Emergency Department and Inpatient Use of
Antibiotics
Taylor C. Bear, MSIVLora J. Stewart, MD
Laura Eichhorn, MSIIIJohn E. Duldner, MD
Case Western Reserve University School of Medicine
Northeastern Ohio Universities College of Medicine
Akron General Medicine Center
Objective
Describe antibiotic use in the emergency department and inpatient settings in patients diagnosed with meningitis.
• 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
MethodsStudy Design
• N=438
• Discharge ICD-9 diagnoses codes for bacterial, aseptic, and fungal meningitis (80 codes)
• Inclusion Criteria: Clinical suspicion/laboratory confirmed diagnosis (CSF WBC >5) of acute meningitis (<2 wks duration)
• Exclusion Criteria: 1. Trauma 2. CNS Malignancy 3. Iatrogenic (i.e. ventricular-perotineal shunt) 4. Incomplete
Documentation
MethodsStudy Sample
• Practice Patterns
• Diagnosis and Treatment
• Cost of Care
• Mortality (Inhospital and 30-Day)
MethodsOverall Study Objectives
• 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
Background
Types of Meningitis
Results
Demographics: Meningitis Distribution
Results
Demographics: Gender
Patients
Type of Meningitis
Results
Demographics: Race
Patients
Type of Meningitis
Results
Demographics: Age
Years
Type of Meningitis
Results
Antibiotics: Emergency Dept
Results
First Antibiotic: Emergency Dept
Patients
Type of Antibiotic
• 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.
Results
Antibiotics: Additional Info
Results
Antibiotics: First Dose
Type of Meningitis
Minutes
45-60 Min
Results
Emergency Dept Disposition
Results
Antibiotics: Inpatient
Results
First Antibiotic: Inpatient
Type of Antibiotic
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.
Results
HIV (+) Positive Patients
Results
Hospital Survival Rate
Patients
Type of Meningitis
• 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.
Conclusions
• Limitations inherent in retrospective reviews.
• Interpretive Bias
• Confounding Factors (Missing Charts/Info)
• Hospital Population vs. General Population
• Data Collection Continues
• Aseptic >>> Bacterial > Fungal
Limitations
• Foundation for Education and Research in Neurological Emergencies
• Principal Investigator/Preceptor: John E. Duldner, Jr., MD
Acknowledgements
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