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