Draft a memo outlining the readiness of the organization to implement the change strategy: SWOT analysis, discussion of challenges see attached, recommendation.
Healthy Student 
AntibioticuseinED.pdf
CLINICAL RESEARCH REPORT
Supplementary material is available with the full text of this article at AJHP online.
Address correspondence to Dr. O’Neal ([email protected]).
© American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals. [email protected].
DOI 10.1093/ajhp/zxz193
Fredrick O’Neal, Pharm.D., BCPS, Clinical Services Group, HCA Healthcare Nashville, and University of Tennessee College of Pharmacy, Nashville, TN.
Joan Kramer, Pharm.D., BCPS, Clinical Services Group, HCA Healthcare Nashville, Nashville,TN.
Mandelin Cooper, Pharm.D., BCPS, Clinical Services Group, HCA Healthcare Nashville, Nashville, TN.
Edward Septimus, M.D., Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.
Sanya Sharma, M.P.H., Clinical Services Group, HCA Healthcare Nashville, Nashville, TN.
L. Hayley Burgess, Pharm.D., BCPP, Clinical Services Group, HCA Healthcare Nashville, Nashville, TN.
Purpose. To assess antibiotic selection, administration, and prescribing practices in emergency departments across a large hospital system using evidence-based practices and susceptibility patterns.
Methods. This retrospective data review was conducted using health system–level electronic data compiled from 145 emergency departments (EDs) across the United States. Data were examined for national general- izability, most common diagnoses of infectious origin seen in nonadmitted patients in the ED, most commonly administered antibiotics in the ED, and geographically defined areas’ unique patterns of antibiotic resistance and susceptibility.
Results. More than 627,000 unique patient encounters and 780,000 anti- biotic administrations were assessed for trends in patient demographics, antibiotics administered for a diagnosis of infectious origin, and correspond- ing susceptibility patterns. Results indicated that practices in the EDs of this health system aligned with evidence-based practices for streptococcal phar- yngitis, otitis media, cellulitis, and uncomplicated urinary tract infections.
Conclusion. These results provide a representative sample of the cur- rent state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for patients visiting the emergency room and treated as outpatients.
Keywords: antibiotic use, antimicrobial, emergency department, health system, pharmacist, stewardship
Am J Health-Syst Pharm. 2019; 76:1753-1761
Overuse and misuse of antibiotics have caused a surge in antibiotic- resistant bacteria.1–5 The Centers for Disease Control and Prevention and World Health Organization have made efforts to develop updates, action plans, and initiatives with the intention of com- batting the growing antibiotic resistance crisis.6,7 The idea that antibiotics may not be effective against common infections is a real possibility within our lifetime.7
In the United States, approximately 117 million emergency department (ED) visits took place in 2007, with 15.7% of visits associated with the use of an antibiotic.6 In the ED and primary care settings, up to 75% of patients pre- senting with acute bronchitis receive
antibiotic prescriptions, although 90% to 95% of cases uncomplicated by an underlying pulmonary disease are of viral origin.8 In addition, up to 60% of patients presenting with other upper respiratory infections or colds receive antibiotic prescriptions.8 More than 140,000 visits to the ED each year are related to adverse events associated with systemic antibiotic use,9 and 30% of all antibiotics prescribed in the out- patient setting, including the ED, may be inappropriate.4
Antimicrobial stewardship program challenges exist within the ED space be- cause of the clear need for rapid patient assessment, expectations for rapid turn- over, local resistance patterns, patient
Analysis of antibiotic use in a large network of emergency departments
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expectations, and suspected need for overly broad bacterial coverage.5,8,10,11 The ED remains an uncharted area for data exploration, particularly when patients are discharged from the ED.12 Antibiograms and resistance patterns vary based on patient history, expo- sure to other aspects of health care, recent antibiotic use, and patient care area. Further, inpatient antibiograms may overestimate resistance in an emergency department because these antibiograms often represent older, sicker patient populations.13,14 Draper and colleagues15 performed data cap- ture and analytics on ED-specific iso- lates versus hospital-wide isolates, reporting that there was a difference of ≥5% susceptibility for at least one an- tibiotic agent in 8 different organisms. Similarly, there are sparse reports of geographic variations in susceptibility patterns or methods to disseminate best practices across a large, collective network of EDs. Thus, our objective was to assess antibiotic selection, ad- ministration, and prescribing practices in EDs across a large hospital system using evidence-based practices and susceptibility patterns.
