Photo Credit: Phuttaphat Tipsana

Antibiotic overuse contributes to antibiotic resistance. Following a set of four principles could improve stewardship efforts in hospitals.

“Antibiotic overuse is contributing to a worldwide crisis in antibiotic resistance in which some pathogens are no longer treatable with antibiotics,” Valerie Vaughn, MD, MSc, notes. “Prior work has shown both that antibiotics prescribed at discharge account for a lot of this overuse and that overuse can increase adverse events for patients. While hospitals have focused on improving prescribing in hospitals, few have monitored or worked to improve discharge prescribing.”

As a result, a wide variation in antibiotic overuse at discharge has emerged, according to Dr. Vaughn.

For a study published in Clinical Infectious Diseases, Dr. Vaugh and colleagues aimed to determine why certain hospitals effectively prescribed appropriate antibiotics at discharge while others experienced high antibiotic overuse. “Our hope was to provide tips on how best to improve antibiotic prescribing at discharge,” she says.

The researchers performed a mixed-methods study across seven hospitals with variable antibiotic overuse at discharge. They also conducted surveys, document analysis, and semi-structured interviews with each hospital’s antibiotic stewardship and clinical stakeholders.

The study included 85 survey respondents, and interviews included 90: 31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, and 12 hospital leaders. Based on survey responses, clinical pharmacists at hospitals with less antibiotic overuse were more likely to report feeling respected by hospitalist colleagues (P=0.001), seen as valuable team members (P=0.001), and comfortable recommending changes to antibiotic prescriptions (P=0.02). Physician’s Weekly (PW) spoke with Dr. Vaughn to learn more about the study results.

PW: What findings from your study are important to emphasize?

Dr. Vaughn: Relationships and team-based work are critically important to providing good care. We found this was true for antibiotic stewardship as well. Hospitals with good hospitalist-pharmacist relationships had better prescribing practices.

We observed that one key to good relationships was having more face-to-face communication, usually through in-person rounds. These relationships created an open forum to talk about antibiotics and suggest changes in a way that built stronger connections and trust between the team members.

Can you also comment on the principles you identified to improve antibiotic stewardship?

These are four principles that hospitals can use to improve antibiotic stewardship. First, hospitals should create easy-to-access local guidelines to ensure everyone’s on the same page about the “right” antibiotic in certain situations. These guidelines can help improve pharmacists’ knowledge and allow them to point to the guidelines when convincing clinicians to change their prescribing practice. Second, building those trusting relationships within the team is critical—and best done by in-person interactions. Third, the guidelines should be adapted into tools that clinicians can use. This means syncing guideline recommendations with order sets and providing education. Finally, infectious disease physician leadership was critical. Some hospitals had truly engaged these clinicians, and those were the highest-performing hospitals. Hospitals that had less engaged infectious disease clinicians or didn’t protect infectious disease clinicians’ time to work on stewardship were less likely to be successful.

What are the implications of your findings?

Hospitals should create local stewardship guidelines, embed those guidelines into the tools used by physicians (eg, order sets), protect the time of the stewardship team to work on stewardship, and promote positive relationships through in-person communication between pharmacists and physicians.

What would you like to see future research focus on? 

Not all hospitals have the same resources. We found that hospitals with fewer resources had less ability to improve antibiotic overuse. We’re working now to develop strategies customized to local resources and asking the question: How can you help hospitals with fewer resources? We believe some low-touch interventions can improve discharge prescribing and might work better for hospitals that, for example, don’t have infectious disease physicians or pharmacists on staff.

We’re testing that through the Reducing Overuse of Antibiotics at Discharge or the ROAD Home trial. The idea is that strategies vary by hospital, and there’s no “one size fits all” solution to antibiotic stewardship. What we mention above is a start, but solutions need to be adapted to local resources.