The majority of antimicrobial stewardship efforts focus on inpatient antibiotic use, however, most antibiotic use occurs in outpatient settings. Antibiotics initiated during hospitalization are often completed after discharge. Medication reconciliation processes seldom focus on the duration of antibiotic therapy (DAT) prescribed. National guidelines recommend limiting DAT for uncomplicated pneumonia cases. A 2013 National VA Medication Utilization Evaluation identified a mean (±SD) DAT for uncomplicated pneumonia of 10.4 (±2.6) days, with 6.2 (±4.1) days prescribed at discharge. As a strategy proposed by the VA Antimicrobial Stewardship Task Force, we developed a medication reconciliation-based protocol designed to minimize uncomplicated pneumonia DAT upon discharge.
A single-center interrupted time-series (ITS) study is ongoing to assess if implementation of the protocol is associated with a reduction in uncomplicated pneumonia DAT. The protocol is used by pharmacists to stratify pneumonia cases and recommend appropriate DAT to providers based on clinical criteria: uncomplicated (5-8 days), moderately complicated (8-14 days), or complicated (≥14 days). Retrospective chart abstraction of DAT and 30-day readmission rates is being performed, aggregated by month.
Analysis to date includes 9 months pre and 6 months post-implementation data for uncomplicated cases (n=307). ITS parameters: mean monthly DAT slope (pre) 0.07 (P=0.2); Δ level -1.57 (P=0.005); Δ slope -0.12 (P=0.3). Mean DAT decreased (15.4%) from 9.4 (±0.4) to 7.9 (±0.4) days pre and post-intervention, and mean DAT prescribed at discharge decreased (25.0%) from 5.4 (±2.4) to 4.0 (±2.9) days, respectively. Mean monthly 30-day readmission slope (pre) -0.37 (P<0.001); Δ level 1.01 (P=0.54); Δ slope -1.50 (P<0.001). Mean monthly 30-day readmission rates decreased from 19.3% to 12.4%.
Mean monthly DAT Δ level and 30 day readmission rates indicate an immediate effect associated with protocol implementation. The medication reconciliation-driven protocol to minimize DAT for patients with uncomplicated pneumonia upon hospital discharge is reducing DAT and appears safe. Final analysis will include 27 months (18 pre, 9 post) intervention data which will increase study power.
R. E. Remington, None
K. Crane, None
M. Wilkin, None