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Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J. European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists). Clin Microbiol Infect 2024; 30:1384-1407. [PMID: 39029872 DOI: 10.1016/j.cmi.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/21/2024]
Abstract
SCOPE This European Society of Clinical Microbiology and Infectious Diseases guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are (a) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? (b) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? (c) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? (d) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? METHODS An expert panel was convened by European Society of Clinical Microbiology and Infectious Diseases and the guideline chair. The panel selected in consensus the four most relevant antimicrobial stewardship topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes and stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. RECOMMENDATIONS The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e. withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very low and low certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.
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Affiliation(s)
- Teske Schoffelen
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany; Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Khalid Eljaaly
- Department of Pharmacy Practice, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pharmacy, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mical Paul
- Infectious Diseases, Rambam Health Care Campus, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Emma Keuleyan
- Department of Clinical Microbiology and Virology, University Hospital Lozenetz, Sofia, Bulgaria; Ministry of Health, Sofia, Bulgaria
| | | | - Nathan Peiffer-Smadja
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, IAME, Paris, France; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Carlos Palos
- Infection Control and Antimicrobial Resistance Committee, Hospital da Luz, Lisbon, Portugal
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Bojana Beovic
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eric Batard
- Emergency Department, CHU Nantes, Nantes, France; Cibles et Médicaments des Infections et du Cancer, IICiMed UR1155, Nantes Université, Nantes, France
| | - Fredrik Resman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Marlies Hulscher
- IQ Health Science Department, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Boerckel HN, Worden LJ, Salvati LA, Jameson AP, Dumkow LE. Reprint of: Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria. J Am Pharm Assoc (2003) 2024; 64:102176. [PMID: 39127941 DOI: 10.1016/j.japh.2024.102176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/14/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. OBJECTIVES The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. METHODS This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. RESULTS Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. CONCLUSIONS Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.
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Tuinte RAM, van Zanten MD, Takamura T, Schoffelen T, Schouten JA, Hulscher MEJL, Hoogerwerf JJ, ten Oever J. Follow-up of patients with urinary tract infections discharged from the emergency department: a mixed methods study. J Antimicrob Chemother 2024; 79:1688-1696. [PMID: 38819815 PMCID: PMC11215544 DOI: 10.1093/jac/dkae169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/08/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES To evaluate the quality of culture follow-up after emergency department (ED) discharge in patients with urinary tract infections (UTIs). METHODS This convergent mixed methods study included an observational cohort study and a qualitative interview study in UTI patients discharged from the ED of a Dutch university hospital. The primary outcomes of the observational study were the proportion of patients requiring adjustment of antibiotic therapy after culture review, and the proportion of patients in whom these adjustments were made. Logistic regression identified factors associated with these outcomes. Interviews assessed patient experiences and transcripts were analysed using inductive thematic content analysis. Integration of the results informed recommendations for high-quality follow-up. RESULTS Out of 455 patients, 285 (63%) required culture-based treatment adjustments. In most patients, no adjustments were made (239/285, 84%). De-escalation was most frequently omitted (98%), followed by discontinuation of antibiotics (92%). A mean of 7.1 (SD 3.8) antibiotic days per patient could have been avoided in 103 patients. Patients with diabetes were less likely to require adjustments (aOR 0.50, 95%-CI 0.29-0.85). Patients with moderate or severe renal impairment (aOR 4.1, 95%-CI 1.45-11.33; aOR 4.2, 95%-CI 1.50-11.94) or recurrent UTIs (aOR 5.0, 95%-CI 2.27-11.18) were more likely to have received necessary adjustments. Twelve interviews also revealed varying degrees of follow-up. Three themes were identified: 'information and communication', 'coordination and accessibility of care' and 'individual needs and preferences'. Recommendations for high-quality follow-up advocate a person centred approach. CONCLUSIONS This study highlights the importance of urine culture follow-up after ED discharge, mainly to reduce unnecessary antibiotic treatment, promote de-escalation and improve patient experience.
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Affiliation(s)
- R A M Tuinte
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- IQ Health Science Department, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
| | - M D van Zanten
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - T Takamura
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - T Schoffelen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J A Schouten
- IQ Health Science Department, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M E J L Hulscher
- IQ Health Science Department, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J J Hoogerwerf
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J ten Oever
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc Community for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, the Netherlands
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Ward MJ, Matheny ME, Rubenstein MD, Bonnet K, Dagostino C, Schlundt DG, Anders S, Reese T, Mixon AS. Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration. BMC Health Serv Res 2024; 24:640. [PMID: 38760660 PMCID: PMC11102113 DOI: 10.1186/s12913-024-11082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
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Affiliation(s)
- Michael J Ward
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA.
- Medicine Service, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael E Matheny
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa D Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Chloe Dagostino
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Shilo Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Ladines-Lim JB, Fischer MA, Linder JA, Chua KP. Appropriateness of Antibiotic Prescribing in US Emergency Department Visits, 2016-2021. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e79. [PMID: 38751940 PMCID: PMC11094377 DOI: 10.1017/ash.2024.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/09/2024] [Accepted: 04/14/2024] [Indexed: 05/18/2024]
Abstract
In this national analysis of US emergency department visits with antibiotic prescribing during 2016-2021, 27.6% of visits resulted in inappropriate antibiotic prescribing: 14.9% had diagnosis codes plausibly antibiotic-related (eg, acute bronchitis), suggesting actual inappropriate prescribing, and 12.6% had diagnosis codes not plausibly antibiotic-related (eg, hypertension), suggesting poor coding quality.
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Affiliation(s)
- Joseph Benigno Ladines-Lim
- Departments of Internal Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kao-Ping Chua
- Susan B. Meister Child Health and Evaluation Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Pulia MS, Schwei RJ, Alexandridis R, Lasarev MR, Harwick E, Glinert R, Haleem A, Hess J, Keenan TD, McBride JA, Redwood R. Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis. JAMA Dermatol 2024; 160:511-517. [PMID: 38536160 PMCID: PMC10974680 DOI: 10.1001/jamadermatol.2024.0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/16/2023] [Indexed: 05/16/2024]
Abstract
Importance Cellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis. Objectives To validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis. Design, Setting, and Participants This prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023. Main Outcomes and Measures Temperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed. Results The final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P < .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]). Conclusions and Relevance In this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis.
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Affiliation(s)
- Michael S. Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Industrial and Systems Engineering, University of Wisconsin–Madison School of Engineering, Madison
| | - Rebecca J. Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Roxana Alexandridis
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Michael R. Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Edward Harwick
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Robert Glinert
- Department of Dermatology, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Ambar Haleem
- Division of Infectious Disease, Department of Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Jamie Hess
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Thomas D. Keenan
- Department of Dermatology, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Joseph A. McBride
- Division of Infectious Disease, Department of Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Division of Infectious Disease, Department of Pediatrics, University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Robert Redwood
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison School of Medicine and Public Health, Madison
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Rafferty A, Talento AF, Drew R, Fitzpatrick P, Tedford K, Barrett M, Mahomed H, O’Regan S, Delany L, O’Connor S, Buseckyte A, Brovchin A, Hassan E, Marzec A, Martin D, Greene C, Marriott J, Cunney R. Where to start? The Irish Emergency Department Antimicrobial Discharge (EDAD) study: a multicentre, prospective cohort analysis. JAC Antimicrob Resist 2024; 6:dlae038. [PMID: 38476772 PMCID: PMC10928668 DOI: 10.1093/jacamr/dlae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/10/2024] [Indexed: 03/14/2024] Open
Abstract
Objectives To determine the percentage of patients across Ireland who are discharged from the Emergency Department (ED) with an antimicrobial prescription, the indication, classification of infections, and guideline compliance. To identify potential areas for antimicrobial stewardship (AMS) interventions in the ED. Patients and methods A multicentre, prospective cohort analysis study in EDs across eight hospitals in Ireland. At each site, patients aged 1 month and older who presented to the ED and were discharged directly from the ED were included. A random selection of records of patients discharged from the ED were reviewed until a minimum of 30 records with an infection diagnosis resulting in an antibiotic prescription were obtained per hospital. The number of patient discharges with no antibiotic prescriptions were included to calculate the denominator. The indication, infection classification and guideline compliance data were collected on the 30 prescriptions in the participating hospitals. Results A total of 2619 patient records were reviewed. Of these, 249 (9.5%) patients were discharged with antimicrobial prescriptions from the ED. Most (158; 63%) were classified as probable bacterial infection, 21 (8%) as probable viral, and 18 (7%) had no documented evidence of infection. Three indications accounted for 73% of antimicrobial prescriptions: skin/soft tissue infection; ear, nose and throat infection; and urinary tract infection. Overall guideline compliance was 64%. Conclusions Several areas for AMS interventions to optimize antimicrobial prescribing in the ED were identified, including targeted local and national guideline reviews, delayed prescribing, improved point-of-care testing and prescriber and patient education.
