Time Out! A Close Look at Antibiotic Use in Post-acute and Long-term Care

Neil Gaffin, MD

Disclosures

October 02, 2018

Bacteriuria Versus Urinary Tract Infection

It was recommended that the trimethoprim-sulfamethoxazole be discontinued, and this was done. Without any focal genitourinary complaints (eg, acute dysuria) and/or systemic evidence of infection, it was though that his leukocytosis was due to chronic lymphocytic leukemia, and his urine testing reflected asymptomatic bacteriuria. Given the high prevalence of asymptomatic bacteriuria in this population (up to 50% of women in long-term care), urine testing alone has a very poor positive predictive value for the diagnosis of urinary tract infections.[11,12]

A Man With Left Rib Pain

An 80-year-old man was admitted to a skilled nursing facility after a prolonged acute care hospitalization, where he had surgery for an incarcerated periumbilical hernia. Other medical history includes asthma and hypertension. Several weeks after admission, he complained of "left rib pain" that was worse with inspiration, which he attributed to "pulling a muscle" in physical therapy. He had no fever, dyspnea, or cough. Vital signs were stable, and he was not hypoxemic. Chest radiography was ordered the following day, which was read as a "modest left lower lobe infiltrate" (Figure 2). No previous film was available for comparison. A WBC count was 14,000 cells/µL. A 7-day course of moxifloxacin was ordered over the telephone by the covering nurse practitioner. By the time the patient received his first dose, he was completely asymptomatic.

Figure 2. Chest x-ray revealing "modest left lower lobe infiltrate." Courtesy of Neil Gaffin, MD.

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