Unnecessary Antimicrobial Use in Patients with Current or Recent <i>Clostridium difficile</i> Infection

Shaughnessy, Megan K.; Amundson, William H.; Kuskowski, Michael A.; DeCarolis, Douglas D.; Johnson, James R.; Drekonja, Dimitri

doi:10.1086/669089

Cited by 56 publications

(33 citation statements)

References 32 publications

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“…Shehab et al estimated over 142,000 annual ED visits for complications due to antibiotic use, with nearly 80% related to allergic reactions (4). In addition, antibiotic use and the risk of Clostridium difficile infection have become important concerns (5,6). Quinolone antibiotics in particular have been shown to cause significant collateral damage and toxicity (i.e., QT prolongation [prolongation of time between the start of the Q wave and the end of the T wave in the heart's electrical cycle], drug interactions, and blood glucose fluctuation) (28,29).…”

Section: Discussionmentioning

confidence: 99%

“…This inappropriate antibiotic use is potentially harmful to the community, fostering the growth of antimicrobial-resistant organisms (3). Other potential consequences include antibiotic-related adverse effects, such as Clostridium difficile-associated disease, antibiotic-associated diarrhea, and allergic reactions (4)(5)(6). Over the past decade, multiple campaigns and interventions have sought to curtail the use of inappropriate antibiotics for ARTIs, focused primarily on outpatient visits.…”

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confidence: 99%

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Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Donnelly

Baddley

Wang

2014

Antimicrob Agents Chemother

113

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Inappropriate use of antibiotics for acute respiratory tract infections (ARTIs) has decreased in many outpatient settings. For patients presenting to U.S. emergency departments (EDs) with ARTIs, antibiotic utilization patterns are unclear. We conducted a retrospective cohort study of ED patients from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We identified patients presenting to U.S. EDs with ARTIs and calculated rates of antibiotic utilization. Diagnoses were classified as antibiotic appropriate (otitis media, sinusitis, pharyngitis, tonsillitis, and nonviral pneumonia) or antibiotic inappropriate (nasopharyngitis, unspecified upper respiratory tract infection, bronchitis or bronchiolitis, viral pneumonia, and influenza).There were 126 million ED visits with a diagnosis of ARTI, and antibiotics were prescribed in 61%. A cute respiratory tract infections (ARTIs) such as bronchitis, sinusitis, and rhinitis account for almost 10% of ambulatory care visits in the United States (1). While many of these infections are caused by viruses, clinicians prescribe antibiotics for over half of the visits for these conditions (1, 2). This inappropriate antibiotic use is potentially harmful to the community, fostering the growth of antimicrobial-resistant organisms (3). Other potential consequences include antibiotic-related adverse effects, such as Clostridium difficile-associated disease, antibiotic-associated diarrhea, and allergic reactions (4-6). Over the past decade, multiple campaigns and interventions have sought to curtail the use of inappropriate antibiotics for ARTIs, focused primarily on outpatient visits. There is evidence of improvement, with ARTI antibiotic prescription rates decreasing among young children and reduction of rates of broad-spectrum antimicrobial use in older persons (1,2,7,8).Much less is known about patterns of antibiotic use for ARTIs among persons visiting emergency departments (EDs). ED use in the United States has increased over the past decade, and Americans rely increasingly on EDs for a wide range of medical conditions due to a combination of barriers to primary care access (9, 10). As a result, the ED has become a common site of care for nonemergent conditions, including ARTIs, particularly among socioeconomically disadvantaged individuals.We sought to characterize antibiotic utilization for ARTIs treated in U.S. emergency departments with the use of national surveillance data. MATERIALS AND METHODSStudy design and data source. We analyzed 2001-to-2010 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). The study was approved by the Institutional Review Board of the University of Alabama at Birmingham.Operated by the National Center for Health Statistics, NHAMCS is a national probability sample characterizing ED (NHAMCS-ED) and outpatient clinic visits at hospitals across the United States (11). Using a four-stage probability design, NHAMCS-ED samples geographically defined areas, hospitals within these areas, emergenc...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Donnelly

