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The incidence of pneumonia in the United States has been estimated at 4 million cases annually, with 20% of episodes requiring hospitalization.1 Hazards of hospitalizing older patients have been well documented.2 Hospitalized older patients are at risk for developing complications such as falls, incontinence, and delirium. Functional deterioration occurs quickly after admission in a significant proportion of hospitalized older patients and typically fails to improve by the time of discharge.3 Studies of the effect of function on pneumonia outcomes in older adults have drawn conflicting conclusions.4,5 In a prospective study to evaluate risk factors for mortality from lower respiratory tract infections in nursing home residents, it was concluded that activity of daily living (ADL) dependency was an important predictor of mortality.4 Similarly, in a prospective study of pneumonia in a Department of Veterans Affairs facility, functional status was found to be a major determinant of survival after pneumonia.5 Alternatively, from a prediction model of 30-day mortality from pneumonia, functional status was not found to be a significant predictor of mortality in nursing home residents.6,7 Few studies have assessed the effect of functional status on pneumonia severity in hospitalized older adults.8,9 In a prospective evaluation of pneumonia in hospitalized community-dwelling older adults and nursing home residents, authors noted that pneumonia mortality was higher in the nursing home residents, but this was mainly attributed to poor baseline functional status.8 Functional status was an independent predictor of short-term and long-term mortality from pneumonia in a study that focused on older adults evaluated in an emergency department setting.9 The main objective of the current study was to examine the role of preadmission functional status on pneumonia severity through assessment of pneumonia presentation, length of stay (LOS), and 30-day mortality of adults aged 60 and older admitted to a university-based hospital. The secondary objective was to understand the effect of an acute infection such as pneumonia on short-term functional impairment.

Objective.To assess the response of long-term care facilities (LTCFs) to the 2004-2005 influenza vaccine shortage and the impact on resident and healthcare worker (HCW) immunization rates.Methods.A 12-item questionnaire was sent to 824 randomly selected LTCFs in December 2004. The following 2 open-ended questions were also asked: “How did you cope with the vaccine shortage?” and “Who helped you get your supply?” Immunization rates reported by LTCF administrators for 2003-2003 and 2003-2004 were compared with those for 2004-2005. Immunization rates were defined as the proportion of all eligible residents and HCWs who received influenza vaccine.Results.Responses were received from 380 LTCFs (46.3%), which had a total of 38,447 beds. Resident mean influenza immunization rates (±SD) decreased from 85% ± 15.3% in 2002-2003 and 85.1% ± 15.3% in 2003-2004 to 81.9% ± 19.4% in the 2004-2005 influenza season (P = .025). The immunization rates among HCWs also decreased from 51% in 2002-2003 and 2003-2004 to 38.4% in 2004-2005 (PConclusions.The influenza vaccine shortage in 2004-2005 impacted immunization practices of LTCFs across the United States, leading to decreases in both resident and HCW vaccination rates. The significant decrease in vaccination rates in LTCFs is of concern and has broad implications for policy makers working on emergency preparedness for a possible pandemic of influenza.

Mupirocin has been used in nursing homes to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA), despite the lack of controlled trials. In this double-blind, randomized study, the efficacy of intranasal mupirocin ointment versus that of placebo in reducing colonization and preventing infection was assessed among persistent carriers of S. aureus. Twice-daily treatment was given for 2 weeks, with a follow-up period of 6 months. Staphylococcal colonization rates were similar between residents at the Ann Arbor Veterans Affairs (VA) Extended Care Center, Michigan (33%), and residents at a community-based long-term care facility in Ann Arbor (36%), although those at the VA Center carried MRSA more often (58% vs. 35%; P = .017). After treatment, mupirocin had eradicated colonization in 93% of residents, whereas 85% of residents who received placebo remained colonized (P < .001). At day 90 after study entry, 61% of the residents in the mupirocin group remained decolonized. Four patients did not respond to mupirocin therapy; 3 of the 4 had mupirocin-resistant S. aureus strains. Thirteen (86%) of 14 residents who became recolonized had the same pretherapy strain; no strain recovered during relapse was resistant to mupirocin. A trend toward reduction in infections was seen with mupirocin treatment.

Objective:To examine the impact of introduction of an alcohol-based hand rub on hand hygiene knowledge and compliance and hand colonization of healthcare workers (HCWs) in a long-term-care facility (LTCF).Methods:Two floors of an LTCF participated. Ward A used the hand rub as an adjunct to soap and water; ward B was the control. HCWs' hands were cultured using the bag-broth technique forStaphylococcus aureus,gram-negative bacilli (GNB),Candida,and vancomycin-resistant enterococci (VRE). HCWs completed a questionnaire at baseline and after an educational intervention and introduction of rub.Results:Hand hygiene practices, knowledge, and opinions did not change after the educational or rub intervention. Ward A HCWs thought that the rub was faster (P= .002) and less drying (P= .04) than soap. Hand hygiene frequency did not differ at baseline between the two floors, but increased on ward A by the end of the study (P= .04). HCWs were colonized frequently with GNB (66%),Candida(41%), S.aureus(20%), and VRE (9%). Although colonization did not change from baseline on either ward, the rub was more effective in clearing GNB (P= .03) and S.aureus(P= .003). Nosocomial infection rates did not change.Conclusion:The alcohol-based hand rub was a faster, more convenient, less drying method of hand hygiene for HCWs in an LTCF, and it improved compliance. Although microbial colonization did not change, the rub was more efficacious in removing pathogens already present on the hands of HCWs.

