# Leveraging inpatient antimicrobial stewardship infrastructure to improve antimicrobial-prescribing at hospital discharge

> **NIH VA I01** · IOWA CITY VA MEDICAL CENTER · 2022 · —

## Abstract

Background: Antimicrobial overuse is one of the strongest risk factors for the emergence of antimicrobial
resistance, an urgent public health problem. Antimicrobial stewardship programs (ASPs) are hospital-based
programs that can reduce unnecessary inpatient antimicrobial use and are therefore an essential tool for
addressing the crisis of antimicrobial resistance. ASPs are mandated in VHA.
Significance: VHA hospitals are only required to monitor their inpatient antimicrobial use. However, at least
40% of antimicrobial exposure associated with a VHA hospital stay is prescribed at hospital discharge and is
taken by the patient after discharge (i.e. post-discharge). These post-discharge antimicrobial prescriptions are
frequently unnecessary or sub-optimal. Reducing post-discharge antimicrobial overuse will minimize patient
harm, such as Clostridioides difficile infections, antimicrobial resistance, and adverse drug events.
Innovation and Impact: This proposal will address two critical gaps in the literature. First, standard ASP
metrics do not capture post-discharge antimicrobial use and therefore miss a substantial amount of hospital-
related antimicrobial exposure. This proposal will evaluate factors that contribute to variation in post-discharge
antimicrobial use across patients and hospitals in order to inform both metric development and the design of
future stewardship interventions. Second, while there are evidence-based strategies for safely reducing
inpatient antimicrobial use, it is unclear how current inpatient ASP activities can decrease post-discharge
antimicrobial overuse. This proposal will explore how inpatient ASP infrastructure, which all VHA hospitals are
expected to have, can be leveraged to reduce unnecessary post-discharge antimicrobial-prescribing.
Specific Aims: Aim 1: Identify factors that contribute to variation in post-discharge antimicrobial use in VHA
acute-care admissions across all facilities by evaluating potential patient-level, hospital-level, and
environmental effects. Identify hospitals that have low observed-to-expected post-discharge antimicrobial use,
low risk-adjusted inpatient antimicrobial use, and perform well on clinical outcomes in antimicrobial-treated
patients. Aim 2: Determine whether being admitted to a hospital with a discharge-focused stewardship process
is associated with less post-discharge antimicrobial exposure, after adjusting for differences in case-mix, ID
expertise, inpatient antimicrobial exposure, and the intensity of inpatient ASP activities. Aim 3: Using qualitative
methods, evaluate attitudes and processes that impede or foster reductions in unnecessary post-discharge
antimicrobial use. We will perform site visits at 6 high- and 4 low-performing sites, as identified in Aim 1.
Methodology: Aim 1 will use VINCI data and linear mixed models to identify factors that influence post-
discharge antimicrobial use. Aim 1 will also rank hospitals on their performance on inpatient and post-
dischar...

## Key facts

- **NIH application ID:** 10421218
- **Project number:** 1I01HX003325-01A2
- **Recipient organization:** IOWA CITY VA MEDICAL CENTER
- **Principal Investigator:** Daniel Livorsi
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2022
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2022-07-01 → 2026-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10421218

## Citation

> US National Institutes of Health, RePORTER application 10421218, Leveraging inpatient antimicrobial stewardship infrastructure to improve antimicrobial-prescribing at hospital discharge (1I01HX003325-01A2). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10421218. Licensed CC0.

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