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Hospital-based stewardship programs designed to reduce the rate of Clostridium difficile infections and antibiotic-related adverse events were associated with reduced use of fluoroquinolone antibiotics during hospitalization, but not at hospital discharge, researchers reported.

In a study involving 48 Michigan hospitals, including 46 with antibiotic stewardship programs, one in three patients hospitalized for pneumonia or urinary tract infections (UTIs) were prescribed fluoroquinolone antibiotics at discharge.

A total of 16% of patients were discharged on fluoroquinolones after receiving other antibiotics during hospitalization, reported Valerie Vaughn, MD, of Michigan Medicine and the VA Ann Arbor Health System, and colleagues, in their study online in .

"In hospitals targeting fluoroquinolone use, the fact that 16% of patients were newly started on fluoroquinolones at discharge was a huge surprise to us," Vaughn told MedPage Today. "There may be times when this is appropriate, but 16% of patients is definitely too large."

She said that when the researchers shared the data with the discharging hospitals, it was a surprise to them as well. Vaughn noted that most stewardship programs did a good job of monitoring antibiotic use among patients while they were hospitalized, but prescribing practices at discharge have not been on their radar.

"I think this study shows that we need to really be mindful of what we are prescribing at discharge, not just during hospitalization," she said. "Stewardship programs need to provide that guidance."

The researchers noted that as many as half of hospitalized patients receive antibiotics, and the most common reasons for antibiotic treatment are for pneumonia or urinary tract infections (UTIs).

Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin, moxifloxacin) have been strongly linked to increased rates of C. diff infection. Use of the drugs has also been increasingly linked to rare, but serious, side effects including tendon rupture, aortic rupture, and irreversible nerve damage.

Hospital antibiotic stewardship programs designed to reduce the use of fluoroquinolones utilize strategies such as pre-prescription approval or prospective audit and feedback, but Vaughn said the impact of these strategies on use of the drugs after hospital discharge has not been well understood.

Study Details

The newly published retrospective study included a cohort of general-care medical patients hospitalized with pneumonia or positive urine culture from December 2015 to September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship).

After controlling for hospital clustering and patient factors, the researchers compared aggregate (inpatient and post-discharge) fluoroquinolone exposure between hospitals with and without fluoroquinolone stewardship.

A total of 11,748 patients (6,820 pneumonia; 4,928 positive urine culture) treated at 48 hospitals were included in the study. In all, 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing.

Among the main findings:

• After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P=0.01)
• Stewardship was also associated with fewer fluoroquinolone treatment days per 1,000 patients (2,282 vs 3,096 days/1,000 patients; P=0.01), driven by lower inpatient prescribing
• Most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P=0.003)

"Hospital-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," the team wrote.

Vaughn explained that fluoroquinolone antibiotics have been widely prescribed in the past because they can be given orally, treat a broad spectrum of infections, and can be used in patients who are allergic to penicillin.

Recent studies have found that the vast majority of people who believe they are allergic to penicillin are not, and Vaughn said clinicians can often determine which patients can safely be treated with the drug by taking a careful history. "It is often possible to tease out from their history if they did or did not have an allergy to penicillin," she added.

The researchers concluded that the study findings have important implications for clinical practice, and they called on hospital stewardship programs to implement discharge guidelines.

"By failing to address antibiotic prescribing at discharge, stewardship interventions may limit their impact on patient safety," the team wrote.

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