Appropriate empirical antibiotic use in the emergency department: full compliance matters!

Impact of 1-hour and 3-hour sepsis time bundles on antibiotic use in emergency departments in Queensland, Australia: a before-and-after cohort study

OBJECTIVE

To determine if the introduction of an emergency department (ED) sepsis screening tool and management bundle affects antibiotic prescribing and use.

DESIGN

Multicentre, cohort, before-and-after study design.

SETTING

Three tertiary hospitals in Queensland, Australia (median bed size 543, range 520-742).

PARTICIPANTS

Adult patients, presenting to the ED with symptoms and signs suggestive of sepsis who had blood cultures collected. These participants were further assessed and stratified as having septic shock, sepsis or infection alone, using Sepsis-3 definitions. The study dates were 1 July 2017-31 March 2020.

INTERVENTION

The breakthrough series collaborative 'Could this be Sepsis?' Programme, aimed at embedding a sepsis screening tool and treatment bundle with weighted-incidence syndromic combined antibiogram-derived antibiotic guidelines in EDs.

MAIN OUTCOME MEASURES

The primary outcome was the rate of empirical prescriptions adherent to antibiotic guidelines during the ED encounter. Secondary outcomes included the empirical prescriptions considered appropriate, effective antibiotics administered within 3 hours and assessment of harm measures.

RESULTS

Of 2591 eligible patients, 721 were randomly selected: 241 in the baseline phase and 480 in the post-intervention phase. The rates of guideline adherence were 54.0% and 59.5%, respectively (adjusted OR (aOR) 1.41 (95% CI 1.00, 1.98)). As compared with baseline, there was an increase in the rates of appropriate antibiotic prescription after bundle implementation (69.9% vs 57.1%, aOR 1.92 (95% CI 1.37, 2.68)). There were no differences between the baseline and post-intervention groups with respect to time to effective antibiotics, adverse effects or ED rates of broad-spectrum antibiotic use.

CONCLUSION AND RELEVANCE

The use of an ED sepsis screening tool and management bundle was associated with an improvement in the rates of appropriate antibiotic prescription without evidence of adverse effects.

Diagnostic uncertainty in infectious diseases: Advocacy for a nosological framework

Diagnostic uncertainty (DU) is frequent in infectious diseases (ID), being recorded in 10% to over 50% of patients. Herein, we show that in several fields of clinical practice, high rates of DU are constant over time. DUs are not taken into account in guidelines, as therapeutic propositions are based on an established diagnosis. Moreover, while other guidelines underline the need for rapid broad-spectrum antibiotic therapy for patients with sepsis, many clinical conditions mimic sepsis and lead to unnecessary antibiotic therapy. Considering DU, many studies have been carried out to look for relevant biomarkers of infections, which also attest to non-infectious diseases mimicking infections. Therefore, diagnosis is often primarily a hypothesis, and empirical antibiotic therapy should be reassessed when microbiological data are available. However, other than for urinary tract infections or unexpected primary bacteremia, the high frequency of sterile microbiological samples implies that DU remains central in follow-up, which does not facilitate clinical management or antibiotic optimization. The main way to resolve the therapeutic challenge of DU could be to precisely describe the latter through a consensual definition that would facilitate consideration of DU and its mandatory therapeutic implications. A consensual definition of DU would also clarify responsibility and accountability for physicians in the antimicrobial approval process and l provide an opportunity to instruct their students in this large field of medical practices and to productively conduct relevant research.

Management of imported malaria in the emergency department: Adequacy compared to guidelines, and impact of the SARS-CoV-2 pandemic

OBJECTIVES

Adequacy of imported malaria management with respect to guidelines in emergency departments (ED) is low. We aimed to identify factors associated with this non-compliance, and a potential impact of the SARS-CoV-2 pandemic.

PATIENTS AND METHODS

Patients presenting with imported malaria at the ED of the hospital of Melun (France), from January 1, 2017 to February 14, 2022 were retrospectively included.

