User login
The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.1 According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.2 A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.3 The ED is a critical and high-yield space for antimicrobial stewardship efforts.4
Urinary tract infections (UTIs) are one of the most common reasons for ED visits.4 In 2018, there were about 3 million UTI discharge diagnoses reported in the US.5 Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.6 Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.6
Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.6 The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.7-13
Program Description
In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).
Methods
This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.
The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.
Results
A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.
The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).
Discussion
Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.6 The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.
Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.
Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.
While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.
Limitations
Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.
Conclusions
Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.
1. Marcozzi D, Carr B, Liferidge A, Baehr N, Browne B.. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv. 2018;48(2):267–288. doi:10.1177/0020731417734498
2. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2021. Updated October 4, 2022. Accessed May 22, 2024. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/antibiotic-use/data/report-2021.html
3. Timbrook TT, Caffrey AR, Ovalle A, et al. Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey. Infect Dis Ther. 2017;6(4):497-505. doi:10.1007/s40121-017-0175-9
4. Pulia M, Redwood R, May L. Antimicrobial stewardship in the emergency department. Emerg Med Clin North. 2018;36(4):853-872. doi:10.1016/j.emc.2018.06.012
5. Weiss A, Jiang H. Most frequent reasons for emergency department visits, 2018. December 16, 2021. Accessed May 22, 2024. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb286-ED-Frequent-Conditions-2018.pdf
6. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008;22(1):73-87. doi:10.1016/j.idc.2007.10.002
7. Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a multidisciplinary culture follow-up program of antimicrobial therapy in the emergency department. Infect Dis Ther. 2014;3(1):45-53. doi:10.1007/s40121-014-0026-x
8. Davis LC, Covey RB, Weston JS, Hu BB, Laine GA. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Syst Pharm. 2016;73(5 Suppl 1):S49-S56. doi:10.2146/sp150036
9. Lingenfelter E, Darkin Z, Fritz K, Youngquist S, Madsen T, Fix M. ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI. Am J Emerg Med. 2016;34(8):1600-1603. doi:10.1016/j.ajem.2016.05.076
10. Zhang X, Rowan N, Pflugeisen BM, Alajbegovic S. Urine culture guided antibiotic interventions: a pharmacist driven antimicrobial stewardship effort in the ED. Am J Emerg Med. 2017;35(4):594-598. doi:10.1016/j.ajem.2016.12.036
11. Percival KM, Valenti KM, Schmittling SE, Strader BD, Lopez RR, Bergman SJ. Impact of an antimicrobial stewardship intervention on urinary tract infection treatment in the ED. Am J Emerg Med. 2015;33(9):1129-1133. doi:10.1016/j.ajem.2015.04.067
12. Almulhim AS, Aldayyen A, Yenina K, Chiappini A, Khan TM. Optimization of antibiotic selection in the emergency department for urine culture follow ups, a retrospective pre-post intervention study: clinical pharmacist efforts. J Pharm Policy Pract. 2019;12(1):8. Published online April 9, 2019. doi:10.1186/s40545-019-0168-z
13. Stoll K, Feltz E, Ebert S. Pharmacist-driven implementation of outpatient antibiotic prescribing algorithms improves guideline adherence in the emergency department. J Pharm Pract. 2021;34(6):875-881. doi:10.1177/0897190020930979
14. Petty LA, Vaughn VM, Flanders SA, et al. Assessment of testing and treatment of asymptomatic bacteriuria initiated in the emergency department. Open Forum Infect Dis. 2020;7(12):ofaa537. Published online November 3, 2020. doi:10.1093/ofid/ofaa537
15. Ingalls EM, Veillette JJ, Olson J, et al. Impact of a multifaceted intervention on antibiotic prescribing for cystitis and asymptomatic bacteriuria in 23 community hospital emergency departments. Hosp Pharm. 2023;58(4):401-407. doi:10.1177/00185787231159578
16. Daniel M, Keller S, Mozafarihashjin M, Pahwa A, Soong C. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178(2):271-276.doi:10.1001/jamainternmed.2017.7290
The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.1 According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.2 A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.3 The ED is a critical and high-yield space for antimicrobial stewardship efforts.4
Urinary tract infections (UTIs) are one of the most common reasons for ED visits.4 In 2018, there were about 3 million UTI discharge diagnoses reported in the US.5 Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.6 Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.6
Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.6 The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.7-13
Program Description
In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).
