Discussion

Our multi-regional HaH program demonstrated a high prevalence of systemic antimicrobial use, consistent with international HaH experiences. ^{Reference Miron-Rubio, Gonzalez-Ramallo and Estrada-Cuxart6} A large proportion of HaH patients received antibiotics, especially ceftriaxone, which aligns with known OPAT practices favoring long-acting, broad-spectrum antibiotics for convenience and coverage. ^{Reference Norris, Shrestha and Allison5} The most common indications in our cohort were respiratory tract infections, urinary tract infections, and skin and soft tissue infections, consistent with prior HaH reports. ^{Reference Moreno Nunez, Garmendia Fernandez and Ruiz Munoz8,Reference Dickinson, Rashid, Weiland, Tjoa, Kim and Huang9} Notably, most patients received an intravenous antibiotic in our program, reflecting the acute-care nature of HaH and its role as a substitute for in-hospital intravenous therapy.

The unique care setting of HaH influences antimicrobial prescribing patterns. In a hospital ward, clinicians have immediate access to a full formulary of parenteral agents, on-demand pharmacy compounding, and services like immediate imaging or specialist consultation. In HaH, practical logistics encourage a more streamlined approach. HaH formularies emphasize a core set of antimicrobials suited to common infections, partly due to operational considerations (eg, home delivery and drug stability). However, many HaH programs partner with their hospital’s inpatient pharmacy to dispense medications, which can facilitate daily dispensing with the added benefit of pharmacist verification. We leverage this capability at some sites to ensure our HaH patients benefit from hospital-grade pharmacy oversight to receive timely first-line antimicrobials without gaps in therapy.

The HaH model offers unique opportunities for antimicrobial stewardship (AMS) that can complement traditional hospital stewardship efforts. HaH care involves a focused patient census and frequent touchpoints, creating an ideal environment for prospective audit-and-feedback on antibiotic use. The implementation of an AMS program in a Spanish HaH program resulted in 98% acceptance of stewardship recommendations and significantly reduced antibiotic-days. ^{Reference Moreno Nunez, Garmendia Fernandez and Ruiz Munoz8} In our program, the care team (physician, nurse, and often a pharmacist or case manager) convene daily to facilitate safe antimicrobial monitoring and continuation of therapy from the traditional BaM setting, which can be fraught with antimicrobial errors. ^{Reference Dickinson, Rashid, Weiland, Tjoa, Kim and Huang9}

An important stewardship consideration in HaH is avoiding unnecessary intravenous therapy. Paradoxically, the convenience of HaH can lead to overuse of intravenous antimicrobials simply because the barrier of hospitalization is removed. Current analyses warn that HaH programs might inadvertently expand the use of advanced interventions to patients who could have been treated with oral drugs, thereby increasing utilization rather than purely substituting for inpatient care. ^{Reference Taylor and Golding10} To guard against this, clinicians should follow established guidelines for when intravenous therapy is truly indicated.

Several limitations should be acknowledged. We did not perform chart review, so we were unable to assess the appropriateness of antimicrobial prescriptions or quantify the total duration of therapy (ie, inclusion of BaM-administered antibiotics or discharge prescriptions). The study was conducted within a single health system, which may limit the generalizability of the findings to other HaH programs with different structures or patient populations.

Our study describes antimicrobial prescribing patterns within a US-based HaH program, revealing high utilization of systemic and intravenous antimicrobials. As HaH programs continue to expand, integrating AMS will be essential to optimize patient outcomes, reduce the burden of antimicrobial resistance, and ensure the sustainability of this innovative care model.