your path: Home > Publications > Position Statements >

Printer-Friendly Version

CLINICAL PRACTICE GUIDELINES

Guideline Abstracted from the IDSA Evaluation of Fever and Infection in Long-term Care Facilities

The recommendations were graded based on the strength and quality of evidence. Strength of evidence was graded as follows:

A = good evidence to support a recommendation for use
B = moderate evidence to support a recommendation for use
C = poor evidence for or against use
D = moderate evidence to support a recommendation against use
E = good evidence to support a recommendation against use

Quality of evidence was graded as follows:

I = evidence from at least one randomized, controlled trial
II = evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments
III = evidence from respected authorities, expert committees, or descriptive studies

• Common infections affecting residents of LTCFs include, in descending order of frequency, infections of the urinary tract, respiratory system, or skin and soft tissues, gastrointestinal infection, and bacteremia.
• Residents of LTCFs may have typical or atypical presentations of infection. Typical findings of infection are fever; cough and yellow sputum (respiratory infection); heat, redness, purulence and skin breakdown (infected pressure ulcer); and erythema and purulence of the eye (conjunctivitis). Atypical manifestations of infection may include a change in mental status or cognitive function or a decline in physical function (eg, inability to perform activities of daily living, new incontinence, falling, or failure to cooperate in rehabilitation). Approximately 15% of elderly patients with bacteremia may be afebrile.
• Tachypnea (respiratory rate of >25 breaths/minute) had a high sensitivity (90%) and specificity (95%) for pneumonia in one observational study.
• Dehydration is a very common finding in patients with infection and should be looked for on examination and lab testing with a blood urea nitrogen, creatinine, and serum sodium.
• In residents of LTCFs, special attention should be paid to specific underlying disorders or conditions such as diabetes mellitus (skin, urinary tract infection [UTI]), chronic obstructive pulmonary disease (pneumonia), poor swallowing or gag reflex (aspiration pneumonia), long-term urinary catheters (UTI), prosthetic devices (eg, artificial joints leading to septic arthritis), altered mental status (aspiration pneumonia), or chronic immobility (pressure ulcer).
• Vital signs are generally obtained on a weekly basis for stable residents requiring long-term care; however, more frequent measurements can be obtained on the basis of nursing judgment or physician order.

• Confirm the diagnosis of disease in index patient.
• Use a uniform case definition for initial and subsequent cases for chart review.
• Plot an epidemic curve.
• Determine whether there is a true outbreak or a pseudo-outbreak (presence of positive laboratory results in the absence of clinical disease).
• Review the relevant literature.
• Inform appropriate administrative personnel of appropriate isolation procedures.
• Gain assistance from local epidemiology personnel in the health department, Centers for Disease Control, or hospital.

• Nursing assistant should measure vital signs: temperature, heart rate, blood pressure, and respiratory rate. (B-II)
• Residents who are suspected of having an infection and have one temperature reading of >100°F (37.8°C), $ [AU: IS THIS TO DENOTE 'THERE EXISTS?' CAN WE DELETE IT?] 2 readings of > 99°F (37.2°C), or an increase of 2°F (1.1°C) over baseline should be reported immediately to the on-site nurse. (B-II)
• The on-site nurse should evaluate for possible site of infection and report information to the advanced practice nurse, physician assistant, or physician for decisions about further evaluation. (B-III)
• Documentation of clinical evaluation, tests, and treatment ordered or withheld should be detailed in the medical record. (B-III)

• As long as no previous advanced directives limit intervention, perform initial diagnostic testing at LTCF. If hospitalization is not needed and resources are available for specimen collection, laboratory tests and radiological studies are to be done in a timely manner. (B-III)
• In the absence of fever, leukocytosis, and/or left shift, and specific clinical manifestations of a focal infection, the likelihood of a bacterial infection is low. Further diagnostic tests for such a bacterial infection may not be indicated because of the potential low yield. (D-II)

• A complete blood count, including peripheral white blood cell (WBC) and differential cell counts, should be performed in all patients suspected of having an infection. (B-II)
• A WBC count greater than 14,000 cells/mm3, or a left shift (percent band neutrophils greater than 6% or total band neutrophil count greater than 1500/mm3) is consistent with a bacterial infection with or without fever. (B-II)

• Diagnostic laboratory evaluation of suspected UTIs in noncatheterized patients should be reserved for those with acute onset of UTI associated with symptoms and signs (eg, fever, dysuria, gross hematuria, new or worsening urinary incontinence, and/or suspected bacteremia). In residents with long-term indwelling urethral catheters, evaluation is indicated if there is suspected urosepsis (ie, fever >100.3°F [38°C], shaking chills, hypotension, and delirium), especially in a setting of recent catheter obstruction or change. (A-II)
• Urinalysis and urine culture should not be performed on asymptomatic residents. (E-II)
• Urine specimens should be a midstream or clean catch from elderly men able to provide them, or from a new and clean external catheter if necessary. (B-II)
• Urine specimens from women should be a clean catch or, if necessary, from a straight catheterization. (B-III)
• Urine specimens from residents with long-term indwelling catheters should be aspirated from the catheter port and not from the drainage bag. (B-II)
• Unless obstruction is suspected, it is not necessary to change the catheter to better assess bladder (or kidney) microbiology. (D-III)
• If urosepsis is suspected, urine and paired blood culture specimens should be sent for culture and antimicrobial susceptibility testing, and a gram stain of uncentrifuged urine should be requested. (B-III)
• The minimum laboratory evaluation for suspected UTI should include a urinalysis for leukocyte esterase by use of a dipstick and microscopic examination for WBCs. (B-II)
• If no pyuria (<10 WBCs per high-power field of spun urine and negative leukocyte esterase by dipstick) is demonstrated, no urine culture need be requested. (E-II)

• Not recommended for patients with suspected bacteremia because of low yield of positive cultures and high mortality rates in LTCF individuals within 24 hours of presentation. (D-III)
• For most residents (pending the resident's or family's approval), suspected bacteremia warrants transfer to an acute care facility. (No level of evidence offered.)

