Antibiotic stewardship interventions to limit fluoroquinolone prescribing among inpatients do not reduce the prescribing of fluoroquinolones at discharge, according to a “real-world snapshot” of the situation. Overall, one third of patients with pneumonia or urinary tract infections (UTIs) received such prescriptions at discharge. There was no difference in fluoroquinolone prescribing rates between hospitals with stewardship programs and those without, researchers found.
“Fluoroquinolone antibiotics are easy to use, but carry a lot of risk for patients and society at large,” said lead author Valerie Vaughn, MD, a hospital medicine specialist at Michigan Medicine, the University of Michigan’s academic medical center in Ann Arbor, in a news release.
Previous studies have shown that fluoroquinolones are associated with Achilles tendon tears, hypoglycemia in people with diabetes, disorientation, delirium, and increased risk for Clostridioides difficile infection and antibiotic resistance.
The new data “show we need to focus on not just their use in hospitals, but also in the prescriptions that we send patients home with. Discharge prescribing is a big loophole,” Vaughn said. The researchers reported their findings in an article published online February 13 in Clinical Infectious Diseases.
Vaughn and colleagues note that although stewardship programs are known to reduce antibiotic prescribing for inpatient care, their effect on aggregate fluoroquinolone prescribing has been unclear. Therefore, the investigators analyzed prescribing data from patients hospitalized with pneumonia (n = 6820) or UTIs (n = 4928) at 48 Michigan hospitals between December 2015 and September 2017.
Overall, 71.5% of patients were prescribed any antibiotic at discharge, and 30.5% received a fluoroquinolone, which was the most commonly prescribed class.
Considering both in-hospital and discharge prescribing, the researchers found that 42.6% of patients received fluorquinolones, including 28.1% of those with asymptomatic bacteriuria. However, two thirds of total fluoroquinolone treatment days were after discharge.
Of the 48 hospitals, 46 (96%) reported having a stewardship program, but just 14 (29%) listed one or more fluoroquinolones among their targeted antibiotics. Most of the institutions used pre-prescription approval (77%) and/or prospective audit and feedback (90%), which were the two interventions targeted by the researchers.
After adjusting for hospital clustering and patient factors, fewer patients were found to have received a fluoroquinolone during hospitalization at facilities with fluoroquinolone stewardship than at hospitals without (37.1% vs 48.2%; P = .01). In addition, there were fewer total days of fluoroquinolone therapy in hospitals with stewardship compared with hospitals without stewardship (2282 vs 3096 days per 1000 patients; P = .01).
However, there was no difference in the proportion of patients who received fluoroquinolones at discharge among those treated at a hospital with stewardship vs those treated at a hospital without a stewardship program (28.0% vs 31.8%; P = .36).
In addition, for nearly half (45.8%) of patients who received a fluoroquinolone in hospitals with stewardship, fluoroquinolone treatment began after discharge, compared with only 18.8% at hospitals without stewardship.
“[H]ospital-based fluoroquinolone stewardship was associated with less inpatient fluoroquinolone use, but appeared to partially shift fluoroquinolone prescribing to discharge, attenuating its association with aggregate fluoroquinolone exposure. By failing to address antibiotic prescribing at discharge, stewardship interventions may limit their impact on patient safety,” the researchers conclude.
A limitation of the study was that it did not address the appropriateness of prescribing fluoroquinolones. The study also considered only two stewardship strategies.
The study was supported by Blue Cross and Blue Shield of Michigan and Blue Care Network as part of their Value Partnerships program. The authors have disclosed no relevant financial relationships.
Clin Infect Dis. Published online February 13, 2019. Full text
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