Journal article
Prospective Audit and Feedback by Antibiotic Stewardship Teams to Reduce Antibiotic Overuse at Hospital Discharge: A Stepped-Wedge Cluster-Randomized Clinical Trial
JAMA network open, Vol.9(1), e2549655
01/02/2026
DOI: 10.1001/jamanetworkopen.2025.49655
PMCID: PMC12789953
PMID: 41511774
Abstract
Antibiotics prescribed at hospital discharge are frequently unnecessary or suboptimal. Strategies to improve prescribing are not well defined.
To evaluate whether a discharge-focused prospective audit and feedback process decreases antibiotic overuse at hospital discharge.
This stepped-wedge cluster-randomized clinical trial was conducted across participating units at 10 hospitals with antibiotic stewardship (AS) teams and supporting staff from December 5, 2022, to November 17, 2023. After a 24-week baseline period, 1 hospital crossed into the intervention arm every 2 weeks.
The intervention consisted of disseminating institutional guidelines for oral antibiotic step-down to frontline prescribers and conducting a prospective audit and feedback process for inpatients receiving antibiotics with an anticipated discharge date in the next 48 hours.
The primary outcome was postdischarge antibiotic use. Secondary outcomes included inpatient antibiotic use, length of hospital stay, and readmission. Manual electronic health record reviews were performed in 434 cases to assess optimal antibiotic prescribing at discharge for patients who met specific criteria. Analysis was performed on a per-protocol basis.
There were 21 842 patient admissions (baseline, 14 288; intervention, 7554) across 10 hospitals. The median (IQR) age was 66 (53-75) years, with 13 380 (61.3%) males. At the hospital level, the mean (SD) number of patients audited by the AS team per week was 19.9 (5.8); approximately one-quarter of these audits (mean [SD], 5.0 [2.6]) resulted in feedback to the frontline prescribers. There were 3133 patients (21.9%) prescribed postdischarge antibiotics at baseline compared with 1645 patients (21.8%) during the intervention (odds ratio, 0.94 [95% CI, 0.84-1.05]). The mean (SD) postdischarge antibiotic duration was 7.1 (5.2) days at baseline compared with 7.6 (5.6) days during the intervention (mean difference, 0.02 [95% CI, -0.50 to 0.53] days). There were no statistical differences during the intervention compared with baseline for inpatient antibiotic duration (mean [SD], 4.4 (3.6) vs 4.2 [3.5] days; mean difference, 0.04 [95% CI, -0.20 to 0.27] days), length of hospital stay (mean [SD], 5.4 [4.8] vs 5.4 [5.0] days; mean difference 0.11 [95% CI, -0.12 to 0.33] days), or hospital readmission within 30 days (odds ratio, 1.02 [95% CI, 0.88-1.18]). Optimal antibiotic prescribing was more common during the intervention (122 of 264 cases [46.2%] vs 100 of 170 cases [58.8%]; odds ratio, 1.61 [95% CI, 1.08-2.40]). A total of 112 inpatient frontline prescribers were sent a postintervention survey; 40 (35.7%) responded, and 34 of 36 (94.4%) believed that the initiative improved antibiotic prescribing at hospital discharge.
In this stepped-wedged cluster-randomized clinical trial conducted across 10 hospitals, discharge-focused prospective audit and feedback did not decrease antibiotic use at hospital discharge but did improve optimal antibiotic prescribing for common and uncomplicated diagnoses. Other AS strategies are needed to decrease unnecessary antibiotic prescribing at this transition of care.
ClincialTrials.gov Identifier: NCT05471726.
Details
- Title: Subtitle
- Prospective Audit and Feedback by Antibiotic Stewardship Teams to Reduce Antibiotic Overuse at Hospital Discharge: A Stepped-Wedge Cluster-Randomized Clinical Trial
- Creators
- Daniel J Livorsi - University of IowaAlyssa M Thompson - Barnes-Jewish West County HospitalMelissa S Green - Barnes-Jewish West County HospitalAngela C Hoelscher - Barnes-Jewish West County HospitalKailye K Chu - Barnes-Jewish West County HospitalElizabeth Neuner - Barnes-Jewish HospitalYvonne Burnett - Missouri Baptist Medical CenterTeri Hopkins - Audie L. Murphy Memorial VA HospitalElizabeth Walter - Audie L. Murphy Memorial VA HospitalRohini Dave - VA Maryland Health Care SystemRavi Tripathi - VA Maryland Health Care SystemHaylie Lohmar - Richard L. Roudebush VA Medical CenterAndrew Dysangco - Richard L. Roudebush VA Medical CenterKelly Percival - University of IowaDilek Ince - University of Iowa, Infectious DiseasesJessica Kolkmeyer - St. Louis Christian CollegeHelen Newland - BJC HealthCareMichael Joshua Hendrix - Washington University in St. LouisGosia Clore - University of IowaCody Poe - University of Iowa Health CareAmy O'Shea - University of Iowa, General Internal MedicineJoseph Tholany - University of IowaKunatum Prasidthrathsint - University of IowaErin Rachmiel - Washington University in St. LouisJahnavi Bongu - Washington University in St. LouisAlice Bewley - Washington University in St. LouisKevin Hsueh - Washington University in St. Louis
- Resource Type
- Journal article
- Publication Details
- JAMA network open, Vol.9(1), e2549655
- DOI
- 10.1001/jamanetworkopen.2025.49655
- PMID
- 41511774
- PMCID
- PMC12789953
- NLM abbreviation
- JAMA Netw Open
- ISSN
- 2574-3805
- eISSN
- 2574-3805
- Publisher
- AMER MEDICAL ASSOC
- Grant note
- CDC Prevention EpiCenter program
This work was funded by the CDC Prevention EpiCenter program.
- Language
- English
- Date published
- 01/02/2026
- Academic Unit
- Infectious Diseases; Pathology; General Internal Medicine; Internal Medicine
- Record Identifier
- 9985116067302771
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