Focus on Antimicrobial Stewardship During Care Transitions

You can help ensure patients get the correct duration of antimicrobial treatment during transitions of care.

Many courses are completed after discharge...and limited evidence suggests 80% of patients are treated 4 days longer than recommended.

Start by re-educating clinicians about appropriate durations.

For example, the latest data suggest a 7-day course is sufficient for most UNcomplicated gram-negative bacteremias...such as a hemodynamically stable, immunocompetent patient with source control.

Use our When Are Shorter Courses Better? chart for details about UTIs, pneumonia, intra-abdominal infections, etc.

Then incorporate strategies to keep appropriate antibiotic durations from unraveling during transitions of care.

For patients admitted on antibiotics, ask how many doses or days of therapy they’ve taken...it may be different than prescribed.

If needed, call the pharmacy or primary care prescriber...and check records from recent admissions.

When adjusting orders, review total antibiotic days...and EHR auto stops...especially during ICU-to-floor transfers.

For example, if switching from IV to PO after 5 days of IV, adjust the oral auto stop to 2 days...instead of defaulting to 7.

Double-check stop dates when de-escalating. For instance, if narrowing from cefepime to ceftriaxone, keep the stop date from the cefepime order.

Also keep the original stop date when making renal adjustments.

Ask admin about having a pharmacist review every antibiotic discharge order...to catch duration errors that may pop up when discharge Rxs are generated.

For transfers to outside facilities, document antibiotic days clearly, such as “day 5 of 7,” along with the start and stop dates.

Key References
  • Hosp Pharm Published online Jun 15, 2020; doi:10.1177/0018578720928265
  • BMC Infect Dis 2018;18(1):225
  • Clin Infect Dis 2019;69(7):1091-8
  • Am J Health Syst Pharm 2020;77(12):943-9
Prescriber's Letter. August 2020, No. 360818


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