By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
Dr. Deresinski reports no financial relationships relevant to this field of study.
SYNOPSIS: Seventy percent of discharge antibiotic prescriptions are inappropriate.
SOURCE: Scarpato SJ, Timko DR, Cluzet VC, et al; CDC Prevention Epicenters Program. An evaluation of antibiotic prescribing practices upon hospital discharge. Infect Control Hosp Epidemiol 2016 Nov 28:1-3. [Epub ahead of print] PubMed PMID: 27890038.
Scarpato et al retrospectively examined the appropriateness of antibiotics prescribed at discharge from their large, quaternary care, urban teaching hospital that offers a robust antimicrobial stewardship program. During 2014, 7,313 patients received 9,750 discharge antibiotic prescriptions, 86% for oral administration and the remainder to be given parenterally.
Both seven-day and 30-day readmission rates were higher in those with a discharge antibiotic prescription than in the general discharge population: 6.4% and 19.4% vs. 3.7% and 13.8%, respectively. Those patients discharged on a parenteral (intravenous or intramuscular) antibiotic experienced readmission rates that were similar to those of patients prescribed oral antibiotics.
An analysis of a randomly selected subset found that as inpatients, a median of 3.5 days (IQ range, 2-5 days) of antibiotics was received, followed by eight days (IQ range, 6-14 days) as outpatients. Seventy percent of prescribed outpatient antibiotics were judged to be inappropriate regarding choice, dose, or duration, and this was true for 87.7% of surgical patients and 57.6% of medical patients. Thus, among those with a documented infection, the prescribed antibiotic was either too broad spectrum or considered to be insufficiently broad spectrum in 13.7%, and 17% of this group received an incorrect dose. The duration of prescribed administration was too short in 7.3% but was excessive in 55%, and the mean duration of unnecessary antibiotic administration was 3.8 days.
My colleague, Marisa Holubar, recently developed a new clinical pathway for management of community-acquired pneumonia at Stanford, and as part of the process, examined the baseline duration of antibiotic treatment, which was, as we expected, longer than recommended in national guidelines. A large portion of that excessive duration resulted from the length of continued antibiotics prescribed at discharge. Although we did not investigate it, our assumption was that a major reason was a lack of taking into consideration the days of therapy received before discharge. Thus, the person writing the discharge prescription may be aware that at least five days are currently recommended and proceed to write a prescription for this duration despite the fact that the patient already had received a prescription, e.g., four days of antibiotic therapy as an inpatient. As suggested by Scarpato et al, additional reasons may be lack of knowledge of recommended durations, lack of familiarity with the patient as a result of “hand-offs,” and a delay in discharge beyond the anticipated date at the time the prescription was written.
The number of days of unnecessary antibiotic administration has some direct cost consequence, but the more important undesirable effects include increased risk of complications, such as allergic reactions and the development of Clostridium difficile infection, as well as the selective pressure exerted on the bacterial ecology with resultant antibiotic resistance.
The problem of inappropriate discharge antibiotic prescribing clearly is one that requires attention and intervention. At the institution where this study was performed, all patients discharged to receive outpatient parenteral antibiotic therapy are followed by a team of infectious disease specialists and pharmacists, but this does not apply to those receiving orally administered antibiotics in the outpatient setting. Interventions suggested by Scarpato et al include medication reconciliation at the time of discharge, prescriber education, and prospective audit and feedback. All will require further engagement for antimicrobial stewardship.