Inappropriate antibiotics prescribed on hospital discharge

NEW ORLEANS — Recent findings presented at ID Week 2016 revealed most antibiotics prescribed on hospital discharge are inappropriate despite strong inpatient antibiotic stewardship programs (ASPs).

“Transitions of care are vulnerable times for patients,” Sarah Scarpato, MD, from the internal medicine department at Hospital of the University of Pennsylvania. “Nearly one-quarter of patients suffer an adverse event from an error in transition of care during hospital discharge. Up to half of patients who suffer an adverse drug reaction at discharge are prescribed an antibiotic.”

Scarpato and colleagues evaluated the rate of inappropriate antimicrobial prescribing at hospital discharge. They conducted a descriptive study of patients prescribed an antimicrobial at discharge from January to December 2014 at an academic quaternary care hospital. They then examined the correctness of antimicrobial agents prescribed on discharge for a sample of 150 randomly selected patients.

They found 9,750 antibiotic prescriptions were written for patients upon hospital discharge: 86% for oral antibiotics and 14% for outpatient antibiotic therapy. Readmission rates for patients discharged on antibiotics were 6.4% at 7 days and 19.4% at 30 days compared with hospital-wide readmission rates of 3.70% and 13.79%. Patients discharged on outpatient antibiotic therapy had a 7-day readmission rate of 5.6% and a 30-day readmission rate of 16.4%. Those discharged on oral antibiotics had readmission rates of 6.5% at 7 days and 19.9% at 30 days.

Results also showed 22% of patients discharged with antibiotics had no clinical indication of infection, 13% had an antibiotic with inappropriate spectrum of activity, 17% received the incorrect dose, 55% received an antibiotic course that was too long, and 7.3% received a course that was too short.

“Antibiotic prescription in the absence of an acceptable indication and inappropriate duration accounted for the vast majority, 76%, of inappropriate prescriptions,” Scarpato said. “Clinicians may have prescribed antibiotics for an inappropriate duration because they did not account for antibiotics given as an inpatient, they were unfamiliar with the patients’ course due to handoffs, they wrote the prescription with a given duration expecting discharge on a different day or they may just not have been familiar with the recommended durations.”

Scarpato said that at her institution, patients that are discharged on parenteral antibiotic therapy are followed by infectious disease physicians and pharmacists, which may account for the lower readmission rates in this population. Patients prescribed oral antibiotics are not monitored, and the higher readmission rates in this population may be a consequence of switching from parenteral to oral antibiotics.

“This study is obviously limited by its retrospective and descriptive nature,” she concluded. “Furthermore, it’s a single center study and it may not be representative of all institutions. Other programs may see higher rates of error or a different distribution of error. However, we believe that it demonstrates a significant and unmet need for antimicrobial stewardship at transitions in care even in institutions such as ours that have a robust inpatient antimicrobial stewardship program.” – by Savannah Demko

Reference:

Scarpato S, et al. Abstract 77. Presented at: IDWeek; October 25-30, 2016; New Orleans.

Disclosure: The researchers report no relevant financial disclosures.