Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Common Infections" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.
Because frail elderly patients are at a higher risk of death and complications from infectious diseases, prompt recognition, assessment, and treatment of infections are imperative.
Does the patient have a change of condition that suggests the presence of an infection?
Infection may present with localized symptoms or with generalized, nonspecific symptoms. Table 4 in the original guideline document lists condition changes that may indicate infection in a long-term care (LTC) patient.
The nursing assistant caring for the patient should promptly notify the nurse on duty of any condition change that is suggestive of infection. The nurse, in turn, should assess the problem in a timely fashion. The focus of the initial nursing assessment may depend on the specificity of the observations or symptoms that suggest the presence of an infection (see Table 5 in the original guideline).
Before contacting the practitioner, the nurse should review the patient's chart and gather relevant information such as vital signs, recent lab reports, and medications ordered.
Recognition of Fever in the LTC Setting
As many as one-third of elderly patients with acute infections may present without a robust febrile response. Basal body temperature in the frail elderly may not be the "normal" value of 98.6°F (37°C).
Determination of basal temperature will allow staff to determine whether the current temperature is 2°F above baseline. It is advisable to keep a record of each patient's basal temperature in the medical record in a place that will not be thinned.
|Table: Criteria for Defining Fever in the LTC Setting
- Increase in temperature of equal to or greater than 2ºF (1.1ºC) from baseline
- Two or more measurements of oral temperature equal to or greater than 99ºF (37.2ºC) or rectal temperature equal to or greater than 99.5ºF (37.5ºC)
- Single measurement of temperature equal to or greater than 100ºF (37.8ºC)
|Adapted from High et al. 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. Clin Infect Dis 2009;48:149-171.
Perform a history and physical examination, and order appropriate laboratory tests.
Appropriate clinical evaluation, including diagnostic testing, should be done promptly in all patients with suspected symptomatic infection, unless an advance directive or the expressed wish of the patient or family explicitly limits such intervention. The Infectious Diseases Society of America (IDSA) recommends a comprehensive evaluation by a registered nurse (RN) if infection is suspected. This evaluation may include abdomen, chest, conjunctiva, heart, hydration (weight), indwelling devices, mental status, oximetry, perineal and perirectal skin (including scrotum), pressure areas on back, review by systems, throat, and vital signs, depending on the patient's presentation. Facilities need protocols to ensure good assessment. Consider performing appropriate lab tests (e.g., complete blood count with differential) if infection is suspected.
When considering initiating antibiotic therapy, it is important to obtain cultures, if possible, because of the prevalence of multi-drug resistant organisms (MDROs) in the LTC setting (see Box 1 in the original guideline document). The white blood count in elderly patients may not rise significantly. To optimize antimicrobial therapy, efforts to identify a specific etiology and obtain susceptibility should be considered.
Table 8 lists in the original guideline document suggested elements of the diagnostic workup for the most common categories of infection in the LTC setting.
Odor is common on wound dressings and does not always indicate the presence of infection. Tissue biopsy or aspiration sampling is the "gold standard" for culture of wound tissue infection and is especially important in the presence of serious infection, systemic toxicity, or poor response to initial therapy. However, swab culture is the most common technique for determining the resistance pattern of wound pathogens (readers may find it helpful to refer to AMDA's clinical practice guidelines on pressure ulcers).
Broad-spectrum antibiotics may be used as empiric therapy, potentially increasing costs and the risk of adverse drug reaction (ADR). The inability to focus and/or de-escalate antibiotic therapy when culture results are available will increase the risk that resistant organisms will be selected.
Assess whether the patient's condition warrants transfer to a hospital.
Avoid hospitalization of LTC patients to the extent possible.
Transfer to a hospital may be appropriate (if it is consistent with the patient's directives) when any of the following conditions exist:
- The patient's vital signs are unstable, and the patient or family desires aggressive intervention.
- Critical diagnostic tests are not available in the facility in the required time period.
- The scope or intensity of the required monitoring or treatment is beyond the facility's capacity.
- Specific infection prevention measures are not available in the facility.
Assess whether the patient's condition warrants implementation of heightened infection control precautions.
The U.S. Centers for Disease Control and Prevention (CDC) recommends applying a two-tiered system of infection precautions consisting of (1) standard precautions and (2) transmission-based precautions.
Standard precautions should be applied to all patients at all times in health care settings. Standard precautions emphasize hand hygiene; use of gloves and gowns when there is potential for exposure to body fluids or when touching bodily fluids, nonintact skin, or moist body areas (e.g., mucous membranes); masks, eye protection, and gowns (when splashing of body fluids is likely); and avoidance of needlestick and other sharps injuries.
Transmission-based precautions should be used for patients with documented or suspected transmissible infectious diseases that cannot be contained using standard precautions. Staff should consider pre-emptive implementation of transmission-based precautions in the presence of uncontained secretions.
Treat the symptoms of infection.
To the extent possible, tailor treatment to the patient's symptoms and signs. For example, if the patient is dyspneic or hypoxic, administer oxygen and treat as needed for wheezing or congestion.
