Discussion

In this national survey of pediatric discharge antimicrobial stewardship practices, most pediatric ASPs reported that they do not perform review of antimicrobial prescriptions at the time of discharge. With an estimated 30% of hospitalized children discharged with an antibiotic prescription, ^{Reference Hersh, Newland and Gerber3} these findings highlight discharge stewardship as an opportunity for improvement during the transition from hospital to home. Although ASP leaders perceived that discharge antimicrobial errors were common, multicenter pediatric data on appropriateness of discharge antibiotic prescriptions are needed to fully understand the scope of the problem.

The optimal approach to discharge antimicrobial stewardship remains unknown, including who should provide oversight, what strategies for pharmacist review should be utilized, and which patient populations and medications to target. ASP strategies for antimicrobial review, such as prospective audit with real-time feedback and approval/denials of restricted antimicrobials, have been successful in improving appropriate antimicrobial use for hospitalized children, ^{Reference Newland, Stach and De Lurgio8} but these have not been studied for pediatric discharge prescriptions. One adult discharge stewardship intervention utilizing prospective audit with real-time feedback was associated with decreased use of antibiotics with broad gram-negative coverage and shorter treatment durations after discharge. ^{Reference Yogo, Shihadeh and Young6} Although pharmacist-led medication reconciliation and review has been associated with decreases in medical errors, readmission, and ED visits, ^{Reference Mekonnen, McLachlan and Brien9} programs may be limited in the resources they have to implement such efforts. In addition, guidelines, pathways, and decision support tools for optimal prescribing of antimicrobials continue to evolve. Efforts to standardize care through institutional guidelines have been shown to improve appropriate antibiotic prescribing for infections such as community-acquired pneumonia. ^{Reference Newman, Hedican, Herigon, Williams, Williams and Newland10} Such guidelines are considered an important aspect of inpatient stewardship strategies because they provide evidence-based treatment recommendations based on local data, and they may require fewer resources than pharmacist review of discharge prescriptions. ^{Reference Gerber, Jackson, Tamma and Zaoutis1}

This study has several limitations. First, we only surveyed leaders from SHARPS collaborative institutions, which are mostly university-affiliated and already have ASPs. Second, we only surveyed one leader per site. Perceived problems and priorities may have differed by respondent, even within the same program. Third, as most institutions do not regularly collect data on the appropriateness of discharge antibiotics, we were unable to compare perceived problems with actual institutional data. Fourth, we did not collect detailed data on categories of antimicrobials reviewed by non-ASP pharmacists or whether they also performed medication reconciliation. Lastly, we were unable to evaluate the effectiveness of reported stewardship interventions.

In conclusion, despite the growing evidence for inappropriate antibiotic use as patients transition from hospital to home, most pediatric ASPs do not review discharge antimicrobial prescriptions. Opportunities may exist for improvements in prescribing at discharge, including drug selection, dose, and duration. Future research should characterize the extent of inappropriate discharge prescribing across multiple institutions to better inform the development of discharge stewardship interventions.