Much Smoke, No Fire Surrounding Inappropriate Antibiotic Use in the ED

Abstract & Commentary

Source: Lautenbach E, et al. Fluoroquinolone utilization in the emergency departments of academic medical centers. Arch Intern Med 2003;163:601-605.

The authors of this retrospective study attempted to evaluate the appropriateness with which emergency physicians prescribe fluoroquinolone (FQ) antibiotics. The records of 50 consecutive patients discharged with a FQ prescription at each of two affiliated emergency departments (EDs) were reviewed by members of the institutions’ infectious disease and pharmacy faculties. Appropriateness of FQ prescription was judged by the authors according to their own antibiotic utilization guidelines, which were distributed via pamphlets and available through the institutions’ computer network. Use of the FQ was considered appropriate if the guideline’s indications were met or if the patient had a contraindication to the recommended therapy.

Of the 100 prescriptions for a FQ, the authors judged 81 to have been inappropriate. Of these inappropriate cases, 43 did not utilize the institutions’ preferred antibiotic choice, 27 provided no evidence of infection based on the clinical evaluation or diagnostic studies, and 11 had inadequate documentation. The vast majority of inappropriate antibiotic use was for urinary tract infections (in which trimethoprim-sulfamethoxazole was recommended) and respiratory illnesses (preferred therapy not stated). The authors conclude that inappropriate FQ use in EDs is extremely common.

Commentary by David J. Karras, MD, FAAEM, FACEP

This article has created a minor stir in the world of infectious diseases. Even a cursory glance at the study, however, reveals extraordinary flaws both in its methodology and its premise, in which one illogical assumption is compounded upon the next. First, while the title and conclusions imply that the study examined practices at multiple EDs, the authors examined prescriptions only at two branches of the same ED system. Thirty-eight of the 81 presumptive designations of "inappropriate" antibiotic use were based on inadequate or incomplete information available to the authors. It’s important to note that the emergency physicians were not instructed in the use of the authors’ guidelines and were not constrained to adhere to them, yet were "tested" for consistency with their recommendations.

Most troubling is that the authors convinced themselves that inconsistency with their homegrown practice guidelines constitutes inappropriate prescribing behavior. Antimicrobial use recommendations published by established expert panels often conflict with one another and usually leave much to the discretion of the treating physician. The authors’ guidelines adhere to the most restrictive expert recommendations for FQ use in various illnesses. While a detailed review of appropriate FQ use is beyond the scope of this abstract, suffice it to say that the Infectious Disease Society of America finds FQ therapy to be appropriate for uncomplicated community-acquired pneumonia,1 and the Sanford Guide recommends FQ therapy as first-line treatment for uncomplicated pyelonephritis.2 Selection of an FQ for either of these conditions, however, is considered inappropriate by the study authors.

In summary, the authors’ desire to limit the use of FQ therapy in their institution does not, ipso facto, make its use inappropriate. Far better studies have documented that physicians in many specialties use antibiotics inappropriately. However, the attempt by these authors to point a finger at emergency physicians is undermined by a study in which the premise, methodology, and conclusions are best described as highly questionable.

Dr. Karras, Associate Professor of Emergency Medicine, Department of Emergency Medicine Temple University School of Medicine, Director of Emergency Medicine Research, Temple University Hospital, Philadelphia, PA, is on the editorial board of Emergency Medicine Alert.

References

1. Bartlett JG, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000;31:387-382.

2. Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy. Hyde Park, VT: Antimicrobial Therapy; 2003.