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Affiliation(s)
- Aisling Rafferty
- Department of Pharmacy, Children’s Health Ireland at Temple Street, Dublin, Ireland
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Alida Fe Talento
- Department of Microbiology, Children’s Health Ireland at Temple Street, Dublin, Ireland
- Department of Microbiology, Royal College of Surgeons, Dublin, Ireland
- Department of Microbiology, Trinity College Dublin, Dublin, Ireland
| | - Richard Drew
- Department of Microbiology, Children’s Health Ireland at Temple Street, Dublin, Ireland
- Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
| | - Patrick Fitzpatrick
- Emergency Department, Children’s Health Ireland at Temple Street, Dublin, Ireland
- Department of General Paediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Kara Tedford
- Department of Pharmacy, Children’s Health Ireland at Crumlin, Dublin, Ireland
| | - Michael Barrett
- Emergency Department, Children’s Health Ireland at Crumlin, Dublin, Ireland
| | - Husnain Mahomed
- Emergency Department, Children’s Health Ireland at Crumlin, Dublin, Ireland
| | - Sabrina O’Regan
- Department of Pharmacy, Portiuncula University Hospital, Galway, Ireland
| | - Louise Delany
- Department of Pharmacy, National Maternity Hospital, Dublin, Ireland
| | - Síle O’Connor
- Department of Pharmacy, University Hospital Kerry, Kerry, Ireland
| | - Agne Buseckyte
- Emergency Department, University Hospital Kerry, Kerry, Ireland
| | - Andrei Brovchin
- Emergency Department, University Hospital Kerry, Kerry, Ireland
| | | | - Anna Marzec
- Department of Pharmacy, Our Lady’s Hospital Navan, Meath, Ireland
| | - Donna Martin
- Department of Pharmacy, Cavan General Hospital, Cavan, Ireland
| | - Clare Greene
- Department of Pharmacy, Midland Regional Hospital, Tullamore, Offaly, Ireland
| | - John Marriott
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Robert Cunney
- Department of Microbiology, Children’s Health Ireland at Temple Street, Dublin, Ireland
- Department of Microbiology, Royal College of Surgeons, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
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Neto A, Sage H, Patel AK, Rivera-Sepulveda A. Antibiotic Stewardship and Treatment of Uncomplicated Urinary Tract Infection (UTI) in Children and Adolescents in the Emergency Department of a Community Hospital. Clin Pediatr (Phila) 2024; 63:357-364. [PMID: 37226473 PMCID: PMC11060847 DOI: 10.1177/00099228231175471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A retrospective, cross-sectional study of children with suspected urinary tract infections (UTIs) 3 months to 18 years of age who had a urinalysis and urine culture (UC) during an emergency department (ED) visit between 2019 and 2020 was performed. Chi-square, Fisher exact, and independent samples T tests were used as appropriate. Median age was 6.6 years (interquartile range = 3.3-12.4). Urinalysis positivity was 92.8%, of which 81.9% of children were prescribed a first-line antibiotic. First-line antibiotic use was 82.7%. Positive UC rate was 84.7%, with 84% receiving a first-line antibiotic (P = .025). The correlation between a positive urinalysis and a positive UC was 80.8% (P < .001). Change of antibiotics based on the uropathogen of positive UCs was 6.3% (P < .001). The urinalysis and UC guided the diagnosis and treatment of UTIs. First-line antibiotics can be safely administered in the ED and prescribed for positive urinalyses. Studies are needed to evaluate the discontinuation of antibiotics with negative UCs as part of antibiotic stewardship initiatives.
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Affiliation(s)
- Arino Neto
- Department of Pediatrics, Nemours Children's Health, Orlando, FL, USA
| | - Hannah Sage
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Amit K Patel
- Division of Emergency Medicine and Urgent Care, Nemours Children's Health, Orlando, FL, USA
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Monari C, Onorato L, Allegorico E, Minerva V, Macera M, Bosso G, Calò F, Pagano A, Russo T, Sansone G, D'Isanto M, Casciotta A, Vanni M, Numis FG, Coppola N. The impact of a non-restrictive Antimicrobial Stewardship Program in the emergency department of a secondary-level Italian hospital. Intern Emerg Med 2024; 19:493-500. [PMID: 37700179 PMCID: PMC10954915 DOI: 10.1007/s11739-023-03418-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023]
Abstract
Evidence supporting the effectiveness of Antimicrobial Stewardship (AMS) Programs in the emergency department (ED) setting is limited. We conducted a prospective cohort study to assess the efficacy of an AMS program in an ED and a short-stay observation unit. The intervention included periodic prospective audits (twice a week), conducted by four infectious disease consultants. Primary outcomes included the difference in the hospital mortality rate, antibiotic consumption, and the incidence of bloodstream infections (BSI) caused by multidrug resistant (MDR) bacteria, before March 2020-February 2021 and after March 2021-February 2022 when the program was implemented. Interrupted time-series analysis was performed to assess the effect of our program. During the 12-month program, we performed 152 audits and evaluated 366 antibiotic therapies out of a total of 853 patients admitted. In the intervention period, we observed a non-statistically significant decrease in total antibiotic consumption, with a change in level of - 31.2 defined daily dose/100 patient-days (PD) (p = 0.71). Likewise, we found no significant variations in the rate of BSI due to MDR Gram-positive (CT - 0.02 events/PD, p = 0.84), MDR Gram-negative bacteria (CT 0.08, p = 0.71), or Candida spp. (CT 0.008, p = 0.86). Conversely, we found a significant decrease in the mortality rate between the pre- and post-intervention periods (- 1.98 deaths/100 PD, CI - 3.9 to - 0.007, p = 0.049). The Antibiotic Stewardship Program in the ED was associated with a significant decrease in the mortality rate. More high-quality studies are needed to determine the most effective ASP strategies in this unique setting.
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Affiliation(s)
- Caterina Monari
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Lorenzo Onorato
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Enrico Allegorico
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Valentina Minerva
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Margherita Macera
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Giorgio Bosso
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Federica Calò
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Antonio Pagano
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Teresa Russo
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Gennaro Sansone
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Marina D'Isanto
- Microbiology Unit, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Antonio Casciotta
- Department of Pharmacology, "Santa Maria Delle Grazie Hospital, Pozzuoli, Italy
| | | | - Fabio Giuliano Numis
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Nicola Coppola
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy.
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Arenz L, Porger A, De Michel M, Weber A, Jung J, Horns H, Gscheidle S, Weiglein T, Pircher J, Becker-Lienau J, Horster S, Klein M, Draenert R. Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department. JAC Antimicrob Resist 2024; 6:dlae026. [PMID: 38410248 PMCID: PMC10895698 DOI: 10.1093/jacamr/dlae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Objectives To explore effectiveness and sustainability of guideline adherence and antibiotic consumption after establishing treatment guidelines and initiating antimicrobial stewardship (AMS) ward rounds in a university hospital emergency department (ED). Methods Data were gathered retrospectively from 2017 to 2021 in the LMU University Hospital in Munich, Germany. Four time periods were compared: P1 (pre-intervention period); P2 (distribution of guideline pocket cards); P3 (reassessment after 3 years); and P4 (refresher of guideline pocket cards and additional daily AMS ward rounds for different medical disciplines). Primary outcome was adherence to guideline pocket cards for community-acquired pneumonia, cystitis, pyelonephritis and COVID-19-associated bacterial pneumonia. Secondary outcomes were reduction in antibiotic consumption and adherence to AMS specialist recommendations. Results The study included 1324 patients. Guideline adherence increased in P2 for each of the infectious diseases entities. After 3 years (P3), guideline adherence decreased again, but was mostly on a higher level than in P1. AMS ward rounds resulted in an additional increase in guideline adherence (P1/P2: 47% versus 58.6%, P = 0.005; P2/P3: 58.6% versus 57.3%, P = 0.750; P3/P4: 57.3% versus 72.5%, P < 0.001). Adherence increased significantly, not only during workdays but also on weekends/nightshifts. Adherence to AMS specialist recommendations was excellent (91.3%). We observed an increase in use of narrow-spectrum antibiotics and a decrease in the application of fluoroquinolones and cephalosporins. Conclusions Establishing treatment guidelines in the ED is effective. However, positive effects can be diminished over time. Daily AMS ward rounds are useful, not only to restore but to further increase guideline adherence significantly.
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Affiliation(s)
- Lukas Arenz
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Annika Porger
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Michaela De Michel
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Alexandra Weber
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Jette Jung
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Max-von-Pettenkofer-Institute Munich, LMU Munich, Elisabeth-Winterhalter-Weg 6, 81377 München, Germany
| | - Heidi Horns
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sandra Gscheidle
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Tobias Weiglein
- Department of Medicine III, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Joachim Pircher
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine I, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Johanna Becker-Lienau
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Matthias Klein
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Neurology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Rika Draenert
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
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Nokhodian Z, Boroumandfar Z, Rostami S, Ataei B. Overuse of Antibiotics: Who is to Blame? A Qualitative Study. Int J Prev Med 2024; 14:133. [PMID: 38449691 PMCID: PMC10916410 DOI: 10.4103/ijpvm.ijpvm_287_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 05/17/2023] [Indexed: 03/08/2024] Open
Abstract
Background The irrational use of antibiotics seriously threatens global health. Clinicians undoubtedly play an essential role in consuming antibiotics in hospitals and communities, and their attitudes may help the health system's optimal treatment of antibiotics. In this study, we reported clinicians' experiences with antibiotics used in Isfahan, Iran. Methods In a qualitative study conducted from October 2020 to March 2021, the experiences of 13 clinicians with different clinical specialties were collected through one-to-one interviews. Participants were selected through purposive sampling until data saturation; data collection was conducted through semi-structured interviews. Conventional content analysis was used to analyze the transcribed interviews. The main category was recognized and subcategorized and coded by three researchers. Results Eight women and five men with a mean work experience of 12.54 ± 10.047 years participated in the study. All of them worried about the overuse of antibiotics and antibiotic resistance. Clinicians believe that the antimicrobial stewardship committee is not active in our country. Laboratory challenges, healthcare providers, the poor performance of the health system, and marketing and business were the main categories of the study. Subcategrories of main categories included inefficiency in the function of laboratories, harmful profit, challenges in medical education, ups and downs of disease treatment, the unacceptable performance of hospitals, failure to upgrade the health system, threats and opportunities, and jobbery. Conclusions The participants of this study believed that excessive use of antibiotics is a serious challenge in our country. Physicians were concerned about antibiotic resistance and believed that the pattern of antibiotic resistance was not routinely reported. Therefore, in our region, we should make more efforts to collect data in this field and provide this information to physicians. Also, this study confirmed many obstacles to implementing the antimicrobial stewardship program, and the infrastructure needs strengthening. There is also a need for cultural changes and the views of physicians.
