Studies have found residency in long-term–care facilities (LTCFs) a risk factor for influenza and pneumonia and have demonstrated that vaccinations against these diseases reduce the risk of disease. However, rates are below Healthy People 2010 goals of 90% for LTCFs. During 1999–2002, a multi-state demonstration project was conducted in LTCFs to implement standing orders programs for immunizations.

Identify nursing home resident–specific characteristics associated with vaccination coverage at baseline.

Facility-level data were collected from self-reported surveys of selected nursing homes in 14 states and from the On-line Survey and Certification Reporting System. Resident-level data, including demographics and physical functioning, were obtained from the Centers for Medicare & Medicaid Services' Minimum Data Set; 2000–2001 vaccination status was obtained by chart review. Influenza vaccination status reflected a single season, whereas pneumococcal vaccination status reflected vaccination in the past. Multilevel analysis was used to control for facility-level variation.

Of 22,188 residents sampled in 249 LTCFs, complete data were obtained for 20,516 (92%). The average coverage for immunizations was 58.5% ± 0.7% for influenza and 34.6% ± 0.3% for pneumococcal. On bivariate analyses, residents with cognitive, psychiatric, or neurologic problems were more likely to be vaccinated; those with accidental injuries, unstable conditions, or cancer were less likely to receive either vaccine. On multilevel analysis, the strongest resident characteristics associated with receipt of immunizations, controlling facility variation, were cognitive deficits and psychiatric illness.

The variation in baseline vaccination coverage associated with LTCF resident characteristics supports the need for strategies to increase vaccination coverage in LTCFs.

Antiviral prophylaxis is recommended for the control of institutional influenza A outbreaks. In long-term–care institutions other than nursing homes, neither the seriousness of influenza nor the risks and benefits of antiviral prophylaxis is clearly understood. We studied the severity of illness due to influenza among adults residing in a center for the developmentally disabled and assessed adverse reactions to amantadine and oseltamivir prophylaxis.

Data were collected from the charts of consenting residents. Complications of upper respiratory tract illness were recorded. Potential adverse events were documented during amantadine and oseltamivir therapy, and during a baseline period with neither medication.

The median age of the 287 participants was 46.4 years. Only 15 (5%) were older than 65 years, and 69 (24%) had chronic underlying medical illness placing them at high risk for influenza. Of the 122 residents with an upper respiratory tract infection, 16 (13%) developed pneumonia, 12 (9.8%) were hospitalized, and 5 (4%) died. Twenty-eight (25%) of 112 residents had an adverse neurologic event while receiving amantadine prophylaxis, compared with 3 (2.7%) receiving no antiviral medication and 5 (4.5%) receiving oseltamivir (P < .001). Sixteen percent of the residents discontinued amantadine due to adverse events; in contrast, adverse events were identified in 2.9% of the residents prescribed oseltamivir, and none discontinued therapy.

Viral respiratory tract infections are associated with a high risk of complications in this population. The rate of adverse neurologic events associated with amantadine was significantly higher than that associated with oseltamivir.

To report on the investigation of a summer outbreak of acute respiratory illness among residents of a Sydney nursing home.

An epidemiologic and microbiological investigation of the resident cohort at the time of the outbreak and medical record review 5 months later.

A nursing home located in Sydney, Australia, during February to July 1999.

The cohort of residents present in the nursing home at the time of the outbreak.

Public health interventions included recommendations regarding hygiene, cohorting of residents and staff, closure to further admissions, and prompt reporting of illness; and virologic and serologic studies of residents.

Of the 69 residents (mean age, 85.1 years), 35 fulfilled the case definition of acute respiratory illness. Influenza A infection was confirmed in 19 residents, and phylogenetic analysis of the resulting isolate, designated H3N2 A/Sydney/203/99, showed that it differed from strains isolated in eastern Australia during the same period. Serologic evidence of Bordetella infection was also found in 10 residents; however, stratified epidemiologic analysis pointed to influenza A as the cause of illness.

The investigation revealed an unusual summer outbreak of influenza A concurrent with subclinical pertussis infection. Surveillance of acute respiratory illness in nursing homes throughout the year, rather than solely during epidemic periods, in combination with appropriate public health laboratory support, would allow initiation of a timely public health response to outbreaks of acute respiratory illness in this setting.

During a hospital obstetric rotation, a medical student demonstrated classic symptoms of pertussis. The diagnosis was confirmed by isolation of Bordetella pertussis. Because this exposure occurred in a high-risk hospital setting, control measures were undertaken to prevent transmission and illness.

To identify secondary cases of pertussis, to determine compliance with chemoprophylaxis recommendations, and to monitor for adverse events associated with chemoprophylaxis following a hospital exposure to pertussis.

More than 500 individuals were potentially exposed, including 168 neonates; antimicrobial chemoprophylaxis was administered to 281 individuals. Fifty-eight neonates and 194 adults began azithromycin chemoprophylaxis; 18 neonates and 2 adults began erythromycin chemoprophylaxis.

Active surveillance was instituted for (1) secondary cases of pertussis among healthcare coworkers, obstetric patients, their neonates, and labor companions and (2) antibiotic compliance and tolerance.

