Antibiotic Overuse After Hospital Discharge: A Multi-hospital Cohort Study

Abstract

Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI) and determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 7/1/2017-7/30/2019 we quantified the proportion of patients discharged with antibiotic overuse, defined as: unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level association between antibiotic overuse after discharge in patients treated for pneumonia vs. UTI. Results Of 21,825 patients treated for infection (12,445 pneumonia; 9,380 UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% pneumonia; 38.7% UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTI, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied five-fold among hospitals (15.9% [95% CI: 8.7%-24.6%] to 80.6% [95% CI:69.4%-88.1%]) and was strongly correlated between conditions (regression coefficient=0.85, P&.001). Conclusion Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all three types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.

Antibiotic prescriptions in the context of suspected bacterial respiratory tract superinfections in the COVID-19 era: a retrospective quantitative analysis of antibiotic consumption and identification of antibiotic prescription drivers

“…In contrast to Vaughn et al . [ 25 ], where 26% of the administered antibiotics included an anti-MRSA coverage, only 1% of our administered antibiotic doses covered MRSA. This is probably due to the low prevalence of MRSA in our setting (2.5% of all tested invasive isolates [ 26 ]) and to the fact that we did not include anti-MRSA antibiotics which were prescribed for other reasons than for (presumed) respiratory tract infections.…”

“…In the driver analysis, the presence of fever at admission, low SpO 2 /FiO 2 , pre-existing pulmonary disease and high neutrophil counts together with a longer length of stay were significantly associated with the administration of at least one antibiotic prescription during admission. Besides a prolonged hospital stay, which enhances the risk of nosocomial infection and a high leukocyte count at admission, none of the reported variables has been proven to be associated with a higher rate of bacterial superinfection in COVID-19 patients [ 25 , 34 ]. As the presence of fever and low SpO 2 /FiO 2 at admission are both, respectively, a diagnostic and a prognostic criterion of bacterial pneumonia [ 35 ], it is comprehensible to find these as possible drivers of antibiotic prescription.…”

“…In a similar multicentre study, Vaughn et al . described the following variables as a predictor of antibiotic therapy in COVID-19 patients: age, BMI, disease severity (e.g., respiratory support and sepsis), the presence of a lobar infiltrate and admission to a for-profit hospital [ 25 ]. The association between age or BMI and antibiotic treatment was not confirmed in our study.…”

“…Moreover, the authors did not exclusively focus on antibiotics started for respiratory tract infections, which is in contrast with our analysis. We decided not to analyze the presence of a lobar infiltrate as a potential predictor of antibiotic prescription, as other authors concluded that the presence of a lobar infiltrate is not predictive for bacterial co-infection [ 25 ]. Even though 51% of the admissions in our study received antibiotics because of a dense consolidation or worsening medical imagery, the presence of denser radiological consolidations is common in the later presentations of COVID-19, without the presence of bacterial co-infection [ 38 – 40 ].…”

Interventions to optimize antimicrobial stewardship

“…20,21 Studies of pneumonia have shown that 57% of patients have antibiotics prescribed at discharge, accounting for 39% of the overall duration and 93% of total excess duration, most often with fluoroquinolones. [22][23][24] Additionally, 44% of discharge antibiotics for UTIs are due to treatment of asymptomatic bacteriuria. 24 Antimicrobial stewardship interventions focusing solely on inpatient use will affect only a fraction of the total use, thus coordinated discharge antimicrobial stewardship interventions are needed.…”