Task Force/Recommendations For Long-Term Care Facilitie
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Task Force/Recommendations For Long-Term Care Facilities
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Nursing homes, other LTCFs, and other medical assisted living facilities pose a unique set of challenges from both the infection control and public health perspectives. Such facilities are not acute care hospitals, and the residents of these facilities are in some ways more similar to community residents than to patients requiring acute care in the hospital setting. At the same time, residents of LTCFs are typically medically fragile, though stable, individuals who may have chronic health conditions that do increase their risk for acquiring Legionnaires' disease if exposed. As such, residents of LTCFs represent a population whose public health needs merit consideration.
For nosocomial legionellosis, the following CDC case definitions are used :
Confirmed nosocomial case: laboratory-confirmed legionellosis that occurs in a patient who has been hospitalized [or otherwise institutionalized] continuously for > 10 days before the onset of illness.
Possible nosocomial case: laboratory-confirmed legionellosis that occurs in a patient 2-9 days after hospital [or other institutional] admission.
[Note: The incubation for Pontiac fever is shorter than for Legionnaires' disease; it is 1-3 days.]
For the purposes of this document, nosocomial infections shall include those acquired in hospitals, LTCFs, or other medical assisted living facilities.
Each LTCF should have a legionellosis control plan. This operational plan should address surveillance and reporting strategies, and when environmental (water distribution system) testing and remediation are necessary. Facility staff should be aware of the water treatment procedures used in the community. Water sources that do not use any residual chemical disinfection or use free chlorine as a residual disinfectant may be at increased risk when compared with water sources that use monochloramine as the chemical residual disinfectant [1,57,58].
I. Differential: Clinicians should consider Legionella species in their differential diagnosis for nosocomial pneumonia.
II. Urine Antigen: All LTCFs should provide Legionella urinary antigen testing either in-house, or contract with another laboratory that can report test results within 48 hours.
III. Cultures: All LTCFs should have a mechanism in place that allows them to submit primary specimens for Legionella cultures to a microbiology laboratory within 48 hours of specimen collection.
IV. DSHS as Reference Laboratory: The DSHS laboratory serves as a secondary reference laboratory for Legionella, with the capability to serotype, speciate, and characterize isolates on a molecular basis. Specimens from possible and definite nosocomial cases should be forwarded to the DSHS.
I. Passive Case Detection
If a resident of the LTCF is diagnosed with Legionnaires' disease, either while residing in the facility or within 9 days of transfer to an acute care hospital for pneumonia, the case should be investigated in a manner similar to the way cases are investigated in the hospital setting.
Any resident confirmed to have Legionella pneumonia who has resided in the LTCF for > 10 days prior to their onset of pneumonia should be considered a nosocomial case for that LTCF. Any resident in a LTCF who develops confirmed Legionella pneumonia from 2 through 9 days after admission should be considered potentially nosocomial to that LTCF. Any patient transferred to the LTCF who develops confirmed Legionella pneumonia from 2 through 9 days after admission should be considered potentially nosocomial to both the receiving and transferring facilities. The transferring facility should be notified of such cases.
Confirmed cases of Legionnaires' disease or Pontiac fever should be reported to the local health department (800-705-8868) as "definitely nosocomial," or "possibly nosocomial," or "not nosocomial" cases within one week of confirmed diagnosis. The report should be submitted on DSHS IDCU Form 5, 02/02; [Form] to the local health department. The local health department should also report to DSHS within one week of confirmed diagnosis. For confirmed cases, the local health department should conduct a site assessment to identify potentially high risk environmental factors.
Outbreaks (defined as two or more institutionally linked cases or possible cases within the same 6-month period) must be reported immediately to the local health department at 1-800-705-8868.
II. Active Case Detection
Once a possible nosocomial case is identified in a LTCF, increased surveillance should be implemented. At a minimum, this should include increased surveillance for pneumonia cases and the collection of clinical specimens (i.e. urine for antigen testing) to determine the etiology of all cases of pneumonia in any resident. Enhanced surveillance should continue for at least 6 months.
Environmental testing, in the context of legionellosis, is the sampling of water and plumbing structures of a facility's water distribution system. The Texas Legionnaires' Disease Task Force does not recommend baseline environmental testing for LTCFs.
Environmental testing should be conducted whenever there are one or more definite nosocomial cases or two or more possible nosocomial cases. Patients who are confirmed as cases are definitely nosocomial if they have not left the facility within the previous 10 days.
Procedures for Environmental (Water Distribution System) Testing
I. Environmental Testing Should Be Conducted According to a Standard Protocol.
II. Legionella Cultures Should Be Qualitative and Not Quantitative.
III. Serotyping and Species Identification Should Be Included in the Results; Hospitals Unable to Speciate Should Send Samples to a Reference Laboratory.
IV. The Results of Any Environmental Cultures Obtained Should Be Provided to Hospital Physicians in Order to Heighten Awareness of the Possibility of Legionella as a Cause for Nosocomial Pneumonia.
Prevention strategies for Legionella pneumonia should be developed and implemented by all LTCFs in Texas as part of their legionellosis control plan.
I. Primary Prevention: Prevention of Legionellosis in LTCFs with No Identified Cases
II. Secondary Prevention: Prevention of Legionellosis in LTCFs with Identified Cases
The following preventive measures should be initiated immediately whenever one definite or two possible nosocomial Legionella cases occurring within a 6 month period are identified: