BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department

Abstract

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection

“…High rates of antibiotic overprescribing (not in accordance with guidelines) are known to exist across NHS medical and dental care [ 26 , 27 , 28 ]. Promulgating clinical practice guidelines is known to have limited effect on changing clinician behaviour [ 29 ] and bundles of interventions to optimise antibiotic prescribing across healthcare have been shown to be beneficial [ 30 ]. Interventions that facilitate shared decision-making between patients and clinicians are included in bundles for use in primary medical care [ 31 ], but no such tools have been reported in primary dental care [ 32 ].…”

Reduction of BSI associated mortality after a sepsis project implementation in the ER of a tertiary referral hospital

“…BCs were processed as previously described 15 . Positive BCs were defined according to Weinstein 8 . Coagulase-negative staphylococci, aerobic and anaerobic diphtheroids, Micrococcus spp., Bacillus spp., and viridans streptococci were considered contaminants if only one bottle was positive, and susceptibility testing was not performed.…”

“…The bundles have been demonstrated to improve survival, through modification of the physician’s clinical approach, and quality improvement 5 , 6 . As happens with poly-trauma, acute myocardial infarction and stroke 7 , also in the sepsis case, bundles application might avoid discontinuous and delayed treatments, by providing a standardised approach for timely and appropriate management of patients 8 .…”

Antimicrobial stewardship programs in emergency departments: how do we measure antimicrobial use? A systematic review

“…The methods used in this type of unit are highly heterogeneous. All these interventions have been designed with strategies for optimising antimicrobial use in these units [16] and have demonstrated, in all cases, benefits by reducing antibiotic prescription in these units [32]. The optimal strategy for ASPs in ED has not yet been established because no study has compared the different interventions proposed for such purposes.…”