Background: Emergency medicine physicians are among the top five specialties prescribing antibiotics. New accreditation standards for outpatient antimicrobial stewardship are now in effect, thus evaluation of antibiotic prescribing practices in the emergency department (ED) are needed. Upper respiratory infections (URI) have been shown to be a common culprit for inappropriate antibiotic use and are among the leading primary diagnoses seen at ED visits. We aimed to assess the management of URIs in the adult and pediatric EDs by diagnosis and provider type, in order to target interventions to improve use.
Methods: In this retrospective, single-center cohort study, we included adult and pediatric patients seen in the ED and discharged home from September 2015 through August 2017. Patients with one of eight ICD-10 primary diagnosis codes associated with URIs were included (Figure 1). The primary outcome was to evaluate prescriber compliance with guidelines for the treatment of URIs among our adult and pediatric ED departments. Secondary outcomes included assessment of patient outcomes (14-day hospital and clinic revisit rates) between the compliant and non-compliant cohorts, and a comparison of prescribing practices among prescriber types.
Results: A total of 1,646 adult ED encounters and 2,589 pediatric ED encounters were included, with overall 84.0% and 94.4% compliance, respectively. Among URIs, compliance rates were low for bronchitis in adult patients (68.3%) and tonsillitis in both the adult (44.3%) and pediatric patients (57.6%). No difference in outcomes, including 14-day hospital and clinic revisit rates, were observed between groups for both the adult (12.7% v. 14.8%, p=0.37) and pediatric (18.8% v. 17.9%, p=0.91) cohorts. Higher rates of non-compliance were seen in adult and pediatric physicians (37.5% and 10.3%) compared to corresponding advanced practice providers (14.9% and 9.6%) and residents (12.1% and 4.5%).
Conclusion: The ED provides care for a large number of patients with URIs and should be a focus for antimicrobial stewardship. To be most effective, future stewardship interventions in the ED should target physician groups, and bronchitis in adults and tonsillitis in all patients.
N. Dillman, None
P. Walker, None
J. Nagel, None