Definitions of the levels of evidence (I-III) and grades of recommendation (A-C) are repeated at the end of the Major Recommendations field.
Resources
Most long-term care facilities (LTCFs) have limited diagnostic equipment on site and are staffed by nursing personnel (primarily certified nurse assistants [CNAs]). Specific data are available to make recommendations for personnel, but no data are available to guide minimal requirements for diagnostic equipment.
- LTCFs should employ sufficient staff to adequately care for all residents (B-III).
Symptoms and Signs of Suspected Infection
Typical symptoms and signs of infection are frequently absent in LTCF residents, and as one ages and becomes more frail, basal body temperature decreases, making it less likely that one will achieve classic definitions of fever. Infection should be suspected in residents with any of the following characteristics:
- Infection should be suspected in LTCF residents with:
- Decline in functional status, defined as new or increasing confusion, incontinence, falling, deteriorating mobility, reduced food intake, or failure to cooperate with staff (B-II).
- Fever, defined as: (1) A single oral temperature >100°F (>37.8°C); or (2) repeated oral temperatures >99°F (>37.2°C) or rectal temperatures >99.5°F (>37.5°C); or (3) an increase in temperature of >2°F (>1.1°C) over the baseline temperature (B-III).
Evaluation of the Resident
CNAs are almost always the first to recognize a symptom or sign of infection in LTCF residents, but data suggest that they frequently misinterpret these clinical clues.
- The initial clinical evaluation of infection should be a 3- tiered approach involving a CNA, the on-site nurse, and an advanced-practice nurse, physician assistant, or physician (B-III).
- CNAs should measure vital signs (temperature, heart rate, blood pressure, and respiratory rate). Residents who are suspected of having an infection or who have fever, as defined previously, should be reported immediately to the on-site nurse (B-II).
Clinical Evaluation
Few data are available to suggest which of the most helpful clinical evaluations should be performed in LTCF residents with suspected infection. However, on the basis of the most common sites of infection and the tenuous physiologic reserve for most residents of LTCFs, the following recommendations can be made:
- Initial clinical evaluation should involve assessment of respiratory rate, hydration status, mental status, oropharynx, conjunctiva, skin (including sacral, perineum, and perirectal areas), chest, heart, abdomen, and indwelling devices (if present) (B-III).
Communication
Effective communication of a resident's status is perhaps intuitive, but some guiding principles can be stated.
- Information should be relayed to the responsible advance practice nurse, physician assistant, or physician for decisions regarding further evaluation (B-III).
- The full extent of the clinical evaluation should be documented as part of the medical record. If specific diagnostic measures are consciously withheld, the reasons should be recorded (B-III).
Laboratory Tests
A full summary of the evaluations for laboratory tests in specific situations is not possible, because they are too numerous to list. The reader is referred to the recommendations for specific syndromes (i.e., urinary tract infection [UTI], pneumonia, gastrointestinal [GI] infection, and skin and soft-tissue infection [SSTI]). However, several overall guiding principles can be highlighted.
Initial Diagnostic Testing
- Advance directives for residents should be reviewed prior to any intervention; if not prohibited by such directives, initial diagnostic tests for suspected infection can be performed in the LTCF if resources are available and if studies can be done in a timely manner (B-III).
Blood Cell Count
- A complete blood cell (CBC) count, including peripheral white blood cell (WBC) and differential cell counts (preferably a manual differential to assess bands and other immature forms), should be performed for all LTCF residents who are suspected of having infection within 12–24 hours of onset of symptoms (or sooner, if the resident is seriously ill), consistent with local standards of practice (B-II).
- The presence of an elevated WBC count (WBC count, >14,000 cells/mm3) or a left shift (percentage of band neutrophils or metamyelocytes, >6%; or total band neutrophil count, >1500 cells/mm3) warrants a careful assessment for bacterial infection in any LTCF resident with suspected infection, with or without fever (B-II).
