Pharmacist-led antimicrobial stewardship at transitions of care from inpatient hospital to home: a scoping review

Abstract

Objective:

To summarize available literature and highlight research gaps pertaining to the role of a pharmacist in providing antimicrobial stewardship (AMS) interventions for antibiotics at transitions of care (TOC) from inpatient hospital settings to home.

Design:

Scoping review.

Methods:

This scoping review follows the Arksey and O’Malley methodological framework. The literature search was conducted using the MEDLINE (OVID) database.

Results:

The MEDLINE (OVID) search returned 45 results. Of these, 26 were excluded during title and abstract screening and 11 were excluded after full-text review. Overall, eight studies were included in this scoping review. In six of the studies, AMS interventions were pharmacist-led. In two studies, they were led by an AMS team which included a pharmacist. Six of the studies used a similar intervention where a pharmacist led the review of antibiotics prior to patient discharge and made recommendations to change therapy where appropriate. The details of how these interventions were carried out vary between studies.

Conclusions:

Overall, all studies included in this scoping review concluded that pharmacists have a role in providing AMS interventions at TOC. This scoping review summarized available literature pertaining to the role of the pharmacist in providing AMS interventions for antibiotics at TOC. Research gaps that were highlighted are optimal level of AMS training for pharmacists providing AMS interventions, optimal workflow, ideal method of communication to the prescriber, and quality improvement metrics.

Introduction

Antimicrobial resistance is a top global public health threat, affecting all countries at all income levels. ¹ In 2019, an estimated 4.95 million deaths were associated with bacterial antimicrobial resistance. ² Of those, approximately 1.27 million were attributable to bacterial antimicrobial resistance. ² Antimicrobial resistance creates the need for more costly and intensive care, while also affecting the productivity of patients and their caregivers. ¹ Notably, data from across the globe exhibits concerning rates of third-generation cephalosporin-resistant E. coli and methicillin-resistant Staphylococcus aureus. ¹

Antimicrobial stewardship (AMS) helps limit the development of organisms resistant to antimicrobials through the promotion of judicious use. ³ Many hospitals have a formal Antimicrobial Stewardship Program (ASP) which supports the implementation of interventions that improve and measure the appropriate use of antimicrobials (selection, dosing, duration of therapy, and route of administration). ³ Pharmacists often play a large role in ASP, with responsibilities that include but are not limited to (1) reviewing patient antimicrobial regimens; (2) influencing choice of antimicrobials through formulary restrictions, decision support systems, and practice guidelines; (3) offering guidance with regards to dosage, preparation, and administration of antimicrobials; (4) ensuring proper antimicrobial duration of therapy; and (5) assessing antimicrobial prescriptions provided at discharge. ⁴ Although antibiotics are commonly prescribed at transitions of care (TOC) (eg, inpatient hospital discharge to home), review of antibiotics at hospital discharge is not a common function of an ASP.

A study published in 2020 by Brower et al sought to assess total antibiotic duration for patients with select infectious disease (ID) diagnoses across TOC from the inpatient to outpatient setting. ⁵ This was done through retrospective analysis of discharge prescriptions for patients admitted to general surgery and medicine services at an academic medical center. ⁵ A total of 101 patients were included in the study. ⁵ The researchers found that most patients (81%) were prescribed antibiotics longer than was recommended by national guidelines with only 3% of patients receiving less than the recommendation. ⁵ These study results highlight a gap in patient care and a potential opportunity for evaluation of antibiotic use at TOC. ⁵

Pharmacists, as medication experts, are well positioned to tailor antimicrobial therapy (eg, dosing, choice of antimicrobial, drug interactions) at the time of TOC from inpatient hospital settings to home. The extent of the literature published on this topic is not currently known, and research gaps have not yet been highlighted.

Objectives

The primary objective of this scoping review is to summarize available literature pertaining to the role of the pharmacist in providing AMS interventions for antibiotics at TOC from inpatient hospital settings to home. The secondary objective is to highlight research gaps pertaining to this topic.

Methods

This scoping review was conducted using the Arksey and O’Malley methodological framework. ⁶ This framework is comprised of five stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. ⁶

Identifying the research question

The research question for this scoping review was: what is known from the existing literature about the role of pharmacists in AMS interventions at the time of hospital discharge? From this, three key concepts were identified: pharmacists, AMS, and TOC. The author, Mishka Danchuk-Lauzon (MDL), consulted with a librarian to create a search strategy.

