709820

research-article2017
AOPXXX10.1177/1060028017709820Annals of PharmacotherapyLosier et al

Review Article
Annals of Pharmacotherapy

A Systematic Review of Antimicrobial

1­–17
© The Author(s) 2017
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DOI: 10.1177/1060028017709820
https://doi.org/10.1177/1060028017709820

Emergency Department journals.sagepub.com/home/aop

Mia Losier1, Tasha D. Ramsey, PharmD1,2,

Kyle John Wilby, PharmD3, and Emily K. Black, PharmD1

Abstract
Background/Objective: To improve antimicrobial utilization, development and implementation of antimicrobial
stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review
was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes
or process of care and/or reduce consequences of antimicrobial use. Methods: This study was completed as a systematic
review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative
Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized
controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-
measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other
than English were excluded. Results: A total of 43 studies meeting inclusion criteria were identified from our search. Patient
or provider education and guideline or clinical pathway implementation were the most commonly reported interventions.
Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed
variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a
decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias. Conclusion:
AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear.
Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit
and feedback are needed.

Keywords
antibiotics, emergency medicine, antibiotic resistance, antiviral, antifungal

Introduction organisms.10 Effective interventions within ASPs, including

Background
Resistance of bacteria known to cause commonly observed
infections has been reported worldwide.1 Increasing resis-
tance has been recognized as a growing health threat.2
Infections caused by resistant organisms have resulted in
increased mortality and length of hospital stay as well as
other consequences that have a considerable cost to both
individual patients and society.1-3 Use of antimicrobial
agents, whether appropriate or inappropriate, is contribut-
ing to increasing rates of resistance.4,5
Antimicrobial stewardship programs (ASPs) have been rec-
ommended as a method of enhancing appropriate use of antimi-
preauthorization (requiring approval for select antimicrobial
agents before prescribing)7 and decreased use of broad-spec-
trum antimicrobials following allergy assessment, have been
shown to reduce antimicrobial use, resulting in cost savings.7
Importance
The vast majority of literature focuses on ASPs in the inpa-
tient setting with limited guidance for ASPs in the emergency
1DalhousieUniversity, Halifax, NS, Canada
2Nova Scotia Health Authority, Halifax, NS, Canada
3Qatar University, Doha, Qatar

