Long-Term Acute Care Hospitals

Clinical Infectious Diseases (Impact Factor: 8.89). 07/2009; 49(3):438-43. DOI: 10.1086/600391
Source: PubMed


Long-term acute care hospitals (LTACHs) are health care facilities that admit complex patients with acute care needs (eg,
mechanical ventilator weaning, administration of intravenous antibiotics, and complex wound care) for a mean duration of stay
of 25 days. LTACHs are different than nursing homes and were initially created in the 1990s in an effort to decrease Medicare
costs by facilitating prompt discharge from intensive care units of patients with difficulty weaning mechanical ventilation;
however, current admission diagnoses are quite broad. Patients admitted to these facilities have multiple comorbidities and
are at risk for colonization with multidrug-resistant organisms. LTACH patients have been shown to have high rates of hospital-acquired
infections, including central vascular catheter-associated bloodstream infection and ventilator-associated pneumonia. In addition,
LTACHs have been implicated in various regional outbreaks of multidrug-resistant organisms. This review summarizes the limited
amount of scientific literature on LTACHs while highlighting their infection control problems, as well as the role LTACHs
play on regional outbreaks.

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Available from: L. Silvia Munoz-Price
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    • "Although the main focus has been on multidrug-resistant infections in the hospital setting, community sources for β-lactamase-mediated resistances are being reported more frequently. Community-acquired ESBLs in locations such as nursing homes or long-term health care residences have been described for several years [31,32,60-62]. As one might expect, the even more deleterious plasmid-encoded carbapenemases are also being described in patients outside the hospital. "
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    ABSTRACT: Multidrug resistance has been increasing among Gram-negative bacteria and is strongly associated with the production of both chromosomal- and plasmid-encoded beta-lactamases, whose number now exceeds 890. Many of the newer enzymes exhibit broad-spectrum hydrolytic activity against most classes of beta-lactams. The most important plasmid-encoded beta-lactamases include (a) AmpC cephalosporinases produced in high quantities, (b) the expanding families of extended-spectrum beta-lactamases such as the CTX-M enzymes that can hydrolyze the advanced-spectrum cephalosporins and monobactams, and (c) carbapenemases from multiple molecular classes that are responsible for resistance to almost all beta-lactams, including the carbapenems. Important plasmid-encoded carbapenemases include (a) the KPC beta-lactamases originating in Klebsiella pneumoniae isolates and now appearing worldwide in pan-resistant Gram-negative pathogens and (b) metallo-beta-lactamases that are produced in organisms with other deleterious beta-lactamases, causing resistance to all beta-lactams except aztreonam. beta-Lactamase genes encoding these enzymes are often carried on plasmids that bear additional resistance determinants for other antibiotic classes. As a result, some infections caused by Gram-negative pathogens can now be treated with only a limited number, if any, antibiotics. Because multidrug resistance in Gram-negative bacteria is observed in both nosocomial and community isolates, eradication of these resistant strains is becoming more difficult.
    Full-text · Article · Jun 2010 · Critical care (London, England)
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    ABSTRACT: To evaluate the effect of bathing patients with 2% chlorhexidine on the rates of central vascular catheter (CVC)-associated bloodstream infection (BSI) at a long-term acute care hospital (LTACH). Quasi-experimental study. A 70-bed LTACH in the greater Chicago area. All consecutive patients admitted to the LTACH during the period from February 2006 to February 2008. For patients at the LTACH, daily 2% chlorhexidine baths were instituted during the period from September 2006 until May 2007 (ie, the intervention period). A preintervention period (in which patients were given daily soap-and-water baths) and a postintervention period (in which patients were given daily nonmedicated baths and weekly 2% chlorhexidine baths) were also observed. The rates of CVC-associated BSI and ventilator-associated pneumonia were analyzed for the intervention period and for the pre- and postintervention periods. The rates of CVC-associated BSI were 9.5, 3.8, and 6.4 cases per 1,000 CVC-days during the preintervention, intervention, and postintervention periods, respectively. By the end of the intervention period, there was a net reduction of 99% in the CVC-associated BSI rate. No changes were seen in the rates of ventilator-associated pneumonia during the preintervention and intervention periods. Daily chlorhexidine baths appeared to be an effective intervention to reduce rates of CVC-associated BSI in an LTACH.
    Full-text · Article · Sep 2009 · Infection Control and Hospital Epidemiology
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    ABSTRACT: To characterize isolates of Klebsiella pneumoniae producing KPC carbapenemase (KPC-Kp) associated with an outbreak in a long-term acute care hospital (LTACH) in South Florida. During 21 March to 20 April 2008, 241 K. pneumoniae isolates detected at Integrated Regional Laboratories (Ft. Lauderdale, FL) for which the ertapenem MICs were > or =4 mg/L were studied. PCR, cloning and sequence analysis were used to detect bla(KPC) and to characterize the beta-lactamase and outer membrane proteins (Omps). The expression level of KPC enzymes was studied by immunoblotting. Genetic relatedness of isolates was investigated with rep-PCR and PFGE. Clinical records of patients were investigated. Seven KPC-Kp strains were isolated from different patients located at a single LTACH, with a further three isolates being recovered from patients at different hospitals. All KPC-Kp isolates in patients from the LTACH and from one hospital patient were genetically related and shared PFGE patterns that clustered with known sequence type (ST) 258 strains. These strains were highly resistant to carbapenems (MICs > or = 32 mg/L) due to an increased level of KPC expression and loss of Omps. Rectal colonization was documented in all LTACH patients with KPC-Kp isolates. Treatment failures were common (crude mortality rate of 69%). Active surveillance and enhanced infection control practices terminated the KPC-Kp outbreak. The detection of KPC-Kp in an LTACH represents a serious infection control and therapeutic challenge in a new clinical setting. The speed at which the epidemic of KPC-Kp is spreading in our healthcare system mandates urgent action.
    Full-text · Article · Sep 2009 · Journal of Antimicrobial Chemotherapy
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