testing on the part of healthcare workers. The worker may insist without documentation, that they have always had a positive PPD, then request a chest x-ray in lieu of an intradermal needle stick. DSD in-service could point out the current national, state and local infection control recommendations do not support the use of a chest x-ray for convenience; it should be explained that compliance with TB testing is a condition of employment.

Educate your staff, patients and visitors; stress hand washing, the most effective deterrent to the transmission of infectious microorganisms. To prevent the transmission of MRSA, washing hands with regular soap and water reduces the numbers of organisms on the hands by washing them down the drain; this action alone, lessens the potential for transmission to others. Always use Standard Precautions and add Transmission Based Precautions if necessary. They are very closely related. Standard Precautions are what we use when we don’t know who has what. Transmission Based Precautions are used when we suspect or know with certainty there is an organism that can be avoided by applying Contact, Airborne or Droplet Precautions. CDC: Preventing MRSA in Healthcare Settings  

The bacteria are spread in the same way other Multi-drug Resistant Organisms are transmitted and those at highest risk are usually hospitalized patients who have been on extensive antimicrobial therapy and have already compromised immune systems.

What should be done about ESBLs in long-term care? First, determine if there is an existing policy. If so, take it to the Infection Control Committee, review it, update and sign off on it to make it current. If you don’t have a policy for ESBLs, now would be a good time to write one, announce its presence to the staff and educate them to its definition, treatment and potential precautions. Standard Precautions are a good place to start; utilize Transmission Based Precautions as indicated. The following document written by the International Infection Control Council is a good resource. ESBLs

The term Standard Precautions speaks for itself. These are basic precautions taken to reduce the possibility of coming in contact with infectious body fluids including blood, secretions, excretions, non-intact skin and mucous membranes. In other words, anything that is warm and wet, except for sweat. Standard Precautions include hand washing, using alcohol hand sanitizers when there are no visible signs of soiling, and barriers such as gloves, gowns, masks and goggles, depending on the situation.

Transmission Based Precautions offer an added level of protection when the route of transmission is suspected or confirmed.  See the CDC 2007 Isolation Guidelines for more information on Droplet, Contact and Airborne Precautions; Centers for Disease Control and Prevention 2007 Isolation Guidelines. There you will also find Appendix A for type and duration of isolation precautions (pg. 94). These recommendations are the accepted standard for hospitals and long-term care facilities.

Next: ESBLs 

Communication from nursing staff to physician could be one of the most important steps toward preventing the misuse of antibiotics. Treatment of suspected infections must be supported by accurately reporting pertinent data gathered by nurses experienced in using established surveillance tools.  McGeer’s Definitions of Infection  is the resource most commonly used for surveillance in long-term care. Nurses need encouragement and education to develop familiarity with established criteria and strong nursing observation skills.

Colonization is defined as the presence of an organism in or on the body but with no clinical signs and symptoms of infection. Infection is defined as tissue invasion by a microorganism accompanied by positive clinical signs and symptoms.

Since health care workers, patients and family alike, could potentially be unaware they are colonized with Multi-Drug Resistant Organisms, it follows they could easily be transmitted from one person to another. Inadequate hand hygiene is the root cause for transmission of pathogens in Long-Term Care and in all other health care settings as well. Health care workers, patients and visitors must do all they can to interrupt the cycle of transmission by consciously and conscientiously washing their hands. 

Multi-drug Resistant organisms are not more virulent than their non-resistant predecessors, but they may be more difficult to treat because they are resistant to many classes of antimicrobials.  Reducing exposure to MDRO’s is accomplished by using the same  approach to preventing transmission of all pathogens found in health care facilities.  

Use Standard Precautions at all times and Transmission Based Precautions for known or suspected infections. CDC Standard Precautions

Always practice responsible Hand Hygiene

Use optimum Room Placement of patients with known infections;  co-hort those with like infectious organisms.  

PPE (Personal Protective Equipment) use gloves, gowns and masks appropriately. Give frequent demonstrations on the correct procedures for donning, removing and disposing of PPE,  followed by staff return demonstrations.  CDC Donning and Removing PPE see illustrations on page 134 & 135 of the CDC 2007 Isolation Guidelines.

