Antimicrobial stewardship in Australian emergency departments

Introduction of an emergency medicine pharmacist-led sepsis alert response system in the emergency department: A cohort study

OBJECTIVE

To determine effects of implementing a sepsis alert response system in the ED that included early intervention by emergency medicine (EM) pharmacists.

METHODS

A prospective cohort (8 February 2016 to 28 February 2018) of patients after implementation of a sepsis alert response system in an Australian ED was compared to a retrospective cohort (3 January 2015 to 7 February 2016) of patients with sepsis who presented during EM pharmacist working hours and were admitted to the ICU.

RESULTS

There were 184 patients, including 80 patients pre- and 104 patients post-implementation. The post-intervention cohort was triaged at a higher acuity, had higher quick Sepsis-related Organ Failure Assessment (qSOFA) scores and higher initial lactate measurements. After the intervention, antimicrobial agents were administered to patients within 60 min of presentation more often (21 [26.3%] to 85 [81.7%], P < 0.001). After adjusting for presenting triage category, admission lactate and presenting qSOFA scores, this association remained significant (adjusted odds ratio 9.99; 95% confidence interval 4.7-21.3). Significant improvements were observed for proportion of patients who had intravenous fluids initiated within 60 min (47.5% vs 72.1%); proportion of patients who had serum lactate measured within 60 min (50.0% vs 77.9%) and proportion of patients who had blood cultures performed within 60 min (52.5% vs 85.6%).

CONCLUSION

Implementation of a sepsis alert response that included early involvement of the EM pharmacist was associated with improvement in time to antimicrobials and other components of the sepsis bundle. An upfront, multidisciplinary approach to patients presenting to the ED with suspected sepsis should be considered more broadly.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Antimicrobial stewardship in diabetic ketoacidosis: a single-centre experience

BACKGROUND

Diabetic ketoacidosis (DKA) is a common and serious complication arising predominantly in patients with type 1 diabetes mellitus. International data demonstrate that infection is one of the most common precipitating causes of DKA. Currently there are limited data regarding the role of antimicrobial stewardship (AMS) in this setting.

AIM

To provide epidemiologic data regarding infections precipitating DKA, microbiological aetiology and antimicrobial prescribing practices in order to inform AMS interventions.

METHODS

Retrospective chart review of all type 1 diabetes mellitus DKA presentations from May 2015 to June 2018.

RESULTS

In total, 249 DKA presentations occurred in 111 patients. Suspected infection accounted for 100/249 (40%) presentations, and only 36/249 (14.5%) were proven or probable infections. Skin and soft tissue infection was the most common (9/36, 25%), followed by urinary tract infection (8/36, 22%) and respiratory tract infection (7/36, 19%). A pathogen was identified in 24/100 presumed infections and included Staphylococcus aureus (24, 46%), Klebsiella pneumoniae (4/24, 17%) and Escherichia coli (3/24, 13%). No viral pathogens were identified. Of 80 empirical antimicrobial prescriptions, 75% were inappropriate based on guideline management of the documented suspected infection. Single agent ceftriaxone was appropriately prescribed in 7/23 (30%) cases, and was most frequently prescribed overall 23/80 (29%).

CONCLUSION

This study demonstrates a lower incidence of infection compared to most previous publications, and suggests that infection-precipitated DKA may be over reported. Furthermore, our findings provide support for the role of AMS in the management of DKA.

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.

Roles of the emergency medicine pharmacist: A systematic review

PURPOSE

Results of a systematic literature review to identify roles for emergency medicine (EM) pharmacists beyond traditionally reported activities and to quantify the benefits of these roles in terms of patient outcomes are reported.

SUMMARY

Emergency department (ED)-based clinical pharmacy is a rapidly growing practice area that has gained support in a number of countries globally, particularly over the last 5-10 years. A systematic literature search covering the period 1995-2016 was conducted to characterize emerging EM pharmacist roles and the impact on patient outcomes. Six databases were searched for research publications on pharmacist participation in patient care in a general ED or trauma center that documented interventions by ED-based pharmacists; 15 results satisfied the inclusion criteria. Six reported studies evaluated EM pharmacist involvement in the care of critically ill patients, 5 studies evaluated antimicrobial stewardship (AMS) activities via pharmacist review of positive cultures, 2 studies assessed pharmacist involvement in generating orders for nurse-administered home medications and 2 reviewed publications focused on EM pharmacist involvement in management of healthcare-associated pneumonia and dosing of phenytoin. A diverse range of positive patient outcomes was identified. The included studies were assessed to be of low quality.

CONCLUSION

A systematic review of the literature revealed 3 key emerging areas of practice for the EM pharmacist that are associated with positive patient outcomes. These included involvement in management of critically ill patients, AMS roles, and ordering of home medications in the ED.

Attitudes and beliefs of Australian emergency department clinicians on antimicrobial stewardship in the emergency department: A qualitative study

OBJECTIVE

To explore the attitudes and beliefs of Australian ED clinicians towards antimicrobial stewardship in the ED.

METHODS

Semi-structured one-to-one interviews were conducted with ED clinicians between March and October 2015. Participants were identified via purposive and snowball sampling. Questionnaires were developed using the literature. Interviews were audio-recorded, transcribed and analysed using thematic analysis via the framework approach. Two researchers coded independently, with one using QSR International's NVivo 10 software and the other manually. Emergent themes were identified and classified.

RESULTS

Twenty-two clinicians (eight doctors, eight nurses and six pharmacists) from seven institutions participated. Participants were aware and concerned about antimicrobial resistance. Clinicians were divided based on their opinion on whether antimicrobials are prescribed appropriately and judiciously in the ED, with many perceiving prescribing to be inappropriate. Prior knowledge of the term 'Antimicrobial Stewardship' was demonstrated by doctors and pharmacists, with a relative lack of awareness by nurses. Four main themes were identified as both barriers and facilitators to antimicrobial stewardship in the ED: individual healthcare provider, resource, organisational and cultural. Uncertainty of diagnosis, time and resource pressures, reliance on previous experience and lack of access to expert opinion were perceived barriers. To facilitate appropriate prescribing, clinicians emphasised the need for routine education and feedback, adequate staffing, robust guidelines, senior medical clinician advocacy and multidisciplinary support.

CONCLUSIONS

Australian ED clinicians were aware of antimicrobial resistance. Many perceive injudicious antimicrobial use as problematic. Consideration of ED clinicians' perceived barriers and facilitators might enhance implementation of antimicrobial stewardship programmes in EDs.

Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia

AIM

To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP).

METHODS

Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded.

RESULTS

Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21).

CONCLUSION

CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.