AMDA Clinical Practice Guideline:

26 Assisted Living Consult January/February 2006

nfections are a significant

source of illness and even

death in assisted living facili-

ties. It is estimated that between 1.6

million and 3.8 million infections

occur annually among residents of

long term care facilities including

ALFs. Furthermore, infections ac-

count for up to half of all resident

transfers from long term care facili-

ties to hospitals; and they result in

an estimated 150,000 to 300,000

hospital admissions annually.

Even when infections don’t re-

quir

e r

esidents to be transferred to

the hospital, these illnesses still are

dangerous and costly. The cost of

antibiotic therapy alone in long term

care facilities ranges from $38 mil-

lion to $137 million annually. And

outbreaks are always a concern. In

fact, outbreaks of infectious diseases

are common in long term care and

other communal living settings.

Infectious diseases are particular-

ly dangerous for elderly individuals,

many of whom already are frail and

have comorbid conditions such as

lung or heart disease. Older adults

residing in ALFs are particularly

prone to developing infection be-

cause of factors that r

esult in im-

paired immune defenses and in

increased risk of exposure to mi-

obes (see Table 1). In such set-

tings, infections can be acquired

through endogenous (within the

body) or exogenous (outside the

body) sources. Indwelling devices,

such as intravenous lines and uri-

nary catheters, are common causes

of infections. Exogenous infections

usually ar

e transmitted by direct

contact (eg, by hands), although

airborne and other forms of trans-

mission also may occur

. Poor hy-

giene (eg, oral) also can be a

source of infection.

This guideline focuses on the

four most common types of infec-

tions in long term care settings: uri-

nary tract, respiratory, gastrointesti-

nal, and skin infections.

Recognition

Because frail elderly residents are at

above-average risk of death and

complications from infectious dis-

eases, prompt recognition, assess-

ment, and tr

eatment of infections

are imperative.

Step 1. Does the resident have a

change of condition that suggests the

presence of an infection? Infection

AMDA Clinical

Practice Guideline:

Managing Common

Infections in the

Assisted Living Setting

January/February 2006 Assisted Living Consult 27

may pr

esent with localized symp-

toms or with generalized, nonspe-

cific ones. Table 2 lists condition

changes that may indicate infection

in an ALF resident.

Caregivers and/or family mem-

bers who assist and/or spend time

with residents should be encour-

aged to pr

omptly notify the duty

nurse of any condition change that

is suggestive of infection. The

nurse, in tur

n, should assess the

problem in a timely fashion. This

initial assessment may depend on

the specificity of the observations

or symptoms that suggest the pres-

ence of infection. For example, if

the resident complains of painful

urination, it is reasonable to consid-

er a possible urinary tract infection.

efore contacting the resident’s

primary care physician, the nurse

should gather relevant information

such as vital signs and medications.

The nurse should be prepared to

describe the resident’s symptoms

and signs as accurately and com-

pletely as possible.

It is important to note that as

many as one-third of elderly resi-

dents with acute infections may

present without a robust febrile re-

sponse. Basal body temperature in

the frail elderly may not be the so-

called “normal” value of 98.6˚ F

(37˚ C). Therefore, absence of a

fever should not be considered an

adequate reason to rule out the

presence of infection in the ALF if

other indicators are present. Acute

infection should be consider

ed a

possibility whenever a frail, elderly

resident experiences an acute

change in condition, regardless of

whether a fever is present.

Methods for taking a resident’s

temperature should be individual-

ized. It is not easy to obtain an ac-

curate temperature in a frail elderly

resident, and no single means will

work in all r

esidents. T

aking an

oral temperature may not be feasi-

ble in residents who have dementia

or are otherwise unable to hold the

thermometer in the mouth for the

required time period. Axillary tem-

perature often is inaccurate.

Some evidence suggests that rec-

tal temperature may be more accu-

rate than either the oral or axillary

method in ALF residents. Some in-

dividuals, however, may be unwill-

ing or unable to cooperate with this

method; and it is not advised in

esidents who have suspected or

confirmed diarrhea.

It also is important to note here

that just as infection may be pr

es-

ent in the frail elderly without a

fever, the presence of a fever does

not always indicate infection.

Step 2. Is the resident at risk for

able 1.

