What are the key recommendations for antibiotic stewardship in the emergency department?

Key Recommendations for Antibiotic Stewardship in the Emergency Department

The implementation of a comprehensive antimicrobial stewardship program in the emergency department should include biomarker testing, rapid diagnostic testing, structured culture follow-up programs, and watchful waiting strategies to optimize antibiotic use and improve patient outcomes. 1

Core Strategies for ED Antibiotic Stewardship

Diagnostic Testing Approaches

• Biomarker testing (PCT, CRP) and rapid pathogen testing should be incorporated to improve antibiotic prescribing decisions for patients presenting with infectious syndromes 1
• Blood cultures should be obtained selectively in patients with community-acquired pneumonia, urinary tract infections, or skin/soft tissue infections, particularly when signs of sepsis are absent 1
• Rapid diagnostic testing helps distinguish between viral and bacterial pathogens, reducing unnecessary antibiotic use and enabling appropriate narrow-spectrum therapy when indicated 1, 2

Prescribing Strategies

• Watchful waiting or delayed antibiotic prescribing should be considered for select patients with lower respiratory tract infections, acute COPD exacerbations, uncomplicated cystitis, or diverticulitis 1
• Structured culture follow-up programs should be implemented for patients discharged from the ED with pending cultures to ensure appropriate antibiotic therapy adjustments 1
• Shortening duration of therapy according to current guidelines reduces selective pressure for resistant bacteria without compromising outcomes 1
• Dose optimization based on patient characteristics, pathogen, infection site, and pharmacokinetic/pharmacodynamic properties improves efficacy and reduces resistance 1

Implementation Tools

• Clinical decision support systems provide real-time feedback on antimicrobial choices and potential side effects 1
• Antimicrobial order forms requiring clinical justification for specific agents help reduce inappropriate prescribing 1
• ED-specific antibiograms should be developed to guide empiric therapy based on local resistance patterns 1, 2
• Streamlining or de-escalation protocols facilitate transition from broad to narrow spectrum antibiotics when culture results become available 1

Organizational Approaches

Multidisciplinary Collaboration

• ED clinician representation on hospital antimicrobial stewardship committees is essential for successful implementation 1
• Collaboration between ED clinicians, pharmacists, microbiologists, and infectious disease specialists yields the most effective stewardship programs 1, 2
• A dedicated pharmacist as part of the ED team plays a critical role in addressing appropriate antibiotic use 1

Education and Engagement

• Active educational programs including seminars and roundtable discussions promote dialogue and clinician engagement 1
• Educational messaging should be tailored to ED-specific practice patterns and challenges 1
• Inclusion of infectious disease topics in departmental grand rounds and inter-specialty conferences facilitates improved antibiotic use 1

Measurement and Feedback

• Process and outcome measures should track antimicrobial utilization and resistance patterns 1
• Post-prescription review with patient follow-up ensures appropriate transitions to outpatient care 1
• Monitoring appropriateness of antibiotic therapy choice, rehospitalization rates, and time to culture review helps evaluate program effectiveness 1

Common Pitfalls and How to Avoid Them

• Overreliance on education alone: Education is essential but insufficient for sustained practice change; combine with complementary strategies to reinforce desired behaviors 1
• Lack of ED-specific approaches: Generic hospital stewardship programs may not address unique ED challenges; tailor interventions to the ED environment 2
• Poor follow-up of discharged patients: Implement structured protocols for culture follow-up to avoid missed opportunities for therapy adjustment 1
• Inadequate engagement of ED leadership: Involve ED thought leaders to ensure optimal engagement of all practice group members 1
• Failure to address barriers to implementation: Understand and address factors that hinder uptake of recommended practices 1

Implementation Considerations

• Recognize that the ED is the entrance gate for patients with infectious diseases and has high rates of antibiotic prescribing that impact downstream care 2
• Adapt implementation strategies to the specific settings and circumstances of individual EDs 1
• Focus on the four key antimicrobial use processes in the ED: making a tentative diagnosis, starting empirical therapy, performing microbiological tests, and following up discharged patients 2
• Acknowledge the tension between appropriate broad-spectrum antibiotic use for life-threatening infections and antimicrobial stewardship goals 1