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Affiliation(s)
- Zary Nokhodian
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Boroumandfar
- Reproductive Science and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soodabeh Rostami
- Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behrooz Ataei
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Musuroi SI, Voinescu A, Musuroi C, Baditoiu LM, Muntean D, Izmendi O, Jumanca R, Licker M. The Challenges of The Diagnostic and Therapeutic Approach of Patients with Infectious Pathology in Emergency Medicine. J Pers Med 2023; 14:46. [PMID: 38248747 PMCID: PMC10821085 DOI: 10.3390/jpm14010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/23/2023] [Accepted: 12/24/2023] [Indexed: 01/23/2024] Open
Abstract
The emergency department (ED) represents an important setting for addressing inappropriate antimicrobial prescribing practices because of the time constraints and the duration of microbiological diagnosis. The purpose of this study is to evaluate the etiology and antimicrobial resistance (AMR) pattern of the community-acquired pathogens, as well as the epidemiological characteristics of patients admitted through the ED, in order to guide appropriate antibiotic therapy. METHODS A retrospective observational study was performed on 657 patients, from whom clinical samples (urine, purulent secretions, blood cultures, etc.) were collected for microbiological diagnosis in the first 3 days after presentation in the ED. The identification of pathogens and the antimicrobial susceptibility testing with minimum inhibitory concentration determination were carried out according to the laboratory protocols. RESULTS From the 767 biological samples analyzed, 903 microbial isolates were identified. E. coli was most frequently isolated (24.25%), followed by Klebsiella spp., S. aureus (SA), and non-fermentative Gram-negative bacilli. E. coli strains maintained their natural susceptibility to most antibiotics tested. In the case of Pseudomonas spp. and Acinetobacter spp., increased rates of AMR were identified. Also, 32.3% of SA strains were community-acquired MRSA. CONCLUSIONS The introduction of rapid microbiological diagnostic methods in emergency medicine is imperative in order to timely identify AMR strains and improve therapeutic protocols.
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Affiliation(s)
- Silvia Ioana Musuroi
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Internal Medicine Department, Municipal Emergency Clinical Hospital, 300254 Timisoara, Romania
| | - Adela Voinescu
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Corina Musuroi
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Luminita Mirela Baditoiu
- Epidemiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Delia Muntean
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Oana Izmendi
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Romanita Jumanca
- Romanian and Foreign Languages Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Monica Licker
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
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Vu MT, Schwartz H, Straube S, Pondicherry N, Emanuels D, Dhanoa J, Bains J, Singh M, Stark N, Peabody C. Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department. Emerg Med J 2023; 40:847-853. [PMID: 37907325 DOI: 10.1136/emermed-2022-213015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 10/04/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.
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Affiliation(s)
- Mai Trang Vu
- UCSF School of Medicine, San Francisco, California, USA
| | - Hope Schwartz
- UCSF School of Medicine, San Francisco, California, USA
| | - Steven Straube
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | | | | | - Jaskirat Dhanoa
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Jaskaran Bains
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Malini Singh
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Nicholas Stark
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
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Yock-Corrales A, Naranjo-Zuñiga G. Regional Perspective of Antimicrobial Stewardship Programs in Latin American Pediatric Emergency Departments. Antibiotics (Basel) 2023; 12:antibiotics12050916. [PMID: 37237820 DOI: 10.3390/antibiotics12050916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/06/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Antibiotic stewardship (AS) programs have become a priority for health authorities to reduce the number of infections by super-resistant microorganisms. The need for these initiatives to minimize the inadequate use of antimicrobials is essential, and the election of the antibiotic in the emergency department usually impacts the choice of treatment if the patients need hospital admission, becoming an opportunity for antibiotic stewardship. In the pediatric population, broad-spectrum antibiotics are more likely to be overprescribed without any evidence-based management, and most of the publications have focused on the prescription of antibiotics in ambulatory settings. Antibiotic stewardship efforts in pediatric emergency departments in Latin American settings are limited. The lack of literature on AS programs in the pediatric emergency departments in Latin America (LA) limits the information available. The aim of this review was to give a regional perspective on how pediatric emergency departments in LA are working towards antimicrobial stewardship.
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Affiliation(s)
- Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Niños "Dr. Carlos Saenz Herrera", Caja Costarricense del Seguro Social (CCSS), San José P.O. Box 1654-1000, Costa Rica
| | - Gabriela Naranjo-Zuñiga
- Infectious Disease Department, Hospital Nacional de Niños "Dr. Carlos Saenz Herrera", Caja Costarricense del Seguro Social (CCSS), San José P.O. Box 1654-1000, Costa Rica
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Kassamali Escobar Z, Bouchard T, Buck C, Sandhu K, Bryson-Cahn C. A single-centre experience rolling out an antibiotic stewardship intervention prior to and during the SARS-CoV-2 pandemic 2019-2022. Drugs Context 2023; 12:dic-2022-7-5. [PMID: 36843621 PMCID: PMC9949760 DOI: 10.7573/dic.2022-7-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 12/13/2022] [Indexed: 02/17/2023] Open
Abstract
Background Antibiotics are prescribed to nearly one-half of patients with viral respiratory tract infections (RTI) in outpatient settings. This use is ineffective and may cause undue harm and excess cost from unnecessary antibiotic exposure. We implemented a multifaceted intervention to address inappropriate antibiotic prescribing for viral RTI. Here, we discuss the impact over 4 years, before and during the SARS-CoV-2 pandemic. Methods This observational study describes the implementation and initial impact of a multimodal stewardship intervention on inappropriate antibiotic prescribing for viral RTIs in outpatient care settings at a single centre. We tracked the rate of visits for viral RTI as well as antibiotic prescribing for viral RTIs in urgent care, primary care and the emergency department between January 2018 and March 2022. Data were collected 1 year prior to implementation and 3 years after implementation. The primary outcome - the rate of inappropriate antibiotics prescribed for viral RTIs - was described by calendar year (CY) to review changes after the stewardship intervention. Results In CY2018, the year prior to implementation of targeted RTI antimicrobial stewardship, the rate of inappropriate RTI antibiotics prescribed was 10% in urgent care, 11% in primary care and 18% in the emergency department (ED). During the first CY of the intervention, rates were 8% in urgent care, 10% in primary care and 16% in the ED. In CY2020, the second year of the intervention, inappropriate RTI antibiotics were prescribed in 5% of urgent care and 3% primary care RTI visits and 15% of ED RTI visits. These rates were similar in CY2021 and the first 3 months of CY2022. Over 30,000 visits for RTIs were seen annually in CY2018 and CY2019. Annual RTI visits dropped to 20,222 in CY2020 and 14,172 in CY2021. Conclusion Although total visits for non-COVID RTIs decreased by approximately 50% during the first 2 years of the SARS-CoV-2 pandemic, an antimicrobial stewardship intervention was associated with decreases in inappropriate antibiotic prescribing for RTIs. This was maintained throughout 2 years of the pandemic.This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Zahra Kassamali Escobar
- Fred Hutchinson Cancer Center, Seattle, WA, USA,University of Washington Center for Stewardship in Medicine, Seattle, WA, USA
| | - Todd Bouchard
- University of Washington Valley Medical Center, Renton, WA, USA
| | - Cameron Buck
- University of Washington Valley Medical Center, Renton, WA, USA
| | | | - Chloe Bryson-Cahn
- University of Washington Center for Stewardship in Medicine, Seattle, WA, USA,Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Ford JS, Morgan Bustamante BL, Virk MK, Ramirez N, Matsumoto CG, Lee DJ, MacDonald S, May L. Use of clinical decision support for antibiotic stewardship in the emergency department and outpatient clinics: An interrupted time-series analysis. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e80. [PMID: 37205319 PMCID: PMC10186615 DOI: 10.1017/ash.2023.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 05/21/2023]
Abstract
Objective To evaluate the impact of implementing clinical decision support (CDS) tools for outpatient antibiotic prescribing in the emergency department (ED) and clinic settings. Design We performed a before-and-after, quasi-experimental study that employed an interrupted time-series analysis. Setting The study institution was a quaternary, academic referral center in Northern California. Participants We included prescriptions for patients in the ED and 21 primary-care clinics within the same health system. Intervention We implemented a CDS tool for azithromycin on March 1, 2020, and a CDS tool for fluoroquinolones (FQs; ie, ciprofloxacin, levofloxacin, and moxifloxacin) on November 1, 2020. The CDS added friction to inappropriate ordering workflows while adding health information technology (HIT) features to easily perform recommended actions. The primary outcome was the number of monthly prescriptions for each antibiotic type, by implementation period (before vs after). Results Immediately after azithromycin-CDS implementation, monthly rates of azithromycin prescribing decreased significantly in both the ED (-24%; 95% CI, -37% to -10%; P < .001) and outpatient clinics (-47%; 95% CI, -56% to -37%; P < .001). In the first month after FQ-CDS implementation in the clinics, there was no significant drop in ciprofloxacin prescriptions; however, there was a significant decrease in ciprofloxacin prescriptions over time (-5% per month; 95% CI, -6% to -3%; P < .001), suggesting a delayed effect of the CDS. Conclusion Implementing CDS tools was associated with an immediate decrease in azithromycin prescriptions, in both the ED and clinics. CDS may serve as a valuable adjunct to existing antimicrobial stewardship programs.
