Antimicrobial Stewardship in the Emergency Department

Pulia, Michael S.; Redwood, Robert; May, Larissa

doi:10.1016/j.emc.2018.06.012

Cited by 67 publications

(51 citation statements)

References 132 publications

(143 reference statements)

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“…It is notable that EM clinicians do not always initiate urine testing. To improve crowding, nurse-initiated order sets and testing protocols are common [ 20 ] and may contribute to unnecessary testing. Likewise, order sets may have prechecked or easily selected orders for urine testing for nonurinary complaints, such as stroke.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Petty

Vaughn

Flanders

et al. 2020

Open Forum Infectious Diseases

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Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by EM clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the emergency department (ED) with ASB (2/2018-2/2020). Using generalized estimating equation models, we assessed a) for factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, b) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N=1830) received antibiotics. EM clinicians ordered urine cultures in 80.0% (N=1970) of patients and initiated treatment in 68.5% (1253/1830). Predictors of EM clinician treatment of ASB vs. no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993/1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; RR 1.16; 95% CI, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% (N=11) vs. 0% (N=0); P=0.02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

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Section: Discussionmentioning

confidence: 99%

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Petty

Vaughn

Flanders

et al. 2020

Open Forum Infectious Diseases

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“… 5 The ED has unique, systems-level barriers to quality improvement interventions that require customized approaches to antibiotic stewardship. 6 It is important to consider how the ongoing pandemic exacerbates existing challenges to antibiotic stewardship for acute respiratory conditions in the ED.…”

Section: Introductionmentioning

confidence: 99%

COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department

Pulia

Wolf

Schulz

et al. 2020

WestJEM

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Due to the rapidly evolving nature of this outbreak, and in the interests of rapid dissemination of reliable, actionable information, this paper went through expedited peer review. Additionally, information should be considered current only at the time of publication and may evolve as the science develops. BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel viral pathogen and its associated clinical syndrome (COVID-19) is the cause of an ongoing global pandemic involving hundreds of thousands of deaths. While current research efforts focus primarily on identifying therapeutic interventions, it is important to consider the collateral effects of COVID-19 on other public health crises.

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“…The literature on effective antibiotic stewardship interventions for EDs and UCCs is limited, but strategies that have proven to be effective include clinical decision support tools, audit and feedback, and dedicated ED pharmacists. 8,27 Implementing stewardship processes in ambulatory care will be important in meeting The Joint Commission's new regulatory requirements.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

Lowery

Alexander

Nair

et al. 2020

Infect. Control Hosp. Epidemiol.

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Objective: Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). Design: This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. Results: There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). Conclusions: Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

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Antimicrobial Stewardship in the Emergency Department

Cited by 67 publications

References 132 publications

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

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