Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High‐Risk Nursing Home Residents. Issue 10 (22nd September 2016) - Eke‐Usim, Angela C.
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.