Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

[Urosepsis: pathophysiology, diagnosis, and management-an update]

Urinary tract infections vary widely in their clinical spectrum, ranging from uncomplicated cystitis to septic shock. Urosepsis accounts for 9-31% of all cases of septicemia and is often associated with nosocomial infections. A major risk factor for urosepsis is the presence of obstructive uropathy, caused by conditions such as urolithiasis, tumors, or strictures. The severity and course of urosepsis depend on both the virulence of the pathogen and the patient's specific immune response. Prompt therapy, including antimicrobial treatment and eradication of the infection source, along with supportive measures for circulatory and respiratory stabilization, and adjunctive therapies such as hemodialysis and glucocorticoid therapy, is crucial. Due to demographic changes, an increase in cases of urosepsis is expected-thus, it is of utmost importance for urologists to be familiar with targeted diagnostics and effective treatment.

Antibiotic Switches in Urinary Tract Infection Are Associated With Atypical Symptoms and Emergent Care

IMPORTANCE

Given worsening global antibiotic resistance, antimicrobial stewardship aims to use the shortest effective duration of the most narrow-spectrum, effective antibiotic for patients with specific urinary symptoms and laboratory testing consistent with urinary tract infection (UTI). Inappropriate treatment and unnecessary antibiotic switching for UTIs harms patients in a multitude of ways.

OBJECTIVE

This study sought to analyze antibiotic treatment failures as measured by antibiotic switching for treatment of UTI in emergent and ambulatory care.

STUDY DESIGN

For this retrospective cohort study, 908 encounters during July 2019 bearing a diagnostic code for UTI/cystitis in a single health care system were reviewed. Urinary and microbiological testing, symptoms endorsed at presentation, and treatments prescribed were extracted from the medical record.

RESULTS

Of 908 patients diagnosed with UTI, 64% of patients (579/908) received antibiotics, 86% of which were empiric. All patients evaluated in emergent care settings were prescribed antibiotics empirically in contrast to 71% of patients in ambulatory settings (P < 0.001). Of patients given antibiotics, 89 of 579 patients (15%, 10% of all 908 patients) were switched to alternative antibiotics within 28 days. Emergent care settings and positive urine cultures were significantly associated with increased antibiotic switching. Patients subjected to switching tended to have higher rates of presenting symptoms inconsistent with UTI.

CONCLUSIONS

Empiric treatment, particularly in an emergent care setting, was frequently inappropriate and associated with increasing rates of antibiotic switching. Given the profound potential contribution to antibiotic resistance, these findings highlight the need for improved diagnostic and prescribing accuracy for UTI.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study)

BACKGROUND

This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations.

METHODS

Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators.

RESULTS

Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators.

CONCLUSIONS

This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

The safety and efficacy of Chinese herbal medicine for pneumonia prevention in high-risk elder residents in the nursing home: A randomized, double-blind clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Nursing home-associated pneumonia (NHAP) is a common type of infection among long-term care residents. Moreover, the mortality of NHAP is also higher than community-acquired pneumonia (CAP). In traditional Chinese medicine (TCM), the decoctions of Banxia Houpo Tang (BHT) and Ding Chuan Tang (DCT) are two formulas supporting the lungs' natural defense systems, helps to expel mucus and promote detoxification.

AIM OF THE STUDY

We designed a concentrated Chinese herbal extract formula called BDT1, that combines the compounds of BHT and DCT. In this study, we evaluated the safety and efficacy of BDT1 for NHAP prevention in high-risk older residents in the nursing home.

MATERIALS AND METHODS

In this randomized, double-blind, placebo-controlled trial, 160 participants aged over 65 years old living in the nursing home were randomly assigned 1:1 to the BDT1 and placebo group. Besides regular medicine, participants received either BDT1 or a placebo for 12 consecutive weeks. The primary outcome was the hospitalization rate for pneumonia in the intervention period and half-year follow-up. The microscopic examination of Gram-stained sputum was also evaluated before and after the trial. Data were analyzed by using the Chi-square test and Wilcoxon Signed Ranks Test with SPSS.

RESULTS

A total of 160 participants were enrolled into two study groups in this study, which was completed with 143 participants analyzed, including 70 subjects in the BDT1 group and 73 subjects in the placebo group. After the 12-week medical treatment, the hospitalization rate for pneumonia was 10.0% and 34.2% in the BDT1 and placebo group respectively. The risk of pneumonia in half a year was lower in the BDT1 group (adjusted hazard ratio = 0.422, 95% CI = 0.226-0.791). Compared to the placebo group, the level of Gram-negative bacilli in the BDT1 group is significantly declined in sputum samples (p < 0.05).

CONCLUSION

In conclusion, the cumulative incidence of pneumonia and related-hospitalization rates declined significantly after 12-weeks of BDT1 treatment. Besides, Chinese herbal medicine BDT1 is a safe therapy without hepatotoxicity or nephrotoxicity.

Diagnostic validation study of rapid urinary tract infection diagnosis kit at peripheral health facilities of West Bengal, India

Patients reporting to the outpatient departments of peripheral health care settings in India with symptoms of urinary tract infection (UTI) receive one or the other antibiotic before culture confirmation and out of the total culture confirmed UTI cases, in less than one third cases the prescribed antibiotics matches to the antibiotic sensitivity test result. Hence, in this study, an indigenous point-of-care (POCT) rapid diagnostic kit (Rapidogram) for UTI was validated against conventional urine culture and sensitivity to understand its possible applicability at peripheral health care settings. This cross-sectional study was conducted during November 2021 to June 2022 in OPDs of two peripheral hospitals. A sample size of 300 was calculated using prevalence of urinary tract infection (UTI) as 33% for sensitivity and specificity using Buderer's formula. Urine specimens were collected following standard aseptic procedures from the recruited suspected UTI cases and transferred to laboratory maintaining the cold chain. The validation work up was done in two sections: lab validation and field validation. Out of 300 urine samples, 29 were found positive for the growth of UTI pathogen by both methods and 267 were found negative by both methods. Thus, the kit shows very high specificity (99.6%; 97.9-99.9%) and considerably high sensitivity (90.6%; 74.9-98.0%). We also observed higher PPV, NPV, test accuracy (> 96%). Diagnostic Odds Ratio and Youden index were respectively 2581 and 0.89. Clinical data showed that 44% of the suspected UTI cases were prescribed at least one antibiotic before urine test. Mostly they received Norfloxacin whereas the mostly identified organism E.coli was sensitive to Nitrofurantoin. In the context of absence of microbiology facility at peripheral setting and rampant empirical use of antibiotics in UTI, this highly specific and sensitive POCT for UTI may be used as it not only identifies the organism, also shows the antibiotic sensitivity pattern.

