Role of body temperature in diagnosing bacterial infection in nursing home residents

Rapid Detection of Influenza Outbreaks in Long-Term Care Facilities Reduces Emergency Room Visits and Hospitalization: A Randomized Trial

OBJECTIVES

To assess whether the use of rapid influenza diagnostic tests (RIDTs) for long-term care facility (LTCF) residents with acute respiratory infection is associated with increased antiviral use and decreased health care utilization.

DESIGN

Nonblinded, pragmatic, randomized controlled trial evaluating a 2-part intervention with modified case identification criteria and nursing staff-initiated collection of nasal swab specimen for on-site RIDT.

SETTING AND PARTICIPANTS

Residents of 20 LTCFs in Wisconsin matched by bed capacity and geographic location and then randomized.

METHODS

Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, antiviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalizations, hospitalizations for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over 3 influenza seasons.

RESULTS

Oseltamivir use for prophylaxis was higher at intervention LTCFs [2.6 vs 1.9 courses per 1000 person-weeks; rate ratio (RR) 1.38, 95% CI 1.24-1.54; P < .001]; rates of oseltamivir use for influenza treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR 0.78, 95% CI 0.64-0.92; P = .004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR 0.79, 95% CI 0.67-0.93; P = .004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR 0.64, 95% CI 0.0.59-0.69; P < .001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality.

CONCLUSIONS AND IMPLICATIONS

The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across 3 combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites.

Detecting Acute Deterioration in Older Adults Living in Residential Aged Care: A Scoping Review

OBJECTIVES

To explore models, processes, or tools implemented in residential aged care (RAC) to support registered nurses (RNs) to identify and respond to the acute deterioration of residents.

DESIGN

Scoping literature review of English Language articles published in peer reviewed journals.

SETTINGS AND PARTICIPANTS

Studies were conducted in RAC facilities providing long-term 24-hour medical, nursing, and social care for people age 65 years or older with age-related disability.

METHODS

We completed a MESH term and key word search of MEDLINE, Embase, CINAHL, PubMed, and Google Scholar. Included studies had (1) part of the intervention based in RAC; (2) had a direct impact on RAC day to day practice; and (3) contained or provided access to the detail of the intervention. Data was charted by author, date, country, study design and the components, genesis, and efficacy of the methods used to identify and respond to acute deterioration.

RESULTS

We found 46 studies detailing models of care, clinical patterns of acute deterioration, and deterioration detection tools. It was not possible to determine which element of the models care had the greatest impact on RN decision making. The clinical patterns of acute deterioration painted a picture of acute deterioration in the frail. There was limited evidence to support the use of existing deterioration detection tools in the RAC population.

CONCLUSION AND IMPLICATIONS

We found no straight forward systematic method to support RAC RNs to identify and respond to the acute deterioration of residents. This is an important practice gap. The clinical pattern of acute deterioration described in the literature has the potential to be used for the development of a tool to support RAC RNs to identify and respond to the acute deterioration of residents.

Symptom- and Prevention-Based Testing of COVID-19 in Nursing Home Residents: A Retrospective Cohort Study

Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (S-based) or because of transmission prevention (TP-based). The investigated study sample included all NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 (n = 380). Clinical symptoms, temperature, and oxygen saturation were extracted from medical records, 7 days before to 14 days after testing. COVID-19 was confirmed in 81 (21%) residents; 36 (44%) S-based and 45 (56%) TP-based: 45. Cycle threshold (CT) values did not differ between the groups. In the 7 days prior to the test falling (32%), somnolence (25%) and fatigue (21%) occurred in both groups. Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents within the S-based group were 2.5 times more likely to increased mortality within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3–5.2). Although, 73% of the T-based group did eventually develop core symptoms. Thus, attention to falling and daily measures of temperature and oxygen saturation can contribute to earlier detection.

Individual factors including age, BMI and heritable factors underlie temperature variation in sickness and in health: an observational, multi-cohort study

Background

Aging affects immunity, potentially altering fever response to infection. We assess effects of biological variables on basal temperature, and during COVID-19 infection, proposing an updated temperature threshold for older adults ≥65 years.

