2026 Eastern States Conference

Authors: Bryn Damico, PharmD; Evan Hurley, PharmD, BCIDP
Learning Objective: Describe the role of a pharmacist in outpatient intravenous antibiotic order review prior to discharge at a community hospital 
Background/Objective: Evaluate a pharmacist review of outpatient intravenous antibiotic orders at discharge on readmission outcomes.   
Methods: This is a single-center retrospective cohort study examining a pharmacist-led review of patients discharged with outpatient intravenous antibiotics in a community hospital. Inclusion criteria include patients with an order for outpatient intravenous antibiotics placed by an infectious disease provider within 10 days of discharge.  Exclusion criteria include patients less than 18 years of age, plans to discharge to a rehabilitation center, or patients who were transferred to an outside hospital. The pre-implementation phase consisted of a chart review of patients with orders for outpatient intravenous antibiotics between January 2025 to June 2025. In the post- implementation phase, pharmacists reviewed outpatient intravenous antibiotic orders once daily, then recommended antibiotic change based on predefined workflow. The primary outcome was infection-related hospital readmission within 30 days of discharge. Secondary outcomes included all-cause readmissions, emergency department visits, all-cause mortality, and adverse events within 30 and 90 days. This quality improvement project does not require Institutional Review Board (IRB) approval. 
Results: There were 33 patients included in the post-implementation cohort. Pharmacists identified interventions in 9 of 33 patients (27%), including antimicrobial selection changes, dose adjustments, and duration changes, of which 5 (56%) were accepted. The primary outcome of infection-related hospital readmission within 30 days occurred in 9% of patients. All-cause readmission at 30 days occurred in 24% of patients and infection-related emergency department visits in 21%. At 90 days, evidence of treatment failure occurred in 9% of patients, adverse events in 12%, and no mortality was observed.
Conclusion: There are opportunities to optimize transitions of care when treating patients with outpatient intravenous antibiotics including dose, route, duration, and antimicrobial selection. Implementation of a pharmacist-led review of OPAT orders prior to discharge is feasible at a community hospital, with pharmacists identifying optimization opportunities in 27% of patients. Evidence of 90-day treatment failure was reduced from 16% pre-implementation to 9% post-implementation, suggesting possible downstream clinical benefit of pharmacist optimization.
Self-Assessment Question: Which of the following ways can pharmacists contribute to reviewing outpatient intravenous antibiotic therapy prior to discharge?