Methods
Setting. This study was ap- proved by the University of Tennessee Institutional Review Board as exempt, nonhuman subjects research. This re- search was developed within a large health system comprising 178 hospitals across 20 U.S. states; of these hospitals, 156 provide ED services. Facilities pro- viding ED services were primarily large, general community hospitals, but also included academic health centers and large, tertiary-referral hospitals. Health-system EDs are typically located in urban and suburban areas, provide emergency services to hospitals ran- ging from 26 to 1,000 beds, and expe- rience approximately 3,500 to 146,000 patient visits annually; of the patients seen in the ED, approximately 22.4% are admitted as an inpatient. Antibiotic protocol usage varies across the health- system; however, standardized re- commendations and order sets are
available for use, with diagnosis reliant on the provider. The health-system for- mulary includes the same antibiotics at each hospital, with minimal variance of selected antibiotics based on suscepti- bility patterns. Medications adminis- tered in the ED are documented using barcoded medication administration, and in a recent survey of our hospitals, 27% employ an ED clinical pharma- cist (n = 143 hospitals). During the study period, more than 7.1 million ED unique visits were reported.
Relative geographic structure was provided by grouping EDs into 1 of 14 geographically defined areas. The geo- graphically defined areas were grouped according to the health system’s opera- tionally defined metrics and are further elaborated on in Table 1. De-identified, patient-level data were obtained from
the health system’s electronic data warehouse. Within the electronic data warehouse, data from 145 EDs were obtained for use in the study. Data from freestanding EDs were unavailable for study inclusion.
Retrospective ED encounter data were obtained from July 1, 2016, through June 30, 2017. Total number of ED patient encounters were identified by principal International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) diagnosis codes for infectious origin. Each principal ICD- 10 code represented a unique patient encounter. Antibiotics administered in the ED were captured through barcode medication administration technology and only included eligible infection- related encounters. Barcode medication administration data for medication scan- ning in 2017 indicated approximately 94.9% compliance. Study inclusion and exclusion criteria are depicted in Figure 1. Excluded data consisted of principal ICD-10 diagnosis codes of noninfectious origin, patients admitted to the hospital as inpatients, and antibiotics adminis- tered to patients who were admitted as inpatients; all other data were included for analysis.
A third-party clinical surveil- lance software that performs real-time electronic health record monitoring captured all bacterial culture iden- tification and susceptibility data re- ported at each ED in the health system. Diagnoses of infectious origin, by ge- ographically defined area, were com- pared with evidence-based guidelines from the Infectious Diseases Society of America, Centers for Disease Control and Prevention, American Academy of Pediatrics, and other current liter- ature and contrasted with antibiotics that were administered in the ED.11,16–26 Finally, antibiograms for July 1, 2016, through June 30, 2017, from the health system by geographic area were used to assess each area’s diagnoses by infectious origin and antibiotics administered.
Assessment. The primary objective was a description of the 20 most common administered antibiotics and the 20 most common coded principal diagnoses of
KEY POINTS • Data compiled from 145 emer-
gency departments across the United States were exam- ined for the most common infectious diagnoses, most commonly administered anti- biotics, and geographic pat- terns of antibiotic resistance and susceptibility.
• The most common diagnoses included urinary tract infec- tions, skin and soft tissue in- fections, and respiratory tract infections, and prescribing patterns showed a general adherence to treatment guide- lines but indicated areas for improvement based on local susceptibility.
• This representative sample of the current state of antibiotic prescribing practices within emergency departments can aid in the assessment and im- plementation of antimicrobial stewardship programs in these settings.
