See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/225059283

Antibiotic stewardship and early discharge from hospital: Impact of a

structured approach to antimicrobial management

Article  in  Journal of Antimicrobial Chemotherapy · May 2012

DOI: 10.1093/jac/dks193 · Source: PubMed

CITATIONS READS

51 1,189

12 authors, including:

Matthew Dryden Kordo Saeed

Public Health England Hampshire Hospitals NHS Foundation Trust
179 PUBLICATIONS   3,693 CITATIONS    67 PUBLICATIONS   319 CITATIONS   

SEE PROFILE SEE PROFILE

Rob Townsend Natalie Parker

Sheffield Teaching Hospitals NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust
37 PUBLICATIONS   231 CITATIONS    6 PUBLICATIONS   60 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

From Himalayas across Rockies to the Alps: Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective.
Vom Hindukusch über Rockies in die Alpen: Verbesserung der Facharztausbildung im Bereich Orthopädie und Unfallchirurgie und Integration View project

ESPAUR View project

All content following this page was uploaded by Kordo Saeed on 17 March 2014.

The user has requested enhancement of the downloaded file.

J Antimicrob Chemother 2012; 67: 2289 – 2296
doi:10.1093/jac/dks193 Advance Access publication 23 May 2012

Antibiotic stewardship and early discharge from hospital: impact of a

structured approach to antimicrobial management
M. Dryden1*, K. Saeed1, R. Townsend2, C. Winnard2, S. Bourne1, N. Parker1, J. Coia3, B. Jones3, W. Lawson4,
P. Wade5, P. Howard6 and S. Marshall7

1
Royal Hampshire County Hospital, Winchester SO22 5DG, UK; 2Northern General Hospital, Sheffield S5 7AU, UK; 3Glasgow Royal
Infirmary, Glasgow G31 2ER, UK; 4Imperial College Healthcare NHS Trust, London, UK; 5Guys & St Thomas’s NHS Foundation Trust,
London SE1 7EH, UK; 6Leeds Teaching Hospitals NHS Trust, Leeds LS1 3BR, UK; 7pH Associates, Marlow SL7 1PG, UK

*Corresponding author. Tel: +44-1962-824451; Fax: +44-1962-825431; E-mail: matthew.dryden@hhft.nhs.uk

Received 16 January 2012; returned 1 March 2012; revised 18 April 2012; accepted 23 April 2012

Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013

Objectives: To assess the impact of an infection team review of patients receiving antibiotics in six hospitals
across the UK and to establish the suitability of these patients for continued care in the community.
Methods: An evaluation audit tool was used to assess all patients on antibiotic treatment on acute wards on a
given day. Clinical and antibiotic use data were collected by an infection team (doctor, nurse and antibiotic
pharmacist). Assessments were made of the requirement for continuing antibiotic treatment, route and dur-
ation [including intravenous (iv)/oral switch] and of the suitability of the patients for discharge from hospital
and their requirement for community support.
Results: Of 1356 patients reviewed, 429 (32%) were on systemic antibiotics, comprising 165 (38%) on iv+oral
antibiotics and 264 (62%) on oral antibiotics alone. Ninety-nine (23%) patients (including 26 on iv antibiotics)
had their antibiotics stopped immediately on clinical grounds. The other 330 (77%) patients (including 139 on iv
antibiotics) needed to continue antibiotics, although 47 (34%) could be switched to oral. Eighty-nine (21%)
patients were considered eligible for discharge, comprising 10 who would have required outpatient parenteral
antibiotic therapy (OPAT), 55 who were suitable for oral outpatient treatment and 24 who had their antibiotics
stopped.
Conclusions: Infection team review had a significant impact on antimicrobial use, facilitating iv to oral switch
and a reduction in the volume of antibiotic use, possibly reducing the risk of healthcare-associated complica-
tions and infections. It identified many patients who could potentially have been managed in the community
with appropriate resources, saving 481 bed-days. The health economics are reported in a companion paper.