crobials and combat resistance.6,7 ASPs have resulted in

Corresponding Author:
improvement in patient care, including fewer adverse drug reac- Emily K. Black, College of Pharmacy, Dalhousie University, 5968 College
tions, a reduction in duration of antimicrobial therapy,8,9 and a Street, PO Box 15000, Halifax, NS B3H 4R2, Canada.
decrease in infections caused by resistant and hospital-acquired Email: Emily.Black@dal.ca
2 Annals of Pharmacotherapy 00(0)
department (ED). However, antimicrobial use in this popula-
tion is common. Infections are one of the most frequent rea-
sons for patients presenting to the ED11 and often result in
antimicrobial prescribing. It is estimated that approximately
15.7% of patients are discharged home from the ED with an
antimicrobial prescription.12 Additionally, anti-infectives are
the drug class most often implicated in medication-related ED
visits, accounting for approximately 25% of these visits.13,14
Understandably, development of an ASP in the ED has been
recommended to optimize antimicrobial use in this setting,
both on initial presentation and at transition of care.15 Despite
recognition of the need for stewardship in the ED, ASPs in
this setting are considered a neglected topic, and the preferred
combination of interventions and required resources, includ-
ing personnel to promote appropriate antibiotic use in the ED
is unknown.16
Goals of This Investigation
The primary objective of this systematic review is to charac-
terize antimicrobial stewardship (AMS) interventions in the
ED and to identify stewardship initiatives that result in
decreased consequences of antimicrobial use (eg, Clostridium
difficile infection, antimicrobial resistance) and improvement
of patient outcomes. The secondary objectives of this study
are to determine the impact of pharmacist participation in
antimicrobial interventions alone or as part of a multidisci-
plinary team in the ED and to identify facilitators and barriers
to implementation of ASPs in the ED.
Methods
To meet the study objectives, a systematic review was com-
pleted. Because of variability in study design, implemented
interventions, outcome measures, and patient population
results were summarized descriptively.
Information Source and Search Strategy
The following databases were searched from inception to
July 2015: MEDLINE (1946 to July 2015), EMBASE
(1974 to July 2015), Cumulative Index to Nursing and
Allied Health Literature (CINAHL; 1981 to July 2015),
Web of Science (1990 to July 2015), and Scopus (1823 to
July 2015). In November 2016, the search was updated in
all databases. In addition, the original search was rescreened
for interventions recommended by the newly published
2016 Infectious Diseases Society of America (IDSA) ASP
implementation guidelines, and the search term preauthori-
zation was added to the original search. The search was
completed by a professional librarian with experience pro-
viding library support to health professions. Coinvestigators’
personal electronic libraries and references of retrieved full-
text studies were also hand searched to identify studies that
may have been missed in the electronic search. A broad and
comprehensive search using terms that combined AMS or
quality improvement/program implementation, and ED
with terms for antimicrobial agents was completed. Search
terms are summarized in the appendix. No limits were
applied.
Inclusion and Exclusion Criteria
The criteria for study design and main outcome measures
were based on the Cochrane Effective Practice and
Organisation of Care (EPOC) reviews.17 Included study
designs were randomized controlled trials, nonrandomized
controlled trials, controlled before-after studies, interrupted
time series studies, and repeated-measures studies.
Uncontrolled before-after studies were also included because
there is a paucity of research on AMS in the ED, with the
majority of studies completed as uncontrolled before-after
studies. Full text manuscripts, short reports or letters to the
editor, and conference proceedings were considered for
inclusion.
Included AMS interventions were those recommended by
the 2007 IDSA development guidelines.6 In addition, inter-
ventions for implementation and optimization of ASPs out-
lined and the 2016 IDSA implementation guidelines were
considered for inclusion.7 Specific interventions considered
for inclusion in this review were the following: prospective
audit with intervention and feedback, preauthorization, for-
mulary restriction, education, guidelines and clinical path-
way implementation, use of antimicrobial order forms,
streamlining or de-escalation of therapy, dose optimization,
parenteral to oral conversion, targeting patients with specific
infections or high-risk antimicrobial agents, prescriber-led
review of appropriateness of antibiotic regimens, use of com-
puterized decision support, pharmacokinetic monitoring and
adjustment program, and allergy assessment.6,7 Strategies to
improve culture review and discharge follow-up were also
included as an intervention of interest as recommended by
May et al15 in their call to action for AMS in the ED.15
Microbiology and laboratory diagnostic interventions were
excluded from our study.
Outcomes of interest considered for inclusion in this
review were as follows: patient outcomes (mortality,
adverse events, rates of Clostridium difficile infections,
rates of resistance to antimicrobials, adherence, and patient
satisfaction); quality of care outcomes (adherence to clini-
cal practice guidelines, and rate of inappropriate antibiotic
prescribing); utilization outcomes (overall frequency of
patients prescribed an antibiotic, defined daily dose, days of
therapy, and length of therapy); and resource use outcomes
(readmission rates, length of hospitalization, and cost).
Studies were excluded if they were completed outside
the ED or did not report on the specific impact of interven-
tions in the ED setting, were descriptive reports, did not
Losier et al 3
evaluate an intervention of interest or report on an outcome
of interest, and were studies that reported solely on time to
antibiotic administration or impact of sepsis bundles.
Articles in languages other than English were excluded on
full-text screening.
Study Selection and Data Extraction
Two investigators with advanced training in pharmacother-
apy and critical appraisal (EKB and KJW) and 1 pharmacy
student (ML) independently screened all titles and abstracts
retrieved through the search. Full-text articles of identified
abstracts that met inclusion criteria were obtained for fur-
ther consideration of eligibility. Any disagreement arising
during eligibility assessment was resolved through discus-
sion. In the event that consensus was not achieved, a fourth
study investigator (TDR) reviewed the abstract/full text in