No secondary cases of pertussis were confirmed by laboratory tests; however, 26 suspected cases and 5 clinically compatible cases were identified. Antibiotic courses were completed by 95% of the individuals who initiated therapy. Neonates taking azithromycin had statistically significantly less gastrointestinal distress compared with neonates taking erythromycin (12% vs 50%; P = .002); there were no cases of infantile hypertrophic pyloric stenosis.

Although it was not possible to assess the effectiveness of the antibiotic regimens, the lack of laboratory-confirmed secondary cases suggests control measures were successful. Data from the 58 neonates who received azithromycin suggest it may be well tolerated in this age group.

Indwelling urinary catheters are the most common source of infections in intensive care units (ICUs). The aim of this study was to evaluate the efficacy of nurse-generated daily reminders to physicians to remove unnecessary urinary catheters 5 days after insertion.

A time-sequence nonrandomized intervention study.

Adult ICUs (medical, surgical, cardiovascular surgical, neurosurgical, and coronary care) of a tertiary-care university medical center.

All patients admitted to the adult ICUs during a 2-year period. The study consisted of a 12-month observational phase (15,960 patient-days) followed by a 12-month intervention phase (15,525 patient-days).

Daily reminders to physicians from the nursing staff to remove unnecessary urinary catheters 5 days after insertion.

The duration of urinary catheterization was significantly reduced during the intervention phase (from 7.0 ± 1.1 days to 4.6 ± 0.7 days; P < .001). The rate of catheter-associated urinary tract infection (CAUTI) was also significantly reduced (from 11.5 ± 3.1 to 8.3 ± 2.5 patients with CAUTI per 1,000 catheter-days; P = .009). There was a linear relationship between the monthly average duration of catheterization and the rate of CAUTI (r = 0.50; P = .01). The excess monthly cost of antibiotics for CAUTI was reduced by 69% (from $4,021 ± $1,800 to $1,220 ± $941; P = .004).

This study demonstrated that a simple measure instituted as part of a continuous quality improvement program significantly reduced the duration of urinary catheterization, rate of CAUTI, and additional costs of antibiotics to manage CAUTI.

To determine the possible role of cockroaches in the epidemiology of nosocomial infections.

Epidemiologic investigation of bacteria and fungi in cockroaches and evaluation of the antibiotic resistance of the bacteria isolated from the insects.

Ninety hospitals in Kaohsiung City and Kaohsiung County in Taiwan.

Cockroaches were collected in clinical and nonclinical areas and microorganisms were isolated from their external surface and alimentary tract. The susceptibilities of Staphylococcus aureus, Enterococcus species, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, and Proteus species to 17 antibiotics were tested.

Cockroach infestation was found in 46.7% of the hospitals studied. Two hundred three cockroaches were collected (139 Periplaneta americana and 64 Blattella germanica). Periplaneta americana was found more often in nonclinical areas (64.5%) and B. germanica in clinical areas (78.1%). There was no statistically significant difference between Periplaneta americana (98.6%) and B. germanica (96.9%) regarding overall isolation rate (P > .05). However, 33 species of bacteria and 16 species of fungi were isolated from Periplaneta americana and only 23 and 12, respectively, from B. germanica. Resistance to ampicillin (13.7% to 100%), chloramphenicol (14.3% to 71.4%), tetracycline (14.3% to 73.3%), and trimethoprim-sulfamethoxazole (14.3% to 57.1%) was found in two gram-positive and five gram-negative bacteria.

Because cockroach infestation occurred in more than 40% of the hospitals and nearly all of the cockroaches harbored bacteria with multidrug resistance and fungi, cockroaches may play a potential role in the epidemiology of nosocomial infections in those hospitals.

To compare the efficacy of the polysaccharide pneumococcal vaccine in older adults between clinical trial and observational studies and to discuss the implications for long-term–care facilities (LTCFs).

A Medline search (to April 2003).

All meta-analyses of randomized and quasi-randomized trials of pneumococcal vaccines with placebo or no treatment were sought. All cohort or case–control studies were sought.

Of the 16 individual randomized clinical trials included in the reviews, 8 compared pneumococcal vaccine in individuals 55 years and older individuals. Only one study specifically addressed LTCF residents. Although no significant protective effect of the vaccine in elderly subpopulations was found, on the basis of wide confidence intervals and small subpopulation sample sizes, beneficial effects, particularly for pneumococcal bacteremia, could not be ruled out. Of the individual observational studies, 11 specifically evaluated vaccine efficacy in older adults. Vaccine efficacy was demonstrated in 9 of the 11 studies with no protective effect was shown in 2 studies.

Although the pooling of clinical trial data does not demonstrate significant efficacy of the pneumococcal polysaccharide vaccine in subgroups of older adults, these subgroup studies lacked power to show significant differences. Observational studies repeatedly demonstrate efficacy in older adults, and the vaccine has been demonstrated to be cost-effective and safe. It is strongly promoted by U.S. and Canadian advisory committees. On the basis of this available evidence, the pneumococcal polysaccharide vaccine should currently be recommended for older adults, especially those who are residents of LTCFs.