Antimicrobial Point Prevalence Survey in four Emergency Departments at Manchester University NHS Foundation Trust
Authors: Garraghan F M 
Published: November 2023

Introduction

Antimicrobial Point Prevalence Surveys (PPS) are a recognised tool to facilitate monitoring of compliance to an organisation’s antimicrobial stewardship (AMS) programme.1 Most PPS tools used within secondary care focus on prescribing of antimicrobials for in-patients. At Manchester University NHS Foundation Trust (MFT) PPS are carried out by clinical pharmacists across all inpatient ward areas. Antimicrobials are one of the most prescribed medicines in the emergency department2 (ED) yet, the current MFT PPS tool does not facilitate undertaking PPS in EDs. A new validated outpatient PPS tool3 from the Global Point Prevalence Survey (GPPS) was released earlier this year.

Aim

To pilot the GPPS outpatient tool in the EDs at MFT to determine the level of compliance with the MFT antimicrobial guidelines within the EDs, estimate the total burden of antimicrobial use and describe types of infections and prescribed antimicrobials within the EDs.

Methods

Following the GPPS outpatient protocol3 the four emergency departments (3 general EDs, and 1 paediatric ED) at MFT were assessed in a ten-day period during May 2023. Each ED was assessed continuously for a 4-hour timeslot on a weekday morning by an AMS pharmacist who retrieved the data from the EPIC electronic patient record system remotely. All patients who were allocated a room/bedspace on ED within the timeslot were audited, including patients who were not prescribed antimicrobials. Guideline compliance was checked with the MFT antimicrobial guidelines. The online GPPS data collection tool was used, generating a data download into an Excel spreadsheet for analysis. This study was a service evaluation and so did not require ethical approval.

Results

180 patients were audited from 4 EDs yielding a total of 41 prescriptions for antimicrobials. 28/180 patients were prescribed one or more antimicrobial, with an overall antimicrobial prescribing rate of 15.5%. Prescribing was higher in the paediatric ED with a rate of 25%.

92.7% (38/41) of antimicrobials were prescribed intravenously (IV). Choice of antimicrobial was compliant in 38/41 (92.7%). Dose was compliant in 40/41 (97.6%). Duration of treatment was compliant in 39/41 (95.1%). Sepsis accounted for 48.8% of indications. 2/41 prescriptions were based on the C Reactive Protein (CRP) biomarker.

Discussion/Conclusion

Whilst the study was only conducted over a short time period, the findings suggested that overall compliance with the MFT antimicrobial guidelines was very good. The prescribing rate of 15.5% was low in comparison to the recent MFT inpatient PPS which showed a prescribing rate of 30%. There is a high rate of diagnosis of sepsis and prescribing of IV antimicrobials in comparison to orals which may be anticipated in the emergency setting.

The GPPS outpatient audit tool provided an opportunity to do a baseline assessment within the EDs across MFT, providing data on prevalence of antimicrobial prescribing and compliance to the MFT guidelines. The GPPS audit tool did not have the utility to review the accuracy of clinical diagnosis of severe infection/sepsis within the ED, or the appropriateness of IV antimicrobial prescribing. Further research should be undertaken to provide assurance on the clinical diagnosis of severe infection and the appropriateness of IV antimicrobial prescribing with the EDs.

References

1. Public Health England. Start Smart then Focus. Antimicrobial Stewardship toolkit for English Hospitals. 2016.

2. Denny K, Appropriateness of antibiotic prescribing in the Emergency Department., JAC, 2019, vol 74 (2) P 515-520

3. Global Point Prevalence Survey, Outpatient module. https://www.global-pps.com/wp-content/uploads/2023/05/Protocol-Global-PPS-outpatient-module_April2023-final.pdf