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Review of antibiotic prescriptions at discharge improves stewardship
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Antibiotic prescribing at a small Veterans Affairs hospital improved following the implementation of antibiotic review at discharge, according to study findings.
“Historically, antimicrobial stewardship has focused on inpatient and long-term care prescribing,” Susanne Barnett, PharmD, BCPS, associate professor of pharmacy at the University of Wisconsin-Madison School of Pharmacy, told Healio. “Our study demonstrated that review of antibiotic prescriptions at the point of discharge can improve prescribing and can be an impactful stewardship tool.”
Infectious Disease News Editorial Board Member Gitanjali Pai, MD, AAHIVS, an infectious diseases specialist at Memorial Hospital in Stilwell, Oklahoma, said discharge stewardship is an “often-missed opportunity.”
“This VA study by Barnett [and colleagues] is a great example of a model of a discharge antibiotic stewardship program,” Pai, who was not involved in the study, told Healio. “As the first study published describing antibiotic discharge prescription recommendations — this study throws light on the impact of antibiotic intervention in this setting, as well as some of the common scenarios warranting intervention or modification.”
Between June 2017 and December 2018, pharmacy technicians at a Midwestern VA hospital retrospectively reviewed pharmacist discharge medication reconciliation notes twice a week to identify patients who were discharged with oral antibiotics.
“I think the two main challenges to performing discharge stewardship are real-time identification of patients who are being discharged on antibiotics and having enough resources to perform timely review and intervention,” Cynthia T. Nguyen, PharmD, an infectious disease pharmacist at UChicago Medicine, told Healio.
Over the course of the study period, the twice-weekly reviews identified 929 patients discharged on oral antibiotics. Barnett and colleagues reported that changes were recommended for 9.7% of prescriptions, with 43% of the antimicrobial stewardship team’s (AST) interventions occurring because antibiotics were not indicated. Almost a quarter — 24% — of interventions occurred because there was an incorrect duration of therapy, and 23% because the AST believed an alternative drug could have been chosen.
“However, since reviews occurred only twice a week, over half of the interventions were unable to be acted upon because the antibiotic course was already complete at the time of review,” Nguyen, who was not involved in the study, noted.
According to Thomas L. Walsh, MD, medical director of the antimicrobial stewardship program (ASP) for the Allegheny Health Network, inpatient settings are where ASPs tend to focus much of their attention. But the outpatient setting is where a “majority of antibiotic prescribing occurs,” Nguyen said.
“It is imperative to ensure appropriateness of antimicrobial therapy at the time of discharge,” Walsh, who was not involved in the study, told Healio. “Unfortunately, a paucity of data exists regarding optimal stewardship processes during the transition from the inpatient setting to the outpatient arena.”
He said the study adds to the literature on this topic, highlighting the impact ASPs can have on antimicrobial prescribing.
“Routine assessment of antimicrobials prescribed at hospital discharge has the potential to directly impact patient care and outcomes by ensuring the appropriate antibiotic is prescribed, and for the appropriate duration,” Barnett said.
Antibiotic review upon discharge is beneficial and necessary to improve patient care, but it comes with challenges, experts agreed.
“Our team — Drs. Balasubramanian, Lata, Crnich, and Kavalier — uncovered barriers unique to discharged patients, such as [the] ability to reach a patient post-discharge, challenges associated with a patient acquiring a new prescription and the additional cost, as well as patient understanding of regimen changes,” Barnett said. “Additional challenges associated with implementing this stewardship initiative include communication of the service to inpatient prescribers and outpatient primary care providers, additional staffing required for rounding, and working through institutional-level processes to identify patients discharged on oral antibiotics.”
Nguyen said time, resources, personnel expertise and availability represent challenges to ASP interventions. Pai suggested “provider comfort level” may be a barrier.
Walsh called for more research into the topic, specifically descriptions of successful ASP strategies deployed at discharge.
“Data on successful approaches deployed by a variety of ASPs [are] much needed,” he said. “As different hospitals experience unique barriers given staffing and workflow limitations for many ASPs, innovative models for reviewing discharge prescriptions in a timely manner are a welcome addition to the existing literature.” – by Marley Ghizzone
Reference:
Barnett SG, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.332.
Disclosures: Barnett and Nguyen report no relevant financial disclosures. Pai reports serving on the advisory boards of AbbVie and Gilead Sciences. Walsh reports receiving consulting fees from Accelerate Diagnostics.