Antimicrobial resistance is a national public health concern. Misuse of antimicrobials for conditions such as upper respiratory infection, urinary tract infections, and cellulitis has led to increased resistance to antimicrobials commonly utilized to treat those infections, such as sulfamethoxazole/trimethoprim and flouroquinolones. The emergency department (ED) is a site where these infections are commonly encountered both in ambulatory patients and in patients requiring admission to a hospital. The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings. However, implementing antimicrobial stewardship programs in the ED is fraught with challenges including diagnostic uncertainty, distractions secondary to patient or clinician turnover, and concerns with patient satisfaction to name just a few. However, this review article highlights successful interventions that have stemmed inappropriate antimicrobial use in the ED setting and warrant further study. This article also proposes other, yet to be validated proposals. Finally, this article serves as a call to action for pharmacists working in antimicrobial stewardship programs and in emergency medicine settings. There needs to be further research on the implementation of these and other interventions to reduce inappropriate antimicrobial use to prevent patient harm and curb the development of antimicrobial resistance.
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Web site. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Updated March 4, 2014. Accessed September 9, 2014.
2.
DellitTHOwensRCMcGowanJE. Infectious diseases society of america and the society for healthcare epidemiology of america guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–177.
3.
CaminsBCKingMDWellsJB. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol. 2009;30(10):931–938.
4.
IngramPRSeetJMBudgeonCA. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Intern Med J. 2012;42(6):719–721.
5.
LevinPDIdreesSSprungCL. Antimicrobial use in the ICU: indications and accuracy—an observational trial. J Hosp Med. 2012;7(9):672–678.
6.
PatelSJOshodiAPrasadP. Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance. Pediatr infect Dis J. 2009;28(12):1047–1051.
7.
FridkinSKBaggsJFaganR. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Weekly Rep. 2014;63(9):194–200.
8.
DonnellyJPBaddleyJWWangHE. Antibiotic utilization for acute respiratory tract infections in U.S. emergency departments. Antimicrob Agents Chemother. 2014;58(3):1451–1457.
9.
MayLMullinsPPinesJ. Demographic and treatment patterns for infections in ambulatory settings in the United States, 2006-2010. Acad Emerg Med. 2014;21(1):17–24.
10.
JenkinsTCSabelALSarconeEE. Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship. Clin Infect Dis. 2010;51(8):895–903.
11.
MayLCosgroveSL’ArchevequeM. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med. 2013;62(1):69–77.
12.
Kroening-RocheJCSoroudiACastilloEM. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med. 2012;43(2):221–227.
13.
SamoreMHBatemanKAlderSC. Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial. JAMA. 2005;294(18);2305–2314.
14.
AubertGCarricajoAVautrinAC. Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit. J Hasp Infect. 2005;59(2):83–89.
15.
BrahmiNBlelYKouraichiN. Impact of ceftazidime restriction on gram-negative bacterial resistance in an intensive care unit. J Infect Chemother. 2006;12(4):190–194.
16.
BakerSNAcquistoNMAshleyED. Pharmacist-managed antimicrobial stewardship program for patients discharged from the emergency department. J Pharm Pract. 2012;25(2):190–194.
17.
DumkowLEKenneyRMMacDonaldNC. Impact of a multidisciplinary culture follow-up program of antimicrobial therapy in the emergency department. Infect Dis Ther. 2014;3(1):45–53.
18.
StevensDLBisnoALChambersHF. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2014;59(2):e10–e52.
19.
KimASutherlandCAKutiJL. Optimal dosing of piperacillin-tazobactam for the treatment of pseudomonas aeruginosa infections: prolonged or continuous infusion?Pharmacotherapy. 2007;27(11):1490–1497.
20.
NicolauDP. Pharmacodynamic optimization of β-lactams in the patient care setting. Crit Care. 2008;12(suppl 4):S2.
21.
HeckerMTFoxCJSonAH. Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting. Plos One. 2014;9(2):e87899.
22.
NicolleLEBradleySColganR. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Inf Dis. 2005;40(5):643–654.
23.
FileTMJrSolomkinJSCosgroveSE. Strategies for improving antimicrobial use and the role of antimicrobial stewardship programs. Clin Inf Dis. 2011;53(S1):S15–S22.
24.
DalenDMZvonarRKJessaminePG. An evaluation of the management of asymptomatic catheter-associated bacteriuria and candiduria at The Ottawa Hospital. Can J Infect Dis Med Microbiol. 2005;16(3):166–170.
25.
GandhiTFlandersSAMarkovitzE. Importance of urinary tract infection to antibiotic use among hospitalized patients. Infect Control Hosp Epidemiol. 2009;30(2):193–195.
