CDC Analysis Finds Faults with Antibiotic Use for Hospitalized Patients

An analysis of medical record data from more than 1,500 patients hospitalized for community acquired pneumonia (CAP) or urinary tract infections (UTI) found that in most cases patients were either given the wrong antibiotic or the duration of antibiotic therapy did not follow guideline recommendations.

The analysis by a team of CDC researchers, led by Shelley S. Magill, MD, PhD of the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, was published in JAMA Network Open.

Based on these findings, “Pew Charitable Trusts, in partnership with CDC and a panel of antibiotic use experts, is recommending the first-ever national targets to reduce inappropriate prescribing of certain antibiotics in U.S. hospitals,” according to a CDC press release.

The CDC has been spearheading efforts to slow the spread of resistant pathogens, and a key element in that initiative is the promotion of appropriate antibiotic use. To that end, in 2014, “the CDC called for acute care hospitals to implement antimicrobial stewardship programs with the goal of improving antimicrobial use to optimize infection cure rates and minimize harms. In 2014 and 2015, the White House released the U.S. National Strategy and Action Plan for Combating Antibiotic-Resistant Bacteria, which established antibiotic stewardship outcomes to accomplish by 2020, including a 20% reduction in inappropriate inpatient antibiotic use for monitored conditions and medications.”

As part of that initiative, a number of studies have assessed the volume of antibiotic use, but they have not focused on the appropriateness, the researchers explained.

Specifically, the researchers looked at the appropriateness of fluoroquinolone and vancomycin treatment at ten Emerging Infections Program sites during a five-month period in 2015. The analysis included data from 1,566 patients who were hospitalized at 192 hospitals. The median age was 67 and just over half (55.2%) were women.

The breakdown was as follows:

• 219 patients were included in the CAP analysis.
• 452 in the UTI analysis.
• 550 in the fluoroquinolone analysis.
• 403 in the vancomycin analysis.
• 58 were included in both the fluoroquinolone and vancomycin analyses.

In the sample as a whole, “treatment was unsupported for 876 of 1,566 patients (55.9%, 95% CI 53.5%-58.4%),” they wrote.

Turning to condition-specific treatment, 79.5% of CAP patients received fluoroquinolone — which is not the recommended antibiotic — as did 76.8% of UTI patients—again a prescribing choice not supported by evidence.

“Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]),” Magill and colleagues wrote.

Overall, flouroquinolones were prescribed without supporting evidence for 46.5% of patients and IV vancomycin for 27.3% of patients.

“One example of an opportunity for improvement suggested by our analysis is excessive treatment duration, which was the most common reason for unsupported CAP treatment and has been reported in multiple other studies. We calculated total treatment duration, including days of inpatient therapy plus the planned duration of post discharge treatment. Current CAP guidelines recommend treatment for a minimum of 5 days, even if the patient has reached clinical stability before 5 days, stating that ’as most patients will achieve clinical stability within the first 48 to 72 hours, a total duration of therapy of 5 days will be appropriate for most patients.’ Exceptions are noted for CAP caused by methicillin-resistant S aureus or Pseudomonas aeruginosa, for which the recommended duration of treatment is 7 days. In our analysis, among 142 patients with CAP for whom duration of therapy was assessed, 103 (72.5%) were treated for at least 8 days. … Given the harm associated with excessive treatment, studies are needed to establish effective approaches to reducing treatment duration, particularly after discharge,” they wrote.

The researchers noted that the analysis was limited to hospitals in just ten states, which may limit the generalizability of the findings. Also, they limited the analysis to just two diagnoses, representing only about 35% of antibiotic use in hospitals. And, because the analysis relied on medical record documentation, incomplete or erroneous records may have been included.

Nonetheless, Magill and colleagues concluded that the analysis does make a strong case for the use of standardized assessments of hospital antimicrobial prescribing quality to estimate their appropriate use.

1. In a cross-sectional study of more than 1,500 hospitalized patients with infections, CDC researchers found that patients received either the wrong antibiotics or the duration of antibiotic treatment was wrong 55.9% of the time.

2. Be aware that the findings suggest the need for improved assessment of hospital antimicrobial prescribing practices with regular reporting of findings.

Peggy Peck, Editor-in-Chief, BreakingMED™

Cat ID: 501

Topic ID: 498,501,254,501,728,791,730,125,190,192,151,925,159