Infectious Diseases in Older Adults of Long‐Term Care Facilities: Update on Approach to Diagnosis and Management

Jump, Robin L.P.; Crnich, Christopher; Mody, Lona; Bradley, Suzanne F.; Nicolle, Lindsay E.; Yoshikawa, Thomas T.

doi:10.1111/jgs.15248

Cited by 81 publications

(89 citation statements)

References 62 publications

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“…Our findings support the idea that healthcare providers should promote immunization against influenza and pneumonia, and rigorously implement prevention practices to avoid the spread of infections, particularly in unvaccinated populations [48]. Vaccination rates in LTCFs have been slowly increasing over time, but many residents remain unvaccinated and considerable improvement in vaccination rates is possible [49].…”

Section: / 691supporting

confidence: 73%

“…Our results suggest that a rigorous examination of how time trends in vaccination rates have impacted time trends in respiratory infections may be necessary to understand the absence of a relationship between the two across included studies. The results of our review also suggest that policy-makers should consider LTCF-specific policies to improve uptake of preventive interventions for reducing the burden of respiratory infections [48].…”

Section: / 691mentioning

confidence: 84%

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The burden of respiratory infections among older adults in long-term care: a systematic review

et al. 2019

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Background Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. Methods We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. Results A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. Conclusions The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts. Electronic supplementary material The online version of this article (10.1186/s12877-019-1236-6) contains supplementary material, which is available to authorized users.

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Section: / 691supporting

confidence: 73%

Section: / 691mentioning

confidence: 84%

The burden of respiratory infections among older adults in long-term care: a systematic review

et al. 2019

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“…Disrupted response pathways during pertussis, measles, influenza A, and hepatitis B would be particularly acute in children and adolescents [54][55][56][57], who as a population can experience offlabel use of antipsychotics in the treatment of ADHD. Disruption in the responses to legionellosis, influenza A, and Staphylococcus aureus infection, all of which are significant causes of morbidity and mortality in nursing home residents [58][59][60], are also predictable. Off-label antipsychotic drug use in nursing homes has been reported to be as high as 37% of patients (with and without dementia) [61].…”

Section: Fig 5 Immune Dysregulation and Infectious Disease Susceptibmentioning

confidence: 99%

The antipsychotic medication, risperidone, causes global immunosuppression in healthy mice

et al. 2019

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Atypical antipsychotic medications such as risperidone are widely prescribed for diverse psychiatric indications including schizophrenia, bipolar disorder and depression. These medications have complex pharmacology and are associated with significant endocrine and metabolic side effects. This class of medications also carries FDA black box warnings due to increased risk of death in elderly patients. Clinical reports indicate that patients treated with these medications are more susceptible to infections; however, the underlying mechanisms/pharmacology are unclear. We have previously reported that risperidone and it's active metabolite distributes to the bone marrow in clinically relevant concentrations in preclinical species, leading us to hypothesize that the hematopoietic system may be impacted by these medications. To test this hypothesis, using proteomic and cytokine array technology, we evaluated the expression of genes involved in inflammatory and immune function following short term (5 days) and longer term (4 weeks) treatment in healthy animals. We report that low-dose risperidone treatment results in global immunosuppression in mice, observed following 5 days of dosing and exacerbated with longer term drug treatment (4 weeks). These data are consistent with increased susceptibility to infection in patients administered these medications and have profound implications for the increasing off-label prescribing to vulnerable patient populations including children and the elderly.

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“…Appropriate use of antibiotics is a timely issue with the rise of MDROs 4,5,[32][33][34][35][36] and CDI in LTC. 37 Several organizations have issued guidelines and recommendations 8,15,[38][39][40] not to treat bacteriuria in older individuals unless there are signs or symptoms of a UTI. Inappropriately labeling a patient as having a UTI may also lead to delayed recognition of the correct underlying problem that caused the individual's symptoms.…”

Section: Discussionmentioning

confidence: 99%

“…8 Randomized and population-based studies reveal no decrease in rate of symptoms or improvement in survival with treatment of ASB in older individuals. [9][10][11][12][13] Current guidelines 8,14,15 recommend against routine screening for and treatment of ASB in older individuals in LTC, as well as in most other clinical situations.…”

mentioning

confidence: 99%

A Statewide Program to Improve Management of Suspected Urinary Tract Infection in Long‐Term Care

Salem‐Schatz¹,

Griswold²,

Kandel

et al. 2019

J American Geriatrics Society

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BACKGROUND/OBJECTIVES Suspected urinary tract infection (UTI) is the most common indication for antibiotic use in long‐term care (LTC). Due to the high prevalence of asymptomatic bacteriuria, for which antibiotics are not warranted, these antibiotics are frequently unnecessary. We implemented a collaborative quality improvement program to improve the management of suspected UTI in LTC residents by increasing awareness of current guidelines, with a focus on decreasing treatment in the absence of symptoms. DESIGN/INTERVENTION Two separate collaboratives included workshops, webinars, and coaching calls. PARTICIPANTS A total of 31 facilities participated in the first collaborative, with 17 submitting sufficient data for analysis and 34 in the second, with data analyzed from 25. MEASUREMENTS Facilities reported monthly numbers of urine cultures, UTI diagnoses, Clostridioides difficile infections (CDIs), and resident days. RESULTS When comparing the baseline period to the first collaborative period, the intercollaborative period to the second collaborative period, and the first collaborative period to the second, the incident rate ratios (95% confidence intervals) were 0.74 (0.68‐0.81), 0.83 (0.73‐0.94), and 0.63 (0.57‐0.69), respectively, for urine culturing rate; 0.73 (0.64‐0.83), 0.86 (0.70‐1.05), and 0.60 (0.51‐0.69), respectively, for UTI diagnosis rate; and 0.56 (0.40‐0.82), 1.61 (0.71‐4.14), and 0.45 (0.27‐0.74), respectively, for CDI rate. CONCLUSION The program we implemented was associated with reductions in urine cultures, UTI diagnosis, and CDI; and it suggests that this type of intervention can promote appropriate management of UTI in the LTC setting. J Am Geriatr Soc 68:62–69, 2019

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Infectious Diseases in Older Adults of Long‐Term Care Facilities: Update on Approach to Diagnosis and Management

Cited by 81 publications

References 62 publications

The burden of respiratory infections among older adults in long-term care: a systematic review

The burden of respiratory infections among older adults in long-term care: a systematic review

The antipsychotic medication, risperidone, causes global immunosuppression in healthy mice

A Statewide Program to Improve Management of Suspected Urinary Tract Infection in Long‐Term Care

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