Susceptibility Factors for Infection Among Older

Adults Residing in Long Term Care Facilities

Factors that result in impaired host defenses

• Age-related decline in immune function

•

Comorbidities (eg, cancer, diabetes)

• Protein-energy malnutrition and volume depletion

• Peripheral vascular disease

• Medication use (eg, antibiotics, chemotherapy, steroids)

• Poor skin condition or impaired skin integrity

•

Kidney stones and impaired bladder emptying (eg, benign prostatic

hyperplasia)

Factors that result in increased risk of exposure to microbes

• Inability to follow appropriate

• Swallowing problems

• Use of indwelling devices,

•

Low rate of immunization

• Inadequate staff handwashing

• Recent hospitalization

• Infectious conditions among respiratory infections

Table 2.

Condition Changes That May Indicate the

Presence of Infection

Condition Changes That May Indicate the Presence of Infection

• Change in

••

Ability to perform activities of daily living

••

Intake of food or fluids

••

Mental status (eg, increasing confusion or lethargy)

••

Physical appearance

••

Skin temperature, color

••

Sleep pattern

••

Urine characteristics

••

ital signs

••

ound characteristics (eg, er

ythema, pus)

• Dizziness

• Puffy, red eyes; excessive tearing

• Fall or deterioration in balance or gait

•

Fever or hypothermia

•

Generalized pain

• Increased coughing, shortness of breath, lung sounds

•

New onset of diar

rhea or incontinence

• Sore throat

•

Suprapubic or flank pain

28 Assisted Living Consult January/February 2006

developing an infection? Table 3 lists

several common risk factors for in-

fection in the long term care setting.

Step 3. Perform a history and

hysical examination and order ap-

propriate laboratory tests. Appropri-

ate clinical evaluation, including di-

agnostic testing, should be done

promptly in all residents with sus-

pected symptomatic infection, un-

less an advance directive or the ex-

pressed wishes of a resident or

family member explicitly limits such

interventions.

Table 4 lists suggested elements

of the diagnostic workup for the

most common categories of infec-

tion in the ALF or other long term

care setting. Note that additional

laboratory tests may be more ap-

propriate for outbreaks of infection

than for isolated cases.

Step 4. Assess whether the resi-

dent’s condition warrants transfer to

a hospital. A

void hospitalization of

ALF residents to the extent possi-

ble. In addition to cost considera-

tions, residents generally benefit

from treatment in familiar surround-

ings. Among the elderly, hospital-

ization can increase discomfort and

confusion. Hospitalization also is

associated with an increased risk of

deconditioning, pressure ulcers,

and colonization with r

esistant or

ganisms.

Transfer to a hospital may be ap-

propriate—if it is consistent with

the resident’s advance directive—

when any of the following condi-

tion exists:

• The resident is clinically unsta-

ble, and the resident or family

desires aggressive intervention.

• Critical diagnostic tests are not

available in the facility or on an

outpatient basis.

• The scope or intensity of the re-

quir

ed treatment is beyond the

facility’s capacity.

• Specific control measures are not

available in the facility.

Step 5. Assess whether the resi-

dent’s condition warrants imple

mentation of heightened infection

control precautions. The U.S. Cen-

ters for Disease Control and Pre-

vention (CDC) recommends apply-

ing a two-tiered system of infection

precautions, as follows:

• Standard precautions should be

applied to all residents. They are

designed to reduce the risk of

transmission of infectious agents

in moist body secretions. Stan-

dard precautions emphasize

handwashing, gloves (when

touching body fluids), masks,

eye pr

otection, and gowns

(when splashing of body fluids

is likely) as well as avoidance of

needlesticks and other sharps in

juries.

• Transmission-based precautions

should be used for r

esidents

with documented or suspected

transmissible infectious diseases.

Transmission-based precautions

include the following elements:

o Precautions for airborne infec-

tions (eg, varicella, tuberculosis)

o Precautions for infections that

spread by droplets (eg, in-

fluenza, streptococcal pneu-

monia)

o Precautions for infections that

spread by person-to-person

contact (eg, MRSA, Salmonella

diarrhea)

While the CDEC guideline was

developed for hospitals, some of its

recommendations are applicable to

ALFs as well.

