Study: Antibiotic Stewardship Programs Do Not Worsen Outcomes in Elderly Patients

Rigorous antibiotic stewardship programs can improve patient outcomes, even among vulnerable elderly patients, according to a new report.

The problem of multidrug resistant (MDR) bacteria is a well-known phenomenon in hospitals around the world. Yet, more than half of Americans who visit the hospital will receive at least 1 antibiotic during their stay, wrote corresponding author Roman A. Tuma, MD, of the Hackensack Meridian School of Medicine, in New Jersey, and colleagues.

Writing in the journal JAC - Antimicrobial Resistance, Tuma and colleagues noted that the CDC estimates that 35,000 Americans die each year due to antibiotic resistant infections and more than 12,000 died from Clostridioides difficile infections (CDIs) infections in 2017.

“The elderly are the most vulnerable patient population because of immune system senescence and multiple comorbidities as well as polypharmacy, leading to multiple drug-drug interactions, and increasing the risk of MDR infections,” Tuma and co-authors wrote.

One primary way to fight these types of infections and deaths is through antibiotic stewardship programs (ASP), which have been studied previously, but with varying results.

Tuma and colleagues wanted to know how the implementation of a rigorous ASP might impact quality metrics among patients over the age of 65 who were hospitalized.

To find out, they compared data from the first 6 months of 2015 (before an ASP was implemented) to data from 2017 (after the ASP was in place) at a single teaching hospital. They assessed patient readmission due to reinfection or CDI, mortality rates, and length of stay. Patients were included in the assessment if they had received antibiotics for pneumonia, urinary tract infection, acute bacterial skin and skin structure infection, or complicated intra-abdominal infection. A total of 544 patients were included in the 2015 cohort; 297 patients were included in the 2017 cohort.

The hospital’s ASP program was led by an ASP team, which consisted of a clinical pharmacist, an infectious disease specialist, and a clinical nurse. The team daily spoke with clinicians to offer antibiotic treatment recommendations, and then assessed patient records to see if the recommendations were followed. If not, the ASP team re-reviewed the case and had a follow-up conversation with the prescribing physician.

The data showed that the program benefited patients. The 30-day readmission rate at the hospital decreased during the ASP period for all types of infections, from 24.9% in 2015 to 9.3% in 2017 (P < .001). Thirty-day readmissions for CDI specifically dropped from 2.4% to 0.3% over the time frame (P = .02). Mortality fell from 9.6% to 5.4% after the implementation of the ASP (P = 003), and the amount the hospital spent each day per patient fell from $23.30 to $4.30.

“Interestingly, we observed a statistically significant decrease in patient mortality in patients whose antibiotic treatments were monitored by the ASP, underscoring the safety of the program,” the authors wrote. “This is an important finding as narrowing and discontinuation of antibiotic therapies can be challenging because of a fear for the ‘wellbeing of patients,’ particularly in a vulnerable, elderly population.”

The authors noted some limitations, including differences in prescribing patterns between the two time frames. For instance, levofloxacin usage differed significantly between the two time periods, likely due to a FDA warning against using fluoroquinolone antibiotics, Tuma and colleagues wrote. Also, the older group was more likely to receive broad-spectrum antibiotics compared to the ASP group.

“Despite the apparent limiting factors of this study, our results suggest that rigorous ASPs can be safely and successfully implemented in elderly, hospitalized patients,” the investigators concluded.

Reference

Mauro J, Kannangara S, Peterson J, Livert D, Tuma RA. Rigorous antibiotic stewardship in the hospitalized elderly population: saving lives and decreasing cost of inpatient care. JAC Antimicrob Resist. 2021;3(3):dlab118. Published 2021 Aug 12. doi:10.1093/jacamr/dlab118