Infection Control & Hospital Epidemiology (2019), 40,18–23 doi:10.1017/ice.2018.288
Original Article
Antibiotic prescribing upon discharge from the hospital to long-term care facilities: Implications for antimicrobial stewardship requirements in post-acute settings
Bo R. Weber PharmD1,2, Brie N. Noble BS1, David T. Bearden PharmD1,2, Christopher J. Crnich MD, PhD3,4,
Katherine D. Ellingson PhD5, Jessina C. McGregor PhD, FSHEA1 and Jon P. Furuno PhD, FSHEA1 1Department of Pharmacy Practice, Oregon State University, Oregon Health & Science University College of Pharmacy, Portland, Oregon, 2Department of Pharmacy Services, Oregon Health & Science University Hospitals and Clinics, Portland, Oregon, 3Medical Service, William S. Middleton Veterans Hospital, Madison, Wisconson, 4Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin and 5Department of Epidemiology and Biostatistics, The University of Arizona College of Public Health, Tucson, Arizona
Abstract
Objective: To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs). Design: Retrospective cohort study. Setting: A 576-bed, academic hospital in Portland, Oregon. Patients: Adult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016. Methods: Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge. Results: Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic 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 CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02–1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02–2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9–1.2). Conclusions: Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.
(Received 9 August 2018; accepted 9 October 2018; electronically published 9 November 2018)
Antibiotic use is prevalent in long-term care facilities (LTCFs); however, 75% of this use may be unnecessary or inappropriate.1,2 Adverse outcomes of inappropriate antibiotic prescribing include increasing antibiotic selective pressure and associated antibiotic resistance, medication side effects and drug interactions, and opportunistic infections including Clostridium difficile.3–8 These adverse outcomes may be exacerbated among LTCF residents
Author for correspondence: Jon P. Furuno, Oregon State University, Oregon Health
& Science University College of Pharmacy, Department of Pharmacy Practice, 2730 SW Moody Ave, Mail Code: CL5CP, Portland, OR 97201. E-mail:
furuno@ohsu.edu PREVIOUS PRESENTATION:These data were presented in part at the 2016 Amer-
ican Society of Health-System Pharmacists Midyear Clinical Meeting and Exposition on December 6, 2016, in Las Vegas, Nevada, and at the 2017 American Society of Health- System Pharmacists Midyear Clinical Meeting and Exposition on December 5, 2017, in Orlando, Florida.
Cite this article: Weber BR, et al. (2019). Antibiotic prescribing upon discharge from
the hospital to long-term care facilities: Implications for antimicrobial stewardship requirements in post-acute settings. Infection Control & Hospital Epidemiology 2019, 40, 18–23. doi: 10.1017/ice.2018.288
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
given the high prevalence of polypharmacy, multimorbidity, and cognitive impairment in this healthcare population. To reduce inappropriate antibiotic use and associated adverse events, the Centers for Medicare and Medicaid Services (CMS) recently required that LTCFs develop and implement an antimicrobial stewardship program as a condition for reimbursement.9
More than one-third of LTCF admissions are initially admitted
from an acute-care hospital, and LTCF residents frequently tran- sition back to hospitals for acute-care needs.10–12 Furthermore, patients requiring subacute care have increased dramatically, due in part to bundled payments that incentivize hospitals to discharge patients earlier.13 As such, many medications in LTCFs are initi- ated in acute-care facilities. However, available data describing antibiotic prescribing upon discharge from the hospital to LTCFs are limited. Although several previous studies have described antibiotic prescribing practices among hospitals and nursing homes separately, optimal prescribing procedures for patients transition- ing from hospitals to nursing homes remain unclear.14–19
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