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Affiliation(s)
- James S. Ford
- Department of Emergency Medicine, University of California–San Francisco, San Francisco, California
| | | | - Mehr Kaur Virk
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Nancy Ramirez
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Cynthia G. Matsumoto
- Office of Population Health and Accountable Care, University of California Davis, Sacramento, California
| | - Daniel Jin Lee
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Scott MacDonald
- Department of Clinical Informatics, University of California Davis Health, Sacramento, California
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
- Author for correspondence: Larissa May, University of California–Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA95817. E-mail:
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McGonagle EA, Karavite DJ, Grundmeier RW, Schmidt SK, May LS, Cohen DM, Cruz AT, Tu SP, Bajaj L, Dayan PS, Mistry RD. Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections. Appl Clin Inform 2023; 14:108-118. [PMID: 36754066 PMCID: PMC9908419 DOI: 10.1055/s-0042-1760082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/16/2022] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVES Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI). METHODS We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow. RESULTS Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117). CONCLUSION Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.
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Affiliation(s)
- Erin A. McGonagle
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Dean J. Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert W. Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Sarah K. Schmidt
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Larissa S. May
- Department of Emergency Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Daniel M. Cohen
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, United States
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Shin-Ping Tu
- Department of Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Lalit Bajaj
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Peter S. Dayan
- Department of Emergency Medicine and Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
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19
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Pulia MS, Schwei RJ, Hesse SP, Werner NE. Characterizing barriers to antibiotic stewardship for skin and soft-tissue infections in the emergency department using a systems engineering framework. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e180. [PMID: 36386011 PMCID: PMC9641503 DOI: 10.1017/ash.2022.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Skin and soft-tissue infections (SSTIs) account for 3% of all emergency department (ED) encounters and are frequently associated with inappropriate antibiotic prescribing. We characterized barriers and facilitators to optimal antibiotic use for SSTIs in the ED using a systems engineering framework and matched them with targeted stewardship interventions. DESIGN AND PARTICIPANTS We conducted semistructured interviews with a purposefully selected sample of emergency physicians. METHODS An interview guide was developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Interviews were recorded, transcribed, and analyzed iteratively until conceptual saturation was achieved. Themes were identified using deductive directed content analysis guided by the SEIPS model. RESULTS We conducted 20 interviews with physicians of varying experience and from different practice settings. Identified barriers to optimal antibiotic prescribing for SSTIs included poor access to follow-up (organization), need for definitive diagnostic tools (tools and technology) and fear over adverse outcomes related to missed infections (person). Identified potential interventions included programs to enhance follow-up care; diagnostic aides (eg, rapid MRSA assays for purulent infections and surface thermal imaging for cellulitis); and shared decision-making tools. CONCLUSIONS Using a systems engineering informed qualitative approach, we successfully characterized barriers and developed targeted antibiotic stewardship interventions for SSTIs managed in the ED work system. The interventions span multiple components of the ED work system and should inform future efforts to improve antibiotic stewardship for SSTIs in this challenging care setting.
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Affiliation(s)
- Michael S. Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin—Madison School of Medicine and Public Health, Madison, Wisconsin
- Department of Industrial and Systems Engineering, University of Wisconsin—Madison, Madison, Wisconsin
| | - Rebecca J. Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin—Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Steven P. Hesse
- University of Wisconsin—Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Nicole E. Werner
- Department of Industrial and Systems Engineering, University of Wisconsin—Madison, Madison, Wisconsin
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20
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Evaluation of the Clinical Outcome and Cost Analysis of Antibiotics in the Treatment of Acute Respiratory Tract Infections in the Emergency Department in Saudi Arabia. Antibiotics (Basel) 2022; 11:antibiotics11111478. [PMID: 36358133 PMCID: PMC9686469 DOI: 10.3390/antibiotics11111478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022] Open
Abstract
This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.
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21
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Jabak SJ, Kawam L, El Mokahal A, Sharara AI. Management of acute diarrhea in the emergency department of a tertiary care university medical center. J Int Med Res 2022; 50:3000605221115385. [PMID: 35942579 PMCID: PMC9373141 DOI: 10.1177/03000605221115385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To examine the management of acute diarrhea in the emergency department (ED)
of a large university medical center. Methods Retrospective cross-sectional study over a 10-month period of adult patients
(age ≥18 years) presenting to the ED with acute diarrhea. Results Data for 780 patients were reviewed; 101 met the exclusion criteria. Of the
679 patients with acute community-acquired diarrhea, 582 (85.7%) were
discharged home and constituted the study cohort of mostly healthy adults
(mean age: 32.5 ± 14.5 years). The rate of antibiotic prescription at
discharge was 26%. Inappropriate use of antibiotics occurred in 28% of the
patients. The presence of fever (odds ratio (OR) = 3.52), leukocytosis
(OR = 1.72), and older age (OR = 1.16) were predictors of antibiotic
prescription. Patients with dehydration, comorbidities, or bloody diarrhea
were more likely to receive antibiotics. Microbiological studies and
cross-sectional imaging were ordered in 12.4% and 11.7% of the patients,
respectively, but provided very low yield (<10% for both) resulting in
significantly higher visit charges. Inappropriately prescribed antibiotics
at discharge resulted in higher charges in the ED compared with no
antibiotic prescription. Conclusion Acute diarrhea management in our ED is suboptimal and does not adhere to
practice guidelines, resulting in unnecessary antibiotic prescriptions,
investigations, and cost.
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Affiliation(s)
| | | | | | - Ala I Sharara
- Ala I. Sharara, Professor of Medicine,
Division of Gastroenterology, American University of Beirut Medical Center, Riad
El-Solh, Beirut 1107 2020, Lebanon.
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22
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Pin M, Somasundaram R, Wrede C, Schwab F, Gastmeier P, Hansen S. Antimicrobial resistance control in the emergency department: a need for concrete improvement. Antimicrob Resist Infect Control 2022; 11:94. [PMID: 35804401 PMCID: PMC9264623 DOI: 10.1186/s13756-022-01135-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/29/2022] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Rational use of antibiotics (AB) and infection prevention and control (IPC) are key measures for reducing antimicrobial resistance (AMR) in healthcare. Nonetheless, transferring evidence into clinical practice in emergency medicine has proven difficult. The extent to which structural requirements for implementing AMR control exist in German emergency departments (ED) was determined in a survey. METHODS Aspects of antimicrobial stewardship (AMS) and IPC implementation were surveyed within the German Association for Emergency Medicine (Deutsche Gesellschaft interdisziplinäre Notfall- und Akutmedizin e.V, DGINA) in 2018. Data were collected using an anonymous online questionnaire on ED characteristics, ED-based-link personnel for IPC and AMS, education and training, process monitoring and specific requirements for AMS and IPC as availability of AMR data and alcohol-based hand rub (AHR) consumption data. Data were analysed descriptively. RESULTS 66 EDs with in median [interquartile range (IQR)] of 30,900 [23,000; 40,000] patient visits participated in the survey. EDs' healthcare worker (HCW) received regular training on hand hygiene (HH) in 67% and on AMS in 20% of EDs. Surveillance of AHR consumption was performed by 73% EDs, surveillance of AB consumption by 64%. Regular audits on HH were performed in 39%. Training and audit activities, showed no significant variations according to EDs' organizational characteristics. HCWs received immediate feedback of HH performance in 29%, in 23% a regular structured feedback of HH was provided. ED-based physicians with (1) specific IPC responsibilities and training were available in 61%, with (2) AMS training and responsibility in 15%. 83% had ED based IPC link nurses with precise ICP responsibilities in place. Essentially resistance data existed at the hospital level (74%) rather than at ED- or regional level (15% and 14% respectively). CONCLUSIONS Management of AMR varies in German EDs, especially in accordance to hospital size and level of emergency care. IPC seems to receive more attention than AMS. Our data indicate the need for more implementation of regular IPC and AMS training in connection with monitoring and feedback in German EDs.
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Affiliation(s)
- Martin Pin
- Florence-Nightingale-Hospital, Kaiserswerther Diakonie, Department of Emergency Medicine, Düsseldorf, Germany
- German Association for Emergency Medicine, (Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin e.V., DGINA), Berlin, Germany
| | - Rajan Somasundaram
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Emergency Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Christian Wrede
- German Association for Emergency Medicine, (Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin e.V., DGINA), Berlin, Germany
- Helios Hospital Berlin-Buch, Department of Emergency Medicine, Berlin, Germany
| | - Frank Schwab
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
- National Reference Centre for Surveillance of Nosocomial Infections, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Petra Gastmeier
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
- National Reference Centre for Surveillance of Nosocomial Infections, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Sonja Hansen
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Emergency Medicine, Campus Benjamin Franklin, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
- National Reference Centre for Surveillance of Nosocomial Infections, Institute of Hygiene and Environmental Medicine, Berlin, Germany
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23
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Ostrow O, Prodanuk M, Foong Y, Singh V, Morrissey L, Harvey G, Campigotto A, Science M. Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department. Pediatrics 2022; 150:188353. [PMID: 35773521 DOI: 10.1542/peds.2021-055866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years. METHODS By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis. RESULTS From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment. CONCLUSIONS A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.
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Affiliation(s)
- Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Michael Prodanuk
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Yen Foong
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Valene Singh
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Laura Morrissey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Greg Harvey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Aaron Campigotto
- Division of Microbiology, Department of Pediatric Laboratory Medicine.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Science
- Division of Infectious Disease, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Departments of Pediatrics
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24
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Azijli K, Minderhoud TC, de Gans CJ, Lieveld AW, Nanayakkara PW. Optimal use of procalcitonin to rule out bacteremia in patients with possible viral infections. J Am Coll Emerg Physicians Open 2022; 3:e12621. [PMID: 35601651 PMCID: PMC9120727 DOI: 10.1002/emp2.12621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective During the winter, many patients present with suspected infection that could be a viral or a bacterial (co)infection. The aim of this study is to investigate whether the optimal use of procalcitonin (PCT) is different in patients with and without proven viral infections for the purpose of excluding bacteremia. We hypothesize that when a viral infection is confirmed, this lowers the probability of bacteremia and, therefore, influences the appropriate cutoff of procalcitonin. Methods This study was conducted in the emergency department of an academic medical center in The Netherlands in the winter seasons of 2019 and 2020. Adults (>18 years) with suspected infection, in whom a blood culture and a rapid polymerase chain reaction test for influenza was performed were included. Results A total of 546 patients were included of whom 47 (8.6%) had a positive blood culture. PCT had an area under the curve of 0.85, 95% confidence interval (95% CI) 0.80-0.91, for prediction of bacteremia. In patients with a proven viral infection (N = 212) PCT < 0.5 μg/L had a sensitivity of 100% (95% CI 63.1-100) and specificity of 81.2% (95% CI 75.1-86.3) to exclude bacteremia. In patients without a viral infection, the procalcitonin cutoff point of < 0.25 μg/L showed a sensitivity of 87.2% (95% CI 72.6-95.7) and specificity of 64.1 % (95% CI 58.3-69.6). Conclusion In patients with a viral infection, our findings suggest that a PCT concentration of <0.50 μg/L makes bacteremia unlikely. However, this finding needs to be confirmed in a larger population of patients with viral infections, especially because the rate of coinfection in our cohort was low.
