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One prescriber’s antibiotic prescription could be another’s problem

Reviewed by: Cynthia T. Nguyen, PharmD; University of Chicago Medicine and Valeria Fabre, MD; Johns Hopkins University School of Medicine

Antibiotic use can cause downstream effects and impact patients beyond the current antibiotic course and/or hospitalization. Prescribers often do not receive feedback regarding the short and long-term consequences of their antibiotic prescribing. Two recently published studies sought to characterize these adverse events.

A multicenter Veterans’ Affairs study evaluated 216 hospitalized patients with a skin and skin structure infection (SSSI) who received vancomycin. In the total population, patients received vancomycin for a median of 5 days and vancomycin associated acute kidney injury (VA-AKI) occurred in 19 (8.8%) patients. 42 (19.4%) patients had a 30-day readmission and most of the readmissions were SSSI related (59.5%). Patients who experienced VA-AKI had higher 30-day readmission rates than those without VA-AKI (42.1% versus 17.3%, p=0.02). In a multivariable analysis, VA-AKI was independently associated with 30-day readmissions (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.00 to 7.80) and non-SSSI-related 30-day readmissions (aOR, 4.66; 95% CI, 1.37 to 15.85). Nearly all of the non-SSSI-related 30-day readmissions were due to cardiac or pulmonary conditions, which the authors suggest may be related to AKI-associated distal organ dysfunction.

10% of outpatient antibiotics are prescribed by dentists for infection prophylaxis, ~81% of these antibiotics are administered to patients who do not meet criteria for prophylaxis (i.e., not at high risk of infective endocarditis). Gross et al. evaluated antibiotic prescriptions from dental visits between 2011 and 2015 using IBM Watson Health Marketscan Commercial Claims/Encounters, Medicare Supplemental, Coordination of Benefits Research databases. Antibiotic prophylaxis was defined as a ≤2-day supply of antibiotics dispensed within 7 days prior to a dental visit. Unnecessary antibiotic prophylaxis was defined as prophylaxis in patients who did not undergo a procedure that manipulated the gingiva or tooth periapex and did not have an appropriate cardiac diagnosis. The primary end point was any antibiotic adverse effect (AAE) within 14 days after prescription: composite of allergy, anaphylaxis, C. difficile infection (CDI), or emergency department (ED) visit. The primary end point of composite AAE incidence rate was measured as events per 1,000 patient days (PD) in the overall cohort and stratified by amoxicillin and clindamycin. 136,177 met inclusion criteria. Antibiotics prescribed included amoxicillin (67.9%), clindamycin (15.5%), cephalexin (8.6%), azithromycin (2.8%), penicillin (1.5%). 1.4% of unnecessary prescriptions were associated with an AAE within 14 days; the incidence of AAE was 1.01 per 1,000 PD. ED visits (83%) and allergies (16%) were the most frequent AAEs, Clostridioides difficile infection (CDI) incidence was 0.009 per 1,000 PD (95% CI, 0.006–0.012). Overall, AAEs were more common with clindamycin (1.167 per 1,000 PD) than amoxicillin (0.958 per 1,000 PD; risk difference, 0.209 per 1,000 PD; 95% CI, 0.108–0.33).

References:

Patel N, Stornelli N, Sangiovanni RJ, Huang DB, Lodise TP. 2020. Effect of vancomycin-associated acute kidney injury on incidence of 30-day readmissions among hospitalized Veterans Affairs patients with skin and skin structure infections. Antimicrob Agents Chemother 64:e01268-20. https://doi.org/10.1128/AAC.01268-20

Gross AE, et al. (2020). Serious antibiotic-related adverse effects following unnecessary dental prophylaxis in the United States. Infection Control & Hospital Epidemiology, https://doi.org/10.1017/ice.2020.1261.

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