Key Points
- Antibiotics are among the most common medications prescribed in nursing homes.
- The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%. More than half of antibiotic courses initiated in nursing home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration).
- Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile (formerly Clostridium difficile) infection, adverse drug effects, drug-drug interactions, and antimicrobial resistance.
- In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.
- The guidance1 is intended to reflect an assessment of the strength of association between bacterial infections and geriatric manifestations and should not be used as the basis for excluding a diagnosis of respiratory viral pathogens.
Management
Symptoms That Should Prompt Further Evaluation for Infection
Fever
- The authors recommend that criteria set forth in the “Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update of the Infectious Disease Society of America” [High KP et al. Clin Infect Dis. 2009;48:149-71] be used to establish the presence of fever in a resident of a nursing home. These include any of the following:
- A single temperature of >100°F (>37.8°C) OR
- Repeated temperatures of >99°F (>37.2°C) OR
- An increase in temperature of >2°F (>1.1°C) over the resident’s baseline non-illness temperature.
The authors recommend that clinicians perform further evaluation for infection in residents who meet one or more of the above definitions of fever, while considering the possibility of non-infectious causes of fever.
Hypothermia
- The authors recommend that clinicians use the following temperature thresholds to define the presence of hypothermia:
- Two or more temperature measurements ≤95.9°F (≤36.0°C) OR
- Two or more temperature measurements documenting a decrease in temperature of >2°F (>1.1°C) from the resident’s baseline non-illness temperature.
The authors recommend that clinicians further evaluate a resident who meets the above definitions of hypothermia for the presence of infection, while considering the possibility of non-infectious causes of hypothermia.
Hypotension
- The authors recommend that clinicians define hypotension as a systolic blood pressure of ≤90 mmHg in an individual with a previously normal systolic blood pressure.
The authors recommend that clinicians further evaluate a resident who meets the definition of new-onset hypotension for the presence of infection, while considering the possibility of non-infectious causes of hypotension.
Hyperglycemia
- Individualized approach.
The authors recommend that clinicians further evaluate a resident with new-onset hyperglycemia for infection, while considering the possibility of non-infectious causes of hyperglycemia.
Delirium
- The authors recommend that clinicians use the Confusion Assessment Method (CAM) to identify the presence of delirium in a resident of a nursing home. CAM requires:
- The presence of acute change in mental status with fluctuating discourse AND
- Inattention; AND EITHER:
- Disorganized thinking; OR
- Altered level of consciousness
The authors recommend that clinicians evaluate a resident who meets the definition of delirium for the presence of infection, while considering the possibility of non-infectious causes of delirium.
Practical Suggestions for Evaluation of Nursing Home Residents with Non-Localizing Signs or Symptoms
This table provides suggestions regarding the components for evaluation for infection in nursing home residents with non-localizing signs or symptoms.
This table was created to help clinicians implement the expert guidance document’s1 recommendations; however, some of the content in this table exceeds the scope set for the expert guidance1 and this document therefore is not endorsed by SHEA.
This is not meant to be a substitute for individual clinical judgment by qualified professionals.
| New-onset symptom, presenting in isolation | Evaluate further for infection? | Potential non-infectious causes | Next steps and/or active monitoring | Components of evaluation for infection |
|---|---|---|---|---|
| Fever | Yes |
|
|
|
| Hypothermia | Yes |
| Take temperature again using the same method within several hours. | Sepsis is a commonly identified trigger of hypothermia. Clinicians should perform a diagnostic evaluation to identify the cause of hypothermia. |
| Hypotension | Yes |
| Assess if hypotension may be post-prandial or medication-induced. | Several studies associate low-blood pressure with poor outcomes. Clinicians should perform a diagnostic evaluation to identify the cause of hypotension. |
| Hyperglycemia | Yes |
| Individualized approach to assess whether hyperglycemia is abnormal, including assessing medication regimen, recent dietary patterns, and baseline pattern of glycemic control. | Because a relationship exists between physiological stress and hyperglycemia in patients with known diabetes and critically ill patients with relative underlying insulin-resistance, evaluate for infection if non-infectious causes are not otherwise explained by medication and diet. |
| Delirium | Yes |
| Not applicable to delirium identified by CAM. | Residents who develop delirium have higher risk of loss of functional status, hospitalization, and death; therefore, evaluate for infection especially if another trigger for delirium is not readily identified. |
This table provides suggestions regarding the components for evaluation for infection in nursing home residents with non-localizing signs or symptoms.
This table was created to help clinicians implement the expert guidance document’s1 recommendations; however, some of the content in this table exceeds the scope set for the expert guidance1 and this document therefore is not endorsed by SHEA.
This is not meant to be a substitute for individual clinical judgment by qualified professionals.
| New-onset symptom, presenting in isolation | Evaluate further for infection? | Potential non-infectious causes (not exhaustive) | Next steps and/or active monitoring |
|---|---|---|---|
| Behavior changes exclusive of delirium | No | Numerous possible infectious and non-infectious causes for myriad potential manifestations, e.g., functional decline, loss of appetite, “not being one’s self,” agitation, weight loss, weakness, lethargy, apathy, etc. A change in behavior in and of itself is not specific enough to trigger a work-up for infection. |
|
| Functional decline | No | Decline in activities of daily living (ADLs) can be both risk factors and consequences of infection. Non-infectious reasons for functional decline include stroke, hip fracture, and congestive heart failure. | Actively monitor residents with abrupt functional decline |
| Falls | No | Insufficient evidence exists to link infectious conditions, e.g. pneumonia, to falls. Patients cultured for UTI following a fall are as likely to have positive urine as those who did not experience a fall. | Not applicable |
| Anorexia | No | Medication | Actively monitor residents with new-onset anorexia |
Isolated Symptoms that Should NOT Prompt Further Evaluation for Infection
Behavioral Changes Exclusive of Delirium
- The authors recommend that clinicians perform a formal delirium assessment when a behavioral change is newly identified in a nursing home resident. If delirium has been excluded, the authors do NOT recommend further evaluation for infection unless additional, more specific signs and symptoms are present.
Functional Decline
- The authors do NOT recommend that clinicians further evaluate a resident with new-onset functional decline for the presence of infection.
Falls
- The authors do NOT recommend that clinicians evaluate a resident who has experienced a fall for the presence of infection.
Anorexia
- The authors do NOT recommend that clinicians further evaluate a resident with new-onset anorexia for the presence of infection.
