Long-Term Chronicles: Infection Surveillance Guidance in Long-Term Care Facilities

Long-Term Care Chronicles With Robbie Hilliard, MSN, RN, CIC

The CDC estimates that up to 70% of nursing home residents receive at least 1 course of systemic antibiotics a year. ¹ One of the best ways to decrease the unnecessary use of antibiotics is to practice antibiotic stewardship activities in long-term care (LTC) settings. Decreasing antibiotic usage can reduce adverse events, decrease antibiotic resistance, and improve outcomes for patients in the LTC setting. It is helpful to know the minimum criteria that should be used to initiate antibiotics in residents of LTC settings. Let’s discuss a few critical concepts that all LTC infection preventionists (IPs) should know.

McGeer Criteria

In 1989, experts in infection control were invited to a consensus conference to establish standardized definitions of infections. These definitions were intended exclusively for long-term care facilities that housed patients for 24-hour care under professional nursing supervision. As the number of patients in LTC facilities grew, surveillance criteria were needed to identify infections in this specialized setting consistently. Residents were advanced in age, cognitively impaired, had indwelling lines such as bladder catheters or gastric tubes, and often required assistance with activities of daily living.

The McGeer criteria, led by Allison McGeer, MD, were published in the American Journal of Infection Control in February 1991.^2,3 They have been revised several times to update various components to modern-day standards of care but remain the measure by which most IPs determine infections in LTC. The clinical value of the McGeer criteria is to determine the number of actual infections and estimate the incidence/prevalence of a specific type of infection.

Loeb Criteria

Nearly a decade later, another consensus conference of experts was held to establish minimum clinical criteria for the initiation of antibiotics in residents of LTC facilities. Headed by Dr Mark Loeb and colleagues, the findings were published in Infection Control and Hospital Epidemiology in February 2001.⁴ These became known as the Loeb criteria. These criteria were intended to inform clinical decision-making often before diagnostic testing results were available. Clinical criteria are on the side of caution, and empirical treatment for residents with a high likelihood of infection is recommended, not just for confirmed infections.

Critical terms

IPs need several critical tools to perform effective surveillance. Infection line lists are tables of key information about each potential case of an infection. Line lists provide demographic information such as name, age, location, symptoms, and any pertinent lab findings. The CDC provides some templates for line lists to aid in organizing data for review.⁵

Device use is also an essential factor in LTC infection surveillance. Awareness of central lines, indwelling Foley catheters, and other devices is essential when a patient shows signs of an infection. Access to positive labs such as microbiology cultures is a necessity as well. Some infections, such as catheter-associated urinary catheter infections, are contingent upon a minimum colony count to be considered a health care-associated infection (HAI).

Lastly, IPs need standardized constitutional infection criteria that are used consistently to assess each case. This can be the CDC criteria for HAIs or the criteria from the National Healthcare and Safety Network, which collects data and benchmarks for HAIs at the national and facility levels. Clear, descriptive documentation of symptoms is also helpful. For example, instead of just indicating “fever,” documentation should include the exact temperature reading, such as 100.9^◦F.

What’s the difference?

It is important to remember that infection surveillance definitions are intended to standardize what health care facilities deem “infections.” They are different from clinical decision-making criteria at the bedside. The criteria defining infections for surveillance purposes were selected to increase the likelihood that the events captured by applying the definitions are actual infections. Presentations of infection in older residents of LTC facilities may be atypical, so failure to meet surveillance definitions may not entirely exclude the presence of infection. Every patient is different and reacts to infections differently.

It’s also important to remember that the McGeer criteria are a retrospective review of clinical data. They look at completed labs and tests that are often unavailable when the patient is seen in a real-time clinical assessment. Failure to meet surveillance definitions does not always mean there was no infection present; conversely, a resident meeting the definition does not always mean an antibiotic was indicated.

While the McGeer criteria help determine if an HAI exists, the Loeb criteria help hold clinicians accountable for appropriate antibiotic initiation. IPs should be able to look at any antibiotics that have been started and see a clear indication using the standardized criteria established for antibiotic stewardship purposes. Again, clear documentation is key.

Often, clinicians may use clinical information such as foul-smelling urine, positive urinalysis, history of urinary tract infection, behavioral or mental status changes, or falls as reasons to start antibiotics. Still, these criteria do not meet standardized infection surveillance definitions for urinary tract infections.

This is where strong antimicrobial stewardship practices come into play and hopefully decrease the amount of unnecessary antibiotics prescribed. LTC surveillance is tricky but has come a long way since it began. These established criteria help level the playing field for all facilities regarding HAIs.

References

1. Antibiotic prescribing and use: core elements of antibiotic stewardship for nursing homes. CDC. March 18, 2024. Accessed December 7, 2024. https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html
2. McGeer A, Campbell B, Emori TG, et al. Definitions of infection surveillance in long-term care facilities. Am J Infect Control. 1991;19(1):1-7. doi:10.1016/0196-6553(91)90154-5
3. Stone ND, Ashraf MS, Calder J, et al; Society for Healthcare Epidemiology Long-Term Care Special Interest Group. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012;33(10):965-977. doi:10.1086/667743
4. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22(2):120-124. doi:10.1086/501875
5. Long-term care (LTC) respiratory surveillance line list. Long-term care (LTC) surveillance outbreak summary. CDC. Updated March 12, 2019. Accessed December 7, 2024. https://www.cdc.gov/long-term-care-facilities/media/pdfs/LTC-Resp-OutbreakResources-P.pdf