Educational intervention to improve ceftriaxone prescription in an emergency department
Ceftriaxone overuse
Keywords:
Emergency Service, Hospital, Practice Patterns, Physicians', Ceftriaxone, Health Care Costs, Drug Resistance, Bacterial
Abstract
Objective: To evaluate the prevalence and appropriateness of ceftriaxone after an educational intervention in an emergency department.
Methods: Quasi-experimental study, which included a consecutive sampling of unscheduled consultations of adult patients, during 2 months pre-intervention and post-intervention. The intervention consisted of training physicians to limit its indication only to specific clinical situations (meningitis, pelvic inflammatory disease, and acute abdomen). Retrospective data were used, with additional manual chart review, to validate appropriateness of antibiotic initiation and drug appropriateness. Descriptive and analytical statistics were used.
Results: Among 28570 visits, 512 received ceftriaxone (1.79%; 95%CI 1.64-1.95), and only 60.54% were hospitalized. Regarding the before-after comparison, we observed a reduction in the rate of use (from 3.66% to 0.63%; p<0.001), the appropriateness in starting an antimicrobial was maintained (from 84.52% to 86.21%; p=0.778), and the appropriateness of ceftriaxone increased significantly (from 41.78% to 84.00% respectively; p<0.001). Additionally, hospital length of stay was reduced (median 6 to 5 days; p=0.014), with no difference in in-hospital mortality (19.44% vs 17.24%; p=0.691), nor in 30-day mortality (23.41% vs 18.96%; p=0.464).
Conclusions: This intervention was effective. These findings represent a fundamental step in programs to optimize the use of hospital antimicrobials, aimed at reducing their overuse and consequent resistance.
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References
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[23] Honda H, Murakami S, Tagashira Y, Uenoyama Y, Goto K, Takamatsu A, et al. Efficacy of a Postprescription Review of Broad-Spectrum Antimicrobial Agents With Feedback: A 4-Year Experience of Antimicrobial Stewardship at a Tertiary Care Center. Open Forum Infect Dis 2018;5:ofy314.
[24] Borde JP, Kern WV, Hug M, Steib-Bauert M, de With K, Busch H-J, et al. Implementation of an intensified antibiotic stewardship programme targeting third-generation cephalosporin and fluoroquinolone use in an emergency medicine department. Emerg Med J 2015;32:509–15.
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[27] Giunta DH, Pedretti AS, Elizondo CM, Grande Ratti MF, González Bernaldo de Quiros F, Waisman GD, et al. Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital. Rev Med Chil 2017;145:557–63.
[28] Gracia G, Ruiz VR, Martínez B, Grande-Ratti MF, Mayer GF. Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department. Enferm Clin 2022;32:279–83.
[2] García-Sánchez P, Del Pino-Bellido C, De Miguel-Cáceres C, Guijarro-Eguinoa FJ, Molina-Gutiérrez MÁ. Amoxicillin overdose in the pediatric emergency department: A descriptive study. Farm Hosp 2022;46:346–9.
[3] Muller A, Lopez-Lozano JM, Bertrand X, Talon D. Relationship between ceftriaxone use and resistance to third-generation cephalosporins among clinical strains of Enterobacter cloacae. J Antimicrob Chemother 2004;54:173–7.
[4] Jacobson KL, Cohen SH, Inciardi JF, King JH, Lippert WE, Iglesias T, et al. The relationship between antecedent antibiotic use and resistance to extended-spectrum cephalosporins in group I beta-lactamase-producing organisms. Clin Infect Dis 1995;21:1107–13.
[5] Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022;399:629–55.
[6] Thriemer K, Katuala Y, Batoko B, Alworonga J-P, Devlieger H, Van Geet C, et al. Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PLoS One 2013;8:e55495.
[7] Shimels T, Bilal AI, Mulugeta A. Evaluation of Ceftriaxone utilization in internal medicine wards of general hospitals in Addis Ababa, Ethiopia: a comparative retrospective study. Journal of Pharmaceutical Policy and Practice 2015;8.
[8] Pirmohamed M, Breckenridge AM, Kitteringham NR, Park BK. Adverse drug reactions. BMJ 1998;316:1295–8.
[9] Kaufman AJ, McCready J, Powis J. Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department. CJEM 2017;19:441–9.
