Stewardship / Resistance Scan for Nov 09, 2018

Antibiotics in long-term care facilities
C diff and adverse outcomes
Stewardship in India

Study: Antibiotics commonly prescribed upon discharge to long-term care

A study today in Infection Control and Hospital Epidemiology reports that 23% of patients at an Oregon hospital were prescribed antibiotics upon discharge to a long-term care facility (LTCF).

In the single-center study, researchers analyzed pharmacy data on all adult patients at Oregon Health and Science University Hospital who were discharged to an LTCF from January 2012 through June 2016. They wanted to quantify the prevalence and characteristics of patients prescribed antibiotics upon discharge to an LTCF and examine the association between receiving an antibiotic prescription upon discharge and healthcare use, including 30-day hospital readmission, 30-day emergency department (ED) visits, and Clostridioides difficile-associated hospital readmission or 60-day ED visit.

Among the 6,107 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge, of whom 24.7% had more than one antibiotic prescription. The most frequently prescribed antibiotics were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). Most records of discharged patients (82.1%) had a diagnosis code for a bacterial infection, with the most prevalent diagnosis being urinary tract infections (35.9%).

Among the patients who received an antibiotic prescription upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of C difficile infection (CDI) on a readmission or ED visit within 60 days of discharge was 1.6%. Following adjustments for confounding, receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02 to 1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02 to 2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9 to 1.2).

The authors conclude, "Our observation that nearly one-quarter of discharges to LTCFs were prescribed antibiotics upon discharge may inform interventions to improve antibiotic prescribing and stewardship efforts in both acute-care and LTCFs."
Nov 9 Infect Control Hosp Epidemiol abstract


Study finds increased risk of adverse outcomes in elderly C diff patients

In another study today in Infection Control and Hospital Epidemiology, researchers with Washington University School of Medicine and Sanofi Pasteur found that CDI in elderly patients is associated with increased risk of short- and long-term adverse outcomes, including all-cause mortality, and the risk exists even for those considered at low risk.

Using 2011 Medicare claims data on all elderly patients coded for CDI and a random sample of uninfected patients, the researchers performed two different analyses to understand the impact of CDI on all-cause mortality and short- and long-term morbidity among elderly patients, and to estimate the differential risk of outcomes on CDI compared to uninfected persons. They wanted to determine whether there is heterogeneity in risk of poor outcomes, as that could affect how CDI prevention efforts are targeted.

The investigators compared claims records of 174,903 patients coded for CDI with those of 1,318,538 control patients. In matched-pairs analyses, CDI was associated with increased risk of death (odds ratio [OR], 1.77; 95% CI, 1.74 to 1.81; attributable mortality, 10.9%), new LTCF transfer (OR, 1.74; 95% CI, 1.67 to 1.82), and new skilled nursing facility transfer (OR, 2.52; 95% CI, 2.46 to 2.58) within 30 days. In a stratified analysis, CDI was associated with greatest risk of 30-day all-cause mortality in people with the lowest baseline probability of CDI (hazard ratio, 3.04; 95% CI, 2.83 to 3.26), with the risk progressively decreasing as the baseline probability of CDI increased. CDI was also associated with increased risk of subsequent 30-day, 90-day, and 1-year hospitalization.

"Our findings suggest that CDI prevention strategies should not be limited to just high-risk populations; lower-risk elderly populations may have the greatest benefit," the authors write. "New strategies to prevent CDI focused on the elderly need to be developed to reduce mortality, morbidity, and decline resulting in loss of independence and institutionalization."
Nov 9 Infect Control Hosp Epidemiol abstract 


Indian antimicrobial stewardship program shows promising results

Researchers report that an antimicrobial stewardship program (ASP) at a large Indian hospital appeared to help reduce prescribing of restricted antibiotics and save money. The study appeared yesterday in Open Forum Infectious Diseases.

The ASP at the 1,300-bed hospital in the state of Kerala was established in February 2016 and included a physician/hospitalist, an intensivist, microbiologists, clinical pharmacists, and an administrative champion. The ASP created a list of restricted antibiotics and tracked appropriate antibiotic selection, including loading dose, maintenance dose, frequency and route, duration of therapy, de-escalation, and compliance with ASP recommendations. Appropriate use was encouraged with positive feedback to providers.

To assess the performance of the ASP, the researchers compared defined daily doses (DDD) and cost of antimicrobials during the pre-implementation period (February 2015 to January 2016) and the post-implementation period (February 2016 to January 2017).

Of the 48,555 patients admitted during the post-implementation phase, 4,613 (10%) received at least one antibiotic, and 1,020 received 1,326 prescriptions for restricted antibiotics. Antibiotic therapy was determined to be appropriate for 56% of the total patient prescriptions. A total of 2,776 instances of inappropriate therapy were noted by the ASP team, with inappropriate duration (29%) the most common reason. Compliance with ASP recommendations was 54%. For all major restricted antibiotics (except carbapenems), DDD per 100 patient-days declined and the mean monthly cost dropped by 14.4%.

The authors of the study say the preliminary results are encouraging, given that ASPs are rare and generally unstructured in India, and suggest that mandating multidisciplinary ASPs in acute care hospitals would be a "wise next step" for policy in India.
Nov 8 Open Forum Infect Dis abstract

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