Tick-TOC: The time for transitions of care (TOC) antibiotic stewardship is now!

Reviewed by Rebekah Moehring, MD, MPH, FIDSA, FSHEA; Duke University, Durham, NC

Antibiotic stewards from Henry Ford Health System and colleagues report results from a CDC-funded quality improvement study focused on improving antibiotic prescribing at discharge. Investigators employed a multifaceted intervention over a 5-hospital system, tailored by site to utilize existing staffing resources from antibiotic stewardship and clinical pharmacists to review and improve both selection and duration of antibiotics prior to discharge. Triggers for PharmD review varied by site, from census lists to electronic alerts to multidisciplinary collaborative rounds. The intervention rolled out in a stepped wedge design among 17 rounding teams, and included PharmD review, documentation, and facilitation of order entry for co-sign by prescribers. A protocolized, health system guideline for syndrome-based antibiotic selection and duration recommendations were used for PharmD reviews and recommendations as well as assessment of the primary outcome of “optimized therapy.” Analyzed patients (N=800) were selected among the 3 steps of implementation when they had a well-defined infectious syndrome, did not have complex infections or immunocompromise, and were prescribed oral antibiotics for discharge (~45% of screened patients analyzed). The results of the time-based modeling analysis showed 4-5x greater odds of optimized therapy in the post-intervention period (multiple assessments of the primary outcome were performed using model including other confounders). Optimized therapy improved from pre- to post-intervention (144 of 400 [36.0%] vs 326 of 400 [81.5%]). Adherence to protocol was lower 63%, suggesting that at least part of the effect was indirect (e.g., Hawthorne effect or learning from prior patient discussions), which suggests that even getting to a portion of discharges could have larger effects.

This study has a lot of highlights to point out for future studies in stewardship: 1) how to lead successful system-level stewardship initiatives 2) stepped wedge design (so practical for QI assessments), 3) tailored approach for specific institutions of varied resources. As a bonus for stewards interested in TOC implementation, the authors provided their system TOC guidelines in the supplement, plus other implementation tools on the Henry Ford website. I wish we had a few more details on how the triggers for review really worked and what trial-and-error PharmDs had to go through to catch patients before their discharge; timing for a TOC intervention seems to be a big logistics barrier in the rush to discharge, aside from devoted pharmacist resources and focus. In all, this report should inspire us stewards to get to work on TOC — right now!

Mercuro et al. Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge. JAMA Network Open. 2022;5(5):e2211331. doi:10.1001/jamanetworkopen.2022.11331 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792123

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