Enhancing Infection Control for Elderly and Medically Compromised Patients

CLINICAL

PRACTICE

ENHANCING INFECTION CONTROL FOR ELDERLY A N D

M E D IC A L L Y

C O M P R O M I S E D

P A T IE N T S

STEPHEN K. SHUMAN, D.D.S., M.S. ; MARTHA L. MOCUSKER, M.D.; MARV K. OWEN, D.D.S.

nfection control in the dental office has taken center stage both within the profession and among patients. Dental professionals and patients alike are concerned about hepatitis B and hum an immunodeficiency virus transmission. To protect the public and the dental team, organized dentistry and government agencies, such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration, have promoted comprehensive infection control guidelines. These recommen­ dations cover barrier tech­ niques, instrum ent handling and sterilization, infectious waste disposal and hepatitis B immunization. While concerns about hepatitis B and AIDS are understandable, other more common conditions—influenza, tuberculosis and methicillinresistant S. aureus infection, for example—can be equally devastating to some patients. Dental professionals who work with older adults and people with underlying health problems should be aware of preventive and screening strategies for these illnesses. INFLUENZA

Symptoms of influenza, a viral illness, include abrupt onset of 76

JADA, Vol. 124, September 1993

A

B

S

T

R

A

C

T

Some patients may be at risk for complications from relatively common infectious diseases. Influenza, tuberculosis and methicillinresistant Staphylococcus aureus infection can lead to illness and even death in elderly, medically compro­ mised and institutionalized individuals. Dental personnel caring for these individuals should adopt preventive strategies that are simple and inexpensive in addition to standard infection control guidelines.

fever, aches, sore throat and a non-productive cough. While other common respiratory infections are brief, influenza may last several days and can lead to more severe illnesses like prim ary influenza pneumonia or secondary bacterial pneumonia.1 Influenza viruses are classi­ fied as A, B or C, according to their internal proteins. Influ­ enza, particularly influenza A, is a major cause of death and

illness in older adults and others with underlying health problems. It results in more frequent hospitalization in such individuals and, combined with pneumonia, ranks fourth among causes of death in the very old. Influenza-related mortality also results from exacerbation of cardiopulmonary and other chronic diseases. The CDC estimates th a t more than 10,000 deaths occurred during each of seven U.S. influenza epidemics between 1977 and 1988. Eighty to 90 percent of deaths attributed to influenza and pneumonia occurred in those aged 65 and older.1Even a moderate epidemic of influenza may cost over $300 million nationally in hospitalizations alone.2 Chronic medical problems place residents of long-term care facilities a t special risk for influenza complications. The virus also spreads rapidly in these settings. As many as 60 percent of nursing home residents may become ill during an influenza outbreak, and nearly 30 percent of those affected may die as a result of the infection, according to the CDC.3 Other high-risk groups for influenza-related complications include diabetics, people taking immunosuppressive medica-

CLINICAL PRACTICE

tions, and adults or children with chronic pulmonary, renal, liver or cardiovascular diseases. Children and teenagers on long­ term aspirin therapy are also at high risk for complications. Influenza B infection in these patients can lead to Reye’s syndrome, characterized by encephalopathy and liver dysfunction.4 Because treatm ent options for influenza are limited, prevention is emphasized— primarily by immunization. Yearly immunization is impor­ ta n t because viral variations cause the vaccine to be less effective in subsequent years. The vaccine is recommended for anyone in a high-risk group or those older than 65. H ealth care professionals who work with high-risk patients in hospitals, nursing homes, other chroniccare facilities and outpatient settings should also be immunized. Amantadine, an antiviral agent, is available for prophylaxis or therapy against influenza A. While it is not a substitute for immunization, am antadine can be used for treatm ent or prophylaxis during outbreaks in institu­ tional settings. It also offers short-term protection after late immunization or until influenza activity in the community has decreased. Amantadine also can benefit people who are immunocom­ promised and may not develop adequate antibodies after vaccination or those for whom immunization is contra­ indicated. Some patients, for example, are allergic to the vaccine. Amantadine has a number of side effects, including dry mouth. Universal precautions reduce 78

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the risk of influenza transm is­ sion during dental procedures. However, influenza also can be spread during personal contact before and after treatm ent. Therefore, dental personnel caring for high-risk individuals should be immunized every year. TUBERCULOSIS

