Article Figures & Data
Figures
- Figure 1.
Antibiotic administered to nursing home residents with a lower respiratory tract infection, by nation and stratum of predicted risk of 1-month mortality.
IM = intramuscular; TMP-SMX - trimethoprim-sulfamethoxazole.
- Figure 2.
Predicted and actual 1- and 3-month mortality, by decile of predicted mortality risk for US and Dutch residents.
The dotted line indicates ideal discrimination, where predicted and actual mortality are equal.
Tables
- Table 1.
Baseline Characteristics and Treatments of Dutch and US Nursing Home Residents Who Received Antibiotics for Lower Respiratory Tract Infection (Percentage Unless Otherwise Noted)
Characteristics and Treatments Received United States (n = 806) Netherlands (n = 415) P* * US-Dutch comparison, χ2 probability for discrete variables, t test probability for continuous variables. † A score of 0 represents independence, 1, some to moderate dependence, and 2, complete dependence. ‡ Because of small numbers, these categories were combined for analysis of Dutch residents. § Four US residents received antibiotics, both intramuscularly and intravenously, making the sum of the percentages exceed 100%. Resident characteristics Demographics Age, year, mean (SD) 86.1 (7.1) 84.5 (6.2) <.001 Female 67.6 66.0 .57 Complete dependence at the time of diagnosis† Dressing 46.5 82.1 <.001 Eating 28.0 55.1 <.001 Mobility 60.9 60.1 .78 Illness signs and symptoms Cough 83.8 76.1 .001 Decreased alertness 27.6 42.0 <.001 New or increased confusion 9.6 8.6 .61 Physical findings on lung examination compatible with pneumonia or other lower respiratory tract infection 81.3 97.3 <.001 Pulse, beats per minute, mean (SD) 87.6 (17.2) 92.5 (16.9) <.001 Purulent sputum 25.6 32.7 .012 Respiratory difficulty 23.4 55.9 <.001 Respiratory rate, breaths per minute, mean (SD) 26.8 (7.0) 26.7 (8.9) .78 Temperature, °C, mean (SD) 37.6 (0.9) 38.5 (0.9) <.001 Comorbidities and conditions Congestive heart failure 32.6 17.9 <.001 Chronic obstructive pulmonary disease 20.2 15.7 .057 Decubitus ulcers 8.8 13.0 .02 Dehydration present 20.9 34.7 <.001 Diabetes mellitus 19.4 16.2 .18 Parkinson disease 9.9 7.5 .16 Severe dementia 25.2 51.1 <.001 Beds in facility, N, mean (SD) 152.0 (115.2) 219.1 (58.2) <.001 Treatments received Antibiotic <.001 Oral amoxicillin 11.3 51.1 Oral amoxicillin/clavulanate 4.0 20.7 Oral doxycycline, tetracycline, macrolide, or trimethoprim-sulfamethoxazole 27.8 13.5 Intramuscular ampicillin or amoxicillin, followed by oral amoxicillin 0.0 11.1 Fluoroquinolone, with or without another agent‡ 13.3 1.4 First-generation or oral second-generation cephalosporin‡ 11.3 0.5 Parenteral second-generation or third-generation cephalosporin‡ 18.2 1.2 Other antibiotic regimens‡ 14.1 0.5 Route of antibiotic administration Oral only 67.9 87.2 <.001 Intramuscular§ 12.4 11.8 .76 Intravenous§ 20.2 1.0 <.001 Hospitalization 30.4 0.2 <.001 Rehydration therapy 34.5 3.0 <.001 - Table 2.
Logistic Regression Models for 1- and 3-Month Mortality for Dutch and US Residents with Lower Respiratory Tract Infections
1-Month Mortality 3-Month Mortality Variable Parameter Estimate Odds Ratio (95% CI) Parameter Estimate Odds Ratio (95% CI) CI = confidence interval. * The odds ratios shown for age, pulse, and respiratory rate are for 10-unit change. † Coding for bladder incontinence is as follows: 1 = continent, 2 = usually continent, 3 = incontinent 2 or more times a week. ‡ Coding for eating dependency is as follows: 0 = independent, 1= requires assistance, 2 = fully dependent. § A nonsignificant P value indicates good fit over the range of mortality risk. Intercept −7.020 −7.302 Age* 0.023 1.25 (0.99 – 1.59) 0.029 1.34 (1.08 – 1.65) Bladder incontinence at time of diagnosis† 0.248 1.28 (1.05 – 1.57) Congestive heart failure 0.330 1.39 (1.03 – 1.88) Decreased alertness 0.465 1.59 (1.15 – 2.20) 0.375 1.46 (1.09 – 1.94) Dehydrated 0.488 1.63 (1.17 – 2.27) 0.452 1.57 (1.16 – 2.12) Eating self-performance at time of diagnosis‡ 0.442 1.56 (1.21 – 2.00) 0.314 1.37 (1.09 – 1.71) Facility has 300 or more beds 0.515 1.67 (1.01 – 2.76) Male 0.576 1.78 (1.27 – 2.49) 0.731 2.08 (1.54 – 2.79) Walking self-performance at diagnosis 0.398 1.49 (1.14 – 1.95) Walking self-performance at diagnosis, squared 0.193 1.21 (1.07 – 1.37) New or increased cough −0.536 0.58 (0.41 – 0.84) −0.497 0.61 (0.44 – 0.85) Parkinson’s disease 0.596 1.81 (1.11 – 2.97) 0.477 1.61 (1.03 – 2.52) Pulse* 0.021 1.24 (1.13 – 1.36) 0.015 1.16 (1.07 – 1.26) Respiratory distress 0.781 2.18 (1.59 – 3.00) 0.469 1.60 (1.20 – 2.13) Respiratory rate* 0.016 1.17 (0.97 – 1.43) C statistic 0.765 0.737 Hosmer-Lemeshow goodness-of-fit statistic, P§ 0.90 0.64
Supplemental Table
Supplemental Table 1. Mortality at 1 and 3 Months by Nation, Initial Antibiotic Treatment, and Mortality Risk Predicted by Logistic Regression Models.
Files in this Data Supplement:
- Supplemental data: Table 1 - PDF file, 2 pages, 118KB
The Article in Brief
Antibiotic Treatment and Survival of Nursing Home Patients with Lower Respiratory Infection: A Cross-National Analysis
By Robin Kruse, PhD, and colleagues
Background: Nursing home residents frequently develop lower respiratory tract infections (LRI), such as pneumonia and bronchitis, however, there is little research to support a specific method of treatment. This study assessed the effects of different antibiotic treatments on the survival of elderly nursing home residents with LRI in the United States and the Netherlands, where treatment approaches are quite different.
What this study found: Thirty-nine different antibiotics were used in the United States, compared with 15 in the Netherlands. Only one Dutch patient was hospitalized, compared with almost one-third of U.S. patients. Use of intravenous antibiotics, multiple antibiotics, intravenous fluids and feed tubes were also relatively rare in the Netherlands, compared with the United States. Although patients in the Netherlands were more severely ill, death rates did not differ between the two countries.
Implications
� More aggressive treatment did not show greater benefit for nursing home patients. This suggests that patients can receive simpler treatments that involve less discomfort.
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