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Table 1. Geographically Defined Areas by Total Number of Unique Patient Encounters and Antibiotic Administrations for EDs in the Health Systema
Areas Geographically Defined Areas Total No. of ED visitsb Total No. of ED Antibiotic Administrationsc
Area 1 Alaska, Idaho, Utah 245,501 18,984
Area 2 California, Nevada 578,337 50,425
Area 3 Colorado, Kansas (Central) 455,561 44,912
Area 4 Florida (East) 616,619 84,196
Area 5 Florida (North) 679,622 91,330
Area 6 Florida (West) 544,155 64,311
Area 7 Georgia, South Carolina 656,735 79,652
Area 8 Indiana, New Hampshire, Virginia 537,534 54,245
Area 9 Kansas, Louisiana, Missouri 456,117 43,662
Area 10 Kentucky, Tennessee 643,293 77,669
Area 11 Oklahoma, Texas (North) 502,315 37,082
Area 12 Texas (Central West) 399,297 46,188
Area 13 Texas (Gulf Coast) 546,966 54,744
Area 14 Texas (San Antonio) 264,147 33,003
aED = emergency department. bTotal number of unique ED visits. cTotal number of antibiotics administered to patients in the ED who were subsequently discharged home from the ED.
Figure 1. Inclusion and exclusion criteria. ED = emergency department.
Unique ED patient visits for coded principal diagnoses:
n = 1,335,403
Excluded: Patients admitted as inpatients from the
ED Patients with coded principal diagnoses of
noninfectious origin n = 708,272
Included: Unique ED patient visits for coded
principal diagnoses of infectious origin n = 627,131
Total ED antibiotics administered: n = 2,466,626
Excluded: Antibiotics administered to patients admitted as inpatients from the ED
n = 1,686,217
Included: Antibiotics administered to patients
discharged from the ED n = 780,409
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infectious origin in EDs across the health system. We assessed for generalizability of our results to the national popula- tion through collection of patient demo- graphic data. There were 3 prespecified secondary outcomes. First, we analyzed the 5 most common diagnoses of infec- tious origin. Second, we similarly ana- lyzed the 5 most commonly administered antibiotics within each geographically defined area. Finally, we evaluated trends in susceptibility patterns of the most commonly isolated organisms from the ED within each geographically defined area. Susceptibility was defined using laboratory-reported results in accord- ance with Clinical Laboratory Standards Institute standards.
Common coded principal diag- noses of infectious origin and common antibiotics-administered results were used in conjunction with data from other sources to provide a robust review of current practices within the health- system EDs. To accomplish this, ICD-10 diagnostic data of nonadmitted patients, evidence-based literature, practice guidelines, and available health-system susceptibility data were all used to- gether to build a layered analysis.
Primary data analysis. Data were analyzed with descriptive statis- tics (e.g., percentages, ratios) between groups by geographic area. Based on the nature of the data, no statistical tests were applicable to the study.
Results
Patient demographics, including gender, race, ethnicity, and age were captured and aggregated at the health- system level to assess for national gen- eralizability. The distributions and contributions to the total from the patient demographics are further de- tailed in Table 2. The results contain the analysis of the data available from 145 health-system EDs with more than 620,131 ED visits of nonadmitted pa- tients having a principal diagnosis of infectious origin and 780,409 corre- sponding antibiotic administrations.
The 20 most frequently identi- fied diagnoses of infectious origin and 20 most commonly administered
antibiotics are included in Tables 3 and 4. The top 20 principal diagnoses ac- counted for approximately 46% of all diagnoses made during the study pe- riod in the health-system EDs. The most common diagnoses included upper and lower urinary tract infec- tions (UTIs), skin and soft tissue infec- tions, and upper and lower respiratory tract infections. For antibiotics admin- istered, the third-generation cephalo- sporin ceftriaxone accounted for nearly one-third (30.6%) of all antibiotics ad- ministered in the health-system EDs. The remaining most common 5 anti- biotics included a mix of antibiotics across several drug classes, including macrolides (azithromycin, 10.8%), lincosamides (clindamycin, 6.6%), fluoroquinolones (levofloxacin, 5.8%), and first-generation cephalosporins (cephalexin, 5.3%).
