Bridging the Gap in Antibiotic Stewardship at Hospital Discharge: Evaluating the Impact of Pharmacist Interventions

ABSTRACT Introduction Transition of care during hospital discharge is a critical period that often leads to medication errors. While antibiotics are among the most prescribed medications, half of these prescription orders are not optimized. The Centers for Disease Control and Prevention provides guidance on stewardship programs and underscores the critical role of pharmacists; however, a gap in stewardship practices at hospital discharge remains. This signals an unmet clinical need for antimicrobial stewardship at discharge to avoid unnecessary antibiotic exposure and identify safe alternatives while maintaining patient safety. Objective To evaluate the impact of pharmacist‐led intervention on the appropriateness of prescribed antibiotic(s) at discharge. Methods This was a quasi‐experimental study conducted at a community teaching hospital from March 2018 to March 2022. Participants were divided into standard of care and intervention groups to compare the appropriateness of prescribed antibiotics following the implementation of pharmacist assessment at the time of discharge. The primary outcome was to evaluate the impact of pharmacist interventions on increasing the appropriateness of prescribed antibiotics at the time of hospital discharge. Secondary outcomes included rates of 30‐day readmission and Clostridioides difficile infection. Results A total of 160 participants were included in the standard of care ( n = 80) and intervention ( n = 80) cohort. Patients in the intervention group were discharged with more appropriate (85% vs. 25%, p < 0.00001) and less broad‐spectrum (26% vs. 49%, p = 0.003) antibiotics when compared with the standard of care group. Pharmacist involvement was associated with a median reduction in antibiotic exposure of 3 days (7 vs. 4, p < 0.00001). No significant differences in secondary outcomes were observed. Conclusion Pharmacist stewardship intervention significantly increased the appropriateness of prescribed antibiotics at discharge by 60% without compromising patient care. Because most antibiotics are meant to be completed post‐discharge, these findings highlight that inpatient antimicrobial stewardship efforts overlook a significant number of patients on antibiotics.