Patients With Advanced Stage Pressure Ulcers: Identifying an Opportunity for Targeted Antimicrobial Stewardship

Abstract

Background. In the setting of a larger study to describe process and outcomes for patients with advanced pressure ulcers (APU) present on hospital admission, we sought to characterize antimicrobial utilization and infectious complications among this patient cohort. This data may inform the development of focused antimicrobial stewardship activities (ASP). Methods. A retrospective cohort study was conducted of all adult patients hospitalized in 2014 at Montefiore Health System (1 rehabilitation and 4 acute care facilities with >1400 licensed beds) with advance stage pressure ulcers (APU) (Stage III, IV, Unstageable and Suspected Deep Tissue Injury) on the trunk (back, buttocks, hips). Demographic, exposures, process and outcomes measures were extracted from internal clinical and administrative databases for all eligible patients. Results. A total of 1501 patients with APU were identified. Patients were older (median: 76 years; IQR: 64-86 years), and 56.83% were female. Patients had high comorbidity levels with a median combined Charlson Comorbidity Index Score of 7.00 and an IQR of 4.00. The most common primary admission diagnoses were altered mental status, fever or septicemia. Almost 90% of APU patients received antibiotics. Most received several antibiotic courses (median 5, range 1-83 courses) within 2014 of which the most commonly prescribed inpatient antibiotics were as follows: vancomycin (24%), ceftriaxone (20%), piperacillin/tazobactam (19%), ciprofloxacin (6%) and cefepime (4%). Infectious complications were common: 199 patients (14%) had bacteremia, where there were 60 patients (4%) with multidrug-resistant pathogens, and 10.9% (163/1501) had C. difficile. Although many APU patients received infectious diseases (31%) or wound care (30.4%) consultation the indication for antibiotics was difficult to determine (i.e. for wound versus other source). The cohort had an inhouse mortality rate of 10.3% and a 30-day readmission rate of 20.3%. Conclusion. This descriptive data suggest that APU patients consume extensive antimicrobials and have a high burden of adverse infectious complications. This population may therefore benefit from targeted ASP activities. Challenges may exist in crafting interventions for such a complex population.