Summary
There is a high prevalence of bacterial infections in long term care facilities (4.4 to 16.2%). This, together with the fact that antimicrobial resistance is a big concern in current medical practice, makes infection control so important in nursing home care.
This article covers the mechanisms of antibacterial resistance and focuses on 4 major antibacterial-resistant bacteria. Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA). Colonisation with MRSA is not uncommon in nursing homes and eradication is probably not necessary. Any clinically important enterococcal infection should be tested for high-level resistance. An infectious disease consultation should be sought for vancomycinresistant enterococcal infections. Gram-negative bacilli have developed multiresistance. Susceptibility testing can identify the most appropriate therapy. Multiresistance should also be considered when treating Streptococcus pneumoniae.
Overall, handwashing is highly recommended. Barrier precautions, minimising hospitalisations and avoiding unnecessary personnel rotation can reduce the chance of resistance spread.
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References
Garibaldi R, Brodine S, Matsumiya S. Infections among patients in nursing homes. Policies, prevalence, and problems. N Engl J Med 1981; 305: 731–5
Franson T, Duthie P, Cooper J, et al. Prevalence survey of infection and their predisposing factors at a hospital-based nursing home care unit. J Am Geriatr Soc 1986; 34: 95–100
Scheckler W, Peterson P. Infections and infection control among residents of eight rural Wisconsin nursing homes. Arch Intern Med 1986; 146: 1981–4
Alvarez S, Serventi I, Lorenz P. Nosocomial infections among patients in long-term facilities. J Gerontol 1988; 43: M9–16
Magaziner J, Tenney JH, DeForge B, et al. Prevalence and characteristics of nursing home-acquired infections in the aged. J Am Geriatr Soc 1991; 39: 1071–8
Katz PR, Beam TRJ, Brand F, et al. Antibiotic use in the nursing home physician practice patterns. Arch Intern Med 1990; 150: 1465–8
Shlaes DM, Currie-McCumber CA, Lehman MH. Introduction of a plasmid encoding the OHIO-1 beta-lactamase to an intermediate-care ward by patient transfer. Infect Control Hosp Epidemiol 1988; 9: 317–9
Strausbaugh LJ, Jackson C, Sewell DL, et al. Methicillin resistant Staphylococcus aureus in extended care facilities: experiences in a veterans’ affairs nursing home and a review of the literature. Infect Control Hosp Epidemiol 1991; 12: 36–45
Gaynes RP, Weinstein RA, Chamberlin W, et al. Antibiotic-resistant flora in nursing home patients admitted to the hospital. Arch Intern Med 1985; 145: 1804–7
Spratt BG. Resistance to antibiotics mediated by target alterations. Science 1994; 264: 388–93
Davis J. Another look at antibiotic resistance. J Gen Microbiol 1992; 138: 1553–9
Bush K. Characterization of beta-lactamases. Antimicrob Agents Chemother 1989; 33: 259–63
Shaw KJ, Rather PN, Hare RS, et al. Molecular genetics of aminoglycoside resistance genes and familial relationships of the aminoglycoside-modifying enzymes. Microb Rev 1993; 57: 138–63
Davis J. Inactivation of antibiotics and the dissemination of resistance genes. Science 1994; 264: 375–82
Cohen SP, Hooper DC, Wolfson JS, et al. Endogenous active efflux of norfloxacin in susceptible Escherichia coli. Antimicrob Agents Chemother 1988; 32: 1187–91
Levy SB. Active efflux mechanisms for antimicrobial resistance. Antimicrob Agents Chemother 1992; 36: 695–703
Nikaido H. Prevention of drug access to bacterial targets: permeability barriers and active efflux. Science 1994; 264: 382–8
Arthur M, Courvalin P. Genetics and mechanisms of glycopeptide resistance in enterococci. Antimicrob Agents Chemother 1993; 37: 1563–71
Hooper DC, Wolfson JS, Souza KS, et al. Mechanisms of quinolone resistance in Escherichia coli: characterization of nfxB and cfxB, two mutant resistance loci decreasing norfloxacin accumulation. Antimicrob Agents Chemother 1989; 33: 283–90
