Programas de optimización del uso de antimicrobianos en los servicios de urgencias españoles: Estudio PROA-URG / Antibiotic stewardship programs in the Spanish emergency services: PROA-URG Study

Introducción: Los programas de optimización de antimicrobianos (PROA) son herramientas clave en la adecuación de estos fármacos. La información disponible sobre la aplicación e indicadores para monitorizar estos programas en urgencias es limitada. El objetivo del estudio es conocer el grado de implantación de programas PROA en los servicios de urgencias, así como el uso de antimicrobianos en estas unidades. Material y métodos. Estudio multicéntrico retrospectivo. Se envió una invitación a todos los participantes del grupo de trabajo de farmacéuticos de urgencias REDFASTER-SEFH. Se utilizó un cuestionario de 21 ítems, contestado por un equipo formado por especialistas en los servicios de farmacia hospitalaria, urgencias, enfermedades infecciosas y microbiología. Resultados. 18 hospitales completaron la encuesta. Catorce (77,8%) disponían de un responsable PROA en la unidad. El valor de DDD por 1000 ingresos osciló entre 36,5 y 400,5 (mediana 100,4 [RIQ:57,2-157,3]). El grupo de carbapenémicos y macrólidos presentó una amplia variabilidad. Únicamente seis (33,3%) hospitales disponían de informe anual de resistencias específico para urocultivos y hemocultivos en urgencias. El porcentaje de multirresistentes en urocultivos fue del 12,5% y en hemocultivos del 12,2%. El porcentaje de adecuación en bacteremia de acuerdo con el resultado del hemocultivo fue del 81,0% (RIQ:74,6-85,0%), y en infección urinaria del 78,0% (RIQ:71,5-88,0%). Conclusiones. Pese a la existencia de responsables PROA, actividades formativas y guías de tratamiento en urgencias, la información sobre el uso de antimicrobianos y el perfil de resistencias en estas unidades es limitado. Futuras actividades han de ir encaminadas a mejorar la información sobre los resultados PROA propios para estas unidades. (AU)

Introduction: Antimicrobial stewardship programs (ASP) have become a key tool in the adaptation of these drugs to the health system. The information available on the application and indicators used in these programs in emergency departments is scarce. The objective of this study is to know theextent of ASP implementation in the emergency departments, as well as the use of antimicrobials in these units. Material and methods. Multicenter retrospective study. An invitation was sent to all participants of the REDFASTER-SEFH emergency pharmacist working group. A questionnaire was used consisting of 21 items, answered by a team made up of a pharmacist, emergency room specialist, infectious disease specialist and microbiologist. Results. Eighteen hospitals completed the survey. Fourteen (77.8%) had an ASP manager. The DDD value per 1000 admissions ranged between 36.5 and 400.5 (median: 100.4 [IQR:57.2-157.3]). Both carbapenem and macrolide group presented wide variability in use. Six (33.3%) hospitals had an annual report on the specific resistance profile for urine and blood cultures. The percentage of multi-drug resistant strains in urine cultures was 12.5% and in blood cultures 12.2%. The percentage of adequacy in the bacteremia treatment was 81.0% (IQR:74.6-85.0%), while in urinary tract infections was 78.0% (IQR:71.5-88.0). Conclusions: Despite the existence of ASP members in emergency services, as well as the training activity and local guidelines is common. knowledge of the use of antimicrobials and resistances is limited. Future activities must be aimed at improving information about the ASP results in these units. (AU)

Utilidad de los diagnósticos alertantes CIE-10 para identificar acontecimientos adversos por los medicamentos en los servicios de urgencias / Usefulness of ICD-10 diagnosis triggers to identify adverse drug events in emergency care