question and provided a final recommendation.
After retrieving full-text articles for included studies, 2
research investigators (EKB and TDR) independently
extracted data using a developed data extraction form,
which was adapted from EPOC to meet study objectives.17
The variables extracted from each manuscript were the fol-
lowing: study characteristics, including design, characteris-
tics of study participants, type of intervention, member of
the health care team that delivered the intervention, type of
outcome measures, results for each outcome measure, and
sources of funding. Our protocol outlined procedures for
contacting original corresponding authors of articles for
further information as needed to ensure complete data
extraction. After reviewing published studies, additional
contact was deemed necessary to clarify the practice setting
of 1 study.18 Any disagreements during data extraction were
discussed and, if necessary, reviewed by a third investigator
(KJW).
Assessment of Bias
Bias of each included study was independently critically
appraised and assessed by 2 investigators (EKB, KJW, or
TDR) using the risk of bias criteria for EPOC reviews.17 In
the event that disagreement arose and consensus could not
be achieved, a third investigator completed the assessment
of bias and provided input. Overall risk of bias was sum-
marized for the primary outcome or outcome of interest
within the study.
Results
A total of 4425 studies were initially screened after dupli-
cates were removed by title and abstract. In November
2016, the literature search was updated and an additional
1453 studies were screened after removing duplicates by
title and abstract. Following the application of inclusion and
exclusion criteria, 43 studies met criteria and were included
in the systematic review (Figure 1). The majority of studies
had an uncontrolled before-and-after design (n = 36). There
were 16 discrepancies in bias assessment; however, consen-
sus was achieved after discussion between reviewers in all
cases. Most studies were rated as having unclear or high
risk of bias. Studies were rated as having unclear risk of
bias if lack of details in study design limited our ability to
assess. The most common reason for listing a study as hav-
ing unclear risk of bias was absence of information on other
interventions or initiatives that may have been implemented
concurrently, leading to change in outcomes. Tables 1, 2,
and 3 summarize details of included studies.
Antimicrobial Stewardship Interventions
The most common interventions described were patient or pro-
vider education and guideline or clinical pathway implementa-
tion alone or in combination with other interventions.19-47 A
number of these studies found a significant improvement in
surrogate outcomes such as adherence to guidelines or appro-
priateness of antimicrobial prescribing26,28,32,35,36,38,42,43,45-47
and decreased antimicrobial use.21,24,30,44,45 Five studies evalu-
ating implementation of guidelines or clinical pathways
alone19,20 or in combination with education28,40 or monitoring
and feedback33 demonstrated statistically significant improve-
ments in clinical outcomes, including hospital length of
stay,19,20,28,40 ED length of stay,33 admission of low risk patients
to hospital,20 admission to the intensive care unit,28 readmis-
sion to ED,28,40 and mortality.28
Only 5 studies described provider audit and feedback
alone or in combination with other AMS interven-
tions.26,33,47-49 One additional study reported providing “per-
sonalized prescriber feedback.”45 Appropriateness of
antimicrobial prescribing and adherence to guidelines sig-
nificantly increased26,45,47-49 and antimicrobial use
decreased.45,49 Hecker et al49 evaluated audit and feedback
in combination with implementation of an electronic order
set and found no significant decrease in treatment failures
or adverse events. Akenroye et al33 failed to find a signifi-
cant reduction in rates of admission or ED return visits.
However, ED length of stay and cost were significantly
reduced when providing education, implementing guide-
lines, and providing monitoring and feedback for infants
with bronchiolitis. Preauthorization was not found to be an
intervention in the ED ASP trials identified. One study
reported on formulary restriction and showed a significant
reduction in ciprofloxacin use.50
Only 2 randomized controlled trials (RCTs) met inclu-
sion criteria. Marrie et al20 evaluated the impact of imple-
menting a critical care pathway on management of CAP as
compared with conventional management in 19 teaching
and community hospitals in Canada. Results demonstrated
a decrease in use of health care resources as outlined in
4 Annals of Pharmacotherapy 00(0)
Figure 1.  Study selection.
Table 2.20 A second RCT by Metlay et al25 evaluated the
impact of implementing an educational program for health
care providers and patients at 16 hospitals in the United
States. The educational intervention focused on promoting
appropriate antibiotic use for acute respiratory tract infec-
tions. One-on-one, small, or large group educational ses-
sions were delivered to clinicians. The educational
presentation included aggregate site-specific data on antibi-
otic use at their site, and they were benchmarked with other
sites. The patient educational intervention included printed
material and a computerized educational module available
in ED waiting rooms. Intervention sites demonstrated a
reduction in antimicrobial use for management of acute
respiratory tract infections (Table 2).
Pharmacist Involvement
Pharmacist involvement was explicitly described in 13
studies.26,27,32,35,36,49,51-57 The remainder of the studies
primarily involved ED physicians and nurses or provided
insufficient details on which ED providers were involved in
the intervention. The most common intervention that
included pharmacist participation was culture review and
follow-up for patients discharged from the ED27,51,53-57 and
education.26,32,35,36 Of the 8 studies that evaluated the impact
of improving the culture and review process for patients
discharged from the ED,18,27,51,53,54,56,57 7 compared pharma-
cist-managed or facilitated culture review and follow-up
with other health care providers.27,51,53-57 Randolph et al51
found a significant decrease in readmission rates within 96
hours with culture review and follow-up by a pharmacist in
consultation with the ED physician compared with a physi-
cian alone. Baker et al27 demonstrated a significant improve-
ment in time to review and patient notification when
pharmacists provided education to providers and partici-
pated in culture review and follow-up. Pharmacist involve-
ment in the culture review and follow-up process also
resulted in an increase in appropriate prescribing and an
Losier et al 5