RESULTS

Among 205 adults and 25 children, biological criteria of severity were fully assessed in 10% of cases; lactates (40%) and blood pH (21%) levels were the main missing variables. Of 74 patients (32%) with severe malaria, 13 were misclassified as uncomplicated malaria. The choice and dosage of treatment were adequate in 85% and 92% of cases, respectively. Treatment conformity was lower in severe malaria cases than in non-severe malaria cases (OR 0.15 [95% CI 0.07-0.31]), with oral treatment in 17 patients with severe malaria; conformity was higher in the intensive care unit (OR 4.10 [95% CI 1.21-13.95]). Patients with severe malaria were more likely to start treatment within 6hours than patients with uncomplicated malaria (OR 1.97 [95% CI 1.08-3.43]), as were patients infected by P.falciparum compared to other species (OR 4.63 [95% CI 1.03-20.90]). Consulting during the SARS-CoV-2 pandemic was the only organizational factor associated with a lower probability of adequate management (OR 0.42 [95% CI 0.23-0.75]).

CONCLUSION

Initial evaluation of malaria severity and time to treatment administration could be improved. These have been adversely impacted by the SARS-CoV-2 pandemic.

Effect of appropriate dose, spectrum, and timing of antibiotics on 28-day mortality in patients with sepsis in the emergency department

Background

Appropriate antibiotics prescribing is key to treatment and to preventing mortality in patients with sepsis. The aim of this study was to determine the effect of the appropriate timing, spectrum, and dose of antibiotics on 28-day mortality in patients with sepsis.

Methods

We performed a retrospective cohort observational study. We enrolled patients with sepsis in the emergency department of a tertiary care hospital between 1 March and 31 July 2019. Patients were coded into an appropriate antibiotics group (time, spectrum, dose) and an inappropriate antibiotics group. We collected information of patient characteristics, comorbidities, vital signs, laboratory test results, and initial treatment. We followed patient outcomes, 28-day mortality, hospital deaths, 28-day ventilator-free days, and 28-day hospital-free days.

Results

A total of 593 patients were enrolled, with 323 (54.46%) in the appropriate antibiotics group. We used multivariate logistic analyses to assess factors for mortality. Primary outcomes of appropriate antibiotics (administration within 60 min of triage, appropriate spectrum and dose) did not affect 28-day mortality (adjusted odds ratio [OR], 0.57; 95% confidence interval [CI] 0.22–1.144; P=0.23). Subgroup analysis showed that appropriate spectrum alone influenced 28-day mortality (adjusted OR, 0.38; 95% CI, 0.15–0.99; P=0.047). Appropriate antibiotics was not associated with in-hospital mortality (adjusted OR, 0.62; 95% CI, 0.29–1.30; P=0.21).

Conclusion

Appropriate antibiotics included timing less than 60 min, spectrum and the dose was not significantly affected in 28-day mortality in emergency sepsis patients.

Trial registration

The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR20211216003.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-022-00416-6.

Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions

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.

Few bacterial co-infections but frequent empiric antibiotic use in the early phase of hospitalized patients with COVID-19: results from a multicentre retrospective cohort study in The Netherlands

BACKGROUND

Knowledge on bacterial co-infections in COVID-19 is crucial to use antibiotics appropriately. Therefore, we aimed to determine the incidence of bacterial co-infections, antibiotic use and application of antimicrobial stewardship principles in hospitalized patients with COVID-19.

METHODS

We performed a retrospective observational study in four hospitals (1 university, 2 non-university teaching, 1 non-teaching hospital) in the Netherlands from March to May 2020 including consecutive patients with PCR-confirmed COVID-19. Data on first microbiological investigations obtained at the discretion of the physician and antibiotic use in the first week of hospital admission were collected.

RESULTS

Twelve (1.2%) of the 925 patients included had a documented bacterial co-infection (75.0% pneumonia) within the first week. Microbiological testing was performed in 749 (81%) patients: sputum cultures in 105 (11.4%), blood cultures in 711 (76.9%), pneumococcal urinary antigen testing in 202 (21.8%), and Legionella urinary antigen testing in 199 (21.5%) patients, with clear variation between hospitals. On presentation 556 (60.1%; range 33.3-73.4%) patients received antibiotics for a median duration of 2 days (IQR 1-4). Intravenous to oral switch was performed in 41 of 413 (9.9%) patients who received intravenous treatment >48 h. Mean adherence to the local guideline on empiric antibiotic therapy on day 1 was on average 60.3% (range 45.3%-74.7%).

CONCLUSIONS

On presentation to the hospital bacterial co-infections are rare, while empiric antibiotic use is abundant. This implies that in patients with COVID-19 empiric antibiotic should be withheld. This has the potential to dramatically reduce the current overuse of antibiotics in the COVID-19 pandemic.