Fever or Suspected infection

Suspect infection in a resident if there are any of the following:

1. Decline in functional status
   • New or increasing confusion
   • New incontinence
   • Deteriorating mobility
2. Reduced food intake or acute loss of appetite
3. Change in behaviour
4. Non-specific symptoms including nausea, vomiting, diarrhoea, malaise, new fatigue, headache
5. Fever: note - a fever is now, in the COVID-19 era, defined as a temperature of >37.5 degrees Celsius
6. Localising symptoms typical for focal infection e.g. acute dysuria or flank pain in urinary tract infection, new productive cough in pneumonia, pain and erythema of skin in cellulitis
7. Symptoms associated with worsening of underlying comorbidities e.g. heart failure or diabetes

Sepsis is common in older persons. Sepsis refers to presence of an infection associated with acute end-organ dysfunction. Frail older people are at increased risk of sepsis and it is a common cause of death in this population. Sepsis should be suspected in older persons with any of:

1. Risk factors for sepsis:

• Immunocompromise (disease or medication-related)
• Recent hospitalisation
• Invasive devices

2. Clinical findings including:

• Fever: note - this is absent in 50 per cent of frail older persons with serious infection
• Hypothermia
• Rigors or shaking chills, where involuntary muscle tremors occur to increase body temperature
• Altered mental status (delirium or reduction in conscious level)
• Tachycardia may be blunted due to use of beta-blockers or with increasing age, reduced responsiveness of the heart to catecholamines
• Relative hypotension (compared to baseline blood pressure)
• Tachypnoea (or respiratory rate >/= 22 breaths per minute) or hypoxaemia (new)

3. Results of investigations:

• Leukopenia (low white cells < 4 x 10^9) or leukocytosis (white cells > 12 x 10^9)
• Increased immature white cells or bands (> 5%)
• Lymphopenia (low lymphocytes)
• Acute kidney injury
• Platelet count < 150 000/mm³
• Elevated blood lactate level, although lactate levels are uncommonly performed in community settings

1. Use appropriate PPE when caring for residents with fever or suspected infection; where potential or confirmed respiratory infection is not yet excluded, review Queensland Health Pandemic Response Guidance Personal
   Protective Equipment (PPE) in Residential Aged Care and Disability accommodation services (PDF 312 kB) for specific advice on PPE in the RACF setting.  Note: all staff should be trained and deemed competent in the proper use of PPE including donning and doffing procedures
2. Isolate the resident with potential infection in a room with the ability to close the door and with a separate toilet, where they should remain and have meals delivered until the source of infection is confirmed and, where indicated, COVID-19 is excluded. Residents requiring droplet or aerosol precautions should be restricted to their room and aerosol generating procedures such as nebulisers and non-invasive ventilation (e.g. CPAP or BiPAP) avoided where clinically appropriate. Where a single room is not available, follow guidance in National Guidelines for the Prevention, Control and Public Health Management of Outbreaks of Acute Respiratory Infection in Residential Care Facilities
3. Place standard and transmission-based precaution signs, liquid soap, alcohol-based hand-rub, paper towels and PPE outside resident’s room (with a hands-free mechanism to allow for safe disposal of PPE items) to remind staff and visitors about the requirement for strict infection control procedures
4. Reinforce hand hygiene with staff and any visitors - ensure adequate supplies of liquid soap, alcohol-based hand-rub and paper towels with hands-free mechanism for disposal
5. Implement enhanced environmental cleaning and disinfection of the resident’s environment and disinfect shared equipment (for example monitors, BP cuffs, thermometers, glucometers) frequently with a neutral detergent followed by a disinfection solution (TGA-registered hospital grade disinfectant effective against COVID-19 or 1000 ppm sodium hypochlorite)
6. Respiratory hygiene and cough etiquette - encourage residents to cover their nose and mouth with the elbow when they cough or sneeze or use tissues and dispose of them into a rubbish bin and perform hand hygiene
7. Monitor staff and ALL residents for symptoms of fever or acute respiratory infection
8. Comply with Commonwealth and State directions and advice

Supportive care of residents with infection is critical to optimising resident outcomes and should include consideration of:

1. Identification and treatment of direct complications of infection, such as development of collections requiring drainage or sepsis (infection with acute end-organ dysfunction):
   • Arrange medical review of residents by GP
   • Institute regular monitoring of vital signs (minimum of four times daily for 72 hours) - notify GP or at GP discretion, the HHS RaSS, if vital signs suggest clinical deterioration (review Recognition of the deteriorating resident)
2. Anticipate, prevent or treat destabilisation of chronic diseases including, for example:
   • Enact diabetes sick-day plan - refer to National Diabetes Services Scheme Diabetes management in aged care handbook
   • Monitor blood glucose levels closely in diabetics, chronic liver disease or in those with reduced oral intake
   • Attention to fluid balance in those with congestive cardiac failure or renal disease
   • GP to review medications and with-hold where indicated e.g. with-hold diuretics and SGLT-2 inhibitors if clinically dehydrated
3. Prevent, identify and treat health-care related complications of acute illness:
   • Implement strategies to prevent, identify and treat delirium
   • Institute falls risk management strategies
   • Encourage oral fluids to minimise dehydration

Prior to initiation of antibiotics, appropriate clinical specimens should be taken to assist in diagnosis and targeting of antibiotic therapy.

Antibiotic selection for infection should be guided by:

1. Allergies: note - in reference to hypersensitivities:
   • Immediate severe hypersensitivity refers to development of extensive urticaria (hives), angioedema (facial / oral swelling), bronchospasm (wheeze) or hypotension, collapse or anaphylaxis within minutes to 2 hours of exposure to a drug
   • Immediate non-severe hypersensitivity refers to development of mild urticaria or mild immediate rash
   • Delayed severe hypersensitivity refers to severe cutaneous drug reactions such as Stevens-Johnson syndrome / toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms (DRESS) etc
   • Delayed non-severe hypersensitivity refers to development of a benign macular, papular (raised) or morbilliform rash occurring several days after starting treatment without systemic or concerning features
2. Prior sensitivities of organisms in this resident if empiric therapy or by current sensitivities if directed therapy
3. Comorbidities with particular emphasis on:
   • Immunosuppression e.g. chronic steroid use / other immunosuppressive drugs
   • Renal or hepatic dysfunction - there may need to be dose adjustment
   • Nutritional status
   • Potential for drug interactions, particularly where there is polypharmacy - for example, specific risk exists in co-prescribing macrolide antibiotics (e.g. clarithromycin, erythromycin) and azole antifungals (e.g. fluconazole, voriconazole)
4. Presence of sepsis versus local infection
5. Antibiotic guidelines for suspected infection source - use antibiotics suggested by:
   • Relevant current version of QH RACF pathway or
   • Therapeutic guidelines: antibiotics (current version)
   • Local HHS specialist advice
6. Resident's ability to swallow or tolerate oral intake - for residents with a gastrostomy or jejunostomy tube, ensure that any medications administered via the tube are in a suitable formulation

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