November 21, 2019
4 min read

A stewardship send-off: Optimizing antimicrobials upon discharge

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact

Much of published antimicrobial stewardship literature has focused on reducing the use of broad-spectrum antibiotic therapy. However, in addition to the use of broad-spectrum antibiotics, prolonged antimicrobial use is also associated with the development of antimicrobial resistance. Durations of therapy often are determined upon discharge, and this transition period has not been a focus of many antimicrobial stewardship interventions.

Overprescribing for pneumonia

Although the optimal durations of therapy are unclear for many infections, national guidelines offer some guidance for many common infections, such as pneumonia. The length of stay for hospitalized patients with pneumonia is typically 3 to 5 days. Consequently, patients may require only a few doses of antibiotics upon discharge to complete their antibiotic course, but unfortunately, many of these patients receive an unnecessarily prolonged course of antibiotics upon discharge.

Cynthia T. Nguyen
Cynthia T. Nguyen

A retrospective study evaluating more than 6,000 patients from 43 hospitals in the Michigan Hospital Medicine Safety Consortium found that two-thirds of acute-care patients admitted for pneumonia received excess antibiotic therapy compared with guideline-recommended durations of therapy. Their findings underscored the impact on patient safety because excess antibiotic therapy also was associated with increased rates of adverse events, wherein each excess day of antibiotic therapy was associated with a 5% increase in the odds of a patient-reported, antibiotic-associated adverse event.

Jerod Nagel
Jerod Nagel

Currently, the community-acquired pneumonia (CAP) guidelines recommend at least 5 days of therapy for patients who achieve validated clinical stability criteria. This recommendation is supported by several randomized controlled trials, including a multicenter study comparing guideline-based duration of therapy to physician-directed duration of therapy, which demonstrated no difference in clinical success when patients were treated for 5 days compared with 10 days.

A successful strategy to reduce antibiotic duration of therapy for CAP has been described in a multicenter study of 600 patients. In this study, the antimicrobial stewardship programs implemented a multipronged intervention, including (1) updating the institutional CAP guidelines, (2) developing and disseminating pocket cards, (3) providing educational lectures and (4) performing a prospective audit with feedback and intervention.

These interventions reduced the median duration of therapy from 9 days to 6 days (P < .001), which was driven by a reduction in postdischarge duration of therapy (5 vs. 3 days, P < .001). Furthermore, guideline-concordant duration of therapy improved (5.6% vs. 42%, P < .001) and there were no differences in length of stay, readmission or mortality. Although the studied interventions were resource intensive, institutions targeting this area can consider decentralizing the prospective audit and feedback aspect of the intervention. For example, frontline pharmacists can perform discharge medication reconciliation.

Additional targets

Pneumonia is not the only area for opportunity for antimicrobial stewardship upon discharge. A recent multicenter evaluation of electronic prescribing data found the median duration of post-discharge antibiotic therapy was 8 days, and post-discharge duration of therapy accounted for 38% of antimicrobial exposure days. Additionally, this study found antibiotics are often prescribed upon discharge for UTIs, skin and soft tissue infections (SSTIs) and intra-abdominal infections (IAIs), and up to 78% of these courses may be excessive.


Other successful targets of antimicrobial stewardship programs upon discharge include outpatient parenteral antibiotic therapy (OPAT), wherein review of patients with planned discharge with OPAT have resulted in the avoidance of OPAT, as well as antibiotic dose and duration adjustments. However, review of OPAT alone may miss opportunities to optimize oral antibiotic therapy upon discharge.

For example, a study evaluating more than 10,000 patients at 48 hospitals found the rate of inpatient fluoroquinolone prescribing among hospitals performing fluoroquinolone stewardship was low compared with hospitals without fluoroquinolone stewardship. Interestingly, however, hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts prescribed upon discharge compared with hospitals without fluoroquinolone stewardship (15.6% vs. 8.4%; P = .003). Given the risks associated with fluoroquinolone use, these findings underscore the need for stewardship through the discharge transition of care.

Another recent study evaluated the transition from the inpatient hospital setting to the nursing home. Among the 40 cases evaluated, 30% were found to have an inappropriate change to the patient’s antibiotic care plan. These errors consisted of inappropriate antibiotic dose (20%), safety/monitoring (18%) and duration (5%) recommendations.

There are several potential barriers to ensuring the optimal prescribing of antibiotics upon discharge, particularly with regard to duration of therapy. First, the discharging prescriber needs to be aware of the full antibiotic plan, including dose, duration and monitoring. This also includes knowing the antibiotic start date and only prescribing the amount of antibiotics sufficient to complete the course. Second, uncertainty with the infectious diagnosis and/or discharge follow-up plan may pressure prescribers to extend durations of therapy. Third, some computerized prescription orders have default durations of therapy for antibiotics. In these scenarios, prescribers may not be prompted to enter or modify the duration or number of doses. Removing these defaults for discharge antibiotic orders can prevent potential excess antibiotic therapy. Finally, it is often difficult to determine whom to communicate with and how to optimize communication at the transition of care.

Opportunities exist to employ antimicrobial stewardship interventions upon discharge. CAP has been a successful target to optimize and reduce duration of therapy, which may also improve patient safety. Additional targets to optimize antimicrobial use and reduce medication errors at transitions of care are OPAT, UTIs, SSTIs and IAIs.