Abstract
Little is known about the contribution of hospital antibiotic prescribing to multidrug-resistant organism (MDRO) burden in nursing homes (NHs). To characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment. This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021. Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories. The primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics. A total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [OR], 1.70; 95% CI, 1.22-2.38) and MDRO environmental contamination (OR, 1.67; 95% CI, 1.17-2.39). Exploratory stratification by C diffogenic agent exposure increased the effect size (MDRO colonization: OR, 1.99; 95% CI, 1.33-2.96; MDRO environmental contamination: OR, 1.86; 95% CI, 1.24-2.79). Likewise, exploratory stratification by exposure to high-risk WHO AWARE antibiotics increased the effect size (MDRO colonization: OR, 2.32; 95% CI, 1.61-3.36; MDRO environmental contamination: OR, 1.86; 95% CI, 1.26-2.75). The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce MDROs in postacute care NHs. This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology.
Highlights
The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce multidrug-resistant organism (MDRO) in postacute care nursing homes (NHs)
This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology
We found that antibiotic use is common in our predominantly post-acute care NH patient population
Summary
Nursing home (NH) patients are at a heightened risk for antibiotic-associated adverse events due to a convergence of patient-, facility-, and health care system–level risk factors.[1,2] NH patients are often older and have multimorbidity, functional disability, indwelling devices, and frequent exposure to antibiotics.[1,2] These patients often traverse multiple health care facilities and are commonly rehospitalized within 30 days.[3,4] Across this population’s health care continuum, antibiotic exposure is common, as approximately 30% to 50% of hospitalized patients and 40% to 70% of NH patients receive an antibiotic.[5,6,7] Antibiotic overuse in this population is associated with multidrug-resistant organism (MDRO) colonization and infection, Clostridioides difficile infection (CDI), selection for antibiotic resistance, rehospitalization, unnecessary health care expenditures, and mortality.[1,2]Our understanding of how hospital and NH infection prevention programming and antibiotic prescribing patterns influence regional health care systems is evolving.[8,9,10] Patient-transfer networks have been implicated in the regional transmission of MDROs.[11,12,13] genomic epidemiology and network modeling have supported the role of patient characteristics, transfer networks, facility-level antibiotic stewardship practices, and health care system–level factors in regional MDRO prevalence, infection rates, and transmission.[11,12,13,14].
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