Methods

Participants were from 4 cohorts: 1 089 unaffected adult TwinsUK volunteers; 520 adults with emergency admission to a London hospital with RT-PCR confirmed SARS-CoV-2 infection; 757 adults with emergency admission to a Birmingham hospital with RT-PCR confirmed SARS-CoV-2 infection and 3 972 adult community-based COVID Symptom Study participants self-reporting a positive RT-PCR test. Heritability was assessed using saturated and univariate ACE models; mixed-effect and multivariable linear regression examined associations between temperature, age, sex, and body mass index (BMI); multivariable logistic regression examined associations between fever (≥37.8°C) and age; receiver operating characteristic (ROC) analysis was used to identify temperature threshold for adults ≥ 65 years.

Results

Among unaffected volunteers, lower BMI (p = .001), and increasing age (p < .001) was associated with lower basal temperature. Basal temperature showed a heritability of 47% (95% confidence interval 18%–57%). In COVID-19+ participants, increasing age was associated with lower temperatures in Birmingham and community-based cohorts (p < .001). For each additional year of age, participants were 1% less likely to demonstrate a fever ≥37.8°C (OR 0.99; p < .001). Combining healthy and COVID-19+ participants, a temperature of 37.4°C in adults ≥65 years had similar sensitivity and specificity to 37.8°C in adults <65 years for discriminating infection.

Conclusions

Aging affects temperature in health and acute infection, with significant heritability, indicating genetic factors contribute to temperature regulation. Our observations suggest a lower threshold (37.4°C/97.3°F) for identifying fever in older adults ≥65 years.

Infections in Older Adults

Infections in elderly patients can prove diagnostically challenging. Age-related factors affecting the immune system in older individuals contribute to nonspecific presentations. Other age-related factors and chronic conditions have symptoms that may or may not point to an infectious diagnosis. Delay in administration of antimicrobials can lead to poor outcomes; however, unnecessary administration of antimicrobials can lead to increased morbidity and contribute to the emergence of multidrug-resistant organisms. Careful clinical assessment and consideration of patient history and risk factors is crucial. When necessary, antimicrobials should be chosen that are appropriate for the diagnosis and deescalated as soon as possible.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

The Winter Respiratory Viral Season During the COVID-19 Pandemic

The winter respiratory virus season always poses challenges for long-term care settings; this winter, severe acute respiratory syndrome coronavirus 2 will compound the usual viral infection challenges. This special article discusses unique considerations that Coronavirus Disease 2019 (COVID-19) brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year's winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Temperature in Nursing Home Residents Systematically Tested for SARS-CoV-2

OBJECTIVES

Many nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever, defined as a temperature of at least 38.0°C. The objective of this study was to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

The Veterans Administration (VA) operates 134 Community Living Centers (CLC), similar to nursing homes, that house residents who cannot live independently. VA guidance to CLCs directed daily clinical screening for COVID-19 that included temperature assessment.

MEASURES

All CLC residents (n = 7325) underwent SARS-CoV-2 testing. We report the temperature in the window of 14 days before and after universal SARS-CoV-2 testing among CLC residents. Baseline temperature was calculated for 5 days before the study window.

RESULTS

SARS-CoV-2 was identified in 443 (6.0%) residents. The average maximum temperature in SARS-CoV-2-positive residents was 37.66 (0.69) compared with 37.11 (0.36) (P = .001) in SARS-CoV-2-negative residents. Temperatures in those with SARS-CoV-2 began rising 7 days before testing and remained elevated during the 14-day follow-up. Among SARS-CoV-2-positive residents, only 26.6% (n = 118) met the fever threshold of 38.0°C during the survey period. Most residents (62.5%, n = 277) with confirmed SARS-CoV-2 did experience 2 or more 0.5°C elevations above their baseline values. One cohort of SARS-CoV-2 residents' (20.3%, n = 90) temperatures never deviated >0.5°C from baseline.

CONCLUSIONS AND IMPLICATIONS

A single screening for temperature is unlikely to detect nursing home residents with SARS-CoV-2. Repeated temperature measurement with a patient-derived baseline can increase sensitivity. The current fever threshold as a screening criteria for SARS-CoV-2 infection should be reconsidered.

