Antibiotic-Resistant Infections Pose Critical Health Issues & Increases Hospital Admissions

Patients at High Risk for Infection While On Antibiotics

• 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 infection
  
  

Urinary tract infections account for around 100,000 hospital admissions annually in the US.¹ Pneumonia and bacterial 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

Antibiotic-resistant Bacterial Infections

• methicillin-resistant Staphylococcus aureus (MRSA)
• vancomycin-resistant Enterococcus (VRE)
• multi-drug-resistant Mycobacterium tuberculosis (MDR-TB)
• carbapenemase-producing Enterobacterales (CPE)
  

Outpatient Parenteral Antibiotic Therapy (OPAT)

As a strategy to reduce inpatient lengths of stay, outpatient parenteral antibiotic therapy (OPAT) is prescribed to 250,000 people in the US per year.³ While OPAT can be highly cost-effective⁴ - for prevention of cellulitis, bone and joint infections and endocarditis - parenteral antibiotic therapy poses a thrombosis and infection risk.

Patient/Caregiver Teaching for Managing Infections and Preventing Hospitalization

1. Take the antibiotic exactly as prescribed. 

If the patient stops treatment before the antibiotic cycle is over the remaining bacteria can continue to multiply, taking longer for the infection to be resolved.

Clear expectations about duration of treatment, as well as daily adherence to a regimen, need to be agreed upon between the clinician and patient when antibiotic treatment is prescribed, ideally at the start of treatment. If an antibiotic is prescribed for a clear indication, and a minimum duration is supported by evidence-based guidance, patients should be advised not to stop treatment until the end of the course. 

2. Report Any Persistent or Exacerbated Symptom Within 2-3 Days of Initiating Antibiotic Therapy

The patient may be receiving the incorrect treatment.

• The infection may be antibiotic-resistant
• The antibiotic maybe ineffective for the particular infection
• Lack of fever is not a reliable symptom in elderly patients

Lack of Fever is not a Reliable Symptom in Elderly Adults

Fever is often not present in elderly adults. An elderly patient - or caregiver - may not recognize signs of infection before sepsis has occurred.

The home health clinician should provide specific teaching for type of infection. According to the Centers for Disease Control and Prevention

• Pain in the abdomen or rectum
• New onset of pain
• Fever (this is sometimes the only sign of an infection)
• Chills and sweats
• Change in mental status
• Change in cough or a new cough
• Sore throat or new mouth sore
• Shortness of breath
• Nasal congestion
• Stiff neck
• Burning or pain with urination
• Unusual vaginal discharge or irritation
• Increased urination
• Redness, soreness, or swelling in any area, including surgical wounds and ports
• Diarrhea
• Vomiting

3. Teach the Patient to Practice Infection Control

• Get plenty of rest and stay hydrated.
• Wash your hands often.
• Stay away from crowds.
• Ask visitors who have a cold to wear a mask. 
• Stay home except to get medical care. Call ahead before visiting your health care provider.
• Ask others to get groceries and household supplies and to refill prescriptions for you.
• Avoid public areas. Try not to take public transportation.
• If you can, wear a mask if you need to go out of the house, or if you are in close contact with someone who is not sick.
• Avoid visitors until you have completely recovered, or until you have no signs and symptoms of infection.
• Avoid preparing food or providing care for others. If you must prepare food or provide care for others, wear a mask and wash your hands before and after doing these things.

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
6. Shrestha NK, Shrestha J, Everett A, et al. (2016). Vascular access complications during outpatient parenteral antimicrobial therapy at home: A retrospective cohort study. Journal of Antimicrobial Chemotherapy 71: 506-512. Webpage: https://watermark.silverchair.com/dkv344.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAjwwggI4BgkqhkiG9w0BBwagggIpMIICJQIBADCCAh4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMlFDs9qQpyoMTugqvAgEQgIIB7-j7mAVlngzmTkCyAoe4mCAzUA-7GNtcFFtPReKNGgAXwsJ2pEQfXsVSYNKORs0CLtIbJuegXOxBOdwf6xo9OgXmkTy3E-H_4_QLfo2CtnqPwkPmdxaH9576R59SWWON0faajxhXWyAL_I5HiOFxoNzS_Ej88UMPQqq4g6m1xKF_XcmFdUG1IhUnnZk9C4N_KsZc0Nli0sbq8dgujKm0EaIyS36MZNE_AhGgvVA5wATJA0w3aOC4g6D0HKgatEWTCAoAd2hbXVT5VHQ3I6GHL83qhjcHkburYXCCWAHjXvr5F3QUV5j3KgxJR3cI2BlM38EptOnOobXpc9lGBI4d0SwPiP8p5TgnhvHYn9D4y7nsdeYkkZCDv8Nf4HVp5mpiiDka9s9dINqTG3gCiStWa0a_GTnHqWNOxLPsjzhRtQE1CskfKapGk6nCBDjtVS5KH2RHolMjWlcjS1H8X-hGK_H7FSHgEIEK2MQyh_ssl1kdcg5nZLlPkD5y3FWMujD5ztlVo6fbon3Yd_jxXh1NSBekRxRrYfqWnBKmH4zXfYGao6Tsi9OEGv1Iaz_bRG2vFeLsMOc0NiVR1y2sNhK_VLy70XhdEyciRTKXAGm5LuTMDneOi2jZ2uMVj41XwYzkBYbkWpCIcYc0YB0mKebNbw
7. Chapman Ann. (2013). Outpatient parenteral antimicrobial therapy BMJ 346: f1585. Webpage: https://www.bmj.com/content/346/bmj.f1585
8. Centers for Disease Control (CDC). Healthcare-Associated Infections: Catheter-associated Urinary Tract Infections (CAUTI). Webpage: https://www.cdc.gov/hai/ca_uti/uti.html
9. Kokosky, Gina. (February 12, 2018). Threat of Drug-Resistant E coli Increases with Pediatric Antibiotic Prescriptions. Pharmacy Times Website: https://www.pharmacytimes.com/news/threat-of-drugresistant-e-coli-increases-with-pediatric-antibiotic-prescriptions-
10. UptoDate.com. (Last Update: January 24, 2018). Patient education: Urinary tract infections in children (Beyond the Basics).