- In the absence of fever, leukocytosis and/or left shift, or specific clinical manifestations of a focal infection, additional diagnostic tests may not be indicated, because of the low potential yield (C-III). Nonbacterial infections, however, cannot be excluded.
Urinalysis and Urine Culture
- Urinalysis and urine cultures should not be performed for asymptomatic residents (A-I).
- In noncatheterized residents, the diagnostic laboratory evaluation of suspected UTI should be reserved for those with acute onset of UTI-associated symptoms and signs (e.g., fever, dysuria, gross hematuria, new or worsening urinary incontinence, and/or suspected bacteremia) (A-II).
- In residents with long-term indwelling urethral catheters, evaluation is indicated if there is suspected urosepsis (i.e., fever, shaking chills, hypotension, or delirium), especially in the context of recent catheter obstruction or change (A-II).
- Appropriately collected urine specimens include a midstream or clean-catch specimen obtained from elderly men who are cooperative and functionally capable; however, it is often necessary to use a freshly applied, clean condom external collection system, with frequent monitoring of the urine bag (BII). Specimen collection from women will often require an in-and-out catheterization (B-III).
- Residents with long-term indwelling urethral catheters and suspected urosepsis should have catheters changed prior to specimen collection and institution of antibiotic therapy (A-II).
- The minimum laboratory evaluation for suspected UTI should include urinalysis for determination of leukocyte esterase and nitrite level by use of a dipstick and a microscopic examination for WBCs (B-II). If pyuria (>10 WBCs/high-power field) or a positive leukocyte esterase or nitrite test is present on dipstick, only then should a urine culture (with antimicrobial susceptibility testing) be ordered (B-III).
- If urosepsis is suspected, urine and paired blood specimens should be obtained, if feasible, for culture and antimicrobial susceptibility testing, and a Gram stain of uncentrifuged urine should be requested (B-III).
Blood Culture
- In a study of older adult nursing home residents, blood cultures were demonstrated to have a low yield and rarely to influence therapy; thus, they are not recommended for most residents of LTCFs (B-II) (note: this may not apply to all types of residents or to all types of LTCFs). Blood cultures may be appropriate for residents in whom bacteremia is highly suspected and if the LTCF has quick access to laboratory facilities, adequate physician coverage to respond to positive culture results, and a capacity to administer parenteral antibiotics.
Pneumonia Evaluation
If pneumonia is clinically suspected and resources are available, the following diagnostic studies should be performed:
- Pulse oximetry should be performed for residents with respiratory rates of >25 breaths/min, to document hypoxemia (oxygen saturation, <90%) in residents with suspected pneumonia and to guide transfer to an acute care facility pending the resident's or family's wishes (B-II).
- Chest radiography should be performed if hypoxemia is documented or suspected, to identify the presence of a new infiltrate compatible with acute pneumonia and to exclude other complicating conditions (e.g., multilobe infiltrates, large pleural effusions, congestive heart failure, or mass lesions) (B-II).
Respiratory Viral Infection Evaluation
- At the onset of a suspected respiratory viral infection outbreak, nasopharyngeal wash or swab samples obtained from the throat and nasopharynx (combined with refrigerated viral transport media in a single tube) should be obtained from several acutely ill residents for transportation to an experienced laboratory for virus isolation and rapid diagnostic testing for influenza A virus and other common viruses (A-III).
Evaluation of SSTI
- Bacterial cultures should be performed only under select conditions. Surface swab cultures are not indicated for the diagnosis of most bacterial SSTIs (A-II), with the exception of conjunctivitis (B-III). Needle aspiration (only skilled physicians should perform this procedure) or deep-tissue biopsy to obtain samples for Gram stain and culture may be appropriate in special circumstances in which unusual pathogens are suspected, fluctuant areas suggest an abscess is present, or initial antimicrobial treatment has been unsuccessful (C-III).