OBJECTIVES: Mortality rates from pneumonia increase steadily with age. Recently, a disease severity model (the Pneumonia Prognosis Index (PPI)) has been developed to predict mortality from community-acquired pneumonia (CAP). PPI ranks severity of pneumonia from 1 to 5, with 5 being most severe. This retrospective study utilizes the PPI to address the prognosis of CAP in older adults. DESIGN: Retrospective review of medical charts. SETTING: Department of Veterans Affairs Medical Center. PARTICIPANTS: All adults aged 60 and older admitted to a Veterans Affairs Medical Center with CAP between January 1 and December 31, 1998. MEASUREMENTS: PPI was calculated using subjects' demographics, comorbidities, presenting symptoms, and laboratory measurements. RESULTS: Eighty-two patients aged 60 and older were admitted with 101 episodes of CAP. The mean age ± standard deviation was 72 ± 9. Seventy-four episodes were admitted from the emergency room, 20 from another hospital, seven from nursing homes, and five from outpatient clinics. Mean length of stay was 7.1 ± 6 days. Comorbid conditions included coronary artery disease, diabetes mellitus, congestive heart failure, neoplasm, stroke, and renal failure. Most episodes fell into higher PPI classes, with 20% in Class 3, 46% in Class 4, and 32% in Class 5. PPI score was significantly related to length of stay (P < .001), intensity of care (P < .0001), and presence of complications (P < .001). Mortality was 14% at 30 days: 0.5% in Class 3, 10.8% in Class 4, and 25% in Class 5. CONCLUSION: The PPI was effective in identifying older adults with CAP who were at risk of a poor outcome, but the practical utility of this index remains to be determined. Further prospective studies are required to elucidate the importance of comorbidities, severity at presentation, and premorbid functional status on clinical and functional outcomes of CAP in older adults. J Am Geriatr Soc 50:434–438, 2002.

Objectives To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia. Design Prospective longitudinal study nested within a randomized trial, using data from control sites. Setting Six NHs in southeast Michigan. Participants NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection). Measurements Clinical and demographic data—including information on incident infections, antibiotic use, and results of diagnostic tests—were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year. Results One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection. Conclusion Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.

Background Methicillin-resistant S. aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are endemic in post-acute care (PAC) settings. We characterize their transmission between patients and environment in 6 PAC facilities in SE Michigan. Methods In a multicenter prospective observational cohort study we collected surveillance cultures of nares, oropharynx, groin, perianal area, wounds, device site(s) and 10 environmental sites collected at enrollment, day 14, and every 30 days thereafter from 651 newly admitted patients. Pulsed-field gel electrophoresis (PFGE) and PCR for SCCmec, agr, and Panton–Valentine leukocidin (pvl) were performed for MRSA. PFGE, and vanA/vanB genotyping were performed for VRE. Results 386/651 (59%) participants were not colonized with MRSA at baseline, had more than 1 follow-up visit and were observed for 15,683 patient-days, over which 5,558 patient and 11,108 environmental swabs were collected. Of these 386 patients, 47 (12%) newly acquired MRSA and had complete strain typing available. 42% of strains were USA 100 HA-MRSA, and 31% were USA 300 CA-MRSA. 14% of strains were non USA 100–1100 strains. For 11/47 (23%), a related MRSA strain was isolated from the environment during the previous visit (Figure 1). 24/47 had a subsequent follow-up visit. In 13/24 (54%) a related MRSA strain was found in the environment on the next visit, suggesting transmission from the patient to the environment (Figure 1). For VRE, PFGE profiles showed high heterogeneity. Among 76 of 296 patients (followed for 11,580 days) who newly acquired VRE, a related VRE was found in the previous visit in 12% of patients, no VRE was found in the previous visit for 42 (55%), and an unrelated strain was present for 33%. In 37 patients for whom a follow-up visit was available, 22% had a related VRE strain in the environment on the subsequent visit and 27% had a new VRE strain. Conclusion New acquisition of VRE was more common than MRSA in this PAC population. Using molecular epidemiologic methods in this large prospective cohort, we show active, frequent and immediate bi-directional transmission between patients and environment. Diminishing environmental contamination has the potential to reduce MDRO transmission to patients in a setting where MRSA and VRE are endemic. Disclosures M. Cassone, National Institute on Aging: Grant Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support; C. Armbruster, Centers for Disease Control and Prevention: Investigator, Research support; E. S. Snitkin, Centers for Disease Control and Prevention: Investigator, Research support; K. Gibson, National Institute on Aging: Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support J. Mantey, National Institute on Aging: Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support; K. C. Reyes, Centers for Disease Control and Prevention: Investigator, Research support S. Altamimi, Centers for Disease Control and Prevention: Investigator, Research support; M. B. Perri, Centers for Disease Control and Prevention: Investigator, Research support; M. J. Zervos, Centers for Disease Control and Prevention: Investigator, Research support; L. Mody, National Institute on Aging: Grant Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support

Twenty-four hour reports are filled out by nurses daily to monitor nursing home (NH) residents and document any changes in residents’ status. Semi-structured interviews conducted with infection preventionists from 12 Southeast Michigan NHs showed that while 24-hour reports were used, they were not standardized for infection prevention activities. Our results indicate they can be an effective communication tool and potentially aid in early recognition of infections and outbreaks.

