Establishing and maintaining an antimicrobial stewardship program (ASP) in the controlled confines of hospital wards is challenging enough, but in the chaos of the emergency department (ED) and outside the hospital grounds, the challenge is magnified. A trio of speakers addressed some of the outpatient challenges at the annual meeting of the Infectious Diseases Society of America in New Orleans, Louisiana.
Antimicrobial stewardship in the ED ripples outward into the rest of the hospital. “The ED is the nexus of the [United States] healthcare system. 20% of the US population goes to an ED each year. ED visits trigger about 75% of all hospital admissions and about 30% of acute care visits. Antibiotics are administered in about 25% of the nearly 35 million ED visits annually in the United States, making them the second most common category of drug used in the US health care system,” said Michael Pulia, MD, MS from the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, in his session.
Antibiotics started in the ED can be continued following admission, at least for awhile, so if the antibiotics used in the ED are inappropriate, the misuse will spill over to subsequent patient care.
“There is a paucity of ED stewardship research. In a systematic review we have done, encompassing 1979 to 2016, only about 40 interventional studies were identified. There was a wide range of strategies making it difficult to compare and our overall rating of methodologic quality was only fair,” said Dr. Putia.
Challenges to antimicrobial stewardship in the ED setting include a lack of perception of antibiotic misuse by some emergency physicians, time pressure to do something for patients despite the knowledge of ramifications later on in terms of antibiotic resistance, variable levels of training for ED staff, variations in regional practices, and compensation for ED physicians that is often linked to the numbers of patients who actually receive treatment.
The ASP challenges for those receiving dialysis are even greater, since dialysis is done in private clinics. However, the fact that dialysis in the US is delivered by just a few companies could make progress easier.
“The risk of [methicillin-resistant Staphylococcus aureus
] infection is 100-fold higher among chronic hemodialysis patients compared to the general population and hemodialysis has been associated with a 13-fold higher risk of [extended spectrum beta-lactamase] producing Klebsiella pneumonia
infections. Chronic hemodialysis patients contribute to the spread of multidrug-resistant organisms in the hospital and community settings,” said Erica D’agata, MD, MPH, Brown University, Providence, Rhode Island, in her session.