Sepsis in LTC

Balance diligence & prudence when treating

by Gretchen Henkel

In 166 nursing home residents admitted to the hospital, urinary tract and respiratory tract infections were the most common sources of sepsis, according to researchers from the State University of New York at Buffalo (Mylotte JM, et al. Clin Infect Dis. 2002; 35(12): 1484-90).

Respiratory tract and urinary tract infections are two of the most common illnesses (and are the most common causes of sepsis) in long-term care. Therefore appropriate management of these infections affords an opportunity to prevent sepsis.

Yet, the very nature of long-term care imposes limitations that render managing infections difficult.

"We have by no means solved the problem of infections in long-term care," reflected Thomas T. Yoshikawa, MD, professor and chairman of the Department of Internal Medicine at Charles R. Drew University and the Martin Luther King, Jr.-Charles R. Drew Medical Center in Los Angeles. Dr. Yoshikawa, who also serves as the editor of the Journal of the American Geriatrics Society, enumerated several characteristics that may impede timely diagnosis and treatment of infections in nursing homes:

• Physicians are often off-site and don't see the patient frequently;
• Fever is not present in 25%-30% of elderly people with serious infections;
• Decisions about prescribing antibiotics or transfer to hospital emergency departments are more difficult when the physician is off-site; and
• Nursing homes may not have the x-ray and laboratory capabilities for conducting appropriate diagnostic tests.

"We tell our trainees that managing a sick patient in the nursing home is much different than managing the same patient in the hospital," said Dr. Yoshikawa. Long-term care physicians must balance treating infection against the patients' risk of developing antimicrobial-resistant pathogens, but they must also respect and honor residents' need for independence and dignity. All of this is occurring within the context of a rising incidence of sepsis in the United States.

Sepsis on the Rise

According to one U.S. epidemiological study, the incidence of sepsis increased significantly from 1979 through 2000 (Martin GS, Mannino DM, Eaton SE, Moss, M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003 April 17; 348; 16: 1546-1554). Using the ICD-9-CM codes for septicemia, bacteremia, disseminated fungal infection, disseminated candida infection, disseminated fungal endocarditis, and organ failure, study author Greg S. Martin, MD, and his coauthors identified more than 10 million cases of sepsis from the National Hospital Discharge Survey. The number of patients with sepsis per year increased from 164,072 in 1979 to 659,935 in 2000.

The study also identified changing trends in sepsis-causing organisms over the 22-year study period. From 1979 to 1987, the predominant organisms causing sepsis were gram-negative bacteria. That trend reversed after 1987, and gram-positive bacteria accounted for 52.1% of sepsis cases by the year 2000, with gram-negative-caused sepsis declining to 37.6% of cases in that same year.

A study by Mylotte et al comprised a retrospective review of sepsis bloodstream infections in nursing home residents from January 1997 to April 2000 and found that Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), and Proteus mirabilis (P. mirabilis) were the most common organisms isolated from the blood cultures of the residents tested (Mylotte JM, Tayara A, Goodnough S. Epidemiology of bloodstream infection in nursing home residents: evaluation in a large cohort from multiple homes. J Clin Infect Dis. 2002 Dec 15; 35(12): 1484-90).

Most long-term care practitioners are all too aware of the real possibility that elderly residents with respiratory or urinary tract infection can develop sepsis. Still, Dan Osterweil, MD, CMD, professor of Medicine and Geriatrics at UCLA, a research associate at the UCLA Borun Center for Gerontological Research, Reseda, Calif., and a member of Caring's editorial board, urged caution when interpreting nursing home data regarding sepsis.

"In many cases these studies use the admitting diagnosis to the hospital," he noted. "In our experience, many of those admitted with a diagnosis of urosepsis, for example, may actually have negative blood cultures and probably have a UTI with dehydration. Nursing home staff still have a lot to learn about detecting infections and reporting them early, and thus avoid the scenario of dehydration presenting with a sepsis-like clinical picture."

Route of Least Resistance

Should every fever be treated as a sign of serious infection warranting antimicrobial therapy? Or should practitioners adopt a wait-and-see stance in case the infection is viral in origin?

"Somewhere in the middle may be the best approach," said Dr. Yoshikawa. But without randomized studies assessing outcomes after treatment of infection to furnish a base of evidence upon which to make informed decisions, long-term care practitioners face dilemmas in such litigious states as California, "where the error of omission [not doing anything] may be a greater risk-management issue than the error of commission [such as prescribing an antibiotic]," he continued.

