Background: Antibiotics are frequently prescribed—and overprescribed—at hospital discharge, leading to adverse-events and patient harm. Antibiotic overuse at discharge varies widely across hospitals, with rates of overuse differing up to 5-fold.(1) Our understanding of what approaches optimize prescribing at discharge is limited. Recently, we published the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework which identifies potential strategies to improve antibiotic prescribing at discharge across three tiers: Tier 1—Critical infrastructure, Tier 2—Broad inpatient interventions, Tier 3—Discharge-specific strategies.(2) Here, we use the ROAD Home framework to assess the association of various antibiotic stewardship strategies with antibiotic overuse at discharge and to describe pathways to improved discharge antibiotic use.
Methods: In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies as described by the ROAD Home Framework. For patients hospitalized at participating hospitals between 7/1/2017 to 7/30/2019 and treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI), we assessed the association of reported strategies with days of antibiotic overuse at discharge. Days of antibiotic overuse at discharge were defined based on national guidelines and included unnecessary antibiotic therapy, excess antibiotic duration, and suboptimal fluoroquinolone use. We evaluated the association of stewardship strategies with days of discharge antibiotic overuse two ways: a) all stewardship strategies assumed to have equal weight, b) strategies weighted based on the ROAD Home Framework with Tier 3 (Discharge-specific) strategies weighted highest.
Results: 39 hospitals with 20,444 patients (56.5% CAP; 43.5% UTI) were included. Survey response rate was 100% (39/39). Hospitals reported a median (IQR) 12 (9-14) of 33 possible stewardship strategies (Table 1). On bivariable analyses, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (aIRR 0.543, 95% CI: 0.335-0.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: 0.927-0.987, per weighted intervention) with discharge-specific stewardship strategies associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Based on these findings, three pathways to improved antibiotic use at discharge were elucidated (described in Figure 1): a) inpatient-focused, b) “doing it all”, and c) discharge-focused.
Conclusions: The more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, different pathways to improve discharge antibiotic use exist. Thus, discharge stewardship strategies should be tailored to existing resources and needs at individual hospitals. Specifically, hospitals with limited stewardship resources and infrastructure should consider implementing a discharge-specific strategy straightaway. In contrast, hospitals that already have substantial inpatient infrastructure may most benefit from proactively incorporating discharge into their existing strategies (rather than creating new interventions).