Identifying relevant studies

The literature search strategy used for this scoping review is provided in Appendix 1. The search was conducted through the MEDLINE database on January 3, 2023.

Study selection

After briefly screening the literature, inclusion and exclusion criteria were developed to help with study selection. Studies detailing pharmacist-led AMS interventions with regard to antibiotics at TOC (inpatient to outpatient/home) were included. The exclusion criteria for this study were as follows: focus on pediatric patients (<18 years of age), pharmacists included but not involved in a primary role, focus on a single disease state, and focus on an emergency medicine setting. The above were excluded as this scoping review was focused on adult patients with TOC from an inpatient hospital setting to outpatient/home with treatment of any disease. The role of pharmacists is a key element in the research question, and thus, they must have been involved in the AMS interventions. Figure 1 provides an overview of the study selection process. Study abstracts and titles were screened by MDL using Covidence software. Subsequently, full-text review of articles was completed by MDL. Citations were managed through EndNote 20.

Figure 1. Flow diagram of included studies.

Charting the data

Key information was charted in Microsoft Excel for Mac (version 16.73). The following information was recorded: authors, year published, country, study design, setting, time frame, TOC type, whether or not the intervention was pharmacist-led, intervention, number of participants in intervention group, control/comparator, number of participants in the control group, results, and conclusion.

Collating, summarizing, and reporting the results

The summarized data in table format can be found in Tables 1 and 2 and are described below. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation was completed to ensure this scoping review met required standards (see supplementary material). ⁷

Table 1. Overview of studies

TOC, transition of care; ID, infectious disease; AMS, antimicrobial stewardship; QI, quality improvement; RXs, prescriptions; PGY-2, postgraduate year two.

Table 2. Comparison of studies

AMS, antimicrobial stewardship; TOC, transitions of care; DRP, drug-related problem; ID, infectious disease; ASP, Antimicrobial Stewardship Program; ME, medication error; RXs, prescriptions; D/C, discharge.

Results

Study characteristics

The MEDLINE search returned 45 results. Of these, 26 were excluded during the title and abstract screening (see Figure 1 for more detail). Subsequently, 19 studies were considered for inclusion in the scoping review. Of these, nine were excluded as they were focused on an emergency medicine setting; one was excluded as it focused on an outpatient setting (urgent care center), and one was excluded as it did not contain a specific intervention. Overall, eight studies were included in this scoping review. ^8–15 All studies were conducted in the United States, except for the study by Chavada et al, which was conducted in Australia. ^8–15 Five of the studies were prospective and three of them were retrospective. ^8–15 The study time frame ranged from 4 weeks to 1 year, and the studies were all conducted between 2013 and 2021. ^8–15 All studies were published between 2018 and 2022. ^8–15 Most were single-center studies in a wide range of institutions such as teaching hospitals, non-teaching hospitals, community hospitals, tertiary care centers, and a quaternary care center. ^8–12,14,15 The study by Mercuro et al was conducted in a health system that included one academic tertiary center and four community hospitals. ¹³ The number of participants in the intervention group ranged quite widely with the study by Leia et al, being the one with the most participants (1,100 participants), and the study by Manis et al, being the one with the least participants (20 participants). ^8–15

Overview of interventions

The type of intervention varied across the included studies. In six of the studies, AMS interventions were pharmacist-led. ^9–14 In two studies, they were led by a team which included a pharmacist (these were AMS teams). ^8,15 The type of TOC was not explicitly stated in any study. In Parsels et al, the type of TOC is not specified, but all prescriptions reviewed were sent to the outpatient hospital pharmacy. ¹⁴ It is implied in other studies that transitions are to an outpatient setting. ^8–13,15 All studies concluded that pharmacists have a role in providing AMS interventions at TOC. ^8–15

Retrospective audit of interventions

The study by Chavada et al retrospectively audited patient discharge prescriptions that were processed by the pharmacy department and noted whether any interventions were performed by the AMS team (which included a pharmacist). ⁸ They found that of the discharge prescriptions that contained antimicrobials, 74% were appropriate for choice of antimicrobial, 64% for the dose and frequency, and 21% for the duration of therapy. ⁸ If the AMS team was involved, discharged prescriptions were more likely to be appropriate. ⁸