Nursing Home Clinicians' Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment

OBJECTIVE

To determine which nursing home (NH) resident characteristics were most important to clinicians' decision to prescribe antibiotics for a suspected urinary tract infection (UTI), including both evidence-based and non-evidence-based characteristics.

DESIGN

Web-based discrete choice experiment with 19 clinical scenarios. For each scenario, clinicians were asked whether they would prescribe an antibiotic for a suspected UTI.

SETTING

Online survey.

PARTICIPANTS

Convenience sample of 876 NH physicians and advanced practice providers who practiced primary care for NH residents in the United States.

METHODS

Each scenario varied information about 10 resident characteristics regarding urinalysis results, resident temperature, lower urinary tract symptoms, physical examination, antibiotic request, mental status, UTI risk, functional status, goals of care, and resident type. We derived importance scores for the characteristics and odds ratios (ORs) for specific information related to each characteristic from a multinomial logistic regression.

RESULTS

Approximately half of the participants were male (56%) with a mean age of 49 years. Resident characteristics differed in their importance (ie, part-worth utility) when deciding whether to prescribe for a suspected UTI: urinalysis results (32%), body temperature (17%), lower urinary tract symptoms (17%), physical examination (15%), antibiotic request (7%), mental status (4%), UTI risk (4%), functional status (3%), goals of care (2%), and resident type (1%). Information about "positive leukocyte esterase, positive nitrates" was associated with highest odds of prescribing [OR 19.6, 95% confidence interval (CI) 16.9, 22.7], followed by "positive leukocyte esterase, negative nitrates" (OR 6.7, 95% CI 5.8, 7.6), and "painful or difficult urination" (OR 4.8, 95% CI 4.2, 5.5).

CONCLUSIONS AND IMPLICATIONS

Although guidelines focus on lower urinary tract symptoms, body temperature, and physical examination for diagnosing a UTI requiring antibiotics, these characteristics were considered less important than urinalysis results, which have inconsistent clinical utility in NH residents. Point-of-care clinical decision support offers an evidence-based prescribing process.

Nursing Home-Associated Pneumonia, Part I: Diagnosis

Pneumonia is 1 of the 3 most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting. In regard to pneumonia in the nursing home setting, practitioners are focused primarily on identifying residents with this infection and choosing a treatment regimen. In this article, the diagnosis of this infection is addressed. Based on published studies and clinical experience, "bedside criteria" for the diagnosis of nursing home-associated pneumonia (NHAP) are proposed that are based primarily on objective respiratory signs and symptoms that can be readily identified by staff. It is also stressed that factors predisposing to aspiration should be identified because there is a risk for aspiration pneumonitis. A previously published decision tool to distinguish between aspiration pneumonia and aspiration pneumonitis is discussed. Because providers are often not present when there is a change in status of a resident, nursing staff are crucial to the diagnosis of NHAP. However, there is variability in staff experience and the ability to obtain and communicate clinical findings to assist providers in making decisions about diagnosis. To deal with this issue, templates have been developed to help staff collect the appropriate information before contacting the provider. The most important diagnostic test in a resident with suspected pneumonia is a chest radiograph. However, studies done more than a decade ago demonstrated considerable variability in radiologists' interpretation of chest radiographs of residents performed in the nursing home. Radiologic techniques have improved considerably with utilization of digital technology, but there have been no recent studies to determine if interpretation of these radiographs is more consistent. An alternative to radiographs is lung ultrasonography, which has been found to be more accurate than chest radiographs in identifying pneumonia in adults; however, this method has not been studied in the nursing home setting. Host biomarkers such as serum C-reactive protein and procalcitonin levels have been studied in adults with pneumonia to distinguish between bacterial and nonbacterial infection, but there has been limited study in NHAP and the findings are conflicting. Lastly, it is stressed that the provider should carefully document the clinical findings and testing that result in a diagnosis of pneumonia to enhance surveillance for infection as well as antimicrobial stewardship activities.

Frequency of Infection during Fever Episodes among Long-Term Care Residents

Background

Empirical data regarding the frequency of infection during fever episodes among women in long-term care facilities are lacking.

Methods

We conducted a case-series analysis of women long-term care residents enrolled in a randomized trial evaluating cranberry capsules to reduce bacteriuria plus pyuria across twenty-one long-term care facilities in CT, USA. Fever episodes identified during adverse event surveillance were assessed using established guidelines for older adults. Among fever episodes, infections were classified using standardized infection surveillance definitions in long-term care residents.

