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Cited by 137Geriatric Care and Nursing HomesInfection Control in HealthcareAntibiotic Use and Resistance

Practice guideline for evaluation of fever and infection in long-term care facilities

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Bentley, David W., Bradley, Suzanne, High, Kevin, Schoenbaum, Stephen, Taler, George, Yoshikawa, Thomas T.·2000·Clinical Infectious Diseases
DOI 10.1086/314013
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Abstract

The elderly population (i.e., persons aged ≥65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that >40% of persons aged ≥65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infection-control measures are not available in the LTCF. Infections and morbidity and mortality from infections are common in frail, elderly residents in LTCFs. Diagnosis may be delayed due to the inability of residents of SNFs to verbalize their complaints. The findings of physical examination are often made difficult to interpret by the presence of multiple comorbid illnesses, and because infection often presents differently in the elderly than in younger adults. Physician visits are infrequent, and most clinical assessments for infection are initiated by persons other than physicians. On-site diagnostic testing is uncommon. As a consequence, antibiotics are often inappropriately prescribed for fever or undefined illness after minimal evaluation. What constitutes an appropriate evaluation of fever and possible infection has not been established in the long-term care setting that provides skilled care. It is the purpose of this paper to provide a rational approach to the evaluation of a potentially infected resident of an LTCF, while acknowledging the limitations in resources and staffing in SNFs. These guidelines are applicable to facilities that provide skilled care and have the capacity to diagnose, treat, and manage new medical problems, including fever. It is hoped that these guidelines will help primary providers, consultants, and other health care personnel recognize infection, initiate appropriate treatment sooner, and improve outcomes, with associated reductions in inappropriate antibiotic use and cost of care. Conversely, the shortcomings of the guidelines are recognized—given the lack of availability of good clinical studies. It is hoped that this document will in the of fever and infection in residents of LTCFs. The population and for long-term care. aged ≥65 years nearly of the population of the United or and is that this population will nearly double over the next 30 years. In has been estimated that >40% of persons will require care in an LTCF at some point during their lifetime. that the number of nursing facility care will from a current of to by the The care is often used as a for facilities for the In the a of that care for patients of all from to The types of LTCFs may from facilities that provide for residents that canno

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  1. Castle SC, Yeh M, Toledo S, Yoshikawa TT, Norman DC. Lowering the temperature criterion improves detection of infections in nursing home residents. Aging Immunol Infect Dis 1993; 4:67-76.
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Authors
Bentley, D. W., Bradley, S., High, K., Schoenbaum, S., Taler, G., & Yoshikawa, T. T.
Affiliations
  • St. Louis VA Medical Center (US)
  • University of Michigan (US)
  • Wake Forest University Health Sciences (US)
  • Harvard University (US)
  • MedStar Washington Hospital Center (US)
  • Charles R. Drew University of Medicine and Science (US)
Corresponding author
Yoshikawa, Thomas T.
ORCID
Bradley, Suzanne
Venue
Clinical Infectious Diseases
Publisher
Oxford University Press (OUP)
Published
2000-09-01
Volume
31
Issue
3
Pages
640-653
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
DOI
10.1086/314013
OpenAlex
W2123071011
Cited by
137
References
117
Citations by year
2025: 1 · 2023: 1 · 2022: 1 · 2021: 3 · 2020: 2 · 2019: 4 · 2018: 2 · 2016: 2 · 2014: 5 · 2013: 3 · 2012: 2
FWCI
23.19
Type
journal article
Language
en
Open access
Locations
  • Clinical Infectious Diseases (publishedVersion)
  • PubMed (publishedVersion)
Funders
Infectious Diseases Society of America
Topics
  • Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
  • Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
Keywords
long-term care facilities, skilled nursing facilities, infection diagnosis, fever evaluation, older adults, nursing home residents, urinary tract infection, respiratory infections, skin and soft tissue infections, gastroenteritis, advance directives, infection control, laboratory testing, frail elderly, clinical practice guideline recommendations, nursing home-acquired infections
MeSH terms
Aged, Fever, Homes for the Aged, Humans, Infections, Long-Term Care

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