Table 1.  Summary of Interventions.

Number of Outcomes With a Statistically Significant Change

Type of Intervention Included Studies From Baseline (n = number of studies)
Guideline or clinical 13 •• Increase in appropriate antibiotic prescribing (n = 4)28,32,40,43
pathway implementation ± •• Decrease in antimicrobial use (n = 3)21,30,44
education19-22,28-30,32,37,40,41,43,44 •• Decrease in ED or hospital length of stay (n = 4)19,20,28,40
•• Decrease in hospital admission or increased discharge from
ED (n = 2)20,28
•• ED readmission within 30 days (n = 2)28,40
•• 30-Day mortality (n = 1)28
Multifaceted 12 •• Increase in appropriate antibiotic prescribing (n = 4)35,36,45,52
intervention18,23,24,26,33,35,36,39,45,47,49,52 •• Increased adherence to guidelines (n = 4)26,36,47,49
•• Decrease in antimicrobial use (n = 4)18,24,45,49
•• Decrease in ED length of stay (n = 1)33
•• Time to follow-up after ED discharge (n = 1)18
•• Total cost per patient (n = 1)33
Culture review and follow-up ± 7 •• Increase in appropriate antibiotic prescribing or frequency of
education27,51,53-57 intervening when antibiotic was inappropriate (n = 3)53,56,57
•• ED readmission within 96 hours (n = 1)51
•• Time to follow-up after ED discharge (n = 1)27
Clinical decision support ± 6 •• Increase in appropriate antibiotic dosing (n = 2)38,46
education38,42,46,58-60 •• Increased adherence to guidelines (n = 3)42,58,59
Education alone25,31,34 3 •• Decrease in antimicrobial use (n = 1)25
Prospective audit and feedback 1 •• Increase in appropriate antibiotic prescribing (n = 1)48
alone48
Formulary restriction50 1 •• Decrease in antimicrobial use (n = 1)50