Methods
This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.
The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.
Results
A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.
The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).
Discussion
Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.6 The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.
Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.
Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.
While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.
Limitations
Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.
Conclusions
Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.
The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.1 According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.2 A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.3 The ED is a critical and high-yield space for antimicrobial stewardship efforts.4
Urinary tract infections (UTIs) are one of the most common reasons for ED visits.4 In 2018, there were about 3 million UTI discharge diagnoses reported in the US.5 Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.6 Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.6
Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.6 The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.7-13
Program Description
In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).
Methods
This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.
The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.
Results
A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.
The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).
Discussion
Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.6 The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.
Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.
Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.
While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.
Limitations
Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.
Conclusions
Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.
1. Marcozzi D, Carr B, Liferidge A, Baehr N, Browne B.. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv. 2018;48(2):267–288. doi:10.1177/0020731417734498
2. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2021. Updated October 4, 2022. Accessed May 22, 2024. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/antibiotic-use/data/report-2021.html
3. Timbrook TT, Caffrey AR, Ovalle A, et al. Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey. Infect Dis Ther. 2017;6(4):497-505. doi:10.1007/s40121-017-0175-9
4. Pulia M, Redwood R, May L. Antimicrobial stewardship in the emergency department. Emerg Med Clin North. 2018;36(4):853-872. doi:10.1016/j.emc.2018.06.012
5. Weiss A, Jiang H. Most frequent reasons for emergency department visits, 2018. December 16, 2021. Accessed May 22, 2024. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb286-ED-Frequent-Conditions-2018.pdf
6. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008;22(1):73-87. doi:10.1016/j.idc.2007.10.002
7. Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a multidisciplinary culture follow-up program of antimicrobial therapy in the emergency department. Infect Dis Ther. 2014;3(1):45-53. doi:10.1007/s40121-014-0026-x
8. Davis LC, Covey RB, Weston JS, Hu BB, Laine GA. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Syst Pharm. 2016;73(5 Suppl 1):S49-S56. doi:10.2146/sp150036
9. Lingenfelter E, Darkin Z, Fritz K, Youngquist S, Madsen T, Fix M. ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI. Am J Emerg Med. 2016;34(8):1600-1603. doi:10.1016/j.ajem.2016.05.076
10. Zhang X, Rowan N, Pflugeisen BM, Alajbegovic S. Urine culture guided antibiotic interventions: a pharmacist driven antimicrobial stewardship effort in the ED. Am J Emerg Med. 2017;35(4):594-598. doi:10.1016/j.ajem.2016.12.036
11. Percival KM, Valenti KM, Schmittling SE, Strader BD, Lopez RR, Bergman SJ. Impact of an antimicrobial stewardship intervention on urinary tract infection treatment in the ED. Am J Emerg Med. 2015;33(9):1129-1133. doi:10.1016/j.ajem.2015.04.067
12. Almulhim AS, Aldayyen A, Yenina K, Chiappini A, Khan TM. Optimization of antibiotic selection in the emergency department for urine culture follow ups, a retrospective pre-post intervention study: clinical pharmacist efforts. J Pharm Policy Pract. 2019;12(1):8. Published online April 9, 2019. doi:10.1186/s40545-019-0168-z
