Skip to main content Accessibility help

Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long-Term–Care Facilities: Results of a Consensus Conference

  • Mark Loeb (a1), David W. Bentley (a2), Suzanne Bradley (a3), Kent Crossley (a4), Richard Garibaldi (a5), Nelson Gantz (a6), Allison McGeer (a7), Robert R. Muder (a8), Joseph Mylotte (a9), Lindsay E. Nicolle (a10), Brenda Nurse (a11), Shirley Paton (a12), Andrew E. Simor (a13), Philip Smith (a14) and Larry Strausbaugh (a15)...


Establishing a clinical diagnosis of infection in residents of long-term–care facilities (LTCFs) is difficult. As a result, deciding when to initiate antibiotics can be particularly challenging. This article describes the establishment of minimum criteria for the initiation of antibiotics in residents of LTCFs. Experts in this area were invited to participate in a consensus conference. Using a modified delphi approach, a questionnaire and selected relevant articles were sent to participants who were asked to rank individual signs and symptoms with respect to their relative importance. Using the results of the weighting by participants, a modification of the nominal group process was used to achieve consensus. Criteria for initiating antibiotics for skin and soft-tissue infections, respiratory infections, urinary infections, and fever where the focus of infection is unknown were developed.


Corresponding author

Hamilton Health Sciences Corp, Henderson General Hospital Site, 711 Concession St, Hamilton, ON L8V 1C3, Canada


