Hospital Discharge a Key Opportunity to Practice Antimicrobial Stewardship

Designing a transitions of care stewardship program and engaging all stakeholders can help cut down on unnecessary antibiotic prescriptions.

A successful transitions of care (TOC) antimicrobial stewardship program cuts down on inappropriate antibiotic prescribing by working across stakeholder groups, investing in education for all levels of care, developing a workflow plan, and tracking key metrics.

Nicholas Mercuro, PharmD, an infectious diseases pharmacist at Maine Medical Center, shared these steps to building a successful TOC stewardship program in a talk at the Making a Difference in Infectious Disease (MAD-ID) 2022 annual meeting, held May 18-21, 2022, in Orlando, Florida. He discussed his presentation in a video interview with Contagion®.

This transcript has been edited for clarity and length.

Contagion®: What is the general trend of antibiotic prescribing at hospital discharge currently?

Mercuro: The general trend of prescribing at hospital discharge, especially with things like community acquired pneumonia [and] urinary tract infections, is prolonged durations of therapy and excessive, unnecessary antibiotics. In particular, for things like asymptomatic bacteruia, estimates in the US between 40% to 70% have either an excess duration and/or unnecessary antibiotics. This can be problematic due to things like increasing Clostridioides difficile, multidrug-resistant infections and antibiotic-related adverse effects. All those increase with every additional day of antibiotic therapy.

Contagion®: In your talk, you discussed the key steps in implementing interventions. Can you summarize those?

Mercuro: The key steps of trying to implement an antimicrobial stewardship program…One is understanding the baseline data and what the benefits are of optimizing an antibiotic regimen at discharge [where] we know [they are given] exceedingly inappropriate[ly]. And then taking a look at your own institution and trying to find, what are your prescribing trends? And are there any specific populations that might benefit the most? So bringing that to the key stakeholders and other people who may be interested in stewardship, getting them on your team, going to all those individual units, getting prescribers, nurses together, informatics to try to build and design this intervention where perhaps you could have a clinical pharmacist intervening at time of discharge.

It's going to be different in all different hospital settings naturally, as you have a variety of resources, maybe different electronic health records, or a different number of stewardship pharmacists or resources or clinicians. And then once you're able to implement that intervention, you want to study it and do quality improvement, spend some metrics on it, the stakeholders are going to be very interested in how successful that intervention may be, and how to further optimize it.

Contagion®: What challenges stand in the way of successful stewardship transitions of care programs?

Mercuro: Some of the biggest challenges of implementing a transitions of care program is going to be to get everybody on the same page who's going to be involved in the intervention, as transitions of care can be complex and intricate, and to have everybody kind of on board and able to put resources forward, especially when resources are very limited. You need to kind of take that pitch, bring it to leaders in the health system, in the C-suite, in all the different departments to bring them together. The widespread education takes a lot of time, so you want to start small, think about the areas [where] you're going to benefit the most to kind of be a model for the rest of the departments and the rest of the floors.

Contagion®: What is the key takeaway here for ID clinicians?

Mercuro: I think some of the key takeaways is that it's very important to understand your own institution so that you can customize these interventions to the resources that you have. Not all of them are going to be the same. You want to leverage electronic health records and interventions where they can be low-hanging fruit wins but, at the same time, be very targeted in your approach [so] you're going to have high success in the population at hand.