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Affiliation(s)
- Kaoutar Azijli
- Department of Emergency MedicineAmsterdam Public Health Research InstituteAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Tanca C. Minderhoud
- Department of General and Acute Internal MedicineAmsterdam Public Health Research InstituteAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Carlijn J. de Gans
- Department of Emergency MedicineAmsterdam Public Health Research InstituteAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of General and Acute Internal MedicineGelre Hospital ApeldoornAmsterdamThe Netherlands
| | - Arthur W.E. Lieveld
- Department of General and Acute Internal MedicineAmsterdam Public Health Research InstituteAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Prabath W.B. Nanayakkara
- Department of General and Acute Internal MedicineAmsterdam Public Health Research InstituteAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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25
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Kovaleski C, Courter JD, Ghulam E, Hagedorn PA, Haslam DB, Kurowski EM, Rudloff J, Szczesniak R, Dexheimer JW. Aligning Provider Prescribing With Guidelines for Soft Tissue Infections. Pediatr Emerg Care 2022; 38:e1063-e1068. [PMID: 35226632 DOI: 10.1097/pec.0000000000002667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite evidence-based guidelines, antibiotics prescribed for uncomplicated skin and soft tissue infections can involve inappropriate microbial coverage. Our aim was to evaluate the appropriateness of antibiotic prescribing practices for mild nonpurulent cellulitis in a pediatric tertiary academic medical center over a 1-year period. METHODS Eligible patients treated in the emergency department or urgent care settings for mild nonpurulent cellulitis from January 2017 to December 2017 were identified by an International Classification of Diseases, Tenth Revision, code for cellulitis. The primary outcome was appropriateness of prescribed antibiotics as delineated by adherence with the Infectious Diseases Society of America guidelines. Secondary outcomes include reutilization rate as defined by revisit to the emergency department/urgent cares within 14 days of the initial encounter. RESULTS A total of 967 encounters were evaluated with 60.0% overall having guideline-adherent care. Common reasons for nonadherence included inappropriate coverage of MRSA with clindamycin (n = 217, 56.1%) and single-agent coverage with sulfamethoxazole-trimethoprim (n = 129, 33.3%). There were 29 revisits within 14 days of initial patient encounters or a reutilization rate of 3.0%, which was not significantly associated with the Infectious Diseases Society of America adherence. CONCLUSIONS Our data show antibiotic prescription for nonpurulent cellulitis as a potential area of standardization and optimization of care at our center.
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Affiliation(s)
| | | | | | | | - David B Haslam
- Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center
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26
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Abstract
OBJECTIVES The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. METHODS We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. RESULTS There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). CONCLUSIONS More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.
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Affiliation(s)
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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27
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Nys CL, Fischer K, Funaro J, Shoff CJ, Theophanous RG, Staton CA, Mando-Vandrick J, Toler R, Shroba J, Turner NA, Liu B, Lee HJ, Moehring RW, Wrenn RH. Impact of Education and Data Feedback on Antibiotic Prescribing for Urinary Tract Infections in the Emergency Department: An Interrupted Time Series Analysis. Clin Infect Dis 2022; 75:1194-1200. [PMID: 35100621 DOI: 10.1093/cid/ciac073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are often misdiagnosed or treated with exceedingly broad-spectrum antibiotics, leading to negative downstream effects. We aimed to implement antimicrobial stewardship (AS) strategies targeting UTI prescribing in the emergency department (ED). METHODS We conducted a quasi-experimental prospective AS intervention outlining appropriate UTI diagnosis and management across three EDs, within an academic and two community hospitals, in North Carolina, United States. The study was divided into three phases, a baseline period and two intervention phases. Phase 1 included introduction of an ED-specific urine antibiogram and UTI guideline, education, and department-specific feedback on UTI diagnosis and antibiotic prescribing. Phase 2 included re-education and provider-specific feedback. Eligible patients included adults with an antibiotic prescription for UTI diagnosed in the ED from 11/13/18 to 3/1/21. Admitted patients were excluded. The primary outcome was guideline-concordant antibiotic use, assessed using an interrupted time series regression analysis with 2-week intervals. RESULTS Overall, 8,742 distinct patients with 10,426 patient encounters were included. Ninety-two percent of all encounters (n=9,583) were diagnosed with cystitis and 8.1% with pyelonephritis (n=843). There was an initial 15% increase in guideline-concordant antibiotic prescribing in Phase 1 compared to the pre-intervention period (incidence rate ratio [IRR] 1.15; 95% confidence interval [CI] 1.03 to 1.29). A significant increase of guideline-concordant prescriptions was seen with every two-week interval during Phase 2 (IRR 1.03; 95% CI 1.01 to 1.04). CONCLUSIONS This multifaceted AS intervention involving a guideline, education, and provider-specific feedback increased guideline-concordant antibiotic choices for treat-and-release patients in the ED.
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Affiliation(s)
- Cara L Nys
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Kristen Fischer
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Jason Funaro
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Christopher J Shoff
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca G Theophanous
- Department of Surgery, Division of Emergency Medicine, Duke University Hospital, Durham, NC, USA
| | - Catherine A Staton
- Department of Surgery, Division of Emergency Medicine, Duke University Hospital, Durham, NC, USA
| | | | - Rachel Toler
- Department of Pharmacy, Duke Regional Hospital, Durham, NC, USA
| | - Jenny Shroba
- Department of Pharmacy, Duke Raleigh Hospital, Durham, NC, USA
| | - Nicholas A Turner
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
| | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
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28
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Kooda K, Canterbury E, Bellolio F. Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2022; 79:374-387. [PMID: 35039180 DOI: 10.1016/j.annemergmed.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to evaluate the impact of pharmacist presence or pharmacist-led antimicrobial stewardship interventions on appropriate prescribing of antibiotics in the emergency department (ED). METHODS Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted. Studies describing the role of pharmacists and their association with antimicrobial stewardship in the ED were included. The comparator for pharmacist intervention was hours without a pharmacist present, preprotocol implementation, and nonpharmacist culture follow-up. RESULTS In total, 24 studies (9,984 patients) were included in the qualitative synthesis, and 22 studies (5,791 patients) had data for the primary outcome and were included for the quantitative assessment (meta-analysis). Appropriate prescribing of antibiotics was more likely with pharmacist intervention (22 studies; odds ratio [OR], 3.47; 95% confidence interval [CI] 2.39 to 5.03), particularly among patients with pneumonia (5 studies; OR, 3.74; 95% CI 2.14 to 6.54) or urinary tract infection (4 studies; OR, 1.76; 95% CI 1.24 to 2.50). Time to culture review was similar with or without pharmacist intervention. Time to appropriate antibiotic was shorter with pharmacist intervention (mean difference, 18.9 hours; 95% CI 11.9 to 25.9; P<.001). Repeat ED visit for the same complaint was not significant (10 studies; OR, 0.65; 95% CI 0.39 to 1.10). CONCLUSION Pharmacist presence and pharmacist-led antimicrobial stewardship interventions appear to be effective for the appropriate prescribing of antibiotics in adult patients presenting to EDs with a variety of infectious syndromes.
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Appropriate Antibiotic Prescribing in the Emergency Department. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ruiz-Ramos J, Vallvé Alcón E, Moreno Ramos F, Santolaya-Perrín R, Guardiola Tey JM. Antimicrobial stewardship programs in emergency departments: how do we measure antimicrobial use? A systematic review. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:610-617. [PMID: 34523327 PMCID: PMC8638771 DOI: 10.37201/req/028.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/25/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The implementation of antimicrobial stewardship programs (ASPs) has become a usual practice in hospital settings. However, the method for monitoring antimicrobial use in accident and emergency departments (ED) is not yet adequately defined. Thus, the objective of this review is to describe antimicrobial use indicators used by ASPs implemented in ED. METHODS A systematic review was performed based on studies found in the following academic research databases: MEDLINE, EMBASE, Web of Science, and Scopus (Period: January 2000 to December 2019). Controlled clinical trials, before-and-after studies, interrupted time series, and repeated measures studies assessing the impact of ASPs on antimicrobial use in ED were included; studies published in languages other than English or Spanish were excluded from this review. RESULTS Twenty-six studies met the inclusion criteria and were included in this systematic review. In total, 15 (62.5%) studies described the ASP team members who collaborated with the ED staff. Most (21; 80.8%) studies used the percentage of patients with an antibiotic prescription as an indicator. Four (15.4%) studies included defined daily dose data. The antibiotic treatment duration was reported in four (15.4%) studies. Only two studies assessed the impact of the ASP using microbiological indicators, both of which used the incidence of infection with Clostridioides difficile as the indicator. CONCLUSIONS The reports of experiences in implementing ASPs in ED show heterogeneous antimicrobial use indicators, which makes it difficult to compare results. Therefore, antimicrobial use indicators for ASPs must be standardised between hospital units.