Courvalin P. Transfer of antibiotic resistance genes between Gram-positive and Gram-negative bacteria. Antimicrob Agents Chemother 1994; 38: 1447–51
Horan TC, White JW, Jarvis WR, et al. Nosocomial infection surveillance, 1984. MMWR CDC Surveill Summ 1986; 35: 17SS–29SS
Panilio AL, Culver DH, Gaynes RP, et al. Methicillin-resistant Staphylococcus aureus in U.S. hospitals, 1975–1991. Infect Control Hosp Epidemiol 1992; 13: 582–6
O’Toole RD, Drew L, Dahlgren BJ, et al. An outbreak of methicillin-resistance staphylococcus aureus infection. Observations in hospital and nursing home. JAMA 1970; 213: 257–63
Hsu CCS, Macaluso CP, Special L, et al. High rate of methicillin resistance of Staphylococcus aureus isolated from hospitalized nursing home patients. Arch Intern Med 1988; 148: 569–70
Frenay HM, Peerbooms PGH, van Leeuwen WJ, et al. Nursing homes: not a source of methicillin-resistant Staphylococcus aureus in the Netherlands [letter]. Clin Infect Dis 1994; 19: 213–4
Bradley SF, Terpenning MS, Ramsey MA, et al. Methicillin-resistant Staphylococcus aureus: colonization and infection in a long-term care facility. Ann Intern Med 1991; 115: 417–22
Feingold K, Siegler EL, Wu B, et al. Methicillin-resistant Staphylococcus aureus colonization in a new nursing home. Aging Clin Exp Res 1994; 6: 368–71
Muder RR, Brennen C, Wagner MM, et al. Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Ann Intern Med 1991; 114: 107–12
Reagan DR, Doebbeling BN, Pfaller MA, et al. Elimination of coincident Staphylococcus aureus nasal and hand carriage with intranasal application of mupirocin calcium ointment. Ann Intern Med 1991; 114: 101–6
Cederna JE, Terpenning MS, Ensberg M, et al. Staphylococcus aureus nasal colonization in a nursing home: eradication with mupirocin. Infect Control Hosp Epidemiol 1990; 11: 13–6
Kauffman CA, Terpenning MS, He X, et al. Attempts to eradicate methicillin-resistant Staphylococcus aureus from a longterm care facility with the use of mupirocin ointment. Am J Med 1993; 94: 371–8
Rahman M, Connolly S, Noble WC, et al. Diversity of staphylococci exhibiting high-level resistance to mupirocin. J Med Microbiol 1990; 33: 97–100
Rahman M, Noble WC, Cookson B. Mupirocin-resistant Staphylococcus aureus [letter]. Lancet 1987 Aug; 387
Mulligan ME, Murray-Leisure KA, Ribner BS, et al. Methicillin-resistant Staphylococcus aureus: a consensus review of the microbiology, pathogenesis, and epidemiology with implications for prevention and management. Am J Med 1993; 94: 313–28
Thomas JC, Bridge J, Waterman S, et al. Transmission and control of methicillin-resistant Staphylococcus aureus in a skilled nursing facility. Infect Control Hosp Epidemiol 1989; 10: 106–10
Ribner BS, Landry MN, Gholson GL. Strict versus modified isolation for prevention of nosocomial transmission of methicillin-resistant Staphylococcus aureus. Infect Control 1986; 7: 317–20
Brumfitt W, Hamilton-Miller J. Methicillin-resistant Staphylococcus aureus. N Engl J Med 1989; 320: 1188–96
Daum TE, Schaberg DR, Terpenning MS, et al. Increasing resistance of Staphylococcus aureus to ciprofloxacin. Antimicrob Agents Chemother 1990; 34: 1862–3
Schaberg DR, Culver DH, Gaynes RP. Major trends in the microbial etiology of nosocomial infection. Am J Med 1991; 91(3B): 72S–5S
Pallares R, Pujol M, Pena C, et al. Cephalosporins as risk factor for nosocomial Enterococcusfaecalis bacteremia. Arch Intern Med 1993; 153: 1581–6
Zervos MJ, Kauffman CA, Therasse PM, et al. Nosocomial infection by gentamicin-resistant Streptococcus faecalis. Ann Intern Med 1987; 106: 687–91
Murray BE. Minireview. Beta-lactamase-producing enterococci. Antimicrob Agents Chemother 1992; 36: 2355–9
Moellering RC, Korzeniowski OM, Sande MA, et al. Species-specific resistance to antimicrobial synergism in Streptococcus faecium and Streptococcus faecalis. J Infect Dis 1979; 140: 203–8
