Discharge Planning – Patients Discharged on Antibiotics

Readmission Risk – Patients Discharged on Antibiotics

Urinary tract infections account for around 100,000 hospital admissions annually in the US.¹ Pneumonia and sepsis are two other major causes of infection-related admissions. According to an article in 2017 in Antimicrobial Resistance and Infection Control, inappropriate antibiotic use in treating Enterobacteriaceae-caused infections is a key factor in promoting patient 30-day re-hospitalizations.²

If you are involved in discharge planning, ensuring that all infection symptoms are documented is imperative. Since 30-day hospital readmissions can result in Medicare (and Medicaid) financial penalties, discharge planners and clinicians need to ensure a patient’s understanding of antibiotic adherence following hospital discharge.

The relationship of specific outpatient antibiotic regimens to increased re-hospitalization risk is discussed below. Also described are bacterial organisms that are the most linked to 30-day readmissions, as well as some emerging drug-resistant organisms.

Outpatient Parenteral Antibiotic Therapy (OPAT)-Associated Infections

As a strategy to reduce inpatient lengths of stay (LOS), outpatient parenteral antibiotic therapy (OPAT) is utilized by around 250,000 people in the US per year.³ While OPAT can be highly cost-effective,⁴ parenteral antibiotic therapy poses a thrombosis and infection risk.

In 2018, a Lancet article suggested that the incidence of complications and hospital readmissions was similar in home-based and hospital-based OPAT patients.⁵ (According to the Journal of Microbial Therapy, 90 percent of OPAT patients receive their OPAT at home.⁶)

The following are three diagnoses especially associated with OPAT:⁷

• Cellulitis;
• Bone and joint infections;
• Endocarditis

Indwelling Urinary Catheters and E. Coli Infections

Between 15-25 percent of inpatients have an indwelling urinary catheter inserted while in the hospital (per the CDC).⁸ This is standard protocol following certain surgeries. As a gram-negative bacteria in the Enterobacteriaceae family, E. coli infections are commonly associated with urinary tract infections (UTIs) resulting from indwelling catheters.

However, UTIs are also common in patients with diabetes, kidney disorders, urinary retention as a surgery complication, and in immobilized (bedridden) patients. An asymptomatic patient with a removed indwelling catheter can be discharged to a rehab center or home, and then develop symptoms of an E. coli UTI.  

Categories of Inpatients Most at Risk for Infections

Five categories of inpatients most at risk of developing an infection while on antibiotics are:

• Cancer patients receiving chemotherapy;
• Patients aged 80 and older;
• Patients living with HIV;
• Patients receiving immunosuppressive medications (g., organ transplant patients);
• Patients with a history of sepsis;

1. Coli Infections in Hospitalized Children

As a bacterial pathogen, E. coli is responsible for 80 percent of infections in children (and is also the most prevalent cause of UTIs in children).⁹ Four risk factors in children for UTIs are:¹⁰

• Young age at UTI inception (e., higher risk associated with boys under 12 months of age, and girls under 4 years of age).
• Having a bladder catheter inserted for a prolonged period of time.
• Having parts of the urinary tract that did not form correctly before birth.
• Having a bladder that does not work properly (or having bladder and bowel co-dysfunction).

Vesicoureteral reflux (VUR)—affecting 1-3 percent of all infants and young children¹¹—is highly-linked to UTIs in children aged 5 and younger. In turn, the resulting UTIs are often treated with antibiotics until the urinary defect corrects itself,¹² and this can contribute to developing a more drug-resistant UTI in later childhood.

Sepsis-Linked Bacteria

One of the bacterial organisms most linked to antibiotic resistance is Staph. aureus. This pathogen is particularly associated with pneumonia, UTIs, surgical site infections, bone and/or joint infections, and endocarditis in hospitalized patients (especially older-aged patients). Following E. coli, Pseudomonas aeruginosa, and enterococci, Staph. aureus accounts for 9 percent of all hospital-acquired infections.¹³

Elderly and debilitated patients are at highest risk for developing Staph. aureus sepsis as inpatients or following discharge. While Vancomycin is still the “drug of choice” for treating MRSA infections, the emergence of Vancomycin-resistant Staph. aureus infections is posing further challenges for treating MRSA-infected patients (per an article in 2018 in Current Medicine Research and Practice).¹⁴

Lack of Fever as Infection Symptom in Elderly Adults

One of the symptoms of infection often not present in elderly adults is fever. Therefore, an elderly discharged patient (or that patient’s unpaid or paid home-based caregiver) may not recognize signs of infection before sepsis has occurred.

