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

Abstract

BackgroundThe complex and fast-paced emergency department (ED) practice setting presents unique challenges that demand a tailored approach to antimicrobial stewardship. In this article, we describe the strategies applied by 1 institution’s antimicrobial stewardship program (ASP) that were successful in improving prescribing practices and outcomes for urinary tract infection (UTI) in the ED.MethodsCore strategies included pre-implementation research characterizing the patient population, antimicrobial resistance patterns, prescribing behavior, and morbidity related to infection; collaboration across multiple disciplines; development and implementation of a UTI treatment algorithm; education to increase awareness of the algorithm and the background and rationale supporting it; audit and feedback; and early evaluation of post-implementation outcomes.ResultsWe observed a rapid change in prescribing post-implementation with increased empiric nitrofurantoin use and reduced cephalosporin use (P < .05). Our elevation of nitrofurantoin to firstline status was supported by our post-implementation analysis showing that its use was independently associated with reduced 30-day return visits (adjusted odds ratio, 0.547; 95% confidence interval, 0.312–0.960). Furthermore, despite a shift to a higher risk population and a corresponding decrease in antimicrobial susceptibility rates post-implementation, the preferential use of nitrofurantoin did not result in higher bug-drug mismatches while 30-day return visits to the ED remained stable.ConclusionsWe demonstrate that an outcomes-based ASP can impart meaningful change to knowledge and attitudes affecting prescribing practices in the ED. The success of our program may be used by other institutions as support for ASP expansion to the ED.

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents

“…The literature identifies two sources of antibiotic overtreatment of UTIs in nursing homes: treatment of nonspecific symptoms and asymptomatic bacteriuria [ 7 ]. Health professionals often consider nonspecific behavioural symptoms as an indication of UTIs in the elderly, but guidelines recommend that these symptoms should not be treated with antibiotics [ 8 , 9 , 10 , 11 ]. Asymptomatic bacteriuria is the presence of bacteria in a urine sample from a patient that shows no signs or symptoms originating from the urinary tract [ 12 ].…”

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

“…This resulted in an increase in adherence to best practices (41% versus 66% p < 0.001) and a change in antibiotic selection which was driven by a decrease in ciprofloxacin utilization. Jorgensen et al developed a UTI treatment algorithm which emphasized nitrofurantoin as a first line option for uncomplicated UTIs, and offered feedback by ASP to providers [20]. This caused an increase in nitrofurantoin prescriptions (16% to 43%, p < 0.001), with a compensatory decrease in cephalexin prescriptions (45% to 10%, p < 0.001).…”

Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department

“…3 The incorporation of ASP principles into culture callback programs can help decrease inappropriate antibiotic utilization and a reduction of ED return visits. 4,5…”