The 5 most frequently identified diagnoses of infectious origin (i.e., UTI, cellulitis, pneumonia, strepto- coccal pharyngitis, and otitis media) were then aligned to evidence-based literature and guidelines, as outlined in supplementary materials (eTables 1–3). UTIs, with nearly 80,000 diag- noses across all health-system EDs, were treated most commonly (52.4% of the time) with administration of ceftriaxone in the ED. The second most administered antibiotic was nitrofur- antoin, representing 7.7% of antibi- otic administrations for this diagnosis. For patients with cellulitis, with more than 34,000 cases diagnosed, most commonly received clindamycin (26.6%); the second most common an- tibiotic administered was sulfameth- oxazole–trimethoprim (SMZ/TMP). Supplementary materials fully sum- marizes this step of the layered analysis for these selected diagnoses.
Antibiotic selection was assessed via review of health system and geographic area organism susceptibility patterns for the most commonly identified and cul- tured organisms isolated from ED visits for reported antibiotics to Escherichia coli (with indicators for urine and nonurine sources) and Staphylococcus species. In our health-system EDs, antibiotics
for cellulitis and uncomplicated UTIs may not be suitable for empiric treat- ment because of area susceptibility pat- terns.22, 26 We found that clindamycin is becoming less viable as an option for treating Staphylococcus-suspected cel- lulitis, with susceptibilities ranging from 81% to 89% for methicillin-susceptible Staphylococcus aureus and 63% to 86% for methicillin-resistant S. aureus. Similarly, we found a trend toward significant re- sistance levels developing in E. coli to SMZ/TMP. Area susceptibility of E. coli to SMZ/TMP ranged from 68% to 81%. Further analysis by area and diagnosis with recommended treatment regimens is detailed in supplementary material.
Discussion
With the expected increase in ED-based population care and
Table 2. Patient Demographicsa
Subgroup % of Total ED
Population
Gender
Female 61.4
Male 38.5
Other/Unknown 0.1
Age, yr
0–1 3.2
2–6 4.5
7–12 3.0
13–17 3.5
18–44 48.8
45–65 21.6
>65 15.3
Race/Ethnicity
American Indian 0.1
Asian/Pacific Is- lander
0.1
Black 22.9
Hispanic 20.3
Other 2.3
Unknown 1.8
White 52.6
aED = emergency department.
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the desire to empirically cover for a broad range of bacterial patho- gens, current literature is attempting to expand on the ED as a valu- able target for antimicrobial stew- ardship programs as the ED is at a critical juncture between the inpa- tient and outpatient settings. 5,9,12,17 Our results provide a snapshot of real-world practices of antibiotic use for nonadmitted patients in the ED. The most common diagnoses of infectious origin from our health- system EDs included upper and lower UTIs skin and soft tissue infections, and upper and lower respiratory tract infections, which does mirror some aspects of the current literature.17,27,28 However, to our knowledge, no cur- rently available data summarizes the
most common infectious diseases diagnosis data for patients not being admitted to the hospital across all age and payer groups in a single reference.
With these thoughts in mind, our study was conducted to elucidate cur- rent practices of antibiotic use for diagnoses of infectious diseases in the ED within a large health system to es- tablish a generalized model for cur- rent national practices. Our patient demographic data were considered to be generally representative of the national population.6 The results of this study can be applied to health- system EDs of varying sizes to assess current antimicrobial stewardship program practices and to identify op- portunities to optimize empiric antibi- otic selection based on susceptibility
patterns and evidence-based treatment recommendations.
