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J Am Geriatr Soc. 2016 Oct;64(10):1975-1980. doi: 10.1111/jgs.14286. Epub 2016 Sep 22.

Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High-Risk Nursing Home Residents.

Author information

1
School of Public Health, University of Michigan, Ann Arbor, Michigan.
2
Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
3
Division of Geriatric and Palliative Care Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.
4
School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.
5
Division of Geriatric and Palliative Care Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan. lonamody@umich.edu.
6
Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. lonamody@umich.edu.

Abstract

OBJECTIVES:

To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia.

DESIGN:

Prospective longitudinal study nested within a randomized trial, using data from control sites.

SETTING:

Six NHs in southeast Michigan.

PARTICIPANTS:

NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection).

MEASUREMENTS:

Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year.

RESULTS:

One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection.

CONCLUSION:

Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.

KEYWORDS:

antibiotic stewardship; functional decline; nursing homes

PMID:
27655061
PMCID:
PMC5119646
DOI:
10.1111/jgs.14286
[Indexed for MEDLINE]
Free PMC Article

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