Does the patient need IV drugs at discharge?
Many times the answer is no
Investigators — evaluating more than 240 patients over a three-month period — found that infectious diseases (ID) physicians correctly identified patients who did not need to be discharged on community-based parenteral anti-infective therapy (CoPAT).1
"Whenever someone leaves the hospital on intravenous (IV) antibiotics in our institution, their case has to be evaluated by an ID physician," says Nabin K. Shrestha, MD, MPH, staff physician in the department of infectious disease at the Cleveland Clinic in Cleveland, OH.
"For some patients we will decide to stop the IV antibiotic, and the question was whether we are causing harm by doing that," he explains. "So we compared emergency department and hospital readmissions within 30 days for these patients."
Researchers found that ID physicians stopped IV antibiotics in 29% of patients, sometimes replacing them with oral medication, and in other cases stopping antibiotics altogether. Of the 69 patients for whom IV antibiotics were stopped, none were readmitted for infection within the 30-day time period, he says.
"Out of the 69 patients 27 did come back to the emergency department, but they returned for other illnesses, like congestive heart failure, and not for infections," Shrestha says. "We felt that was very positive, and we were very happy with what we found."
In most hospitals an ID physician evaluation is not necessary before discharging patients on IV antibiotics. This represents a lost opportunity for antimicrobial stewardship at a time of care transition out of the hospital, and probably results in a large proportion of patients being discharged with antibiotics when they don't need them, Shrestha notes.
Even hospitals that have antimicrobial stewardship programs usually limit their stewardship of antibiotic use to hospitalized patients and do not have mechanisms in place to control antibiotic use at points of care transition, he adds.
"In our institution we've built up a culture where they're evaluated by infectious disease physicians," he says. "It takes a lot of commitment to do it that way."
Cleveland Clinic physicians will request an ID physician consultation for the purpose of managing a patient's post-discharge antibiotics while the patient is still hospitalized.
"The doctors think the patient needs antibiotics, and they have to call the infectious disease physician to make that happen," Shrestha says. "We screen the patient and are fully involved in the care, deciding whether the patient needs antibiotics and whether it should be IV or oral antibiotics."
When ID physicians evaluate patients at discharge, they look for evidence of infection and other associated medical and social factors to help decide if antibiotics are necessary, and, if so, which antibiotics are most appropriate.
"Sometimes you agree there's an infection and it needs to be treated," Shrestha says. "We speak with the patient, look through the records, and we take responsibility for that patient."
They also make follow-up arrangements for the patient, including a visit to see the ID physician in the ID clinic when it's appropriate. About 86% of patients had a follow-up appointment with an ID physician, he says.
Several health care systems have contacted Shrestha to discuss the study and the Cleveland Clinic's antimicrobial stewardship program, and others are considering instituting a program like this. But it takes time and resources.
Having an ID physician consultation is a model that would be feasible in larger health care institutions. But all hospitals could follow some of the same antimicrobial stewardship practices, including stopping antibiotic use at discharge when there is no clinical evidence the patient has an ongoing infection, Shrestha says.
Controlling antimicrobial prescribing reduces antimicrobial resistance and Clostridium difficile infections and they save health systems money. Expanding these practices to the discharge process will increase the benefits, the study says. The key would be to target higher risk antimicrobial treatment plans.
"I think we have significant challenges today because of a lack of antibiotics for some serious infections," Shrestha says. "We're seeing very few new antibiotics being developed, and the ones we have are developing resistance increasingly, and there are some strains of bacteria where doctors have difficulty finding any antibiotic that works."
These problems make antimicrobial stewardship an increasingly attractive step toward reducing resistance.
"Different institutions have different constraints, so we can't specify exactly what they need to do, but every institution should think about antimicrobial stewardship and do something about it," Shrestha says.
Reference
- Shrestha NK, Bhaskaran A, Scalera NM, et al. Antimicrobial stewardship at transition of care from hospital to community. Infect Cont Hosp Epi 2012;33(4):401-404.
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