Keywords: antibiotic treatment, hospital length of stay, OPAT, patient pathway

the community with continued antibiotic therapy, providing

Introduction
Management of infections within the hospital setting represents
a significant burden to the UK National Health Service (NHS).1
The current emphasis on cost control and managed care has
created an impetus to discharge patients as soon as possible
or avoid hospital admission altogether for therapeutic interven-
tions that have traditionally been delivered in hospitals.2,3 The
input of infection specialists in the assessment of severity of
infection and the management of antibiotics is important for
the quality of care as well as cost containment.4
For patients treated within the hospital setting, once the
acute infection has been controlled with intravenous (iv) or oral
antibiotics, it is possible for patients to be discharged back to
there is some support or monitoring in the community, over
and above that which would usually be expected in primary
care.5 Some hospitals offer outpatient parenteral antibiotic
therapy (OPAT) outside the hospital setting, and standards for
OPAT have been developed,6 – 10 and it is likely that a proportion
of patients can be switched from iv to oral treatment and can
continue their treatment by this route in the community.5
Early discharge of suitable patients with appropriate support
would free beds and secondary care NHS resources. This would
improve capacity, reduce cost, improve patient choice and
satisfaction, potentially reduce healthcare-associated infections
(HCAIs) and other complications and allow resources to be
re-allocated to increase patient throughput and decrease

# The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
For Permissions, please e-mail: journals.permissions@oup.com

2289
Dryden et al.
waiting times. Above all, being discharged from hospital and
receiving care at home would appear to be what most patients
want, according to the National Concern for Healthcare
Infections.11
An evaluation tool was developed to assist ward-based infec-
tion teams with antibiotic management and stewardship, but
also to assist assessment for early discharge. Early discharge cri-
teria were developed (Figure 1) by a working party of physicians,
surgeons, antimicrobial pharmacists and a patient representa-
tive. In a series of meetings, a structured discussion technique
(Delphi method) was used to establish the agreed criteria.
These criteria were included in the evaluation tool, a short
forma that allows details of antibiotic use, infection manage-
ment and discharge planning to be recorded.
The primary objective was to assess patients being treated for
infection with antibiotics in hospital, and to judge whether they
were receiving the most appropriate antibiotic, at the right
dose and the most appropriate route and whether they were
suitable for completing their treatment out of hospital. In add-
ition, the potential bed-day savings that might be realized if
the patient completed his/her antibiotic treatment out of
hospital was estimated, and a financial analysis is reported in
a companion paper.12
Methods
The evaluations were carried out prospectively by infection teams on
daily routine ward rounds in six hospital Trusts across the UK in 2010.
The individual hospitals were not comparable, as they varied in size,
specialties and function and included a mix of acute hospitals, general
Criteria for antibiotic change and early discharge: X – not essential,
iv/oral switch
Appropriate duration for clinical focus
based on guidelines/accepted practice
Able to tolerate and absorb oral Abx
Infection is resolving clinically and
inflammatory markers (WBC count and CRP)
are falling
No sepsis syndrome
Patient has no comorbidities
that may preclude them from
being sent home
Patient is medically fit for discharge
Post-discharge care plan in place
Figure 1. Criteria for antibiotic change and early discharge criteria. Abx, antibiotics.
2290
hospitals, teaching and specialist tertiary referral centres. The infection
teams were not uniform either, but this variation reflects the nature of
clinical infection teams in routine practice across the UK. At a
minimum they consisted of a physician trained in antibiotic management
(infectious diseases or microbiologist) and an antibiotic pharmacist. The
evaluation tool was the same across the sites.
Data were collected prospectively on acute medical and surgical
wards during routine ward rounds. Antibiotic management decisions
were made at that time and either acted on immediately by the infection
team or communicated immediately to the regular medical team. Anti-
biotic changes included stopping antibiotics and switching from iv to oral
administration (Figure 1). Any change in antibiotic use was documented
in the patient notes with a request for the regular team to contact the
infection team if there were any concerns or patient deterioration. A clin-
ical decision based on the early discharge criteria (Figure 1) was made at
the same time as to whether the patient needed to continue antibiotic
therapy in hospital or outside. However, this decision was purely academ-
ic to determine a potential early discharge date if the resources for out-
patient management had been available. The aim was to establish which
Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013
patients with infection might be suitable for early discharge if there
was suitable enhanced care and monitoring available in the community.
The methods and results of an economic assessment are reported in a
companion paper.12
Each patient’s suitability for discharge was formally assessed by using
the evaluation tool with agreed criteria for suitability/unsuitability for
discharge.
The criteria assessed for suitability for discharge were infection clinic-
ally stable or improving, resolution of fever and haemodynamically
stable, improving inflammatory markers [white blood cell (WBC) count
and C-reactive protein (CRP)], no complex infection requiring continued
hospital care and the absence of any other major factor preventing dis-
charge (co-morbidity, requirement for significant further medical or sur-
gical input requiring major rehabilitation or social services input, patient
- essential
Stop Abx Early discharge
× ×
× ×
× ×
× ×
× ×
Infection team impact on antibiotic management
or health team choice). All these criteria needed to be met to be suitable
for early discharge (Figure 1). In addition, for oral therapy, the patient
needed to be able to take fluids and food by mouth. All patients
judged to be suitable for discharge on the day of review were followed
up to find the actual date of discharge. The difference in days was the
bed-days that could have been saved if the patient had been discharged
on the day of review.
All data were recorded anonymously on a data collection form.
Patients were identified by a unique number on the data collection
form, which was linked to their hospital number and data via a log
that remained on the hospital premises. After collection, anonymized
JAC
data were entered into a study database for data cleaning and analysis,
and preparation of a report of results for each hospital.
Results
In the six hospitals a total of 1356 patients were reviewed, of
whom 429 (32%) were receiving antibiotics. Of these patients,
165 (38%) were on iv+oral antibiotics and 264 (62%) were on
oral antibiotics alone. The range of antimicrobial agents used
was extensive (Table 1). Ninety-nine (23%) patients on antibiotics

