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Patients presenting to the emergency department (ED) represent a heterogeneous population comprised of all ages, various backgrounds, such as from the community and skilled-nursing facilities (SNFs), and at various risks for resistant pathogens. The aim of this study was to compare patient group-specific urinary antibiograms in the ED. Adults presented to the ED with an ICD 9/10 code urinary tract infection (UTI) diagnosis during July 2015 to June 2016 were randomly selected (n ϭ 500) to extract relevant demographic, laboratory, and clinical data from the medical record. Urinary Escherichia coli antibiograms were compared between institutional versus ED and among ED patients (male versus female; age of 18 to 64 years versus Ն65 years; female aged 18 to 50 years versus Ͼ50 years; home versus SNF; and admitted versus discharged). E. coli grew from 56% (145/259) of the positive urine cultures. Overall ciprofloxacin (CIP), trimethoprim-sulfamethoxazole (SXT), and cefazolin (CFZ) susceptibilities were Ͻ71%. Differences in antibiograms were the following: lower CFZ and SXT susceptibilities in ED versus institutional (CFZ, 67% versus 86% [P ϭ 0.001]; SXT, 66% versus 74% [P ϭ 0.02]), lower ampicillin and gentamicin susceptibilities in females aged 18 to 50 years versus Ͼ50 years (32% versus 52% [P ϭ 0.04]; 78% versus 93% [P ϭ 0.02]), lower CIP susceptibilities in the elderly (64% versus 81%; P ϭ 0.03), SNF versus home (35% versus 77%; P Ͻ 0.001), admitted versus discharged (63% versus 78%; P ϭ 0.04), and lower SXT susceptibilities in patients aged Ͻ65 years versus the elderly (58% versus 71%; P ϭ 0.01). Nitrofurantoin showed Ͼ80% susceptibility in all groups. Patient group-specific urinary antibiograms revealed distinct differences in E. coli susceptibility and should be developed to better inform empirical UTI therapy selection in the ED.KEYWORDS antibiogram, antimicrobial stewardship, emergency department, urinary tract infection U rinary tract infections (UTIs) are among the top 3 infections encountered in the emergency department (ED), accounting for nearly 2 million visits for females of all ages and 160,000 visits for males aged 65 years and older in the United States (1). Selection of antibiotic therapy for UTIs in the ED is challenging due to the absence of microbiologic data at the time of clinical decision and patient discharge or transfer. Furthermore, the increasing emergence of antimicrobial resistance among uropathogens in both the community and inpatient settings (2, 3) presents a significant challenge for ED clinicians to balance prompt initiation of effective empirical antibiotics without overprescribing broad-spectrum antibiotics. Incorporating local antibiograms into clinical decision-making can assist in the selection of appropriate empirical therapy (4, 5). Institution-wide antibiograms, however, may not accurately reflect susceptibility

BackgroundThe complex and fast-paced emergency department (ED) practice setting presents unique challenges that demand a tailored approach to antimicrobial stewardship. In this article, we describe the strategies applied by 1 institution’s antimicrobial stewardship program (ASP) that were successful in improving prescribing practices and outcomes for urinary tract infection (UTI) in the ED.MethodsCore strategies included pre-implementation research characterizing the patient population, antimicrobial resistance patterns, prescribing behavior, and morbidity related to infection; collaboration across multiple disciplines; development and implementation of a UTI treatment algorithm; education to increase awareness of the algorithm and the background and rationale supporting it; audit and feedback; and early evaluation of post-implementation outcomes.ResultsWe observed a rapid change in prescribing post-implementation with increased empiric nitrofurantoin use and reduced cephalosporin use (P < .05). Our elevation of nitrofurantoin to firstline status was supported by our post-implementation analysis showing that its use was independently associated with reduced 30-day return visits (adjusted odds ratio, 0.547; 95% confidence interval, 0.312–0.960). Furthermore, despite a shift to a higher risk population and a corresponding decrease in antimicrobial susceptibility rates post-implementation, the preferential use of nitrofurantoin did not result in higher bug-drug mismatches while 30-day return visits to the ED remained stable.ConclusionsWe demonstrate that an outcomes-based ASP can impart meaningful change to knowledge and attitudes affecting prescribing practices in the ED. The success of our program may be used by other institutions as support for ASP expansion to the ED.

Background Information on maternal and fetal outcomes of pregnancy in women with D‐transposition of the great arteries is limited. We conducted a systematic literature review on pregnancies in women with transposition of the great arteries after atrial and arterial switch operations to better define maternal and fetal risk. Methods and Results A systematic review was performed on studies between 2000 and 2021 that identified 676 pregnancies in 444 women with transposition of the great arteries. A total of 556 pregnancies in women with atrial switch operation were tolerated by most cases with low mortality (0.6%). Most common maternal complications, however, were arrhythmias (9%) and heart failure (8%) associated with serious morbidity in some patients. Worsening functional capacity, right ventricular function, and tricuspid regurgitation occurred in ≈20% of the cases. Rate of fetal and neonatal mortality was 1.4% and 0.8%, respectively, and rate of prematurity was 32%. A total of 120 pregnancies in women with arterial switch operation were associated with no maternal mortality, numerically lower rates of arrhythmias and heart failure (6% and 5%, respectively), significantly lower rate of prematurity (11%; P <0.001), and only 1 fetal loss. Conclusions Pregnancy is tolerated by most women with transposition of the great arteries and atrial switch operation with low mortality but important morbidity. Most common maternal complications were arrhythmias, heart failure, worsening of right ventricular function, and tricuspid regurgitation. There was also a high incidence of prematurity and increased rate of fetal loss and neonatal mortality. Outcome of pregnancy in women after arterial switch operations is more favorable, with reduced incidence of maternal complications and fetal outcomes similar to women without underlying cardiac disease.

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