Often, the following type of situation develops: On a Saturday evening, Mrs. Grove, an 89-year-old long-term care resident who has a history of recurrent UTIs, suddenly develops fever, chills, and confusion. Concerned, the certified nurse assistant reports Mrs. Grove's symptoms to the advance practice nurse, who takes Mrs. Grove's vital signs and puts in a call to the woman's physician. The nurse presses the doctor to prescribe an antibiotic, even though results from a urine culture won't be available for at least 24 hours.

This situation is typical, said Dr. Osterweil, of situations in which nursing home staff may press for prescription of antibiotics out of fear they'll be reprimanded if they don't by supervisors who, in turn, misguidedly respond to perceptions that regulations mandate this.

"In fact," said Dr. Osterweil, "this is partially true. In the old [nursing home survey] Tag 315/319 on urinary incontinence, there is language alluding to the association of UI to UTI--meaning that if UTI is identified in the context of an incontinent resident, the state surveyors often interpret it as a result of poor care and cite for that.

"Furthermore, in the scope of severity, this scenario is penalized at a higher level than simply citing poor care. The American Medical Directors Association has been working with the Centers for Medicare and Medicaid Services to remedy this situation," he explained.

Nevertheless, a physician presented with pressure from nursing staff may often take "the route of least resistance," said Dr. Yoshikawa and prescribe antibiotics anyway. Frequent prescribing of antibiotics has contributed to the emergence of highly resistant pathogens among geriatric patients (Yoshikawa TT. Antimicrobial resistance and aging: beginning of the end of the antibiotic era? J Am Geriatr Soc.2002 Jul; 50(7): S226-S229). Methicillin-resistant S. aureus (MRSA), penicillin-resistant S. pneumoniae, vancomycin-resistant enterococci, and multiple drug-resistant gram-negative bacilli are among these pathogens.

Eventually, clinicians will encounter infections caused by highly resistant pathogens for which no effective antibiotics will be available.

"Clinicians could then be experiencing the same frustrations of not being able to treat infections effectively as were seen in the pre-antibiotic era," cautioned Dr. Yoshikawa.

Alert to Signs of Sepsis

In lieu of sufficient research upon which to base a new standard of care, long-term care facilities can draw on consensus guidelines such as those developed and published in JAGS (Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infection in long-term care facilities. J Am Geriatr Soc. 2001; 49: 210-222).

Dr. Yoshikawa was the committee chair for the guidelines endeavor spearheaded by the Infectious Diseases Society of America; the guidelines were subsequently published in other specialty society journals, including the Journal of the American Medical Directors Association (Bentley, DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infection in long-term care facilities. JAMDA. 2001; 2: 246-258).

"We've not done enough studies to look at this problem [of infection] to be able to proceed with evidence-based medicine," said Dr. Yoshikawa, who noted that JAGS continues to receive an increased number of submissions related to studying infection in the LTC setting.

The first line of defense must be prevention of septic episodes in the first place. Once systemic infection sets in, patients' conditions can devolve quickly to respiratory failure, organ failure, and death. LTC facilities may not have the capabilities to manage these patients.

As outlined in the 2001 JAGS article (Bentley, et al) the onset of bacteremia may include such nonspecific symptoms as lethargy, confusion, falls, abdominal pain, nausea, vomiting, and incontinence. Although fever of at least 100 degrees Fahrenheit is usually present, some older people may have afebrile bacteremia. Other symptoms may include shaking chills, shock, a total band neutrophil count of >1,500/mm³, and a lymphocyte count of <1,000 cells/mm³. Although lung and urinary tract infections are the most common causes of sepsis, staff members must also remain alert to infected pressure ulcers or scabies skin infections.

To Transfer or Not?

Because transfer to hospital emergency departments often causes more problems, such as translocation trauma and colonization with drug-resistant bacteria, LTC facilities must be judicious with transfer decisions, according to Drs. Osterweil and Yoshikawa.

In early stages of mild to moderate or uncomplicated infections, residents can often be treated with oral quinolones, intramuscular injections of third-generation cephalosporins, or even a broad-spectrum oral antibiotic for common bacterial illnesses. Decisions to transfer are made based on many factors, including whether the patient appears septic and the comfort level of the physician, to manage a patient at the facility, said Dr. Yoshikawa.

However when sepsis is suspected or validated by blood culture, transfer may be warranted. The need for specialized interventions, technological support, monitoring of procedures, and therapies may dictate a transfer to the hospital. Advance directives, as well as patient and family preference, then play an important role in the decision.

Dr. Yoshikawa believes that as studies of infection and sepsis in nursing home residents mature, the "state of the art" management of infection will continue to evolve. "Once these studies come to fruition, we can have better approaches to these problems, and will be better able to determine the best circumstances for waiting or for starting treatment. As it stands now, even if we are experts who have been in the field [of long-term care], the decision is not easy."

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