Streptococcal pharyngitis, most commonly attributed to the pathogen group A Streptococcus, was treated most often with penicillin, followed by amox- icillin, ceftriaxone, azithromycin, and clindamycin (supplementary mate- rial).19,25 This pattern of treatment shows a general adherence to treatment guide- lines, but does pose a unique question for our health system to address the possible overuse of ceftriaxone across all indications, specifically in our most commonly diagnosed infectious dis- eases (UTI, cellulitis, pneumonia), in- cluding outside of the study EDs.19,29
The majority of antibiotic use for streptococcal pharyngitis aligned with evidence-based recommendations, while indications such as cellulitis and uncomplicated UTI show the impor- tance of ongoing education in appro- priate selection of empiric antibiotics. The majority of patients diagnosed with pneumonia received ceftriaxone in the ED; this result may be related to a retired inpatient core measure when administration of the first antibiotic dose within a 4-hour window was en- couraged to avoid fallouts.30 Although the core measure was retired before the time period of this descriptive analysis, provider disposition may have played a role in antibiotic use in the ED. The data we gathered offers excellent objectives for stewardship programs to identify common infectious indications for antibiotic treatment and support ap- propriate—albeit narrow—initial anti- biotic choices when able as well as oral antibiotic options.
Of skin and soft tissue infections, 42% include streptococci.31 Although clindamycin methicillin-resistant S. aureus (MRSA) susceptibilities ranged from 63% to 86% depending on geo- graphic area, this antibiotic was admin- istered most frequently in the majority of areas for cellulitis. Based on these trends across the country, there may be opportunities for providers to move away from use of clindamycin for em- piric management of MRSA cellulitis as
Table 3. Top 20 Coded Diagnoses of Infectious Origin Across the Health System’s Emergency Departments
Principal ICD-10 Diagnosis
No. Diagnoses (% of Total)
(n = 627,131)
Urinary tract infection 79,116 (12.6)
Cellulitis 34,484 (5.5)
Pneumonia 24,143 (3.8)
Streptococcal pharyngitis 17,743 (2.8)
Otitis media 17,684 (2.8)
Nephritis 14,365 (2.3)
Acute pharyngitis 14,218 (2.3)
Periapical abscess 10,887 (1.7)
Diverticulitis 8,868 (1.4)
Gastroenteritis and colitis 8,684 (1.4)
Bronchitis (acute or chronic not specified) 8,586 (1.4)
Acute exacerbation of chronic obstructive pulmonary disease 8,288 (1.3)
Acute vaginitis 6,726 (1.0)
Acute upper respiratory infection 5,671 (0.9)
Acute bronchitis 5,480 (0.9)
Acute appendicitis 5,402 (0.9)
Contact or exposure to sexually transmitted infection 4,727 (0.8)
Urethritis 4,638 (0.7)
Acute tonsillitis 4,587 (0.7)
Fever, unspecified 4,418 (0.7)
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resistance approaches 10% or more. S. aureus susceptibility data indicated that SMZ/TMP has 97% to 100% suscepti- bilities in non-MRSA and 84% to 99% in MRSA cultures isolated from ED cul- tures; SMZ/TMP could be an alternative to clindamycin in appropriate patient populations. In patients with a known or suspected sulfa allergy, doxycycline was also a reasonable alternative and provided coverage for MRSA isolates with 93% to 100% susceptibility re- ported from the health-system EDs; for non-MRSA isolates, the susceptibility rates were 99% to 100%, where reported.
The fluoroquinolone (FQ) drug class was among the top 5 antibiotics used across all areas for treatment of UTI. Use of FQs must be weighed against the risks of serious adverse re- actions after assessing local suscepti- bilities. Our findings also support the
national consensus for restricting fluor- oquinolone usage in uncomplicated UTIs, with E. coli susceptibilities ran- ging from 69% to 87%. Geographic area data for SMZ/TMP susceptibilities for urinary E. coli isolates ranged from 68% to 78%, which is below the threshold for a guideline-recommended empiric regimen.22 Fosfomycin was not among the top 5 antibiotics used to treat UTIs and may be an option for uncom- plicated UTIs; a significant prohibi- tive factor with regards to fosfomycin use is its significant cost compared with other alternatives. We found that cefazolin susceptibilities ranged from 76% to 97%. Of the 14 geographic areas, 10 reported cefazolin susceptibilities greater than 90%, indicating that cer- tain areas should consider first-gen- eration cephalosporin regimens for empiric UTI treatment.