- If a pressure ulcer demonstrates poor healing and/or persistent purulent drainage, obtain deep specimens for culture of tissue and bone specimens at the time of surgical debridement or biopsy (B-II). Magnetic resonance imaging (MRI), is the most sensitive imaging modality to detect osteomyelitis, but bone biopsy for histopathologic examination definitively confirms the diagnosis and is most useful in guiding antimicrobial therapy (A-III).
- For suspected mucocutaneous fungal infection, a scraping can be performed for potassium hydroxide 10% preparation to verify the presence of yeast or dermatophytes (B-III). If mucocutaneous candidiasis is refractory to empirical treatment, culture can be performed for the detection of drug-resistant species (B-III).
- For suspected herpes simplex or herpes zoster, skin scrapings may be examined for the presence of giant cells (Tzanck preparation) and/or sent for culture, immunofluorescent viral antigen studies, or PCR (A-III).
- Scabies should be considered in any nursing home resident with a generalized rash that is unexplained. Diagnosis should be attempted by light microscopy demonstration of mites, eggs, or mite feces on mineral oil preparations of several scrapings (B-III). If proper diagnostic equipment is not available and if clinical experience with scabies is limited, consider consultation with a dermatologist to inspect or obtain scrapings from suspected persons (C-III).
Evaluation of GI Infection
- In the absence of an outbreak of GI illness, residents with symptoms of gastroenteritis consistent with small bowel infection and a stable clinical status should be evaluated before 7 days for volume assessment, but no laboratory evaluation is required unless the resident is severely ill or symptoms persist beyond 7 days. In such cases, presence of Giardia species and other protozoa should be examined in stool specimens (B-III).
- If the resident exhibits symptoms of colitis (e.g., severe fever, abdominal cramps, and/or diarrhea, with or without blood and/or WBCs in the stool), initial evaluation for Clostridium (C.) difficile should be performed, especially if the patient has received antibiotics within the previous 30 days. Submit a single diarrheal stool specimen to the laboratory for a C. difficile toxin assay. If diarrhea persists and if the assay result is negative, submit 1 or 2 additional stool specimens for the toxin assay (A-II).
- In a patient with symptoms of colitis but no history of antibiotic use within the previous 30 days and/or a negative C. difficile evaluation result, one should submit a stool sample for culture for isolation of the most frequent invasive enteropathogens (i.e., Campylobacter jejuni, Salmonella and Shigella species, and Escherichia coli O157:H7) (A-II).
- Local public health authorities should be consulted if rates of gastroenteritis or colitis exceed baseline thresholds in the facility (if these thresholds are known), if >2 cases occur at the same time in the same unit, or if a reportable pathogen is isolated (B-III).
- Intra-abdominal infections and abscesses can occur in LTCF residents as a consequence of GI pathology. These complications are relatively uncommon but are associated with substantial morbidity and mortality; evaluation and treatment of possible abscesses should be performed in an acute care setting (B-III).
Suspected Outbreak
A broad description of an outbreak investigation is beyond the scope of these guidelines, but a general guide is provided, including circumstances in which appropriate authorities (e.g., the Centers for Disease Control and Prevention) should be notified. An important aspect of the outbreak investigation is that residents with advanced directives that prohibit testing can and often should be tested if the goal is not for care of that specific patient but reduction in the risk of illness in others.
- During a possible outbreak of infection, testing of residents, regardless of advanced directive status, may be war ranted for diagnostic and infection-control purposes for the protection of other residents and staff (B-III).
Definitions:
Quality of Evidence
- Evidence from >1 properly randomized, controlled trial
- Evidence from >1 well-designed clinical trial, without randomization; from cohort or case-controlled analytical studies (preferably from >1 center); from multiple time- series; or from dramatic results from uncontrolled experiments
- Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Strength of Recommendation
- Good evidence to support a recommendation for use
- Moderate evidence to support a recommendation for use
- Poor evidence to support a recommendation
