Infectious disease/concepts
A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies

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Background

Antimicrobial resistance is a mounting public health concern. Antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase–producing organisms have emerged and expanded their presence from health care settings to the community.1, 2, 3 Inappropriate antimicrobial use has been described as the most important preventable cause of drug resistance in both hospital and community settings.4, 5, 6, 7 Estimated rates of inappropriate and unnecessary

Importance

EDs represent a critical setting for initiating interventions that could reduce inappropriate antibiotic prescribing. As ED clinicians, we routinely prescribe antimicrobials to patients for a variety of conditions, including skin and soft-tissue infections, urinary tract infections, bloodstream infections, and upper and lower respiratory tract infections. Because EDs sit at the interface of the inpatient and outpatient settings, ED practitioners have the unique opportunity to affect

Challenges to Antimicrobial Stewardship in the ED Setting

There is a set of distinct challenges associated with providing systematic education and oversight for antimicrobial stewardship in the ED setting, including high rates of ED crowding,24 rapid rate of patient turnover, the need for quick decisionmaking usually without consultation, and the large and varied mix of providers who work in a shift-based scheduling format, with relatively high rates of staff turnover versus other clinical settings.25 Specific barriers to implementing other public

ED Approaches to Antimicrobial Stewardship

In this concept article, we review antimicrobial stewardship strategies, lessons learned from the literature in other settings, and existing clinical practice guidelines. The discussion includes critical interpretation of the findings or recommendations in relation to ED practice and is followed by a general set of recommendations for decreasing unnecessary antibiotic use in ED settings. The factors important in translating antimicrobial stewardship interventions to the ED are drawn both from

Conclusions

Globally, clinicians practicing in ED settings must acknowledge and address the increasing problem of antimicrobial resistance stewardship, which requires that EDs take an active role in designing and systematically studying strategies to improve antimicrobial stewardship in these settings. Because not all antimicrobial stewardship strategies are applicable to the ED, programs must be developed through partnership between the ED and other key stakeholders, including local communities,

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    Publication date: Available online November 2, 2012.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Drs. May and Talan report receiving research support from Cepheid. Dr. Cosgrove reports receiving an unrestricted grant from AdvanDx. Dr. Rothman reports serving as a one-time consultant for an expert panel for Forest Research Institute and reports receiving grant funding for research from IBIS (now Abbott Biosciences) and Cepheid. This research was supported by award numbers UL1TR000075 and KL2TR000076 from the NIH National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.

    Supervising editors: Kathy J. Rinnert, MD, MPH; Donald M. Yealy, MD

    A podcast for this article is available at www.annemergmed.com.

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