Current State of Knowledge on the Definition, Pathophysiology, Etiology, Outcomes, and Management of Fever in the Intensive Care Unit

Fever-an elevated body temperature-is a prominent feature of a wide range of disease conditions and is a common finding in intensive care, affecting up to 70% of patients in the intensive care unit (ICU). The causes of fever in the ICU are multifactorial, and it can be due to a number of infective and noninfective etiologies. The production of fever represents a complex physiological, adaptive host response that is beneficial for host defense and survival but can be maladaptive and harmful if left unabated. Despite any cause, fever is associated with a wide range of cellular, local, and systemic effects, including multiorgan dysfunction, systemic inflammation, poor neurological recovery, and an increased risk of mortality. This narrative review presents the current state-of-the-art knowledge on the definition, pathophysiology, etiology, and outcomes of fever in the ICU and highlights evidence-based findings regarding the management of fever in the intensive care setting.

Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents

One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.

Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU

RATIONALE

Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation.

OBJECTIVES

This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

PANEL DESIGN

The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline.

METHODS

We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements.

RESULTS

The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data.

CONCLUSIONS

The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.

Fluoroquinolone-Induced Seizure in a Patient Receiving End-of-Life Care: A Case Report

When caring for patients nearing the end of live (EOL), healthcare providers must carefully assess the potential benefits and drawbacks of common medical interventions, such as starting antibiotic treatment. Antibiotic use during this stage can be a challenging and multifaceted situation, encompassing important clinical, social, and ethical considerations. While physicians may be motivated to prescribe antibiotics to terminally ill patients in hopes of prolonging survival and alleviating symptoms, it's crucial to recognize that these drugs can have significant implications for individuals at the EOL. Factors like advanced age, frailty, and multiple medication use make these patients more vulnerable to adverse events caused by antibiotics. For instance, fluoroquinolones, a specific type of antibiotics, have been linked to central nervous system toxicity and neurological side effects, including seizures. Geriatric patients, who often have underlying risk factors, are particularly susceptible to fluoroquinolone-induced seizures. However, there have also been reports of otherwise healthy individuals experiencing seizures as a result of fluoroquinolone use. This report sheds light on the complexities associated with initiating antibiotic therapy in patients nearing the EOL.

The value of fever assessment in addition to the Early Detection Infection Scale (EDIS). A validation study in nursing home residents in Sweden

BACKGROUND

In order to improve detection of suspected infections in frail elderly there is an urgent need for development of decision support tools, that can be used in the daily work of all healthcare professionals for assessing non-specific and specific changes. The aim was to study non-specific signs and symptoms and fever temperature for early detection of ongoing infection in frail elderly, and how these correlates to provide the instrument, the Early Detection Infection Scale (EDIS), which is used to assess changes in health condition in frail elderly.

METHODS

This was an explorative, prospective cohort study, including 45 nursing home residents, 76 to 99 years, in Sweden. Nursing assistants measured morning ear body temperature twice a week and used the EDIS to assess individual health condition daily for six months. The outcome comprised events of suspected infection, compiled from nursing and medical patient records. Factor analysis and multivariate logistic regression analysis were performed to analyse data.

RESULTS

Fifteen residents were diagnosed with at least one infection during the six-month follow-up and 189 observations related to 72 events of suspected infection were recorded. The first factor analysis revealed that the components, change in cognitive and physical function, general signs and symptoms of illness, increased tenderness, change in eye expression and food intake and change in emotions explained 61% of the variance. The second factor analysis, adding temperature assessed as fever to > 1.0 °C from individual normal, resulted in change in physical function and food intake, confusion and signs and symptoms from respiratory and urinary tract, general signs and symptoms of illness and fever and increased tenderness, explaining 59% of the variance. In the first regression analysis, increased tenderness and change in eye expression and food intake, and in the second change in physical function and food intake, general signs and symptoms of illness and fever (> 1.0 °C from individual normal) and increased tenderness were significantly associated with increased risk for ongoing infection.

CONCLUSION

No items in the EDIS should be removed at present, and assessment of fever as > 1.0 °C from individual normal is a valuable addition. The EDIS has the potential to make it easier for first line caregivers to systematically assess changes in health condition in fragile elderly people and helps observations to be communicated in a standardised way throughout the care process. The EDIS thus contributes to ensuring that the decisions not being taken at the wrong level of care.

Age Differences in Comorbidities, Presenting Symptoms, and Outcomes of Influenza Illness Requiring Hospitalization: A Worldwide Perspective From the Global Influenza Hospital Surveillance Network

Background

The Global Influenza Hospital Surveillance Network (GIHSN) was established in 2012 to conduct coordinated worldwide influenza surveillance. In this study, we describe underlying comorbidities, symptoms, and outcomes in patients hospitalized with influenza.

Methods

Between November 2018 and October 2019, GIHSN included 19 sites in 18 countries using a standardized surveillance protocol. Influenza infection was laboratory-confirmed with reverse-transcription polymerase chain reaction. A multivariate logistic regression model was utilized to analyze the extent to which various risk factors predict severe outcomes.

Results

Of 16 022 enrolled patients, 21.9% had laboratory-confirmed influenza; 49.2% of influenza cases were A/H1N1pdm09. Fever and cough were the most common symptoms, although they decreased with age (P < .001). Shortness of breath was uncommon among those <50 years but increased with age (P < .001). Middle and older age and history of underlying diabetes or chronic obstructive pulmonary disease were associated with increased odds of death and intensive care unit (ICU) admission, and male sex and influenza vaccination were associated with lower odds. The ICU admissions and mortality occurred across the age spectrum.

Conclusions

Both virus and host factors contributed to influenza burden. We identified age differences in comorbidities, presenting symptoms, and adverse clinical outcomes among those hospitalized with influenza and benefit from influenza vaccination in protecting against adverse clinical outcomes. The GIHSN provides an ongoing platform for global understanding of hospitalized influenza illness.

Clinical expressions, characteristics and treatments of confirmed COVID-19 in nursing home residents: a systematic review

BACKGROUND

The coronavirus 2019 (COVID-19) pandemic has led to a high rate of infections, frequent outbreaks, and high mortality rates in nursing homes (NH) worldwide. To protect and improve the treatment and care of the vulnerable NH population, it is pivotal to systematise and synthesise data from cases of COVID-19 among NH residents. In our systematic review, we therefore aimed to describe the clinical expressions, characteristics, and treatments of NH residents confirmed to have COVID-19.