Table 1. Distribution of antibiotics prescribed, by route (not mutually exclusive)

Antibiotic iv prescriptions Oral prescriptions Total prescriptions Percentage of prescriptions

Co-amoxiclav 35 65 100 18
Amoxicillin 9 46 55 9.9

Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013

Flucloxacillin 20 34 54 9.7
Piperacillin/tazobactam am 54 54 9.7
Metronidazole 21 22 43 7.7
Doxycycline 42 42 7.6
Trimethoprim 36 36 6.5
Clarithromycin 2 26 28 5.0
Vancomycin 16 2 18 3.2
Benzylpenicillin 16 16 2.9
Meropenem 16 16 2.9
Ciprofloxacin 2 11 13 2.3
Clindamycin 3 5 8 1.4
Gentamicin 8 8 1.4
Cefalexin 6 6 1.0
Cefuroxime 6 6 1.0
Linezolid 6 6 1.0
Nitrofurantoin 5 5 0.9
Rifampicin 1 4 5 0.9
Teicoplanin 5 5 0.9
Sodium fusidate 4 4 0.7
Co-trimoxazole 1 2 3 0.5
Moxifloxacin 3 3 0.5
Azithromycin 2 2 0.4
Co-fluampicil 2 2 0.4
Levofloxacin 1 1 2 0.4
Oxytetracycline 2 2 0.4
Penicillin V 2 2 0.4
Cefradine 1 1 0.2
Ceftazidime 1 1 0.2
Ceftriaxone 1 1 0.2
Chloramphenicol 1 1 0.2
Colistin 1a 0.2
Ertapenem 1 1 0.2
Erythromycin 1 1 0.2
Ethambutol 1 1 0.2
Fluconazole 1 1 0.2
Rifampicin 1 1 0.2
Tobramycin 1 1 0.2
Voriconazole 1 1 0.2

Total prescriptions 222 333 556 100

a
Nebulized.

2291
Dryden et al.

(including 26 on iv treatment) had their antibiotics stopped im-
mediately on clinical grounds (Figure 2). The clinical indications
for antibiotic treatment as well as suitability or otherwise for
early discharge are illustrated in Figure 3.
Three-hundred-and-thirty (77%) patients needed to continue
antibiotics. Thirty-four per cent (47/139) of those on iv antibiotics
were switched to oral treatment. In the follow-up with the
regular clinical teams, no adverse effects as a result of altering
antibiotic prescriptions were noted. One-fifth (89/429) of all
patients on antibiotics were recommended for discharge on
the basis of having met the improvement criteria in the evalu-
ation tool and on the basis of clinical assessment during the
review.
Patients suitable for OPAT
Of the 89 patients who were suitable for discharge, 55 were suit-
stopped and 10 (from five of the six hospitals) would have
required OPAT. The focus of infection in these patients were pros-
thetic joint (4), intra-abdominal (2), vascular graft (1), endocardi-
tis (1) and respiratory tract (2).
Assessment of patients for discharge
On the basis of the discharge criteria, 89 (21%) patients on anti-
biotics were considered suitable for immediate discharge on the
day of review by the infection teams in the six hospitals. All of
these patients would have required additional monitoring and
care by a hospital team after discharge rather than discharge
to the care of their general practitioner (GP). This accounted for
almost 20% of patients on iv+oral antibiotics and 20% of
those on oral antibiotics alone. Although this study did not
specifically address the level of enhanced monitoring and care
required, it is likely that for most patients this would have

Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013

able for oral outpatient treatment, 24 had their antibiotics included regular clinical review of the focus of infection,

Patients on acute medical and surgical wards

in 6 hospitals
1356

Patients on
antibiotics
429
iv (± oral) antibiotics Oral antibiotics
165 264

Does patient still require ANY antibiotic?

iv (± oral) antibiotics Oral antibiotics

Patient No Patient
Yes Yes No
suitable suitable for
for 26 139 191 73
discharge?
discharge?

No Yes No Yes
21 5 Patient 54 19
Suitable oral
suitable for
alternative? discharge?

No Yes No Yes
92 47 153 38

Stop: 99 could stop antibiotics immediately,

Suitable for Patient 26 on iv
suitable for
iv OPAT? discharge?
Continue: 330 patients needed to continue
iv/oral switch: of the 139 patients remaining
on iv antibiotics, 47 could be switched to oral
No Yes No Yes immediately
82 10 30 17 Discharge : 89/429 (21%) patients were
recommended for discharge:
10 patients on iv OPAT
55 patients discharged on oral therapy
24 discharged with no therapy

Figure 2. Summary of early discharge and antibiotic management data.

2292
Infection team impact on antibiotic management JAC
monitoring vital observations and ensuring antibiotic administra- available for 73 patients during the study period. If these
tion and compliance until such time as the care of the patient 73 patients had been discharged at the time of the review,
could be transferred to the GP. 483 bed-days could have been saved.

Reasons preventing patient discharge Discussion

The evaluation tool asked whether the patient could be dis-
This evaluation described the clinical impact of a formal antibiot-
charged that day with enhanced care in the community. The
ic review by teams of infection specialists in six hospitals. Signifi-
89 patients described above were suitable, with the remainder
cant changes in the duration of antibiotic use and route of
being unsuitable. The main reason for the latter was that
administration were achieved, resulting in a considerable reduc-
the patients required continued surgical and or medical input.
tion in antibiotic usage. Although formal clinical outcome was
Co-morbidities, rehabilitation and social service requirements
not measured in this study, follow-up with the regular clinical
were other reasons preventing discharge (Figure 4).
teams did not reveal any detrimental consequences of antibiotic
alteration. The economic impact is reported in a companion
Potential bed-days saved paper.12 In contrast to other such reviews of antibiotic use, this
evaluation also assessed the potential for early discharge in
Of the 89 patients considered suitable for discharge by the infec-
these patients.

Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013

tion teams on the days of review, an actual discharge date was
Resistance to currently available antimicrobials is a global
public health threat. Resistance is closely associated with the
180 selective pressure of antibiotics, and therefore the volume of
160 Unsuitable antibiotic use.13,14 One strategy for countering the threat of
Suitable
resistance is to reduce the volume of antibiotic use without
140
detriment to patients. In hospitals this can be achieved by recom-
Focus of infection

120 mendations, guidelines and care bundles,15 – 17 or by regular

100 reviews of antibiotic use by an antimicrobial management team
or infection specialists.18 – 20
80
Antibiotic choices can be influenced in a cost-effective fashion
60 by an infection team without sacrificing patient safety. In one
40 study, 50% of patients initially treated with expensive parenteral
antibiotics had their regimens refined after 3 days of therapy,
20
and these modifications resulted in good clinical outcomes
0 with a substantial reduction in antibiotic expense.21 In another
RT
I TI UT
I
IA
I ne iti
s S study, the intervention of an antimicrobial management team
SS Bo rd CN
a resulted in a reduction in patient charges by slightly more than
d oc
En $4000 and hospital costs by $2000.22 In this study, we have
demonstrated for the first time in the UK that infection team
Figure 3. Focus of infection and suitability for early discharge. RTI, intervention results in a reduction in the use of iv antibiotics,
respiratory tract infection; SSTI, skin and soft tissue infection; UTI, earlier iv/oral switch and shorter duration of antibiotic therapy,
urinary tract infection, IAI, intra-abdominal infection; CNS, CNS infection. although clinical outcomes were not formally measured. Along