Tuberculosis is caused by Mycobacterium tuberculosis. TB most often affects the lungs and is spread primarily by airborne particles. When a TB-infected individual coughs, aerosolized droplet nuclei are produced. These nuclei can remain suspended in the air for long periods and be inhaled by uninfected individuals. Once infected, an individual m ust be treated with an antituberculous agent to kill the organism. People with healthy immune systems generally do not become ill. Instead, they can harbor the infection, remaining asymptomatic, for years. They are not contagious during this period of latent infection. The only evidence of infection may be a positive TB skin test. Because of a sharp increase of cases reported nationally and outbreaks of multidrugresistant TB, the CDC regards tuberculosis as a greater concern today than at any other time in recent history.5 In 1984, 39,000 more TB cases were reported in the United States than expected, reversing the steady decline of cases reported since the 1950s. Much of this increase has been associated with HIV infection.5 About 10 to 15 million Ameri­ cans are now infected with TB, of whom nearly 10 percent eventually will develop active tuberculosis.5Almost 90 percent

of TB cases result from reactivation of an earlier infection.6 Older adults also account for a significant proportion of TB cases. In 1987, although they made up only 12 percent of the population, elderly people accounted for 27 percent of the TB-related deaths.7People who live in nursing homes are nearly twice as likely to have tuberculosis as communitydwelling elderly. The risk of infection for those who live in long-term care facilities also increases with each year of residence. A study of Arkansas nursing home residents found reactivity conversion rates, from negative to positive, of 3.5 to 5 percent per year.8The majority of TB cases among the elderly, however, still occur in community settings.5 Drug-resistant TB is now a further cause for concern. In a national survey, the CDC found th a t about 14 percent of cases reported in the first quarter of 1991 involved organisms resistant to at least one anti­ tuberculosis medication.5Three percent were resistant to the two first-choice drugs for TB treatm ent, rifampin and isoniazid. Between 1990 and 1992, the CDC also investigated 200 cases of MDR-TB in hospitals and prisons in Florida and New York.910 Most of these cases involved individuals infected with HIV and organ­ isms th a t were resistant to as many as seven antituberculosis drugs. While these organisms were detected in hospitals and prisons, their emergence in other long-term care settings is a major concern. These m ulti­ drug-resistant organisms appear more virulent, with

CLINICAL PRACTICE

higher m ortality rates than other organisms. MDR-TB is also characterized by a shorter interval between diagnosis and death. Transmission of MDRTB to health care workers, with some mortality, has been reported.1112 Neither the CDC nor OSHA has identified dentistry as high risk for TB transmission. However, one outbreak of TB was related to dental treatm ent in G reat B ritain.13Fourteen children and one adult were reportedly infected after tooth extractions performed by a dentist who had active TB. The extraction sites could have been contaminated with mycobac­ teria from the dentist’s fingers or by airborne particles if the dentist coughed or sneezed during the procedures. C urrent infection control precautions, such as masks and gloves, were not commonly used at th at time. Standard infection control measures, including face masks, should reduce the risk of air­ borne TB transm ission to dental staff. Despite this, dental personnel who have substantial exposure to high-risk groups— residents of long-term care facilities, correctional institu­ tions, the homeless or individ­ uals infected with HIV—should be tested for TB infection periodically. The CDC provides no firm recommendations on how often health care workers should be tested, but has recently begun to develop such guidelines.5The CDC has also proposed to develop guidelines th a t would require annual TB skin testing for non-health care profes­ sionals working in high-risk institutional settings, such as homeless shelters and prisons. 80

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TABLE

PREVENTING THE SPREAD OF COMMON INFECTIOUS AGENTS. INFECTIOUS AGENT INFLUENZA VIRUS

PREVENTIVE MEASURES

U n iv e r sa l preca u tion s A n n u al im m u n iza tio n A m a n ta d in e

RISK GROUP

P eop le 65 and older N u r sin g hom e r e sid e n ts R esid en ts o f chronic care fa c ilitie s (all a ges) P a tie n ts w ith chronic sy ste m ic d isea ses: p u lm on ary, cardio­ v a scu la r, m etab olic (e.g. d ia b etes), ren a l im m u n o su p p ressed in d iv id u a ls (H IV or m edication-induced) C h ild ren /teen a g ers (6 mo. to 18 yr.) on lo n g -term a sp irin th erap y

TB BACILLUS

U n iv e r s a l p reca u tion s

H IV -in fected in d iv id u a ls

A n n u a l TB scree n in g

N u r sin g hom e r e sid e n ts P riso n in m a te s T he h o m eless

MRSA

U n iv e r sa l p recau tion s Thorough, h a n d ­ w a sh in g

Individual state regulations vary considerably regarding the testing of employees in long­ term care facilities, although about half of them now require annual skin testing.14 METHICILL.IN-RESISTANT STAPHYLOCOCCUS AUREUS

S. aureus is a common hum an pathogen th a t may cause superficial skin and mucosal infections, as well as abscesses and systemic complications like pneumonia, gastroenteritis, osteomyelitis and septicemia.1516 Shortly after the introduction of methicillin, the first semisynthetic penicillin, in 1960, strains of resistant S.