26.
CopeMCevallosMECadleRM. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis. 2009;48(9):1182–1188.
27.
LoebMBrazilKLohfeldL. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669.
28.
PavesePSaurelNLabarereJ. Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study. Infect Control Hosp Epidemiol. 2009;30(6):596–599.
29.
PallinDJCamargoCASchuurJD. Skin infections and antibiotic stewardship: analysis of emergency department prescribing practices, 2007–2010. West J Emerg Med. 2014;15(3):282–289.
30.
JengABeheshtiMLiJ. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore). 2010;89(4):217–226.
31.
BowenACLilliebridgeRATongSY. Is Streptococcus pyogenes resistant or susceptible to trimethoprim-sulfamethoxazole?J Clin Microbiol. 2012;50(12):4067–4072.
32.
Clinicaltrials.gov. Uncomplicated Skin and Soft Tissue Infections Caused by Community-Associated Methicillin-Resistant Staphylococcus Aureus. Web site. https://clinicaltrials.gov/ct2/show/NCT00730028. Published August 7, 2008. Updated May 7, 2015. Accessed February 19, 2015.
33.
Clinicaltrials.gov. Strategies Using Off-Patent Antibiotics for Methicillin Resistant S. Aureus “STOP MRSA”. Web site. https://clinicaltrials.gov/ct2/show/study/NCT00729937. Published August 7, 2008. Updated January 29, 2015. Accessed February 19, 2015.
34.
Anzctr.org. An open label randomised controlled trial to determine if 5 days of once-daily oral trimethoprim-sulfamethoxazole or three days of twice-daily oral trimethoprim-sulfamethoxazole will lead to non-inferior cure rates of impetigo compared to a single dose of intramuscular benzathine penicillin G (the current gold standard treatment) in children living in remote Aboriginal communities between the age of 12 weeks to less than 13 years. Web site. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83543. Published January 28, 2009. Accessed February 19, 2015.
PartaMGoebelMMatloobiM. Identification of methicillin-resistant or methicillin-susceptible staphylococcus aureus in blood cultures and wound swabs by GeneXpert. J Clin Microbiol. 2009;47(5):1609–1610. Letter.
37.
TalanDAKrishnadasaATerpSM. Rapid MRSA PCR Testing in the emergency department reduces inappropriate antibiotics for patients hospitalized with skin and soft tissue infections [abstract]. In: Proceedings of the Infectious Diseases Society of America Annual Meeting; 2011 Oct 20-23; Boston, MA. Arlington (VA): IDSA; 2011. Abstract nr 226.
38.
Clinicaltrials.gov. Antimicrobial stewardship through MRSA diagnosis in emergency department (ED) patients with abscesses. Web site. http://clinicaltrials.gov/ct2/show/NCT01523899. Published January 26, 2012. Updated March 9, 2015. Accessed September 9, 2014.
39.
DarkPWilsonCBlackwoodB. Accuracy of LightCycler® SeptiFast for the detection and identification of pathogens in the blood of patients with suspected sepsis: a systematic review protocol. BMJ Open. 2012;2(1):e000392.
40.
ChangSSHsiehWHLiuTS. Multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis – a systemic review and meta-analysis. PLoS One. 2013;8(5):e62323.
41.
MencacciALeliCCardacciaA. Procalcitonin predicts real-time PCR results in blood samples from patients with suspected sepsis. PLoS One. 2012;7(12):e53279.
42.
SakranJVMichettiCPSheridanMJ. The utility of procalcitonin in critically ill trauma patients. J Trauma Acute Care Surg. 2012;73(2):413–418.
43.
SchuetzPChrist-CrainMThomannR. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059–1066.
44.
AlbrichWCDusemundFBucherB. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012;172(9):715–722.
45.
TangJLongWYanL. Procalcitonin guided antibiotic therapy of acute exacerbations of asthma: a randomized controlled trial. BMC Infect Dis. 2013;13:596.
46.
MullerFChrist-CrainMBregenzerT. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138(1):121–129.
47.
HochreiterMKohlerTSchweigerAM. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial. Crit Care. 2009;13(3):R83.
48.
BishopBMBonJJTrienskiTL. Effect of introducing procalcitonin on antimicrobial therapy duration in patients with sepsis and/or pneumonia in the intensive care unit. Ann Pharmacother. 2014;48(5):577–583.
49.
NobreVHarbarthSGrafJD. Use of procalcitonin to shorten antibiotic treatment duration in septic patients: a randomized trial. Am J Respir Crit Care Med. 2008;177(5):498–505.
50.
JensenJUHeinLLundgrenB. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med. 2011;39(9):2048–2058.
