Prospective audit and feedback led by hospital antibiotic stewardship teams does not reduce the frequency or duration of antibiotics prescribed at discharge, although prescribing quality did improve in selected patients with uncomplicated infections, a recent study has found.
This stepped-wedge cluster-randomised clinical trial determined whether providing structured audit and feedback to frontline prescribers shortly before discharge could safely reduce unnecessary or suboptimal antibiotic prescribing at this transition of care.
Published in JAMA Network Open, it involved antibiotic stewardship teams across 10 acute-care hospitals in the United States.
Each participating hospital crossed from a 24-week baseline period into the intervention phase at two-week intervals between December 2022 and November 2023.
The intervention comprised dissemination of local oral antibiotic step-down guidelines, education of prescribers and prospective audit and feedback for inpatients expected to be discharged within 48 hours.
The analysis included 21,842 adult admissions across the 10 hospitals, with 14,288 during baseline and 7,554 during the intervention. Patients had a median age of 66 years, 61.3% were male and more than 97.0% were managed by internal medicine services. Patients who died in hospital or were transferred to another facility were excluded, and outcomes were assessed only for those discharged to the community.
Post-discharge antibiotic use
The primary outcome was post-discharge antibiotic use, which were prescribed at discharge for 21.9% of patients during baseline and 21.8% during the intervention (odds ratio (OR) 0.94; 95% CI 0.84–1.05).
Among those receiving antibiotics, mean post-discharge duration was 7.1 days at baseline and 7.6 days during the intervention, with no statistically significant difference. There were also no significant differences in inpatient antibiotic duration, length of stay or 30-day readmission rates.
However, manual electronic health record review of 434 selected cases with common, uncomplicated infections showed improved prescribing quality. Optimal antibiotic prescribing at discharge increased from 46.2% at baseline to 58.8% during the intervention (OR 1.61; 95% CI 1.08–2.40). Total antibiotic duration was shorter for intra-abdominal and biliary infections, but not for other infection types.
Noting that the intervention did not decrease overall post-discharge antibiotic use, the researchers said that it was possible that antibiotic stewardship strategies applied earlier in the hospital stay decreased the need for optimisation as the patient approached hospital discharge.
According to the study’s survey results, frontline prescribers said one in every five antibiotic stewardship team recommendations was not made in a timely manner, suggesting that improved communication and collaboration would be needed to see a greater benefit in antibiotic optimisation at discharge.
Alternative or more automated stewardship strategies required
The researchers highlighted several study limitations, including relatively short intervention periods at some sites, variability in implementation, inability to directly measure recommendation acceptance and exclusion of patients discharged to other facilities or with more complex infections.
They concluded that discharge-focused audit and feedback alone was insufficient to reduce overall antibiotic overuse and suggested that alternative or more automated stewardship strategies may be needed to improve antibiotic prescribing at hospital discharge.
Nevertheless, frontline prescribers who responded to the study survey said they found the antibiotic stewardship team’s feedback helpful and wanted the discharge-focused process to continue, the researchers noted.
Reference
Livorsi DJ et al. Prospective Audit and Feedback by Antibiotic Stewardship Teams to Reduce Antibiotic Overuse at Hospital Discharge. JAMA Netw Open 2026 Jan 2;9(1):e2549655.