METHODS

We conducted two comprehensive literature searches in several electronic databases: (1) PubMed, (2) CINAHL, (3) AgeLine, (4) Embase, and (5) PsycINFO in April and July 2021. Of the 438 articles screened, 19 were included in our sample, and we used the Newcastle-Ottawa Assessment Scale to assess the quality of the reported studies. A weighted mean (M_weighted), was calculated to account for the large variation in sample sizes of the studies, and due to heterogeneity among the studies, we report our findings in a narrative synthesis.

RESULTS

According to the mean weights (M_weighted), common symptoms and signs in NH residents confirmed to have COVID-19 were fever (53.7%), cough (56.5%), hypoxia (32.3%), and delirium or confusion (31.2%). Common comorbidities were hypertension (78.6%), dementia or cognitive impairment (55.3%), and cardiovascular diseases (52.0%). Six studies presented data concerning medical and pharmacological treatments, such as inhalers, oxygen supplementation, anticoagulation, and parenteral/enteral fluids or nutrition. The treatments were used to improve outcomes, as part of palliative care, or as end-of-life treatment. Transfers to hospital for NH residents with confirmed COVID-19 were reported in six of the included studies, and the rate of hospital transfers ranged from 6.9% to 50% in this population. In the 17 studies reporting mortality, 40.2% of the NH residents died during the studies' observation periods.

CONCLUSIONS

Our systematic review allowed us to summarise important clinical findings about COVID-19 among NH residents and to identify the population's risk factors for serious illness and death caused by the disease. However, the treatment and care of NH residents with severe COVID-19 warrant further investigation.

Nursing home-associated bloodstream infection: A scoping review

OBJECTIVE

To update a 2005 review of nursing home-associated bloodstream infection (NHABSI) regarding sources, organisms, antibiotic resistance, and outcome.

METHODS

A scoping review of studies of NHABSI identified by searching Google Scholar and Medline with OVID for the period January 1, 2004, to June 30, 2021, was conducted.

RESULTS

Overall, 6 studies of NHABSI were identified. Only 1 study was conducted with residents in North American facilities whereas in the 2005 review all studies were conducted in North America. Escherichia coli was the most common blood isolate, the urinary tract was the most common source of NHABSI; and the case-fatality rates ranged from 21% to 28%. These findings were comparable to those in the 2005 review. However, the proportion of NHABSI episodes due to antibiotic-resistant organisms increased substantially compared to the 2005 review. The most common antibiotic-resistant organisms were extended-spectrum β-lactamase-producing E. coli and Klebsiella spp. The 2 studies that evaluated the relationship between appropriate empiric antibiotic therapy and outcome came to different conclusions.

CONCLUSIONS

The only major difference between the 2 reviews in the epidemiology of NHABSI was the marked increase in antibiotic resistance among blood isolates. Despite the increased antibiotic resistance, the case fatality rates in the current review were comparable to those reported in the 2005 review. However, the impact of appropriate empiric antibiotic therapy on outcome of NHABSI remains unclear.

Ali G, Alzubaidi K, Ali B, Ismail A, Daghfal J, Almaslamani M, Hadi HA. Microbiological and clinical characteristics of invasive Group B Streptococcal blood stream infections in children and adults from Qatar

INTRODUCTION

Group B Streptococci (GBS) colonize almost one third of human gastrointestinal and genitourinary tracts, particularly in females. The aim of this study is to evaluate the epidemiology, microbiological characteristics, and clinical outcomes of invasive GBS disease in Qatar from all age groups.

METHODS

A retrospective study was conducted on patients with confirmed GBS blood stream infections during the period between January 2015 and March 2019. Microbiological identification was performed using automated BD PhoenixTM system, while additional antimicrobial susceptibility tests were performed using E test and disc diffusion methods.

RESULT

During the four years period, the incidence steadily rose from 1.48 to 2.09 cases per 100.000 population. Out of 196 confirmed cases of invasive GBS infections, the majority were females (63.7%, 125/196) of which 44.8% were pregnant and 53.6% were colonized. Three distinct affected age groups were identified: children ≤ 4 years of age (35.7%), young adults 25-34 (20.9%) and the elderly ≥ 65 year (17.4%). Presenting symptoms were mild with fever in 53% of cases while 89% of cases had Pitt bacteraemia score of ≤ 2. Isolates were universally sensitive to penicillin, ceftriaxone, and vancomycin at 100% but with significant resistance to erythromycin (49%) and clindamycin (28.6%) while 16.8% had inducible clindamycin resistance. Clinical outcomes showed cure rate of 87.25% with complications in (8.76%) and 4% mortality.

CONCLUSION

There is a rising trend of Group B Streptococcal blood stream infections in Qatar with significantly high clindamycin and erythromycin resistance rates. Universal susceptibility rates were demonstrated for penicillin, ceftriaxone, and vancomycin.

Impact of an Educational Program on Improving Nurses’ Management of Fever: An Experimental Study

Background: Despite a public information campaign “To Break the Myth of Fever”, nurses continued to overtreat fever. This study hypothesized that the campaign lacked the detailed rationale essential to alter nurses’ attitudes and behaviors. Aim: To evaluate the effect of the educational program on nurses’ knowledge, attitudes, and behaviors related to fever management. Design: A randomized experimental design using a time series analysis. Methods: A random sample of 58 medical/surgical nurses was evenly divided into an intervention and a control group. The intervention group received an educational program on fever and fever management. Both groups completed a pretest and four posttests using investigator-developed instruments: a questionnaire on knowledge and attitudes about fever management and a fever treatment checklist to audit charts. Results: The intervention group had markedly higher knowledge scores and reduced use of ice pillows at all four posttests, as well as lower use of antipyretics overall, except for the first posttest, despite no sustained change in attitude. Conclusions: An educational program for fever management can effectively improve clinical nurses’ knowledge and attitudes about fever management.

