Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP. AIM: In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients. METHODS: This was a single-centre 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 <24h) were evaluated by an infectious disease specialist and an emergency department 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 emergency department, 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-compliance 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). CONCLUSION: The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Evaluating antibiotic therapies prescribed to adult patients in the emergency department.

OBJECTIVES: The proper use of antibiotics is a public health priority to preserve their effectiveness. Little data is available on outpatient antibiotic prescriptions, especially in the emergency department. We aimed to assess the quality of outpatient antibiotic prescriptions in our hospital. PATIENTS AND METHODS: Retrospective monocentric study of antibiotic prescriptions written to adult patients managed at the emergency department without hospitalization (November 15th, 2012-November 15th, 2013). Prescriptions were evaluated by an infectious disease specialist and an emergency physician on the basis of local recommendations compiled from national and international guidelines. RESULTS: A total of 760 prescriptions were reviewed. The most frequent indications were urinary tract infections (n=263; 34.6%), cutaneous infections (n=198; 26.05%), respiratory tract infections (n=101; 13.28%), and ENT infections (n=62; 8.15%). The most frequently prescribed antibiotics were fluoroquinolones (n=314; 40.83%) and amoxicillin-clavulanic acid (n=245; 31.85%). Overall, 455 prescriptions (59.86%) did not comply with guidelines. The main reasons for inadequacy were the absence of an indication for antibiotic therapy (n=197; 40.7%), an inadequate spectrum of activity, i.e. too broad, (n=95; 19.62%), and excessive treatment duration (n=87; 17.97%). Rates of inadequate prescriptions were 82.26% for ENT infections, 71.2% for cutaneous infections, 46.53% for respiratory tract infections, and 38.4% for urinary tract infections. CONCLUSION: Antibiotic prescriptions written to outpatients in the emergency department are often inadequate. Enhancing prescribers' training and handing out guidelines is therefore necessary. The quality of these prescriptions should then be re-assessed.

Deliberate drug poisonings admitted to an emergency department in Paris area - a descriptive study and assessment of risk factors for intensive care admission.

OBJECTIVE: Each year, approximately 165,000 poisonings are managed in the emergency departments (ED) in France. We performed a descriptive analysis of self-poisoned patients admitted to a university hospital ED in the Paris metropolitan area (France) aimed at investigating their outcome and the risk factors for transfer to the intensive care unit (ICU). PATIENTS AND METHODS: We retrospectively reviewed patients' records and performed multivariate logistic regression analysis to identify risk factors for ICU admission. RESULTS: During 4 years, 882 self-poisoned patients (median age, 38 years [IQR, 26-47]; sex-ratio, 1M/3F) were admitted to the ED, representing 0.7% of all referred patients. Poisonings mainly resulted from multidrug exposures (53%), including benzodiazepines (78%), serotonin reuptake inhibitors (17%), acetaminophen (13%), antipsychotics (9.5%), imidazopyridines (9.5%), antihypertensive drugs (3%), and polycyclic antidepressants (1.3%). Ethanol was involved in 20% of the exposures. Patients were briefly (<24h) monitored in the ED (55%), transferred to the psychiatric department (30%), medical ward (2%) or ICU (6%), and took an irregular discharge (7%). Among the patients transferred to the ICU, 25% were mechanically ventilated and only one died. Risk factors for ICU admission included antihypertensive (Odds ratio (OR), 40.6; 95%-confidence interval (CI), 7.5-221.9) or antipsychotic drug ingestion (OR, 5.3; CI, 2.0-14.4), male gender (OR, 3.3; CI, 1.30-8.8), and consciousness impairment (OR, 2.1; CI, 1.8-2.5 per point lost in Glasgow coma score). CONCLUSIONS: Deliberate drug exposure represents a frequent cause of ED admission. Psychotropic drugs are most commonly involved. Transfer to the ICU is rare and predicted by male gender, drug class, and coma depth.

[Observatory of the elderly over 80 years supported by the mobile emergency and resuscitation service]. / Observatoire du sujet âgé de plus de 80 ans pris en charge en urgence par le service mobile d'urgence et de réanimation.

Emergency medical services (EMS) received an increasing number of calls for patients aged 80 and older. The goal of the present study was to evaluate outcome and functional dependence of patients aged 80 and older who EMS managed in the prehospital theater. This prospective study was conducted over 1 year (September 2007-August 2008), all consecutive patients aged 80 and older managed by a medical team during the study period were included. Characteristics of patients, including previous health status and functional dependence, were recorded on-the scene by the attending physician. Three-month mortality was recorded, as well as ADL score. Data are expressed as mean values±standard deviations, medians and interquartile ranges (IQRs), and percentages and compared using univariate and multivariate analysis. P<0.05 was considered the threshold for significance. Five hundred twenty-three patients were included. Mean age was 86 ± 5. Median ADL index was 2 (IQR 0-9), and 63% of patients were living at home. At 3 months, the survival rate was 66% (n=273) and the proportion of patients living at home was 64% (P=0.9), the median ADL index of survivors was 2 (IQR 0-8) vs 1 (IQR 0-6) initially for this subpopulation, P=0.01. Our study confirms utility and efficacy of full access of elderly persons to advanced life support especially for self-patients and not restricted based on aging per se. The development and daily use of tools for rapid assessment of autonomy should enable practitioners to innovate and thus, adapt their management.