A study conducted at Michigan hospitals highlights the role pharmacists can play in improving antimicrobial prescribing during care transitions.
The study, published this week in JAMA network opened, found that a pharmacist-led, multidisciplinary review of discharge planning for patients leaving the hospital with an antimicrobial prescription for an uncomplicated infection was associated with markedly improved antimicrobial prescribing. There was also a reduction in the harm associated with antimicrobials following the implementation of the program.
The study authors say the findings also highlight transitions of care — the movement of patients from one healthcare facility to another — as an important and overlooked focus of antimicrobial stewardship in hospitals.
“The findings of this quality improvement study suggest that using resources to provide additional assessment and intervention to antimicrobial discharge therapies may lead to improvements in the quality and safety of antimicrobial prescriptions,” they wrote.
Overuse of antibiotics at discharge
The quality improvement study, conducted at five hospitals at the Henry Ford Health System in southeastern Michigan from September 2018 to August 2019, evaluated a program aimed at facilitating the optimal prescribing of oral antimicrobials at discharge using a existing pharmacy practice model for care transitions with local guidelines for antibiotic use and duration.
In the intervention, which was carried out in 17 different departments of the five hospitals, clinical pharmacists worked with primary care teams to identify patients who needed to be discharged with an antimicrobial prescription, to determine who would be eligible to complete the antimicrobial course with oral therapy. after discharge and make other recommendations to optimize therapy. The methods differed somewhat between academic medical center and community hospitals.
While few antimicrobial stewardship interventions target the discharge process, previous studies indicate this is a concern. In a 2020 study conducted at 46 Michigan hospitals, of more than 21,000 patients treated for pneumonia or urinary tract infections, nearly half (49.1%) had antibiotic overuse at discharge, defined as either unnecessary antibiotic use, prolonged expensive or suboptimal use of fluoroquinolones. The main conclusion of that study was that overuse of antibiotics after discharge is a common problem influenced by prescribing culture and physician behavior and should be addressed through antimicrobial stewardship programs.
To evaluate the effectiveness of the intervention in the new study, Henry Ford Health System researchers, in collaboration with the Centers for Disease Control and Prevention, analyzed adult patients in the five hospitals who had urinary tract, respiratory tract, skin and other soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge.
The primary endpoint was the frequency of optimized antimicrobial prescriptions at discharge. Health system guidelines were used to evaluate optimal therapy.
Five times higher degree of optimal prescribing
Of the 800 patients prescribed antimicrobials at discharge (400 pre-intervention, 400 post-intervention), the most common diagnoses were pneumonia (33%), upper respiratory tract infection and/or acute exacerbation of chronic obstructive pulmonary disease (26.8% ), and urinary tract infection (25.4%). Patients in the post-intervention group were more than five times more likely to receive an optimal antimicrobial prescription than those in the pre-intervention group (time-adjusted generalized estimation equation odds ratio, 5.63; 95% confidence interval [CI]3.69 to 8.60).
The increase in optimized prescribing at discharge in the post-intervention period was seen in both academic (37.4% absolute increase; 95% CI, 27.5% to 46.7%) and community hospital (43.2%; 95 %CI, 32.4% to 52.8). %) settings. Reduction in prolonged treatment duration (44.2% pre-intervention vs 37 9.2% post-intervention; mean difference, −35.0%), non-guideline concordant antimicrobial selection (20.2% vs. 6.0%; mean difference, −14.3%) and treatment of asymptomatic bacteriuria (9.2% vs. 2.5%; mean difference, −6.8%) were the major contributing components of prescribing improved discharge procedures.
“By using pharmacists to strengthen institutional protocols, we were able to successfully address and modify the following areas of antimicrobial optimization: minimization of unnecessary antimicrobial days of prolonged duration and patients without infections; avoidance of therapies that are too broad.” not in accordance with local guidelines, or targeting pathogens not susceptible to the antimicrobial agent, and transitioning from intravenous agents to accessible and affordable oral options as soon as possible,” the authors wrote.
There were no differences in unadjusted analyzes for clinical resolution, readmission after 30 days, or mortality. Less serious antimicrobial adverse events were identified in the post-intervention period (3.2%) compared to the pre-intervention period (9%) (time-adjusted generalized estimation equation odds ratio, 0.40; 95% CI, 0.18 to 0.88 ).
The authors say the findings highlight the critical role pharmacists play in optimizing antimicrobial prescribing at discharge.
“The synergistic relationships between prescriber and pharmacist in antimicrobial stewardship programs facilitate better care and services,” they wrote.