Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States

PURPOSE

To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States.

METHODS

We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, β-lactam + macrolide, β-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.).

RESULTS

Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location.

CONCLUSIONS

Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.

Impact of a Medication Reconciliation Pharmacist Program on Appropriateness of Community-Acquired Pneumonia Treatment Durations at Hospital Discharge

Background

Antimicrobial stewardship programs have made large efforts to minimize the inappropriate use of antibiotics. Implementation of these programs can be challenging, since many institutions have limited resources. Utilizing resources that already exist may be beneficial, including medication reconciliation pharmacist (MRP) programs. This study aims to evaluate the impact of a MRP program on appropriateness of community-acquired pneumonia (CAP) treatment durations at hospital discharge.

Methods

This study was a retrospective, observational, single-center study comparing the total days of antibiotic therapy for CAP in the preintervention period (9/2020-11/2020) versus the post-intervention period (9/2021-11/2021). Implementation of a new clinical intervention occurred between the 2 periods and included education to MRPs on appropriate CAP treatment durations and on documentation of recommendations. Data was collected utilizing a chart review of the electronic medical record of patients diagnosed with CAP using ICD-10 codes. The primary objective of this study was to compare the total days of antibiotic therapy in the pre-intervention period versus the postintervention period.

Results

One-hundred fifty-five patients were included in the primary analysis. When observing total days of antibiotic therapy, there was no change from the pre-intervention period at 8 days compared to the postintervention period (P = .109). When analyzing antibiotic days of therapy at discharge, there was a decrease from 4.55 days in the preintervention period compared to 3.8 days in the post-intervention period (P = .109). The incidence of those with appropriate treatment durations, defined as 5 to 7 days of antibiotic therapy, was higher in the post-intervention period (26.5% in the pre-intervention group vs 37.9% in the post-intervention group, P = .460).

Conclusions

There was a non-statistically significant decrease in median days of antimicrobial therapy for CAP at hospital discharge after implementation of a new clinical intervention targeting antibiotic days of therapy. Though median total antibiotic days of therapy were similar between both time periods, patients had an overall increase in incidence of appropriate duration of therapy, defined as 5 to 7 days, after intervention. Further studies are necessary to show how MRPs have a positive impact on improving outpatient antibiotic prescribing at hospital discharge.

Interventions to improve antibiotic prescribing at hospital discharge: A systematic review

A large proportion of antibiotic use associated with hospitalization occurs immediately after discharge, representing an important focus for antimicrobial stewardship programs. This review identified few studies evaluating the effect of interventions aimed at improving discharge antibiotic prescribing. Antimicrobial stewardship to improve postdischarge antibiotic prescribing is an unmet need warranting further study.

The Impact of the Duration of Antibiotic Therapy in Patients With Community-Onset Pneumonia on Readmission Rates: A Retrospective Cohort Study

BACKGROUND

Recent publications have confirmed that 70% of hospitalized adults with uncomplicated community-acquired pneumonia and health-care-associated pneumonia are prescribed a duration therapy that exceeds current guideline recommendations.

OBJECTIVE

The primary objective is to evaluate the relationship between antibiotic duration and all-cause 30-day readmission rates. Secondary outcomes include pneumonia-specific 30-day readmission rate and identification of risk factors for readmission.

METHODS

Patients aged ≥18 years with a primary diagnosis of pneumonia from January 1, 2016, to December 31, 2016, were included in this single-center, retrospective cohort study. Patients were categorized by antibiotic therapy duration of ≤7 days (n = 139) or >7 days (n = 286), and outcomes were analyzed in both bivariate and multivariate models. A multivariate logistic regression was used to assess the relationship between all-cause 30-day readmission and antibiotic days.

RESULTS

Baseline characteristics were not significantly different between the 2 groups. All-cause 30-day readmission rates were 15.8% and 15.5% for patients who received ≤7 days versus >7 days of antibiotics, respectively (P = .95). Pneumonia-specific 30-day readmission occurred in 3.6% of patients who received antibiotics for ≤7 days compared to 3.5% of patients who received antibiotics for >7 days (P = .95). Multivariate logistic regression showed no statistically significant association between readmission rate and antibiotic duration of >7 days. Statistically significant risk factors for readmission identified by logistic regression include ≥3 hospital admissions within the previous year, a hematocrit <30% at discharge, a history of chronic obstructive pulmonary disorder (COPD), and weight.