Results

We identified 123 fever episodes among 80 women long-term care residents. Median age was 88 years (range, 65–101), and 81% (N=65) had dementia. Among 123 fever episodes, 79 (64%) met criteria for 86 total infections (lower respiratory tract, N=43; pneumonia, N=27; gastroenteritis, N=9; urinary tract, N=7).

Conclusion

Data from this study suggest that approximately two-thirds of fever episodes involve infection among women in long-term care facilities. These data may guide provider assessments of fever in older adult women in long-term care facilities.

Can Sepsis Be Detected in the Nursing Home Prior to the Need for Hospital Transfer?

OBJECTIVES

To determine whether and to what extent simple screening tools might identify nursing home (NH) residents who are at high risk of becoming septic.

DESIGN

Retrospective chart audit of all residents who had been hospitalized and returned to participating NHs during the study period.

SETTING AND PARTICIPANTS

A total of 236 NH residents, 59 of whom returned from hospitals with a diagnosis of sepsis and 177 who had nonsepsis discharge diagnoses, from 31 community NHs that are typical of US nursing homes overall.

MEASURES

NH documentation of vital signs, mental status change, and medical provider visits 0-12 and 13-72 hours prior to the hospitalization. The specificity and sensitivity of 5 screening tools were evaluated for their ability to detect residents with incipient sepsis during 0-12 and 13-72 hours prior to hospitalization: The Systemic Inflammatory Response Syndrome criteria, the quick Sequential Organ Failure Assessment (SOFA), the 100-100-100 Early Detection Tool, and temperature thresholds of 99.0°F and 100.2°F. In addition, to validate the hospital diagnosis of sepsis, hospital discharge records in the NHs were audited to calculate SOFA scores.

RESULTS

Documentation of 1 or more vital signs was absent in 26%-34% of cases. Among persons with complete vital sign documentation, during the 12 hours prior to hospitalization, the most sensitive screening tools were the 100-100-100 Criteria (79%) and an oral temperature >99.0°F (51%); and the most specific tools being a temperature >100.2°F (93%), the quick SOFA (88%), the Systemic Inflammatory Response Syndrome criteria (86%), and a temperature >99.0°F (85%). Many SOFA data points were missing from the record; in spite of this, 65% of cases met criteria for sepsis.

CONCLUSIONS

NHs need better systems to monitor NH residents whose status is changing, and to present that information to medical providers in real time, either through rapid medical response programs or telemetry.

Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review

INTRODUCTION

Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH.

METHODS

PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines).

RESULTS

A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations.

DISCUSSION

The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization.

CONCLUSION

Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents

OBJECTIVES

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship.

METHODS

Chart review of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics.

RESULTS

Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7 days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7 days.

DISCUSSION

Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance.

Urine Culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing

OBJECTIVE To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs) DESIGN Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period SETTING 31 NHs in North Carolina PARTICIPANTS 254 NH residents who had a urine culture ordered within the 1-month study period METHODS We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs. RESULTS Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000-99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%). CONCLUSIONS Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available. Infect Control Hosp Epidemiol 2017;38:524-531.

Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management

New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.

Changes in vital signs as predictors of bacterial infection in home care: a multi-center prospective cohort study

OBJECTIVES

To explore whether the combination of changes in heart rate and body temperature can predict bacterial infection in home care patients.

METHODS

This multicenter, prospective cohort study was conducted in Japan from March 2012 through December 2013 and involved three clinics. The study population comprised all patients who received regular home visit services for at least 3 months and met one of the following inclusion criteria: 1) fever over 37.5°C at home visit, 2) physician's clinical suspicion of fever, or 3) physician's suspicion of bacterial infection. We collected temperature and heart rate data on the day of enrollment, and determined the probable causes of fever after treatment of febrile episodes. We defined the combination of changes in heart rate and body temperature as delta HR/BT. We calculated two types of delta HR/BT, averaged and assumed, using different baseline values for heart rate and body temperature.