Team choice

Awaiting nursing home

Other

Requires social services

Requires rehabilitation

Comorbidities

Requires medical or surgical input

0 10 20 30 40 50 60

Figure 4. Distribution of reason(s) preventing discharge. Since reasons are not mutually exclusive, this graph presents results as percentages of total
reasons, not percentages of patients with a particular reason.

2293
Dryden et al.
with the potential for early discharge in some of these patients,
the infection team intervention led to significant economic
advantages.12
Criteria have already been developed to improve the monitor-
ing of inpatient antibiotic prescribing,7,15 and many of these
recommendations have been incorporated into quality improve-
ment programmes such as the UK Department of Health and
European Union antibiotic prescribing bundles.16,17 Nevertheless,
it is clear from routine practice that these recommendations are
not always followed in an effective way because this evaluation
has clearly demonstrated that intervention by an infection team
made a substantial difference in the duration of therapy and
iv/oral switch, despite such recommendations being included in
hospital policies. This study suggests that there is still much po-
tential for improvement in inpatient antibiotic management, and
if guidelines and bundles do not provide clear enough directions,
then this may be best achieved by the regular input of an infec-
tion team. There is precedence for this. Where the advice of in-
fection teams is not followed, the clinical outcome is worse.23
Infection consultations for patients with staphylococcal bacter-
aemia resulted in improved treatment, the removal of infected
foci, the detection of complications and better outcomes.15 – 17
Furthermore, there is evidence that in the absence of infection
specialist input, there is poor assessment of the severity of infec-
tion, resulting in over-treatment of less severe infection and
under-treatment of severe infection.4,24 Infection team evalu-
ation therefore has the potential to improve the quality of anti-
biotic prescribing, optimize the treatment of infections, contain
the costs associated with antibiotic use and bed-days and
reduce antibiotic-associated collateral damage. There is thus a
compelling argument for infection teams to be resourced to
manage all antibiotic use, although clearly this would have
huge logistical implications.
It can be argued that this study had limitations due to the
lack of uniformity between the six sites. The data from each
evaluation were applicable only to the local hospital involved,
as the hospitals differed in size, specialties and function. Al-
though inclusion criteria were acute medical or surgical cases,
the wards and patient groups selected were not uniform, and
the infection teams carrying out the review and assessment of
patients were made up of different people at each hospital.
The number of patients reviewed per hospital was also not pro-
portional to the total bed complement. However, the lack of uni-
formity between the sites and the teams demonstrated that
the evaluation tool can be effectively used in a variety of clinical
settings. The antibiotic review and patient assessment for dis-
charge and outpatient antibiotic treatment were done using a
systematic approach and with agreed criteria. Data were col-
lected using consistent methodology. The rounds were educa-
tional and contributed directly to patient management. The
evaluation was applicable and reproducible in any hospital as
part of a formal antibiotic review and early discharge pro-
gramme. The study was multicentred and involved hospitals of
very different size, specialties and function.
Optimal antibiotic management should now be obligatory
in all healthcare institutions,16,17 and toolkits exist to support
antibiotic stewardship.7 Table 1 shows the range of antibiotics
used in the patients prior to the intervention. The choice of
agents reflects some adherence to the currently fashionable
UK national advice to avoid the four ‘C’ antibiotics, thought to
2294
be at higher risk of promoting Clostridium difficile colitis. The use
of cephalosporins, ciprofloxacin (quinolones) and clindamycin
were low, in keeping with the recommendations. In contrast,
however, co-amoxiclav was the most commonly used agent.
Antibiotic resistance is directly related to the volume of anti-
biotic use.13,14 Hence, reducing the volume of total antibiotic
use may be an important intervention for reducing levels of re-
sistance.25 This review resulted in almost a quarter of patients
having their antibiotics stopped immediately. This in itself is
