The Society for Health Care Epidemiology has drafted recommendations to help control antibiotic resistance in LTCFs and cross-infection include antibiotic restriction practices, surveillance, nontreatment of asymptomatic bacteruria, minimizing topical antibiotics, hand washing, and barrier precautions for wound care (108). We propose that, for LTCFs, the following additional items be specifically stressed (1) education, (2) surveillance, (3) antibiotic control, and (4) immunization.
Continuing medical education concerning the imprudent use of antibiotics needs to be the first step. Alerting staff to the dangers of excess antibiotic use and epidemiology of current outbreaks will help with enforcing infection control guidelines in the community. Education of nursing staff is also needed to determine if infection is really present. As a guide we encourage the use of the definitions of infection in LTCFs developed by McGeer and colleagues (110). Nursing personnel who are instructed in the use of these guidelines can assist physicians with treatment decisions. Infection control surveillance also helps to identify the presence and spread of resistance. It is our belief that identifying patients coming from hospitals where PRP, VRE, and ESBLs are endemic should be a nursing facility physician and infection control priority. Identifying nursing facility residents who have been treated with multiple courses of antibiotics in hospital will also alert health care workers to this potential problem. Although not proven in prospective studies, screening high-risk patients for colonization by antibiotic-resistant bacteria, particularly ESBLs, may help contain a potential outbreak (111). Screening for VRE should also be a consideration in high-risk LTCFs.
Clinicians should be "ecologically responsible" in their prescribing of antibiotics. The unnecessary use of broad-spectrum antibiotics to treat susceptible organisms should be strongly discouraged. There should be clear guidelines in place for using vancomycin in the nursing facility (e.g., MRSA, ^-lactam allergy, metronidazole failures in treatment of C. difficile colitis, or surgical prophylaxis in p-lactam-allergic patients). Limits to the length of antibiotic administration should also be enforced. Using third-generation cephalosporins and quinolones in LTCFs only when they are absolutely necessary in the treatment of UTIs or URI/LRTIs may limit the emergence of multiresistant Gram-negative bacilli and VRE. Restricting antibiotic formularies for LTCFs has been suggested as a potential means to this end. Alerting physicians to the number of treatment courses of quinolones or advanced generation cephalosporins used can stem overprescribing. Treatment algorithms are not yet a common practice in the nursing home and should be developed.
Immunization of the elderly with pneumococcal polysaccharide vaccine should also be a clinical and administrative priority. The vaccine should be strongly encouraged in everyone 65 yr and older admitted to an LTCF. It can be given at the time of influenza vaccine and should be part of a nursing facility admission medical care regimen. Care-
ful review of patient records should be undertaken to ensure immunization when the patient's or family's recollection is not reliable. Once administered, the information can be entered in a patient log book that serves as a reminder for the next immunization. Pneumococcal polysaccharide vaccination is extremely safe and can and should be repeated every 6 yr for select high-risk groups of elderly persons. (See Chapter 23.)
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