Clinical Characteristics of Patients with Pyogenic Vertebral Osteomyelitis and Concurrent Infections and Their Clinical Outcomes

Patients with pyogenic vertebral osteomyelitis (PVO) often develop concurrent infections, and a significant number of these patients show rapid deterioration in their medical condition, leading to mortality without PVO-related structural instability or neurological deficits. To improve clinical outcomes, we investigated the clinical presentation and treatment outcomes of patients with PVO and concurrent infections. This study included 695 patients with PVO, of which 175 (25%) had concurrent infections and 520 (75%) did not. The clinical characteristics of the two groups were compared, and multivariable analysis was performed to identify the association between concurrent infections and clinical outcomes. Patients with concurrent infections were older and had more comorbidities than those without. Moreover, there were significant intergroup differences in the anatomical involvement of PVO, and patients with concurrent infections had a higher number of regions involved more frequently than those without concurrent infections (15% vs. 6%). In contrast, patients with concurrent infections showed a lower degree of focal invasiveness, including a lower incidence of posterior abscess (47% vs. 59%; p = 0.008) and fewer neurological impairments according to the American Spinal Injury Association grade (p < 0.001) than those without concurrent infections. The causative organisms also differed significantly between the two groups, and patients with concurrent infections had a greater proportion of Gram-negative infections (31% vs. 16%, respectively) and a smaller proportion of methicillin-resistant S. aureus infections than those without concurrent infections (6% vs. 24%). Consequently, their clinical outcomes were significantly different, and patients with concurrent infections showed lower recurrence and higher mortality rates. We investigated the 1-year recurrence and mortality rates and their 95% confidence intervals according to the types of concurrent infections and their time of diagnosis and found variations in these parameters. Our results, based on a large number of patients, can be practically used as a reasonable reference to warn clinicians of the clinical risks of concurrent infections in patients with PVO and to help predict their clinical outcomes.

Standards and quality of care for older persons in long term care facilities: a scoping review

BACKGROUND

Caring for older persons has become a global necessity to ensure functional ability and healthy ageing. It is of paramount importance that standards of care are monitored, especially for older persons who live in long term care facilities (LTCF). We, therefore, scoped and summarised evidence relating to standards and the quality of care for older persons in LTCFs in gerontological literature globally.

METHODS

We conducted a scoping review using Askey and O'Malley's framework, including Levac et al. recommendations. PubMed, CINAHL, Health Sources, Scopus, Cochrane Library, and Google Scholar were searched with no date limitation up to May 2020 using keywords, Boolean terms, and medical subject headings. We also consulted the World Health Organization website and the reference list of included articles for evidence sources. This review also included peer-reviewed publications and grey literature in English that focused on standards and quality of care for older residents in LTCFs. Two reviewers independently screened the title, abstract, and full-text of evidence sources screening stages and performed the data extraction. Thematic content analysis was used, and a summary of the findings are reported narratively.

RESULTS

Sixteen evidence sources published from 1989 to 2017 met this study's eligibility criteria out of 73,845 citations obtained from the broader search. The majority of the studies were conducted in the USA 56% (9/16), and others were from Canada, Hong Kong, Ireland, Norway, Israel, Japan, and France. The included studies presented evidence on the effectiveness of prompted voiding intervention for urinary incontinence in LTCFs (37.5%), the efficacy of professional support to LTCF staff (18.8%), and the prevention-effectiveness of a pressure ulcer programme in LTCFs (6.3%). Others presented evidence on regulation and quality of care (12.5%); nursing documentation and quality of care (6.3%); medical, nursing, and psychosocial standards on the quality of care (6.3%); medication safety using the Beer criteria (6.3%); and the quality of morning care provision (6.3%).

CONCLUSION

This study suggests most studies relating to standards and quality of care in LTCFs focus on effectiveness of interventions, few on people-centredness and safety, and are mainly conducted in European countries and the United States of America. Future studies on people-centerdness, safety, and geographical settings with limited or no evidence are recommended.

Predictive Value of Urinalysis and Recent Antibiotic Exposure to Distinguish Between Bacteriuria, Candiduria, and No-Growth Urine

PURPOSE

Urinary tract infections are diagnosed by clinical symptoms and detection of causative uropathogen. Antibiotics are usually not indicated in candiduria and no-growth urine. We aimed to develop a predictive score to distinguish bacteriuria, candiduria, and no-growth urine, and to describe the distribution of microorganisms in urine.

PATIENTS AND METHODS

A single-center, retrospective cohort study was conducted between January 2017 and November 2017. Patients with concomitant urinalysis and urine culture were randomly sorted for a clinical prediction model. Multivariable regression analysis was performed to determine factors associated with bacteriuria, candiduria, and no-growth urine. A scoring system was constructed by rounding the regression coefficient for each predictor to integers. Accuracy of the score was measured by the concordance index (c-index).

RESULTS

There were 8091 positive urine cultures: bacteria 85.6%, Candida 13.7%. Randomly selected cases were sorted into derivation and validation cohorts (448 cases and 272 cases, respectively). Numerous yeast on urinalysis predicted candiduria with complete accuracy; therefore, it was excluded from a score construction. We developed a NABY score based on: positive nitrite, 1 point; Antibiotic exposure within 30 days, -2 points; numerous Bacteria in urine, 2 points; few Yeast in urine, -2 points; moderate Yeast in urine, -5 points. The c-index was 0.85 (derivation) and 0.82 (validation). A score ≥0 predicted 76% and 54% of bacteriuria in the derivation and validation cohorts, respectively. A score ≤-3 predicted 96% of candiduria in both cohorts.

CONCLUSION

Numerous yeast on urinalysis and the NABY score may help identify patients with a low risk of bacteriuria in whom empiric antibiotics for UTIs can be avoided.

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.

Multifactorial causation of early onset colorectal cancer

The multiple-hit hypothesis of cancer, including colorectal cancer (CRC), states that neoplastic development requires a sequence of mutations and epigenetic changes in driver genes. We have previously proposed that obesity increases CRC risk by supporting neoplastic development through adipokine-induced signaling, and this proliferative signaling substitutes for specific driver gene mutations. In support of this hypothesis, analyses of The Cancer Genome Atlas (TCGA) mutation data have revealed that obese patients with microsatellite stable CRC exhibit fewer driver gene mutations than CRC patients with normal body mass index. The lower number of driver gene mutations required for cancer development may shorten the neoplastic process and lead to an early onset of CRC. Therefore, obesity could be one factor explaining the rise of CRC incidence among younger individuals (< 50 years of age); furthermore, early onset CRC has been associated with the increasing incidence of metabolic syndrome and obesity in this age group. However, CRC incidence among older individuals (> 50 years of age) is stable or declining, despite the high rates of metabolic syndrome and obesity in this age group. In search for explanations of this phenomenon, we discuss several factors that may contribute to the divergent CRC incidence trends in populations under, and above, the age of 50, despite the rising levels of metabolic syndrome and obesity across all ages. First, older individuals with metabolic dysregulation are more frequently on maintenance medications, such as aspirin, β-blockers, lipid-lowering drugs, ACE inhibitors, metformin, etc., compared to younger individuals. Such treatments may suppress specific adipokine-induced proliferative signaling pathways, and therefore counteract and slow down neoplastic development in medicated overweight/obese individuals. Second, in the past decades, the incidence of infectious diseases accompanied by febrile episodes has been decreasing and the use of antipyretics increasing. Compared to normal cells, neoplastic cells are more sensitive to high body temperature; therefore, the decreased number of febrile episodes in childhood and adolescence may contribute to increased cancer incidence before the age of 50. Third, obesity at younger age may expand the stem cell compartment. An increased number of intestinal stem cells and stem cell divisions translates into a higher probability of sporadic mutations in the stem cells, and therefore, a greater chance of neoplasia. In conclusion, we hypothesize that early onset CRC has multifactorial causation and the proposed associations could be examined through analyses of existing data.

