Image of Theresa Rowe, DO

A change in a nursing home resident’s mental status does not always point to infection, caution the authors of revised clinical guidance from the Society for Healthcare Epidemiology of America. 

“The misattribution of non-localizing signs and symptoms to infection represents a major barrier to improving the appropriateness of antibiotics in nursing homes,” wrote Theresa Rowe, DO, of Northwestern University, and colleagues.

The new paper, released Wednesday, gives long-term care clinicians a framework for infection workups when residents present with a non-specific sign or symptom. It also reviews the latest evidence on how best to evaluate the non-localized signs of infection that clinicians often use to start antibiotics prior to confirmation by lab tests and imaging.

“When nursing home residents present with subtle nonspecific signs and symptoms, clinicians should consider causes other than infection,” said Rowe. “However, there are certain signs and symptoms, such as fever, that may warrant a work-up for infection.”

Older adults with infections present differently than younger adults. Fever can be blunted or absent in serious bacterial infections, for example, whereas dementia can make the diagnosis challenging due to a potentially unreliable health history.

Rowe and colleagues describe symptoms that generally should prompt further evaluation for infection. These include fever, hypothermia, low blood pressure, high blood sugar and delirium or worsening mental status. The authors also discuss symptoms that should not on their own prompt further evaluation for infection, but should be considered in the full context of the patient’s condition. These include behavioral changes, functional decline, falls and anorexia.

The paper, “SHEA Expert Guidance: Reliability of Non-Localizing Signs and Symptoms as Indicators of the Presence of Infection in Residents of Nursing Homes,” was published in Infection Control & Hospital Epidemiology.

The authors plan to follow up with a paper addressing evaluation for specific syndromes and use of antibiotics to treat them.