Objetivos: Evaluar la utilidad de una herramienta basada en los códigos diagnósticos CIE-10 para identificar a los pacientes que consultan a un servicio de urgencias por acontecimientos adversos por medicamentos (AAM). Métodos: Estudio observacional prospectivo, en el cual se incluyeron los pacientes que acudieron a un servicio de urgencias durante el periodo de mayo-agosto de 2022 con un diagnóstico codificado con alguno de los 27 diagnósticos CIE-10 establecidos como alertantes para el estudio. La confirmación de la presencia de AAM a partir de dichos diagnósticos se realizó analizando los fármacos prescritos previamente al ingreso, a través de un debate entre expertos y mediante una entrevista telefónica con los pacientes. Resultados: Se evaluaron 1.143 pacientes con diagnósticos alertantes, de los cuales 310 (27,1%) correspondieron a pacientes cuya consulta se atribuyó a un AAM. El 58,4% de los AAM se detectaron mediante 3 códigos diagnósticos: K59.0-Estreñimiento (n = 87; 28,1%), I16.9-Crisis hipertensiva (n = 72; 23,2%) e I95.1-Hipotensión ortostática (n = 22; 7,1%). Los códigos diagnósticos con mayor grado de asociación con AAM fueron: E16.2-Hipoglucemia no especificada (73,7%) y E11.65-Diabetes mellitus tipo 2 con hiperglucemia (71,4%), mientras que los diagnósticos D62-Anemia poshemorrágica aguda e I74.3-Embolia y trombosis de arterias de los miembros inferiores no identificaron ningún AAM. Conclusiones: Los códigos CIE-10 asociados a diagnósticos alertantes son una herramienta de utilidad para identificar a los pacientes que consultan los servicios de urgencias por AAM y podrían ser utilizados para abordar las intervenciones de prevención secundaria dirigidas a evitar nuevas consultas al sistema sanitario. (AU)

Objectives: To assess the usefulness of a tool based on ICD-10 diagnostic codes to identify patients who consult an emergency department for adverse drug events (ADE). Methods: Prospective observational study, in which patients discharged from an emergency department during May to August 2022 with a diagnosis coded with one of the 27 ICD-10 diagnoses considered as triggers were included. ADE confirmation was carried out by analyzing drugs prescribed prior to admission, and through a discussion among experts and a phone interview with patients after hospital discharge. Results: 1,143 patients with trigger diagnoses were evaluated, of which 310 (27.1%) corresponded to patients whose emergency visit was attributed to an ADE. A 58.4% of ADE consultations were found with three diagnostic codes: K59.0-Constipation (n = 87; 28.1%), I16.9-Hypertensive Crisis (n = 72; 23.2%) and I95.1-Orthostatic hypotension (n = 22; 7.1%). The diagnoses with the highest degree of association with consultations attributed to ADE were E16.2-Hypoglycemia, unspecified (73.7%) and E11.65-Type 2 diabetes mellitus with hyperglycemia (71.4%), while diagnoses D62-Acute posthemorrhagic anemia and I74.3-Embolism and thrombosis of arteries of the lower limbs were not attributed to any case of ADE. Conclusions: The ICD-10 codes associated with trigger diagnoses are a useful tool to identify patients who consult the emergency services with ADE and could be used to apply secondary prevention programs to avoid new consultations to the health care system. (AU)

[Translated article] Usefulness of ICD-10 diagnostic triggers to identify adverse drug events in emergency care.

OBJECTIVES: To assess the usefulness of a tool based on ICD-10 diagnostic codes to identify patients who consult an emergency department for adverse drug events (ADE). METHODS: Prospective observational study, in which patients discharged from an emergency department during May to August 2022 with a diagnosis coded with one of the 27 ICD-10 diagnoses considered as triggers were included. ADE confirmation was carried out by analyzing drugs prescribed prior to admission, and through a discussion among experts and a phone interview with patients after hospital discharge. RESULTS: 1143 patients with trigger diagnoses were evaluated, of which 310 (27.1%) corresponded to patients whose emergency visit was attributed to an ADE. A 58.4% of ADE consultations were found with three diagnostic codes: K59.0-Constipation (n = 87; 28.1%), I16.9-Hypertensive Crisis (n = 72; 23.2%) and I95.1-Orthostatic hypotension (n = 22; 7.1%). The diagnoses with the highest degree of association with consultations attributed to ADE were E16.2-Hypoglycemia, unspecified (73.7%) and E11.65-Type 2 diabetes mellitus with hyperglycemia (71.4%), while diagnoses D62-Acute posthemorrhagic anemia and I74.3-Embolism and thrombosis of arteries of the lower limbs were not attributed to any case of ADE. CONCLUSIONS: The ICD-10 codes associated with trigger diagnoses are a useful tool to identify patients who consult the emergency services with ADE and could be used to apply secondary prevention programs to avoid new consultations to the health care system.

Anticholinergic burden and revisit risk in frail patients with pharmacological sleepiness.

