Antimicrobial Stewardship in Emergency Departments

Publication Date: July 17, 2024
Last Updated: July 18, 2024

Summary of Recommendations

Biomarkers

We suggest the use of procalcitonin in the ED to guide the initiation of antibiotics for patients with suspected LRTI who are likely to be admitted to the hospital. (C, M )
620
We suggest the use of procalcitonin in the ED to guide the initiation of antibiotics for patients with acute exacerbation of asthma who are likely to be admitted to the hospital. (C, L )
620
We suggest the use of procalcitonin in the ED to guide the initiation of antibiotics for patients with acute exacerbation of COPD who are likely to be admitted to the hospital. (C, M )
620
We suggest against the use of procalcitonin in the ED to guide the initiation of antibiotics for patients with dyspnea and suspected or known heart disease who are likely to be admitted to the hospital. (C, L )
620
We suggest against the use of procalcitonin based on the criterion of fever alone in patients in the ED to guide the initiation of antibiotics. (C, VL )
620
We suggest against the use of CRP in the ED to guide the initiation of antibiotics for patients with respiratory tract infections. (C, VL )
620

Rapid pathogen tests

We suggest against the use of rapid NAAT or rapid antigen tests for influenza to reduce the initiation of antibiotics in the ED. (C, L )
620
We suggest against the use of multiplex PCR for respiratory pathogens to reduce the initiation of antibiotics in the ED. (C, L )
620
We suggest against the routine use of urinary antigen testing for Streptococcus pneumoniae in patients with LRTI in the ED. (C, VL )
620
We suggest against the routine use of urinary antigen testing for Legionella pneumophila in patients with LRTI in the ED. (C, VL )
620
We suggest the use of urinary antigen testing for Legionella pneumophila in patients with LRTI in the ED with suspected legionellosis or in outbreak settings to guide the use of narrow-spectrum antibiotic therapy. (U, CC)
620
We suggest MRSA PCR for purulent skin and soft tissue infections in the ED to guide antibiotic therapy in setting with high prevalence of community-acquired MRSA. (C, VL )
620

Blood cultures

Community acquired pneumonia

We suggest against obtaining blood cultures routinely in patients presenting to the ED with a diagnosis of non-severe CAP. (C, L )
620
We suggest obtaining blood cultures in patients admitted with severe CAP, e.g., patients with PSI score IV or V or with indications for ICU admission. (U, CC)
620
We suggest obtaining blood cultures in patients admitted with CAP and risk factors for or initiated on therapy for unusual or resistant pathogens. (U, CC)
620
We suggest obtaining blood cultures in patients admitted with CAP and immunocompromised state. (U, CC)
620

Urinary tract infection with systemic symptoms

We suggest against obtaining blood cultures routinely in patients presenting to the ED with UTI with systemic symptoms without anatomical abnormalities of the urinary tract in whom a good quality urine sample for culture is available. (C, VL )
620
We suggest obtaining blood cultures in patients presenting to the ED with UTI with systemic symptoms and antibiotic pretreatment. (U, CC)
620
We suggest obtaining blood cultures in patients presenting to the ED with a chronic indwelling catheter and UTI with systemic symptoms. (U, CC)
620
We suggest obtaining blood cultures in immunocompromised patients presenting to the ED with UTI with systemic symptoms. (U, CC)
620

Skin and soft tissue infections

We suggest against routinely obtaining blood cultures in patients presenting to the ED with cellulitis/erysipelas. (C, VL )
620
We suggest obtaining blood cultures in immunocompromised patients presenting to the ED with cellulitis/erysipelas. (U, CC)
620
We suggest obtaining blood cultures in patients presenting to the ED with cellulitis/erysipelas in clinical situations associated with high risk of non-standard pathogens. (U, CC)
620
We suggest obtaining blood cultures in patients presenting to the ED with cellulitis/erysipelas who have an intravascular prosthesis, a pacemaker or a valvular prosthesis. (U, CC)
620

Watchful waiting/withholding antibiotic treatment

We recommend withholding antibiotics in patients presenting to the ED with LRTI and no clinical suspicion of pneumonia.

(S, M )
620
We suggest withholding antibiotics in patients presenting to the ED with non-severe acute exacerbation of COPD and low suspicion of bacterial pneumonia. (C, VL )
620
We suggest against withholding antibiotics in patients presenting to the ED with a provisional diagnosis of cystitis. (C, M )
620
We recommend withholding antibiotics in immunocompetent patients presenting to the ED with an uncomplicated diverticulitis. (S, M )
620
Clear instructions on self-monitoring of signs and symptoms and when to re-seek medical attention should be given to all patients with LRTI, acute exacerbation of COPD or uncomplicated diverticulitis, who are discharged from the ED without antibiotics. (U, CC)
620

Structured culture follow-up

We recommend a structured culture follow-up process/program after discharge from the ED.

(S, L )
620

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Antimicrobial Stewardship in Emergency Departments

Authoring Organization

European Society of Clinical Microbiology and Infectious Diseases

Publication Month/Year

July 17, 2024

Last Updated Month/Year

July 22, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

European

Document Objectives

This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D000073602 - Antimicrobial Stewardship

Keywords

Antibiotic Stewardship, Antimicrobial Stewardship

Source Citation

Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J, on behalf of the ESCMID Study Group for Antimicrobial Stewardship (ESGAP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for Antimicrobial Stewardship in Emergency Departments (endorsed by European Association of Hospital Pharmacists), Clinical Microbiology and Infection, https://doi.org/10.1016/j.cmi.2024.05.014