Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

Mercuro, Nicholas J; Medler, Corey; Kenney, Rachel M.; MacDonald, Nancy; Neuhauser, Melinda M.; Hicks, Lauri A.; Srinivasan, Arjun; Divine, George; Beaulac, Amy; Eriksson, Erin; Kendall, Ronald; Martínez, M. Sarmiento; Weinmann, Allison; Zervos, Marcus J.; Davis, Susan L.

doi:10.1001/jamanetworkopen.2022.11331

Cited by 17 publications

(18 citation statements)

References 23 publications

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“…17 Another pharmacist-driven transition of care model implemented in multiple facility types was also associated with improved antibiotic prescribing at discharge. 19 Resources developed for this pharmacist-driven intervention can be modified to optimize practice models and workflow at discharge in different community and academic hospital settings. 20 Most stewardship programs rely on manual assessments of appropriateness to define and target specific conditions for improvement.…”

Section: Discussionmentioning

confidence: 99%

Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013–2020

McCarthy,

Baggs,

Wolford

et al. 2024

Infect. Control Hosp. Epidemiol.

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Objective: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020. Methods: We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2–10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT. Results: There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18–64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18–64 years and by 27% (68%–50%) among patients aged ≥65 years. Conclusions: Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections.

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Section: Discussionmentioning

confidence: 99%

Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013–2020

McCarthy,

Baggs,

Wolford

et al. 2024

Infect. Control Hosp. Epidemiol.

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“…In addition, pharmacists are often involved in converting medications from parenteral into oral therapy in hospitalized patients, and may be able to increase the use of oral agents for ESBL-E bacteremias. A recent study evaluated the impact of a pharmacistdriven intervention to improve oral antibiotic selection and duration for common infections at hospital discharge [38]. Results demonstrated an increase in guideline-concordant prescriptions from 36% to 81.5% (p < 0.001) following the intervention.…”

Section: Discussionmentioning

confidence: 99%

Risk Factors for Bloodstream Infections Due to ESBL-Producing Escherichia coli, Klebsiella spp., and Proteus mirabilis

et al. 2023

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(1) Background: Risk factors for extended-spectrum beta-lactamase (ESBL) infections could vary geographically. The purpose of this study was to identify local risk factors for ESBL production in patients with Gram-negative bacteremia. (2) Methods: This retrospective observational study included adult patients admitted from January 2019 to July 2021 and had positive blood cultures for E. coli, K. pneumoniae, K. oxytoca, and P. mirabilis. Patients with ESBL infection were matched to a non-ESBL-producing infection with the same organism. (3) Results: A total of 150 patients were included: 50 in the ESBL group and 100 in the non-ESBL group. Patients in the ESBL group had a longer length of stay (11 vs. 7 days, p < 0.001), but not increased mortality (14% vs. 15%, p = 0.87) Multivariate analysis identified the receipt of >1 antibiotic in the last 90 days as a risk factor for ESBL infection (OR = 3.448, 95% CI = 1.494–7.957; p = 0.004); (4) Conclusions: Recent antimicrobial use was identified as an independent risk factors for ESBL-producing Enterobacterales infections. Knowledge of this risk may improve empirical therapy and reduce inappropriate use.

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“…13 A limited number of studies have shown the impact of discharge antibiotic prescriptions stewardship by specialty-trained pharmacists. 8,[14][15][16][17] In a retrospective descriptive study of 1,100 adult patients at high risk for readmission and mortality, TOC pharmacists intervened in 298 discharge antimicrobial medications. 14 Common intervention types were dosing (30%) and treatment duration (25%), most of which were accepted by the discharging prescribers.…”

Section: Discussionmentioning

confidence: 99%

“…In a multicenter, quality improvement study of 800 patients, utilizing pharmacists to proactively identify soon to be discharged patients and to create optimal oral discharge prescriptions for final approval provided effective TOC at hospital discharge. 17 However, this practice model requires multiple clinical pharmacists who are already integrated within the medical teams.…”

Section: Discussionmentioning

confidence: 99%

Impact of a pharmacy department–wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge

Halcomb

Johnson

2022

ASHE

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Objective: To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Design: Single-center before-and-after study. Setting: Acute-care, academic, community hospital in Santa Barbara, California. Patients: Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Intervention: Antimicrobial stewardship–initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. Results: In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. Conclusions: A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

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Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

Cited by 17 publications

References 23 publications

Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013–2020

Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013–2020

Risk Factors for Bloodstream Infections Due to ESBL-Producing Escherichia coli, Klebsiella spp., and Proteus mirabilis

Impact of a pharmacy department–wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge

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