Breathe Easy

Managing respiratory infections in LTC facilities requires well-defined policies, effective surveillance & strong communication

by Joanne Kaldy

Respiratory infections continue to plague long-term care facilities, putting residents and staff at risk. Healthcare practitioners and providers face challenges in addressing these conditions, including identifying infections in cognitively impaired residents, preventing antibiotic resistance, and determining when infections can be treated in the facility and when residents should be transferred to a hospital.

While not a panacea, a combination of well-defined policies, effective surveillance, and solid staff communication and education can help facilities maximize respiratory infection management.

Identification Challenges

Respiratory infections are common in long-term care facilities. These include upper respiratory tract infections, such as pharyngitis and sinusitis, and lower tract infections, such as pneumonia and bronchitis. While all of these conditions can be serious in the long-term care setting, only pneumonia can prove fatal.

It can be difficult to identify respiratory infections in the elderly because they may not exhibit typical symptoms. David Mehr, MD, MS, associate professor, Department of Family and Community Medicine, University of Missouri, Columbia, noted that, in one of his studies, most of the patients identified as having pneumonia were coughing--although only about 40% had fever. He said that about 95% of pneumonia patients had at least one respiratory symptom, such as cough, new or increased sputum production, new or increased physical findings on chest examination, or breathing difficulty.

"One or two respiratory symptoms should alert you to a problem," he said, adding that it's also important to consider nonspecific symptoms, such as worsening confusion, decline in activity, decreased appetite, or increased falls.

The causes of respiratory infections differ between long-term care residents and community-dwelling elderly. Example: Because long-term care residents frequently have underlying conditions, such as chronic obstructive pulmonary disease, they are more likely to develop pneumonia due to Klebsiella pneumoniae or Staphylococcus aureus (which have higher mortality rates) than their community-dwelling counterparts.¹ Legionella pneumonia also is a concern in long-term care facilities.

Tests that are useful for other patient populations may not be as valuable when diagnosing the elderly. For instance, the isolation of an Enterobacteriaceae from the sputum of a resident with lower respiratory tract infection has a low predictive value for identifying the infecting microorganism.² Diagnosis of pneumonia in long-term care also may be hindered by lack of access to chest x-ray equipment and the difficulty of obtaining good sputum specimens from elderly individuals.³

Another diagnostic challenge: Often, long-term care residents are functionally impaired. Immobility increases the risk of infections, such as Methicillin-resistant S. aureus (MRSA). At the same time, impaired cognition can complicate identification.

"The identification of acute infectious diseases is especially difficult in residents with low baseline mental and functional status," said Paul Drinka, MD, CMD, medical director of the Wisconsin Veterans Home, King, Wis. "When a resident who is normally conversant, mobile, and involved in activities becomes ill, a change in status is easy to detect. On the other hand, a resident who is dependent and not conversant has little function left to lose; and they are unable to localize or communicate focal symptoms."

Dr. Drinka suggested that any change in functional status be followed by a focused respiratory assessment that includes vital signs, oximetry, specific inquiry regarding respiratory symptoms, and an assessment of respiratory signs including chest auscultation. For cognitively impaired patients, Dr. Drinka explained that decreased oral intake may be a "functional tip-off" suggestive of an infection.

Dr. Mehr emphasized that x-rays are helpful if readily available, but are not mandatory. It's important to note that results may appear normal if the resident is dehydrated. It may be necessary to rehydrate the resident to get a more accurate result. Of course, chest x-rays can show other pulmonary conditions (e.g., congestive heart failure, pulmonary malignancies, pulmonary fibrosis, or emphysematous changes), further complicating diagnosis.

Clinicians should not count on x-rays alone to determine treatment outcomes, as it may take up to 18 weeks for results to return to normal for elderly individuals with respiratory infections.¹

Nutrition (body mass index) and ability to perform activities of daily living can help predict mortality. Helpful lab values include blood urea nitrogen and a white blood count to determine if there is an increase in total counts as well as immature forms, or bands.

Antibiotics May Not Be the Answer

Determining treatment goals will help establish what interventions to implement. Chronically ill patients and those near the end of life are more likely candidates for palliative care--rather than aggressive care or curative treatment. Healthier patients have more treatment options.

"Individuals who are at low risk for mortality may be excellent candidates to have their infection managed in the facility, instead of being hospitalized," said Dr. Mehr, who suggested that the clinician determine the severity of the infection, the best course of treatment, and whether care should be delivered in the facility or the hospital. Then they should discuss all of this with the resident and/or the resident's family.

"Residents or family members often nix hospitalization as an option," he said. "We need to explain the pros and cons to them, outline our recommendations, and help them to make a decision that they can feel good about."