Provide supportive measures for patients with a suspected or confirmed infection.
Comfort measures and interim treatment for a suspected infection may begin while assessment of the problem continues.
- Cover the patient with a blanket if he or she feels cold.
- If the patient is feverish, remove blankets or apply a cool cloth or ice packs to the forehead.
- Increase fluid intake, if feasible, to prevent volume depletion. Monitor and assess intake and output.
Fever should be treated if:
- It is causing the patient discomfort, or
- The patient shows signs of hemodynamic instability (e.g., pulse rate greater than 100 beats per minute or hypotension)
Prescribe appropriate antibiotic therapy.
Treatment with antibiotics is appropriate when the practitioner determines on the basis of an evaluation that the most likely cause of the patient's symptoms is a bacterial infection. Consider the patient's general condition, prognosis, advance directives, and expressed patient or family preferences when determining whether to proceed with antibiotic treatment.
For specific viral or fungal infections, antiviral or antifungal agents may be warranted. Individualize the choice of antibiotic (see Appendix A of the original guideline document for sources of guidance on appropriate antibiotic selection).
Monitor the patient's response to treatment.
Direct-care staff should closely monitor each patient who is being treated for an infection. Practitioners should provide nursing staff with information about what to look for as they care for the patient and when to report their observations to a nurse as well as information about any changes anticipated in the patient's care plan.
Take appropriate steps to contain an identified outbreak of the infection.
|Table: Steps Involved in Recognizing an Outbreak of Infectious Disease
- Confirm the diagnosis in the index patient.
- Develop a system for finding suspected cases, including a uniform case definition to be used in chart review and patient evaluation.
- Using the case finding method, perform a chart review and prospectively follow suspected new cases.
- 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.
- Facilities need to have policies and procedures in place for common outbreak pathogens.
- Inform appropriate administrative staff (e.g., director of nursing, all department heads, medical director, attending physicians) of isolation procedures, if required.
- Seek assistance in managing the outbreak from the local health department or an infection preventionist.
- Maintain a line list for each case and report the outbreak to the appropriate public health authority, if applicable.
|Adapted from High et al. 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. Clin Infect Dis 2009; 48: 149-171.
Implement an immunization program for all facility patients.
To increase the number of LTC patients who are vaccinated against influenza, the Centers for Medicare and Medicaid Services recommends that facilities use standing orders, with patient or caregiver consent, to administer annual flu vaccinations to current patients and new admissions during the flu season.
All persons should receive pneumococcal vaccine at age 65. Those who were vaccinated before age 65 should receive another dose at age 65 or later if at least 5 years have passed since their previous dose. Those who receive the vaccine at or after age 65 should receive only a single dose. For most persons for whom pneumococcal vaccine is indicated, the Advisory Committee on Immunization Practices (ACIP) does not recommend routine revaccination.
Tetanus, Diphtheria, and Pertussis Vaccines
For adults aged 65 years or more, tetanus diphtheria vaccine (Td) is the recommended vaccine formulation. For adults aged 19 to 64 years, a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) should replace the next Td booster. A single dose of Tdap is also recommended for adults aged 65 years or more who have or anticipate having contact with children aged 12 months or less. Adults aged 65 years or more may be given a single dose of Tdap. Tdap can be administered regardless of the interval since the last tetanus or diphtheria-toxoid containing vaccine. LTC clinicians should be aware of the potential for outbreaks of pertussis among older adults, including LTC patients.
The CDC recommends one dose of zoster vaccine for patients aged 60 years or more. AMDA does not have a position specific to the zoster vaccine, and available data in LTC settings are limited. Anyone aged 60 years or more who does not have contraindications or use medications that compromise the immune system can be considered for vaccination.
Implement a facility-wide infection control program that conforms to federal and state regulations and current standards of practice.
See Table 3 in the original guideline document for recommended components of an infection control program.
Monitor the management of infections in the facility.
LTC facilities should maintain records of patients treated for an infection. Such records alone, however, are of limited utility for improving infection prevention and control. Aggregate data analysis that provides information about patterns of specific infections is much more useful.
Monitor antibiotic use in the facility.
It is important to develop specific indications for starting antibiotics rather than starting antibiotics for vague indications. Reviewing the culture and sensitivity results, when available, also encourages appropriate prescribing of those medications and may limit the development of antibiotic-resistant organisms within the facility.
The information collected about antibiotic use should form the basis of a program to promote judicious use of antibiotics. For example, ensure that information about the use of antibiotics for symptomatic infections is included in the patient's record as part of the treatment plan. To the extent possible, minimize antibiotic use, particularly the use of broad-spectrum agents, following review of cultures or resolution of signs of infection.
Auditing Antibiotic Use
Because of increases in MDROs, review of the use of antibiotics (including comparing prescribed antibiotics with susceptibility reports) is a vital aspect of the prevention and control program. In some facilities, a more intense audit of antibiotic use may be warranted because of antibiotic resistance, or to improve the appropriateness of antibiotic prescribing.
Report the results of the audit to the facility's medical staff. When a high rate of inappropriate antibiotic use is identified, develop a plan for improvement.