BackgroundAntimicrobial stewardship (AMS) interventions largely target inpatient antimicrobial prescribing. Literature on appropriateness of antimicrobials prescribed at the interface between hospital and the community is minimal. This study was designed to assess the appropriateness of antimicrobials prescribed on hospital discharge and evaluate the impact of AMS interventions.MethodsPatients with discharge medications processed by the pharmacy were identified using a computerized pharmacy medication tracker over a four week period. The antimicrobials prescribed on discharge were assessed independently for appropriateness of antimicrobial choice, dose, frequency and duration. Data on various AMS interventions was collected. Univariate followed by multivariate logistic regression (MVLR) analysis was performed using SPSS V 23 (IBM, California).ResultsA total of 892 discharge prescriptions were processed by the pharmacy department, 236 of which contained antibiotic prescriptions. Of these, 74% were appropriate for antimicrobial choice, 64% for dose, 64% for frequency and 21% for duration. In particular, 71% of patients received a course in excess of Therapeutic Guidelines-Australia(TG-A) recommended length of treatment. On univariate analysis, discharge antimicrobial prescriptions were more likely to be appropriate for antimicrobial choice, frequency and duration; appropriate microbiological specimens were more likely to be taken and targeted therapy more likely to be given when the AMS team was involved. On MVLR, appropriateness with antimicrobial dosing frequency [OR 5.6(1.9–19.2)], microbiological specimens [OR 4.3(1.6–11.6)] and receipt of targeted therapy [OR 2.8(1.8–6.2)] with AMS involvement remained significant.ConclusionsA large discrepancy exists between antimicrobial regimens prescribed on hospital discharge and those recommended in consensus guidelines, particularly concerning duration of treatment. While AMS interventions are well established for improving antimicrobial prescribing in hospital inpatients, the hospital-community interface remains a challenge in terms of antimicrobial prescribing and exposes patients to potential harm. There is a clear need for AMS interventions to extend to antimicrobial therapy prescribed on discharge.

The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.

There has been a progressive rise in the incidence of blood stream infections (BSI) caused by multidrug-resistant Gram-negative organisms (MDR GN), which cause increased morbidity and mortality. For this reason, recent studies have focused on risk factors of acquisition of carbapenemase-producing Enterobacteriaceae and extended-spectrum beta-lactamase producers. However, there is limited data on risk factors for BSI caused by AmpC-producing Enterobacteriaceae (AmpC EC), especially in low prevalence settings such as Australia. This study was performed to identify risk factors for acquisition of AmpC E. coli, using a retrospective matched case control design over a 3-year period. Patients with BSI caused by AmpC E. coli were matched with controls (third generation cephalosporin susceptible E. coli) by age and site of infection (n = 21). There was no significant difference in age, sex, clinical outcome, time to onset of BSI, recent antibiotic use (last 3 months), comorbidities (type 2 diabetes mellitus, renal failure) intensive care unit admission, underlying hematological condition, immunosuppressant use, APACHE II score, or any recent urological procedures (within last 3 months) between the two groups. On univariate analysis, the AmpC E. coli group were more likely to have had a surgical procedure in hospital and lived in a residential aged care facility. On multivariate logistic regression analysis, a recent surgical procedure was associated with the onset of AmpC E. coli BSI (Odd’s Ratio (OR) 4.78, p = 0.034). We concluded that in a relatively low prevalence setting such as Australia, AmpC E. coli BSI is potentially associated with surgery performed in hospital due to previous antibiotic exposure and longer hospitalization.

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