Emergency Department and Impatient Use of Antibiotics

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Emergency Department and Inpatient Use of
Antibiotics
Taylor C. Bear, MSIV Lora J. Stewart, MD Laura
Eichhorn, MSIII John E. Duldner, MD
Case Western Reserve University School of
Medicine Northeastern Ohio Universities College
of Medicine Akron General Medicine Center
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Objective
Describe antibiotic use in the emergency
department and inpatient settings in patients
diagnosed with meningitis.
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Methods
Study Design

• Multihospital, Retrospective Review
• Akron Genernal Med Center, Akron, OH
• Community Health Partners, Lorain, OH
• MetroHealth Medical Center, Cleveland, OH
• Study Period January 1, 1996 to December 31,
  2000

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Methods
Study Sample

• N438
• Discharge ICD-9 diagnoses codes for bacterial,
  aseptic, and fungal meningitis (80 codes)
• Inclusion Criteria Clinical suspicion/laboratory
  confirmed diagnosis (CSF WBC gt5) of acute
  meningitis (lt2 wks duration)
• Exclusion Criteria 1. Trauma 2. CNS Malignancy
  3. Iatrogenic (i.e. ventricular-perotineal
  shunt) 4. Incomplete Documentation

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Methods
Overall Study Objectives

• Practice Patterns
• Diagnosis and Treatment
• Cost of Care
• Mortality (Inhospital and 30-Day)

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Background
Types of Meningitis

• Bacterial--Purulent infection within subarachnoid
  space that is followed by CNS inflammation.
• Most common etiologies--S. pneumoniae, N.
  meningitidis
• Aseptic--Clinical syndrome of meningeal
  inflammation in which common bacterial agents are
  not identified in CSF.
• Most common etiology--Enteroviruses
• Fungal

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Results
Demographics Meningitis Distribution
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Results
Demographics Gender
Patients
Type of Meningitis
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Results
Demographics Race
Patients
Type of Meningitis
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Results
Demographics Age
Years
Type of Meningitis
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Results
Antibiotics Emergency Dept
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Results
First Antibiotic Emergency Dept
Patients
Type of Antibiotic
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Results
Antibiotics Additional Info

• 35.5 (16/45) of patients with bacterial
  meningitis received a second antibiotic in the
  ED.
• 12 (46/389) of patients with aseptic meningitis
  received a second antibiotic in the ED.
• Vancomycin was the most common second antibiotic
  given in both groups.

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Results
Antibiotics First Dose
Minutes
45-60 Min
Type of Meningitis
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Results
Emergency Dept Disposition
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Results
Antibiotics Inpatient
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Results
First Antibiotic Inpatient
Patients
Type of Antibiotic
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Results
HIV () Positive Patients

• 4 (17/438) were HIV (). (10 Viral, 7 Fungal)
• 35 (6/17) received an antibiotic (5 Ceftriaxone,
  1 Ceftizoxime) the ED. (No difference in time
  to first antibiotic in HIV () patients.) No
  patient received an anti-fungal in the ED.
• 82 (14/17) received antibiotics as an inpatient.
• 41 (7/17) received an anti-fungal as an
  inpatient.

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Results
Hospital Survival Rate
Patients
Type of Meningitis
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Conclusions

• Although antibiotics are routinely prescribed in
  meningitis, time to first dose is inadequate.
• Ceftriaxone is the most commonly prescribed
  antibiotic in ALL meningitis types in ED and
  inpatient settings (EXCEPT inpatient fungal).
• Discrepancies between emergency dept and
  inpatient antibiotic use exist, particularly in
  HIV () patients.
• Survival rate for ALL meningitis types is
  EXCELLENT.

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Limitations

• Limitations inherent in retrospective reviews.
• Interpretive Bias
• Confounding Factors (Missing Charts/Info)
• Hospital Population vs. General Population
• Data Collection Continues
• Aseptic gtgtgt Bacterial gt Fungal

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Acknowledgements

• Foundation for Education and Research in
  Neurological Emergencies
• Principal Investigator/Preceptor John E.
  Duldner, Jr., MD