Unraveling indications for discharge antibiotics: the Devil's in the details

Discharge is a pivotal transition of care moment; however, discharge antibiotic stewardship efforts have historically been limited. Our institution has a mandatory indication field for inpatient antibiotic orders. Using the last-ordered inpatient antibiotic indication ("Last Inpatient Indication"), we assessed the utility of this field compared to the ICD-10 in inferring clinician intent for discharge antibiotics, to forgo the need for manual chart review to assess antibiotic appropriateness.

We extracted electronic medical record data on adult inpatient encounters in 2023 with ≤2 discharge antibiotics. We reviewed a random subset of 300 encounters to determine if the ICD-10 or Last Inpatient Indication had higher agreement with clinician intent for discharge antibiotics, as determined by chart notes. To facilitate comparison, we created a dictionary classifying ICD-10 indications.

We included 3,414 encounters. The most common discharge antibiotics were amoxicillin/clavulanate (24%) and ciprofloxacin (15%). The most common ICD-10s were non-infectious (48%) and sepsis (18%). In the subset of chart-reviewed encounters, the Last Inpatient Indication agreed with the documented clinician intent for discharge antibiotic more often than the ICD-10 (84% vs 28%). Applying institutional guidelines, we were able to use the Last Inpatient Indication to assess appropriate duration and choice of discharge antibiotics for select infections.

The Last Inpatient Indication outperformed ICD-10s in inferring clinician intent for discharge antibiotics and can be used to efficiently assess antibiotic appropriateness without need for manual chart review. Usefulness of ICD-10s was limited by high percentage of non-infectious and sepsis codes.