Isolation of r

esidents with infec

tions is problematic in most ALFs,

where social interaction and inde-

pendent and free mobility are com-

mon. In fact, isolation may not be

practical; and it may even have

negative social implications. Strict

adherence to hygiene practices and

the use of gloves in the presence

of infectious secretions often can

prevent the need for isolation. Resi-

dents who have poor hygiene prac-

tices or who are coughing uncon-

trollably may need to be isolated to

event transmission of the infec-

tion to other residents, facility staff,

and visitors. Each ALF should adapt

the aspects of the CDC isolation

system that apply to its own needs.

Residents with symptomatic C.

dif

ficile

colitis may be managed

without isolation, provided that

able 3.

ommon Risk Factors for Infections in the ALF

or Other Long Term Care Setting

Common risk factors for infection in the long term care setting can be

identified using the mnemonic SICK.

Skin (eg, impaired skin condition or integrity)

Iatrogenic (eg, antibiotics, chemotherapy, feeding tubes, steroids, urinary

catheters, venous lines)

Comorbid conditions (eg, chronic obstructive pulmonary disease [COPD],

diabetes, malnutrition, neoplasm, swallowing problems)

Kidney stones, dehydration, enlarged prostate

Avoid hospitalization

of ALF residents to the

extent possible.

In addition to cost

considerations, residents

generally benefit from

treatment in familiar

surroundings.

January/February 2006 Assisted Living Consult 29

they are continent, have a private

bathroom, and are both cognitively

able and willing to follow pr

oper

hygienic standards, including wash-

ing hands after using the toilet.

Other gastr

ointestinal infections,

such as Salmonella colitis or viral

gastroenteritis, may require more

stringent measures.

Treatment

Step 6. Treat the symptoms of in-

fection. T

o the extent possible,

treatment should be tailored to the

resident’s symptoms. For example,

if the resident is dyspneic or hy-

poxic, it will be important to ad

minister oxygen and treat as need-

ed for wheezing or congestion.

ovide supportive measures for

the resident with a suspected or

able 4.

uggested Options for the Evaluation of the Most Common Categories of

Infections in the ALF or Other Long Term Care Setting

Category of Physical Diagnostics

Suspected Infection Symptoms Examination Tests* Chart/History

Gastrointestinal Inquire about nausea, Hydration status C. difficile toxin assay Antibiotic use

omiting, abdominal Abdominal tenderness Stool culture for enteric Use of laxatives or other

pain, diarrhea, and loss Bowel sounds pathogens (eg, medications with

of appetite Occult blood in stool

Salmonella, Shigella) laxative effects

Rectal examination Stool tests for occult History of use of medica-

uspect infectious colitis, blood, ova, and tions that affect intestinal

including possible

C. parasites if diarrhea flora (eg, H2 blockers)

difficile toxin, if patient persists Other concurrent cases in

has received antibiotics the facility

within past 30 days and Optional: Food history

has 3 or more watery Stool analysis for Food intolerances

or unformed stools within leukocytes Increased residual volume

24 hours, with or without Abdominal X-ray to rule of tube feeding

abdominal pain** out noninfectious causes Prior bowel pattern

Respiratory Labored breathing Respiratory rate and Chest X-ray Chronic aspiration

Elevated respiratory rate pattern Pulse oximetry (if Prior pneumonia

Congestion Change in lung sounds possible) Immunocompromised

Productive cough Use of accessory Sputum gram stain, History of COPD, asthma,

muscles to breathe sputum culture tuberculosis (TB)

(labored breathing) (optional; must be History of travel (eg, to rule

performed by appro- out severe acute respiratory

priately trained staff) syndrome [SARS])

Recent chest X-ray results

Skin Warm, cold, red, tender Changes in color, tem- Skin scrapings for sus- History of wounds, pressure

skin perature, integrity, pur- pected scabies (if suspect- ulcers, dermatitis, use of

Rash ulent drainage, or odor on clinical grounds) invasive devices

Drainage Streaking lymphangitis Proper cultures (routine (catheter, feeding tube,

Pain Staging for pressure swabs and cultures are intravenous line)

Other concurrent cases Swelling not helpful for chronic

(scabies) Tenderness wounds)

Induration If bone is exposed or

patient has a chronic non-

healing wound, rule out

osteomyelitis

Urinary tract Frequency, urgency Bladder distension Urinalysis Neurogenic bladder

Dysuria Suprapubic tenderness Urine culture and sensi- Urinary incontinence

Hesitancy

Flank pain

tivity if urinalysis is Prostatic hyperplasia

Persistent malodorous Males: Prostate, scrotum positive Chronic bacterial prostatitis

Back pain

tender

ness, abscess,

Assessment of post void Surgery

Pyuria swelling, pain residual volumes Prior catheter use

Recurrent infections

Kidney stones

White blood cell count with dif

fer

ential, blood cultures, or both may be indicated if systemic infection is suspected.

