Guidance on Non-Specific Symptoms of Infection Aims to Reduce Inappropriate Antibiotic Use in Nursing Homes

Society for Healthcare Epidemiology of America updates clinical recommendations on evaluating symptoms to diagnose infection
December 09, 2020

There is a widespread belief that a change in the mental status or an increase in falls in a nursing home resident may indicate an underlying infection. This contributes to the overuse of antibiotics, according to revised clinical guidance by the Society for Healthcare Epidemiology of America. The guidance, published in Infection Control & Hospital Epidemiology, outlines criteria on evaluating non-localizing symptoms as indicators of infection.

“When nursing home residents present with subtle non-specific signs and symptoms, clinicians should consider causes other than infection,” said Theresa Rowe, DO, an author of the guidance and assistant professor of medicine at Northwestern University Feinberg School of Medicine. “However, there are certain signs and symptoms such as fever, that may warrant a work-up for infection.”

The paper, “SHEA Expert Guidance: Reliability of Non-Localizing Signs and Symptoms as Indicators of the Presence of Infection in Residents of Nursing Homes,” provides a framework for when to initiate a work-up for infection when a resident in a long-term care facility or nursing home presents with a non-specific sign or symptom. It evaluates the latest evidence evaluating non-localized signs of infection often used to start antibiotics before lab tests and imaging can confirm infections.

Manifestations of infection change with age, and older adults with infections present differently than younger adults. For example, fever – a cardinal sign of infection – can be blunted or absent in older adults with serious bacterial infections. Likewise, dementia can present significant challenges to diagnosis, including difficulty in obtaining a reliable history.

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

“This guidance should not send the message that residents with certain non-specific signs or symptoms can’t have an infection,” Rowe said. “They certainly can, especially with signs such as fever or delirium. However, when certain non-specific signs and symptoms such as anorexia are present in isolation, work-up for infection may not be the best initial approach.” 


Theresa Rowe, Bjorg Marit Anderson David B. Banach, Kristina Bryant, Sarah B. Doernberg, Robin L.P. Jump, Mark Loeb, Daniel J. Morgan, Andrew M. Morris, Rekha Murth, David A. Nace, Nimalie D. Stone, Christopher J. Crnich. “SHEA Expert Guidance: Reliability of Non-Localizing Signs and Symptoms as Indicators of the Presence of Infection in Residents of Nursing Homes.” Infection Control & Hospital Epidemiology. Web (November 17, 2020).

About ICHE
Published through a partnership between the Society for Healthcare Epidemiology of America and Cambridge University Press, Infection Control & Hospital Epidemiology provides original, peer-reviewed scientific articles for anyone involved with an infection control or epidemiology program in a hospital or healthcare facility. ICHE is ranked 41st out of 89 Infectious Disease Journals in the latest Web of Knowledge Journal Citation Reports from Thomson Reuters.

The Society for Healthcare Epidemiology of America (SHEA) is a professional society representing more than 2,000 physicians and other healthcare professionals around the world who possess expertise and passion for healthcare epidemiology, infection prevention, and antimicrobial stewardship. The society’s work improves public health by establishing infection-prevention measures and supporting antibiotic stewardship among healthcare providers, hospitals, and health systems. This is accomplished by leading research studies, translating research into clinical practice, developing evidence-based policies, optimizing antibiotic stewardship, and advancing the field of healthcare epidemiology. SHEA and its members strive to improve patient outcomes and create a safer, healthier future for all. Visit SHEA online at and

About Cambridge University Press
Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence. Its extensive peer-reviewed publishing lists comprise 45,000 titles covering academic research, professional development, over 400 research journals, school-level education, English language teaching and bible publishing. Playing a leading role in today’s international marketplace, Cambridge University Press has over 50 offices around the globe, and it distributes its products to nearly every country in the world. For further information about Cambridge University Press, visit

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