The Infectious Diseases Society of America (IDSA) suggests the following guidelines for hospital admission of residents with pneumonia:

• Severely abnormal vital signs, including a pulse rate over 125 beats per minute, a systolic blood pressure of less than 90, or a respiratory rate in excess of 30 breaths/min;
• An alteration in mental status from the patient's baseline;
• Hypoxemia (p0₂<60 mm mercury while breathing room air);
• Complications, such as emphysema, septic arthritis, meningitis, or endocarditis;
• Severe hematologic or chemical abnormalities, if markedly different from baseline (Na<130, Hct<30%, absolute neutrophil counts [ANC] <1,000, BUN>50, Cr>2.5); and
• Acute comorbidity, such as chronic obstructive pulmonary disease, pulmonary disease, neoplastic disease, congestive heart failure, cerebrovascular disease, renal or liver disease, each of which would require acute-care facility admission in its own right.

Dr. Mehr observed that strictly following the IDSA's guidelines may lead to the hospitalization of many patients who needn't or shouldn't be treated there. Instead, he advocates a more intensive surveillance system and individualized assessment.

Clues for Better Surveillance

An effective surveillance and early identification system enable staff and practitioners to treat patients before they become critically ill, better determine when hospitalization is appropriate, and ensure optimal treatment for each patient.

The best system is one that combines a formula⁴ with the clinician's judgment. "You can't just plug in a formula and expect it to work on its own," said Dr. Mehr. "But in conjunction with sound judgment, you can help identify people who may not look ill, but who are [or] vice versa.

"A good system potentially gives you an idea as to how likely a patient is to die, which--in turn--gives you clues as to how aggressively to treat them," he added. "If you decide that you will have to pull out all the stops to keep a patient alive, you need to determine if that is an appropriate course of action. Far too often, we see pneumonia and we automatically think 'hospitalization' and 'antibiotics.'"

Dr. Drinka has conducted yearly surveillance for influenza and viral respiratory illness that includes enlisting public health officials or the closest virology laboratory to track and report community viral isolates.⁵ An onsite registered nurse also tracks the date of onset of new respiratory illnesses and collects specimens for rapid diagnostic tests and viral cultures.

The Texas Department of Health offers these steps to establishing a surveillance system.

1. Determine:
   • Infections that your facility wants to identify and track;
   • Type of information needed to identify those illnesses;
   • Processes and procedures needed to collect needed information; and
   • Triggers for data collection (e.g., specific or nonspecific symptoms and physician orders, such as cultures or antibiotic medication).
2. Identify data sources, including staff reports, resident medical records, and independent residents assessments.
3. Follow up on all transfers to acute-care facilities.
4. Adopt written definitions for diagnosing nosocomial infections.
5. Collect data on a regular basis.

To view a sample data collection worksheet, visit http://mqa.dhs.state.tx.us/QMWeb/InfControl.htm and click "sample surveillance worksheet" in the text.

Reduce Antibiotic Anxiety

Guidelines from the American Thoracic Society and other sources recommend an empirical approach to selecting antibiotics for treating pneumonia and other respiratory infections. In the long-term care setting, the pathogens responsible for pneumonia shift toward S. aureus and gram-negatives, as well as aspiration of normal flora, including anaerobes. There also is a greater likelihood of infection with resistant organisms including MRSA and penicillin and/or levofloxacin-resistant pneumococcus.

"Unfortunately empiric therapy tends to select these organisms but may not cover them," observed Dr. Drinka, who believes inappropriate use of antibiotics can be lessened by a practitioner visit early in the course of treatment. He said that individual can identify residents who don't need antibiotic treatment.

Your facility's guidelines or policies regarding antibiotic use should "emphasize the fact that the empiric choice of antibiotics in respiratory infections and pneumonia should always be considered a precarious, monitored therapeutic trial," encouraged Dr. Drinka. "This trial may fail because of the existence of resistant organisms, recurrent aspiration, or an untreated comorbidity."

He also advocated reasonable attempts to obtain cultures, including a quality sputum specimen, and a complete blood count. "Cultures are especially important in the nursing home because of the possibility of resistant pathogens, such as MRSA or levofloxacin-resistant pneumococcus, that would not be covered by the usual empiric therapies," he said. "In addition, if a facility performs few cultures, practitioners have no basis for tracking the rise of antibiotic resistance or for selecting empiric antibiotics based on local data."

Breathe Easier with Effective Management

Respiratory infection control is different in long-term care facilities than in hospital settings because of their unique staffing issues and patient populations.

"One important aspect of respiratory infection management that seems to be neglected is the need to critically review current medications when there is a change in status," explained Dr. Drinka. "In the case of pneumonia, for example, one must re-evaluate the dose of diuretics and sedating medications."

Often respiratory infections are associated with decreased oral intake and dehydration, which complicate mobilization of secretions. Recurrent aspiration is a common cause of failure to respond to antibiotic therapy, so it is important to review the use of sedating medications.

This article originally appeared in Caring for the Ages, December 2003; Vol. 4, No. 12, p. 22-31. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission.

The opinions expressed by the authors are their own
and not necessarily those of AMDA or of Elsevier.