**Bently, et al

30 Assisted Living Consult January/February 2006

confirmed infection. Comfort meas-

ures and interim treatment for a

suspected infection may begin

while assessment of the problem

ontinues:

• Cover the resident with a blanket

if he or she feels cold.

• If the resident is feverish, re-

move blankets or apply a cool

cloth or ice packs to the fore-

head.

• Increase fluid intake, if feasible,

to prevent volume depletion.

It is important to keep in mind

that fever is the body’s mechanism

for fighting infection. As such, it

may not always require treatment.

Fever should be treated, however,

if it is causing the resident discom-

fort, the resident is at risk for dehy-

dration, and/or the resident shows

signs of hemodynamic instability

(eg, pulse rate greater than 100

BPM or hypotension).

When fever is present, administer

a mild antifever medication (eg,

acetaminophen) if a protocol or

practitioner order exists. Check the

resident’s temperature within one

hour of administering acetamino-

phen and every four to six hours

thereafter. Encourage oral fluid in-

take or administer fluids parenterally

to avoid dehydration. Strategies for

increasing fluid intake include offer-

ing fluids at regular intervals; vary-

ing the types of fluids offered; and

offering foods with a high fluid con-

tent, such as Jell-O and pudding.

Infection is associated with a

catabolic state and anorexia, and

infected residents may be at risk of

weight loss. Carefully monitor the

nutritional status of residents with

infection, and initiate nutritional in-

terventions (eg, increased food por-

tions) without delay if indicated.

Manage the ef

fects of the infec-

tion on the resident’s comorbid

conditions. For example, monitor

blood glucose levels mor

e frequent-

ly in residents with diabetes, and

adjust the treatment regimen to ac-

count for the ef

fects of infection.

Diarrhea in the ALF may be

caused by viral gastroenteritis, med-

ications, or antibiotic-related colitis—

including C. difficile colitis. Monitor

residents with diarrhea carefully for

vidence of volume depletion and

electrolyte imbalance. Limit the use

of antidiarrheal medications to the

extent possible because their use

may prolong the duration of infec-

tion. Administering live yogurt cul-

ture by mouth may help to return

bowel flora to normal.

Step 7. Prescribe appropriate an-

tibiotic therapy. Treatment with an-

tibiotics is appropriate when the

resident’s physician determines on

the basis of an evaluation that the

most likely cause of the resident’s

symptoms is a bacterial infection.

Consider the resident’s general con-

dition, prognosis, advance direc-

tives, and expressed resident or

family preferences when determin-

ing whether to proceed with antibi-

otic treatment. For specific viral or

fungal infections, antiviral or anti-

fungal agents may be warranted.

It is important to individualize

the choice of antibiotic. The follow-

ing factors should be consider

when selecting an antibiotic:

• The severity of the resident’s ill-

ness and the stability of his or

her condition

• The nature and location of the

infection

• The resident’s medical history

and coexisting conditions

•

The resident’s known drug aller-

gies, if any, and history of ad-

verse drug reactions

• Prior culture and sensitivity data

for the resident

• The risk of interactions with oth-

er medications that the resident

is taking

• The facility’s drug sensitivity pro-

file.

• The drug’s cost and availability

on a formulary, if relevant

• The ease of administering the

drug (eg, single daily dose ver-

sus multiple doses)

Elderly ALF residents are at in-

creased risk of drug-related adverse

effects because of the physiologic

effects of aging on kidney and liver

function, the pr

esence of comorbid

conditions, and the use of multiple

medications. The use of antibiotics

increases the risk for potentially

harmful drug interactions in addi-

tion to the adverse effects associat-

ed with antibiotics themselves.

The antibiotic agent selected

should:

• Be active against the most likely

pathogens

• Have as narrow a spectrum as

possible

• Achieve therapeutic concentra-

tions at the site of infection

• Be well tolerated

• Have low toxicity

• Be the least expensive effective

treatment options

Doses and dose intervals should

consider the resident’s weight and

the reduced renal function present

in elderly individuals. A duration of

eatment that is appropriate to ef-

fectively treat the infection should

be specified up front. For certain an-

tibiotics, drug levels and r

enal func-

tion must be monitored periodically.