A cu te care p a tie n ts N u r sin g hom e re sid e n ts D eb ilita ted in d iv id u a ls

aureus were reported. Since then, numerous reports of methicillin-resistant S. aureus from around the world have confirmed the rising incidence of this organism.17 MRSA is a nosocomial infection, primarily spread on the hands of health care workers. Residents of long-term care facilities are frequently affected—one study isolated MRSA cultures from 22 percent of the residents.18 Common sites of colonization include the anterior nares, pressure sores, sputum and stoma sites. There is relatively little information on the prevalence of oral colonization with this organism. Isolation of S. aureus

CLINICAL PRACTICE

from the mouth has been reported, but with minimal differentiation of bacterial strains.19'21A more detailed study in Japan, however, found th a t one-third of children tested for oral colonization by tongue culture were positive for S. aureus and six of the 100 strains isolated were resistant to methicillin.22 Patients who are colonized by MRSA are at greater risk for significant staphylococcal infections. One study reported a nearly fourfold increase in these infections among residents with persistent nasal colonization of MRSA.23 Dentists could encounter MRSA among at-risk individuals in the form of significant orofacial infections, such as acute parotitis, for which customary antibiotics may be ineffective.24 Infective endocarditis can also be caused by MRSA and may become more common as MRSA becomes more prevalent in hospitals, nursing homes and commu­ nities.25While MRSA-related endocarditis is thought to originate primarily from sources other than the mouth, the possibility of intraoral MRSA raises questions about the potential for MRSA bacteremia related to dental treatm ent. It is not clear th at resistant staphylococci are more virulent, but treatm ent generally requires an antibiotic such as vancomycin, which is not easily administered, costly and potentially more toxic to patients. Individuals with active clin­ ical infection due to methicillinresistant staphylococci should be treated with antibiotics in the appropriate fashion. How­ ever, management of people 82

JADA, Yol. 124, September 1993

colonized with MRSA is controversial. The organism is most commonly transm itted by hand contact, although infected body fluids can also spread the organism. It is not thought to be spread by the airborne route. Using antibiotics to clear the organism from carriers has been widely regarded as ineffective, although a topical antibiotic ointment of 2 percent mupirocin eliminated nasal and hand carriage of the organism in young health care workers for up to three months.26 Because individuals may be colonized for a prolonged period (a median of 118 days has been reported23), physically isolating colonized individuals is not practical. Isolating these patients from other residents also may be unethical because of the potential psychosocial consequences. Housing MRSAcolonized residents on designated units, or cohorting, has been proposed, but the feasibility of this approach is not known. Currently, prevention of MRSA infection relies on thorough handwashing and

Dr. Shuman is

Dr. Owen is a dental

director, Oral Health

fellow, Oral Health

S ervices for Older

Services for Older

A dults Graduate

A dults Graduate

Program, Depart­

Program, Depart­

ment of Preventive

ment of Preventive

S ciences, University

Sciences, University

of M innesota School

o f Minnesota School

of Dentistry, 15-136

of Dentistry, Minne­

M alcolm Moos

apolis. She is

Tower, 515 Delaware

supported by a

St. SE, Minneapolis

Faculty Training

55455-0348.

Grant in Geriatric

Address requests for

M edicine and

reprints to Dr.

Dentistry (PHS grant

Shuman.

No. 5D31AH95005).

universal precautions, with which the dental team is quite familiar. While some sugges­ tions have been made about the dental m anagement of MRSAinfected individuals,2728 there are as yet no firm studies on which to base specific recom­ mendations. Likewise, no current evidence supports routinely limiting dental care of colonized individuals. Though the likelihood of MRSA orofacial infection seems low, dental professionals should maintain some index of suspicion—especially when treating high-risk individuals who have significant orofacial infections. Laboratory culture and sensitivity testing are essential to conclusively identify MRSA as the causative agent in such infections. If MRSA is a factor, appropriate antibiotic therapy should begin promptly to avoid significant morbidity or mortality. CONCLUSIONS

Certain patients may be at higher risk for complications stemming from infections with certain common, and perhaps underestimated, agents. Influenza virus, tuberculosis bacillus and methicillinresistant S. aureus infections are among those posing extra risk to select individuals. Elderly, medically compromised or institutionalized patients are at particular risk. Dental professionals treating these patients should adopt some simple, inexpensive precautions in addition to current infection control guidelines. Annual influenza vaccination and TB screening, and a heightened awareness of MRSA infection are recom­ mended for dental pro-

CLINICAL PRACTICE

fessionals. ■ The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinion or official policies of the American Dental Association.