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Affiliation(s)
- J Ruiz-Ramos
- Jesus Ruiz, Pharmacy Department, Hospital Santa Creu i Sant Pau. C/San Quintín 89, 08041 Barcelona, Spain.
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Rainess RA, Patel VV, Cavanaugh JB, Hill J. Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department. J Pharm Technol 2021; 37:140-146. [PMID: 34752582 DOI: 10.1177/87551225211000363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The impact that an antimicrobial stewardship program can have on an inpatient setting has been well documented, but there are limited data on the use of an antimicrobial stewardship program in the emergency department (ED). Objective: The objective of this study was to assess the impact of adding a pharmacist service to a midlevel provider-driven culture follow-up program in the ED on achieving optimal therapy. Methods: This was a quasi-experimental study with designations of pre- and post-interventions conducted at a large community hospital with the pre-intervention phase occurring from June 1, 2019, to August 31, 2019, and the post-intervention phase occurring from January 1, 2020, to March 31, 2020. The primary outcome was optimal antimicrobial therapy: a composite of optimal antibiotic, dose, and duration, prescribed after the culture resulted. Secondary outcomes included optimal antibiotic, dose, duration, and return to the ED within 30 days due to infection. Results: Optimal antimicrobial therapy received after the culture resulted occurred in 59 patients (26.81%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .003). For the secondary outcomes, optimal antibiotic choice occurred in 115 patients (52.27%) in the pre-implementation phase and 66 patients (72.53%) in the implementation phase (P = .001). Optimal antibiotic dose occurred in 113 patients (51.36%) in the pre-implementation phase and 65 patients (71.43%) in the implementation phase (P = .001). Optimal antibiotic duration occurred in 65 patients (29.55%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .014). Conclusions: The addition of a clinical pharmacist service in a midlevel provider-driven ED culture callback program resulted in an increased rate of achieving optimal antimicrobial therapy.
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Affiliation(s)
| | - Vishal V Patel
- Community Medical Center, Toms River, NJ, USA.,Idaho College of Osteopathic Medicine, Meridian, ID, USA
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Chen J, Navarro E, Nuñez E, Gau V. Rapid Electrochemical-Based PCR-Less Microbial Quantification and Antimicrobial Susceptibility Profiling Directly From Blood and Urine With Unknown Microbial Load or Species. Front Bioeng Biotechnol 2021; 9:744198. [PMID: 34604191 PMCID: PMC8481646 DOI: 10.3389/fbioe.2021.744198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
Novel molecular platforms are available for identifying (ID) the causative agents of microbial infections and generating antimicrobial susceptibility testing (AST) profiles, which can inform the suitable course of treatment. Many methods claim to perform AST in minutes or hours, often ignoring the need for time-consuming steps such as enrichment cultures and isolation of pure cultures. In clinical microbiology laboratories, an infectious microbial must first be cultured (overnight to days) and identified at the species level, followed by a subsequent AST with an additional turnaround time of 12-48 h due to the need for regrowth of the organism in the absence and presence of relevant antibiotics. Here, we present an electrochemical-based direct-from-specimen ID/AST method for reporting directly from unprocessed urine and blood in hours. In a limit of detection study of 0.5-ml whole blood samples for point-of-care and pediatric applications, 16.7% (4/24) of samples contrived at 2 CFU/ml and 100% (24/24) of samples contrived at 6 CFU/ml were reported positive in 6.5 h, indicating a limit of detection of 6 CFU/ml. In a separate direct-from-specimen AST study, the categorical susceptibility was reported correctly for blinded susceptible, intermediate, resistant, and polymicrobial contrived specimens in 4 h.
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Acquisto NM, Slocum GW, Bilhimer MH, Awad NI, Justice SB, Kelly GF, Makhoul T, Patanwala AE, Peksa GD, Porter B, Truoccolo DMS, Treu CN, Weant KA, Thomas MC. Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update. Am J Health Syst Pharm 2021; 77:1284-1335. [PMID: 32766731 DOI: 10.1093/ajhp/zxaa178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | | | - Nadia I Awad
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Gregory F Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Therese Makhoul
- Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, CA
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT
| | | | - Cierra N Treu
- Department of Pharmacy, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY
| | - Kyle A Weant
- Medical University of South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Michael C Thomas
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
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Mixon MA, Dietrich S, Bushong B, Peksa GD, Rogoszewski R, Theiler A, Spears L, Werth J, Meister E, Martin MS. Urinary tract infection pocket card effect on preferred antimicrobial prescribing for cystitis among patients discharged from the emergency department. Am J Health Syst Pharm 2021; 78:1417-1425. [PMID: 33889933 PMCID: PMC8083212 DOI: 10.1093/ajhp/zxab175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the impact of a urinary tract infection (UTI) pocket card on preferred antibiotic prescribing for patients discharged from the emergency department (ED) with a diagnosis of cystitis. METHODS A multicenter, retrospective, pre-post study was conducted to compare outcomes following the introduction of a UTI pocket card. The primary outcome was prescribing rates for institutional first-line preferred antibiotics (cephalexin and nitrofurantoin) versus other antimicrobials for cystitis. Secondary outcomes included prescriber adherence to recommended therapy in regards to discharge dose, frequency, duration, and healthcare utilization rates. RESULTS The study included 915 patients in total, 407 in the preintervention group and 508 in the postintervention group. The frequency of preferred antibiotic prescribing was significantly increased after the introduction of a UTI pocket card compared to prior to its introduction (81.7% vs 72.0%, P = 0.001). Significant increases in prescribing of an appropriate antibiotic dose (78.0% vs 66.8%, P < 0.0001) and frequency (64.2% vs 47.4%, P < 0.0001) were also found post intervention. No significant differences were seen between the pre- and postintervention groups with regards to healthcare utilization rates. CONCLUSION A UTI pocket card increased preferred antibiotic prescribing for cystitis in the ED. This study provides data on a successful antimicrobial stewardship intervention in the ED setting.
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Affiliation(s)
| | - Scott Dietrich
- Department of Pharmacy, Medical Center of the Rockies, Loveland, CO,USA
| | | | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL,USA
| | - Ryan Rogoszewski
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Alexander Theiler
- Department of Emergency Medicine, Emergency Physicians of the Rockies, Fort Collins CO,USA
| | - Lindsey Spears
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Joshua Werth
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Erin Meister
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Matthew Steven Martin
- Department of Emergency Medicine, Emergency Physicians of the Rockies, Fort Collins CO,USA
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Appropriateness of antimicrobial prescribing in the high-burden emergency department of a tertiary hospital in Malaysia. Int J Clin Pharm 2021; 43:1337-1344. [PMID: 33677792 DOI: 10.1007/s11096-021-01255-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/31/2021] [Accepted: 02/20/2021] [Indexed: 10/22/2022]
Abstract
Background Appropriate antimicrobial prescribing in the emergency department (ED) is a challenge due to diagnostic uncertainty, time pressure, and clinical inertia. Objective To assess the appropriateness of antimicrobial prescribing in the ED. Setting This study was conducted in the inpatient ED of a tertiary hospital in Malaysia. Method We conducted a 6-month retrospective antimicrobial prescriptions analysis among ED patients who received intravenous antimicrobial. Antimicrobial prescriptions of conveniently selected adult patients were evaluated with the medication appropriateness index. Main outcome measure Appropriateness of antimicrobial prescribing was the primary outcome measure. Results We analysed 310 patients with 326 antimicrobial prescriptions. Ceftriaxone (41.1%, n = 134) and amoxicillin-clavulanate (36.5%, n = 119) were the most common antimicrobials prescribed. Respiratory infections (71.5%, n = 233) was the main indication for antimicrobial therapy in the ED. All antimicrobials prescribed were indicated as per the Malaysian antimicrobial guidelines. The overall rate of inappropriate antimicrobial prescribing was 53.1% (n = 173). Thirty-two (9.8%) antimicrobials were prescribed with inappropriate doses; the majority was related to beta-lactam/beta-lactamase dose (p = 0.002). One hundred and forty-three (43.9%) antimicrobials prescribed had alternatives with similar efficacy but were less costly; which referring to ceftriaxone usage (p < 0.001). Conclusions The inappropriate antimicrobial prescribing in the emergency department is prevalent. This emphasises the importance of conducting antimicrobial stewardship initiative in the ED to improve the appropriate dosing of beta-lactam/beta-lactamase inhibitors as well as the judicious use of ceftriaxone.
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Ducharme J, Self WH, Osborn TM, Ledeboer NA, Romanowsky J, Sweeney TE, Liesenfeld O, Rothman RE. A Multi-mRNA Host-Response Molecular Blood Test for the Diagnosis and Prognosis of Acute Infections and Sepsis: Proceedings from a Clinical Advisory Panel. J Pers Med 2020; 10:jpm10040266. [PMID: 33297498 PMCID: PMC7762405 DOI: 10.3390/jpm10040266] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/12/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022] Open
Abstract
Current diagnostics are insufficient for diagnosis and prognosis of acute infections and sepsis. Clinical decisions including prescription and timing of antibiotics, ordering of additional diagnostics and level-of-care decisions rely on understanding etiology and implications of a clinical presentation. Host mRNA signatures can differentiate infectious from noninfectious etiologies, bacterial from viral infections, and predict 30-day mortality. The 29-host-mRNA blood-based InSepTM test (Inflammatix, Burlingame, CA, formerly known as HostDxTM Sepsis) combines machine learning algorithms with a rapid point-of-care platform with less than 30 min turnaround time to enable rapid diagnosis of acute infections and sepsis, as well as prediction of disease severity. A scientific advisory panel including emergency medicine, infectious disease, intensive care and clinical pathology physicians discussed technical and clinical requirements in preparation of successful introduction of InSep into the market. Topics included intended use; patient populations of greatest need; patient journey and sample flow in the emergency department (ED) and beyond; clinical and biomarker-based decision algorithms; performance characteristics for clinical utility; assay and instrument requirements; and result readouts. The panel identified clear demand for a solution like InSep, requirements regarding test performance and interpretability, and a need for focused medical education due to the innovative but complex nature of the result readout. Innovative diagnostic solutions such as the InSep test could improve management of patients with suspected acute infections and sepsis in the ED, thereby lessening the overall burden of these conditions on patients and the healthcare system.