Meanwhile, halting ingestion of oral antibiotics before the full course of prescribed treatment can also lead to recurrence of the infection (and this is a pervasive problem in discharged patients who do not understand the importance of completing their prescribed antibiotic course).

Therefore, discharge planners and clinicians need to ensure that elderly patients discharged home (and their family or paid caregivers) are familiarized with a range of infection symptoms in order to seek treatment for an infection as early as possible.

Post-Operative Pneumonia and Pathogens

Pneumonia is among the most frequent complications following thoracic, aortic, and abdominal surgeries. Four risk factors besides elderly age are:¹⁵

1. Extensive smoking history;
2. Co-disorder of obstructive sleep apnea;
3. Use of general anesthesia during surgery;
4. Immunocompromised patient status

The three most commonly-identified pathogens in patient with hospital-acquired pneumonia (HAP) are:¹⁶

• aureus (in 30 percent of patients diagnosed with HAP);
• Pseudomonas aeruginosa (in 24 percent of patients diagnosed with HAP);
• Klebsiella species (in 11 percent of patients diagnosed with HAP)

Effective treatment of Klebsiella infections has become progressively more difficult due to an increase in this pathogen’s antibiotic resistance (including carbapenem resistance).

How Predicting Hospital Readmissions Can Decrease Costs

Reported in Critical Care Medicine in 2018 was that total hospital costs related to sepsis are twice that associated with other conditions.¹⁷ This article also noted hospital admission for sepsis was linked to a 75 percent longer LOS than for most other diagnosed conditions.

Prevention of sepsis is one strategy to reduce overall hospital costs, in that discharged patients with well-treated infections and close medical follow-up are less likely to progress to sepsis— necessitating a 30-day hospital readmission.

As a discharge planner, clinician, or hospital administrator, SHARP software can assist you in predicting hospital readmission risks in patients preparing for discharge. This includes patients discharged on antibiotics in treatment for an infection.

• Click here to download an article published in 2018 titled, “Colonization, Infection, and the Accessory Genome of Klebsiella pneumoniae”.

• Click here to download an article published in 2018 titled, “The “Centrality of Sepsis”: A Review on Incidence, Mortality, and Cost of Care”.

References:

1. Simmering JE, Tang F, Cavanaugh JE, et al. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open Forum Infectious Diseases 4(1): ofw281. [doi:10.1093/ofid/ofw281] Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414046/
2. Zilberberg MD, Nathanson BH, Sulham K, et al. (2017). 30-day readmission, antibiotics costs and costs of delay to adequate treatment of Enterobacteriaceae UTI, pneumonia, and sepsis: A retrospective cohort study. Antimicrobial Resistance and Infection Control 6: 124. Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717819/
3. Allison GM, Muldoon EG, Kent DM, et al. (2013). Prediction model for 30-day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clinical Infectious Diseases 58(6): 812-819. Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935501/
4. Yan M, Elligsen M, Simor AE, et al. (2016). Patient Characteristics and Outcomes of Outpatient Parenteral Antimicrobial Therapy: A Retrospective Study. Canadian Journal of Infectious Diseases and Medical Microbiology 2016: 8435257. Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904566/
5. Bryant PA, and Katz NT. (2018). Inpatient versus outpatient parenteral antibiotic therapy at home for acute infections in children: A systematic review. The Lancet 18(2): PE45-E54. Webpage: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30345-6/fulltext
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12. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Urine Blockage in Newborns. Webpage: https://www.niddk.nih.gov/health-information/urologic-diseases/urine-blockage-newborns
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15. Pusey-Reid E. (2014). Preventing Postoperative Pneumonia. Nursing2018 Critical Care 9(4): 42-47. Webpage: https://www.nursingcenter.com/journalarticle?Article_ID=2501188&Journal_ID=606913&Issue_ID=2500979
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