Medicare patients present for readmission for C. difficile in 13% of cases, but outpatient monotherapy may curb readmission rates.
When Medicare Part A and D patients are discharged from the hospital after a diagnosis of Clostridium difficile (C. difficile), a significant age are readmitted within 90 days with the infection, according to a new report.
Investigators from the University of Massachusetts Medical School sampled 5% of Medicare beneficiary claims in order to collect the unique data from continuations of metronidazole, vancomycin, or treatment with both and the rates of readmission in the elderly population. The study examined data from January 1, 2009, to December 31, 2011. The patient files provided information on demographic data, inpatient claims, procedures, length of stay, intensive care unit stay, and discharge disposition.
“Our findings suggest patients well enough to be discharged without any CDI-directed therapy may benefit from outpatient monotherapy to reduce readmission due to recurrence, or failure to eradicate,” study authors Charles Psoinos, MD, MS, and Henna Santry (pictured), MD, told MD Magazine. “Additionally, patients who require ongoing treatment with both vancomycin and metronidazole at the time of hospital discharge have particularly high odds of re-admission. Therefore, this subgroup of patients with severe disease may benefit from extended in-patient dual therapy until they are well enough to require only monotherapy with metronidazole.”
The study authors noted that current C. difficile literature is inconsistent in suggesting the best treatments, though agreed that metronidazole 500 mg orally 3 times daily is best for mild to moderate infections. For more severe or complicated infections, the literature suggests vancomycin 125 mg or 500 mg orally every 6 hours with or without concurrent metronidazole.
Of the study populations, 1% were admitted to the hospital with a primary or secondary diagnosis of C. difficile infection, the researchers reported. Of those, 8.8% died during hospitalization, while 10% of those discharged alive were sent to hospice or another acute hospital. The remaining 7042 patients continued to be studied.
Of that group, 13% were readmitted with a primary diagnosis of C. difficile infection within 90 days, the researchers learned. About one-third of patients were not readmitted for any reason within 90 days, and the rest were readmitted with a primary diagnosis that was not C. difficile. The researchers then compared the patients readmitted with C. difficile to those who were not readmitted for any reason (total patient population of 2898).
Among that group, 38% were discharged on no therapy, while 12% were discharged on a vancomycin-only regimen. Another 39% were released on metronidazole only, while the final 10% were discharged on dual therapy.
Despite the “no treatment” patients being statistically older, all patients were about 80 years old. There was no difference in race, and between 36% and 48% of patients were discharged on an antibiotic not intended to treat C. difficile infection.
The patients discharged with no therapy experienced the longest length of stay - about 9 days - compared to the other treatment groups (5 and 6 days). In further analysis accounting for age, gender, discharge therapies, discharge on other antibiotics, index hospitalization length of stay, emergency index admission, and primary C. difficile diagnosis during hospitalization, the monotherapy patients (only vancomycin or only metronidazole) had reduced odds of 90-day readmission compared to the no therapy patients. The dual-therapy patient readmission rates were similar to the no therapy patients.
The authors noted that further studies are needed to determine and define this relationship. The study was published in the World Journal of Surgery. The findings were also presented as a podium presentation at the American Association for the Surgery of Trauma Annual Meeting in Las Vegas in September.