Antimicrobial Stewardship in the ED: The Buck Stops Here

Caitlin Carter

July 13, 2017

Antimicrobial overuse is the most significant preventable cause of drug resistance in both hospital and community settings[i].

Antibiotic overuse occurs among practitioners in nearly 2/3 of cases.

Overuse contributes to the growth of antibiotic resistant pathogens and the spread of antibiotic resistant infections that lead to increased morbidity, mortality, and health care costs.

Antimicrobial stewardship has emerged as a solution to combat this dangerous and preventable threat to patient safety. Antimicrobial stewardship is a collection of policies, guidelines, surveillance, data transparency, education, and evaluation to optimize antibiotic-prescribing practices. These strategies can lead to better patient outcomes, a decrease in adverse events and infections, and an optimized use of resources.

Last year the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America released a set of evidenced-based guidelines on antimicrobial stewardship in clinical settings[ii]. These guidelines serve to improve and measure the appropriate use of antibiotics across dosing, duration of care, and route of administration. While these guidelines were developed by a panel of clinicians and investigators across various medical disciplines.

Emergency physicians have a unique vantage point to affect antimicrobial stewardship in inpatient and outpatient settings.

The initial choice of antibiotic in the Emergency Department (ED) has important downstream implications. ED clinicians routinely prescribe antimicrobials for patients with skin and soft-tissue infections, urinary tract infections, bloodstream infections, as well as upper and lower respiratory infections. Broad-spectrum antibiotics are sometimes overused in EDs and other ambulatory settings, and in observational studies have shown significant overprescribing for acute bronchitis and other conditions.

Antimicrobial stewardship in ED settings is particularly challenging due to the high rates of ED crowding, the rapid rate of patient turnover, the need for quick decisions without consultation, the shift-based scheduling format of providers, and higher staff turnover rates than in other clinical settings. In addition, there are provider-centered factors that impact stewardship. This includes a perceived lack of efficacy, concerns about resource availability and reimbursement, as well as perceived hindrance to operational efficiency. Providers are also concerned about medical liability and patient satisfaction, which has shown to be an important facet of antibiotic prescription in the ED.

Challenges to antimicrobial stewardship in ED settings are unique, numerous, and require strategies that consider the ED as well as other key stakeholders. ED specific guidelines are still needed that consider clinical decision support systems, post prescription review, rapid diagnostics, duration of therapy, dosage, and ED antibiogram development.

To learn more about antimicrobial stewardship and implications for emergency medicine please see Dr. Larissa May’s podcast and webinar available only through Urgent Matters. For an overview of antibiotic use in pneumonia, please see Dr. Jesse Pines’ webinar on the burden of community-acquired pneumonia and current issues in emergency care.

These programs were funded through an educational grant from Cempra, Inc. (CEMP) who had no role in the content.

[i] May, L., Cosgrove, S., et al. “A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies.” Annals of Emergency Medicine (2013).

[ii] Barlam, T.F., Cosgrove, S.E., et al. “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.” Clinical Infectious Diseases (2016).

Caitlin Carter, MPH is a research associate and manager for the Urgent Matters program


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