Total duration of antimicrobial therapy resulting from inpatient hospitalization

Abstract

Objective:To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays.Design:Multicenter, retrospective cohort study.Setting:Two community hospitals and 1 academic medical center.Patients:Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent.Methods:We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization.Results:A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1–360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days.Conclusion:Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.

Total duration instead of in-hospital antibiotic days: reaching beyond the hospital walls

“…Electronic dispensing data from retail pharmacies is not readily retrievable by most hospital programmes. Electronic prescriptions from hospital clinicians, or 'e-scripts', can be accessed from electronic health records and used to calculate antibiotic days, although there may be incomplete uptake of electronic systems by prescribers [2]. In the current Veterans Affairs study, antibiotic days for patients discharged to long-term care or receiving outpatient parenteral antibiotic therapy were not measurable.…”

“…Our understanding of the size and impact of post-discharge antibiotic use is still emerging. Smaller descriptive studies suggested that up to 40% of antibiotic days attributed to an inpatient stay occurred post-discharge [1,2]. In this issue, Feller and colleagues validated these estimates in a large sample of 122 hospitals within the US Veterans Affairs Health System [3].…”

“…These default settings may or may not be rigorously reviewed or even under the control of a hospital using shared or 'standard' versions of electronic health records and medication information platforms. Further, prescribers may 'restart the clock' on antibiotics using electronic duration defaults rather than including inpatient antibiotic days in total duration calculations for an individual patient [2]. Simple adjustments in communication, clarifying documentation strategies, or verbal antibiotic 'time outs' or multidisciplinary 'huddles' before discharge may be other strategies to better define the antibiotic clock for handoffs between clinicians and in transitions from inpatient to post-discharge settings (Table 1).…”

Interventions to improve antibiotic prescribing at hospital discharge: A systematic review

“…Recent studies suggest that 30%-40% of antibiotic use associated with an inpatient stay occurs after discharge. [1][2][3] Studies evaluating the appropriateness of antibiotic prescribing at discharge have estimated that 50%-70% of antibiotic discharge prescriptions are inappropriate, and courses are often longer than necessary. [3][4][5] Discharge antibiotic prescribing is an important factor contributing to inappropriate antibiotic use, but it is unknown whether interventions targeting this stage of prescribing are effective.…”

Improving antibiotic use through antimicrobial stewardship interventions upon discharge

“…To the Editor-Employing antimicrobial stewardship principles at every phase of patient care is crucial. Although much of the antimicrobial stewardship literature is focused among inpatients, Dyer et al 1 have identified an important opportunity to measure and reduce antimicrobial exposure postdischarge. Excessive outpatient antibiotic therapy for treatment of pneumonia is associated with increased risk for adverse effects.…”