• Pulse oximetry should be performed in individuals with respiratory rate greater than 25 to document hypoxemia (saturation of less than 90%) as a further clue to the diagnosis of pneumonia. Hypoxemia serves as an important predictor of short-term (30-day) mortality and impending respiratory failure requiring transfer to an acute care facility pending the patient's or family's wishes. (B-II)
• A chest radiograph should be taken if hypoxemia is documented or suspected to evaluate for pneumonia and exclude other conditions (eg, multilobe infiltrates, congestive heart failure, large pleural effusions, or mass lesions). (C-III)
• If pneumonia is suspected, respiratory secretions should be obtained and transported within one to two hours of collection for Gram staining with cytological screening for squamous epithelial cells, culture, and sensitivity. (C-III)
• Purulent sputum should be cultured only if Gram stain shows less than 25 squamous epithelial cells per low-power field. (A-I)

• At the onset of a suspected respiratory viral infection outbreak, swab samples should be obtained from the throat and nasopharynx of several acutely ill patients. These swabs should be combined in a single tube containing refrigerated viral transport media for transport to an experienced laboratory for virus isolation and rapid diagnostic testing for influenza A and other common viruses. (A-III)

• Skin and soft tissue cultures should be performed under select conditions. Surface swab cultures are not indicated for cellulitis. (E-III)
• Fine needle aspirates for Gram staining and culture may be appropriate in special circumstances in which unusual pathogens are suspected (eg, Gram-negative bacilli in diabetics), fluctuant areas suggesting an abscess is present, or if initial antimicrobial treatment has been unsuccessful. (C-III)
• Pressure ulcers are frequently colonized with polymicrobial flora, and a surface swab culture should not be done. (E-III)
• If a pressure ulcer shows poor healing and/or persistent purulent drainage, culture specimens should be obtained from purulent drainage or deep infected tissue at the time of surgical debridement or biopsy. (B-II)
• Scabies outbreaks are suspected based on the finding of more than one unexplained rash in residents. Visual identification of mites or eggs should be done by adding a drop of mineral oil to a scalpel, scraping suspicious burrows, and examining the scrapings under a low-power microscope. (C-III)
• If proper diagnostic equipment is not available or clinical expertise with scabies is limited, consider dermatology consultation. (C-III)

• If a resident has new-onset diarrhea, low-grade fever, no clinical deterioration, and there is no outbreak in the facility, no stool specimen needs to be sent for laboratory evaluation. (D-III)
• If a resident develops diarrhea within 30 days of receiving an antibiotic, a stool has to be sent for Clostridium difficile toxin assay. (A-II)
• If diarrhea persists and toxin assay is negative, one or two more stool specimens need to be sent for toxin assay. (A-II)
• If a resident has severe fever, abdominal cramps, and/or bloody diarrhea or WBCs in stool, and there is no history of antibiotics given within 30 days, send a stool for culture of the most frequent invasive enteropathogens (eg, Campylobacter jejuni, Salmonella and Shigella species, Escherichia coli O157:H7). (A-II)
• In most instances in which patients are severely ill with diarrhea, there is often associated bacteremia. Prompt transfer to an acute care facility is warranted for most residents (pending the resident's or family's approval). (A-II)

• Upon admission to a LTCF, discussions outlining general parameters (including advance directives) for transfer to an acute care facility should be a standard component of the evaluation and should be documented in the medical record. (B-III)
• The attending physician should make decisions regarding transfer according to an advance directive or as informed by the resident or his/her family or caregiver. (A-III)
• In the absence of an advance directive or directions from the resident, the family, or the caregiver, the attending physician's decision regarding a transfer should be based on available institutional policies; clinical condition, underlying disease(s), and prognosis of the resident; efficacy and cost effectiveness of interventions and acute care; and/or capacity of the LTCF to provide necessary care and support to the resident. (B-III)
• When a transfer decision is made, the rationale for transfer to another facility for care should be documented in a progress note or in the discharge summary. (B-III)
• The LTCF should establish a process for ongoing review and analysis of cases in which the resident is transferred to an acute care facility or to an emergency department, even when the resident returns to the LTCF without admission. (B-III)

• A licensed nurse (licensed practical nurse or registered nurse) should document a change in clinical status of a LTCF resident.
• A licensed nurse should communicate, in a timely manner defined by the LTCF, directly to the physician, advance-practice nurse, or physician assistant any change in a resident's status.
• Temperature, pulse, respiration rate, and blood pressure should be measured and recorded in the medical record of LTCF residents suspected of an infection.
• A physician, advance-practice nurse, or physician assistant should make an appropriate assessment of the clinical status of LTCF residents suspected of having an infection.
• When a LTCF resident is transferred to an acute care facility, the reason(s) for the transfer should be documentation in the individual's medical record.

This American Geriatrics Society (AGS) Abstracted Guideline was abstracted from Clinical Infectious Diseases 2000;31:640-653 on behalf of the AGS Clinical Practice Committee by Herbert C. Sier, MD, Rebecca D. Elon, MD, MPH, and Samuel C. Durso, MD.

Address correspondence to: American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118. E-mail: info.amger@americangeriatrics.org.