(P14) Nursing Home Bacteremia, a Topic of Controversy

Introduction: This case depicts an atypical clinical presentation of bacteremia in a patient with complex pathology. Patients with bacteremia of unknown source have a greater mortality rate and difficult to manage especially in the nursing home setting. There is paucity of data in terms of bacteremia management in nursing home.

Case Description: This is a 79 yo F, who is a resident at one our Nursing home facilities and had 4 blood cultures which were positive for Streptococcus Mitis. Patient has a significant history for dementia, atrial fibrillation, supraventricular tachycardia, moderate aortic stenosis, congestive heart failure, adrenal insufficiency, severe pulmonary hypertension. Patient was sent to ED for tachycardia. In ED was found to have a HR of 130 b/min, she was in accelerated junctional rhythm transitioned to Atrial fibrillation. Subsequently HR was stabilized with Cardizem . Infectious work up was non revealing with normal lactic acid, WBC count, no infiltrate on CXR, blood culture were collected. Patient was sent back to our facility since stable. Hospital called us and reported positive blood cultures, second set collected was positive. Susceptibility mentioned that this bacteria is usually susceptible to Penicillin.
The complexity of the case resides in the fact that the patient was clinically stable, afebrile, with no complaints, detailed physical exam showed no obvious source of infection. Patient had a III/VI systolic murmur with irradiation on the carotids which was not changed in character. Since the patient was hemodynamically stable, afebrile, lab work was non indicative of infection, we decided to treat the patient empirically with 2 weeks of ceftriaxone. Repeated blood cultures at 48 hour from antibiotic initiation were negative. Patient remained afebrile with no complaints. We also ordered a transthoracic echo which at this time is still pending.

Discussion: Bacteremia in elderly has a significant mortality rate. There is a paucity of data in terms of managing patients with bacteremia in the nursing home. Per one study published in Archives of Family Medicine in 1995 mortality rate was 31%. With increasing in our older adults population, there will be a significant increase in the nursing home residents. Knowing the history and the clinical baseline for our patients is fundamental in medical decision making process.
We need further research and establish guidelines for Long Term Care Bacteremia Management. This will bring a significant decrease in cost for hospitalization and lower the hazards associated with older adult hospitalization.