A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies

May, Larissa; Cosgrove, Sara E.; L'Archeveque, Michelle; Talan, David M.; Payne, Perry W.; Jordan, Jeanne A.; Rothman, Richard E.

doi:10.1016/j.annemergmed.2012.09.002

Cited by 120 publications

(128 citation statements)

References 82 publications

(81 reference statements)

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“…Antimicrobial stewardship programs (ASPs) have become a standard practice at U.S. hospitals but have focused primarily on inpatients. Recent literature highlights the success of ASPs in reducing inappropriate antibiotic use in both outpatient and inpatient settings through seminars, roundtable discussions, and personal feedback (25,30). However, the ED has unique challenges that may not be amenable to standard ASPs.…”

Section: Discussionmentioning

confidence: 99%

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Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Donnelly

Baddley

Wang

2014

Antimicrob Agents Chemother

113

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Inappropriate use of antibiotics for acute respiratory tract infections (ARTIs) has decreased in many outpatient settings. For patients presenting to U.S. emergency departments (EDs) with ARTIs, antibiotic utilization patterns are unclear. We conducted a retrospective cohort study of ED patients from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We identified patients presenting to U.S. EDs with ARTIs and calculated rates of antibiotic utilization. Diagnoses were classified as antibiotic appropriate (otitis media, sinusitis, pharyngitis, tonsillitis, and nonviral pneumonia) or antibiotic inappropriate (nasopharyngitis, unspecified upper respiratory tract infection, bronchitis or bronchiolitis, viral pneumonia, and influenza).There were 126 million ED visits with a diagnosis of ARTI, and antibiotics were prescribed in 61%. A cute respiratory tract infections (ARTIs) such as bronchitis, sinusitis, and rhinitis account for almost 10% of ambulatory care visits in the United States (1). While many of these infections are caused by viruses, clinicians prescribe antibiotics for over half of the visits for these conditions (1, 2). This inappropriate antibiotic use is potentially harmful to the community, fostering the growth of antimicrobial-resistant organisms (3). Other potential consequences include antibiotic-related adverse effects, such as Clostridium difficile-associated disease, antibiotic-associated diarrhea, and allergic reactions (4-6). Over the past decade, multiple campaigns and interventions have sought to curtail the use of inappropriate antibiotics for ARTIs, focused primarily on outpatient visits. There is evidence of improvement, with ARTI antibiotic prescription rates decreasing among young children and reduction of rates of broad-spectrum antimicrobial use in older persons (1,2,7,8).Much less is known about patterns of antibiotic use for ARTIs among persons visiting emergency departments (EDs). ED use in the United States has increased over the past decade, and Americans rely increasingly on EDs for a wide range of medical conditions due to a combination of barriers to primary care access (9, 10). As a result, the ED has become a common site of care for nonemergent conditions, including ARTIs, particularly among socioeconomically disadvantaged individuals.We sought to characterize antibiotic utilization for ARTIs treated in U.S. emergency departments with the use of national surveillance data. MATERIALS AND METHODSStudy design and data source. We analyzed 2001-to-2010 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). The study was approved by the Institutional Review Board of the University of Alabama at Birmingham.Operated by the National Center for Health Statistics, NHAMCS is a national probability sample characterizing ED (NHAMCS-ED) and outpatient clinic visits at hospitals across the United States (11). Using a four-stage probability design, NHAMCS-ED samples geographically defined areas, hospitals within these areas, emergenc...

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Section: Discussionmentioning

confidence: 99%

“…Sustained antibiotic use among adult ARTI patients is likely attributable to a mixture of factors, including patient expectations and the ED environment (24). Specifically, the complexity of ARTI treatment in the ED and the difficulty of making a definitive diagnosis contribute to inappropriate use (25).…”

Section: Discussionmentioning

confidence: 99%

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Donnelly

Baddley

Wang

2014

Antimicrob Agents Chemother

113

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“…Another core principle is the pharmacist as a crucial member of antimicrobial stewardship programs, because they are knowledgeable on the interpretation of culture and sensitivity results, the appropriate use of antimicrobials, medication dosing, recognition of allergies, route of administration, duration of therapy, and drug interactions. [2][3][4][5] Review of microbiological test results and subsequent modification of empiric antimicrobial therapy may be a daunting task for ED health care personnel due to high patient volume and frequent interruptions. The emergency medicine pharmacist (EMP) is perfectly positioned and equipped with the proper knowledge and tools to review these results and facilitate appropriate modifications to therapy when necessary.…”

mentioning

confidence: 99%

“…[2][3][4][5] While proven effective in the inpatient setting, many antimicrobial stewardship programs do not include emergency department (ED) patients in their initiatives. 2,4 The Infectious Diseases Society of America (IDSA) and the Society for Healthcare and Epidemiology of America (SHEA) have identified the clinical A ntimicrobial stewardship is a collection of strategies aimed at optimizing the use of antimicrobials while minimizing unintended consequences of therapy, such as the emergence of resistance due to overuse. [1][2][3] Selecting the correct dose, route, and duration of therapy accompanied by educational initiatives are among the core principles of these programs.…”

mentioning

confidence: 99%

“…2,4 The Infectious Diseases Society of America (IDSA) and the Society for Healthcare and Epidemiology of America (SHEA) have identified the clinical A ntimicrobial stewardship is a collection of strategies aimed at optimizing the use of antimicrobials while minimizing unintended consequences of therapy, such as the emergence of resistance due to overuse. [1][2][3] Selecting the correct dose, route, and duration of therapy accompanied by educational initiatives are among the core principles of these programs. Another core principle is the pharmacist as a crucial member of antimicrobial stewardship programs, because they are knowledgeable on the interpretation of culture and sensitivity results, the appropriate use of antimicrobials, medication dosing, recognition of allergies, route of administration, duration of therapy, and drug interactions.…”

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confidence: 99%

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Evaluation of Pharmacist Impact on Culture Review Process for Patients Discharged from the Emergency Department

et al. 2016

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Background Accurate and timely review of microbiological test results is a core component of antimicrobial stewardship. There is documented success of these programs in the inpatient setting; however, emergency department (ED) patients are typically not included in these initiatives. Objectives To assess the impact of an emergency medicine pharmacist (EMP)–facilitated review process of positive microbiological test results from patients discharged from the ED as measured by time to positive result review and number of indicated interventions completed. Methods This was a retrospective study that compared EMP-facilitated to ED charge nurse (CN)–facilitated physician review of randomly selected positive microbiological test results. Groups were compared concurrently within the time frame of July 1, 2012 through December 31, 2012. Results One hundred seventy-eight positive microbiological test results were included (EMP, n = 91; CN, n = 87). The median (IQR) time to initial review was 3 (1.0–6.3) hours for the EMP and 2 (0.3–5.5) hours for the CN group ( p = .35). Four percent (1/25) of indicated interventions were not completed in the EMP group versus 47% (14/30) in the CN group ( p = .0004). Conclusion An EMP was significantly less likely to miss an intervention when indicated with no difference in time to review of positive microbiological results. These findings support the role of the EMP in antimicrobial stewardship in the ED.

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Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis

Pulia,

Schwei,

Alexandridis

et al. 2024

JAMA Dermatol

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ImportanceCellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis.ObjectivesTo validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis.Design, Setting, and ParticipantsThis prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023.Main Outcomes and MeasuresTemperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed.ResultsThe final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P &lt; .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]).Conclusions and RelevanceIn this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis.

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A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies

Cited by 120 publications

References 82 publications

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Evaluation of Pharmacist Impact on Culture Review Process for Patients Discharged from the Emergency Department

Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis

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