Zervos MJ, Terpenning MS, Schaberg DR, et al. High-level aminoglycoside resistant enterococci. Colonization of nursing home and acute care hospital patients. Arch Intern Med 1987; 147: 1591–4
Leclercq R, Derlot E, Duval J, et al. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med 1988; 319: 157–61
Leclercq R, Derlot E, Weber M, et al. Transferable vancomycin and teicoplanin resistance in Enterococcus faecium. Antimicrob Agents Chemother 1989; 33: 10–5
Shlaes DM, Bouvet A, Devine C, et al. Inducible, transferable resistance to vancomycin in Enterococcus faecalis A256. Antimicrob Agents Chemother 1989; 33: 198–203
Livornese LL, Dias S, Samel C, et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992; 117: 112–6
Terpenning MS, Bradley SF, Wan JY, et al. Colonization and infection with antibiotic-resistant bacteria in a long-term care facility. J Am Geriatr Soc 1994; 42: 1062–9
Michielsen W, Vandevondele D, Verschraegen G, et al. Bacterial surveillance cultures in a geriatric ward. Age Ageing 1993; 22: 221–6
Philippon A, Labia R, Jacoby G. Mini review. Extended-spectrum beta-lactamases. Antimicrob Agents Chemother 1989; 33: 1131–6
Chow JW, Fine MJ, Shales DM, et al. Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy. Ann Intern Med 1991; 115: 585–90
Rice LB, Willey SHP, Medeiros AA, et al. Outbreak of ceftazidime resistance caused by extended-spectrum betalactamases at a Massachusetts chronic care facility. Antimicrob Agents Chemother 1990; 34: 2193–9
Heikkila E, Sundstrom L, Huovinen P. Trimethoprim resistance in E. coli from a geriatric unit. Antimicrob Agents Chemother 1990; 34: 2013–5
Muder RR, Brennen C, Goetz AM, et al. Association with prior fluoroquinolone therapy of widespread ciprofloxacin resistance among Gram-negative isolates in a veterans affairs medical center. Antimicrob Agents Chemother 1991; 35: 256–8
Wingard E, Shales JH, Mortimer EA. Colonization and crosscolonization of nursing home patients with trimethoprim-resistant gram-negative bacilli. Clin Infect Dis 1993; 16: 75–81
Shales DM, Lehman M, Currie-McCumber CA, et al. Prevalence of colonization with antibiotic resistant Gram-negative bacilli in a nursing home care unit: the importance of crosscolonization as documented by plasmid analysis. Infect Control 1986; 7: 538–45
MacArthur RD, Lehman MH, Currie-McCumber CA, et al. The epidemiology of gentamicin-resistant Pseudomonas aeruginosa on an intermediate care unit. Am J Epidemiol 1988; 128: 821–7
Hofmann JH, Cetron MS, Farley MM, et al. The prevalence of drug-resistant Streptococcus pneumoniae in Atlanta. N Engl J Med 1995 Aug; 333: 481–6
Dawson S, Pallett A, Davidson A, et al. Outbreaks of multiresistant pneumococci [letter]. J Hosp Infect 1992; 22: 328–9
Friedland IR, McCracken GH. Management of infections caused by antibiotic-resistant Streptococcus pneumoniae. N Engl J Med 1994; 331: 377–82
Fiebach N, Beckett W. Prevention of respiratory infections in adults. Arch Intern Med 1994; 28: 2545–57
Butler JC, Breiman RF, Campbell JF, et al. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993; 270: 1826–31
McCue JD. Rationale for the use of oral fluoroquinolones as empirical treatment of nursing home infections. Arch Fam Med 1994; 3: 157–64
Centers for Disease Control. Prevention and control of influenza. Recommendations of the practices advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep 1995; 44(RR-3): 1–22
Belshe RB, Burk B, Newman F, et al. Resistance of influenza A virus amantadine and rimantadine: results of one decade of surveillance. J Infect Dis 1989; 159: 430–5
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Mao, CA., Siegler, E.L. & Abrutyn, E. Antimicrobial Resistance Patterns in Long Term Geriatric Care. Drugs & Aging 8, 162–170 (1996). https://doi.org/10.2165/00002512-199608030-00002
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DOI: https://doi.org/10.2165/00002512-199608030-00002