Impact of fever thresholds in detection of COVID-19 in Department of Veterans Affairs Community Living Center residents

Background

Among nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID‐19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID‐19 infections as symptomatic, pre‐symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS‐CoV‐2.

Methods

Residents with positive SARS‐CoV‐2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre‐symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS‐CoV‐2 test, respectively. All‐cause 30‐day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS‐CoV‐2 tests.

Results

From March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS‐CoV‐2 using RT‐PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre‐symptomatic, and 811 (52%) were asymptomatic. All‐cause 30‐day mortality among residents with symptomatic and pre‐symptomatic COVID‐19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR‐CoV‐2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773.

Conclusions

All‐cause 30‐day mortality was similar among VA CLC residents with symptomatic or pre‐symptomatic COVID‐19 infection, and lower than rates reported in non‐VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.

Asymptomatic But Altered? When Urinalysis Holds the Key

Altered mental status (AMS) is a common symptom in geriatric patients, especially in the long-term care setting. Traditionally, AMS has been associated with urinary tract infections (UTIs) in older people. However, data correlating UTIs with AMS are lacking. For this reason, asymptomatic bacteriuria (ASB) guidelines do not recommend using non-specific symptoms, such as AMS, to indicate a potential diagnosis of UTI. It is important to distinguish between colonization and infection, which can be done through proper interpretation of a urine analysis in the presence of UTI-specific symptomatology. In the absence of UTIspecific symptoms, alternative diagnoses for AMS should be explored. Consultant pharmacists are a key stakeholder and partner in ensuring appropriate antimicrobial prescribing practices, including identification of ASB in older patients.

Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients

OBJECTIVES

Obtaining body temperature is a quick and easy method to screen for acute infection such as COVID-19. Currently, the predictive value of body temperature for acute infection is inhibited by failure to account for other readily available variables that affect temperature values. In this proof-of-concept study, we sought to improve COVID-19 pretest probability estimation by incorporating covariates known to be associated with body temperature, including patient age, sex, comorbidities, month, and time of day.

METHODS

For patients discharged from an academic hospital emergency department after testing for COVID-19 in March and April of 2020, we abstracted clinical data. We reviewed physician documentation to retrospectively generate estimates of pretest probability for COVID-19. Using patients' COVID-19 PCR test results as a gold standard, we compared AUCs of logistic regression models predicting COVID-19 positivity that used: (1) body temperature alone; (2) body temperature and pretest probability; (3) body temperature, pretest probability, and body temperature-relevant covariates. Calibration plots and bootstrap validation were used to assess predictive performance for model #3.

RESULTS

Data from 117 patients were included. The models' AUCs were: (1) 0.69 (2) 0.72, and (3) 0.76, respectively. The absolute difference in AUC was 0.029 (95% CI -0.057 to 0.114, p=0.25) between model 2 and 1 and 0.038 (95% CI -0.021 to 0.097, p=0.10) between model 3 and 2.

CONCLUSIONS

By incorporating covariates known to affect body temperature, we demonstrated improved pretest probability estimates of acute COVID-19 infection. Future work should be undertaken to further develop and validate our model in a larger, multi-institutional sample.

Evaluation of Antibiotic Initiation Tools in End-of-Life Care

BACKGROUND

Hospice patients are frequently confronted with potentially infectious complications necessitating antibiotic consideration. Information regarding the appropriate use of antibiotics and their impact on symptom management in hospice patients are unknown.

OBJECTIVES

This study aimed to evaluate and describe the use of an antibiotic initiation tool in patients admitted to outpatient hospice services. The primary outcome assessed the percentage of antibiotics that were appropriately initiated based on Loeb's Minimum Criteria (LMC) for Antibiotic Initiation Tool. Secondary outcomes included the number of patients with documented symptom resolution following antibiotic completion, the number of antibiotic courses that were successfully completed, and treatment-related adverse events.

METHODS

This was a retrospective, multisite, descriptive analysis of hospice patients treated with antibiotics between April 2019 and September 2020.

RESULTS

Two hundred and thirty patients were assessed for inclusion, with 172 meeting eligibility criteria and receiving a total of 201 antibiotic courses. Based on LMC, 84 of the 201 (42%) antibiotics ordered were appropriate, with 60% of these LMC-approved courses resulting in symptom resolution. Out of 201 total courses, 99 (49%) resulted in symptom resolution. Overall, 160 (80%) antibiotic courses were successfully completed.

CONCLUSION

In this study, antibiotic initiation in hospice patients frequently did not meet LMC. Less than half of the antibiotics prescribed led to symptom resolution despite antibiotic course completion in most patients. There is no consensus or guidelines directing appropriate antibiotic decision-making in hospice patients. The appropriate use of antibiotics in terminally ill patients warrants additional research.

Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988-2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran's Q = 166,837.8, p < .001, I² = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

COVID-19 disease trajectories among nursing home residents

Introduction

Older adults are at greater risk of both infection with and mortality from COVID‐19. Many U.S. nursing homes have been devastated by the COVID‐19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID‐19.

Setting and Methods

This is a case series of 74 residents with COVID‐19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents.

Results

The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID‐19 infection. A subset of residents with COVID‐19 infection experienced a rapidly progressive, fatal course.

Discussion/Conclusions

Nursing home residents infected with COVID‐19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post‐disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.

COVID-19: Clinical Presentation and Prognostic Factors of Severe Disease and Mortality in the Oldest-Old Population: A Cohort Study

Introduction

The oldest-old population (80 years or older) has the highest lethality from COVID-19. There is little information on the clinical presentation and specific prognostic factors for this group. This trial evaluated the clinical presentation and prognostic factors of severe disease and mortality in the oldest-old population.

Methods

This is an ambispective cohort study of oldest-old patients hospitalized for respiratory infection associated with COVID-19 and with a positive test by RT-PCR. The clinical presentation and the factors associated with severe disease and mortality were evaluated (logistic regression). All patients were followed up until discharge or death.