interesting, and is an important benefit even without any cost
savings related to early discharge. It shows that the resourcing
of an infection team (consisting of at least an infection
medical specialist with an antibiotic pharmacist), and giving
the team the authority to alter antibiotic prescribing, can result
in a reduction in the volume of antibiotic use, increased iv to
oral switch and probably improved de-escalation from broad-
spectrum to narrower spectrum antibiotic prescribing. If carried
Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013
out on a wide scale, this would have significant cost advantages,
but probably more importantly it will reduce the selective pres-
sure of antibiotics on microorganisms. This could be an import-
ant factor in controlling antibiotic resistance in units where
multidrug resistance is high.26,27
More than one-third of all patients were on iv+oral antibio-
tics, and on review the infection teams considered that 15%
no longer required their antibiotic therapy and could stop imme-
diately. More than one-third of the remaining patients on iv anti-
biotics had a clinical need to continue antibiotic therapy but no
longer required the iv route for antibiotic administration and
could be switched to an appropriate oral formulation. While
the iv route has benefits and is necessary in specific clinical situa-
tions, it is associated with higher risks, costs and staff time than
the oral route. This result suggests there is a need for educating
staff on the differences, benefits and risks between oral and iv
administration, and when and how to choose the iv route appro-
priately. Reducing or avoiding unnecessary use of iv therapy
would reduce the costs associated with drugs, equipment and
staff time, and improve the quality of patient care and product-
ivity on the ward. In addition, a reduction in peripheral line days
would reduce the risk of vascular line-associated infection and
bacteraemia, which is an increasingly important consideration
for all UK hospitals.
Ten patients on iv therapy were judged to be suitable for early
discharge and therefore suitable for OPAT. In this evaluation
there was a role for OPAT, but the numbers were low. This
study demonstrated that an OPAT service is a useful asset for
antibiotic management in secondary care, but the majority of
patients on antibiotics can be switched to oral treatment on
discharge.
Often the decision and responsibility to discontinue or change
iv to oral antibiotics is left to a more senior member of the
medical or surgical staff who may be available to review patients
less frequently than needed for optimum efficiency in antibiotic
management. Antibiotic rounds with an infection team can be
used as a bedside educational tool for medical staff, encouraging
multidisciplinary interaction between clinical teams and ultim-
ately resulting in positive feedback for ward staff in antibiotic
management and stewardship.
There is little facility in the UK for regular monitoring of con-
valescent patients in the community. Care is either in the hos-
pital or there has to be a transfer of clinical responsibility to
Infection team impact on antibiotic management
primary care. Many patients remain in the hospital for supervised
monitoring and antibiotic administration, and there is a need for
a middle way for patients whose clinical signs are resolving. This
study has demonstrated that there is a significant group of
patients that would benefit from such an approach.
A major finding of the evaluation was that at the time of
review, 21% of patients fulfilled the criteria for early discharge
and could have continued their treatment in the community.
Once patients with acute infection are stabilized, much of their
continuing care involves monitoring, drug administration and
supportive treatment such as wound care. Delivering this at
home would be preferable to most patients.6,10,11 To achieve
this in practice, a mechanism for community support and mon-
itoring needs to be in place. This community service could take
the form of domiciliary visits, return to the outpatient clinic or
telephone calls. The service would have to represent a level of
care somewhere between the hospital and the GP. One model
of delivery for this would be a ‘virtual ward’, whereby the
patient would remain registered with the hospital, but would
be accommodated at home or in a nursing home and their
care would be monitored by a nursing team for the virtual
ward.28 To our knowledge, such a system does not exist yet in
the UK for the management of infection, but has the potential
