Impact of pharmacist-led antimicrobial stewardship on the treatment of urinary tract infections and pyelonephritis in the Emergency Department

Background: Antibiotic prescribing patterns for the treatment of urinary tract infections (UTI) in the Emergency Department (ED) have historically been suboptimal. Previous literature has shown that the implementation of best-practice guidelines for the treatment of UTI in the Emergency Department (ED) increased overall prescribing appropriateness from 2.3% to 20%. The purpose of this study was to evaluate the impact of a pharmacist-led ASP on prescribing practices within the ED for the treatment of UTI, pyelonephritis, and asymptomatic bacteriuria.

Methods: A retrospective, quasi-experimental study was conducted comparing adult patients discharged from the ED following collection of a urine culture before (No-ASP; January to June 2011) and after (ED-ASP; January to June 2015) implementation of ED pharmacy services and outpatient empiric therapy guidelines. Patients were excluded who were pregnant, neutropenic, had a history of renal transplant, or chronic indwelling urinary catheter. Demographic information, microbiological characteristics, antimicrobial therapy prescribed, and patient outcomes, including revisit within 72 hours and the need for change in therapy at follow-up, were as collected. The primary outcome was total guideline-concordant prescribing (drug, dose, and duration).

Results: 230 patients were included with115 patients per group. Overall guideline-concordant prescribing occurred 38.3% vs 57.4% in the No-ASP and ED-ASP groups, respectively (p=0.004). In a subgroup analysis of patients receiving antibiotics for UTI, overall guideline-concordant prescribing occurred 3.6% in the No-ASP vs 19% in the ED-ASP group (p=0.017), primarily associated with an increase in nitrofurantoin (11.8%, p=0.170) and decrease in TMP/SMX prescribing (21.4%, p=0.006).There was a decrease in mean duration of antibiotic therapy prescribed by approximately 2 days (p=0.003). Inappropriate antibiotics for asymptomatic bacteriuria were given to 35.2% vs 20.7% of patients in the No-ASP and ED-ASP groups, respectively (p=0.045).

Conclusion: Implementation of a pharmacist-led ED ASP program significantly improved guideline-concordant prescribing for patients diagnosed with UTI and asymptomatic bacteriuria.