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MRSA and VRE in the nursing home
It is difficult to apply the practice of hospital infection control to the realities of a long-term care facility.
A plastic surgeon recently visited our VA long-term care nursing home (no IV services or respirators) to see, in consultation, a resident with a pressure ulcer on the leg that was colonized with methicillin-resistant Staphylococcus aureus (MRSA). The resident, who was alert and mobile in a wheel chair, was in a two-bed room and took his meals in the common dining room. He also took part in the daily social group activities of the nursing home. The pressure ulcer was kept covered with a dressing.
The surgeon, who had little experience with nursing homes, was appalled by our lack of what he considered adequate infection control measures. He did not understand how we could allow the resident to be in a two-bed room as opposed to an isolation room and be allowed to be in contact with other residents. He proceeded to describe how we should keep the resident isolated in a single room and impose strict precautions, preventing contact with other residents.
For those who do not have significant nursing home experience or responsibility, when dealing with residents who are colonized or infected with MRSA or vancomycin-resistant enterococci (VRE), it is difficult to apply the practice of infection control in the hospital environment to the realities and practicalities of infection control in the long-term care facility.
There are three major concepts that are operative in the nursing home environment when considering infection control issues and an infected or colonized resident. The first concept (which is the same as in the hospital environment) is to recognize actual or potential risks to other residents and take appropriate steps to minimize these risks; the keyword in the long-term care facility is “appropriate.” The second two concepts are factors that modify the first concept and stress the issue of appropriate steps: 1) the principle that resident lifestyle and function is paramount in a long-term care facility; and 2) the fact that funding for infection control personnel, equipment and procedures in the nursing home is minimal even at the best-funded facilities, and operationally, there is usually little feasibility of isolating or cohorting large numbers of residents.
Isolation not called for
Our facility is unusual in having both a part-time infection control nurse and a salaried, part-time infectious diseases specialist on staff. There is daily surveillance of infections (eg, pneumonia, diarrhea, cellulitis, etc.) and tracking of antimicrobial susceptibilities of isolates. While we follow universal precautions (ie, hand washing after every resident contact), we do not isolate or restrict activity of residents with MRSA or VRE colonization. Efforts are made to keep lesions covered with bandages. Residents with MRSA in sputum are asked to cough into tissues. Gloves are used for most resident care, and caretakers use gloves and gowns when there is a risk for contact with body fluids. There is no effort made to identify asymptomatic carriers.
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Some advocate various degrees of isolation or cohorting of residents who are colonized with MRSA or VRE. In fact, in the absence of an outbreak of infection caused by these organisms, there is little evidence in the literature for efficacy of isolation of the individual resident. Unlike the acute care hospital, there are no post-operative patients and few if any residents who are so immunocompromised (eg, neutropenic) that they are at high risk of infection from a carrier. To be sure, there is likely some risk associated with the individually colonized patient, but it is rare that an outbreak occurs.
It is not feasible to isolate all MRSA and VRE carriers. Many of the residents carry these organisms in their nasopharynx, skin, sputum, urine or feces, and identifying and isolating all carriers would be extremely expensive and next to impossible. Pressure ulcers are commonly colonized. Various studies have indicated that up to 25% of the residents may be colonized with VRE and up to 25% with MRSA in some nursing homes. More recent surveys would probably yield higher numbers. Of interest, there are usually multiple different strains of VRE and MRSA present in the nursing home at the same time. Part of the explanation for this observation is the fact that most of the colonization occurs when the resident is in an acute care hospital and not in the long-term care facility.
Making residents feel at home
Most important is the critical concept of maintaining the functional status of each resident at the highest possible level and maintaining their comfort, social skills and dignity. Preventing residents from eating in a common dining room or engaging in group social activities or rehabilitation is an unwarranted restriction that should not be undertaken unless it can be clearly demonstrated that doing so improves the health and outcomes of other residents. For example, isolating and applying special precautions to residents with untreated pulmonary tuberculosis clearly benefits the health of other residents. However, this is not the case with MRSA or VRE carriers unless an outbreak of infection occurs that can be traced to such a resident. The use of the term “resident” rather than patient is a fitting reminder that the facility is their home and that they need to be treated in a manner that is as close as possible to what is expected in their own home.
Colonized residents with large wounds that cannot be totally covered or those with sputum production who do not cough into a tissue constitute a higher theoretical risk to others and not surprisingly are often housed on a dementia unit. Decisions about isolation usually are made on a case-by-case basis. However, in the absence of an outbreak caused by an organism colonizing one of these residents, in my judgment, there is insufficient evidence in the literature to justify restricting the freedom of movement of even these residents except under extraordinary circumstances.
Donald Kaye has had a distinguished academic career, and even in “retirement” he remains fully active. Among other things, he is the medical director and a staff physician at a Pennsylvania Veterans Administration (VA) nursing home and before that was the principal investigator of a National Institute of Aging program project grant for more than 10 years. Thus he has extensive insights into the care of nursing home and life-care community residents. He has written extensively on infections, especially urinary tract infections, in the elderly. Among other appointments, he also serves as a member of the Infectious Disease News Editorial Board. His insights into the management of infection control issues in the nursing home environment are both instructive and humane.
– Theodore C. Eickhoff, MD
Chief Medical Editor
For more information:
- Donald Kaye, MD, is Medical Director and Staff Physician, Pennsylvania Veterans Administration (VA) nursing home, Gladwyne, Pennsylvania.