Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone-prescribing at Hospital Discharge: A Retrospective Analysis among 122 Veterans Health Administration Hospitals

OBJECTIVES: Despite increasing awareness of harms, fluoroquinolones are still frequently prescribed to inpatients and at hospital discharge. Our goal was to describe fluoroquinolone-prescribing at hospital discharge across the Veterans Health Administration (VHA) and to contrast fluoroquinolone-prescribing volume and appropriateness across 3 antimicrobial stewardship strategy-types. METHODS: We analyzed a retrospective cohort of patients hospitalized at 122 VHA acute-care hospitals during 2014-2016. Data from a mandatory VHA survey were used to identify 9 hospitals that self-reported one of 3 strategies for optimizing fluoroquinolone-prescribing: prospective audit-and-feedback (PAF), restrictive policies (RP), and no strategy. Manual chart reviews to assess fluoroquinolone appropriateness at hospital discharge (i.e. post-discharge) were performed across the 9 hospitals (3 hospitals and 125 cases per strategy-type). RESULTS: There were 1.7 million patient-admissions. Overall, there were 1,727,478 fluoroquinolone days of therapy (DOTs) with 674,918 (39.1%) DOTs prescribed for inpatients and 1,052,560 (60.9%) DOTs received post-discharge. Among the 9 reviewed hospitals, post-discharge fluoroquinolone exposure was lower at hospitals using RP compared to no strategy (3.8% vs 9.3%, p=0.012). Post-discharge fluoroquinolones were deemed inappropriate in 154 of 375 (41.1%) patients. Fluoroquinolones were more likely to be inappropriate at hospitals without a strategy (52.8%) versus either RP or PAF (35.2%) (p=0.001). CONCLUSIONS: In this retrospective cohort, the majority of fluoroquinolone DOTs occurred after hospital discharge. A large proportion of post-discharge fluoroquinolone prescriptions were inappropriate, especially in hospitals without a strategy to manage fluoroquinolone-prescribing. Our findings suggest that stewardship efforts to minimize and improve fluoroquinolone-prescribing should also focus on antibiotic-prescribing at hospital discharge.