Tigecycline is one of the few remaining therapeutic options for extensively drug-resistant (XDR) Gram-negative bacilli (GNB). MICs of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by the Etest compared to determinations by the broth microdilution (BMD) method. The study aim was to compare the susceptibility of GNB to tigecycline by four different testing methods. GNB were collected from six health care systems (25 hospitals) in southeast Michigan from January 2010 to September 2011. Tigecycline MICs among A. baumannii , carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae , and susceptible Enterobacteriaceae isolates were determined by Etest, BMD, Vitek-2, and MicroScan. Nonsusceptibility was categorized as a tigecycline MIC of ≥4 μg/ml for both A. baumannii and Enterobacteriaceae . The study included 4,427 isolates: 2,065 ESBL-producing Enterobacteriaceae , 1,105 A. baumannii , 888 susceptible Enterobacteriaceae , and 369 CRE isolates. Tigecycline nonsusceptibility among A. baumannii isolates was significantly more common as determined by Etest compared to that determined by BMD (odds ratio [OR], 10.3; P < 0.001), MicroScan (OR, 12.4; P < 0.001), or Vitek-2 (OR, 9.4; P < 0.001). These differences were not evident with the other pathogens. Tigecycline MICs varied greatly according to the in vitro testing methods among A. baumannii isolates. Etest should probably not be used by laboratories for tigecycline MIC testing of A. baumannii isolates, since MICs are significantly elevated with Etest compared to those determined by the three other methods.

Importance Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice. Objective To review management of asymptomatic bacteriuria and symptomatic UTI and review prevention of recurrent UTIs in older community-dwelling women. Evidence Review A search of Ovid (Medline, PsycINFO, Embase) for English-language human studies conducted among adults aged 65 years and older and published in peer-reviewed journals from 1946 to November 20, 2013. Results The clinical spectrum of UTIs ranges from asymptomatic bacteriuria, to symptomatic and recurrent UTIs, to sepsis associated with UTI requiring hospitalization. Recent evidence helps differentiate asymptomatic bacteriuria from symptomatic UTI. Asymptomatic bacteriuria is transient in older women, often resolves without any treatment, and is not associated with morbidity or mortality. The diagnosis of symptomatic UTI is made when a patient has both clinical features and laboratory evidence of a urinary infection. Absent other causes, patients presenting with any 2 of the following meet the clinical diagnostic criteria for symptomatic UTI: fever, worsened urinary urgency or frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A positive urine culture (≥10 5 CFU/mL) with no more than 2 uropathogens and pyuria confirms the diagnosis of UTI. Risk factors for recurrent symptomatic UTI include diabetes, functional disability, recent sexual intercourse, prior history of urogynecologic surgery, urinary retention, and urinary incontinence. Testing for UTI is easily performed in the clinic using dipstick tests. When there is a low pretest probability of UTI, a negative dipstick result for leukocyte esterase and nitrites excludes infection. Antibiotics are selected by identifying the uropathogen, knowing local resistance rates, and considering adverse effect profiles. Chronic suppressive antibiotics for 6 to 12 months and vaginal estrogen therapy effectively reduce symptomatic UTI episodes and should be considered in patients with recurrent UTIs. Conclusions and Relevance Establishing a diagnosis of symptomatic UTI in older women requires careful clinical evaluation with possible laboratory assessment using urinalysis and urine culture. Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Asymptomatic bacteriuria in older women should not be treated.

Urinary tract infections (UTIs) are common, especially in older women Your urinary tract is made up of the bladder, the urethra, the ureters, and the kidneys. Urine is made by the kidneys. It then passes through the ureters to the bladder. It is stored in the bladder before leaving your body through the urethra.

A case-control study of patients with stools assayed forClostridium difficiletoxin over a 24-month period at a Veterans Affairs hospital found that the majority of cases (70.6%) occurred in temporal clusters. Clustering was particularly evident on a designated human immunodeficiency virus (RW) unit. Thirty-four (75.5%) of 45 HIV-infected patients withC difficile-associated diarrhea (CDAD) died during their hospitalization. Third-generation cephalosporins were the antibiotics most strongly associated with CDAD.

In this randomized clinical trial in nursing homes, manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding, did not significantly reduce the incidence of a first radiographically confirmed pneumonia compared with usual care.

Objectives We examined the molecular basis of the emergence of mupirocin resistance in a methicillin-resistant Staphylococcus aureus (MRSA) strain colonizing a nursing home resident undergoing mupirocin prophylaxis. Patient and methods A persistent carrier of mupirocin-susceptible MRSA participated in a trial of mupirocin for nasal decolonization among nursing home residents. During prophylaxis a high-level mupirocin-resistant MRSA emerged in the nasal isolates from this patient. S. aureus and coagulase-negative staphylococci were isolated prior to, during and after 14 days of mupirocin treatment. The staphylococcal isolates and their plasmids were examined by molecular genetic methods. Results All mupirocin-susceptible and -resistant MRSA isolates possessed the same genotype. The patient was also colonized by a single mupirocin-resistant Staphylococcus epidermidis strain. The mupirocin-resistant MRSA and S. epidermidis strains harboured identical plasmids that carried the mupA determinant and genes for conjugative DNA transfer in staphylococci. These plasmids could be transferred in vitro from both clinical isolates to S. aureus RN2677. Conclusions The MRSA strain contained a conjugative plasmid expressing mupA that was identical with that found in the S. epidermidis strain which colonized the patient. These findings suggest that transfer of mupA from S. epidermidis to MRSA probably occurred during mupirocin prophylaxis.

