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PICTURE: A new study on antibiotic prescription reveals that one-third of patients discharged from 48 Michigan hospitals for pneumonia or urinary tract infections have received a prescription for an antibiotic fluoroquinolone …
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Credit: University of Michigan
While hospitals are trying to cut down on powerful but risky antibiotic prescriptions for their patients, a new study shows that many of these patients are still returning home with prescriptions for these same medications, thus increasing the risk of "high blood pressure". infection, from "superbug" to torn tendons.
In fact, hospitals that said they were actively trying to reduce the use of a group of antibiotics called fluoroquinolones were twice as likely to discharge patients from a new one. prescription for one of the drugs in this risk group.
In total, one-third of the patients studied received a fluoroquinolone prescription at the end of their hospital stay, despite the fact that current guidelines advocate restricted use due to side effects.
And in all of Michigan's 48 participating hospitals, discharge orders accounted for two-thirds of the total supply of fluoroquinolones prescribed to almost 12,000 patients treated for pneumonia or urinary tract infection. Medications accounted for 42% of all antibiotics prescribed at the exit.
"Fluoroquinolone antibiotics are easy to use, but pose a significant risk to patients and society in general," says Valerie Vaughn, MD, MSc, lead author of the new article and hospital medicine specialist at Michigan Medicine, University. from Michigan University Medical Center. "These results show that we need to focus not only on their use in hospitals, but also on the orders with which we refer patients home." Exit orders are a big loophole. "
Vaughn and colleagues report results in the newspaper Clinical Infectious Diseases. The data comes from the Michigan Hospital Medicine Safety (HMS) Consortium, which brings together hospitalists, internal medicine specialists, and infectious disease specialists from across the state, to improve care. provided to hospitalized patients.
The data come from patients treated for pneumonia or urinary tract infection over a period of almost two years ending in the fall of 2017. This includes the first nine months after the national organizations started asking hospitals to put in place a program to monitor and reduce the use of antibiotics.
Called "antimicrobial stewardship", these programs stem from the need to curb the rise of "superbugs" or bacteria that evolve to resist treatment and threaten the lives of patients.
A family of antibiotics at risk
Fluoroquinolones include brands like Cipro and Levaquin, as well as generic antibiotics whose name ends with "floxacin". They have been particularly related to the proliferation of drug-resistant organisms and potentially life-threatening intestinal infections caused by an opportunistic microbe called Clostridiodes difficile.
They have also been badociated with Achilles tendon ruptures, dangerously low blood sugar levels in people with diabetes, and mental health problems including disorientation and delirium.
The US Food and Drug Administration (FDA) has issued several "black box" warnings about their side effects – most recently in December, with the warning that fluoroquinolones could cause breakage of the aorta, the big one. artery leading from the heart to the rest of the skin. body.
This warning suggests to doctors not to prescribe medications to the elderly, hypertensives and people at risk or history of aneurysm.
Wiser choices are needed
The new study focuses on pneumonia and urinary tract infections since both conditions account for nearly half of the use of antibiotics in hospitals. Most patients with these conditions are treated by hospitalists or general internists, rather than specialists in infectious diseases who focus mainly on the most serious cases.
In total, more than 10% of the study patients were treated with a fluoroquinolone antibiotic on discharge from the hospital.
Although fluoroquinolones are just one group of antibiotics that doctors can choose from, Dr. Vaughn says they have the benefit of being able to treat a wide range of organisms infectious and to be used in patients allergic to penicillin.
They also come in pill form, rather than needing to be delivered intravenously, which makes them much more attractive for discharge prescriptions.
But if patients finish their hospitalization without them, then they are probably not the right treatment choice after they leave the hospital, says Vaughn.
"When patients first enter the hospital, doctors usually do not have test results that show the cause of their infection," which may guide the choice of antibiotics, Vaughn says. They may also not know if the patient is allergic to penicillin.
"But when you leave, you will have more results and history, most of the information you will have about them," she adds. "This makes the discharge prescription a prime place for stewardship programs and for the choice of antibiotics to be more of an active thought than a retrospective reflection."
Next steps
The phenomenon observed in the new study – in which exit fluoroquinolone prescribing rates in hospitals with active antimicrobial management programs was higher – deserves further investigation, Vaughn said.
Fourteen of the hospitals participating in the study had implemented specific measures to require the review of fluoroquinolone prescriptions during an inpatient stay.
In these hospitals, more than 78% of fluoroquinolones were prescribed at discharge, compared with 68% of the 34 other hospitals, almost all of which had an antimicrobial management program but did not specifically focus on fluoroquinolones.
While pharmacists and infection control specialists may monitor prescriptions in hospital, they may not have access to or focus on prescriptions. Electronic health record systems track medications administered to inpatients and outpatients, but they are often in separate sections of the record.
In fact, says Vaughn, when the HMS team showed the partnership doctors the hospital-specific data on the prescription of antibiotics at the exit, it was the first time time that most users saw such data.
Since the data was shared, several hospitals in the consortium have begun to pay special attention to the discharge prescription of fluoroquinolones and others are preparing to do so. For example, a project is underway to improve the prescription of antibiotics when going out to Michigan Medicine.
If the prescription drops, the side effects of the drugs should also. The researchers noted that paying close attention to the appropriate fluoroquinolone prescription in the UK resulted in a 60% fall in C. diff infections.
In the United States, hospitals can be financially penalized if a large proportion of their hospitalized patients develop C. diff infections during their stay. But these penalties do not apply if the patient develops a C. diff infection after leaving the hospital.
For patients and families
Inpatients usually do not express a preference for the antibiotic they receive – except to say they have penicillin allergy if they think so, says Vaughn.
Patients and their families can say that they do not want fluoroquinolone in the hospital or out of the hospital, especially if they have diabetes, high blood pressure. , history of aneurysm or tendon or muscle problems. Patients with a history of C. difficile should be particularly cautious.
In addition, says Vaughn, patients often think they are not allergic to penicillin. If they tell their health care team that they have an allergy to penicillin while they are not tested to be sure, it might mean that they will be prescribed an antibiotic. at high risk.
Patients who have already had a penicillin allergy test or who have had shortness of breath or hives after receiving a penicillin-containing medication should make sure that their chart is evidence of this. However, patients with stomach upset or diarrhea after taking penicillin do not generally show any allergy and should ask to be screened to be absolutely certain and able to receive the drug. antibiotic with the lowest risk.
Even if the doctor specifically recommends a fluoroquinolone, patients and their families may request to receive the shortest possible treatment to reduce the risk of side effects. Research has shown that short-term treatments are often safe and effective.
"In this age of wise choice in medicine, our mantra should be that less is more when it comes to antibiotics," Vaughn says.
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In addition to Vaughn, the authors of the study are the three HMS leaders: Scott Flanders MD, UM Hospice, Vineet Chopra, M.Sc., Head of the UM Division of Hospital Medicine, and Tejal Gandhi, MD, Infectious Disease Specialist at UM, and Anna Conlon, Ph.D. and Anurag N. Malani, MD Vaughn, of Flanders and Chopra are members of the UM Institute for Health Policy and Innovation and the Program for Strengthening UM / VA patient safety.
Blue Cross and Blue Shield of Michigan and Blue Care Network provide support to HMS through the BCBSM Value Partnerships program. HMS is one of nearly 20 collaborative quality initiatives.
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