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Affiliation(s)
- James Ducharme
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37220, USA;
| | - Tiffany M. Osborn
- Department of Medicine, Division of Emergency Medicine and Department of Surgery, Washington University, St. Louis, MO 63110, USA;
| | - Nathan A. Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | | | | | - Oliver Liesenfeld
- Inflammatix Inc., Burlingame, CA 94010, USA; (J.R.); (T.E.S.)
- Correspondence: ; Tel.: +1-925-963-9470
| | - Richard E. Rothman
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, MD 21264, USA;
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Abstract
Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.
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May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
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May L, Nguyen MH, Trajano R, Tancredi D, Aliyev ER, Mooso B, Anderson C, Ondak S, Yang N, Cohen S, Wiedeman J, Miller LG. A multifaceted intervention improves antibiotic stewardship for skin and soft tissues infections. Am J Emerg Med 2020; 46:374-381. [PMID: 33139143 DOI: 10.1016/j.ajem.2020.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Assess the effectiveness of a multifaceted stewardship intervention to reduce frequency and duration of inappropriate antibiotic use for emergency department (ED) patients with skin and soft tissue infections (SSTI). We hypothesized the antibiotic stewardship program would reduce antibiotic duration and improve guideline adherence in discharged SSTI patients. DESIGN Nonrandomized controlled trial. SETTING Academic EDs (intervention site and control site). PATIENTS OR PARTICIPANTS Attending physicians and nurse practitioners at participating EDs. INTERVENTION(S) Education regarding guideline-based treatment of SSTI, tests of antimicrobial treatment of SSTI, implementation of a clinical treatment algorithm and order set in the electronic health record, and ED clinicians' audit and feedback. RESULTS We examined 583 SSTIs. At the intervention site, clinician adherence to guidelines improved from 41% to 51% (aOR = 2.13 [95% CI: 1.20-3.79]). At the control site, there were no changes in adherence during the "intervention" period (aOR = 1.17 [0.65-2.12]). The between-site comparison of these during vs. pre-intervention odds ratios was not different (aOR = 1.82 [0.79-4.21]). Antibiotic duration decreased by 26% at the intervention site during the intervention compared to pre-intervention (Adjusted Geometric Mean Ratio [95% CI] = 0.74 [0.66-0.84]). Adherence was inversely associated with SSTI severity (severe vs mild; adjusted OR 0.42 [0.20-0.89]) and purulence (0.32 [0.21-0.47]). Mean antibiotic prescription duration was 1.95 days shorter (95% CI: 1.54-2.33) in the time period following the intervention than pre-intervention period. CONCLUSIONS A multifaceted intervention resulted in modest improvement in adherence to guidelines compared to a control site, driven by treatment duration reductions.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Megan H Nguyen
- Western University of Health Sciences, Pomona, CA, United States of America; Division of Infectious Diseases, Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, United States of America.
| | - Renee Trajano
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA
| | - Daniel Tancredi
- Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd., Sacramento, CA 95817, USA.
| | - Elmar R Aliyev
- Health Economics Department, School of Pharmacy, University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90089, USA.
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Chance Anderson
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Susan Ondak
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA
| | - Nuen Yang
- Division of Biostatistics, University of California, Davis, One Shields Avenue, Davis, CA 95616, USA.
| | - Stuart Cohen
- Division of Infectious Diseases, University of California, Davis, 4150 V Street, Sacramento, CA 95817, USA.
| | - Jean Wiedeman
- Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd., Sacramento, CA 95817, USA.
| | - Loren G Miller
- Division of Infectious Diseases, UCLA Medical Center, 1000 W. Carson St. Box 466, Torrance, CA 90509, USA.
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Maddali N, Cantin A, Koshy S, Eiting E, Fedorenko M. Antibiotic prescribing patterns for adult urinary tract infections within emergency department and urgent care settings. Am J Emerg Med 2020; 45:464-471. [PMID: 33067064 DOI: 10.1016/j.ajem.2020.09.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022] Open
Abstract
Urinary tract infections (UTI) are a common reason for emergency department (ED) and urgent care (UC) visits. Fluoroquinolones (FQ) are frequently prescribed for treatment of UTI in the outpatient setting; however, data evaluating prescribing patterns after FDA safety warnings is limited, especially in UC. The study goal was to investigate and compare antimicrobial prescribing for UTIs in a single-site ED and an off-site UC in an urban, academic health system. This retrospective study included patients presenting with a UTI to the ED or UC between January and June 2018. Those 18 years or older with uncomplicated, complicated UTI, or pyelonephritis were included. Exclusion criteria were catheter-related UTI, urinary tract abnormalities, immunocompromised, or hospitalization. Primary outcome was FQ prescribing rate for all UTI in the ED and UC. Secondary outcomes were rates of non-FQ prescribing, re-presentation, bug-drug mismatch, and treatment durations. 184 patients were included. FQ prescribing rate was similar in ED and UC (21.2% vs. 16.3%, p = 0.4). Non-FQs prescribed in ED and UC were nitrofurantoin (20.2% vs 53.6%), beta-lactams (46.1% vs 22.6%), and trimethoprim/sulfamethoxazole (12.5% vs. 5%). A longer than recommended duration was identified in 46.3% UC patients compared to 21.2% ED patients. Thirty-day re-presentation with persistent UTI symptoms occurred more frequently in the ED compared to UC (13.5% vs. 7.5%). Predictors of FQ prescribing on logistic regression were male, recurrent UTI, and malignancy. FQ prescribing rate for UTI treatment was low with no difference between ED and UC. Opportunity exists to improve treatment duration and antimicrobial choice.
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Affiliation(s)
- Navya Maddali
- Department of Pharmacy, Mount Sinai Beth Israel, New York, NY, United States.
| | - Amanda Cantin
- Department of Pharmacy, Mount Sinai Beth Israel, New York, NY, United States
| | - Sanjana Koshy
- Division of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, United States; Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Erick Eiting
- Department of Emergency Medicine, Mount Sinai Beth Israel, New York, NY, United States; Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Marianna Fedorenko
- Department of Pharmacy, Mount Sinai Beth Israel, New York, NY, United States
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Benkő R, Gajdács M, Matuz M, Bodó G, Lázár A, Hajdú E, Papfalvi E, Hannauer P, Erdélyi P, Pető Z. Prevalence and Antibiotic Resistance of ESKAPE Pathogens Isolated in the Emergency Department of a Tertiary Care Teaching Hospital in Hungary: A 5-Year Retrospective Survey. Antibiotics (Basel) 2020; 9:antibiotics9090624. [PMID: 32961770 PMCID: PMC7560131 DOI: 10.3390/antibiotics9090624] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Antibiotic treatments initiated on Emergency Departments (ED) are empirical. Therefore, knowledge of local susceptibility patterns is important. Despite this, data on expected pathogens and their resistance profile are scarce from EDs internationally. The study aim was to assess the epidemiology and resistance patterns of bacterial isolates from a tertiary-care ED over 5 years, focusing on ESKAPE bacteria (including the Enterobacterales group). After removal of duplicates, n = 6887 individual bacterial isolates were recovered, out of which n = 4974 (72.22%) were ESKAPE isolates. E. coli was the most frequent isolate (2193, 44.1%), followed by the Klebsiella genus (664; 13.4%). The third most frequent isolate was S. aureus (561, 11.3%). In total, multi-drug resistance (MDR) was present in 23.8% and was most prevalent in A. baumanii (65.5%), P. mirabilis (42.7%), and K. pneumoniae (32.6%). MRSA was isolated in 19.6%, while ESBL-producing Enterobacterales in 17.7%, and these were associated with remarkably higher resistance to other antibacterials as well. Difficult-to-treat resistance (DTR) was detected in 0.5%. The frequent isolation of some ESKAPE bacteria and the detected considerable acquired resistance among ED patients raise concern. The revealed data identified problematic pathogens and will guide us to set up the optimal empiric antibiotic protocol for clinicians.
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Affiliation(s)
- Ria Benkő
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
- Correspondence: ; Tel.: +36-62-342572
| | - Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary;
| | - Mária Matuz
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Gabriella Bodó
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Andrea Lázár
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary;
| | - Edit Hajdú
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Erika Papfalvi
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Peter Hannauer
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Péter Erdélyi
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Zoltán Pető
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
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Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments. Appl Clin Inform 2020; 11:589-597. [PMID: 32906153 DOI: 10.1055/s-0040-1715893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions. METHODS Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis. RESULTS Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing. DISCUSSION The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization). CONCLUSION Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Noel Metcalf
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Larissa S May
- Department of Emergency Medicine, UC Davis Health, Davis, California, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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Pulia MS, Wolf I, Schulz LT, Pop-Vicas A, Schwei RJ, Lindenauer PK. COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department. West J Emerg Med 2020; 21:1283-1286. [PMID: 32970587 PMCID: PMC7514390 DOI: 10.5811/westjem.2020.7.48848] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.