Assess patients for group activities. In general, if a patient’s wounds are covered and contained, if they are not exhibiting signs and symptoms of infection, and if they are able to demonstrate responsible hygiene practices, it is usually acceptable for them to leave their room. Check the Policies & Procedures for your facility. Conversely, if wounds cannot be covered and drainage contained, if the patient is confused or unable to engage in good hygiene practices, if they demonstrate clinical signs of infection such as fever, active vomiting/diarrhea or if they are coughing productively, they should remain in their rooms until their signs and symptoms have subsided. Again, review and educate your staff to your facility Policy & Procedures, which should be updated as needed for federal, state and local Standards of Care and Best Practice Guidelines.

What should you as the Infection Preventionist, do in this situation?

Confirm the nurses who have placed the calls to the physician have assessed the patient completely before calling and also confirm they have reported in detail, the fact that the patient is not exhibiting any signs and symptoms of UTI such as dysuria, flank pain, frequency, etc.

In-service the nursing staff on Urinary tract infection; use Mcgeer’s Definitions of Infection for surveillance in long-term care facilities (A. Mcgeer, MD, et all, 1991) this is the standard used in most long-term care facilities. The document can be found under resources on this site. Point out the differences between infection (positive signs and symptoms) and bacteriuria (the presence of bacteria in the urine with no signs and symptoms of infection). Remind nurses of the association between inappropriate use of antibiotics and C. Difficile disease. 

Call the patient’s physician, discuss the facts with him, ask if the patient could have bacteriuria and ask if he wants to continue current antibiotic therapy. If there is no resolution to the problem you should contact your facility’s Medical Director and ask for their expertise and possible intervention. See Pub Med.org 

Consider this a potential case of Shingles; This is the same virus that causes Chicken Pox, a disease that used to be prevalent in childhood until an FDA approved vaccine was developed in 1995 (CDC.gov/vaccines/2009). After Chicken Pox runs its course, the Varicella Zoster Virus remains dormant in the body for life, and in some cases, the virus re-surfaces years later as Shingles. The typical signs and symptoms of Shingles include a painful rash with fluid filled blisters that are limited to one side of the face or body. Headache, malaise and fever may also be present. Anyone who has had Chicken Pox, including children, may develop Shingles, but it is more common in older people, those with impaired immune systems or people on immunosuppressive drugs, such as steroids.

Report your findings in detail to the DON and the patient’s physician. Treatment for a confirmed case of Shingles may include prescriptions for anti-virals such as Zovirax, Acyclovir, or Valtrex. Pain medications may also be prescribed.

Educate patients, staff and family members; explain that Shingles itself cannot be transmitted to anyone else, in other words, you cannot “catch” Shingles, it is a re-activation of the Chicken Pox Virus. Draining blisters are potentially contagious to those who have never had Chicken Pox. If they come in contact with the draining blisters, they could be at risk for developing Chicken Pox. This is important information, especially to women who may be pregnant, because Chicken Pox can cause birth defects.

Standard precautions should be used for all patients in Long-term Care. The CDC’s 2007 Isolation Guidelines recommend Standard Precautions for Shingles. Contact Precautions may be used while the Shingles blisters are draining but once they are dried and crusted over, the patient is no longer considered contagious.

Patients and health care workers who have not had Chicken Pox should not be placed in contact with a patient diagnosed with Shingles while the blisters are draining. See CDC Shingles in Short.

The staff developer needs to promote staff education on the benefits of vaccination. Why are healthcare workers resistant to taking vaccines? The most common answer I hear to this question is fear of needle sticks. Fear of a needle stick is a meager excuse for not taking advan tage of Hepatitis B and Influenza vaccines. There is also a lot of resistance to TB testing on the part of healthcare workers. The worker may insist without documentation, that they have always had a positive PPD, then request a chest x-ray in lieu of an intradermal needle stick. DSD in-service could point out the current national, state and local infection control recommendations do not support the use of a chest x-ray for convenience; it should be explained that compliance with TB testing is a condition of employment.