Emergency Department Urinary Antibiograms Differ by Specific Patient Group

Abstract

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

Pattern of Antimicrobial Resistance to <i>Escherichia Coli</i> Among the Urinary Tract Infection Patients in Bangladesh

“…[24] Increasing resistance trends in US and Canada and lower susceptibility also support our finding. [4,12,25] b. Nitrofurantoin: It is an oral form, cheap, less side effects and most effective antibiotics which are commonly used in UTIs patients in our country. We have found that Nitrofurantoin is only 4.7% resistance to E coli in the present study and accounted the lowest resistance form antibiotics to it.…”

“…[18,26,27] But less increasing resistance (from 0.7% to 0.9%) and higher susceptibility (>80%) in US support our report. [4,25] c. Ciprofloxacin: The quinolone derivative, Ciprofloxacin is used empirically not only in UTIs but also in various forms infections due to its safety profile and cheap in price. Its oral form is widely used in uncomplicated UTI patients.…”

Leveraging Antimicrobial Stewardship in the Emergency Department to Improve the Quality of Urinary Tract Infection Management and Outcomes

“…Pre-implementation review of antimicrobial prescribing and outcomes for patients treated for UTI in the ED revealed substantial opportunity for improvement [ 6 , 12 ]. We therefore assembled a multidisciplinary working group comprised of the ASP team plus ED pharmacists and physicians to develop a best practice UTI empiric antimicrobial treatment algorithm for patients discharged directly from the ED.…”

“…We therefore assembled a multidisciplinary working group comprised of the ASP team plus ED pharmacists and physicians to develop a best practice UTI empiric antimicrobial treatment algorithm for patients discharged directly from the ED. Antimicrobial therapy recommendations contained within the algorithm were based upon national and professional society guidelines, primary literature and findings from our background research characterizing the patient population, antimicrobial resistance patterns, prescribing behavior, and morbidity related to infection, as reported previously [ 2 , 4 , 6 , 12–27 ]. Several features of our algorithm are noteworthy.…”

“…Furthermore, E. coli fluoroquinolone susceptibility rates were higher among patients diagnosed with pyelonephritis and stable for discharge (87%). For males, in whom prostate involvement is almost always a concern, our antibiogram showed agents with good prostate penetration (ie, sulfamethoxazole-trimethoprim and fluoroquinolones) to have unreliable activity against common uropathogens [ 12 ]. With marginally higher susceptibility, we promoted sulfamethoxazole-trimethoprim over fluoroquinolones and suggested fosfomycin as an alternative.…”