Evaluation of discharge antibiotic prescribing at a freestanding children’s hospital: Opportunities for Stewardship

Background: The focus of most antibiotic stewardship programs is inpatient prescribing, however, a substantial percentage of hospitalized children are discharged with an antibiotic to complete at home. Adult studies, even in hospitals with comprehensive stewardship programs, have identified high rates of suboptimal antibiotic prescribing at discharge. Similar studies in pediatrics are lacking.

Methods: We retrospectively reviewed discharge antibiotic prescriptions at Primary Children’s Hospital (PCH) from January 1^st, 2016 – December 31^st, 2016. PCH has a comprehensive stewardship program that focuses on inpatient prescribing and discharge prescriptions for IV antibiotics but does not review discharges with oral antibiotics. We characterized the overall percentage of hospital discharges prescribed antibiotics, route (IV/oral) and antibiotic classes. For a randomly selected sample of prescriptions, we conducted chart reviews to identify suboptimal prescribing in the following categories based on national/local guidelines in the following categories: incorrect antibiotic choice, formulation, dose and duration. We calculated the percentage of discharge antibiotic prescriptions determined to be suboptimal overall and within drug classes, route and clinical indications.

Results: During 2016, 2,835 patient discharges (22% of total discharges) were prescribed 3,487 discharge antibiotic prescriptions. An IV antibiotic was prescribed in 10% of patient discharges with antibiotics. The most common antibiotic classes were aminopenicillins (24%), sulfonamides (13%), 1^st/3^rdgeneration cephalosporins (17%) and fluoroquinolones (7%). We reviewed 138 prescriptions for 110 patients of which 29% were considered suboptimal. The most common categories of suboptimal prescribing were duration (9%), drug selection (7%), and dose (7%). When prescriptions for medical prophylaxis were excluded, 35% were suboptimal. The percentage of suboptimal prescriptions was higher for oral (32%) than IV (5% P = 0.01).

Conclusion: A large percentage of pediatric discharges include antibiotic prescriptions which are frequently suboptimal. Hospital-based stewardship programs can enhance value by including greater focus on discharge prescribing.