Impact of Inpatient Pharmacist Review of Discharge Antibiotics

A food for thought as an ambulatory antibiotic stewardship initiative.

According to the Centers for Disease Control and Prevention (CDC), about a third of all antibiotics prescribed in hospitals are unwarranted or suboptimal.1 The infectious diseases most associated with inappropriate antibiotic prescribing are: community-acquired pneumonia (CAP), skin and soft-tissue infection (SSTI), and urinary tract infection (UTI).2

Interestingly, most of the antibiotics started in the hospitals are completed after hospital discharge.4-7 Therefore, an effective antibiotic stewardship intervention would be to review and optimize discharge antibiotic prescriptions at the point of hospital discharge.

Halcomb and colleagues conducted a single-center, quasi-experimental study at a community-based hospital to evaluate the impact of implementing a department-wide transitions-of-care (TOC) policy on the rate of appropriate discharge antibiotic prescriptions.3 The TOC policy required inpatient pharmacists to conduct real-time review of oral discharge antibiotics that are to be dispensed by the hospital-operated outpatient pharmacy. The antimicrobial stewardship pharmacist provided education to all inpatient pharmacists on the new policy. The inpatient pharmacists directly contacted the prescribers to make interventions or to obtain clarifications when needed.

The study included adult patients who were discharged with oral antibiotics for the indications of CAP, SSTI, and UTI. Some of the reasons for exclusion included admission in the emergency department only, diagnosis with deep-seated infections (e.g., osteomyelitis, endocarditis), and treatment with chronic immunosuppressive therapy.

The primary outcome was the rate of inappropriate antibiotic prescriptions, which was compared between pre- (September 16, 2019 – December 16, 2019) and post-implementation (March 1, 2021 – May 31, 2021) phases. The appropriateness of prescriptions was based four areas: antibiotic dose, treatment duration, antibiotic choice, and need for antibiotic at discharge. Details on each area can be found in the article.3

A total of 260 prescriptions (pre- vs. post-implementation, 140 vs. 120 prescriptions) were included in the final analysis. Baseline characteristics were similar between the two groups except for mean age (pre- vs. post-implementation, 66 vs. 60 years; P<0.001).

The rate of inappropriate antibiotic prescribing decreased significantly in the post-implementation phase (52% vs. 34%; P = 0.005) with numerical decrease in inappropriate prescriptions in each category of dosage, treatment duration (except in CAP), antibiotic selection, and need for continued antibiotics after discharge (Table).

Summary of Inappropriate Prescribing Patterns and Antibiotic Days of Therapy

The rates of inappropriate antibiotic dose (pre- vs. post-implementation, 15% vs. 2%; P<0.001) and treatment duration for SSTI (57% vs. 15%; P<0.001) were significantly lower in the post-implementation phase (Table). The median total antibiotic days was shorter in the post-implementation phase by one day (Table). Notably, about 60% of antibiotic exposure occurred after hospital discharge. There was no difference in the 30-day readmission rates between the two groups.

This retrospective study has several limitations, such as its single-centered nature, seasonally mismatched pre- and post-implementation phases, and inconsistencies in pharmacist intervention documentations due to staffing shortages during the post-implementation phase. However, its findings support feasibility of implementing a department-wide TOC policy to require inpatient pharmacist review of discharge antibiotic prescriptions. Additionally, the policy led to a significant decrease in the rate of inappropriate discharge antibiotic prescriptions.

The integration of non-stewardship pharmacists into the day-to-day antibiotic stewardship workflow is notable and may be up for consideration by stewardship programs that lack resources to review discharge antibiotic prescriptions.8,9


  1. The core elements of hospital antibiotic stewardship programs, 2019. Centers for Disease Control and Prevention. Published in 2019. Accessed February 5, 2023.
  2. Barnett SG, Lata P, Kavalier M, Crnich C, Balasubramanian P. Antibiotic assessment at hospital discharge-Room for stewardship intervention. Infect Control Hosp Epidemiol. 2020;41(2):209-211. doi:10.1017/ice.2019.332
  3. Halcomb SM, Johnson A, Kang-Birken SL. Impact of a pharmacy department–wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge. ASHE. 2022;2(1):e185.
  4. Yogo N, Haas MK, Knepper BC, Burman WJ, Mehler PS, Jenkins TC. Antibiotic prescribing at the transition from hospitalization to discharge: a target for antibiotic stewardship. Infect Control Hosp Epidemiol. 2015; 36:474–478. doi:10.1017/ice.2014.85
  5. Feller J, Lund BC, Perencevich EN, et al. Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network. Clin Microbiol Infect. 2020;26:327–332. doi:10.1016/j.cmi.2019.09.016
  6. Vaughn VM, Gandhi TN, Chopra V, et al. Antibiotic overuse after hospital discharge: a multihospital cohort study. Clin Infect Dis. 2021;73: e4499–e4506. doi:10.1093/cid/ciaa1372
  7. Conner M, Harris W, Bomkamp J. ADD it up: an evaluation of antibiotic duration at hospital discharge at a community hospital. Open Forum Infect Dis. 2021;8:ofab399.doi:10.1093/ofid/ofab399
  8. Parsels KA, Kufel WD, Burgess J, et al. Hospital discharge: an opportune time for antimicrobial stewardship. Ann Pharmacother. 2022;56: 869–877. doi:10.1177/10600280211052677
  9. Barnett SG, Lata P, Kavalier M, Crnich C, Balasubramanian P. Antibiotic assessment at hospital discharge—room for stewardship intervention. Infect Control Hosp Epidemiol. 2020;41:209–211. doi:10.1017/ice.2019.332
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