Results

A total of 103 patients (59.2% female) were included. The most frequent symptoms were fever (68.9%), dyspnoea (60.2%), and cough (39.8%), and 11.7% presented confusion. Fifty-nine patients (57.3%) presented severe disease, and 59 died, with 43 patients (41.7%) presenting both of these. In the multivariate analysis, female sex (odds ratio [OR] 0.31, 95% confidence interval [95% CI] 0.13–0.73, p 0.0074) and serum lactate dehydrogenase (LDH) (OR 2.55, 95% CI 1.21–5.37, p 0.0139) were associated with severe disease, and serum sodium was associated with mortality (OR 3.12, 95% CI 1.18–8.26, p 0.0222). No chronic disease or pharmacological treatment was associated with worse outcomes.

Conclusions

The typical presenting symptoms of respiratory infection in COVID-19 are less frequent in the oldest-old population. Male sex and LDH level are associated with severe disease, and the serum sodium level is associated with mortality in this population.

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Health Heterogeneity in Older Adults: Exploration in the Canadian Longitudinal Study on Aging

BACKGROUND

A widely held dictum in aging research is that heterogeneity in health increases with age, but the basis for this claim has not been fully investigated. We examined heterogeneity at different ages across health characteristics to describe variation and trends; we investigated the comparative importance of between-age versus within-age heterogeneity.

DESIGN

This was a cohort study.

SETTING

Community-dwelling older adults.

PARTICIPANTS

A total of 30,097 adults aged 45 to 86 years, from the Canadian Longitudinal Study on Aging, were included.

MEASUREMENTS

Thirty-four health characteristics in eight domains (physical measures, vital signs, physiological measures, physical performance, function/disability, chronic conditions, frailty, laboratory values) were assessed cross-sectionally. We used regression models to examine heterogeneity in health characteristics (using absolute deviation) and domains (using effective variance) in relation to age. Comparison between between-age and within-age heterogeneity was quantified by estimating the age threshold at which the former exceeds the latter.

RESULTS

Of the 34 health characteristics, 17 showed increased heterogeneity, 8 decreased, and 9 no association with age. The associations between heterogeneity and age increased generally but were nonlinear for most domains and nonmonotonic for some. We observed peak heterogeneity at approximately 70 years. Between-age heterogeneity, compared with within-age heterogeneity, was most important for forced expiratory volume in 1 second and grip strength but varied across characteristics.

CONCLUSION

Overall health heterogeneity increases with age but does not uniformly increase across all variables and domains. Heterogeneity in aging reinforces the need for geriatric assessment and personalized care, depending on which health characteristics are assessed, their measurement properties, and their referent group. Our findings suggest further research to develop improved single-dimension and multidimensional instruments, as well as specific vital and laboratory reference ranges for older adults.

What are the factors that cause emergency home visit in home medical care in Japan?

BACKGROUND

In the home medical care setting, the factors causing emergency home visits (EHV) remain unclear. This study aimed to determine those factors and examine their relationship with EHV requests.

METHODS

This is a single-center retrospective observational study from data obtained from a home medical care clinic. We assessed the association between frequency of EHV and age, gender, level of care-needed, cancer, and medical device in use with using Poisson regression analysis.

RESULTS

A total of 608 EHV in 214 patients were analyzed. Common chief complaints were fever, death, and dyspnea. As factors that affect frequency of EHV because of fever, higher care-needed level (RR: 3.35; 95% CI: 1.95-5.74, P < .001), urinary catheter use (RR: 1.94; 95% CI: 1.22-3.08, P = .005), and central venous port use (RR: 2.39; 95% CI: 1.44-3.96, P = .001) showed significant correlation. Regarding EHV because of dyspnea, lung tumor (RR: 2.71; 95% CI: 1.26-5.84, P = .011) and home oxygen use (RR: 3.96; 95% CI: 2.05-7.68, P < .001) showed significant correlation. Regarding EHV because of all chief complaints, higher care-needed level (RR: 1.59; 95% CI: 1.12-2.26, P = .009), urinary catheter use (RR: 1.78; 95% CI: 1.13-2.93, P = .014), and central venous port use (RR: 1.75; 95% CI: 1.04-2.93, P = .034) showed positive correlation.

CONCLUSION

The factors associated with frequency of EHV because of fever or all chief complaints were urinary catheter use, central venous port use, and higher care-needed level. As for dyspnea, they were lung cancer and home oxygen use. Our study suggests that the burdens on medical staffs, patients, and their families can be reduced through recognizing these risk factors.

Body Temperature Is Associated With Cognitive Performance in Older Adults With and Without Mild Cognitive Impairment: A Cross-sectional Analysis

Wearable devices for remote and continuous health monitoring in older populations frequently include sensors for body temperature measurements (i.e., skin and core body temperatures). Healthy aging is associated with core body temperatures that are in the lower range of age-related normal values (36.3 ± 0.6°C, oral temperature), while patients with Alzheimer's disease (AD) exhibit core body temperatures above normal values (up to 0.2°C). However, the relation of body temperature measures with neurocognitive health in older adults remains unknown. This study aimed to explore the association of body temperature with cognitive performance in older adults with and without mild cognitive impairment (MCI). Eighty community-dwelling older adults (≥65 years) participated, of which 54 participants were cognitively healthy and 26 participants met the criteria for MCI. Skin temperatures at the rib cage and the scapula were measured in the laboratory (single-point measurement) and neuropsychological tests were conducted to assess general cognitive performance, episodic memory, verbal fluency, executive function, and processing speed. In a subgroup (n = 15, nine healthy, six MCI), skin and core body temperatures were measured continuously during 12 h of habitual daily activities (long-term measurement). Spearman's partial correlation analyses, controlled for age, revealed that lower median body temperature and higher peak-to-peak body temperature amplitude was associated with better general cognitive performance and with better performance in specific domains of cognition; [e.g., rib median skin temperature (single-point) vs. processing speed: rs = 0.33, p = 0.002; rib median skin temperature (long-term) vs. executive function: rs = 0.56, p = 0.023; and peak-to-peak core body temperature amplitude (long-term) vs. episodic memory: rs = 0.51, p = 0.032]. Additionally, cognitively healthy older adults showed lower median body temperature and higher peak-to-peak body temperature amplitude compared to older adults with MCI (e.g., rib median skin temperature, single-point: p = 0.035, r = 0.20). We conclude that both skin and core body temperature measures are potential early biomarkers of cognitive decline and preclinical symptoms of MCI/AD. It may therefore be promising to integrate body temperature measures into multi-parameter systems for the remote and continuous monitoring of neurocognitive health in older adults.

The Incidence, Characteristics, and Use of Suspected Nephrotoxic Drugs in Elderly Patients with Community-Acquired Acute Kidney Injury

PURPOSE

Acute kidney injury (AKI) is a major health problem with poor prognosis. However, little is known about elderly community-acquired-AKI (CA-AKI). This study aimed to investigate the incidence, clinical characteristics, outcomes and use of suspected nephrotoxic medications after CA-AKI in the elderly.

