loading . . . Improving Discharge Antibiotic Use via Prospective Audit and Feedback—The Importance of Contextual Variation Antibiotics prescribed at hospital discharge account for 40% to 50% of antibiotic days received by hospitalized adults with infections in the US.1 Yet, up to 70% of discharge antibiotic prescriptions are suboptimal—they are unnecessary, have an excessive duration, or use an overly broad agent.2 These suboptimal prescriptions contribute to direct patient- and population-level harms. Given the safety implications, there is increasing recognition that transitions of care are an important target for antibiotic stewardship interventions.3
Hospital discharge is a dynamic clinical moment in which to modify prescribing. The literature on discharge antibiotic stewardship interventions reports a number of strategies with varied success.4 One commonly evaluated approach, which is a cornerstone stewardship strategy for hospitalized patients, is prospective audit (ie, real-time review of antibiotic prescriptions for appropriateness at or near the time of discharge) and feedback (PAF) to prescribers. Successful PAF interventions of discharge prescriptions have been led by clinical or infectious diseases pharmacists.5 These discharge-focused PAF interventions are resource intensive, so evidence on effectiveness is needed to inform implementation efforts across diverse hospital contexts.6 The few studies evaluating PAF at discharge have been nonrandomized and, with 1 notable exception,5 conducted in a single center. Therefore, the stepped-wedge cluster-randomized clinical trial reported by Livorsi et al7 is a welcome addition to the literature on discharge stewardship.
The study by Livorsi et al7 examined the impact of a discharge-focused PAF intervention on antibiotic overuse at discharge across 10 US hospitals. Sites were eligible to participate if they had not yet implemented a discharge-focused PAF process. They were recruited from the Centers for Disease Control and Prevention (CDC) Epicenters Program and the authors’ professional networks.
The intervention itself was pragmatic, with sites having flexibility in their approach to operationalizing PAF. Antibiotic stewardship teams selected which inpatient units to target with PAF, developed their own process to identify pending discharges for review, and chose the way real-time feedback was delivered to prescribers. In addition to adopting discharge-focused PAF, hospitals created or updated institutional antibiotic prescribing guidelines for common infections and provided education to prescribers on targeted units prior to the intervention start. Hospitals began the study in the control condition for a 24-week baseline period. During the intervention period, hospitals crossed into the intervention group every 2 weeks, with time in the intervention period ranging from 8 to 26 weeks.
The primary effectiveness outcome was postdischarge antibiotic use, defined as the frequency at which postdischarge antibiotics were prescribed and, if prescribed, the postdischarge length of therapy. A manual health record review was also performed in a subset of patients with common infections targeted by guidelines. Optimal prescribing was defined as a combination of appropriate antibiotic selection and duration. Implementation outcome data were collected weekly during the intervention and postimplementation periods.
Unfortunately, Livorsi et al7 did not find support for the effectiveness of the intervention on postdischarge antibiotic use. They did, however, see an improvement in antibiotic appropriateness in the subset of patients with skin and soft tissue, urinary tract (including asymptomatic bacteriuria), intra-abdominal, and respiratory tract infections who were evaluated via health record review and for whom institutional guidelines existed. Although at first glance this could be viewed as a negative study, there are several aspects of the design that likely blunted the effects of the intervention.
First, the inability to achieve a change in the primary outcome of postdischarge antibiotic use is not wholly surprising. Unlike prior studies, Livorsi et al7 included all patients discharged to the community—many of whom may have been complicated cases where stopping antibiotics or shortening duration is challenging. Approximately half of the patients evaluated in health record review were excluded because they had complicated infections. Additionally, Livorsi et al7 were unable to obtain data on patients discharged to skilled nursing facilities or on outpatient parenteral antibiotic therapy, who may have accounted for a substantial amount of antibiotic prescribing after discharge. It is worthwhile to consider what magnitude of change in the primary outcome could have been expected, given the heterogeneity of patients cared for in these settings. It is possible that Livorsi et al7 expected the intervention to apply to a larger proportion of patients than actually occurred. Improvement in discharge stewardship targets that can be thought of as low-hanging fruit, such as uncomplicated community-acquired pneumonia, may be an important first step in establishing the value of such an approach.
Second, although hospitals remained in the intervention phase for 8 to 26 weeks, the short 2-week intervals between crossovers may have limited opportunities for learning and adaptation across sites as the intervention rolled out. It is understandable that Livorsi et al7 were attempting to evaluate this intervention efficiently across multiple sites, but it is possible that more time in the intervention period could have led to greater impact. Discharge-focused PAF can be a complicated process, given the practical challenges in estimating time of discharge, finding an appropriate venue in which to deliver feedback, and providing feedback at a time when changes to discharge prescriptions can still be made. Both the stewardship teams making the intervention and the clinicians receiving feedback may improve in their abilities to give or receive information over repeated exposures. This may have been especially important in the 2 hospitals that had not previously implemented any form of PAF. Although the numbers are too small to compare across individual sites, a hypothesis-generating exercise could examine the range of effects across hospitals. This would have been especially powerful, given the wealth of data Livorsi et al7 gathered on implementation dynamics across sites. Future multisite research should design intervention studies that permit opportunities for subgroup analysis.
Livorsi et al7 are to be especially commended for the inclusion of such granular and robust implementation details across participating sites. It is helpful to have insight into the approaches that each hospital used to operationalize discharge-focused PAF, especially because another potential explanation for the lack of an observed effect could be related to the approach to delivering feedback. In preparing for the intervention, Livorsi et al7 provided some general guidance to sites in their protocol about how PAF should work, which included an emphasis on timeliness, a preference for real-time in-person or telephone feedback (although electronic, asynchronous communication was acceptable), and the intended recipients of feedback. Despite these recommendations, 6 of the 10 included hospitals primarily used electronic messaging for PAF recommendations rather than in-person or telephone feedback. The stewardship literature has not yet established a criterion standard approach for how to deliver PAF. Electronic communication does not allow for the subtleties of interpersonal interactions to be expressed, which may shape the acceptability of a recommendation to modify a prescription. Feasibility concerns with real-time in-person or telephone feedback may make it a less appealing option, but more research is needed to define optimal PAF implementation. This is especially true when considering hospital discharge, as communication during transitions of care may be more fragmented and time-sensitive than at earlier time points.
While this pragmatic, multicenter collaboration designed to improve overall antibiotic prescribing at the time of hospital discharge by Livorsi et al7 had no impact on the primary outcome, some improvement for common infections was observed. Hospital-level implementation data presented by Livorsi et al7 highlight the importance of contextual variation on antibiotic stewardship. While one size does not fit all, there is a need for more information on the way that local adaptations might impact intervention success.
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Article Information
Published: January 9, 2026. doi:10.1001/jamanetworkopen.2025.49620Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2026 Szymczak JE et al. JAMA Network Open.Corresponding Author: Julia E. Szymczak, PhD, Department of Internal Medicine, Division of Epidemiology, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84132 ([email protected]).Conflict of Interest Disclosures: None reported.
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