Abbreviation: ED, emergency department.

increase in frequency of intervening for inappropriate ther-
apy.53,56,57 Two studies showed no significant difference in
pharmacist-managed culture review and follow-up com-
pared with that of other health care providers for appropri-
ateness of therapy, ED revisits, and readmission.54,55
Facilitators and Barriers
Few studies discussed facilitators and barriers to imple-
menting AMS interventions. A study by Demonchy et al58
evaluating the impact of a computer decision support sys-
tem on compliance with guidelines for urinary tract infec-
tions highlighted acceptability of guidelines as the main
barrier resulting in differences between participating EDs.
Strategies to facilitate successful implementation of this
intervention by the authors of the study included multidisci-
plinary involvement, respect for professional autonomy,
timely availability at point of care and during decision mak-
ing, integration of intervention into workflow, automatic
initiation of the intervention tailored to patient data, and
short duration of use.58 Although most studies did not spe-
cifically comment on facilitators or barriers, the need for
additional resources was identified through our literature
search. The most commonly reported additional resources
were personnel, including dedicated ID specialists, pharma-
cists, nurses, specialists in informatics, and AMS teams for
the ED,18,19,24,26,27,32,35,36,47-49,51-58 and use of information
technology (IT), including computerized order entry, elec-
tronic medical records, computer decision support, and
automated dispensing cabinets.18,35,38,42,46,49,52,54,59,60
Discussion
The growing role of AMS in the ED is seen in the number
of trials and variety of interventions identified in the litera-
ture. ASPs are recommended in the ED to encourage appro-
priate use of antimicrobial agents because infections are a
common reason for presentation to the ED and antimicrobi-
als are frequently prescribed on discharge.11,12,15 To foster
program success, AMS interventions require customization
to the local needs, prescriber behavior, barriers, and
resources of the ED.7
Interventions identified in our review have a few distinc-
tions from the IDSA ASP development and implementation
guideline recommendations.6,7 Despite core recommenda-
tions for preauthorization and prospective audit and feedback
in ASPs, none of the trials described preauthorization, and
only 6 of the 43 trials assessed some form of audit and/or
feedback to providers. This is not surprising given that chal-
lenges to implementing these interventions in the ED setting
exist. Barriers to implementing AMS interventions as high-
lighted by May et al15 in their call to action, which may limit
6
Table 2.  Full Texts and Short Reports.
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Clinical pathway or guideline implementation with or without education

