Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Diseases Society of America

Abstract

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided. EXECUTIVE SUMMARY By the year 2030, 20% of the United States population is estimated to be aged 65 years, and almost 30 million

Preliminary study on serum paraoxonase-1 status and chemokine (C-C motif) ligand 2 in hospitalized elderly patients with catheter-associated asymptomatic bacteriuria

“…UTI is very frequent in hospitalized older patients [1], and the majority of cases of nosocomial UTI are associated with an indwelling urinary catheter. Considerable time and resources are spent reducing the rate of catheterassociated UTI (CAUTI), and this has important implications for the patient and the clinical environment [2].…”

Besonderheiten des älteren Notfallpatienten

“…Allerdings spielt gerade bei der Behandlung von Infektionen der Zeitpunkt der antimikrobiellen Therapie eine entscheidende Rolle und steht in direktem Zusammenhang mit der Sterblichkeit [23]. Für die klinische Arbeit ist es zudem wichtig, zu wissen, dass die Körpertemperatur betagter Patienten aufgrund der oben beschriebenen physiologischen Veränderungen auch bei schweren Infektionen niedriger ist als bei jüngeren Erwachsenen [24]. Eine hohe Körpertemperatur bei alten Patienten ist daher eher mit einer schwerwiegenden viralen oder bakteriellen Infektion assoziiert als bei jungen Patienten.…”

Antimicrobial Stewardship Strategies in Nursing Homes: Urinary Tract Infections

“…Urinalysis and culture are inadequate for differentiating symptomatic UTI from asymptomatic bacteriuria which frequently occurs in residents within long-term care facilities [15]. Fever response, typically considered necessary to diagnose UTI in the absence of other reported symptoms, can also be reduced in frail and older adults, making it more challenging to rely on this objective marker to help distinguish asymptomatic bacteriuria from UTI [16,17]. Furthermore, UTIs in nursing home residents frequently contribute to emergency room visits and hospitalizations, though asymptomatic bacteriuria may also be misdiagnosed as a UTI in these settings [18].…”

“…As many as 56 % of antimicrobials used within the nursing home setting are for suspected urinary tract infections; however, a large proportion of antimicrobials may be inappropriate [19, 20••]. Before treating a UTI, nursing home residents should express signs or symptoms of infection and have a positive urine culture [16,21,22]. However, residents with asymptomatic bacteriuria who have a positive urine culture but no signs or symptoms of infection frequently receive antimicrobials [20••, 23].…”

“…With the overuse and misuse of antimicrobials in the nursing home setting, antimicrobial stewardship programs will be essential in providing clarity and guidance on prescribing antimicrobials for UTIs. Loeb et al along with the Infectious Diseases Society of America recommend that nursing home residents be treated if they present with signs and symptoms of infection along with a positive urine culture (10 5 cfu/mL) [16,22]. Crnich et al has created an algorithm to provide guidance in determining when to prescribe antimicrobials for a UTI [25].…”