Opportunities for future research may focus on automation and com- puterization strategies to improve medication practices, such as use of health-system alerts for alternative antibiotic selection based on indica- tion and geographic area susceptibility patterns. Additional opportunities in- clude standardization and use of evi- dence-based order sets for antibiotic selection by indication, with analysis of usage patterns and trending of or- ganism susceptibility, and exploration of choice of antibiotic selection in EDs with clinical pharmacists compared with EDs without clinical pharmacists.
While our study reported antibiotic use based on principal ICD-10 diag- nosis and area susceptibility for specific diagnoses, identification of specific or- ganisms, patient outcome, and indi- vidual hospital susceptibilities were not able to be considered. Further, antibi- otic selection based on patient presen- tation and symptoms was not able to be assessed as patient-specific data were not captured, nor were recent past an- tibiotic exposure and unique patient- specific risk factors (e.g., allergies) available in our data set for analysis. The result of this is a corresponding difficulty in interpretation of some of the results and usage patterns within the data. In addition, ICD-10 coding diagnosis is often inconsistent both in practice and validation, and no internal standard was developed to identify granular, patient-level data for diag- nosis code validity. Finally, the order of administration and number of anti- biotics per encounter and pharmacist impact on antibiotic selection in the ED were not available for analysis within the data. The authors have attempted to thoroughly review and standardize the data as much as the large volume of data allows. There is recognized op- portunity to drill further into the data and provide more in-depth analyses of specific subsets of the population, in- cluding, but not limited to, insured or uninsured, homelessness, and/or pa- tient complexity (i.e., morbidity index).
This study provided a high-level overview on the state of administration
Table 4. Top 20 Antibiotics Administered Across the Health System’s Emergency Departments
Antibiotic No. Administrations (% of Total)
(n = 780,409)
Ceftriaxone 238,748 (30.6)
Azithromycin 84,029 (10.8)
Clindamycin 51,819 (6.6)
Levofloxacin 45,244 (5.8)
Cephalexin 41,596 (5.3)
Metronidazole 34,825 (4.5)
Sulfamethoxazole–trimethoprim 32,875 (4.2)
Ciprofloxacin 30,097 (3.9)
Amoxicillin 29,323 (3.8)
Penicillin 25,641 (3.3)
Piperacillin–tazobactam 23,217 (3.0)
Augmentin 22,290 (2.9)
Cefazolin 21,489 (2.8)
Vancomycin 21,372 (2.7)
Nitrofurantoin 17,020 (2.2)
Doxycycline 12,413 (1.6)
Ampicillin–sulbactam 4,999 (0.6)
Cefepime 3,344 (0.4)
Ampicillin 1,402 (0.2)
Meropenem 999 (0.1)
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and use of antibiotics in the EDs within a large health system that is represen- tative of the national population of nonadmitted patients. Our results sup- port the use of all available data to deter- mine optimal strategies for supporting antimicrobial stewardship programs making customized decisions locally and improving patient care. Our results also identified opportunities to educate EDs about treatment options beyond first- or second-line guideline-based treatment because of the ongoing issue of antibiotic resistance. We found that recommended treatment in practice may sometimes be modified because guidelines are general and may not apply based on local circumstances. Health systems of varying sizes are en- couraged to assess empiric antibiotic use with a similar data reconstruction to identify best practices and opportun- ities to advance antibiotic prescribing for patients discharged from the ED.
Conclusion
These results provide a represen- tative sample of the current state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for pa- tients visiting the emergency room and treated as an outpatient.
Acknowledgments The authors of this manuscript would like to thank Dr. Karla Miller and Dr. Kimberly Korwek for their contributions and support to the preparation of this manuscript.
Disclosures This research was supported (in whole or in part) by HCA Healthcare. The views expressed in this publication represent those of the au- thors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. The authors have declared no potential conflicts of interest.
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