The Great Debate: To Extend or Not Extend?

Antibiotics are commonly administered to patients hospitalized in the United States, and lower respiratory tract infections (eg, community-acquired pneumonia [CAP]) are among the most common reasons for hospitalized patients in the United States to receive antibiotics.¹ Approximately two-thirds of patients who are hospitalized for CAP receive antibiotic therapy beyond the recommended duration, which is predominately due to an excess of therapy upon discharge.²

Patients residing in rural areas are more likely to experience suboptimal antibiotic prescribing.³ It remains unclear whether a patient’s home location and access to follow-up care affect prescribing practices upon hospital discharge.

A recent study published in Open Forum Infectious Diseases examined antibiotic prescribing decisions for CAP based on 2 factors: rurality and postdischarge follow-up.⁴ Hospitalists at a large academic medical center in a midsized Midwestern US city were surveyed in November 2019.⁴ The survey, developed using Qualtrics XM and experiential survey methodology, randomly assigned hospitalists to view one of 2 clinical vignettes: a patient with CAP living in a rural area or one living in a local urban/suburban area.⁴ The study aimed to determine whether clinicians prescribed longer antibiotic courses at discharge to patients from rural areas compared with local urban/suburban locations.⁴ The vignette included a hospitalized patient with CAP who was admitted for 3 days. On day 3, the patient had an elevated white blood cell count, productive cough, heart rate of 90 to 110 beats per minute, and oxygen saturation of 90% with slight exertion.⁴ According to 2007 CAP guidelines, the patient showed clinical improvement and met clinical stability criteria, and they requested to be discharged.^4,5 The scenario was intended to mimic real-life decision-making.⁴ The ambiguity was to assess whether the patient’s access to care or discharge location made an impact on the clinician’s discharge plan decision.⁴

Hospitalists were provided with additional details regarding the patient’s residence and follow-up availability. In the rural scenario, the patient lived 6 hours away from the discharging hospital and 2 hours from the nearest hospital and could not access their primary care physician for 2 weeks.⁴ In the local urban/suburban scenario, the patient lived close to the medical center, with a scheduled primary care follow-up available in 1 week.⁴ Hospitalists were asked to choose between the following antibiotic treatment options:⁴

• Discontinue therapy (total of 3 days)

• Transition to amoxicillin/clavulanate and azithromycin to complete 5 days

• Transition to amoxicillin/clavulanate and azithromycin to complete 7 days

• Transition to amoxicillin/clavulanate and azithromycin to complete 10 days

Of the 102 hospitalists randomly assigned, 70% (71 of 102) participated and completed the survey.⁴ The majority of the respondents were men, practiced hospital medicine for a mean of 6.9 years, and performed approximately 91% of their clinical duties on an inpatient medicine service.⁴ The rural scenario was assigned to 29 hospitalists (41%), and the local urban/suburban scenario was assigned to 42 (59%).⁴ (See survey results in Table below.) Hospitalists assigned to the rural scenario were significantly more likely to choose a longer duration of therapy than those in the urban/suburban scenario (38% [11/29] vs 10% [4/42]; P = .004).⁴ Although literature is inconclusive on whether patient disposition and follow-up access influence discharge decisions, findings from this study indicate that there may be a potential to overprescribe even when clinical criteria do not warrant it.

Data looking at effectiveness of hospital follow-up are varied.^6,7 Although findings from this study showed statistically significant results that discharge location and hospital follow-up timing might influence antibiotic prescribing habits, the study is not without limitations. The absence of clinician training-level data (eg, doctor of medicine/doctor of osteopathic medicine vs nurse practitioner/physician assistant) may have affected interpretations of prescribing confidence, as the majority of clinicians were in practice less than 5 years. Additionally, the authors noted that the hospitalist group was comprised of high performers, which could have introduced bias by inflating perceived compliance with established guidelines at the institution.⁴ Moreover, this study predates the COVID-19 pandemic. Since then, telemedicine has expanded access to health care providers, which may mitigate some of the barriers faced by patients in resource-limited areas.⁴ It remains unclear whether proximity to health care or timing of follow-up most influences prescribing behavior. A third scenario (eg, an urban/suburban patient with delayed follow-up) could have clarified this distinction.

Understanding clinicians’ motivations for antibiotic prescribing is essential to improving antimicrobial use and stewardship efforts. This study has a unique design to provide insight into discharge decisions. A larger, multicenter study could better identify underlying drivers. Although a patient’s location cannot be changed, greater postpandemic telemedicine availability could help ensure appropriate antibiotic durations.

References

1. Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA. 2014;312(14):1438-1446. doi:10.1001/jama.2014.12923

2. Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med. 2019;171(3):153-163. doi:10.7326/M18-3640

3. Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control. 2021;10(1):105. doi:10.1186/s13756-021-00964-1

4. Dunn GE, White AT, Giesler DL, et al. Influence of access to care on decision-making about antibiotic duration at discharge. Open Forum Infect Dis. 2025;12(7):ofaf346. doi:10.1093/ofid/ofaf346

5. Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72. doi:10.1086/511159

6. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528. doi:10.7326/0003-4819-155-8-201110180-00008

7. Shen E, Koyama SY, Huynh DN, et al. Association of a dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a Medicare Advantage population. JAMA Intern Med. 2017;177(1):132-135. doi:10.1001/jamainternmed.2016.7061