Emergency Department and Inpatient Use of Antibiotics

1. Emergency Department and Inpatient Use of Antibiotics Taylor C. Bear, MSIV Lora J. Stewart, MD Laura Eichhorn, MSIII John E. Duldner, MD Case Western Reserve University School of Medicine Northeastern Ohio Universities College of Medicine Akron General Medicine Center

2. Objective Describe antibiotic use in the emergency department and inpatient settings in patients diagnosed with meningitis.

3. Methods Study Design • 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

4. Methods Study Sample • 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

5. Methods Overall Study Objectives • Practice Patterns • Diagnosis and Treatment • Cost of Care • Mortality (Inhospital and 30-Day)

6. Background Types of Meningitis • 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

7. Results Demographics: Meningitis Distribution

8. Results Demographics: Gender Patients Type of Meningitis

9. Results Demographics: Race Patients Type of Meningitis

10. Results Demographics: Age Years Type of Meningitis

11. Results Antibiotics: Emergency Dept

12. Results First Antibiotic: Emergency Dept Patients Type of Antibiotic

13. Results Antibiotics: Additional Info • 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.

14. Results Antibiotics: First Dose Minutes 45-60 Min Type of Meningitis

15. Results Emergency Dept Disposition

16. Results Antibiotics: Inpatient

17. Results First Antibiotic: Inpatient Patients Type of Antibiotic

18. Results HIV (+) Positive 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.

19. Results Hospital Survival Rate Patients Type of Meningitis

20. Conclusions • 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.

21. Limitations • Limitations inherent in retrospective reviews. • Interpretive Bias • Confounding Factors (Missing Charts/Info) • Hospital Population vs. General Population • Data Collection Continues • Aseptic >>> Bacterial > Fungal

22. Acknowledgements • Foundation for Education and Research in Neurological Emergencies • Principal Investigator/Preceptor: John E. Duldner, Jr., MD