Hide All
1. Mylotte, JM. Antimicrobial prescribing in long-term care facilities: prospective evaluation of potential antimicrobial use and cost indicators. Am J Infect Control 1999;27:1019.
2. Montgomery, P, Semenchuk, M, Nicolle, LE. Antimicrobial use in nursing homes in Manitoba. Journal of Geriatric Drug Therapy 1995;9:5574.
3. Warren, JW, Palumbo, FB, Fitterman, L, Speedie, SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc 1991;39:963972.
4. Katz, PR, Beam, TR Jr Brand, F, Boyce, K. Antibiotic use in the nursing home. Physician practice patterns. Arch Intern Med 1990;150:14651468.
5. Smith, PW. Nursing home infection control: a status report. Infect Control Hosp Epidemiol 1998;19:366369.
6. Armstrong-Evans, M, Lift, M, McArthur, MA, Willey, B, Cann, D, Liska, S, et al. Control of transmission of vancomycin-resistant Enterococcus faecium in a long-term–care facility. Infect Control Hosp Epidemiol 1999;20:312317.
7. Greenaway, CA, Miller, MA. Lack of transmission of vancomycin-resistant enterococci in three long-term–care facilities. Infect Control Hosp Epidemiol 1999;20:341343.
8. Wiener, J, Quinn, JP, Bradford, PA, Goering, RV, Nathan, C, Bush, K, et al. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 1999;281:517523.
9. Terpenning, MS, Bradley, SF, Yan, JY, Chenoweth, CE, Jorgensen, KA, Kauffman, CA. Colonization and infection with antibiotic-resistant bacteria in a long-term care facility. J Am Geriatr Soc 1994;42:10621069.
10. Wingard, E, Shlaes, JH, Mortimer, EA, Shlaes, DM. Colonization and cross-colonization of nursing home patients with trimethoprim-resistant gram-negative bacilli. Clin Infect Dis 1993;16:7581.
11. Chenoweth, CE, Bradley, SF, Terpenning, MS, Zarins, LT, Ramsey, MA, Schaberg, DR, et al. Colonization and transmission of high-level gentamicin-resistant enterococci in a long-term care facility. J Am Geriatr Soc 1994;15:703709.
12. Gaynes, RP, Weinstein, RA, Chamberlin, W, Kabins, SA. Antibiotic-resistant flora in nursing home patients admitted to the hospital. Arch Intern Med 1985;145:18041807.
13. Rice, LB, Willey, SH, Papanicolaou, GA, Medeiros, AA, Eliopoulos, GM, Moellering, RC Jr et al. Outbreak of ceftazidime resistance caused by extended-spectrum β-lactamases at a Massachusetts chronic care facility. Antimicrob Agents Chemother 1990;34:21932199.
14. Muder, RR, Brennen, C, Goetz, AM, Wagener, MM, Rihs, JD. Association with prior fluoroquinolone therapy of widespread ciprofloxacin resistance among gram-negative isolates in a Veterans Affairs medical center. Antimicrob Agents Chemother 1991;35:256258.
15. Nicolle, LE, Bentley, D, Garibaldi, R, Neuhaus, E, Smith, P, SHEA Long-Term Care Committee. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 1996;17:119128.
16. Nicolle, LE, Strausbaugh, LJ, Garibaldi, RA. Infections and antibiotic resistance in long-term care facilities. Clin Microbiol Rev 1996;9:117.
17. Strausbaugh, LJ, Joseph, C. Epidemiology and prevention of infections in residents of long-term care facilities. In: Mayhall, CG, ed. Hospital Epidemiology and Infection Control. Baltimore, MD: Williams and Wilkins;1996:11511170.
18. Zimmer, JG, Bentley, DW, Valenti, WM, Watson, NM. Systemic antibiotic use in nursing homes. J Am Geriatr Soc 1986;34:703710.
19. Jones, SR, Parker, DF, Liebow, ES, Kimbrough, RC, Frear, RS. Appropriateness of antibiotic therapy in long-term care facilities. Am J Med 1987;83:499502.
20. Metlay, JP, Kapoor, WN, Fine, MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 1997;278:14401445.
21. Wipf, JE, Lipsky, BA, Hirschmann, JV, Boyko, EJ, Takasugi, J, Peugeot, RL, et al. Diagnosing pneumonia by physical examination: relevant or relic? Arch Intern Med 1999;159:10821087.
22. McGeer, A, Campbell, B, Emori, TG, Hierholzer, WJ, Jackson, MM, Nicolle, LE, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:17.
23. Jones, J, Hunter, D. Consensus methods for medical and health services research. BMJ 1995;311:376380.
24. Orr, PH, Peeling, RW, Fast, M, Brunka, J, Duckworth, H, Harding, GK, et al. Serological study of responses to selected pathogens causing respiratory tract infection in the institutionalized elderly. Clin Infect Dis 1996;23:12401245.
25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. Text Revision.
26. Ball, P, Chodosh, S, Grossman, R, Tillotson, M, Wilson, R. Causes, epidemiology, and treatment of bronchial infections. Infect Med. 2000;17:186189.
27. Wasserman, M, Levinstein, M, Keller, E, Lee, S, Yoshikawa, TT. Utility of fever, white blood cells, and differential count in predicting bacterial infections in the elderly. J Am Geriatr Soc 1989;37:537543.
28. Nicolle, LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997;11:647662.
29. Nicolle, LE, Bjornson, J, Harding, GK, MacDonnell, JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:14201425.
30. Nicolle, LE, Mayhew, JW, Bryan, L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized women. Am J Med 1987;83:2733.
31. Ouslander, JG, Schapira, M, Schnelle, JF, Uman, G, Fingold, S, Tuico, E, et al. Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Ann Intern Med 1995;122:749754.
32. Abrutyn, E, Mossey, J, Berlin, JA, Boscia, J, Levison, M, Pitsakis, P, et al. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women. Ann Intern Med 1994;120:827833.
33. Cookson, BD. The emergence of mupirocin resistance: a challenge to infection control and antibiotic prescribing practice. J Antimicrob Chemother 1998;41:1118.

Related content

Powered by UNSILO

Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long-Term–Care Facilities: Results of a Consensus Conference

  • Mark Loeb (a1), David W. Bentley (a2), Suzanne Bradley (a3), Kent Crossley (a4), Richard Garibaldi (a5), Nelson Gantz (a6), Allison McGeer (a7), Robert R. Muder (a8), Joseph Mylotte (a9), Lindsay E. Nicolle (a10), Brenda Nurse (a11), Shirley Paton (a12), Andrew E. Simor (a13), Philip Smith (a14) and Larry Strausbaugh (a15)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.