Current practices of antimicrobial stewardship in the emergency department: A cross-sectional study from a tertiary care centre in North India

Sir,

Antimicrobial stewardship (AMS) is defined as a co-ordinated set of interventions designed to measure and improve the appropriate use of antimicrobials by promoting the selection of the right drug, at the right dose, for the right duration, and administered by the right route. ¹ The growing need for AMS is backed up by the fact that 700,000 patients succumb to infections by drug-resistant organisms every year, making it one of the leading causes of mortality. ² The Emergency department (ED) is one of the first points of contact for many patients; their course of management through the ED therefore has wide-ranging implications. ³ About half of the top 10 causes of ED admissions are due to infection and of the empirical choices of antimicrobial therapy, 30–50% may be inappropriate. ⁴

In a cross-sectional observational study over 5 weeks in early 2022, we made observations from patients admitted to our ED; out of 73 (of whom, 70% were judged critically ill), an infective etiology was suggested clinically in two thirds and by routine laboratory parameters in one third, but microbiological evidence was found in only four. Three quarters of infections were community-acquired, with pneumonia being the most common (40%). Cultures or other microbiological tests were sent off in only 20%, and a rapid diagnostic test for malaria only in one. Of five blood cultures sent, four proved were positive, with two showing methicillin-resistant coagulase-negative Staphylococci, and one Serratia marcescens, and one Serratia marcesens, and Klebsiella pneumoniae each. On subsequent review of the appropriateness of antibiotic prescription, we found almost half to inappropriate. These were deemed inappropriate due to wrong indication (57.6%), inappropriate dosage (36.4%), improper escalation or de-escalation (30.3%), or incorrect route of administration (30.3%). Generating an ED specific antibiogram would aid in AMS.

In the presence of resource limitations, such an intervention will be difficult. A designated antibiotic stewardship team, strict adherence to guidelines, applying stringent infection control, and pursuing focused research on antibiotic resistance profiles will bring us a step closer to our goal.