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

Extract

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% (1), and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration) (2-8). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI) (2), adverse drug effects (9-11), drug–drug interactions, and antimicrobial resistance (12-14). In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes (15-17).

There is increasing interest in implementing interventions to promote the deliberate application of clinical criteria as an approach to improving antibiotic decision making in nursing homes (18-20). A consensus conference held by members of the Society for Healthcare Epidemiology of America (SHEA) first developed minimum criteria that should be present before prescribing antibiotics in long-term care settings (7), known as the “Loeb Minimum Criteria” (7). These criteria were developed with clinicians’ empiric antibiotic decision-making in mind; they contrast with existing infection surveillance criteria that were designed primarily for the retrospective determination of treatment appropriateness from of laboratory and imaging study results (21). The Loeb Minimum Criteria, published in 2001, have allowed practitioners to make decisions regarding whether to start antibiotics for a resident before laboratory and imaging results are available (7).

Since then structure and delivery of nursing home care has changed significantly (7). For this reason, SHEA convened an expert panel to examine nonlocalizing signs and symptoms as indicators of infection in residents of nursing homes, such as behavior changes and falls, which practitioners may consider indicators of infection and reasons to initiate antibiotics. For example, in a prospective cohort study of residents of 25 nursing homes, the most documented presenting symptom for suspected urinary tract infection (UTI) was mental status changes. (22). In a survey of nursing-home practitioners, the most common triggers for suspecting UTIs in residents of nursing homes were changes in mental status (93%) and fever (83%) (23).

Practitioners may base empiric antibiotic prescribing decisions for nursing-home residents with nonlocalizing signs or symptoms on the premise that manifestations of infection change with age and that older adults with infections present differently than younger adults (24,25). For example, fever—a cardinal sign of infection—can be blunted or absent in older adults with serious bacterial infections (26). Likewise, dementia can present significant challenges to diagnosis, including difficulty in obtaining a reliable history. Although individual studies may point to an association of a nonlocalizing symptom with infection, within the body of literature, the reliability of nonlocalizing signs and symptoms in establishing a clinical suspicion of infection remains poorly understood.

The misattribution of nonlocalizing signs and symptoms to infection represents a major barrier to improving the appropriateness of antibiotics in nursing homes. Thus, we evaluated the clinical reliability of several nonlocalizing signs and symptoms as indicators of infection among residents of nursing homes, and our results and recommendations are presented here. This guidance document is intended to form the foundation for an update to the Loeb Minimum Criteria (7), and it will be followed by another document addressing evaluation for specific syndromes and use of antibiotics to treat them.

To view the full guidance and its recommendations, please visit the Cambridge University Press website.