Clinical factors can be used to identify UTI patients at high risk of MDR urinary pathogens.

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IntroductionThe emergency department (ED) plays a critical role in the management of life-threatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate. The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients.MethodsRetrospective before-after cohort study of all patients (n=278) treated with vancomycin in a 60,000-visit Midwestern academic ED (March 2008 and April 2011) and admitted to an intensive care unit. The primary outcome was the proportion of vancomycin doses defined as “appropriate” based on recorded actual body weight. We also evaluated secondary outcomes of mortality and length of stay.ResultsThe EMR dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p<0.001) and a 10.3% absolute improvement in first-dose appropriateness (34.3% vs. 24.0%, p=0.07). After controlling for age, gender, methicillin-resistant staphylococcus aureus infection, and Acute Physiology and Chronic Health Evaluation II score, 28-day in-hospital mortality (odds ratio OR 1.72; 95% CI [0.76–3.88], p=0.12) was not affected.ConclusionA computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.

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INTRODUC TI ONUrinary tract infections (UTI) are a commonly treated infection in the emergency department (ED), accounting for approximately 3 million visits annually, and 15% of all outpatient antibiotics in the United States (US). [1][2][3][4] Enterobacterales remain the most common cause of UTIs and are associated with increased rates of in vitro resistance to commonly prescribed antibioitics. 5,6 In particular, the prevalence of Escherichia coli resistance to commonly prescribed antibiotics such as trimethoprim/sulfamethoxazole (TMP/SMX), fluroquinolones (FQ; e.g., ciprofloxacin and levofloxacin), and beta-lactams has continued to increase in most regions of the United States, and underscores the importance of using local antibiograms for selecting empiric treatment in patients diagnosed with a UTI in the ED. 5,7 Many geographic regions in the United States are reporting prevalences of FQ-resistant (FQR) and TMP/SMX-resistant Enterobacterales of >10%, with some areas with rates >20%, exceeding threshold rates (>10%) recommended by the Infectious