Dr. M cC u ske r is staff physician, Division of Geriatric Medicine and Extended Care,

1. Centers for Hennepin County Disease Control. Medical Center; and Prevention and assistant professor, control of influenza: Department of recommendations of Medicine, University the Immunization of Minnesota Practices Advisory M edical School, Committee (ACIP). Minneapolis. MMWR 1992;41(No. RR-9):1-17. 2. Centers for Disease Control. Influenza—United States, 1989-90 and 1990-91 seasons. In: CDC Surveillance Summaries, May 29,1992. MMWR 1992;41(No. SS-3):35-46. 3. Centers for Disease Control. Update on adult immunization: recommendations of the

Immunization Practices Advisory Committee (ACIP). MMWR 1991 ;40 (No. RR-12):34. 4. Seay AR. Reye’s syndrome. In: Conn’s current therapy, 1992. Philadelphia: Saunders; 1992:856-9. 5. Centers for Disease Control. National action plan to combat multidrug resistant tuberculosis; Meeting the challenge of multidrug-resistant tuberculosis: summary of a conference; M anagement of persons exposed to multi drug-resistant tuberculosis. MMWR 1992;41(No. RR-11)5-71. 6. Yoshikawa TT. Tuberculosis in aging adults. J Am G eriatr Soc 1992;40:178-87. 7. Centers for Disease Control. Prevention and control of tuberculosis in facilities providing long-term care to the elderly: recommendations of the Advisory Committee for Elimination of Tuberculosis. MMWR 1990;39(No. RR-10):7-13. 8. Stead WW, Lofgren JP, Warren E, et al. Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med 1985;312:1483-7. 9. Centers for Disease Control and Prevention. Nosocomial transmission of multidrug-resistant tuberculosis to health care workers and HIV infected patients in an urban hospital—Florida. MMWTl 1990;39(40):718-22.

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10. Centers for Disease Control. Nosocomial transmission of multidrug resistant tuberculosis among HIV-infected persons— Florida and New York, 1988-1991. MMWR 1991;40(34):585-91. 11. Beck-Sague C, Dooley SW, Hutton MD, et al. Hospital outbreak of multidrugresistant Mycobacterium tuberculosis infections. JAMA 1992;268:1280-6. 12. Centers for Disease Control. National action plan to combat multidrug resistant tuberculosis. MMWR 1992;4(No. RR-11)5-48. 13. Roderick Smith WH, Mason KD, Davies D, Onions JP. Intraoral pulmonary tuberculosis following dental treatment. Lancet 1982;1:842-4. 14. Crossley K, Nelson L, Irvine P. State regulations governing infection control issues in long-term care. J Am Geriatr Soc 1992;40:251-4. 15. Sheagren JN. Staphylococcus aureus: the persistent pathogen. Part I. N Engl J Med 1984;310:1368-73. 16. Sheagren JN. Staphylococcus aureus: The persisten pathogen. Part II. N Engl J Med 1984;310:1437-42. 17. Wenzel RP, Nettleman MD, Jones RN, Pfaller MA. Methicillin-resistant Staphylococcus aureus: Implications for the 1990s and effective control measures. Am J Med 1991;91(supplement 3B):221-7. 18. Murphy S, Denman S, Bennett RG, Greenough WB, Lindsay J, Zelesnick LB. Methicillin-resistant Staphylococcus aureus colonization in a long-term care facility. J Am Geriatr Soc 1992;40:213-7. 19. Knighton HT. Coagulase-positive staphylococci in oral and nasal areas of dental students: a four-year study. J Dent Res 1965;44:467-70. 20. Socransky SS, Manganiello SD. The oral microbiota of man from birth to senility. J Periodontol 1971;42:485-94. 21. Kondell PA, Nord CE, Nordenram G. Characterization of Staphylococcus aureus isolates from oral surgical outpatients compared to isolates from hospitalized and non-hospitalized individuals. In t J Oral Surg 1984;13:416-22. 22. Miyake Y, Iwai T, Sugai, M et al. Incidence and characterization of Staphylococcus aureus from the tongues of children. J Dent Res 1991;70:1045-7. 23. Müder RR, Brennen C, Wagener MM, et al. Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Ann Intern Med 1991;114:107-12. 24. Rousseau P. Acute suppurative parotitis. J Am Geriatr Soc 1990;38:897-8. 25. Bradley SF. Methicillin-resistant Staphylococcus aureus infection. Clin Geriat Med 1992;8:853-68. 26. Reagan DR, Doebbeling BN, Pfaller MA, et al. Elimination of coincident Staphylococcus aureus nasal and hand carriage with intranasal application of mupirocin calcium ointment. Ann Intern Med 1991;114:101-6. 27. Staat RH, Van Stewart A, Stewart JF. MRSA: an important consideration for geriatric dentistry practitioners. Spec Care Dentist 1991;11:197-9. 28. Antonelli JR, Valenza JA. Methicillinresistant Staphylococcus aureus: a crisis in infection control. Compend Contin Educ Dent 1993;14:22-30.