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July/August 2010
Patient Care and Science
EIN Update: When to Stop Inpatient Antibiotic Treatment

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds the EIN. The reader assumes all risks in using this information.

A recent discussion on the EIN listserv highlighted a wide range of practices for placing limits on the duration of treatment­ when ordering inpatient antibiotics, underscoring the great need for more research in this area.

An EIN member from California asked: “What is your policy regarding length of treatment when ordering antibiotics for inpatients? Is it required that the length of the prescription be specified, or is it open-ended? Is it possible to specify the length, with pharmacy providing a hard stop?

The unofficial poll generated a variety of responses, from 20 members in 13 states, illustrating a need for additional data. “Sadly, there are very few studies in the literature that measure the necessary duration of antibiotic therapy,” a respondent from Texas wrote. “We use a 10-day automatic stop order unless the physician reorders the antibiotic or a stop date is specified with the original antibiotic order.”

An Ohio EIN member reported the availability of both options through an electronic health record (EHR) system: “The ordering physician may specify a hard stop that is enforced by the pharmacy or choose to leave the duration open ended.”

A member from New Hampshire responded that “some, but not all, of our hospitals had a hard stop policy, but there were occasional problems when patients receiving longer-term treatment for osteomyelitis, endocarditis, etc., had their therapy mistakenly stopped too soon. Another option that we’ll likely implement is an automatic review with ID input when a prescription hits the two week mark. This is probably more clinically appropriate than a hard stop order.”

Two other respondents shared similar cautions about hard stops. An alternative may be “to have the pharmacists keeping an eye on the antibiotics and if it appears the patient is nearing the end of their course, discuss the physician’s thoughts with them,” a member from Missouri suggested. If done in a collegial manner, this could be effective at preventing excessive antibiotic use.

An EIN member from Texas shared an experience gained from implementing hard stops: Unless the approach “is paired with an auto-alerting mechanism with a good communication loop built into it, we learned that it’s not going to be very successful,” the member noted. “Prospective audits by the pharmacist may still be our best approach to stop excessively long treatment.”

Another Texas respondent described a multi-tiered approach. For some antibiotics, such as vancomycin and imipenem, “we have a five-day stop unless the order is written for a specific period, so that if you just write the antibiotic (and indication, of course) you get a reminder at four days, and then it’s stopped if you don’t renew.” If a physician specifies 10 days, “you get 10 days without a reminder. Other, cheaper antibiotics do not get the reminders.” Any patient on three or more antibiotics or for more than 14 days is supposed to be reviewed by the pharmacy or an infection control analyst.

A member in Illinois reported the use of a “specified duration of therapy, with hard stops unless there is a follow up either in the form of a phone call or an ID consultation.” A respondent in Wisconsin described a similar strategy: “In circumstances where we have a fixed duration (for example, antibiotic lock for a central line infection) for patients who will remain beyond the period of antibiotic use, [a specified duration] makes sense.”

An open-ended approached described by a Minnesota respondent also included Antibiotic Management Teams that evaluate duration, as well as selection and appropriateness.

More study is needed to answer these questions, and IDSA has been a strong advocate for funding research on antibacterial resistance.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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