Benenson Before-and-after To assess impact of
et al, study implementing a clinical
1999 19 pathway for pneumonia
on time to antibiotic
administration, treatment of
patients in the ED, length of United States
stay, and mortality
Marrie et al, Randomized To assess the impact of a
200020 controlled trial critical care pathway on
management of CAP
Smabrekke Controlled before- To reduce the proportion
et al, and-after study of patients with AOM
200221 receiving an antibiotic and
to increase the relative use
of penicillin V
Diaz et al, Before-and-after To assess the impact of
200422 study implementing guidelines for
diagnosis and treatment of
pharyngitis
Julian-Jimenez Before-and-after To determine the impact of
et al, study implementing guidelines
201328 for CAP on discharge or
admission, appropriateness
of antibiotics, ED length of
stay, readmission rates, and
mortality
Adults with Clinical pathway development Physicians and Preintervention vs postintervention 1 (10-12 months Dedicated High
pneumonia admitted and implementation. nurses postimplementation) vs postintervention 2 (34-36 nurse
to the ED at a large Monitoring of antibiotic months postimplementation)
community teaching therapy by a clinical pathway • Length of stay (days)
hospital in the nurse   ○  9.7 vs 8.9 vs 6.4 (P < 0.0001)
• Mortality
  ○  9.6% vs 5.2% vs 4.9% (P = 0.42)
Adults with CAP Implementation of a clinical Nurses and Difference between critical pathway and conventional N/A Low
presenting to the pathway to manage CAP physicians management
ED at teaching • Change in Short Form 36 physical component
hospitals in Canada summary scale 6 weeks after completing antibiotics
  ○  2.4 points (NS)
Critical pathway vs conventional management
• Median length of stay (days)
  ○  5.0 vs 6.7 (P = 0.01)
• Number of bed days per patient managed
  ○  4.4 vs 6.1 (P = 0.04)
• Overall hospital admission
  ○  53% vs 63% (P = 0.11)
• Admission of low-risk patients
  ○  31% vs 49% (P = 0.01)
Children with AOM Provider and patient Patients, nurses, Preintervention vs postintervention N/A High
presenting to EDs in educational intervention and physicians • Proportion receiving an antibiotic
Norway (presentation to health   ○  Control site: 95% vs 91% (P = 0.5)
care providers, pamphlets   ○  Intervention site: 90% vs 74% (P < 0.01)
in waiting room, and verbal • Proportion receiving penicillin V
follow-up to patients) and   ○  Control site: 68% vs 78% (P = 0.09)
guideline implementation   ○  Intervention site: 72% vs 85% (P < 0.01)
Children with sore Provider education and Nurses and Preintervention vs postintervention N/A Unclear
throat at a children’s pathway implementation physicians • Appropriateness of treatment
teaching hospital in   ○  44% vs 91%
the United States
Adults with CAP Guideline implementation and Physicians Preintervention vs postintervention N/A High
at a tertiary-level provider education • Appropriate choice of antibiotic
hospital in Spain   ○  60.4% vs 95.5% (P < 0.001)
• Appropriate dose and route
  ○  57.1% vs 95.5% (P < 0.001)
• Antibiotic duration (days)
  ○  11.8 vs 10.4 (P < 0.001)
• Readmission to ED within 30 days
  ○  28.6% vs 4.5% (P = 0.01)
• Hospital length of stay (days)
  ○  8.7 vs 7.6 (P = 0.01)
• Discharged from the ED
  ○  36.5% vs 19.5% (P < 0.001)
• Observe and discharge from the ED
  ○  9% vs 16% (P = 0.033)
• Admission to ward
  ○  36.5% vs 37.5% (NS)
• Admission to ICU
  ○  6% vs 12% (P = 0.020)
• 30-Day mortality
  ○  15% vs 8.5% (P = 0.044)
(continued)
 Table 2. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Johnson et al, Before-and-after To assess the impact of Children (<2 years National guideline Specific Preintervention vs postintervention N/A Unclear
201329 study developing and releasing of age) with development and publication providers not • Received an antibiotic
national bronchiolitis bronchiolitis from targeted   ○  33.6% vs 29.7% (P = 0.51)
guidelines on care of the National
children in the ED Hospital Ambulatory
Medical Care Survey
in the United States
Angoulvant Before-and-after To evaluate the impact of Children with acute Development and Physicians Preintervention vs postintervention N/A Unclear
et al, study national guidelines on respiratory tract implementation of local • Amoxicillin prescriptions
201430 antibiotic prescribing for infections at 7 EDs guidelines based on national   ○  34% vs 84.7%
acute respiratory tract in France guidelines for acute • Amoxicillin-clavulanate prescriptions
infections respiratory tract infections   ○  43.0% vs 10.2%
in France • Cefpodoxime prescriptions
  ○  16.6% vs 2.5%
• Proportion prescribed an antibiotic
  ○  26.0% vs 24.2% (P < 0.0001)
Landry et al, Before-and-after To develop, implement, and Adults with a UTI Development of an Physicians, Preintervention vs postintervention ED pharmacist High
201432 study evaluate an algorithm for in the ED of an algorithm for treatment of nurses, and • Adherence of empirical prescribing to best practice
management of UTIs in academic tertiary uncomplicated UTIs and pharmacists   ○  41% vs 66% (P < 0.001)
the ED care center in implementation through
Canada education of prescribers
Powell et al, Before-and-after To assess the impact of Children receiving Guideline and order template Physicians Preintervention vs postintervention N/A High
201537 study guideline and order vancomycin at implementation • Vancomycin utilization
set implementation on a pediatric ED   ○  4% vs 3% (NS)
vancomycin use and and subsequently • Appropriateness of vancomycin by diagnosis
appropriateness of therapy admitted to hospital   ○  98% vs 99% (NS)
in the United States • Appropriateness of vancomycin dose
  ○  100% In both groups
Multifaceted interventions
Burchett Before-and-after To improve the process of Children with Using the Plan-Do-Study-Act Physicians, nurse Preintervention vs postintervention Dedicated High
et al, study providing urine culture symptoms of a UTI cycle multiple interventions, practitioners, • Time to follow-up (hours) providers
201518 follow-up from EDs in the including creation of a physician   ○  20.1 vs 7.1 (P = 0.003) to complete
United States 2-hour designated culture assistants • Discontinuation of unnecessary antibiotic use in culture
follow-up shift, implementing patients with negative urine cultures follow-up, IT
an e-prescribing system,   ○  8.8% vs 74.4% (P < 0.001) support
including preferred
pharmacies on patient
profile, staff training, and
implementation of clinical
care guidelines
Woolley Before-and-after To assess the impact of Adults presenting to Education and dissemination Physicians Preintervention vs postintervention N/A Unclear
et al, study introducing guidelines on an ED at a teaching of Centor scoring system • Inappropriate antibiotic prescribing
200523 clinical practice hospital in the and integration into ED   ○  44% vs 11%
United Kingdom guidelines • Correct antibiotic choice
with sore throat,   ○  60% vs 100%
pharyngitis, and
tonsillitis

