Reply to Mercuro et al

To the Editor—We read with great interest the assessment by Mercuro and colleagues [1] of a single month of adult fluoroquinolone prescribing at hospital discharge. Although analyses of large national data sets are critical for understanding the epidemiology of prescribing, we agree with the authors that observational studies, medication use evaluations, and surveys that identify common errors in antibiotic prescribing are needed to identify targets for antibiotic stewardship action at the local level. Their study highlights an important opportunity to improve antibiotic prescribing at the time of hospital discharge. Antibiotics are commonly prescribed when patients are discharged from the hospital [2], and are frequently prescribed inappropriately [3–5]. One analysis found that most antibiotic prescriptions at discharge were oral (86.0%), and fluoroquinolones were the most common antibiotic class prescribed (23.5%) [5].

Antibiotic stewardship is increasingly recognized as a patient safety priority, and the percentage of hospitals implementing the Centers for Disease Control and Prevention’s “Core Elements of Hospital Antibiotic Stewardship Programs” has been increasing [6]. Hospital antibiotic stewardship programs have been successful in improving antibiotic use and in decreasing the rates of antibiotic resistance and Clostridium difficile infection [7, 8]. However, such programs primarily focus on antibiotic prescribing during hospitalization, and most do not review antibiotic prescriptions at discharge, especially oral prescriptions. Review of discharge antibiotic prescriptions can improve prescribing, not only in the outpatient setting but also in nursing homes, where up to 50% of antibiotic courses in post–acute care residents are initiated in the hospital [9].

One of the most common causes of inappropriate prescribing at discharge is an unnecessarily prolonged duration of the treatment course. In a study by Scarpato et al [5], 55% of inappropriate prescriptions on discharge were due to prolonged duration, with patients receiving an average of 3.8 days of unnecessary antibiotics. Another review found that 33% of inappropriate prescriptions were due to excessive duration, and approximately 65% of total antibiotic treatment duration was completed after hospital discharge [4]. The data reported by Mercuro et al [1] are similar; more than half of fluoroquinolone prescriptions were deemed to be too long in duration. With increasing evidence that shorter courses of therapy may be as effective as longer courses [10], targeting the duration of antibiotic prescriptions at hospital discharge can play an important role in decreasing inappropriate antibiotic use.

Mercuro et al [1] also highlight the need for more sophisticated and durable behavioral interventions, whether targeted at inpatient care, outpatient care, or transitions. Insights from implementation science and behavioral economics can help drive the next stage of antibiotic stewardship. It is clear, however, that antibiotic stewardship interventions at care transitions can optimize antibiotic use and improve patient outcomes, with ripple effects in all healthcare settings.

Notes

Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

Financial support This work was supported by the CDC (grant CDC/NCEZID 17IPA1708453 to A. L. H, D. J. S., and A. T. P), the National Institutes of Health (grants 1R01AI125642-01 and R21HD090955 to A. T. P.), and the Agency for Healthcare Research and Quality (grant K08 HS23320-03 to A. L. H.).

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.