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86 Antimicrobial Stewardship Through Mandatory Pre-Discharge Infectious Disease Consultation for Community-based Parenteral Anti-infective Therapy

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Nabin K. Shrestha, MD, MPH , Cleveland Clinic, Cleveland, OH
Archana Bhaskaran, MD , Cleveland Clinic, Cleveland, OH
Nikole M. Scalera, MD, MS , Cleveland Clinic, Cleveland, OH
Steven K. Schmitt, MD , Cleveland Clinic, Cleveland, OH
Susan J. Rehm, MD , Cleveland Clinic, Cleveland, OH
Steven M. Gordon, MD , Cleveland Clinic, Cleveland, OH
Background: Community-based parenteral anti-infective therapy (CoPAT) is the administration of parenteral antibiotics after hospital discharge. Infectious disease (ID) evaluation before hospital discharge can be expected to provide antimicrobial stewardship in this process by reducing unnecessary antibiotic use.

Objective: To describe the antimicrobial stewardship function provided by mandatory ID consultation for CoPAT.

Methods: The Cleveland Clinic has a policy of mandatory ID consultation for CoPAT. All discharges from Feb 15, 2010 to May 14, 2010 where the ID service was consulted for consideration of CoPAT were reviewed to determine the proportions where CoPAT was approved or denied. Emergency department (ED) visits and rehospitalizations within 30 days of hospital discharge were compared for the patients in whom CoPAT was approved and denied.

Results: Over a three-month period, there were 244 hospital discharges after ID consultation for CoPAT. Parenteral antibiotics were felt not to be warranted in 69 (28%) of these discharges, and CoPAT was denied. Outpatient ID follow-up appointments with the same physician who saw the patient in hospital were scheduled for 150 (90%) of 175 patients discharged on CoPAT and 17 (32%) of the 69 patients denied CoPAT. Twenty-seven (39%) of the 69 patients denied CoPAT visited the ED or were readmitted within 30 days compared with 46 (26%) of 129 discharged on CoPAT (OR 1.80, 95% C.I. 0.99 – 3.29, p-value 0.05). For the 27 patients denied CoPAT who visited the ED or were readmitted, reasons for ED visit or readmission were: new clinical problem [18 pts], worsening of existing chronic condition [6], lack of access to clinician (for pain medications) post discharge [2], and elective readmission for surgery [1]. No ED visit or readmission was related to lack of parenteral antibiotic at discharge. 

Conclusions: Mandatory ID consultation for CoPAT substantially reduces unnecessary parenteral antibiotic therapy at hospital discharge, thus serving as a powerful and effective antimicrobial stewardship strategy.