MATERIALS AND METHODS

A total of 36,445 patients aged over 60 years were recruited from 2013 to 2016. Through an electronic database, we collected the demographic and medical history data, and admission lab results from all patients.

RESULTS

A total of 2371 patients with CA-AKI were identified. The incidence of CA-AKI was 26.03% in the elderly. The proportion of CA-AKI patients with chronic comorbidities and Charlson comorbidity index score were higher than that of non-AKI patients. After CA-AKI, the proportions of exposure to non-steroidal anti-inflammatory drugs (NSAIDs), iodine contrast agent, angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were significantly decreased (p < 0.001). However, the proportion of other possible nephrotoxic drugs (including aminoglycosides, glycopeptide antibiotics, antifungal agents, beta lactam antibiotics, diuretic, ferralia, adrenergic receptor agonists and drugs for cardiac insufficiency therapy) still increased after CA-AKI (p < 0.001). Compared with non-AKI patients, CA-AKI patients had higher percentage of cardiogenic shock, multiple organ failure, transferring to intensive care unit, cardio-pulmonary resuscitation, hemodialysis, and mortality (p < 0.001). Moreover, CA-AKI patients had worse prognosis when more kinds of suspected nephrotoxic drugs were used (p < 0.001).

CONCLUSION

The incidence of CA-AKI in the elderly was high, with more complex chronic complications and poor clinical outcomes. The use of most suspected nephrotoxic drugs still increased and was associated with worse prognosis after CA-AKI.

Development and Application of a Surveillance Method for Healthcare-Associated Infections in Long-Term Care Hospitals in Korea

Background

This study developed a surveillance method for healthcare-associated infections (HAIs) in long-term care hospitals (LTCHs) and investigated the current status of HAIs in LTCHs in Korea.

Methods

We applied the HAI-related surveillance criteria for long-term care facilities developed by McGeer in six LTCHs.

Results

The 197 confirmed HAIs corresponded to incidence rates of 30.38/100 inpatients and 1.57/1,000 days of hospitalization and included 84 cases of respiratory tract infection (43.8%), 78 cases of systemic infection (40.6%), 24 cases of gastrointestinal tract infection (12.5%), and 6 cases of skin and soft tissue mucosal infection (2.1%). The subtypes included 78 cases of unexplained febrile illness (40.6%); 40 cases of pneumonia (20.8%); 27 cases of lower respiratory tract infection (14.1%); 21 cases of gastroenteritis (10.9%); 9 cases of influenza-like illness (4.7%); 8 cases of common cold or pharyngitis (4.2%); 4 cases of cellulitis, soft tissue, or wound infection (2.1%); 3 cases of Clostridium difficile infection (1.6%); 1 case of conjunctivitis (0.5%); and 1 case of fungal oral/perioral and skin infection (0.5%).

Conclusion

Establishing an HAI surveillance method for LTCHs and identifying HAI rates and risk factors among LTCH patients may help prevent HAIs in LTCHs in Korea.

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.

Association of dementia diagnosis with urinary tract infection in the emergency department

OBJECTIVES

Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug-resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown.

METHODS

To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities.

RESULTS

In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively).

CONCLUSION

This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

Comparison of clinical characteristics of patients with pandemic SARS-CoV-2-related and community-acquired pneumonias in Hungary - a pilot historical case-control study

The distinction between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related and community-acquired pneumonias poses significant difficulties, as both frequently involve the elderly. This study aimed to predict the risk of SARS-CoV-2-related pneumonia based on clinical characteristics at hospital presentation. Case-control study of all patients admitted for pneumonia at Semmelweis University Emergency Department. Cases (n = 30) were patients diagnosed with SARS-CoV-2-related pneumonia (based on polymerase chain reaction test) between 26 March 2020 and 30 April 2020; controls (n = 82) were historical pneumonia cases between 1 January 2019 and 30 April 2019. Logistic models were built with SARS-CoV-2 infection as outcome using clinical characteristics at presentation. Patients with SARS-CoV-2-related pneumonia were younger (mean difference, 95% CI: 9.3, 3.2-15.5 years) and had a higher lymphocyte count, lower C-reactive protein, presented more frequently with bilateral infiltrate, less frequently with abdominal pain, diarrhoea, and nausea in age- and sex-adjusted models. A logistic model using age, sex, abdominal pain, C-reactive protein, and the presence of bilateral infiltrate as predictors had an excellent discrimination (AUC 0.88, 95% CI: 0.81-0.96) and calibration (p = 0.27-Hosmer-Lemeshow test). The clinical use of our screening prediction model could improve the discrimination of SARS-CoV-2 related from other community-acquired pneumonias and thus help patient triage based on commonly used diagnostic approaches. However, external validation in independent datasets is required before its clinical use.

Sensitivity of C-reactive protein and procalcitonin measured by Point-of-Care tests to diagnose urinary tract infections in nursing home residents: a cross-sectional study

Background

Diagnosing urinary tract infections (UTIs) in nursing home residents is complex, as specific urinary symptoms are often absent and asymptomatic bacteriuria (ASB) is prevalent. The aim of this study was to assess the sensitivity of blood C-reactive protein (CRP) and procalcitonin (PCT), measured by point-of-care tests (PoCTs), to diagnose UTIs in this setting.

Methods

Elderly residents (≥65 years old) with a suspected UTI were recruited from psychogeriatric, somatic, or rehabilitation wards across 13 participating nursing homes. CRP and PCT were tested simultaneously in the same study participants. To assess the tests’ sensitivities, a stringent definition of “true” UTI was used that included the presence of symptoms, urinary leucocytes, a positive urine culture, and symptom resolution during antibiotic treatment covering isolated uropathogen(s). The original sample size was 440 suspected UTI episodes, in order to detect a clinically relevant sensitivity of at least 65% when calculated using the matched analysis approach to compare both PoCTs.

Results

After enrollment of 302 episodes (68.6% of the planned sample size), an unplanned and funder-mandated interim analysis was done, resulting in premature discontinuation of the study for futility. For 247 of 266 eligible episodes, all mandatory items required for the true UTI definition (92.9%) were available. In total, 49 episodes fulfilled our stringent UTI definition (19.8%). The sensitivities of CRP (cut-off, 6.5 mg/L) and PCT (cut-off, 0.025 ng/mL) were 52.3% (95% confidence interval [CI], 36.7–67.5%) and 37.0% (95% CI, 23.2–52.5%), respectively.

Conclusions

Our results indicate that CRP and PCT are not suitable tests for distinguishing UTI and ASB in nursing home residents.

