Antibiotic Resistance in Nursing Homes and Day Care Centers

What’s the Problem?

Bacterial infections are common in nursing homes and day care centers where bacteria can pass easily among people. Personal contact in these settings is very common and difficult to control; outbreaks of a bacterial infection occur easily. The bacterium Streptococcus pneumoniae (often called pneumococcus) causes many common infections like pneumonia and ear infections. It is a leading cause of illness and death in the U.S. each year.

Antibiotics are generally used to combat bacterial infections like pneumococcus. But because antibiotic use is so common (sometimes inappropriately prescribed) in both young and elderly populations, their care centers are often ideal settings for drug-resistant strains of pneumococcus to emerge. Between 10% and 40% of pneumococcus infections are drug resistant. Drug-resistant pneumococcal infections have been rising steadily over the past decade, and infection with a drug-resistant strain of pneumococcus can result in serious illness or death if the drug-resistance is not diagnosed soon enough.

In the past, pneumococcus infections could be cured with penicillin. But penicillin-resistant and multi-drug resistant strains of pneumococcus are emerging in the U. S. and are widespread in some groups of people. When bacteria become resistant to antibiotic drugs, treatment options diminish; what once were easily treated diseases can become more serious, even deadly.

Who’s at Risk?

The very young and the very old, who are often in day care and nursing homes, are at greatest risk for infections when outbreaks occur. People who work and live in nursing homes and children and workers in day care centers can develop antibiotic-resistant pneumococcus infections. Frequent use of antibiotic medications also puts people at risk for drug-resistant pneumococcus. Estimates are that every year pneumococcus causes 7 million cases of otitis media (ear infection) in children; 100,000 – 135,000 hospitalizations for pneumonia; 50,000 cases of bloodstream infection; and 3,000 cases of meningitis. Socioeconomic and other factors contribute to a high number of new cases each year among African American and American Indian populations.

Can It Be Prevented?

Yes, drug-resistant outbreaks can be prevented or reduced with careful use of antibiotics, and pneumococcus infections can be prevented with a vaccine.

Antibiotics cannot cure a cold, the flu, or bronchitis because these diseases are caused by viruses, not bacteria. People prescribed an antibiotic should follow the instructions carefully and take all of the antibiotic even if they begin feeling better before the medicine is finished.

Vaccines are often underused in nursing homes because many doctors do not see pneumonia as a problem or may not believe the vaccine is effective. Physicians may mistakenly believe that repeated vaccination is harmful, and it is difficult to determine whether a person has already been vaccinated. Only 45% of persons 65 years of age or older have been vaccinated; in most nursing home outbreaks, fewer than 5% of residents had been vaccinated.

The licensed vaccine is not effective for children under age 2. A new, but not yet licensed vaccine has just been tested in a large research study and appears to be highly effective in infants.

Tips for Scripts

• ENCOURAGE viewers at risk for pneumococcal infection to obtain vaccinations because most infections can be prevented with a vaccine.
• INFORM viewers that high-risk people include the elderly, children under 2, and people with weakened immune systems.
• REMIND viewers that overuse of antibiotics can make bacteria resistant. Careful use of antibiotics by health care providers and patients reduces resistance rates, serious illness, and even death.

Case Examples

1. Two weeks after healthy, 16-month-old Melissa starts at a day care center, she develops a fever and pulls on her ears. Her pediatrician diagnoses otitis media, a common bacterial ear infection, and prescribes an oral antibiotic. But Melissa’s condition grows worse and she is hospitalized with fever, vomiting, and lethargy. Spinal tap results show bacterial meningitis caused by pneumococcus, the same organism that caused her ear infection. She is put on IV antibiotics but with no improvement. An abscess develops in her brain, causing a coma. She is then put on vancomycin, the strongest antibiotic available, and starts to get better.
2. Several elderly nursing home residents visit a hospital emergency room; they have high fevers, shortness of breath, and coughing. Doctors suspect pneumonia, prescribe a standard antibiotic, and release the patients. A few days later, the patients return; blood tests reveal pneumococcal bacteria still in their bloodstreams. One resident dies; the hospital calls the state health department to investigate. They find the residents had not been vaccinated as recommended. The investigator is stumped by the antibiotic failures. More residents die and the investigation continues. Investigators learn of similar cases reported to the CDC, indicating a growing public health problem. The remaining patients are treated with an IV antibiotic and all other nursing home residents are vaccinated against pneumococcus, ending the outbreak.