As they enter their retirement years, 76 million baby boomers with chronic illnesses will have an unprecedented impact on the health care system in the United States.1 Emerging provider-level accountable care organizations are charged with care management across the entire health care spectrum.2 For many older adults, residence in a nursing home (NH) is inevitable, and the “institution” truly becomes their “home.” Nursing homes also service a “short-stay” post–acute care population that is young, sick, prone to rehospitalization, and at a high risk of health care–associated complications like infections and adverse drug events. The Centers for Medicare and Medicaid Services, ie, the US taxpayers, pays over 60% of NH expenditure.3,4 As NHs become a partner in the health care delivery reform, they will undoubtedly be tasked to enhance the quality of care and resident safety to reduce inter-facility transfers. Most NHs are unprepared to address the myriad challenges posed by providing care for 2 disparate long-stay and short-stay populations within this emerging framework. In an effort to maintain a homelike environment and enhance the quality of life for older long-stay adults in NHs, physical environments are being designed as a “home” rather than a medical institution. Nursing home residents have greater autonomy in determining their daily care and other activities to synchronize with their “at-home” preferences.5 Close relationships between residents, families, staff, and community is encouraged. While laudable, timely, and right fully embraced, these preferential characteristics create a dichotomy between the need for a nurturing “home” environment for long-stay residents and the need to reduce health care–associated complications in higher-acuity short-stay residents. Caring for both short-stay and long-stay residents under the same roof raises the need to re-evaluate major areas of quality improvement. Nursing home care within the new health care framework will require a balance between the encouragement of highly individualized care and attention to quality-improvement programs to ensure vulnerable populations are safe. Let us consider infection prevention as an example. Health care workers, who are seen more as friends and helpers than nursing personnel, still need to enforce evidence-based procedures such as having residents perform hand hygiene before meals. Health care workers will need to practice hand hygiene and wear gloves as recommended, even when taking care of someone they have known for many years.6 Wearing masks for short periods to contain an influenza outbreak is still required even if it means using creative and alternative means of communication for the hearing impaired. Using door caddies for protective gowns and gloves may give the appearance of an “institutional environment” but are necessary equipment in rooms of high-risk people, such as those with Clostridium difficile infection. Nursing home residents are at high risk of acquiring multidrug resistant organisms from prior health care exposures and from other residents during their NH stay.7,8 Nursing homes offer many opportunities of unintentional and unrecognized transmission such as shared dining rooms, rehabilitation equipment, and other recreation areas. In hospitals, isolation in a private room with use of gloves, gowns, and barrier precautions is the primary approach to preventing transmission of multi-drug resistant organisms. In contrast with hospitalized patients who typically do not socialize with one another and for whom isolation is short lived, adoption of this strategy in NHs results in social stigma and isolation and constrains a homelike environment. For these reasons, the use of isolation precautions may be minimized to those patients who are unable to perform adequate personal hygiene or have wounds or uncontrolled secretions. Although it may be possible to minimize certain practices such as isolation precautions in NHs, other measures cannot be displaced in any institutionalized or homelike setting. A reluctance to install wall-mounted alcohol-based hand rub because of the fear that this evokes a “hospital-like environment” ignores the fact that these products significantly reduce pathogen transmission. Similarly, personal protective equipment (gowns, gloves, and masks) must be readily available at the point of care even if residents can see them. Finally, policies for outbreak response must be implemented rapidly even if that response temporarily interferes with care. How does infection prevention in NHs differ from home care? In home care, a caregiver is dealing with a single individual. In institutions, where people live together (eg, schools, military), infectious outbreaks are well known and the institutions have infection prevention processes in place. Nursing homes are no exception. In joint-living situations, infections are spread from person to person, from contaminated surfaces, or by droplets (eg, methicillin-resistant Staphylococcus aureus, group A streptococcus, norovirus, influenza). Additional pathogens, such as C difficile, vancomycin-resistant enterococci, and resistant gram-negative bacteria affect the debilitated and are resistant to antibiotics. These infectious agents are spread to other vulnerable residents by the hands of health care workers who become transiently colonized while going from resident to resident. These agents also spread to hospitals as patients move from NHs to acute care, making it a global health care issue. Rethinking infection prevention is but one dimension of an overall quality-improvement program and patient safety. Frequent readmissions to acute care in short-stay residents, antipsychotic use in long-stay residents, pressure ulcers, staffing ratios, leadership turnover, and survey-related violations need to be urgently addressed. A heightened awareness and deliberate response is required to prevent unintentional erosion of evidence-based quality improvement measures as older adults make frequent transitions from home to the hospital to a NH, each with their unique culture, philosophy, and goals of care. Efforts to define the best practices must focus on strategies that are effective in NHs and that limit disruption of social and rehabilitative activities. Quality-improvement personnel should be empowered to conduct innovative projects that reduce hospital transfers while enhancing resident outcomes. Even though short-stay Medicare residents account of approximately 10% of all NH residents, programs enhancing their quality of care will benefit the entire NH population and reduce readmissions. The accountable care organizations and academic medical centers should consider this care setting as an area prime for research and innovation. Only a strong strategic dialogue and partnership between NH leaders, quality-improvement programs, direct-care providers, consumers, and referring hospitals will assure that older adults receive high-quality care in integrated health care systems.

Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.Infect Control Hosp Epidemiol 2012;33(10):965-977

Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers.Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008.The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size.Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P.001), Chronic obstructive pulmonary disease (z = 3.9; P.001), and cancer (z = 8.5; P.001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease.With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes.