OBJECTIVE: Drug-induced sleepiness is a frequent cause of emergency department (ED) visits for frail patients. The aim of this study was to assess the impact of anticholinergic burden on 90-day revisitation risk for frail patients who visit the ED due to drug-induced sleepiness. METHODS: This was a retrospective study in which patients treated at a fragility care area of an ED who sought consultation for drug-associated sleepiness from June 2020 to June 2021 were included. To evaluate the 90-day revisitation risk factors, a multivariate analysis was performed, including those factors with a p<0.200 from a previous univariate model. A Cox regression model was performed to assess the impact of a high burden on the time until 90-day ED revisitation. RESULTS: One hundred and forty-eight patients were included (mean age 80.7±12.3 years). The median number of drugs that patients were currently on at emergency admission was eight (range 2-19), while at hospital discharge it was nine (range 2-20), with the median number of central nervous system (CNS) depressant drugs on admission being three (range 1-6). Thirty-five (23.6%) patients revisited the ED 90 days after discharge for sleepiness or agitation. In the multivariate model, a significant association was observed between a high anticholinergic burden during treatment at discharge (OR 3.74, 95% CI 1.36 to 9.71), chronic kidney disease (OR 2.87, 95% CI 1.19 to 6.81), and the risk of 90-day revisitation. Patients with high anticholinergic burden had a shorter time to revisit than those with medium or low anticholinergic burden (HR 1.96, 95% CI 1.05 to 3.99). CONCLUSIONS: Patients with pharmacological sleepiness and a high anticholinergic burden in their chronic treatment carry a greater risk of revisitation to EDs, and should be considered candidates for specific interventions after visiting these units.

Cost-effectiveness analysis of implementing a secondary prevention programme in those patients who visited an emergency department for drug-related problems.

OBJECTIVE: To evaluate the cost-effectiveness of a secondary prevention programme in patients admitted to the emergency department due to drug-related problems (DRPs). METHODS: A decision model compared costs and outcomes of patients with DRPs admitted to the emergency department. Model variables and costs, along with their distributions, were obtained from the trial results and literature. The study was performed from the perspective of the National Health System including only direct costs. KEY FINDINGS: The implementation of a secondary prevention programme for DRPs reduces costs associated with emergency department revisits, with an annual net benefit of €87 639. Considering a mortality rate attributable to readmission of 4.7%, the cost per life-years gained (LYG) with the implementation of this programme was €2205. In the short term, the reduction in the number of revisits following the programme implementation was the variable that most affected the model, with the benefit threshold value corresponding to a relative reduction of 12.4% of the number of revisits of patients with DRPs to obtain benefits. CONCLUSIONS: Implementing a secondary prevention programme is cost-effective for patients with DRPs admitted to the emergency department. Implementation costs will be exceeded by reducing revisits to the emergency department.

Cefepime Dosing Requirements in Elderly Patients Attended in the Emergency Rooms.

OBJECTIVE: This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room. METHODS: Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals. RESULTS: One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30-60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study. CONCLUSIONS: Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.

Risk factors for emergency department revisit in elderly patients with gastrointestinal bleeding secondary to anticoagulant therapy.

OBJECTIVE: To evaluate the frequency of emergency department (ED) revisits among elderly patients with gastrointestinal bleeding secondary to anticoagulant treatment and identify factors associated with an increased risk of ED revisits. METHODS: A 3-year retrospective observational study was designed, including elderly patients (≥65 years) with atrial fibrillation and undergoing oral anticoagulation therapy who visited the ED for gastrointestinal bleeding. To evaluate the risk factors for 30-day revisit, a multivariate analysis was designed including comorbidities, concomitant treatment, change in anticoagulant treatment and prescription of direct-acting oral anticoagulants. RESULTS: 80 patients were included. At discharge, anticoagulation therapy was modified in 21 (26.2%) patients; and changed from an oral anticoagulant to heparin in 17 (21.2%) patients and to another oral anticoagulant in 4 (5.0%) patients. Anticoagulant treatment was withdrawn in 5 (6.3%) patients at discharge. Eleven (13.7%) patients revisited the ED 30 days after hospital discharge for bleeding episodes. No differences in the frequency of revisit to the ED were observed in the patients who changed their anticoagulant treatment at discharge. In the multivariate analysis, chronic kidney disease was the only factor significantly associated with revisits at 30 days. CONCLUSIONS: Elderly patients who experience a first episode of gastrointestinal bleeding have a high risk of revisiting the ED for a bleeding episode, with no particular differences between the types of anticoagulant prescribed at discharge.