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Research ArticleOriginal Research

Antibiotic Treatment and Survival of Nursing Home Patients With Lower Respiratory Tract Infection: A Cross-National Analysis

Robin L. Kruse, David R. Mehr, Jenny T. van der Steen, Marcel E. Ooms, Richard W. Madsen, Ashley K. Sherman, Ralph B. D’Agostino, Gerrit van der Wal and Miel W. Ribbe
The Annals of Family Medicine September 2005, 3 (5) 422-429; DOI: https://doi.org/10.1370/afm.389
Robin L. Kruse
PhD
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David R. Mehr
MD, MS
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Jenny T. van der Steen
PhD
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Marcel E. Ooms
MD, PhD
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Richard W. Madsen
PhD
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Ashley K. Sherman
MA
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Ralph B. D’Agostino
PhD
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Gerrit van der Wal
MD, PhD
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Miel W. Ribbe
MD, PhD
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Figures

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  • Figure 1.
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    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.
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    Figure 2.
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    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

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    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 ReceivedUnited 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
        Female67.666.0.57
    Complete dependence at the time of diagnosis†
        Dressing46.582.1<.001
        Eating28.055.1<.001
        Mobility60.960.1.78
    Illness signs and symptoms
        Cough83.876.1.001
        Decreased alertness27.642.0<.001
        New or increased confusion9.68.6.61
        Physical findings on lung examination compatible with pneumonia or other lower respiratory tract infection81.397.3<.001
        Pulse, beats per minute, mean (SD)87.6 (17.2)92.5 (16.9)<.001
        Purulent sputum25.632.7.012
        Respiratory difficulty23.455.9<.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 failure32.617.9<.001
    Chronic obstructive pulmonary disease20.215.7.057
    Decubitus ulcers8.813.0.02
    Dehydration present20.934.7<.001
    Diabetes mellitus19.416.2.18
    Parkinson disease9.97.5.16
    Severe dementia25.251.1<.001
    Beds in facility, N, mean (SD) 152.0 (115.2)219.1 (58.2)<.001
    Treatments received
    Antibiotic<.001
        Oral amoxicillin11.351.1
        Oral amoxicillin/clavulanate4.020.7
        Oral doxycycline, tetracycline, macrolide, or trimethoprim-sulfamethoxazole27.813.5
        Intramuscular ampicillin or amoxicillin, followed by oral amoxicillin0.011.1
        Fluoroquinolone, with or without another agent‡13.31.4
        First-generation or oral second-generation cephalosporin‡11.30.5
        Parenteral second-generation or third-generation cephalosporin‡18.21.2
        Other antibiotic regimens‡14.10.5
    Route of antibiotic administration
        Oral only67.987.2<.001
        Intramuscular§12.411.8.76
        Intravenous§20.21.0<.001
    Hospitalization30.40.2<.001
    Rehydration therapy34.53.0<.001
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    Table 2.

    Logistic Regression Models for 1- and 3-Month Mortality for Dutch and US Residents with Lower Respiratory Tract Infections

    1-Month Mortality3-Month Mortality
    VariableParameter EstimateOdds Ratio (95% CI)Parameter EstimateOdds 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*0.0231.25 (0.99 – 1.59)0.0291.34 (1.08 – 1.65)
    Bladder incontinence at time of diagnosis†0.2481.28 (1.05 – 1.57)
    Congestive heart failure0.3301.39 (1.03 – 1.88)
    Decreased alertness0.4651.59 (1.15 – 2.20)0.3751.46 (1.09 – 1.94)
    Dehydrated0.4881.63 (1.17 – 2.27)0.4521.57 (1.16 – 2.12)
    Eating self-performance at time of diagnosis‡0.4421.56 (1.21 – 2.00)0.3141.37 (1.09 – 1.71)
    Facility has 300 or more beds0.5151.67 (1.01 – 2.76)
    Male0.5761.78 (1.27 – 2.49)0.7312.08 (1.54 – 2.79)
    Walking self-performance at diagnosis0.3981.49 (1.14 – 1.95)
    Walking self-performance at diagnosis, squared0.1931.21 (1.07 – 1.37)
    New or increased cough−0.5360.58 (0.41 – 0.84)−0.4970.61 (0.44 – 0.85)
    Parkinson’s disease0.5961.81 (1.11 – 2.97)0.4771.61 (1.03 – 2.52)
    Pulse*0.0211.24 (1.13 – 1.36)0.0151.16 (1.07 – 1.26)
    Respiratory distress0.7812.18 (1.59 – 3.00)0.4691.60 (1.20 – 2.13)
    Respiratory rate*0.0161.17 (0.97 – 1.43)
    C statistic0.7650.737
    Hosmer-Lemeshow goodness-of-fit statistic, P§0.900.64

Additional Files

  • Figures
  • Tables
  • 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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The Annals of Family Medicine: 3 (5)
The Annals of Family Medicine: 3 (5)
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1 Sep 2005
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Antibiotic Treatment and Survival of Nursing Home Patients With Lower Respiratory Tract Infection: A Cross-National Analysis
Robin L. Kruse, David R. Mehr, Jenny T. van der Steen, Marcel E. Ooms, Richard W. Madsen, Ashley K. Sherman, Ralph B. D’Agostino, Gerrit van der Wal, Miel W. Ribbe
The Annals of Family Medicine Sep 2005, 3 (5) 422-429; DOI: 10.1370/afm.389

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Antibiotic Treatment and Survival of Nursing Home Patients With Lower Respiratory Tract Infection: A Cross-National Analysis
Robin L. Kruse, David R. Mehr, Jenny T. van der Steen, Marcel E. Ooms, Richard W. Madsen, Ashley K. Sherman, Ralph B. D’Agostino, Gerrit van der Wal, Miel W. Ribbe
The Annals of Family Medicine Sep 2005, 3 (5) 422-429; DOI: 10.1370/afm.389
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