RESULTS

A total of 124 patients were enrolled and 194 episodes of fever were analyzed during the study period. The sensitivity, specificity, positive predictive value, and negative predictive value for the average delta HR/BT with a cut-off ≥ 20 were 20.4% (95% CI, 16.7-23.3), 84.2% (95% CI, 75.2-91.0), 75.7% (95% CI, 61.8-86.2), and 30.6% (95% CI, 27.3-33.0), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the assumed delta HR/BT with a cut-off ≥ 5 was 91.2% (95% CI, 89.2-94.0), 8.9% (95% CI, 4.1-15.7), 70.9% (95% CI, 69.3-73.0), and 29.4% (95% CI, 13.6-51.8), respectively.

CONCLUSIONS

The combination of changes in heart rate and body temperature could help physicians determine whether home care patients have bacterial infections.

Evaluation and Management of the Nursing Home Resident With Respiratory Symptoms and an Equivocal Chest X-Ray Report

OBJECTIVES

Pneumonia is a leading cause of morbidity and mortality in nursing home (NH) residents. Chest x-ray evidence is considered a key diagnostic criterion for pneumonia by the Infectious Disease Society of America (IDSA) diagnostic guidelines, the modified McGeer diagnostic criteria, and the Loeb criteria for initiating antibiotics; however, x-ray interpretation is often equivocal. We conducted chart audits of patients in NHs who had chest x-rays for new respiratory symptoms to determine the degree of ambiguity in the radiology reports and their relationship to antibiotic prescription decisions.

DESIGN

Cross-sectional study.

SETTING

Thirty-one NHs in North Carolina.

PARTICIPANTS

Two hundred twenty-six NH residents who had a chest x-ray.

METHODS

Medical charts were abstracted to record (1) the patient's clinical presentation when a chest x-ray was ordered, (2) the verbatim report of the chest x-ray, and (3) the patient's course during the subsequent 7 days. To standardize the radiologist reports, a seven-category coding system was developed, which was further aggregated into three groups based on the radiologist's description of the likelihood of pneumonia.

RESULTS

Of the 226 chest x-rays, 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation.

CONCLUSION

The moderate rate of ambiguous x-ray interpretations in NH residents is likely a combination of the poor quality of portable x-rays, a high prevalence of chronic lung conditions, and conservative (ie, cautious) decision making by radiologists whose interpretation is based on little clinical information and a suboptimal quality film. As a result, data suggest that chest x-rays obtained in NHs may unnecessarily encourage antibiotic prescribing because a majority of readings are ambiguous or show a low likelihood of pneumonia, yet more than half of the patients are still treated. From an antibiotic stewardship standpoint, the apparent solution is to more closely rely on clinical signs and symptoms for diagnosis of pneumonia and to place less emphasis on the role of the chest x-ray given the high number of unclear readings.

Clinical Features of Infection in Older Adults

The impact of infectious diseases on older adults is far greater than on younger adults because of significantly higher morbidity and mortality caused by infection. The reasons for this greater impact include factors such as lower physiologic reserve due to age and chronic disease, age-related changes in host defenses, loss of mobility, higher risk for polypharmacy and adverse drug reactions, and being on drugs that increase the risk for infection (e.g., anticholinergic and other sedating medications increase the risk for pneumonia).

Pneumonia Identification Using Nursing Home Records

Pneumonia is a leading cause of death among nursing home residents; consequently, prevention and treatment are important for quality improvement. To be pragmatic, quality improvement depends on sensitive case identification using nursing home records; however, no studies have examined the reliability of different methods of pneumonia case finding from records. The current authors compared three established strategies for defining pneumonia using records from 1,119 residents across 16 nursing homes: recorded diagnosis of pneumonia, modified McGeer criteria (chest x-ray infiltrate plus specified signs/symptoms), and antibiotic prescription plus pneumonia-specific signs. Chart diagnosis detected 107 cases, modified McGeer criteria detected 84 cases, and antibiotic prescription detected 47 cases. Diagnosis included all cases identified by the McGeer criteria and all but one case identified by antibiotic use. Based on findings, recorded diagnosis of pneumonia is a highly sensitive and pragmatic method to ascertain pneumonia in nursing homes, and is recommended for use in quality improvement and research. [Res Gerontol Nurs. 2016; 9(3):109-114.].

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.