Antimicrobial Stewardship After Patient Discharge Is Lacking

The importance of antimicrobial stewardship is becoming more widely recognized and implemented across healthcare facilities. However, this cautious prescribing of antibiotics tends to end at discharge, despite this being when most antibiotics courses are completed.

One study, presented this week at the Making a Difference in Infectious Diseases (MAD-ID) 2022 Annual Meeting, noted that more than 50% of antimicrobials prescribed in outpatient settings may be unnecessary. There has not been sufficient research into antibiotic prescription patterns and outcomes after hospital discharge. Led by presenting author Ahmi Lim, PharmD, this study compared the outcomes of outpatient adults receiving community-acquired pneumonia (CAP) treatment.

The single-center, retrospective cohort study included adults (18 years and older) discharged with a CAP-related ICD-10 code between 2019 and 2021. The primary study objective was patient outcome, as defined by the Desirability Of Outcome Ranking (DOOR) system. Secondary outcomes of interest were duration of treatment after discharge, adverse event profile, 30-day readmission, and mortality.

Patients with emergency department discharges, COVID-19, cystic fibrosis, bronchiectasis, other structural lung disease diagnoses, or who were pregnancy or on comfort measures were all excluded. The investigators utilized multivariable logistic regression analysis to identify any associations with poor DOOR outcomes.

A total of 133 patients were included in the study, 83 of whom were discharged on antibiotics (62.4%). The average age of the cohort was 70 years, and 52% were male. Demographics were similar across study groups. According to the 2019 American Thoracic Society/Infectious Diseases Society of America guidelines, 93% of patients had non-severe CAP.

In the prior 90 days, 16% (n = 17) of patients had hospitalization and intravenous antibiotic use. Risk factors for multidrug-resistant pathogens were low, as no patients had a documented history of respiratory methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa infection within a year of their hospital admission.

Of the patients who received discharge antibiotics, 49% (n = 39) were deemed unnecessary, with 79% (n = 31) receiving longer courses, 13% (n = 5) with inappropriate doses, 5% (n = 2) with shorter courses, and 3% (n = 1) with inappropriate antibiotics.

A total of 12% (n = 16) of patients had poor DOOR outcomes, or 13% (n = 11) of the outpatients and 10% (n = 5) of the inpatients. The average duration of antibiotics after discharge was 3 days, and the most common antibiotics prescribed to the discharge patients were doxycycline (40%) and levofloxacin (39%).

There was not a significant difference between the DOOR outcomes of those who finished their antibiotics before discharge and those who continued an antibiotics course after discharge. However, almost 50% of CAP antibiotic discharge prescriptions were inappropriate, with the majority of these attributed to prolonged treatment duration.

The study investigators reemphasized the importance of continuing antimicrobial stewardship efforts in outpatient settings. They recommended future study on the effects of outpatient antibiotic usage on patient outcomes with a larger cohort. The investigators concluded by noting that sharing data with stakeholders and utilizing electronic medical records could improve antibiotic prescribing after discharge.

This study, “Discharge Antibiotic Use in Hospitalized Adults with Community-Acquired Pneumonia (CAP),” was accepted as an abstract for the Making a Difference in Infectious Diseases (MAD-ID) 2022 Annual Meeting.