[10] Oltra Hostalet F, Núñez-Núñez M, Portillo Cano MDM, Navarro Bustos C, Rodríguez-Baño J, Retamar Gentil P. Analysis of quality antimicrobial agent use in the emergency department of a tertiary care hospital. Emergencias 2018;30:297–302.
[11] Blomberg B, Manji KP, Urassa WK, Tamim BS, Mwakagile DSM, Jureen R, et al. Antimicrobial resistance predicts death in Tanzanian children with bloodstream infections: a prospective cohort study. BMC Infect Dis 2007;7:1–14.
[12] Ayele AA, Gebresillassie BM, Erku DA, Gebreyohannes EA, Demssie DG, Mersha AG, et al. Prospective evaluation of Ceftriaxone use in medical and emergency wards of Gondar university referral hospital, Ethiopia. Pharmacol Res Perspect 2018;6.
[13] Kizito M, Lalitha R, Kajumbula H, Ssenyonga R, Muyanja D, Byakika-Kibwika P. Antibiotic Prevalence Study and Factors Influencing Prescription of WHO Watch Category Antibiotic Ceftriaxone in a Tertiary Care Private Not for Profit Hospital in Uganda. Antibiotics 2021;10.
[14] Ramos Lázaro J, Smithson A, Jovè Vidal N, Batida Vila MT. Clinical predictors of ceftriaxone resistance in microorganisms causing febrile urinary tract infections in men. Emergencias 2018;30:21–7.
[15] Muhammed OS, Nasir BB. Drug Use Evaluation of Ceftriaxone in Ras-Desta Memorial General Hospital, Ethiopia. Drug Healthc Patient Saf 2020;12:161.
[16] Chiotos K, Han JH, Tamma PD. Carbapenem-Resistant Enterobacteriaceae Infections in Children. Curr Infect Dis Rep 2016;18:2.
[17] Heffernan AJ, Curran RA, Denny KJ, Sime FB, Stanford CL, McWhinney B, et al. Ceftriaxone dosing in patients admitted from the emergency department with sepsis. Eur J Clin Pharmacol 2021;77:207–14.
[18] Organización Mundial de la Salud (OMS). Es fundamental la implementación de Programas de Optimización de Antimicrobianos (PROA). Noviembre 2021. Disponible en: https://www.paho.org/es/noticias/17-11-2021-es-fundamental-implementacion-programas-optimizacion-antimicrobianos-proa (accessed April 6, 2023).
[19] Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543.
[20] Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:1–12.
[21] Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543.
[22] Adhikari S, Piza M, Taylor P, Deshpande K, Lam D, Konecny P. Sustained multimodal antimicrobial stewardship in an Australian tertiary intensive care unit from 2008-2015: an interrupted time-series analysis. Int J Antimicrob Agents 2018;51:620–8.
[23] Honda H, Murakami S, Tagashira Y, Uenoyama Y, Goto K, Takamatsu A, et al. Efficacy of a Postprescription Review of Broad-Spectrum Antimicrobial Agents With Feedback: A 4-Year Experience of Antimicrobial Stewardship at a Tertiary Care Center. Open Forum Infect Dis 2018;5:ofy314.
[24] Borde JP, Kern WV, Hug M, Steib-Bauert M, de With K, Busch H-J, et al. Implementation of an intensified antibiotic stewardship programme targeting third-generation cephalosporin and fluoroquinolone use in an emergency medicine department. Emerg Med J 2015;32:509–15.
[25] Davey P, Sneddon J, Nathwani D. Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Rev Clin Pharmacol 2010;3:667–86.
[26] UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018. GOVUK 2013. https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018 (accessed February 25, 2023).
[27] Giunta DH, Pedretti AS, Elizondo CM, Grande Ratti MF, González Bernaldo de Quiros F, Waisman GD, et al. Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital. Rev Med Chil 2017;145:557–63.
[28] Gracia G, Ruiz VR, Martínez B, Grande-Ratti MF, Mayer GF. Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department. Enferm Clin 2022;32:279–83.
Published
2023-07-24
How to Cite
Grande Ratti, M. F., Sanchez, M., Genoud, N., Arguello, F., Burokas, M. S., Staneloni, M. I., Martínez, B. J., & Nemirovsky, C. (2023). Educational intervention to improve ceftriaxone prescription in an emergency department. Actualizaciones En Sida E Infectología, 31(112). https://doi.org/10.52226/revista.v31i112.196
Section
Original article