Antibiotics should not be used to

eat viral illnesses such as colds,

influenza, and viral gastroenteritis;

Fever should be treated

if it is causing the

resident discomfort, the

resident is at risk for

dehydration, and/or the

resident shows signs of

hemodynamic instability

(eg, pulse rate greater

than 100 BPM or

hypotension).

January/February 2006 Assisted Living Consult 31

asymptomatic bacteriuria; or bacter-

ial colonization without clinical

signs of infection.

It is ethically acceptable not to

ffer antibiotic treatments to a resi-

dent who is receiving palliative

care. However, an antibiotic may

be prescribed to a palliative care

resident who has a bacterial infec-

tion to relieve discomfort or to pro-

tect the health of others.

Monitoring

Step 8. Monitor the resident’s

progress. Caregiving staff should

closely monitor each resident who

is being treated for an infection.

Nursing staff should advise care-

givers about what to look for as

they work with residents and when

to report their observations—as

well as any changes anticipated in

the resident’s care plan.

A nurse should evaluate the resi-

dent who has an infection at least

once during every shift while the

resident is unstable or significantly

symptomatic. The nurse also should

document relevant findings. The

evaluation should include the resi-

dent’s general condition and a com-

parison of actual progress with ex-

pected progress as noted in the

original care plan.

The r

esident’s physician should

be notified promptly if the resi-

dent’s condition worsens. Allow ap-

proximately three days for antibi-

otics to show effectiveness. If the

resident’s condition shows no im-

provement after that time and hos-

pitalization is a relevant option, re-

consider the treatment strategy and

whether the resident should be

transferred to the hospital.

Nurses and other appropriate

staff should provide the resident’s

physician with enough detailed in-

for

mation to allow him or her to

determine the resident’s progress

and identify possible complications.

It is helpful if the physician is avail

able to assess the resident in a

timely fashion.

Car

egiving staff should under-

stand that symptoms and abnormal

test results related to an infection

do not necessarily resolve quickly.

For example, a fever may persist

for several days after appropriate

treatment for infection is begun.

Step 9. Take appropriate steps

to contain an identified outbreak of

the infection. An outbreak has been

defined as “the occurrence of more

cases of a particular infection than

is normally expected, the occur-

rence of an unusual organism, or

the occurrence of unusual antibiotic

resistance patterns.” An outbreak

may be suspected if three or more

cases of the same infection are

identified within 24 hours in the

same unit or other defined area

without an adequate explanation.

For certain types of infections,

however, such as tuberculosis or

salmonella, even a single new case

should trigger an evaluation for an

outbr

eak.

Each state health department has

its own definition of what consti-

tutes an outbr

eak of infection in that

state and its own requirements for

how quickly facilities must respond

to and r

eport outbreaks. Facility staff

must be familiar with their state’s re-

quirements and should obtain guid-

ance on managing an outbreak from

state public health officials at the

earliest opportunity.

The goal of a coordinated ap-

proach to an infectious disease out-

break is to protect individuals and

the public from undue exposure to

infection while mitigating the im-

pact on the quality of life of the

people directly and indirectly af-

fected by the outbreak. It is impor-

tant to use antibiotics only for as

long as needed to resolve sympto-

matic infections or control active

risk to others. It is usually not nec-

essary to try to eradicate organisms

entirely.

Table 5 lists the steps involved

in recognizing an outbreak. Table 6

lists the most common causes of in-

fectious disease outbreaks in long

term care facilities.

Step 10. Implement an immu

nization program for all facility resi-

dents. Influenza vaccine is advised

yearly for all r

esidents. Although

vaccination is somewhat less effec-

tive in the elderly than in younger

people, it has been estimated to r

duce the risk of influenza-related

Table 5.

teps Involved in Recognizing an Outbreak

f Infectious Disease

1. Confirm the diagnosis in the index patient.

. Develop a uniform case definition to be used in chart review and patient

evaluation.

3. Using the case definition, perform a chart review and prospectively follow

suspected new cases.

4. Plot an “epidemic” curve that includes a sufficient period before the index

case to establish whether an outbreak truly exists.

5. Determine whether the outbreak is a “pseudo-outbreak” (i.e., positive lab

results in the absence of clinical disease) that has been recognized as a

result of a change in procedures or surveillance rather than a true increase

in cases of the infection.

