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.

To begin with, The Preventionist needs to be skilled at administering and interpreting PPDs. Classes are usually available for nurses at the County Health Department; this is a very worthwhile investment for every long-term care facility because realistically speaking, many facilities see frequent staff turnover and in the case of the staff developer, several nurses could be interpreting the results of PPD’s. What are their credentials? Have they been certified? Being a nurse does not infer the skills necessary to interpret redness, swelling, or indurations. One nurse may read an induration incorrectly this year and that reading will affect the results of the annual PPD next year.

The CDC has designed an excellent wall chart for the correct administration and interpretation of PPD’s. The poster is a large and provides actual pictures of administration and interpretations of real indurations. I have personally ordered these posters along with informational fact sheets and brochures to give to my facilities. These were cost free. 

Link for TB Interpretation Fact Sheets  

Link is for the PPD Administration and Interpretation wall chart; PPD Wall Chart

To get back to what you would do if an employee converted their annual PPD. If there is a conversion, a chest x-ray is ordered and is susequently read as negative by a Radiologist, what then? Is the employee simply sent back to work? Consider this; why would someone convert from a negative PPD to a positive? Either the reading was not accurately  interpreted or the person may have been exposed to some form of Tuberculosis. If a chest x-ray is read as negative, that may rule out an active TB cavitary lesion but it does not rule out latent TB. LTB is not infectious to other people but should be evaluated by the health department or a physician. At that time a decision will be made regarding treatment options for Latent TB.   

So my advice in the case of PPD conversions is to make sure the nurse who is administrating and interpreting the PPD is qualified to do so. If there is a conversion from negative to positive, always refer the healthcare worker to the County Health Department and follow their recommendations.  

I receive calls and questions from Staff Developers and Directors of Nursing on a daily basis.  Remember when we were young students working on a report and we asked our parents how to spell a word?  We wanted the answer immediately but instead, they told us to “look it up”. Now I sound like the parent but isn’t it a fact that when we take the time to “look it up” the answer stays with us? Here are some typical questions I may receive on any given day.

QUESTION:

In the past two days I have 15 residents with nausea, vomiting and diarrhea, what should I do?  

ANSWER:

What is your policy and procedure for managing outbreaks? It should be in your Infection Control Manual. Follow your Policies and Procedures. All outbreaks are reportable; call the patient’s physicians for orders. Notify the DON/Administrator and Medical Director. Notify the County Health Department and Licensing.  Initiate strict isolation precautions.  

QUESTION:

We have a patient who had a positive MRSA culture of the nares while admitted to the hospital. Does the patient need respiratory isolation in Long-term Care?

ANSWER:

What is your P & P for patients who are colonized (asymptomatic but culture positive)? This should be in your Infection Control Manual.

QUESTION:

We have a patient with MRSA in the urine. Can we put her in a room with a patient with a history of VRE? (Vancomycin Resistant Enterococcus)

ANSWER:

Your Infection Control manual should contain a policy on room placement of MRSA and VRE patients. It recommended they not be co-horted because the VRE patient is resistant to Vancomycin, the antibiotic used in the treatment of MRSA. If she picks up an MRSA infection, it will be more difficult to treat.  

QUESTION:

 We have a patient who needs a skin scraping to rule out Scabies, does the lab do that?

ANSWER:

Skin scrapings are considered an invasive procedure and should be collected by physicians or nurses who have had medical training in proper collection. In many states, Phlebotomists, LVN’s and unlicensed personnel are not qualified to do this. Your facility should have a P & P on the collection of specimens. Check your Infection Control Manual and check your state guidelines.

QUESTION:

I need environmental rounds and line listing forms.  Do you have any I could use?

ANSWER:

All of the forms you need should be included in your Infection Control Manual.

QUESTION:

We have a patient with Shingles (Varicella Zoster), is she contagious? Does she need isolation?

ANSWER:

The Infection Control Manual should contain P & P ‘S on patients with Shingles and on the types of isolation guidelines your facility adheres to. If not, look at the CDC 2007 Isolation Guidelines.  CDC Guidelines for Isolation Precautions  Appendix A.  

QUESTION

Do I have to report cases of C. Difficile to the County Health Department and licensing?

ANSWER:

Check in guess what? Your Infection Control Manual.  There should be a list of reportable diseases for your particular County Health Department.

When facing a dilemma most of us just want a quick answer but most of the answers to these questions can be found right in your own Infection Control Manual.  It is true, you might have to dig a little but becoming familiar with the manual is very important because if the Infection Control Committee has signed off on the manual, the implication is they have approved the policies and procedures and are following them.