PHILADELPHIA — Early infectious disease consultation in the emergency department can improve antibiotic prescribing and reduce unnecessary use, according to a recent study.
"Just a small intervention, having an infectious disease specialist on board, can actually prevent admissions, and possibly more if we did this on a larger scale," Theresa Madaline, MD, attending infectious disease physician at Montefiore Medical Center in Bronx, New York, told Medscape Medical News.
Researchers at Montefiore initiated the study because an audit of antibiotic use in their emergency department showed that 61% of patients who received antibiotics in the hospital were started in emergency, and 30% to 60% of these cases were not optimal.
Dr Madaline presented the study results here at IDWeek 2014.
Published data have shown that more than half of patients seen in emergency with viral upper respiratory tract infections are inappropriately prescribed antibiotics. For patients with serious conditions such as sepsis, the timely administration of the right antibiotics can reduce morbidity and mortality.
The researchers ran a pilot program in which a dedicated infectious disease specialist worked together with antibiotic stewardship program physicians and hospital pharmacists Monday to Friday during daytime hours.
Calls to the infectious disease physician were triggered by staff in the emergency department or by the antibiotic stewardship program physicians during routine auditing of antibiotic orders. After reviewing cases, the infectious disease specialist made recommendations about antibiotic selection, dosing, duration, and additional testing.
Of the 331 consults during the 6-month study period, the most common clinical syndromes were pneumonia (30.5%), sepsis (16.9%), skin and soft tissue infections (11.2%), and urinary tract infections and pyelonephritis (11.2%).
In 92% of the cases, physicians prescribed the recommended antibiotic regimen. Each patient required an average of one follow-up visit after the initial consultation.
Table 1. Results of Infectious Disease Consult in Emergency Department
| Outcome | Percent |
| Staff accept antibiotic recommendation | 92 |
| Patient recommended for discharge | 11 |
| Patient discharged from hospital | 6 |
Twenty hospital admissions were prevented. Pneumonia is particularly problematic during flu season; if a radiologist reads an x-ray and reports "can't rule out pneumonia," the physician might feel safest admitting the patient, Dr Madaline explained.
But after a full evaluation, an infectious disease specialist might decide that the patient really has the flu and recommend discharge with or without a prescription for oseltamivir (Tamiflu, Genentech). During flu season, "I think emergency department physicians really appreciate the help because they're inundated with people," she said.
Of the 331 consults, 152 patients were prescribed appropriate regimens and 179 were not.
Table 2. Reasons for Inappropriate Prescribing
| Reason | Inappropriate Prescriptions (n = 179) |
| No antibiotics needed | 34 |
| Change to oral antibiotics | 19 |
| Coverage too broad | 55 |
| Coverage too narrow | 31 |
| Other* | 40 |
| *History of multidrug-resistant bacteria, allergy, incorrect dose, or wrong drug for the clinical syndrome. |
|
The infectious disease physician spent an average of four additional hours a day on consults and in communication with emergency department staff. Dr Madaline said consulting in the emergency department is fairly labor intensive for the infectious diseases staff, and an additional physician has recently been hired at Montefiore. Future plans include a cost savings analysis and the assessment of morbidity and mortality outcomes and readmission rates.
The key to a successful emergency department antibiotic stewardship program is collaboration. "You have to have buy-in from both sides," Dr Madaline pointed out. "This has been a really successful program because we've worked with the emergency department and listened to what they need."
Pranita Tamma, MD, director of pediatric antimicrobial stewardship at Johns Hopkins Hospital in Baltimore, praised the Montefiore program for including the emergency department because most programs usually focus on inpatients. "We forget that there's a large percentage of patients who come to the hospital and don't get admitted," she told Medscape Medical News. They may just be prescribed a 7- to 10-day course of antibiotics and sent home.
An antibiotic stewardship program in the emergency department could have a huge impact on antibiotic use "because more patients are sent home, rather than admitted," Dr Tamma noted. For institutions that already have an inpatient program, she said it should be easy to extend it to the outpatient side by working with their emergency physicians and other providers.
In a separate study presented at IDWeek 2014, in which infectious disease physicians educated community pediatricians and gave them feedback through audits, researchers found that adherence to best antibiotic prescribing practices quickly waned when the feedback stopped. "In the emergency department, compared with most traditional outpatient settings, you can constantly do that feedback because it is part of the hospital," Dr Tamma pointed out.
There are two reasons emergency department providers can inappropriately prescribe antibiotics, she said. One is that they might feel they should do it "just in case" the patient has a bacterial infection, and the other is that it takes less time to prescribe something than to explain to a patient why no prescription is needed.
Dr Madaline and Dr Tamma have disclosed no relevant financial relationships.
IDWeek 2014: Abstract 228. Presented October 9, 2014.
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Cite this: Specialist in Emergency Department Improves Antibiotic Use - Medscape - Oct 13, 2014.
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