Highlights
- Prospective audit and feedback (PAF) at discharge significantly improved the rate of optimal antibiotic prescribing from 46.2% to 58.8% (OR 1.61).
- The intervention did not reduce the overall proportion of patients receiving post-discharge antibiotics (21.9% at baseline vs. 21.8% during intervention).
- There were no significant differences in inpatient antibiotic duration, hospital length of stay, or 30-day readmission rates between the two periods.
- Frontline prescribers expressed high satisfaction, with 94.4% believing the initiative improved discharge-related prescribing practices.
The Hidden Frontier of Antibiotic Stewardship: The Hospital Discharge
For decades, hospital-based antibiotic stewardship (AS) programs have focused their efforts on the inpatient setting—optimizing empirical therapy, promoting de-escalation, and enforcing IV-to-oral transitions. However, the point of hospital discharge remains a significant and often overlooked gap in stewardship efforts. Research suggests that up to 50% of antibiotics prescribed at discharge are unnecessary or suboptimal, often involving excessive durations or inappropriate spectrum of activity. This “discharge stewardship gap” contributes significantly to the global burden of antimicrobial resistance, adverse drug events, and Clostridioides difficile infections.
The transition of care from the inpatient team to the outpatient setting is notoriously chaotic. Discharge prescriptions are frequently written by junior residents or rotating staff who may not have been present for the initial diagnosis or the early clinical course. Furthermore, the pressure to expedite discharge often leads to the use of “default” durations (e.g., a standard 7-day or 10-day course) regardless of the inpatient days already completed. To address this, the study by Livorsi et al. investigated whether a systematic prospective audit and feedback (PAF) mechanism specifically targeting the discharge window could mitigate antibiotic overuse.
Methodology: A Stepped-Wedge Cluster-Randomized Approach
This study employed a stepped-wedge cluster-randomized clinical trial design, conducted across 10 hospitals from December 2022 to November 2023. This design is particularly robust for evaluating health system interventions, as it allows all participating sites to eventually receive the intervention while maintaining a randomized schedule for the rollout. The trial included a 24-week baseline period, after which one hospital transitioned into the intervention arm every two weeks.
The study population was large and diverse, encompassing 21,842 patient admissions. The participants had a median age of 66 years, and the cohort was predominantly male (61.3%). By including 10 different hospitals, the researchers aimed to capture a realistic cross-section of antibiotic stewardship practices across varying institutional cultures and resource levels.
The Intervention: Discharge-Focused Prospective Audit and Feedback
The intervention was two-pronged. First, institutional guidelines for oral antibiotic step-down and appropriate durations for common infections (such as community-acquired pneumonia, urinary tract infections, and skin/soft tissue infections) were disseminated to frontline prescribers. Second, AS teams conducted a prospective audit and feedback process. This involved reviewing the charts of inpatients receiving antibiotics who had an anticipated discharge date within the next 48 hours. When the AS team identified an opportunity for optimization—such as shortening a duration, changing to a narrower-spectrum agent, or discontinuing therapy altogether—they provided direct feedback to the frontline prescribers.
Key Findings: Quality Over Quantity
Primary Outcome: Post-Discharge Antibiotic Use
Despite the intensive efforts of the stewardship teams, the primary outcome of the study—the overall volume of post-discharge antibiotic use—did not show a statistically significant decrease. At baseline, 21.9% of patients were prescribed antibiotics at discharge, compared to 21.8% during the intervention period (odds ratio [OR], 0.94; 95% CI, 0.84-1.05). Furthermore, the mean duration of post-discharge antibiotics remained nearly identical, with 7.1 days at baseline and 7.6 days during the intervention (mean difference, 0.02 days).
Secondary Outcomes and Safety Metrics
The study also monitored several secondary outcomes to ensure that the intervention did not inadvertently harm patients or increase hospital workload. There were no significant changes in the duration of inpatient antibiotic use (4.4 days vs. 4.2 days) or the total hospital length of stay (5.4 days in both groups). Most importantly, from a safety perspective, the 30-day hospital readmission rate remained stable (OR, 1.02; 95% CI, 0.88-1.18), suggesting that stewardship efforts did not lead to undertreatment of infections.