The epidemiology of new acquisition of antibiotic-resistant organisms (AROs) in community-based skilled nursing facilities (SNFs) is not well studied. To define the incidence, persistence of, and time to new colonization with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CAZ r ) and ciprofloxacin-resistant (CIP r ) Gram-negative bacteria (GNB) in SNFs, SNF residents were enrolled and specimens from the nares, oropharynx, groin, perianal area, and wounds were prospectively cultured monthly. Standard microbiological tests were used to identify MRSA, VRE, and CAZ r and CIP r GNB. Residents with at least 3 months of follow-up were included in the analysis. Colonized residents were categorized as having either preexisting or new acquisition. The time to colonization for new acquisition of AROs was calculated. Eighty-two residents met the eligibility criteria. New acquisition of AROs was common. For example, of the 59 residents colonized with CIP r GNB, 28 (47%) were colonized with CIP r GNB at the start of the study (96% persistent and 4% intermittent), and 31 (53%) acquired CIP r GNB at the facility (61% persistent). The time to new acquisition was shortest for CIP r GNB, at a mean of 75.5 days; the time to new acquisition for MRSA was 126.6 days ( P = 0.007 versus CIP r GNB), that for CAZ r was 176.0 days ( P = 0.0001 versus CIP r GNB), and that for VRE was 186.0 days ( P = 0.0004 versus CIP r GNB). Functional status was significantly associated with new acquisition of AROs (odds ratio [OR], 1.24; P = 0.01). New acquisition of AROs, in particular CIP r GNB and MRSA, is common in SNFs. CIP r GNB are acquired rapidly. Additional longitudinal studies to investigate risk factors for ARO acquisition are required.

Over 1.5 million people live in 16,000 nursing homes in the USA and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Emerging infections and antibiotic-resistant organisms in an institutional environment where there is substantial antimicrobial overuse and the population is older, frailer and sicker, create unique challenges for infection control. This review discusses the common infections, challenges, and a framework for a practical infection prevention program.

Background. Methicillin-resistant Staphylococcus aureus (MRSA) remains sensitive to vancomycin; when vancomycin-resistant S. aureus (VRSA) emerges, treatment becomes more complex. VRSA emergence is attributed to conjugative transfer of the vancomycin-resistance gene cluster from vancomycin-resistant enterococci (VRE) to MRSA. Because cocolonization with MRSA and VRE precedes VRSA development, this study investigates the epidemiology of cocolonization in skilled nursing facility (SNF) residents at high risk for MRSA or VRE colonization. Methods. A prospective observational study conducted at 15 SNFs in southeast Michigan. Overall, 178 residents (90 with indwelling urinary catheters and/or feeding tubes and 88 device-free) were cultured monthly for MRSA and VRE, and clinical data were recorded. Results. The incidence of MRSA/VRE cocolonization among residents with indwelling devices was 6.5 per 100 resident-months; 5.2 (95% confidence interval [CI]: 1.49‐18.1) times that among those without devices. MRSA/ VRE cocolonization in the device group occurred most frequently in wounds (4.1 per 100 resident-months). In a logistic regression analysis limited to residents with devices, functional disability (rate ratio [RR], 1.3; 95% CI: 1.1‐1.4) and wound presence (RR, 3.4; 95% CI: 1.4‐8.6) were independent risk factors of cocolonization. Conclusions. In a population of SNF residents, individuals with indwelling devices who also had functional disability or wounds were at greatest risk of MRSA/VRE cocolonization. These individuals should be routinely monitored for the presence of VRSA colonization.

We evaluated the prevalence of colonization with all gram-negative bacilli (GNB) and with ciprofloxacin-resistant GNB among nursing home residents with and without indwelling devices. We found that device presence increases the risk of colonization with all GNB and with ciprofloxacin-resistant GNB. Colonization with ciprofloxacin-resistant GNB increases with decreasing functional status.

To assess the knowledge of recommended urinary catheter care practices among nursing home (NH) healthcare workers (HCWs) in southeast Michigan.Self-administered survey.Seven NHs in southeast Michigan.HCWs.The survey included questions about respondent characteristics and knowledge about indications, care, and personal hygiene pertaining to urinary catheters. The association between knowledge measures and occupation (nurses vs aides) was assessed using generalized estimating equations.Three hundred fifty-six of 440 HCWs (81%) responded. More than 90% of HCWs were aware of measures such as cleaning around the catheter daily, glove use, and hand hygiene with catheter manipulation. They were less aware of research-proven recommendations of not disconnecting the catheter from its bag (59% nurses, 30% aides, P.001), not routinely irrigating the catheter (48% nurses, 8% aides, P.001), and hand hygiene after casual contact (60% nurses, 69% aides, P=.07). HCWs were also unaware of recommendations regarding alcohol-based hand rub (27% nurses and 32% aides with correct responses, P=.38). HCWs reported informal (e.g., nurse supervisors) and formal (in-services) sources of knowledge about catheter care.Significant discrepancies remain between research-proven recommendations pertaining to urinary catheter care and HCWs' knowledge. Nurses and aides differ in their knowledge of recommendations against harmful practices, such as disconnecting the catheter from the bag and routinely irrigating catheters. Further research should focus on strategies to enhance dissemination of proven infection control practices in NHs.

