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

The elderly population (i.e., persons aged > or = 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 > or = 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.