Posté par ITgium le 27 October 2014
With a growing oriented elderly population, the nursing homes will be an important issue in China for the decades to come.
The Wolong intends to respond to the many questions being raised.
What could be a practical infection prevention program?
A review of current issues and challenges
In nursing homes, the acuity of illness of the elderly population has increased substantially in the last decade, as has the risk of acquiring new infections.
Nursing homes have been associated with high rates of morbidity and mortality.
It is well known that nursing homes residents are at risk of infection because of frequent hospital stays, advanced age, exposure to multiple courses of antibiotics and numerous comorbidities. Older adults also have a diminished immune response including phenotypic and functional changes in T-cells. Other factors include malnutrition, multiple comorbidities and polypharmacy, with use of medications that may diminish host defenses.
In addition, older adults with cognitive impairment may not be compliant with personal hygiene and hand washing, and may have functional impairment that leads to immobility, and urinary and fecal incontinence, thereby increasing their risk for acquiring new infections and for transmission of those infections.
Common infections in Nursing homes
Urinary tract, respiratory and skin and soft tissue infections are the most common endemic infections among nursing homes residents.
Epidemic infections commonly reported include viral gastroenteritis (such as norovirus infections), influenza and skin infections (e.g., methicillin-resistant Staphylococcus aureus and skin and soft tissue infections).
Antibiotic-resistant organisms are endemic in Nursing homes and can cause infections that may be difficult and expensive to treat.
Empirical and often inappropriate antimicrobial usage is extensive in all settings, but particularly in Nursing homes.
Outbreaks of seasonal influenza are reported frequently.
Pneumonia is an inflammatory condition of the lung affecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases.
Pneumonia and lower respiratory tract infections remain the leading cause of mortality in nursing homes residents and a primary reason for resident transfer to a hospital.
Pneumonia can manifest in the elderly with some atypical signs and symptoms, and may constitute a challenge for diagnosis in the NH setting.
Indeed, 25% of older adults may not develop fever in the presence of pneumonia and other infectious processes, and are less likely to complain of chills, myalgia and pleuritic chest pain compared with younger patients.
Aspiration pneumonia is common in the nursing homes population and is often associated with oropharyngeal dysphagia and regurgitation of gastric contents. Inadequate oral care significantly increases the risk for developing pneumonia.
Chest radiographs are helpful to define the presence of a new infiltrate, the severity of the disease and the presence of complications.
However, some nursing homes have limited or no access to radiological services, and the diagnosis is made clinically.
Urinary tract infection
UTI is the most common infection and perhaps the most over-diagnosed infection in Nursing homes. The presence of an indwelling urinary catheter increases the risk of both UTIs and bacteriuria.
For example, approximately 3–7% of nursinf homes residents with an indwelling urinary catheter will acquire a UTI with each day the catheter remains in place.
Guidelines to prevent indwelling catheter-associated UTIs include limiting the use of urinary catheters, minimizing the duration of urinary catheter use, diligent hand hygiene before and after any manipulation of the catheter, using aseptic technique to insert the catheter, maintaining a closed drainage system, and keeping the retention bag below the level of the bladder.
Viral and bacterial gastroenteritis cause the majority of diarrheal outbreaks in Nursing homes. Older adults are known to have a decreased production of gastric acid, and therefore, are at a higher risk for developing infectious gastroenteritis. The clinical course of gastroenteritis is usually self-limited.
Norovirus remains a common cause of gastroenteritis and is responsible for more than 50% of all gastroenteritis outbreaks worldwide.
Clostridium difficile is an emerging cause of infectious diarrhea in NHs.
Skin & soft tissue infections
Older Nursing homes residents are particularly predisposed to skin and soft tissue infections due to several physiologic changes that occur with aging, including atrophy of epidermis and dermis, reduced resistance to external insults, and prolonged wound healing.
Dry pruritic skin can serve as a portal of entry for pathogens. Acute bacterial infections in NHs include cellulitis, erysipelas and necrotizing fasciitis. Chronic wound infections, which are more common, include infected pressure ulcers, diabetic wound infections and vascular ulcers. Other skin infections include intertrigo, tenia versicolor, viral skin infections such as herpes zoster and simplex, and scabies.
Dental plaque has been particularly studied as a source of bacteria that may cause respiratory infections.
Some study showed an association between periodontal disease and increased mortality from pneumonia. These studies emphasize the need to provide adequate oral care to NH residents.
A systematic review of randomized controlled trials reveals that oral hygiene has positive preventive effects on pneumonia and respiratory tract infections in elderly hospitalized patients and NH residents, with absolute risk reductions of 6.6–11.7%.
The American experience
Population : 1.7 million people
Nursing homes : 16,000
Age : More than 88% of these people are 65 years of age and older, More than 45% are age 85 years and older.
An average of 2 million infections have taken place in nursing homes in the USA (2013).
Precise estimates on the prevalence and incidence of infections in nursing homes are difficult to obtain due to a remarkable diversity in those being cared for in this setting.