Category: Professional Posters
Purpose: The impact of antimicrobial stewardship (ASP) is well established in the inpatient setting. There is a set of challenges to implement ASP in the emergency department (ED) due to overcrowding and high turn over rate. Since 2012, there has been a call for action to expand ASP in the ED as it significantly impacts antimicrobial resistance in the community. Several studies report that antimicrobial prescribing is inappropriate in the emergency department globally. At Al Wakra Hospital (Hamad Medical Corporation), we demonstrate an initiative to implement ASP in the ED.
Methods: The implementation of ASP project was initiated by a comprehensive review of local and international guidelines. A number of Infectious Diseases (ID) champions were selected to lead the project, conduct data analysis and provide education. A simplified guide was created for physicians followed by extensive education composed of a series of lectures, visual aids, handouts and reminder emails. Project goals included: offer standardized process, improve quality of care, decrease un-necessary prescription broad spectrum antimicrobials, decrease prevalence of multiple drug resistant organisms, adhere to local antimicrobial guidelines and provide a methodology for continuous prospective and retrospective monitoring of antimicrobial prescribing. A compliance rate for each physicians is calculated and individual education is provided based on their compliance rate. A clinical pharmacist is present during one shift per day for prospective monitoring and active intervention and on call for the rest of the day for consultation. Data collection include analysis of most commonly prescribed antimicrobials, analysis of prescribing pattern for urinary tract infection, skin and soft tissue infection and upper respiratory tract infection, analysis of IV antimicrobials prescription by ED physicians as outpatient. This report is a retrospective observational analysis of antimicrobial prescribing for the main infectious diseases in the ED over a period of one month (July 2018).
Results: The overall adherence of antimicrobial prescribing is 68%. Inappropriate outpatient prescription is 32%. Post implementation of ASP in the ED, the most common antimicrobial prescribed for urinary tract infection is nitrofurnatoin (44%) which is appropriate. The project contributed to significant success in treating upper respiratory tract infections. Prior to implementation, ciprofloxacin was widely utilized which is not appropriate as per local or international guidelines. Post implementation, the main antimicrobials prescribed for upper respiratory tract infection are Amoxicillin clavulanate (41%), azithromycin (26%) and clarithromycin (18%) which is appropriate according to local guidelines. Antimicrobial prescribing for skin and soft tissue infection is mostly inappropriate with IV ceftriaxone being the main antibiotic prescribed (52%). It was noted that Emergency Department physicians are liberally prescribing IV antimicrobials for various indications in an outpatient setting with a low appropriateness rate of 20%. Ceftriaxone was the most common antimicrobial prescribed antibiotic and is prescribed for inappropriate indications such as skin and soft tissue infection and tonsillitis.
Conclusion: Implementation of antimicrobial stewardship in the ED is a challenging process that requires continuous monitoring and education. At Al Wakra Hospital, there is a structured antimicrobial stewardship program in which the clinical pharmacist plays a vital role towards its success. The ASP program proved its efficiency in improving antimicrobial prescribing for urinary tract infection and upper respiratory tract infections. However, improvement is still required for IV antimicrobial prescribing and treatment of skin and soft tissue infections.