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Affiliation(s)
- Michael S. Pulia
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Emergency Medicine, Madison, Wisconsin
| | - Ian Wolf
- University of Wisconsin Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - Lucas T. Schulz
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Pharmacy, Madison, Wisconsin
| | - Aurora Pop-Vicas
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Medicine, Madison, Wisconsin
| | - Rebecca J. Schwei
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Emergency Medicine, Madison, Wisconsin
| | - Peter K. Lindenauer
- University of Massachusetts Medical School - Baystate, Department of Medicine, Springfield, Massachusetts
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Stoll K, Feltz E, Ebert S. Pharmacist-Driven Implementation of Outpatient Antibiotic Prescribing Algorithms Improves Guideline Adherence in the Emergency Department. J Pharm Pract 2020; 34:875-881. [DOI: 10.1177/0897190020930979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Inappropriate prescribing of antibiotics has been identified as the most important modifiable risk factor for antimicrobial resistance. Objective: The purpose of this project was to improve guideline adherence and promote optimal use of outpatient antibiotics in the emergency department (ED). Methods: Prescribing algorithms for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) were developed to integrate clinical practice guideline recommendations with local ED antibiogram data. Outcomes were evaluated through chart review of patients prescribed outpatient antibiotics by ED providers. The primary outcome was adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged. Results: When compared to patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 353) received more antibiotic prescriptions that were completely guideline adherent (61.5% vs 11.7%, P < .00001). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (87.3% vs 45.5%, P < .00001), dose (91.5% vs 77.2%, P < .00001), and duration of therapy (71.1% vs 39.1%, P < .01). Additionally, fluoroquinolone prescribing rates were reduced (2.3% vs 12.3%, P < .00001). A reduction in all-cause 30-day returns to the ED or urgent care was observed (15.3% vs 21.5%, P = .036). Conclusion: Pharmacist-driven implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI.
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Affiliation(s)
| | - Erik Feltz
- UnityPoint Health–Meriter, Madison, WI, USA
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Pulia MS, Hesse S, Schwei RJ, Schulz LT, Sethi A, Hamedani A. Inappropriate Antibiotic Prescribing for Respiratory Conditions Does Not Improve Press Ganey Patient Satisfaction Scores in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa214. [PMID: 32617378 PMCID: PMC7320835 DOI: 10.1093/ofid/ofaa214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/02/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The literature has mixed results regarding the relationship between antibiotic prescribing and patient satisfaction in the emergency department (ED) for antibiotic-inappropriate respiratory diagnoses. The objective of the study was to determine if ED patients who receive nonindicated antibiotic prescriptions for respiratory tract conditions have increased Press Ganey patient satisfaction scores compared with those who do not receive antibiotics. METHODS This was a retrospective observational study. Using an administrative electronic health record data set from 2 EDs in the Midwest, we identified 619 ED encounters resulting in discharge for antibiotic-inappropriate respiratory diagnoses with a corresponding Press Ganey patient satisfaction survey. We compared sociodemographics, encounter variables, and overall Press Ganey patient satisfaction scores between those who did and did not receive antibiotics. We analyzed Press Ganey scores by categorical score distribution and as a dichotomized scale of top box (5) vs other scores. A logistic regression estimated the odds of a top box Press Ganey patient satisfaction score based on antibiotic prescribing while controlling for other covariates. RESULTS In the final sample, 158 (26%) encounters involving antibiotic-inappropriate respiratory diagnoses involved an antibiotic prescription. There were no differences in sociodemographic, encounter or categorical, or top box Press Ganey overall patient satisfaction scores between the groups that did and did not receive inappropriate antibiotics. In the fully adjusted regression model, antibiotic prescriptions were not associated with increased odds of top box Press Ganey patient satisfaction score (odds ratio, 0.78; 95% CI, 0.53-1.14). CONCLUSIONS Our findings suggest that nonindicated antibiotic prescribing for respiratory tract conditions is not a primary driver of overall Press Ganey scores in the ED.
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Affiliation(s)
- Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Steven Hesse
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Ajay Sethi
- Department of Population Health, Madison, Wisconsin, USA
| | - Azita Hamedani
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Impact of implementing a non-restrictive antibiotic stewardship program in an emergency department: a four-year quasi-experimental prospective study. Sci Rep 2020; 10:8194. [PMID: 32424172 PMCID: PMC7235006 DOI: 10.1038/s41598-020-65222-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022] Open
Abstract
Antibiotic resistance is increasing worldwide. The implementation of antibiotic stewardship programmes (ASPs) is of utmost importance to optimize antibiotic use in order to prevent resistance development without harming patients. The emergency department (ED), cornerstone between hospital and community, represents a crucial setting for addressing ASP implementation; however, evidence data on ASP in ED are poor. In this study, a 4-year, non-restrictive, multi-faceted ASP was implemented in a general ED with the aim to evaluate its impact on antibiotic use and costs. Secondly, the study focused on assessing the impact on length of hospital stay (LOS), Clostridioides difficile infection (CDI) incidence rate, and mortality in the patients' group admitted from ED to medical wards. The ASP implementation was associated with a reduction of antibiotic use and costs. A mild but sustained LOS decrease in all medical wards and a significant downward trend of CDI incidence rate were observed, while mortality did not significantly change. In conclusion, the implementation of our ED-based ASP has demonstrated to be feasible and safe and might clinically benefit the hospital admitted patients' group. Further research is needed to identify the most suitable ASP design for ED and the key outcome measures to reliably assess its effectiveness.
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Denny KJ, Gartside JG, Alcorn K, Cross JW, Maloney S, Keijzers G. Appropriateness of antibiotic prescribing in the Emergency Department. J Antimicrob Chemother 2020; 74:515-520. [PMID: 30445465 PMCID: PMC6337898 DOI: 10.1093/jac/dky447] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/03/2018] [Indexed: 12/23/2022] Open
Abstract
Background Antibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce. Objectives To describe the appropriateness of antibiotic prescribing in the ED. Methods A retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines. Results A total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%–21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%–38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night). Conclusions Inappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.
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Affiliation(s)
- Kerina J Denny
- Gold Coast University Hospital, Gold Coast, Australia.,Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | | | - Kylie Alcorn
- Gold Coast University Hospital, Gold Coast, Australia
| | - Jack W Cross
- Gold Coast University Hospital, Gold Coast, Australia
| | | | - Gerben Keijzers
- Gold Coast University Hospital, Gold Coast, Australia.,School of Medicine, Bond University, Gold Coast, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
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Chardavoyne PC, Kasmire KE. Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections. West J Emerg Med 2020; 21:633-639. [PMID: 32421512 PMCID: PMC7234695 DOI: 10.5811/westjem.2020.1.45944] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/31/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Urinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis. Methods We conducted a retrospective study of females ages 2–50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram. Results A total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926). Conclusion This study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.
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Affiliation(s)
| | - Kathryn E Kasmire
- Pennsylvania State College of Medicine, Hershey, Pennsylvania.,Penn State Health Milton S. Hershey Medical Center, Division of Emergency Medicine, Hershey, Pennsylvania
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Wu JY, Balmat R, Kahle ML, Blynn M, Hipp R, Podolsky S, Fertel BS. Evaluation of a health system-wide pharmacist-driven emergency department laboratory follow-up and antimicrobial management program. Am J Emerg Med 2019; 38:2591-2595. [PMID: 31918897 DOI: 10.1016/j.ajem.2019.12.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency Department (ED) follow-up programs ensure that cultures, laboratory studies, and empiric antimicrobials are appropriately managed post-discharge. We sought to provide a comprehensive assessment of a pharmacist-driven laboratory follow-up process in a large, integrated health system. METHODS A retrospective, observational review of 13 EDs was conducted. Patients were included if they had a laboratory study sent from the ED between December 1, 2017 and May 31, 2018 that did not result while the patient was in the ED. Microbiology results analyzed were urine, wound, respiratory, stool, throat, bacterial vaginosis, vaginal candidiasis, and sexually transmitted infections (STI). Examples of laboratory results assessed were metabolic panels and drug levels. The primary objective was to quantify the number of interventions made by pharmacists. RESULTS During a 6-month period, pharmacists reviewed 9107 microbiology results and 6211 laboratory results. The majority of results were urine cultures (3998, 50.6%) followed by STI results (1198, 15.2%). Of 7663 encounters, 39.8% required interventions and/or follow-up with a total of 3049 interventions made and 3333 patients educated. The most common interventions were initiation of therapy (1629, 53.4%), change in medication (505, 16.6%), and follow-up with a clinician (322, 10.6%). Pharmacists reviewed microbiology results and completed interventions in a median of 25.3 h from the time the result was received in the electronic health record. CONCLUSION Almost 40% of ED encounters required an intervention after discharge. A pharmacist led laboratory follow-up program is an important adjunct to facilitating stewardship and culture management in the ED.
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Affiliation(s)
- Janet Y Wu
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Ryan Balmat
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Maria L Kahle
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Meredith Blynn
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Rachel Hipp
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Seth Podolsky
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America; Enterprise Quality and Safety, Cleveland Clinic, Cleveland, OH, United States of America
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Evans CD, Lewis JWS. Collaborative Antimicrobial Stewardship in the Health Department. Infect Dis Clin North Am 2019; 34:145-160. [PMID: 31836328 DOI: 10.1016/j.idc.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Given the population-level implications of antibiotic resistance and the importance of antibiotic stewardship in containment and prevention of resistance, public health has a vested interest in strengthening antibiotic stewardship efforts. There are opportunities for public health collaboration at all levels including local health departments, state public health programs, and through federal public health entities. This article discusses existing public health stewardship activities, opportunities for collaboration between public health and key partners in antibiotic stewardship programs, the potential for improvement and expansion of current activities, and possible new modes of collaboration that could be pursued.
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Affiliation(s)
- Christopher D Evans
- Tennessee Department of Health, Healthcare Associated Infections and Antimicrobial Resistance Program, 710 James Robertson Parkway, Nashville, TN 37243, USA.
| | - James W S Lewis
- North Carolina Department of Health and Human Services, Division of Public Health Communicable Disease Branch, 225 North McDowell Street, Raleigh, NC 27603, USA; UNC GIllings School of Global Public Health, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599-7400, USA; UNC School of Medicine, 321 S Columbia Street, Chapel Hill, NC 27516, USA.
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