Appropriateness of antibiotic selection for pneumonia in the emergency department: pre- and post-order set changes.

OBJECTIVES: Emergency department (ED) providers face pressure to meet sepsis mandates such as prompt administration of antibiotic therapy, which can lead to the overuse of broad-spectrum antibiotics. In recent years, there has also been a push to adhere to institutional antibiotic stewardship goals including decreasing inappropriate antibiotic therapy and limiting duration of therapy. Previous literature has demonstrated that the incorporation of clinical decision support (CDS) tools in electronic medical records can aid in guiding appropriate antibiotic prescribing. Therefore, the objective of this study was to determine whether the implementation of a CDS tool could improve antibiotic selection for pneumonia management in the ED. METHODS: This was a retrospective single-centre observational study conducted in patients that presented to the ED with pneumonia. In November 2018, a CDS tool was incorporated into the ED sepsis order set to guide practitioners in selecting appropriate antibiotics for pneumonia. Antibiotic prescribing patterns were assessed pre-CDS (January-February 2018) and post-CDS (January-February 2019) implementation. Patients were included if they were 18 years of age or older, had an ED visit with ICD10 code reflective of pneumonia, and had at least one antibiotic ordered from the ED sepsis order set. The primary endpoint was the percentage of patients prescribed appropriate antibiotic therapy for pneumonia based on patient risk factors pre- and post-CDS implementation. KEY FINDINGS: There were 161 patients in the pre-CDS group and 119 patients in the post-CDS group included in the study. There was a significant improvement in the selection of appropriate antibiotics in the post-CDS group (31.9% versus 65.3%, P < 0.0001) with no significant differences in duration of antibiotics, intubation rates, vasopressor initiation, length of stay, mortality or 30-day readmission. CONCLUSION: The implementation of a CDS tool for empiric management of pneumonia in the ED significantly improved the selection of appropriate antibiotics.

Mastoiditis and meningitis complicating an aural foreign body.

Children commonly present to emergency departments with foreign bodies in the ear. In addition, physicians place wicks in the ear canal as part of the treatment of otitis externa. Usually, these foreign bodies are easily removed, but occasionally, removal must be deferred or is delayed by parents. Therefore, the dangers of retained foreign bodies are important for the emergency physician to be aware of. We report the highly unusual case of a 12-year-old girl who presented with ear pain for 3 weeks. She was found to have an ear wick in place as part of the treatment of otalgia. She was subsequently diagnosed with mastoiditis and meningitis. This is first time mastoiditis and meningitis has been reported as a complication of ear wick placement, although not the only case of an intracranial complication of an aural foreign body.