Impact of Pharmacist Led Culture Review in the Emergency Department for Discharged Patients Warranting Antimicrobial Regimen Modification

Background:Studies incorporating an emergency medicine pharmacist (EPh) into culture review in the emergency department (ED) have demonstrated stewardship benefits. This study aims to evaluate outcomes of an EPh-managed culture follow-up program for patients discharged from the ED.

Methods:This was a single center, retrospective, interventional study of patients discharged from the ED with urinary tract (UTIs) or skin-and-soft-tissue infections (SSTIs) warranting antimicrobial regimen modification. Eight-month time periods were compared before and after transition to an EPh-led culture follow-up. Primary outcome was number of antibiotic days of therapy prescribed. Secondary outcomes were appropriateness of therapy with respect to agent and duration of therapy, medication-related adverse events, and 30-day readmissions. Mann-Whitney U and chi-squared statistical tests were used to analyze primary and secondary outcomes, respectively.

Results: A total of 173 patients met study inclusion, 118 in the pre-EPh and 55 in the post-EPh group. The median number of antibiotic days prescribed for cystitis was 5 [5, 7] and 5 [3, 5] in the pre and post-EPh groups, respectively (p=0.014, Table 1). Although medians were equal, the result was significant due to overall shorter durations of antibiotic therapy prescribed in the post-EPh group. Similarly, median antibiotic days prescribed for pyelonephritis/complicated UTI (cUTI) was significantly reduced from 10 [7, 14] in the pre-EPh group to 7 [7, 10] days in the post-EPh group, p=0.034. Appropriate prescribing significantly increased from 71.2% to 85.5% of overall cases in the post-EPh group compared to the pre-EPh group, p=0.042. There was no difference in medication-related adverse events and 30-day readmissions.

Conclusion: Addition of a pharmacist to a culture follow-up program in the ED resulted in a decreased number of antibiotic days prescribed for discharged patients warranting antimicrobial regimen modification for UTIs and increased appropriate prescribing for UTIs and SSTIs. Table 1. Duration of antibiotic therapy in days.

Infection	Pre-EPh (n=118)		Post-EPh (n=55)		p-value
	No.	Median [IQR]	No.	Median [IQR]
Cystitis	65	5 [5, 7]	18	5 [3, 5]	0.014
Pyelonephritis/cUTI	28	10 [7, 14]	18	7 [7, 10]	0.034
SSTI	25	10 [7, 10]	19	7 [7, 10]	0.203