Pathogenicity islands (PAIs) are a specific group of genomic islands that contribute to genomic variability and virulence of bacterial pathogens. Using a strain-specific comparative genomic hybridization array, we report the identification of a 94-kb PAI, designated ICE Pm1 , that is common to Proteus mirabilis , Providencia stuartii , and Morganella morganii . These organisms are highly prevalent etiologic agents of catheter-associated urinary tract infections (caUTI), the most common hospital acquired infection. ICE Pm1 carries virulence factors that are important for colonization of the urinary tract, including a known toxin ( Proteus toxic agglutinin) and the high pathogenicity island of Yersinia spp. In addition, this PAI shares homology and gene organization similar to the PAIs of other bacterial pathogens, several of which have been classified as mobile integrative and conjugative elements (ICEs). Isolates from this study were cultured from patients with caUTI and show identical sequence similarity at three loci within ICE Pm1 , suggesting its transfer between bacterial genera. Screening for the presence of ICE Pm1 among P. mirabilis colonizing isolates showed that ICE Pm1 is more prevalent in urine isolates compared to P. mirabilis strains isolated from other body sites ( P < 0.0001), further suggesting that it contributes to niche specificity and is positively selected for in the urinary tract.

Healthcare delivery has moved from acute care hospitals to multiple settings, including subacute care, long-term care or nursing home (NH), rehabilitation, assisted living, home, and outpatient settings.

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption. Infect Control Hosp Epidemiol 2008; 29:1177-1180

To assess use of urinary collection devices (external, intermittent, and indwelling catheters; pads or briefs) and examine predictors of indwelling catheters in skilled nursing facilities (SNFs).Retrospective cohort study.SNFs in California, Florida, Michigan, New York, and Texas.All patients admitted to SNFs in 2003 who remained there for 1 year (N=57,302).Characteristics of patients who used different collection strategies (indwelling, intermittent, and external catheterization; pads or briefs) and predictors of indwelling urinary catheterization from the Nursing Home Minimum Data Set using multinomial logistic regression.The prevalence of indwelling catheterization was 12.6% at admission and 4.5% at the annual assessment (P.001). Intermittent and external catheterization were infrequently used (1% at admission and annual assessment). Paraplegia, quadriplegia, multiple sclerosis, and comatose state were strongly associated with indwelling catheterization. Male residents were more likely to use an indwelling catheter at every assessment, as were obese patients; individuals with diabetes mellitus, renal failure, skin conditions, deep vein thrombosis, aphasia, or end-stage disease; and those who were taking more medications.Coinciding with federal regulations, urinary catheterization was lower than has been reported previously and declined over time. Further reduction should be targeted at the evaluation of skin problems, appropriateness of multiple medications, and alternative measures in patients with diabetes mellitus, obesity, deep vein thrombosis, and communication problems.

Background. We sought to characterize the clinical and molecular epidemiologic characteristics of Staphylococcus aureus colonization (especially extranasal colonization) and to determine the extent to which communityassociated methicillin-resistant S. aureus (MRSA) has emerged in community nursing homes. Methods. The study enrolled a total of 213 residents, with or without an indwelling device, from 14 nursing homes in southeastern Michigan. Samples were obtained from the nares, oropharynx, groin, perianal area, wounds, and enteral feeding tube site. Standard microbiologic methods were used to identify methicillin-susceptible S. aureus and MRSA. Molecular epidemiologic methods included pulsed-field gel electrophoresis, PCR detection of Panton-Valentine leukocidin, and SCCmec and agr typing. Results. One hundred thirty-one residents (62%) were colonized with S. aureus (MRSA colonization in 86). S. aureus colonization occurred in 80 (76%) of 105 residents with indwelling devices and in 51 (47%) of 108 residents without indwelling devices ( ). Of the 86 residents who were colonized with MRSA, nares culture P ! .001 results were positive for only 56 (65%). Residents with devices in place were more likely to be colonized at multiple sites. Eleven different strains of MRSA were identified by pulsed-field gel electrophoresis. Seventy-three residents (85%) were colonized with hospital-associated SCCmec II strains, and 8 (9%) were colonized with communityassociated SCCmec IV strains, 2 of which carried Panton-Valentine leukocidin. Conclusions. Extranasal colonization with MRSA is common among nursing home residents—particularly among residents with an indwelling device. We documented the emergence of community-associated SCCmec IV MRSA strains in the community nursing home setting in southeastern Michigan.

There are few studies that have assessed factors influencing infection control practices among health care workers (HCW) in nursing homes. We conducted a cross-sectional survey of HCWs (N = 392) in 4 nursing homes to assess whether knowledge, beliefs, and perceptions influence reported hand hygiene habits. Positive perceptions and beliefs regarding effectiveness of infection control in nursing homes were associated with reported appropriate glove use and fingernail characteristics, respectively, among HCWs. Further research on hand hygiene interventions, including targeted educational in-services should be conducted in the nursing home setting.

Background Information regarding the incidence of antibiotic-resistant infection in residents of skilled nursing facilities is lacking. Methods The incidence and predictors of antibiotic-resistant infection were investigated in 56,182 long-term residents of 3314 skilled nursing facilities in California, Florida, Michigan, New York, and Texas. Results The annual incidence was 12.7 cases per 1000 long-term residents overall, which varied by state (highest incidence, New York) and type of admitting facility (highest incidence, rehabilitation hospital). The incidence was greater in younger residents, males, and residents with paraplegia, quadriplegia, peripheral vascular disease, or diabetes mellitus. Dialysis, urinary catheterization, feeding tubes, tracheostomy, and use of intravenous medications were associated with elevated risk. Adjusted odds ratios (ORs) were greatest in residents with paraplegia (OR = 2.86; 95% confidence interval [CI] = 1.67 to 4.89) and those receiving dialysis (OR = 2.84; 95% CI = 1.84 to 4.37). Conclusion There is significant variation in the risk of antibiotic-resistant infection by admitting diagnosis, device use, and facility characteristics.