for enhancing the patient’s experience and recovery, as well as
reducing costs and HCAIs.
Most patients do not want to stay in hospital longer than is
necessary. A patient group—National Concern for Healthcare
Infection—has listed many patient benefits for care outside
the hospital environment.11 Other studies have listed advan-
tages and disadvantages for early discharge over hospital
stay6,8 and these are fairly consistent and agree with what the
patients themselves want (Table 2).
The main reason preventing discharge of the remaining 79%
of patients was that they had a need for further medical or sur-
gical input, rehabilitation, co-morbidities and social services
needs. All of these were beyond the control of the infection
team. Each of these reasons merits further investigation to iden-
tify appropriate strategies to resolve the issues in each case.
Increasing the frequency and availability of specialist medical
and surgical review and the accessibility and timeliness of
Table 2. Advantages and disadvantages of early discharge9 – 11
Advantages Disadvantages
Home environment Disruption to home life
Personal and social issues: improved Stressful for family and
dignity, reduced social isolation, requirement for family
improved nutrition and hydration, caregivers
less sleep deprivation
Continued attendance at work/ Compliance
school
Reduced risk of HCAIs and pressure Decreased supervision and
sores monitoring
Better use of hospital beds Access to emergency care
Patient empowerment Non-adherence to medical
advice
Reduced healthcare costs Misuse of iv access
JAC
rehabilitation and social services might have an additional con-
siderable impact on patient flow through secondary care.
Early discharge review showed a potential savings of 483
bed-days that could have been realized from continuing infection
treatment in the community. This was just from a snapshot
review on a specific day in each hospital. If such a review pro-
gramme was introduced into routine care throughout hospitals,
the bed-days saved and economic gain over time would be
even more marked. Full details of an economic analysis under-
taken alongside this study are reported in a companion
paper.12 One other study has shown marked economic gains
from early iv/oral switch and discharge from hospital in patients
with resistant Gram-positive infections.5
The results of this evaluation clearly indicate that a more
structured approach to antibiotic management can result in
improved antibiotic stewardship, a reduction in volume of anti-
biotic use and more rapid iv/oral switch. Introduction of this
Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013
approach into clinical practice in a routine way would be educa-
tional as well as improving the quality of antibiotic use in hospi-
tals. It is likely that the development of community care teams
to monitor patients with infection out of hospital could reduce
the length of hospital stay. A more detailed cost analysis on
the antibiotic management and early discharge data from this
study accompanies this paper.12
Funding
Data were generated by the authors within their routine work. Authors
were not funded for data collection. An unrestricted educational grant
from Pfizer supported the meetings of the authors to develop the stan-
dards and discuss the progress of the work. Pfizer funded pH Associates
to assist with data management.
Transparency declarations
The authors have no financial or intellectual conflicts of interest with
respect to this study. Pfizer, who funded the meetings, and pH Associates
did not play any decision-making role in the study analysis.
References
1 Plowman R, Graves N, Griffin MA et al. The rate and cost of
hospital-acquired infections occurring in patients admitted to selected
specialties of a district general hospital in England and the national
burden imposed. J Hosp Infect 2001; 47: 198– 209.
2 Balinsky W, Nesbitt S. Cost-effectiveness of outpatient parenteral
antibiotics: a review of the literature. Am J Med 1989; 87: 301– 5.
3 Combined Working Party of the British Society for Antimicrobial
Chemotherapy and the Hospital Infection Society. Guidelines on the
control of methicillin-resistant Staphylococcus aureus in the
community. J Hosp Infect 1995; 31: 1 –12.
4 Koerner R, Johnson AP. Changes in the classification and management
of skin and soft tissue infections. J Antimicrob Chemother 2011; 66:
232–4.
5 Desai M, Franklin BD, Holmes AH et al. A new approach to treatment of
resistant Gram-positive infections: potential impact of targeted IV to oral
switch on length of stay. BMC Infect Dis 2006; 6: 94.
6 Nathwani D. The management of skin and soft tissue infections:
