Impact of clinical pharmacist discharge prescription review on the appropriateness of antibiotic therapy: a retrospective comparison

BACKGROUND: Inappropriate antibiotic prescribing upon hospital discharge has been identified as a significant problem. Despite high rates of antibiotic prescription errors, there is no widely accepted antimicrobial stewardship initiative to prevent such errors. AIM: The primary objective of this study was to determine the impact of hospital-based clinical pharmacist discharge prescription review on the appropriateness of antibiotic prescriptions. METHOD: This was an observational study comparing the appropriateness of hospital discharge antibiotic prescriptions between two similar internal medicine services. One cohort of patients was admitted to medicine services where rounding clinical pharmacists performed routine antibiotic discharge assessment, and the comparator cohort was admitted to hospitalist services without routine pharmacist discharge antibiotic review. RESULTS: Our study included 150 cases per cohort. Baseline characteristics were similar between groups, except for increased age (p = 0.025) and fewer cases of acute bacterial skin & skin structure infections (p = 0.001) in the hospitalist cohort. Antibiotic appropriateness was considerably greater in the medicine (pharmacist) group versus hospitalist group [(83% versus 54%, respectively (p < 0.00001)]. The difference in appropriateness was mainly driven by pneumonia and urinary tract infection prescriptions. CONCLUSION: Appropriateness of antibiotic prescriptions significantly improved in the setting of pharmacist discharge review. This initiative highlights the important role of clinical pharmacists in outpatient antimicrobial stewardship.