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J Am Coll Clin Pharm


Over half of antimicrobials ordered at hospital discharge are not optimized, many of which having longer than necessary durations or inappropriate for the indication. Unnecessary antimicrobial exposures increase the risks of adverse events, antibiotic resistance, and Clostridioides difficile infections. However, discharge prescribing often escapes the purview of inpatient antimicrobial stewardship programs and few interventions have been implemented to optimize antibiotic use during transitions of care (TOC). Herein, the aim was to highlight critical steps and challenges in the implementation of a TOC antimicrobial stewardship program designed to improve prescribing at hospital discharge. In a five-hospital health system, a pharmacist-led intervention was implemented during TOC, with the objective of improving oral antibiotic selection and duration. Among a multidisciplinary team of physicians, case managers, and nurses, the pharmacists engaged in three strategies: (a) early identification of patients to be discharged on oral antibiotics; (b) collaborative planning and communication regarding guideline-recommended antibiotic selection and duration; and (c) facilitation of discharge antibiotic prescription with appropriate stop date. Barriers to completing the intervention on each patient in this experience included: timely identification of eligible patients prior to discharge, stewardship periods of reduced staffing during evenings and weekends, and onboarding of new staff and trainees to the process. Other major challenges that stewardship and pharmacy departments will face include adoption of best-practice guidelines for discharge, obtaining support from local physician champions, extending the intervention to various service lines and departments with limited resources, and engaging stakeholders to support the program and intervention. This experience demonstrated that pharmacist-led antimicrobial stewardship at discharge can be successful in both academic and community settings.





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