outpatient parenteral antibiotic therapy in the United Kingdom.
Chemotherapy 2001; 47 Suppl 1: 17–23.
2295
Dryden et al.
7 Cooke J, Alexander K, Charani E et al. Antimicrobial stewardship: an
evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute
hospitals. J Antimicrob Chemother 2010; 65: 2669– 73.
8 Seaton RA, Sharp E, Bezlyak V et al. Factors associated with outcome
and duration of therapy in outpatient parenteral antibiotic therapy
(OPAT) patients with skin and soft-tissue infections. Int J Antimicrob
Agents 2011; 38: 243–8.
9 Nathwani D. Developments in outpatient parenteral antimicrobial
therapy (OPAT) for Gram-positive infections in Europe, and the potential
impact of daptomycin. J Antimicrob Chemother 2009; 64: 447–53.
10 Chapman AL, Seaton RA, Cooper MA et al. Good practice
recommendations for outpatient parenteral antimicrobial therapy
(OPAT) in adults in the UK: a consensus statement. J Antimicrob
Chemother 2012; 67: 1053 –62.
11 National Concern for Healthcare Infections. http://www.nc-hi.com/
(14 June 2011, date last accessed).
12 Gray A, Dryden M, Charos A. Antibiotic management and early
discharge from hospital: an economic analysis. J Antimicrob Chemother
2012; 67: 2297– 2302.
13 Kahlmeter G, Cars O. Pan-European comparison of non-hospital
antibiotic use and resistance in community E. coli. In: Abstracts of the
Forty-first Interscience Conference on Antimicrobial Agents and
Chemotherapy, Chicago, IL, USA, 2001. Abstract C2-1862, p. 136.
American Society for Microbiology, Washington, DC.
14 Goossens H, Ferech M, Vander Stichele R et al. Outpatient antibiotic
use in Europe and association with resistance: a cross-national
database study. Lancet 2005; 365: 579– 87.
15 Pulcini C, Defres S, Aggarwal I et al. Design of a ‘day 3 bundle’ to
improve the reassessment of inpatient empirical antibiotic
prescriptions. J Antimicrob Chemother 2008; 61: 1384 –8.
16 Department of Health. The Health and Social Care Act 2008: Code of
Practice for Health and Adult Social Care on the Prevention and Control
of Infections and Related Guidance. London, 2009. http://www.dh.gov.
uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_110288 (14 June 2011, date last accessed).
17 European Council. Council Recommendation of 15.11.2001 on the
Prudent Use of Antimicrobial Agents in Human Medicine (2002/77/EC).
2296
View publication stats
OJ L34 of 5.2.2002, p. 13. http://europa.eu/legislation_summaries/
public_health/threats_to_health/c11569_en.htm (11 May 2012, date
last accessed).
18 Rieg S, Peyerl-Hoffmann G, de With K et al. Mortality of S. aureus
bacteremia and infectious diseases specialist consultation—a study of
521 patients in Germany. J Infect 2009; 59: 232– 9.
19 Fowler VG Jr, Sanders LL, Sexton DJ et al. Outcome of Staphylococcus
aureus bacteremia according to compliance with recommendations of
infectious diseases specialists: experience with 244 patients. Clin Infect
Dis 1998; 27: 478–86.
20 Jenkins TC, Price CS, Sabel AL et al. Impact of routine infectious diseases
service consultation on the evaluation, management, and outcomes of
Staphylococcus aureus bacteremia. Clin Infect Dis 2008; 46: 1000–8.
21 Fraser GL, Stogsdill P, Dickens JD et al. Antibiotic optimization. An
evaluation of patient safety and economic outcomes. Arch Intern Med
1997; 157: 1689– 94.
22 Gums JG, Yancey RW Jr, Hamilton CA et al. A randomized, prospective
Downloaded from http://jac.oxfordjournals.org/ by guest on February 19, 2013
study measuring outcomes after antibiotic therapy intervention by a
multidisciplinary consult team. Pharmacotherapy 1999; 19: 1369 –77.
23 Sellier E, Pavese P, Gennai S et al. Factors and outcomes associated
with physicians’ adherence to recommendations of infectious disease
consultations for inpatients. J Antimicrob Chemother 2010; 65: 156–62.
24 Marwick C, Broomhall J, McCowan C et al. Severity assessment of
skin and soft tissue infections: cohort study of management and
outcomes for hospitalized patients. J Antimicrob Chemother 2011;
66: 387– 97.
25 Dryden MS, Cooke J, Davey P. Antibiotic stewardship—more education and
regulation not more availability? J Antimicrob Chemother 2009; 64: 885–8.
26 Neuhauser MM, Weinstein RA, Rydman R et al. Antibiotic resistance
among Gram-negative bacilli in US intensive care units: implications for
fluoroquinolone use. JAMA 2003; 289: 885– 8.
27 Sanyal SC, Mokaddas EM. The increase in carbapenem use and
emergence of Stenotrophomonas maltophilia as an important
nosocomial pathogen. J Chemother 1999; 11: 28 –33.
28 Virtual Wards. http://en.wikipedia.org/wiki/Virtual_Wards (14 June
2011, date last accessed).