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

Abstract

Objectives To evaluate the use of diagnostic testing prior to treating an infection in nursing home (NH) residents with indwelling devices suspected of having a urinary tract infection (UTI) or pneumonia. Design Prospective longitudinal study nested within a randomized trial Setting Six NHs in Southeast Michigan Participants 162 NH residents with an indwelling urinary catheter and/or enteral feeding tube with 695 follow-up visits [189/695 (28%) visits with an infection]. Measurements Patient-specific 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 one year. Results : More than half (100/162 [62%]) of NH residents with indwelling devices had an incident infection requiring antibiotics, with substantial variations between NHs. Besides presence of infection-specific symptoms, change in function was a significant predictor for ordering a chest x-ray to detect pneumonia (OR = 1.7; P = 0.01). Similarly, change in mentation was a significant predictor for ordering a UA (OR = 1.9; P = 0.02), chest x-ray (OR = 3.3; P < 0.01), and blood culture (OR = 2.3; P = 0.02). Empiric antibiotic use before having laboratory data occurred in 50 of 233 suspected UTI (21.5%) and 16 of 53 (30.2%) suspected pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection. Conclusion In this study nested within a cluster randomized trial and using data from control sites, we show that constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing with subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.

Epidemiology and clinical features of COVID-19 outbreaks in aged care facilities: A systematic review and meta-analysis

“…[ 83 , 84 ] Diagnosis of clinical infections amongst frail and older people is particularly challenging due to presence of multiple co-morbidities and presentation with atypical constitutional symptoms reported in earlier studies and national guidelines. [85] , [86] , [87] , [88] Similar difficulties have been reported in several studies where residents were asymptomatic at the time of diagnosis and subsequently developed symptoms during the course of illness and required supervised coordinated care. [ 38 , 49 , 55 , 67 ] Care homes have comparatively higher rates of dementia, delirium, and cognitive dysfunctional co-morbidities.…”

Urine Culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing

“…8,23,24 Mental status change was the symptom or sign most commonly documented in the 48 hours before this sample of NH residents had urine cultures obtained, and this observation has been noted previously regarding catheterized NH residents. 12 The likely reason for obtaining cultures in these patients is concern that any change in cognition could represent incipient delirium, a common and dangerous condition in acutely ill hospital patients. 25 However, most NH residents have dementia, which in the absence of acute illness is frequently associated with fluctuation in cognitive status, including affective, hyperactive, and delusional symptoms.…”

“…Urine testing often drives prescribing; so a key component of antibiotic stewardship around NH UTIs must be the ordering and interpretation of urine tests. 6,12 Evidence-based guidelines for urine testing have been developed; the most explicit are the 2008 update by the Infectious Diseases Society of America (IDSA), 13 the consensus criteria of Loeb, et al, 14,15 and the updated criteria of Genao and Buhr. 16 All of these rely heavily on focal urinary tract symptoms as a prerequisite of testing.…”

Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes

“…Nursing home residents have a high prevalence of multimorbidity and cognitive impairment, which increase the risk of infection and reduce the ability to effectively communicate symptoms. Infections often present with atypical symptoms, such as fatigue, confusion, and functional decline . Furthermore, there is a burgeoning population of short‐stay residents in nursing homes receiving post–acute care who often present with higher severity of illness, prevalence of antibiotic use both in the hospital and on discharge, and indwelling devices, increasing the risk of acquisition and infection by multi–drug‐resistant organisms .…”

“…Infections often present with atypical symptoms, such as fatigue, confusion, and functional decline. 8 Furthermore, there is a burgeoning population of short-stay residents in nursing homes receiving post-acute care who often present with higher severity of illness, prevalence of antibiotic use both in the hospital and on discharge, and indwelling devices, increasing the risk of acquisition and infection by multi-drug-resistant organisms. 9,10 Beyond challenges in resident characteristics and presentation of infection, there are additional barriers to optimizing antibiotic use in nursing homes, including the frequently fragmented administrative structure in this setting, lack of tools to support empiric antibiotic prescribing, and lack of education regarding guidelines and current evidence to support best practices.…”