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C. difficile associated with increased risk for adverse outcomes in elderly patients

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November 26, 2018

Clostridium difficile infection is associated with increased risk for short- and long-term adverse outcomes in elderly patients, including transfer to short- and long-term care facilities, according to recently published findings in Infection Control & Hospital Epidemiology.

Results from another study published in the same journal showed that patients were frequently prescribed antibiotics upon discharge to long-term care facilities (LTCFs), which was significantly associated with 30-day ED visits and C. difficile infection within 60 days.

Clostridium difficile is the most common microorganism associated with death in persons with gastroenteritis and the single most common organism responsible for U.S. health care-associated infections,” Margaret A. Olsen, PhD, MPH, professor of medicine in the division of infectious diseases at Washington University of Medicine, and colleagues wrote. “Although C. difficile infection (CDI) is clearly associated with morbidity and mortality, the incremental impact of CDI on mortality is not clear.”

To quantify short- and long-term outcomes of CDI in the elderly, researchers performed a retrospective study using 2011 Medicare claims records for 174,903 CDI patients and 1,318,538 control patients. Results showed that CDI in the elderly population was associated with an increased risk for death (OR 1.77; 95% CI, 1.74-1.81; attributable mortality 10.9%) and new transfer to a LTCF (OR 1.74; 95% CI, 1.67-1.82) or short-term skilled-nursing facility (OR 2.52; 95% CI, 2.46-2.58) within 30 days.

According to Olsen and colleagues, the increased mortality risk associated with CDI was higher in those with low baseline CDI risk and decreased as baseline risk increased.

“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 concluded. “New strategies to prevent CDI focused on the elderly need to be developed to reduce mortality, morbidity, and decline resulting in losses of independence and institutionalization.”

In the second study, Bo R. Weber, PharmD, of the department of pharmacy practice at Oregon State University, and colleagues examined prescribing upon discharge from a Portland, Oregon, hospital to LTCFs and found that around 23% of patients were prescribed antibiotics, with around 1 in 5 prescriptions being for fluoroquinolones.

“Antibiotic use is prevalent in LTCFs; however, 75% of this use may be unnecessary or inappropriate,” Weber and colleagues wrote. “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 [C. difficile]. These adverse outcomes may be exacerbated among LTCF residents given the high prevalence of polypharmacy, multimorbidity, and cognitive impairment in this health care population.”

The retrospective cohort study included adult patients at a 576-bed academic hospital who were discharged to an LTCF between Jan. 1, 2012, and June 30, 2016. Weber and colleagues aimed to quantify the association between receiving an antibiotic prescription and 30-day ED visit, and CDI on a readmission.

Results of the study showed that among the 6,701 discharges to an LTCF, 22.9% of patients were prescribed an antibiotic — including just 10.4% who had an ID consultation — with 24.7% of those patients receiving more than one. Most patients who received an antibiotic prescription —87.1% — had recorded evidence of a potential infectious indication using a diagnosis code for a bacterial infection, a positive clinical culture for a bacterial organism or a positive C. difficile toxin assay during the index admission, Weber and colleagues reported.

“This study provides novel data on the frequency and characteristics of antibiotics prescribed upon discharge to LTCFs,” the authors concluded. “Future work should address the frequency of inappropriate antibiotic prescribing in this patient population, associations with outcomes beyond the index facility, and outcomes within the LTCF post transition.” – by Caitlyn Stulpin

Disclosures: Olsen reports receiving consulting and speaking fees from Pfizer. Weber reports no relevant financial disclosures. Please see the studies for all other authors’ relevant financial disclosures.

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