Rational use of antimicrobials in home hospitalisation

Dear Editor,

In the article published by Sánchez Fabra et al.,¹ the authors draw attention to the margin for improvement in the quality of prescribing of antimicrobial agents in hospital at home (HaH) for patients with pneumonia, mainly in terms of de-escalation (reduction of the antimicrobial spectrum) and sequential therapy (change from intravenous to oral).

For some years now, a range of studies have drawn attention to the inappropriate use of outpatient parenteral antimicrobial treatment,^2–6 particularly in care models in which the clinical monitoring and maintenance of parenteral therapy is not in the hands of experienced professionals, but rather depends on outsourced agencies or services used in an attempt to facilitate early discharge from hospitals. Moreover, several publications have also warned of an unusually high number of complications of outpatient intravenous treatment, particularly associated with venous access.⁷

The hospital-based model of HaH does not appear to be exposed to the level of risk of inappropriate antimicrobial treatment and complications that other studies describe.⁸ However, as Sánchez Fabra et al point out, the fact that about half of the patients in the study did not have de-escalation or sequential therapy when indicated is no trivial matter. Analysing this situation and adapting to the recommendations of the guidelines is a requirement for any healthcare model -no less for hospital at home- and it has been shown that there is room for improvement.

Nonetheless, the study leaves unanswered questions that deserve a more detailed analysis. As the authors argue, there could be circumstances not included in the medical records which might require IV antibiotic therapy to continue for longer than recommended in the clinical practice guidelines. As far as de-escalation is concerned, at times, reducing the spectrum of antimicrobial activity can mean the use of drugs with greater frequency of administration, and this may be a limitation, depending on the organisation, resources and coverage hours of the hospital-at-home units. That may not be a sufficient reason to continue an antibiotic with a higher spectrum of activity, but the alternative may sometimes be for the patient to remain in hospital, an option which is also not without risk.

In addition, the authors observed that patients coming from Accident and Emergency (A&E) had a better quality of prescription (request for tests, adequacy of the prescription, de-escalation, sequential therapy, duration of treatment) than those who came from the ward. This difference would be worrying if the assignment to a conventional admission or hospital at home directly from A&E had been random. However, this was not the case, and the fact that the patients admitted directly from A&E were younger and had less comorbidity does not allow us to conclude that the differences are due to the care by a single physician (for the HaH) being more ideal than the care by two (ward and HaH). As the authors argue, in the case of readmissions at 30 days, the aspect that seemed to weigh most heavily on the quality of the prescription were the characteristics of the patient and not the dynamics of the HaH.

The study does not specify whether or not the mean hospital stay of 2.5 days included patients admitted directly to hospital at home from A&E. If they were not included, the stay was short enough for the HaH practitioner to have made the decision about de-escalation or sequential therapy with the same diligence as previously non-hospitalised patients, and would be another argument in favour of the differences observed being due to the profile of the patients. If the calculation of the mean stay included patients admitted from A&E (in which case the mean stay would be longer, considering only conventionally hospitalised patients), the deficiency in the treatment could have already occurred on the inpatient ward.

In summary, this is a necessary article alerting to the need to implement programmes for rational use of antimicrobials in hospital at home with the same rigour as in hospitals.