Association between emergency department sepsis order set design and delay to second dose piperacillin-tazobactam administration.

BACKGROUND: Delay to first antibiotic dose in patients with sepsis has been associated with increased mortality. Second dose antibiotic delay has also been linked to worsened patient outcomes. Optimal methods to decrease second dose delay are currently unclear. The primary objective of this study was to evaluate the association between updating an emergency department (ED) sepsis order set design from one-time doses to scheduled antibiotic frequencies and delay to administration of second piperacillin-tazobactam dose. METHODS: This retrospective cohort study was conducted at eleven hospitals in a large, integrated health system and included adult patients treated in the ED with at least one dose of piperacillin-tazobactam ordered through an ED sepsis order set over a two year period. Patients were excluded if they received less than two doses of piperacillin-tazobactam. Midway through the study period, the enterprise-wide ED sepsis order set was updated to include scheduled antibiotic frequencies. Two patient cohorts receiving piperacillin-tazobactam were compared: those in the year before the order set update and those in the year post-update. The primary outcome was major delay, defined as an administration delay >25% of the recommended dosing interval, which was evaluated with multivariable logistic regression and interrupted time series analysis. RESULTS: 3219 patients were included: 1222 in the pre-update group and 1997 in the post-update group. The proportion of patients who experienced major second dose delay was significantly lower in the post-update group (32.7% vs 25.6%, p < 0.01; adjusted OR 0.64, 95% CI 0.52 to 0.78). No between-group difference was detected in the slope of monthly major delay frequency, but there was a significant level change (post-update change -10%, 95% CI -17.9% to -1.9%). CONCLUSIONS: Including scheduled antibiotic frequencies in ED sepsis order sets is a pragmatic mechanism to decrease delays in second antibiotic doses.

Risk Factors for Trimethoprim and Sulfamethoxazole-Resistant Escherichia Coli in ED Patients with Urinary Tract Infections.

BACKGROUND: While trimethoprim-sulfamethoxazole (TMP-SMX) is recommended as one of the first-line empiric therapies for treatment of acute uncomplicated cystitis, institutions that observe resistance rates exceeding 20% for Escherichia coli (E. coli) should utilize alternative empiric antibiotic therapy per the Infectious Diseases Society of America (IDSA). Identifying risk factors associated with TMP-SMX resistance in E. coli may help guide empiric antibiotic prescribing for urinary tract infections (UTIs). METHODS: This multicenter, retrospective study included adult patients who were discharged from 12 emergency departments (EDs) with a urine culture positive for E. coli between January 1, 2019 and December 31, 2019. Logistic regression was used to assess the relationship between potential risk factors and TMP-SMX resistance. The overall institutional antimicrobial resistance rates for E. coli were compared to the rates seen in the study population of ED urinary isolates. RESULTS: Among 427 patients included from a randomized sample of 500 with a urine culture positive for E. coli, 107 (25.1%) were resistant to TMP-SMX. Three predictors of TMP-SMX resistance were identified: recurrent UTI (OR 2.27 [95% CI 1.27-3.99]), genitourinary abnormalities (OR 2.31 [95% CI 1.17-4.49]), and TMP-SMX use within 90 days (OR 8.77 [95% CI 3.19-28.12]). When the antibiotic susceptibilities for this ED cohort were compared to the institutional antibiogram, the TMP-SMX resistance rate was found to be higher in the ED population (25.1% vs 20%). CONCLUSIONS: TMP-SMX should likely be avoided as first-line therapy for UTI in patients who have recurrent UTIs, genitourinary abnormalities, or have previously received TMP-SMX within the past 90 days. The use of an ED-specific antibiogram should be considered for assessing local resistance rates in this population.