CONCLUSION

The use of prolonged antibiotic therapy for the treatment of community-onset pneumonia was not associated with a decrease in all-cause or pneumonia-specific 30-day readmission rates.

Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network

OBJECTIVES

Antimicrobial stewardship programmes have focused on reducing inappropriate inpatient antimicrobial prescribing, but several small studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. In this study, we describe the prescribing of oral antimicrobials at hospital discharge across an integrated national healthcare system. At the hospital level, we also compare total inpatient antimicrobial use and post-discharge oral antimicrobial use.

METHODS

This retrospective cross-sectional study used national administrative data to identify all acute-care admissions during 2014-2016 within the Veterans Health Administration (VHA). We evaluated inpatient days of therapy (DOT) and post-discharge DOT, defined as oral outpatient antimicrobials dispensed at the time of hospital discharge. At the hospital level, inpatient DOT/100 admissions were compared with post-discharge DOT/100 admissions using Spearman's rank-order correlation.

RESULTS

There were 1 681 701 acute-care admissions across 122 hospitals, and 335 369 (19.9%) were prescribed an oral antimicrobial at discharge. Fluoroquinolones (38.3%) were the most common post-discharge antimicrobial. At the hospital level, median inpatient antimicrobial use was 331.3 (interquartile range (IQR) 284.9-367.9) DOT/100 admissions and median post-discharge use was 209.5 (IQR 181.5-239.6) DOT/100 admissions. Thirty-nine per cent of the total duration of antimicrobial exposure occurred after discharge. At the hospital-level, the metrics of inpatient DOT/100 admissions and post-discharge DOT/100 admissions were weakly positively correlated with rho=0.44 (p < 0.001).

CONCLUSIONS

A large proportion of antimicrobial exposure among hospitalized patients occurred immediately following discharge. Antimicrobial-prescribing at hospital discharge provides an opportunity for antimicrobial stewardship. Hospital-level stewardship metrics need to include both inpatient and post-discharge antimicrobial-prescribing to provide a comprehensive assessment of hospital-associated antimicrobial use.

Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department

OBJECTIVE

To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP).

METHODS

An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts.

KEY FINDINGS

A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/β-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/β-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS).

CONCLUSIONS

The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.

'Careful goodbye at the door': is there role for antimicrobial stewardship interventions for antimicrobial therapy prescribed on hospital discharge?

BACKGROUND

Antimicrobial stewardship (AMS) interventions largely target inpatient antimicrobial prescribing. Literature on appropriateness of antimicrobials prescribed at the interface between hospital and the community is minimal. This study was designed to assess the appropriateness of antimicrobials prescribed on hospital discharge and evaluate the impact of AMS interventions.

METHODS

Patients with discharge medications processed by the pharmacy were identified using a computerized pharmacy medication tracker over a four week period. The antimicrobials prescribed on discharge were assessed independently for appropriateness of antimicrobial choice, dose, frequency and duration. Data on various AMS interventions was collected. Univariate followed by multivariate logistic regression (MVLR) analysis was performed using SPSS V 23 (IBM, California).

RESULTS

A total of 892 discharge prescriptions were processed by the pharmacy department, 236 of which contained antibiotic prescriptions. Of these, 74% were appropriate for antimicrobial choice, 64% for dose, 64% for frequency and 21% for duration. In particular, 71% of patients received a course in excess of Therapeutic Guidelines-Australia(TG-A) recommended length of treatment. On univariate analysis, discharge antimicrobial prescriptions were more likely to be appropriate for antimicrobial choice, frequency and duration; appropriate microbiological specimens were more likely to be taken and targeted therapy more likely to be given when the AMS team was involved. On MVLR, appropriateness with antimicrobial dosing frequency [OR 5.6(1.9-19.2)], microbiological specimens [OR 4.3(1.6-11.6)] and receipt of targeted therapy [OR 2.8(1.8-6.2)] with AMS involvement remained significant.

CONCLUSIONS

A large discrepancy exists between antimicrobial regimens prescribed on hospital discharge and those recommended in consensus guidelines, particularly concerning duration of treatment. While AMS interventions are well established for improving antimicrobial prescribing in hospital inpatients, the hospital-community interface remains a challenge in terms of antimicrobial prescribing and exposes patients to potential harm. There is a clear need for AMS interventions to extend to antimicrobial therapy prescribed on discharge.