13. Stoll K, Feltz E, Ebert S. Pharmacist-driven implementation of outpatient antibiotic prescribing algorithms improves guideline adherence in the emergency department. J Pharm Pract. 2021;34(6):875-881. doi:10.1177/0897190020930979
14. Petty LA, Vaughn VM, Flanders SA, et al. Assessment of testing and treatment of asymptomatic bacteriuria initiated in the emergency department. Open Forum Infect Dis. 2020;7(12):ofaa537. Published online November 3, 2020. doi:10.1093/ofid/ofaa537
15. Ingalls EM, Veillette JJ, Olson J, et al. Impact of a multifaceted intervention on antibiotic prescribing for cystitis and asymptomatic bacteriuria in 23 community hospital emergency departments. Hosp Pharm. 2023;58(4):401-407. doi:10.1177/00185787231159578
16. Daniel M, Keller S, Mozafarihashjin M, Pahwa A, Soong C. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178(2):271-276.doi:10.1001/jamainternmed.2017.7290
1. Marcozzi D, Carr B, Liferidge A, Baehr N, Browne B.. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv. 2018;48(2):267–288. doi:10.1177/0020731417734498
2. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2021. Updated October 4, 2022. Accessed May 22, 2024. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/antibiotic-use/data/report-2021.html
3. Timbrook TT, Caffrey AR, Ovalle A, et al. Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey. Infect Dis Ther. 2017;6(4):497-505. doi:10.1007/s40121-017-0175-9
4. Pulia M, Redwood R, May L. Antimicrobial stewardship in the emergency department. Emerg Med Clin North. 2018;36(4):853-872. doi:10.1016/j.emc.2018.06.012
5. Weiss A, Jiang H. Most frequent reasons for emergency department visits, 2018. December 16, 2021. Accessed May 22, 2024. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb286-ED-Frequent-Conditions-2018.pdf
6. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008;22(1):73-87. doi:10.1016/j.idc.2007.10.002
7. Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a multidisciplinary culture follow-up program of antimicrobial therapy in the emergency department. Infect Dis Ther. 2014;3(1):45-53. doi:10.1007/s40121-014-0026-x
8. Davis LC, Covey RB, Weston JS, Hu BB, Laine GA. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Syst Pharm. 2016;73(5 Suppl 1):S49-S56. doi:10.2146/sp150036
9. Lingenfelter E, Darkin Z, Fritz K, Youngquist S, Madsen T, Fix M. ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI. Am J Emerg Med. 2016;34(8):1600-1603. doi:10.1016/j.ajem.2016.05.076
10. Zhang X, Rowan N, Pflugeisen BM, Alajbegovic S. Urine culture guided antibiotic interventions: a pharmacist driven antimicrobial stewardship effort in the ED. Am J Emerg Med. 2017;35(4):594-598. doi:10.1016/j.ajem.2016.12.036
11. Percival KM, Valenti KM, Schmittling SE, Strader BD, Lopez RR, Bergman SJ. Impact of an antimicrobial stewardship intervention on urinary tract infection treatment in the ED. Am J Emerg Med. 2015;33(9):1129-1133. doi:10.1016/j.ajem.2015.04.067
12. Almulhim AS, Aldayyen A, Yenina K, Chiappini A, Khan TM. Optimization of antibiotic selection in the emergency department for urine culture follow ups, a retrospective pre-post intervention study: clinical pharmacist efforts. J Pharm Policy Pract. 2019;12(1):8. Published online April 9, 2019. doi:10.1186/s40545-019-0168-z
13. Stoll K, Feltz E, Ebert S. Pharmacist-driven implementation of outpatient antibiotic prescribing algorithms improves guideline adherence in the emergency department. J Pharm Pract. 2021;34(6):875-881. doi:10.1177/0897190020930979
14. Petty LA, Vaughn VM, Flanders SA, et al. Assessment of testing and treatment of asymptomatic bacteriuria initiated in the emergency department. Open Forum Infect Dis. 2020;7(12):ofaa537. Published online November 3, 2020. doi:10.1093/ofid/ofaa537
15. Ingalls EM, Veillette JJ, Olson J, et al. Impact of a multifaceted intervention on antibiotic prescribing for cystitis and asymptomatic bacteriuria in 23 community hospital emergency departments. Hosp Pharm. 2023;58(4):401-407. doi:10.1177/00185787231159578
16. Daniel M, Keller S, Mozafarihashjin M, Pahwa A, Soong C. An implementation guide to reducing overtreatment of asymptomatic bacteriuria. JAMA Intern Med. 2018;178(2):271-276.doi:10.1001/jamainternmed.2017.7290