Factors associated with inappropriate intravenous antibiotic prescription in patients discharged from the emergency department

Abstract

What is known and Objective Since 2011, a collaborative territorial network for urgent care has been deployed in Hospital de la Santa Creu i Sant Pau area, which allows direct and early transfer of patients with frailty from the hospital emergency department (ED) to other healthcare settings according to the destination's adequacy. This study aimed to identify factors associated with inappropriate intravenous antibiotic treatment prescribed on referral of patients with frailty based on microbiological culture and analyse the effect of inappropriate prescription on ED reconsultations for any cause 30 days after hospital discharge. Methods This observational, retrospective study was performed at a tertiary hospital between March 2018 and February 2019 and included 264 patients. A multivariate analysis, including variables with a P‐value <.2 in the previous univariate analysis, was conducted. The variables included in the analysis were age, sex, patient comorbidities (COPD, diabetes and chronic kidney disease), antibiotic treatment in the last 30 days and patient referral (nursing home or family home). Results and Discussion Multidrug‐resistant bacteria were isolated from 85 patients (51.5% of the isolates). In total, 159 patients received carbapenem, of whom 87 (54.7%) had non–drug‐resistant bacteria. The antibiotic was considered inappropriate in 33 patients (12.5%) according to an antibiogram. Only 71 (26.8%) patients had a definitive culture on discharge. Moreover, 73 (28.3%) patients were readmitted after 30 days. Patients with an inappropriate antibiotic treatment had more reconsultations within 30 days than those with adequate treatment (59.3% vs 24.5%; P < .001). In a multivariate analysis, an inappropriate prescription was significantly associated with a higher number of reconsultations at 30 days (OR, 3.22 [1.37‐7.57]). What is new and Conclusion In patients discharged from the ED with intravenous antibiotics, the empirical prescription of an inappropriate drug according to the final culture is a frequent problem and is related to a higher number of reconsultations. This highlights the need to implement early communication strategies with outpatient units to optimize antibiotic therapy once microbiological results are known.

Antibiotic stewardship programs in the Spanish emergency services: PROA-URG Study

“…No en vano, los resultados muestran un porcentaje de infecciones por multirresistentes superior al 12%. Estos datos son ligeramente inferiores a los publicados por otros autores en los servicios de urgencias [9,20], que han reportado aislamientos por cepas multirresistentes cercanos al 20% de las muestras. Este hecho, unido al aumento del número de pacientes frágiles con múltiples comorbilidades atendidos en estas unidades hace presuponer una tendencia creciente a lo largo de los próximos años.…”

“…Por otro lado, el consumo de carbapenémicos se ha situado en torno al 5% del consumo global en la mayor parte de centros. El incremento progresivo de cepas productoras de betalactamasas en los SUH [ 19 ] está minimizando la disponibilidad de alternativas para el manejo del tratamiento empírico en urgencias. Es por ello esencial que los equipos PROA mantengan una adecuada monitorización del uso de estos fármacos en los SUH y ofrecer alternativas a los mismos en procesos infecciosos menos graves.…”

“…Los resultados microbiológicos obtenidos en este estudio muestran un bajo conocimiento por parte de las unidades de urgencias relativas al perfil de resistencias propias tanto en muestras de urocultivo como en hemocultivo. Dada la importancia señalada por múltiples organismos de adaptar el tratamiento empírico al perfil de resistencia local [ 5 , 6 , 19 ], es necesario una estrecha colaboración de los servicios de microbiología, a fin de detectar nuevos perfiles de resistencia atendidas en la unidad que no sean sensibles de las pautas de tratamiento empírico recomendado. No en vano, los resultados muestran un porcentaje de infecciones por multirresistentes superior al 12%.…”