The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study

Abstract

Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown. Methods This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015–September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship. Results There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003). Conclusions Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing.

Total duration of antimicrobial therapy resulting from inpatient hospitalization

“…Our data are consistent with those of Scarpato et al, 15 who noted a similar fluoroquinolone prescribing rate of 23.5% when evaluating discharge prescriptions from the Hospital of the University of Pennsylvania. Our fluoroquinolone prescribing rate was lower than the 40% rate described by Yogo et al 8 for discharge prescriptions filled within 7 days posthospitalization, lower than the 47%-49% rate of outpatient prescribing noted in a study of community acquired pneumonia by Yi et al, 24 and lower than the 30.5% rate cited by Vaughn et al 25 from patients diagnosed with urinary tract infection or community-acquired pneumonia in 48 hospitals in the Michigan Hospital Medicine Safety Consortium. 1,8,24,25 The inpatient stewardship programs at all 3 study hospitals were actively engaged in initiatives to decrease inpatient fluoroquinolone prescribing due to resistance of common pathogens to these agents and the increased risk Clostridioides difficile infections.…”

“…Our fluoroquinolone prescribing rate was lower than the 40% rate described by Yogo et al 8 for discharge prescriptions filled within 7 days posthospitalization, lower than the 47%-49% rate of outpatient prescribing noted in a study of community acquired pneumonia by Yi et al, 24 and lower than the 30.5% rate cited by Vaughn et al 25 from patients diagnosed with urinary tract infection or community-acquired pneumonia in 48 hospitals in the Michigan Hospital Medicine Safety Consortium. 1,8,24,25 The inpatient stewardship programs at all 3 study hospitals were actively engaged in initiatives to decrease inpatient fluoroquinolone prescribing due to resistance of common pathogens to these agents and the increased risk Clostridioides difficile infections. 26,27 Based on this growing body of literature incorporating postdischarge antibiotics, ASPs should focus on discharge processes as a key area to promote avoidance of fluoroquinolones and shorter, syndrome-based durations.…”

“…26,27 Based on this growing body of literature incorporating postdischarge antibiotics, ASPs should focus on discharge processes as a key area to promote avoidance of fluoroquinolones and shorter, syndrome-based durations. 25 Syndrome-focused antimicrobial stewardship has been identified as a strategy to better engage with clinicians. Institutionspecific syndromic guidelines and order sets, however, often focus on empiric therapy and do not address decisions after the time of antibiotic initiation.…”

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era

“…23 Although systematic changes to attract trainees to the field of ID and to antibiotic stewardship may help, this is a long-term solution. 24,25 Other options to help distribute ID expertise across hospitals include access to expertise through quality collaboratives 26 or "tele-stewardship" in which antibiotic use data are collected remotely and ID physicians are available via a stewardship "hotline." 27 The Infectious Diseases Society of America suggests telestewardship as a way to provide cost-effective subspecialty care to resource-limited populations.…”

Effects of Fluoroquinolone Restriction In the hospital on the Development Of sensitivity of Selected Bacterial Pathogens

“…Their effect aims both against gram-negative and some gram-positive bacteria. Though in infections they are not the drugs of first choice, they are well tolerated by patients, very popular with physicians, and widely employed throughout the world (Morales et al 2018, Vaughn et al 2019).…”