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

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


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.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Anti-Bacterial Agents / therapeutic use*
  • Drug Prescriptions* / standards
  • Drug Prescriptions* / statistics & numerical data
  • Female
  • Homes for the Aged / statistics & numerical data*
  • Humans
  • Lung / diagnostic imaging
  • Male
  • Medication Therapy Management / standards
  • Medication Therapy Management / statistics & numerical data
  • Michigan
  • Nursing Homes / statistics & numerical data*
  • Pneumonia* / diagnosis
  • Pneumonia* / drug therapy
  • Radiography* / methods
  • Radiography* / statistics & numerical data
  • Symptom Assessment / methods
  • Urinalysis* / methods
  • Urinalysis* / statistics & numerical data
  • Urinary Tract Infections* / diagnosis
  • Urinary Tract Infections* / drug therapy


  • Anti-Bacterial Agents