Baddley

Wang

2014

Antimicrob Agents Chemother

113

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“…This is especially true in lieu of recent findings that up to 26 percent of patients with a current or a recent history of CDI receive unnecessary and potentially avoidable antimicrobial exposure. 84 Antimicrobial stewardship efforts should be an essential component of any intervention aimed at reducing the risk of CDI.…”

Section: Patient Risk Factorsmentioning

confidence: 99%

Epidemiology of Clostridium difficile Infection

DePestel

Aronoff

2013

Journal of Pharmacy Practice

212

162

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There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st Century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the U.S. and Europe suggest the incidence of CDI may have reached a crescendo in recent years and is perhaps beginning to plateau. The acute-care direct costs of CDI were estimated to be $4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in acute-care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, identify populations at risk, and characterize the molecular epidemiology of strains causing CDI.

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“…In practice, antimicrobial usage is frequently inappropriate with regard to treatment indication, choice of agent, or treatment duration. [1][2][3][4][5] Inappropriate antimicrobial therapy leads to excess antimicrobial resistance, adverse events, and health care costs. [6][7][8][9][10][11][12][13] Promotion of excess in antimicrobial resistance is particularly troubling in an age when multidrug-resistant organisms can no longer be effectively treated by any available antibiotics and few potentially effective agents are under development.…”

mentioning

confidence: 99%

Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam

et al. 2015

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Background: Antibiotic time-outs can promote critical thinking and greater attention to reviewing indications for continuation. Objective: We pilot tested an antibiotic time-out program at a tertiary care teaching hospital where vancomycin and piperacillin-tazobactam continuation past day 3 had previously required infectious diseases service approval. Methods: The time-out program consisted of 3 components: (1) an electronic antimicrobial dashboard that aggregated infection-relevant clinical data; (2) a templated note in the electronic medical record that included a structured review of antibiotic indications and that provided automatic approval of continuation of therapy when indicated; and (3) an educational and social marketing campaign. Results: In the first 6 months of program implementation, vancomycin was discontinued by day 5 in 93/145 (64%) courses where a time-out was performed on day 4 versus in 96/199 (48%) 1 year prior (P = .04). Seven vancomycin continuations via template (5% of time-outs) were guidelinediscordant by retrospective chart review versus none 1 year prior (P = .002). Piperacillin-tazobactam was discontinued by day 5 in 70/105 (67%) courses versus 58/93 (62%) 1 year prior (P = .55); 9 continuations (9% of time-outs) were guideline-discordant versus two 1 year prior (P = .06). A usability survey completed by 32 physicians demonstrated modest satisfaction with the overall program, antimicrobial dashboard, and renewal templates. Conclusions: By providing practitioners with clinical informatics support and guidance, the intervention increased provider confidence in making decisions to de-escalate antimicrobial therapy in ambiguous circumstances wherein they previously sought authorization for continuation from an antimicrobial steward. 1-5 Inappropriate antimicrobial therapy leads to excess antimicrobial resistance, adverse events, and health care costs. Key6-13 Promotion of excess in antimicrobial resistance is particularly troubling in an age when multidrug-resistant organisms can no longer be effectively treated by any available antibiotics and few potentially effective agents are under development.14 Antimicrobial stewardship may be broadly defined as a program or series of interventions to improve the appropriateness of antimicrobial use, and it is a key strategy in combating antimicrobial resistance.9,15-17 Unfortunately, best practices in stewardship remain unclear.18 Whereas available data indicate that restrictive interventions (ie, limiting access to antibiotics through formulary or approval policies) have a significantly greater impact on prescribing practices in the short term than do persuasive measures such as dissemination of educational resources and/or outreach, reminders, or audit-feedback, these benefits do not persist, are less scalable, and can provoke negative reactions from providers who prefer to maintain autonomy in decision making. 19,20 Thus, stewardship must find a balance between restrictive and persuasive methods of influencing antimicrobial prescriptio...

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Unnecessary Antimicrobial Use in Patients with Current or Recent Clostridium difficile Infection

Abstract: Twenty-six percent of patients with recent CDI received only unnecessary (and therefore potentially avoidable) antimicrobials. Heightened awareness and caution are needed when antimicrobial therapy is contemplated for patients with recent CDI.

Cited by 56 publications

References 32 publications

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Epidemiology of Clostridium difficile Infection

Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam

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