Postdischarge intervention

The intervention in the study by Jones et al was conducted postdischarge. ¹⁰ In their study, they followed up on unresolved cultures and whether the pathogen was susceptible to the prescribed antimicrobials, if not susceptible, a recommendation to change therapy was made to the prescriber. ¹⁰ When compared to a historical cohort, there was a 3.6-fold increase in AMS-related interventions among the discharged patients; additionally, inappropriate outpatient antimicrobial use was reduced by 39%. ¹⁰

Predischarge intervention

The remaining six studies all used a similar intervention where a pharmacist facilitated the review of antimicrobials prior to patient discharge and made recommendations to change therapy where appropriate. ^9,11–16 The details of how these interventions were carried out vary slightly between studies. ^9,11–16 For example, in the study by Parsels et al, discharge prescriptions for antimicrobials sent to the hospital outpatient pharmacy were reviewed by the inpatient ID pharmacist (who was alerted by the outpatient pharmacist of these). ¹⁴ Prescribers were then contacted if issues were identified and recommendations were made. ¹⁴ In the study by Leja et al, TOC pharmacists reviewed discharge medication lists to optimize their pharmacological therapy (including antimicrobials). ¹¹ Prescribers were then contacted if issues were identified and recommendations were made. ¹¹ Results of these studies are summarized in Tables 1 and 2.

Discussion

All studies included in the scoping review highlighted the opportunity or importance of pharmacist-led AMS interventions at discharge. ^8–15 From the literature summarized in the scoping review, key elements have been identified that need to be considered for the successful implementation of AMS interventions by pharmacists at discharge.

AMS training

Pharmacists included in the studies had varied backgrounds, these included AMS, ID, TOC, and no specialization. ^8–15 It is not clear from the literature whether an AMS intervention at TOC has the same impact when recommended by a pharmacist specialized in AMS/ID compared to a pharmacist with no specialization. This needs to be clarified as many ASPs may not be able to receive additional funding and expand their activities to patients at TOC. For pharmacists with no specialized training in AMS/ID, it would be helpful to define the type of training needed to provide AMS interventions, ensuring that this practice is generalizable.

Workflow

Workflows vary greatly across hospitals, as evidenced by the various approaches to AMS interventions described in studies included in this scoping review. Therefore, the optimal approach to implementing AMS interventions is likely site specific with established guiding principles. Establishing the AMS interventions as routine practice and communicating impact is likely important for consistency. AMS interventions may become a component of an already established workflow where a pharmacist is involved (such as medication reconciliation on discharge) for ease of implementation.

Additional research is needed regarding optimal timing for the AMS intervention. In five of the studies reviewed, the AMS intervention was conducted prior to discharge. ^9,12–15 In one of the studies, it was conducted after discharge. ¹⁰

Interprofessional communication

A crucial step in conducting AMS interventions is the communication to the prescriber of the recommendation. ^9,10,12–15 Consideration should be made for the way in which AMS interventions are communicated for successful implementation while avoiding delays in patient care. Responsibilities regarding order adaptation and patient counseling also need to be defined.

For individual institutions, the process should be mapped prior to being implemented. There may be process barriers to implementation such as Electronic Health Record limitations, medical directives that need to be put into place, and inadequate staffing.

Quality improvement

Metrics need to be defined that can be used to assess the success of implementation of pharmacist-led AMS interventions at TOC. It will be important to track the impact of pharmacist-led AMS interventions on appropriate baseline metrics. This data can be used for continuous quality improvement, increased funding, and identification of gaps in the process.

Strengths and limitations

This scoping review has many strengths. First, this scoping review provides a comprehensive overview of the available literature related to the research question. Second, this scoping review highlights research gaps and provides direction for future research. Third, the methodology used to conduct this scoping review is commonly used and easily replicable. Finally, the literature included in this scoping review is quite diverse with regard to methodology, size, and type of intervention.

This scoping review carries some limitations. First, due to the nature of scoping review methodology, the quality of studies was not assessed. Second, only one database was searched for literature. However, MEDLINE OVID is one of the most widely used databases for medical research, and the search was conducted with the help of a librarian to ensure it was comprehensive.

Overall, the literature included in this scoping review suggests that pharmacist-led AMS interventions prior to discharge from an inpatient hospital setting to home is a potentially beneficial strategy for reducing inappropriate antibiotic use at TOC. Many evidence gaps were highlighted that need to be addressed for successful implementation of these interventions. Further research should be conducted to determine: optimal level of AMS training for pharmacists providing AMS interventions, ideal workflow, ideal method of communication with the prescriber, and quality improvement metrics.