Improving urinary tract infection treatment through a multifaceted antimicrobial stewardship intervention in the emergency department.

BACKGROUND: Urinary tract infection (UTI) is frequently encountered in the emergency department (ED). We assessed an antibiotic stewardship intervention tailored for the ED. The primary objective was improving overall adherence to agent choice and treatment duration. The secondary objective was a decrease in fluoroquinolone prescription. METHODS: This pre-post study included patients discharged from the ED with a UTI diagnosis. The intensive intervention period lasted three months and involved dissemination of guidelines, short lectures, incorporation of order sets into electronic ED charts and weekly personal audit and feedback. The following 11-month phase was a booster period consisting of monthly text messages of the treatment protocol. Assessment of adherence to the protocol was compared between the three-month pre-intervention period and the last two months of the intensive intervention period, as well as with the last two months of the booster period. RESULTS: A total of 177 patients were included in the pre-intervention period, 156 in the intervention period, and 94 in the late follow-up assessing the booster period. Median age was 49 (18-94) years, 78.2% were female, 84.8% had cystitis. During the intervention period, protocol adherence with antibiotic selection and duration increased from 41% to 84% (p < 0.001). Adherence remained high in the late follow-up period (73.4% vs. 41%, p < 0.001). Fluoroquinolone use decreased from 19.1% pre-intervention, to 5% in the intervention and 7.4% in the late follow-up periods (p < 0.001). CONCLUSIONS: An antibiotic stewardship intervention in a busy ED resulted in adherence to treatment protocols, including a decrease in fluoroquinolone use. A monthly reminder preserved most of the effect for a year.

Will more restrictive indications decrease rates of urinary catheterisation? An historical comparative study.

OBJECTIVES: To determine if more restrictive indications for urinary catheterisation reinforced by daily chart review will lower catheterisation rates. DESIGN: An historical comparative observational study. SETTING: An internal medicine department in a regional hospital in Israel. PARTICIPANTS: The authors compared 882 patients hospitalised after a change in policy to an historical cohort of 690 hospitalised patients. Exclusions included patients less than age 30 and those with bladder outlet obstruction. INTERVENTION: Emergency and internal medicine department physicians received instruction on a more restricted urinary catheterisation policy. During daily chart rounds, admissions were discussed with an emphasis on the appropriateness of all new urinary catheter insertions. MAIN OUTCOME MEASURES: The primary outcome measure was catheterisation rate by admission diagnosis. Secondary outcome measures were the need for post-admission in hospital catheterisations and the rate of indwelling catheters 14 or more days after discharge. RESULTS: There was a reduction in catheterisation rate in patients with congestive heart failure from 30/106 (29.3%) to 3/107 (2.8%) (p<0.001), in patients with an admission diagnosis of fever unable to provide a urine sample for culture from 35/132 (26.5%) to 12/153 (7.8%) (p<0.001) and in patients admitted for palliative care from 51.7% (15/29) to 12.0% (3/25) (p=0.002). The overall rate of catheterisation decreased from 17.5% (121/690) to 6.6% (58/882) (p<0.001). There was only one indicated catheterisation after admission due to the change in policy, and the proportion of patients discharged with catheters decreased. CONCLUSION: The use of more restrictive indications for urinary catheterisation along with daily chart rounds can reduce the rate of urinary catheterisation in an internal medicine department without adverse consequences.

Increased emergency department chief complaints of fever identified the influenza (H1N1) pandemic before outpatient symptom surveillance.

OBJECTIVE: To determine whether a sentinel clinic network or an emergency department (ED) was more timely in identifying the 2009 influenza A (H1N1) pandemic. METHODS: All reasons for presenting to the adult regional medical ED were coded online by admission secretaries, without the aid of medical personnel. Increased influenza activity defined by weekly chief complaints of fever was compared with activity defined by the Israel Center for Disease Control (viral surveillance as well as a large sentinel clinic network). RESULTS: Influenza activity during the pandemic increased in the ED 2 weeks before outpatient sentinel clinics. During the pandemic, maximal ED activity was much higher than in previous seasons. Maximal activity during the past 5 years correlated with the timeliness of the chief complaint of fever in identifying the onset of epidemics. CONCLUSION: Chief complaint of fever in the ED can be a sensitive marker of increased influenza activity and might replace the use of sentinel clinics.

Rizatriptan RPD for severe migraine in the emergency department--a multicenter study.

Many patients with severe migraine come to the Emergency Department (ED) due to failure of different drug regimens to stop their headache. We treated 98 patients with severe migraine who were seen in three different EDs. We used rizatriptan RPD wafers 10 mg and observed the patients for 2 h. We found that at 2 h, 92.9% (91/98) of the patients had pain relief, and 73.5% were pain free. The mean time to pain relief was 26.9 +/- 29.6 min with a median of 15 min, and the time to pain free was 70.2 +/- 47.3 min with a median of 75 min. Eighty-five percent of the patients were free of associated symptoms, such as nausea and vomiting, at 2 h with a mean time to symptom free of 55 +/- 47.5 min and a median of 45 min. Rizatriptan was reported to be much better than other drugs by 74.4% of the patients. Side effects were minor and transient. Recurrence of migraine occurred part of the day in 17.1% of the patients and all day or almost all day in 8.6% of the patients only. The results were consistent in all three EDs. We conclude that rizatriptan RPD is very effective and reliable as a first-line therapy for acute migraine in the ED. It dissolves immediately in the mouth without the inconvenience of an injection. It works fast and has few side effects and low headache recurrence.