Antimicrobial stewardship to optimize antimicrobial use for outpatients at emergency department

Antimicrobial stewardship programs (ASPs) have proven to be effective in optimizing antibiotic use for inpatients. However, Emergency Department (ED)’s fast-paced clinical setting can be challenging for a successful ASP | The Journal of Hospital Infection

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Aim: In April 2015, an ASP was implemented in our ED and we aimed to determine its impact on antimicrobial use for outpatients.

Methods: Monocentric study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016).

For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24hours) were evaluated by an infectious disease specialist (IDS) and an ED physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

Findings: Before and after ASP, 34,671 and 35,925 consultations were registered at our ED, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (p<0.0001). There were 484 (62.9%) and 271 (46.7%) (p<0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliances included unnecessary antimicrobial prescriptions, 197 (25.6%) vs. 101 (17.4%) (p<0.0005); inappropriate spectrum, 108 (14.0%) vs. 54 (9.3%) (p=0.008); excessive treatment duration, 87 (11.3%) vs. 53 (9.1%) (p>0.05); and inappropriate choices, 11 (1.4%) vs. 15 (2.6%) (p>0.05).

Conclusions: The implementation of an ASP dramatically decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Full reference: Dinh, A. et al. (2017) Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department. The Journal of Hospital Infection. Published online: 8th July 2017

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One Hospital System’s Journey to Reduce Clostridium Difficile

Delaney, M.B. Journal of Emergency Nursing | Published online: 4 April 2017

A colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.

Image source: Annie Cavanagh – Wellcome Images // CC BY-NC-ND 4.0

Problem: Albert Einstein defines insanity as doing the same thing over again but expecting different results. Although the United States claims to reduce antibiotic abuse, practice strict isolation, and clean meticulously, the burden of Clostridium difficile outpaces goals. Unless innovative approaches are tried, we risk culling elderly, immunosuppressed, and otherwise debilitated populations. Emergency departments are a primary access point for patients who are unable to wait for primary care. As a result, many patients with diarrhea are seen in emergency departments.

Methods: This article describes one hospital system’s quality improvement trial of disposable commode pails (DCPs) for high-acuity patients in 3 of 5 institutions. The rationale was to prevent staff from touching surfaces heavily contaminated with C difficile. Staff members were not to wash or reuse commode buckets between patients. Instead, DCPs were substituted, and only the commode chairs were wiped. For quantitative date, C difficile infections (CDIs) were compared across hospitals. Staff members were surveyed for qualitative data.

Read the full abstract here

Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

Frota, P.O. et al. American Journal of Infection Control. Published online: 24 August 2016

Highlights

  • The interventions immediately improved the effectiveness of cleaning.
  • These improvements disappeared after four months of interventions.
  • Microfiber cloths did not impact any increase in cleaning effectiveness.
  • Continuous education and feedback on cleaning practices appear to be warranted.
  • This policy should be adapted to the particularities of each health care setting.

Abstract

Background: Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

Methods: This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions—feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

Results: We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

Conclusions: The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

Read the abstract here

A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care

Beam, C. et al. Journal of Emergency Nursing. Published online: July 21 2016

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Image shows digitally colorized electron micograph of influenza virions 

Concern about antibiotic overuse has become heightened as bacterial resistance to antibiotics continues to increase. Patients experiencing respiratory symptoms frequently present to urgent/emergent care settings such as fast-track emergency care departments and primary care retail settings with the expectation that they will be prescribed antibiotics.

The Centers for Disease Control and Prevention (CDC) reports that approximately 2 million people will become ill with bacteria that are resistant to at least one antibiotic, approximately 23,000 people die as a direct result of these infections, and many others die as a result of complications related to antibiotic-resistant infections.

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The influence of contaminated urine cultures in inpatient and emergency department settings

Klausing, B.T. et al. American Journal of Infection Control. Published online: 13 June 2016

Highlights

  • Urine culture contamination results in substantial impact to patients.
  • Morbidity includes unnecessary testing and antibiotic exposure.
  • Reducing urine culture contamination is an important quality intervention.

We retrospectively evaluated 131 patients with contaminated urine cultures during a 12-month period. Sixty-four patients (48.8%) experienced 139 potential complications related to these specimens. The most common complication was inappropriate antibiotic administration (noted in 58 patients [44.3%]). Contaminated urine cultures led to additional diagnostic evaluation and unnecessary antibiotic use.

Read the abstract here

Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department

 

Arntz, P.R.H. et al. American Journal of Infection Control. Published online: 6 May 2016

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Highlights:

  • A total of 1,007 opportunities for handrubs were recorded in the emergency department. Hand hygiene (HH) compliance increased significantly (P < .001) after the first intervention week to 40.5% (95% confidence interval [CI], 33%-48%) and stabilized (P = .075) after the second intervention week to 49.5% (95% CI, 43%-56%).
  • The total number of alcohol dispensers was increased from 25 to 55. Within every 5-m radius in the emergency department an alcohol dispenser was placed. Existing alcohol-based handrub was switched for a different brand for its proven skin friendliness.
  • Profession-specific analysis revealed a significant increase over the phases of the study in both subgroups, the physicians and nurses.
  • Regarding the frequency of hand hygiene indications, indication 4 (hand hygiene after touching a patient) composed most indications (31.6%). The increase of compliance applied for all indications; the highest and lowest relative improvements appeared to be indication 3, after contact with body fluids (700% of baseline), and indication 4, after patient contact (136% of baseline), respectively.
  • During the baseline observations, the effect of the time of day (day vs evening and week vs weekend) and the type of patient (surgical patients vs patients with infection vs others without infection) showed no significant effect on hand hygiene compliance.

 

Read the abstract here