Infection Control & Hospital Epidemiology
Table 2. Distribution of Antibiotic Classes Prescribed on Discharge to a Long- Term Care Facility (n=1,906)
Antibiotic Class Cephalosporins First generation
Second generation Third generation Fourth generation Fifth generation Fluoroquinolones Penicillins
Natural penicillins
Semisynthetic penicillins Aminopenicillins
β-lactam/β-lactamase inhibitors Antipseudomonal penicillins
Sulfonamides Glycopeptides Metronidazole Tetracyclines Lincosamides Nitrofurantoin Macrolides
Carbapenems Lipopeptides Rifaximin Linezolid
Aminoglycosides Rifampin
Aztreonam Fosfomycin
No. (%) Diagnosis
389 (20.4) 139 (35.7) 7 (1.8)
212 (54.5) 20 (5.1) 11 (2.8)
364 (19.1) 318 (16.7) 16 (5.0) 31 (9.8) 55 (17.3) 163 (51.3) 53 (16.7) 208 (10.9) 204 (10.7) 104 (5.5) 65 (3.4) 60 (3.1) 42 (2.2) 36 (1.9) 34 (1.8) 28 (1.5) 24 (1.3) 10 (0.5) 9 (0.5) 7 (0.4) 3 (0.2) 1 (0.1)
received an antibiotic upon discharge compared to 0.8% in patients who did not receive an antibiotic upon discharge (P=.005). Despite these unadjusted results, statistical significance only remained for the associations with 30-day ED visits (adjusted OR, 1.2; 95% CI, 1.02–1.5) and CDI within 60 days (adjusted OR, 1.7; 95% CI, 1.02–2.8) following adjustment for confounding (Table 4).
Discussion
We quantified the frequency and characteristics of patients pre- scribed antibiotics upon discharge from an acute care hospital to LTCFs. Our major finding was that 23% of patients were
Urinary tract infections
Bloodstream infection, endocarditis Other bacterial diseases
Skin and soft-tissue infections Pneumonia
Osteomyelitis
Clostridium difficile infection Intra-abdominal infections Infections in other conditions Respiratory tract infections Mouth/pharynx infections Otitis media
Syphilis and other venereal diseases Tuberculosis/other mycobacteria
No. (%)
451 (35.9) 338 (26.9) 248 (19.7) 173 (13.8) 104 (8.3) 93 (7.4) 66 (5.2) 55 (4.4) 40 (3.2) 39 (3.1) 10 (0.8) 4 (0.3) 2 (0.2) 2 (0.2)
Note. Diagnosis types are not mutually exclusive, 283 of 1,258 (22%) of discharges had more than one diagnosis code for a bacterial infection.
prescribed an antibiotic upon discharge, of which 19% were fluoroquinolones. The most prevalent diagnosis code for a bac- terial infection during the index admission for patients receiving antibiotics upon discharge was for UTIs. Furthermore, receiving antibiotics upon discharge to an LTCF was significantly asso- ciated with 30-day ED visits and CDI within 60 days of discharge, even following adjustment for confounding. These findings may have important implications for further study and successful implementation of antimicrobial stewardship programs in LTCFs. To our knowledge, no previous study has described antibiotic prescribing upon discharge to LTCFs. 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. Similarly, little is known about the proportion of antibiotic use in LTCFs that are hospital initiated. Richards et al23 conducted a study among 105 post–acute-care residents across 7 LTCFs in Georgia. In that study, 50% of prescribed antibiotics were initiated in the hospital, and fluoroquinolones were the most commonly prescribed antibiotic class (53%). Improving antibiotic prescribing upon discharge to LTCFs will
likely require a specialized intervention beyond existing stew- ardship activities. Although this study was not limited to dis- charges to LTCFs, Scarpato et al24 investigated the appropriateness of antibiotic prescribing upon hospital discharge. Despite maintaining a robust antimicrobial stewardship program, they reported that 70% of antibiotic prescriptions upon discharge were inappropriate based on the drug choice, dose, or duration. Furthermore, 19.4% of patients prescribed antibiotics upon dis- charge were readmitted to the hospital within 30 days, compared to 13.8% of patients hospital-wide. Based on these results, they recommended medication reconciliation by trained pharmacists, prescriber education, and prospective audit and feedback to
21
Table 3. Distribution of Diagnoses for Bacterial Infections Indications During the Index Hospital Admission Among Patients Receiving Antibiotics upon Dis- charge to a Long-Term Care Facility (n=1,258)
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