Importance Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. Objective To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. Design, setting, and participants Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. Interventions Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. Main outcomes and measures The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. Results In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. Conclusions and relevance Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. Trial registration clinicaltrials.gov Identifier: NCT01062841.

Evaluate the effect of preadmission functional status on severity of pneumonia, length of hospital stay (LOS), and all-cause 30-day and 1-year mortality of adults aged 60 and older and to understand the effect of pneumonia on short-term functional impairment.Prospective cohort study.University hospital.One hundred twelve patients with radiograph-proven pneumonia (mean age 74.6) were enrolled.Functional status and comorbidities were assessed using the Functional Autonomy Measurement System (SMAF) and Charlson Comorbidity Index. Clinical information was used to calculate the Pneumonia Prognostic Index (PPI).Eighty-four (75%) patients were functionally independent (FI) before admission, with a SMAF score of 40 or lower. Dementia and aspiration history were higher in the group that was functionally dependent (FD) before admission (P.001). The FI group had less-severe pneumonia per the PPI and shorter mean LOS+/-standard deviation (5.62+/-0.51 days) than the FD group (11.42+/-2.58, P.004). The FI group had lower 1-year mortality (19/65, 23%) than the FD group (14/28, 50%), and the difference remained significant after adjusting for Charlson Index and severity of illness (P=.009). All patients lost function after admission, with loss being more pronounced in the FI group (mean change 19.24+/-12.9 vs 4.72+/-6.55, P.001).Older adults who were FI before admission were more likely to present with less-severe pneumonia and have a shorter LOS. In addition, further loss of function was common in these patients. Assessment of function before and during hospitalization should be an integral part of clinical evaluation in all older adults with pneumonia.

Persistent colonization with Staphylococcus aureus was assessed in 22 nursing home residents. Eighteen residents (82%) remained colonized with the same strain found at baseline; 6 (33%) of 18 residents transiently acquired a new strain. Four residents (18%) acquired a new persistent strain. Residents colonized with methicillin‐resistant S. aureus were more likely to acquire a new strain (67%) than were residents colonized with methicillin‐susceptible S. aureus (20%) ( \documentclass{aastex} \usepackage{amsbsy} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{bm} \usepackage{mathrsfs} \usepackage{pifont} \usepackage{stmaryrd} \usepackage{textcomp} \usepackage{portland,xspace} \usepackage{amsmath,amsxtra} \usepackage[OT2,OT1]{fontenc} \newcommand\cyr{ \renewcommand\rmdefault{wncyr} \renewcommand\sfdefault{wncyss} \renewcommand\encodingdefault{OT2} \normalfont \selectfont} \DeclareTextFontCommand{\textcyr}{\cyr} \pagestyle{empty} \DeclareMathSizes{10}{9}{7}{6} \begin{document} \landscape $P=.04$ \end{d...

Background Studies on adherence to infection control policies in nursing homes (NHs) are limited. This pilot study explores the use of various infection control practices and the role of infection control practitioners in southeast Michigan NHs. Methods A 43-item self-administered questionnaire and explanatory cover letter were mailed to 105 licensed NHs in southeast Michigan. A second mailing was sent to the nonresponders 4 weeks later. Results Significant variability existed in adoption of various infection control measures with respect to time spent in infection control activities (50% of facilities having a full-time infection control practitioner), definitions used in monitoring infections, and immunization rates (influenza: range, 0%-100%; mean, 73.2%; pneumococcal: range, 0%-100%; mean, 38.5%). Conclusion Although strides have been made in infection control research in NHs, significant variations exist in implementation of infection control methods and guidelines. Future research should focus on identifying barriers to infection control in NHs.

