Impact of a Pharmacist-Led Emergency Department Urinary Tract Infection Aftercare Program
Background: Current evidence demonstrates that a significant proportion of prescriptions for antibiotics that originate from the emergency department (ED) are inappropriate. Urinary tract infections (UTIs) are a frequent indication for prescribing an antibiotic in the ED. The Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) piloted a pharmacist-led ED aftercare program to promote appropriate antimicrobial management of outpatient UTIs.
Methods: A single center, retrospective chart review included veterans discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital.
Results: Of 449 veterans with an index UTI ED aftercare follow-up, 200 patients were evaluated. A cystitis diagnosis was made for 132 patients (66.0%) and 121 (60.5%) were empirically prescribed ß-lactams. For 98 of 133 (73.6%) cases, appropriate empiric antibiotic selection led to no changes in index therapy. Sixty-seven cases required pharmacist intervention. Therapy modifications were made for 34 (17.0%) patients and 33 (16.5%) patients discontinued treatment. Discontinued therapy helped patients avoid 144 days of antibiotic exposure. Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days.
Conclusions: Implementation of a pharmacist-driven UTI ED aftercare program at a US Department of Veterans Affairs medical center reduced unnecessary antimicrobial exposure and improved antibiotic management of UTIs.
Results
A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.
The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).
Discussion
Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.6 The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.
Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.
Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.
While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.