The Silver Lining: Improvements in Optimal Prescribing
While the total volume of antibiotics did not drop, the *quality* of the prescriptions that were written improved significantly. Through manual electronic health record reviews of 434 cases, the researchers assessed whether the discharge prescriptions met criteria for “optimal” prescribing. In the intervention group, 58.8% of cases were deemed optimal, compared to 46.2% at baseline (OR, 1.61; 95% CI, 1.08-2.40). This suggests that while the stewardship teams were not stopping antibiotics entirely, they were successful in ensuring the right drug was given for the right duration when an infection was present.
Expert Commentary and Clinical Interpretation
The Disconnect Between Quality and Volume
The most striking finding of this trial is the disconnect between improving the quality of prescriptions and reducing the overall volume. This suggests that the “momentum” of antibiotic therapy is difficult to break at the point of discharge. Clinical inertia often dictates that if a patient has been on a treatment course, they should finish it, even if clinical evidence suggests a shorter course would suffice. The AS teams audited an average of 19.9 patients per week, but only about 25% of those audits resulted in actual feedback. This may indicate that many patients did not meet the specific criteria for intervention or that the AS teams were selective in their feedback to avoid “alert fatigue” among prescribers.
The Challenges of Discharge Timing
One of the primary hurdles in discharge stewardship is the unpredictable nature of the discharge itself. Providing feedback within a 48-hour window is difficult when discharge orders are often written in a rush on the morning of departure. If the AS team identifies an issue *after* the prescription has been sent to the pharmacy and the patient has left the building, the opportunity for intervention is lost. This highlights the need for more integrated, real-time decision support tools within the electronic health record that can provide guidance at the exact moment the discharge order is being entered.
Prescriber Acceptance
The post-intervention survey results were overwhelmingly positive. Among the frontline prescribers who responded, 94.4% believed the initiative improved prescribing. This high level of acceptance is crucial for the long-term sustainability of AS programs. It suggests that clinicians are not resistant to stewardship; rather, they may simply lack the time or specific expertise to optimize every discharge prescription amidst their other responsibilities.
Study Limitations
While the study was well-designed, several limitations must be considered. First, the per-protocol analysis might overestimate the intervention’s effect in some areas while underestimating the logistical challenges of a real-world rollout. Second, the manual review for “optimal prescribing” was limited to a subset of common diagnoses, which may not represent the full spectrum of infectious diseases seen in a general hospital population. Finally, the study was conducted within a single year; longer-term follow-up would be needed to determine if these improvements in quality are maintained or if they eventually lead to a reduction in antibiotic volume as institutional culture shifts.
Conclusion: Where Do We Go From Here?
The trial by Livorsi et al. demonstrates that discharge-focused prospective audit and feedback is an effective tool for improving the appropriateness of antibiotic therapy, but it is not a panacea for reducing overall antibiotic use. To achieve a significant reduction in the volume of post-discharge antibiotics, AS programs may need to move beyond simple feedback and toward more structural changes. This could include mandatory “antibiotic timeouts” at discharge, automated duration limits based on the diagnosis, or the implementation of “handshake stewardship” where stewardship teams and clinical teams review every discharge plan together.</n
Ultimately, the transition of care remains a vulnerable period for medication errors and suboptimal therapy. This study provides a valuable roadmap for hospitals looking to extend their stewardship efforts beyond the inpatient ward, emphasizing that even when we cannot reduce the quantity of antibiotics, we can—and should—strive to improve their quality.
Funding and Clinical Trial Registration
This study was supported by various institutional antibiotic stewardship funds and supporting staff at the 10 participating hospitals. ClinicalTrials.gov Identifier: NCT05471726.
References
- Livorsi DJ, Thompson AM, Green MS, et al. Prospective Audit and Feedback by Antibiotic Stewardship Teams to Reduce Antibiotic Overuse at Hospital Discharge: A Stepped-Wedge Cluster-Randomized Clinical Trial. JAMA Netw Open. 2026;9(1):e2549655. doi:10.1001/jamanetworkopen.2025.49655.
- Vaughn VM, Flanders SA, Schiff GD, et al. The “Stewardship Gap”: Antibiotic Prescribing at Hospital Discharge. Clin Infect Dis. 2020;71(8):1915-1922.
- CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019.
