Antimicrobial stewardship in the emergency department: a prospective cohort study

Abstract

Antibiotic resistance is increasing globally. Implementing antibiotic stewardship programs (ASPs) to optimize the everyday use of antibiotics while preventing development and progression of resistance is of utmost importance. One of the most crucial points where the implementation of these programs can have a clinical impact is the emergency room, where often the antibiotic treatments are started. The evidence-based data concerning ASPs in the emergency room are scarce. In the following study, we implemented a 4-year non-restrictive, multi-faced ASP in the non-surgical emergency room at the university hospital of Tübingen, Germany. The study was divided in four phases (Prospective epidemiological and clinical data collection (Phase I, 2014); Prospective audit and feedback (Phase III, Jan- Dec 2016); Active infection diseases consultation service (Phase III, Jan – Dec 2016); Random audit and periodical feedback (Phase IV, Jan- Dec 2017)). Additionally we assessed the impact of an ASP on the length of stay (LOS) and incidence rate of clostridium difficile infections (CDI) as well as the mortality rate in the patients’ group admitted from ED to medical wards. The implementation of the ASP was linked to a reduction of antibiotic usage from 31.12. DDD/100PDs ((CI) 95% - 67,50 to 5,27, p 0,0092) at the beginng of phase II and a further reduction of 7.20 DDD/100 (CI 95% -40.94 to 26.54, p 0.669) at the beginning of phase III (table 2, figure 7). The cost was reduced by 691,5€/100PDs (SD: 263 EUROs/100 PDs) in phase I to 358.7€/100 PDs (SD: 189 €/100 PDs) in phase II, 262.5 €/100 PDs (SD: 162 €/100 PDs) in phase III and 263.3 €/100 PDs (SD: 162 €/100 PDs) in phase IV (p < 0.001). We also observed a non-significant yet sustained decline in LOS in all departments of the medical clinic (table 3) and a significant reduction of CDI-rates (table 4) while mortality did not significantly change (table 3). In conclusion, that implementation of an ASP has demonstrated to be feasible and safe and might clinically benefit the hospital admitted patients’ group. Further studies are required to identify the most beneficial ASP-design for emergency rooms and the key outcome measures to reliably assess its effectiveness.