Even as hospitals try to cut back on prescribing fluoroquinolones—powerful but risky antibiotics—many patients still head home with prescriptions for those same drugs, a new study shows.
In fact, the hospitals that say they are trying to reduce the use of fluoroquinolones are twice as likely to discharge patients with a new prescription for one of the drugs in that risky group.
In all, one-third of the patients researchers studied received a fluoroquinolone prescription at the end of their hospital stay, despite current guidelines calling for restricted use because of dangerous side effects. FDA warnings
Fluoroquinolones include name brands like Cipro and Levaquin and generic antibiotics whose names end in “-floxacin.” They have been especially linked to the rise of drug-resistant organisms and potentially life-threatening gut infections with an opportunistic microbe called Clostridioides difficile .
They are also linked to ruptures of Achilles tendons, dangerously low blood sugar levels in people with diabetes, and mental health problems including disorientation and delirium.
The US Food and Drug Administration has issued several “black box” warnings about their side effects—most recently in December with a warning that fluoroquinolones could cause rupture of the aorta, the huge artery leading from the heart to the rest of the body.
That warning suggests doctors should not prescribe the drugs to the elderly, people with high blood pressure, and people with a risk or history of aneurysms.
Still, across all 48 Michigan hospitals in the study, discharge-related prescriptions accounted for two-thirds of the fluoroquinolone supply prescribed to the nearly 12,000 patients treated for pneumonia or urinary tract infections.
The drugs accounted for 42 percent of all antibiotics prescribed at discharge.
“Fluoroquinolone antibiotics are easy to use but carry a lot of risk for patients and society at large,” says Valerie Vaughn, a hospital medicine specialist at Michigan Medicine, the University of Michigan’s academic medical center, and lead author of the paper, which appears in Clinical Infectious Diseases .
“These results show we need to focus on not just their use in hospitals, but also in the prescriptions that we send patients home with,” she says. “Discharge prescribing is a big loophole.” Choose wisely
Researchers used Michigan Hospital Medicine Safety Consortium data from patients treated for pneumonia or UTIs over a nearly two-year period ending in fall 2017. That includes the first nine months after national organizations began requiring hospitals to have a program for tracking and reducing use of antibiotics.
Called antimicrobial stewardship, such programs stem from a need to curb the rise of superbugs, or bacteria that evolve to resist treatment and threaten patients’ lives.
The new study focuses on pneumonia and UTIs because these conditions account for almost half of antibiotic use in hospitals. Hospitalists and general internists are largely the ones to care for these patients, rather than infectious diseases specialists, who mainly focus on the most serious cases.
In all, hospital personnel switched more than 10 percent of patients in the study to a fluoroquinolone antibiotic at discharge. While fluoroquinolones are just one group of antibiotics that doctors can choose, they have the advantage of being able to treat a broad spectrum of infectious organisms and can treat patients who are allergic to penicillin.
They also come in pill form rather than intravenously, which makes them much more attractive for discharge prescriptions.
But if patients are getting through their hospitalization without them, then fluoroquinolones are probably not the right choice for treatment after they leave the hospital, Vaughn says.
“When patients first come in to the hospital, doctors don’t typically have test results to show what’s causing their infection,” which could guide antibiotic choice, Vaughn says. They also may not know if the patient is allergic to penicillin.
“But by the time they’re leaving, you have more results and history—the most information you’re going to have about them,” she says. “This makes the discharge prescription a great place for stewardship programs to intervene and to make antibiotic choice more of an active thought than an afterthought.” After discharge
The fact that hospitals that have active antimicrobial stewardship programs have higher rates of prescribing fluoroquinolones at discharge deserves more scrutiny, Vaughn says.
Fourteen hospitals in the study had measures in place to require review of fluoroquinolone prescriptions during hospitalization. In these hospitals, more than 78 percent of the supply of fluoroquinolones was prescribed at discharge, compared with 68 percent of the supply for the other 34 hospitals, nearly all of which had antimicrobial stewardship programs but no special emphasis on fluoroquinolones.
It may be that while pharmacists and infection prevention specialists are keeping an eye on in-hospital prescribing, they don’t have access to, or don’t focus on, the prescriptions written at discharge. Electronic health record systems track both inpatient and discharge medications, but they are often in separate sections of the record.
In fact, when researchers showed hospital-specific data on discharge antibiotic prescribing to the physicians in the partnership, it was the first time most had seen it.
After researchers shared the data, several hospitals in the consortium started paying special attention to discharge prescribing of fluoroquinolones, and others are preparing to. If prescribing drops, drug side effects should, too.
Special focus on appropriate fluoroquinolone prescribing in the United Kingdom resulted in a 60 percent drop in C. diff infections, the researchers say.
In the US, hospitals can face financial penalties if a high proportion of their inpatients develop C. diff infections during their stay. But those penalties don’t apply if the patients develop C. diff after they leave the hospital. Speak up
Hospitalized patients don’t usually express a preference for which antibiotic they receive, except for saying they have a penicillin allergy if they think they do, Vaughn says.
Patients and their families can speak up about not wanting a fluoroquinolone in the hospital or at discharge, especially if they have conditions such as diabetes, high blood pressure, history of aneurysm, or tendon or muscle problems. Patients with a history of C. diff should be especially wary.
Furthermore, Vaughn says, patients often think they have a penicillin allergy when they don’t. If they tell their health care team they have a penicillin allergy, that might receive a higher-risk antibiotic instead.
Patients who have a past test confirming their penicillin allergy, or who experienced shortness of breath or hives after receiving a penicillin-containing drug, should make sure their record notes this. Patients who have an upset stomach or diarrhea after taking penicillin typically don’t have an allergy. Less is better
Even if the doctor recommends a fluoroquinolone, patients and families can ask for the shortest course possible, to reduce the risk of side effects. Previous research shows that often short courses of the drugs are safe and effective.
“In this era of choosing wisely in medicine, our mantra should be that less is more when it comes to antibiotics,” Vaughn says.
Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program funded the work.
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