Clinical Trials Registration

Netherlands Trial Registry NL6293.

"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: a qualitative study

BACKGROUND

Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals' perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect.

METHODS

We conducted a qualitative inquiry (2018-2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research.

RESULTS

All respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents' persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence.

CONCLUSIONS

Our study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.

Presence of urinary symptoms in bacteremic urinary tract infection: a retrospective cohort study of Escherichia coli bacteremia

Background

It is important to understand clinical features of bacteremic urinary tract infection (bUTI), because bUTI is a serious infection that requires prompt diagnosis and antibiotic therapy. Escherichia coli is the most common and important uropathogen. The objective of our study was to characterize the clinical presentation of E coli bUTI.

Methods

Retrospective cohort study of consecutive adult patients admitted for community acquired E. coli bacteremia from January 1, 2015 to December 31, 2016 was conducted at 4 acute care academic and community hospitals in Toronto, Ontario, Canada. Logistic regression models were developed to identify E coli bUTI cases without urinary symptoms.

Results

Of 462 patients with E. coli bacteremia, 284 (61.5%) patients had a urinary source. Of these 284 patients, 161 (56.7%) had urinary symptoms. In a multivariable model, bUTI without urinary symptoms were associated with older age (age < 65 years as reference, age 65–74 years had OR of 2.13 95% CI 0.99–4.59 p = 0.0523; age 75–84 years had OR of 1.80 95% CI 0.91–3.57 p = 0.0914; age > =85 years had OR of 2.95 95% CI 1.44–6.18 p = 0.0036) and delirium (OR of 2.12 95% CI 1.13–4.03 p = 0.0207). Sepsis by SIRS criteria was present in 274 (96.5%) of all bUTI cases and 119 (96.8%) of bUTI cases without urinary symptoms.

Conclusion

The majority of patients with E. coli bacteremia had a urinary source. A significant proportion of bUTI cases had no urinary symptoms elicited on history. Elderly and delirious patients were more likely to have bUTI without urinary symptoms. In elderly and delirious patients with sepsis by SIRS criteria but without a clear infectious source, clinicians should suspect, investigate, and treat for bUTI.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12879-020-05499-1.

Common Co-morbidities Are Challenging in the Diagnosis of Middle East Respiratory Syndrome (MERS-CoV) in Saudi Arabia

BACKGROUND AND OBJECTIVE

Middle East respiratory syndrome coronavirus (MERS-CoV) is a relatively recent human disease reported initially in Saudi Arabia in September, 2012. Morbidities investigation includes a process of excluding other possible options until certain suspected cases are confirmed.

MATERIAL AND METHODS

In this study, we formulated a model under the authorization of the Saudi Ministry of Health to accurately identify cases among admitted suspected cases depending on specific signs and symptoms. Real-time polymerase chain reaction was used for confirmation of the positive cases.

RESULTS

The results showed that the number of patients with combined symptoms of fever/sore throat and fever/cough/SOB was significantly higher in confirmed cases than in non-confirmed cases (p<0.05). Besides, the number of confirmed MERS-CoV cases was significantly higher among cases included in the study than excluded cases. It was also clearly demonstrated that fever combined with other symptoms represents 60% of the confirmed cases, which is significantly higher than for cases with other combined symptoms (p<0.0001).

CONCLUSION

To the best of our knowledge, there are no appropriate diagnostic models that can differentiate human MERS-CoV infection among other respiratory infections. Therefore, we recommend the adoption of this newly established model of MERS-CoV to short- list corona suspected cases in Saudi Arabia.

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).

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

OBJECTIVES

To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.

DESIGN

Web-based discrete choice experiment with 19 clinical scenarios.

SETTING AND PARTICIPANTS

Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.

METHODS

Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.

RESULTS

For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group.

CONCLUSIONS AND IMPLICATIONS

This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.

A snapshot of geriatric infections in Turkey: ratio of geriatric inpatients in hospitals and evaluation of their infectious diseases: A multicenter point prevalence study

INTRODUCTION

The human population is aging at an astonishing rate. The aim of this study is to capture a situation snapshot revealing the proportion of individuals aged 65 years and over among inpatients in healthcare institutions in Turkey and the prevalence and type of infections in this patient group in order to draw a road map.

MATERIALS AND METHODS

Hospitalized patients over 65 years at any of the 62 hospitals in 29 cities across Turkey on February 9, 2017 were included in the study. Web-based SurveyMonkey was used for data recording and evaluation system.

RESULTS

Of 17,351 patients 5871 (33.8%) were ≥65 years old. The mean age was 75.1±7.2 years; 3075 (52.4%) patients were male. Infection was reason for admission for 1556 (26.5%) patients. Pneumonia was the most common infection. The median length of hospital stay was 5 days (IQR: 2-11 days). The Antibiotic therapy was initiated for 2917 (49.7%) patients at the time of admission, and 23% of the antibiotics prescribed were inappropriate. Healthcare-associated infections developed in 1059 (18%) patients. Urinary catheters were placed in 2388 (40.7%) patients with 7.5% invalid indication.

CONCLUSION

This study used real data to reveal the proportion of elderly patients in hospital admissions. The interventions done, infections developed during hospitalization, length of hospital stay, and excessive drug load emphasize the significant impact on health costs and illustrate the importance of preventive medicine in this group of patients.

Ethical and Logistical Considerations of Caring for Older Adults on Inpatient Psychiatry During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has brought challenges to delivery of care for older adults on inpatient psychiatry. We describe two cases: patient A, a 62-year-old woman who initially refused screening for potential COVID-19, bringing up questions about threshold for capacity when public health is at risk and questions about whether screening for infection should be different in older adults. The other case, patient B, is that of an 83-year-old man who was on the unit when patient A tested positive, and brought up concerns for risk of dissemination in the context of wandering, spitting behaviors, and inability to adhere to room isolation or masking measures. We review measures taken to decrease risk of transmission and improve screening for infection in older adults.

Covid-19 Infection in Older Adults: A Geriatrician's Perspective

The pandemic of the Covid-19 virus has become the main issue all over the world. In its current form, the disease is more severe in geriatric cases and individuals with chronic disease, even causing death. In older adults and atypical presentations, testing strategies for Covid-19, potential drug interactions of experimental Covid-19 therapies, and ageism are important issues in the course of the disease. Therefore, health-care professionals should be aware of these, and screening policies for Covid-19 should also include atypical presentations with or without classical symptoms of the illness in older adults. Furthermore, evaluation of individuals > 65 years of age from a geriatrician's perspective is very important, because Covid-19 is severe and fatal in seniors.