6. Review the r

elevant literature.

7. Inform appropriate administrative staff (e.g., director of nursing, all

department heads, medical director, and attending practitioners) of

isolation procedures, if required.

8. Seek assistance in managing the outbr

eak from the local health

department, a local hospital, or the U.S. Centers for Disease Control and

Prevention.

32 Assisted Living Consult January/February 2006

hospitalizations and death in older

people by up to 70%.

To increase the number of ALF

residents who are vaccinated

against influenza, the Centers for

Medicare and Medicaid Services

recommends that facilities use

standing orders, with resident or

caregiver consent, to administer an-

nual flu vaccinations to current resi-

dents and new admissions during

flu season. Facilities also may wish

to consider engaging in community

outr

each by of

fering flu vaccine

clinics for residents’ families and

other visitors to the ALF.

The 23-valent pneumococcal

vaccine is recommended for all

adults over 65 years old. It also is

recommended for people at high

risk for pneumococcal pneumonia,

including those with diabetes and

chronic cardiac, lung, and renal dis-

eases. Residents who previously

were vaccinated with the 14-valent

vaccine should be revaccinated

with the 23-valent one if they are

age 65 or older or ar

e at high risk.

The indications for revaccination

with pneumococcal vaccine are

contr

oversial. The American College

of Physicians recommends revacci-

nation after six years for older resi-

dents who r

eceived pneumococcal

vaccine before age 65; for high-risk

residents with asplenia, nephritic

syndrome, or renal failure; and for

residents with renal transplants. In-

suf

ficient data are available current-

ly about the value of revaccination

every six years in health elderly

people.

Recommendations for tetanus/

diphtheria (Td) vaccination in older

persons are the same as those for

younger adults. More than half of

tetanus cases occur in people aged

60 and older, and appropriate vac-

cination is 100% ef

fective. All adults

should complete a primary series of

Td toxoid. If a resident had an in-

complete series or has an uncertain

history, the entire primary series

should be given.

Step 11. Implement a facility-

wide infection control program that

conforms to federal and state regu-

lations. Recommended components

of an infection control program in-

clude the following:

• Surveillance for infections

• Hygiene practices to prevent

transmission of infections

• Outbreak control procedures

• Resident health programs

•

Employee health and education

programs

• Monitoring of resident-care prac-

tices

• Monitoring of antibiotic use

• Reporting of diseases to public

health authorities

Step 12. Monitor the manage-

ent of infections in the facility. An

effective infection control program

should be based on an understand-

ing of several factors, including:

• The types of organisms that most

commonly cause infections in

the facility

• Sources of infection

• Levels of employee compliance

with hygiene practices such as

handwashing

• Patterns of antiobiotic resistance

Equally important is the monitor-

ing of outcomes from infections to

determine whether they were ap-

propriate and consistent with resi-

dent care plans.

Step 13. Monitor antibiotic use

in the facility. Inappropriate antibi-

otic use can af

fect the success or

failure of an infection control pro-

gram. Reviewing the use of antibi-

otics encourages appropriate pre-

scribing of those medications and

may limit the development of an-

tibiotic-resistant organisms within

the facility.

The review of antibiotic use

should be conducted by a multidis-

ciplinary gr

oup. Data should be r

viewed at regular intervals.

Summary

Infections are common and are a fre-

quent source of illness and death in

long term care facilities. The consis-

tent application of sound manage-

ment principles to treating residents

and adhering to a comprehensive in-

fection control program have been

shown to reduce the impact of infec-

tion in ALFs and other long term

care facilities. The processes and ac-

tions r

ecommended in this guideline

should help ALFs to systematically

manage and improve the care of res-

idents who develop infections. ALC

To order this or other AMDA clinical

practice guidelines, see the or

ganiza-

tion’s Web site at www.amda.com.

Table 6.

Most Common Causes of Infectious Disease Outbreaks

in Long Term Care Facilities

Respiratory

• Influenza and influenza-like illnesses

• Other respiratory viruses (e.g., acute respiratory disease with or without

fever)

• Tuberculosis

Gastrointestinal

• C. difficile

• Salmonellosis

• Viral gastroenteritis

• E. coli O157:H7 colitis

Other

• Scabies

• Conjunctivitis

• Group A streptococcal infections

• MRSA infections