Empirical and often inappropriate antimicrobial usage is extensive in all settings, but particularly in nursing homes (NHs).1 Frequently, a clinical course of antibiotics is initiated without an adequate clinical evaluation. For example, up to one-third of prescriptions for suspected urinary tract infection in NH residents are for asymptomatic patients who are bacteriuric.2 Inappropriate antibiotic usage also results from errors in drug choice, the duration or dosage of antibiotics, and the lack of appropriate laboratory testing. Unnecessary and inappropriate use of antimicrobials, like other systemic drugs, has dire consequences such as drug interactions, adverse drug events, development of antimicrobial resistance, and excess costs.1,3-5 Although appropriate antimicrobial usage is desired, its application in NHs is challenging, predominantly as a consequence of delay in diagnosis due to the absence of on-site physicians, lack of clinical findings in older adults, presentation of infection with generalized systemic symptoms (such as confusion and falls) rather than infection-specific presentation, and lack of on-site diagnostics.1 Several strategies have been studied or proposed to reduce inappropriate antimicrobial practices in NHs. These include antimicrobial use review by the infection control committee to monitor antibiotics prescribed in the NH; development and promotion of programs to optimize judicious antibiotic use; and as-needed audits to assess antibiotic appropriateness, prevalence of antibiotic resistance, and antibiotic-related adverse events.1,6 A recent study in multiple NHs in the United States and Canada evaluated the effectiveness of a more-proactive approach to minimizing inappropriate antimicrobial practices.7 This study advocated the use of clinical algorithms targeted to physicians and nurses and implementing a multicomponent program of education, written material, real-time reminders, and outreach visits to reduce urinary tract infections in NHs. The authors showed a 31% reduction in antimicrobial use for urinary tract infections, although they did not show a reduction in overall antimicrobial use. In another randomized study in 20 NHs in the United States, a multicomponent educational intervention focusing on NH-acquired pneumonia led to a significant improvement in guideline adherence, but the study did not show a change in the use of oral antibiotics.8 This issue of the Journal of the American Geriatrics Society (JAGS) contains two articles that evaluate the effect of educational interventions to optimize overall antimicrobial prescribing for common infections in NHs.9,10 The first study, by Monette et al., was conducted in eight public NHs in Ontario, Canada.9 Their goal was to propose a realistic educational intervention to optimize antibiotic prescribing practices for a variety of infections, including urinary tract infections, skin and soft tissue infections, and pneumonia. Because a facility-wide intervention was used, cluster randomization design was employed to reduce the risk of contamination between study and control units. With the assistance of each facility pharmacist, they developed an antibiotic guide listing common infections; recommended empirical antibiotics; and the dosage, frequency, and duration of treatment. This guide was then mailed twice (2 months apart) to the physicians in the experimental arm. Data on antibiotic prescribing practices were also collected. They demonstrated that inappropriate antibiotic prescriptions decreased 20.5% in the experimental group, compared with 5.1% in the control group. As with any randomized, controlled trial, true effect, confounding, bias, or random error could explain these results. Their study design, sample size calculations, and multivariate analyses reduced the chances of random error and other confounding factors, although the study’s high refusal rate (19/30 NHs refused to participate), which could suggest that the study approach may not be generalizable to all NHs, could have introduced some bias. In addition, the need for an in-house pharmacist, because this intervention was essentially a pharmacist-directed intervention, could limit the applicability of this intervention. Nonetheless, the study demonstrated the effectiveness of mailing an antibiotic guide to physicians in reducing inappropriate antibiotic prescribing. The second study, by Schwartz et al.,10 evaluated the effectiveness of educational interventions targeted to physicians providing care at a single large hospital-based NH in Chicago, Illinois. Their intervention consisted of four teaching sessions, which included national guidelines, hospital resistance data, physician feedback, and distribution of booklets detailing institutional guidelines on optimal management of various infections found in NH residents. Their follow-up data showed improvement in the diagnosis of infection as reflected by the documentation of specific infections based on guideline-specific criteria. Furthermore, the authors noted improvement in antibiotic prescribing practices, aligning them more with their institutional guidelines for a sustained follow-up period of 2 years. Although their hospital-based NH facility had the advantage of on-site diagnostic capabilities and on-site infectious disease consultants, the study supports prior evidence that diagnosis and antibiotic prescribing can be improved in a sustained fashion by using educational interventions targeting healthcare providers. These studies prompt the obvious next research questions: Do these educational interventions aimed at adhering to established guidelines and optimizing antibiotic prescriptions eventually lead to reductions in morbidity, hospitalizations, and death and declines in antibiotic resistance? Do these interventions reduce drug interactions and adverse drug events? What are the short- and long-term cost implications? In summary, it is now well known that a significant proportion of antibiotic use in NHs is inappropriate and potentially harmful. Tough systemic challenges in diagnosing and effectively treating infections and the lack of clinical trials have limited prior efforts to optimize antibiotic use in this setting. Recent studies, including the two papers in this month’s JAGS, offer simple interventions that could lead to a change in prescribing practices among NH physicians, although periodic education and reminders for all healthcare staff will be required for a sustained effect. Although the facilities that implement these interventions may differ from the study facilities, the proposed interventions are achievable under the leadership of an effective champion Fan infection control practitioner or a medical director. With the growing body of evidence demonstrating the effectiveness of simple educational interventions, a proactive approach to curbing and eventually eliminating inappropriate antibiotic usage in NHs is no longer optional.

Background Many hospitalizations for residents of skilled nursing facilities are potentially avoidable. Factors that could prevent hospitalization for urinary tract infection (UTI) were investigated, with focus on patient mobility. Methods A retrospective cohort study was conducted using 2003–2004 data from the Centers for Medicare and Medicaid Services. The study included 408,192 residents of 4267 skilled nursing facilities in California, Florida, Michigan, New York, and Texas. The patients were followed over time, from admission to the skilled nursing facility to discharge or, for those who were not discharged, for 1 year. Cox proportional hazards regression was conducted with hospitalization for UTI as the outcome. Results The ability to walk was associated with a 69% lower rate of hospitalization for UTI. Maintaining or improving walking ability over time reduced the risk of hospitalization for UTI by 39% to 76% for patients with various conditions. For residents with severe mobility problems, such as being in a wheelchair or having a missing limb, maintaining or improving mobility (in bed or when transferring) reduced the risk of hospitalization for UTI by 38% to 80%. Other potentially modifiable predictors included a physician visit at the time of admission to the skilled nursing facility (Hazard Ratio (HR), 0.68), use of an indwelling urinary catheter (HR, 2.78), infection with Clostridium difficile or an antibiotic-resistant microorganism (HR, 1.20), and use of 10 or more medications (HR, 1.31). Patient characteristics associated with hospitalization for UTI were advancing age, being Hispanic or African-American, and having diabetes mellitus, renal failure, Parkinson's disease, dementia, or stroke. Conclusion Maintaining or improving mobility (walking, transferring between positions, or moving in bed) was associated with a lower risk of hospitalization for UTI. A physician visit at the time of admission to the skilled nursing facility also reduced the risk of hospitalization for UTI.

Background Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels). Methods A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded. Results Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, β2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16). Conclusion Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.