Abstract
BackgroundAntibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment.MethodsWe conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013–2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment.ResultsAmong 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01–1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54–2.44).ConclusionIn this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
Highlights
Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents
From 2013 to 2018, we identified 19,701 Community Living Center (CLC) residents with an incident urinary tract infection (UTI) treated in 120 Veterans Affairs (VA) CLCs treated for at least 3 days
Receipt of potentially suboptimal antibiotic treatment was associated with a small increased hazard of the composite poor clinical outcome as compared with optimal antibiotic treatment
Summary
Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Antibiotics are used frequently in older residents for many reasons, including higher risk of infection due to immunosuppression, malnutrition, dehydration, presence of multiple comorbidities, and functional impairment [4,5,6,7]. Several other issues such as diagnostic uncertainty, the atypical and/or subtle presentation of common infections, and the frequency of colonization with antibiotic-resistant pathogens contribute to antibiotic use in this population [5]. Up to 75% of antibiotic treatment in LTCFs may be inappropriate, putting already vulnerable residents at risk for unintended consequences of antibiotic use, including selection for colonization or infection with resistant organisms and Clostridioides difficile, antibiotic allergies, and other adverse drug effects and drug toxicities [12,13,14]
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