Among the busy halls of emergency departments nationwide, a silent battle against antimicrobial resistance is unfolding.
A recent analysis of more than 152 million ED visits nationwide found 27.6% resulted in inappropriate antibiotic prescribing. Of these, 54% had diagnoses for which antibiotics may have been wrongly prescribed, while 46% involved conditions unrelated to antibiotics, suggesting possible coding errors.
"Findings suggest that ED antibiotic stewardship initiatives should focus both on reducing antibiotic prescribing for infectious, antibiotic-inappropriate conditions and on improving coding quality for antibiotic prescriptions," researchers said.
Emergency department clinicians play an essential role in the fight against antimicrobial resistance, as antibiotics initiated during an ED visit are frequently continued throughout the patient's hospital stay, according to Anurag Malani, MD, medical director of hospital epidemiology, antimicrobial stewardship and special pathogens at Trinity Health Ann Arbor in Michigan.
Dr. Malani noted that ED providers face a challenging work environment where they must balance many priorities. However, he emphasized that antimicrobial resistance cannot fall by the wayside, as ED providers' care decisions significantly shape the directory of patients' care and directly affect the course of antibiotic resistance.
"They are busy, dealing with overcrowding and juggling many different things," he said. "But when antibiotics are initiated in the ED, they are often continued throughout the hospitalization."
Trinity Health Ann Arbor's antimicrobial stewardship team makes a conscious effort to involve ED providers in its committee meetings, guideline development efforts, and audit and feedback work when appropriate.
The antibiotic stewardship committee includes both an ED physician and a pharmacist who offer a valuable front-line perspective that helps mold initiatives and communications to ED teams, according to Dr. Malani.
Once a month, Dr. Malani also joins an ED physician, ED pharmacist, hospitalist, infectious disease pharmacist and data abstractor to review a group of medical cases in which all performance metrics were met, along with those that missed the mark as part of a state collaborative. Dr. Malani said incorporating ED clinicians in these discussions has given them a better understanding into why certain care decisions may have been made.
"To understand why [ED physicians] may do the things they do can be difficult, unless you are actually in their shoes," Dr. Malani said. "So that's actually been really helpful."
Once cases are reviewed and opportunities for improvement are identified, Dr. Malani often taps ED leaders to share the feedback with emergency medicine physicians.
"Sometimes that may be better received as it's coming from more of a peer," he said.
The benefits of a robust antimicrobial resistance program
While hospital executives often understand the importance of antimicrobial stewardship, it can be challenging to secure resources for it. At the same time, there is no winning formula or national standard for what antimicrobial stewardship programs should look like, which results in a good deal of variation both within and between systems.
Despite these challenges, the benefits of supporting robust antimicrobial stewardship programs are clear.
"I really think it's a win-win when you can improve the way we use antibiotics to optimize patient outcomes … and provide more cost-effective care to potentially get patients out earlier," Dr. Malani said. Antimicrobial stewardship also plays a key role in preventing healthcare-associated infections, which can cause worse outcomes and costly federal penalties for hospitals.
Moreover, health systems have a regulatory incentive to enhance their antimicrobial stewardship efforts. Starting in 2025, CMS is poised to require hospitals to report antimicrobial resistance rates separately from antimicrobial use, according to its Inpatient Prospective Payment System proposed rule released April 10. The proposed rule would require eligible hospitals to report data on both measures to the CDC's National Healthcare Safety Network as part of the Medicare Promoting Interoperability Program. The program encourages healthcare data exchange for public health purposes.
By endorsing these initiatives, hospital executives can improve care quality while simultaneously achieving cost savings and improving operational efficiency. This approach not only aligns with clinical goals but also supports the financial health of the institution, making it a strategic priority for hospital leadership.