Appropriate or Not? A Look at Antibiotic Use in the Emergency Department

Highlighted Study:

Denny KJ, Gartside JG, Alcorn K, et al. Appropriateness of antibiotic prescribing in the Emergency Department. J Antimicrob Chemother. 2019 Feb 1;74(2):515-520. doi: 10.1093/jac/dky447.

Appropriate antibiotic prescribing has been a focus of many hospital initiatives nationwide and for this reason, many institutions now have well established antimicrobial stewardship programs in place. The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events, improvement in rates of antibiotic susceptibilities, and optimization of resource utilization.¹ The Emergency Department (ED) is 1 area of hospitals that is not often subjected to overview by inpatient antimicrobial stewardship programs due to patient discharges, diagnostic uncertainty, and time constraints. However, this area is a crucial component to appropriate antibiotic prescribing. ED providers have the unique opportunity to impact antibiotic prescribing in both inpatient and outpatient settings.² So, how are EDs doing with antibiotic prescribing? Denny et al. set out to describe the overall incidence of antibiotic prescribing at a busy, tertiary-level academic ED.

This was a retrospective, observational study looking at the current prescribing of antimicrobials at a large, public tertiary ED in Queensland, Australia. All consecutive patients who presented to the ED over a 4-week period in 2016 were included in the study. If a patient received at least 1 systemic antibiotic during their ED visit, all clinical and laboratory data was abstracted from the electronic medical record and reviewed.

The primary objective was to describe the appropriateness of antibiotic prescribing in the ED. The presumed indication for antibiotic prescribing was taken from the front line ordering clinician’s documentation in the electronic medical record. The appropriateness of prescriptions was compared to evidence-based guidelines and expert opinion using a pre-established antibiotic appropriateness assessment tool, the National Antibiotic Prescribing Survey (NAPS) (Table).³ Antibiotic appropriateness was assessed for predefined subgroups based on age, gender, indication for antibiotics (treatment versus prophylaxis), and whether the patient met criteria for sepsis.

A panel of experts, including members from Emergency Medicine, Infectious Diseases, Microbiology, and a senior Antimicrobial Stewardship pharmacist, were chosen to evaluate the appropriateness of the prescribing antibiotics. Each patient was randomized between 2 experts, who were provided with only the data available to the ED provider at the time of the decision making. The antibiotic prescribing was categorized as either optimal, adequate, suboptimal, inadequate, or not assessable. If the 2 experts did not agree on the categorization of the appropriateness, the case was discussed between all 4 experts. If the Infectious Diseases or Microbiology experts were involved in the decision making, the antimicrobial was automatically deemed optimal.

During the 4-week study period, a total of 7497 patients presented to the ED and 1019 of these patients received at least 1 antibiotic (13.6%, 95% CI 12.8%-14.4%). Only 5 (0.5%) of the patients were discussed with an Infectious Diseases or Microbiology clinician. Six hundred-forty (62.8%) of the antibiotic prescriptions were assessed to be optimal or adequate, 152 (14.9%) were assessed to be suboptimal, 181 (17.8%) were assessed to be inadequate, and 46 (4.5%) were not assessable.

The mostly common reason for antibiotics to be classified as suboptimal was that the chosen antibiotic(s) were too broad or had unnecessary overlap in spectrum of activity (67.8%; 103/152). The most common reason for antibiotics to be categorized as inadequate was that the indication didn’t require antimicrobial therapy (53.6%; 97/181). Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% vs 22.9%; difference 14.1%, 95% CI 7.2%-21.0%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition, reason for antibiotic administration, or time of shift.

Throughout the study period, antibiotics were commonly prescribed, with nearly 1 in 8 patients receiving an antibiotic during their visit. Approximately 1 out of every 3 antibiotics prescribed was considered suboptimal or inadequate. These data add to the importance of appropriate antimicrobial prescribing and the need for antimicrobial stewardship in various clinical settings. Inpatient antimicrobial stewardship programs should consider implementing strategies to expand their programs to include EDs. This intervention would likely require additional resources such as expansion of antimicrobial stewardship teams, computerized decision support, and/or antimicrobial stewardship training of ED colleagues. However, providing real time feedback about the appropriateness of antibiotic prescribing can help combat antimicrobial resistance, treatment failure, and unnecessary adverse events due to inappropriate antimicrobial prescribing.

References:

1. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016 May 15;62(10):e51-77. doi: 10.1093/cid/ciw118.
2. May L, Cosgrove S, L’Archeveque M, et al. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med. 2013 Jul;62(1):69-77.e doi: 10.1016/j.annemergmed.2012.09.002.
3. Australian Commission on Safety and Quality in Health Care. Antimicrobial Prescribing Practice in Australian Hospitals: Results of the 2015 National Antimicrobial Prescribing Survey. Australian Commission on Safety and Quality in Health Care website: https://bit.ly/2VdydO Published December 2016. Accessed March 31, 2019.