(continued)

7
8
Table 2. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Borde et al Before-and-after To investigate intervention- Patients with most Guideline revision of most Physicians Consumption (DDD/100 patient-days) Dedicated ID Unclear
201524 study with ITS related effects at frequent infections frequent infections, • Overall antibiotic use specialist
analysis reducing third-generation at an academic education by ID specialist,   ○  7% Relative reduction (P = 0.24)
cephalosporin and teaching hospital and intensified ID • Third-generation cephalosporins
fluoroquinolone use and tertiary referral consultations, print and   ○  68% Relative reduction (P < 0.001)
center in Germany electronic access to • Fluoroquinolones
recommendations   ○  22% Relative reduction (P < 0.05)
McIntosh Before-and-after To improve use of the Adults with CAP at Drug use evaluation (review, Physicians, Concordant antibiotic therapy AMS team Unclear
et al, study pneumonia severity Australian hospitals feedback, and educational nurses, and • Audit 1 (baseline) = 20%; audit 2 = 30% (P < member to
201126 assessment tool and intervention) pharmacists 0.0001); and audit 3 = 29% (P = 0.0009) complete
concordance with antibiotic audit and
prescribing guidelines provide
feedback and
education
Akenroye Before-and-after Reduce unnecessary resource Infants with Development and Physicians • Administration of antibiotic N/A Unclear
et al, with ITS analysis utilization and improve the bronchiolitis at a implementation of   ○  −4% (95% CI = −9.0 to 0.7)
201433 value of care tertiary, university- bronchiolitis guideline • Rates of admission
affiliated pediatric with provider education,   ○  0.8% (95% CI = −2.0 to 3.0)
hospital in the monitoring, and feedback • ED return visits within 72 hours
United States   ○  −1.1% (95% CI = −3.9 to 1.7)
• ED length of stay
  ○  −41 minutes (95% CI = −16 to −65 minutes)
• Mean cost per patient
  ○  −$197 (95% CI = −$136 to −$259)
Buising et al, Before-and-after To assess the impact of Adults diagnosed with Academic detailing (one- Physicians and Baseline vs postintervention 1 (academic detailing) vs Computer High
200835 study with ITS an AMS intervention on CAP in an ED at an on-one education and pharmacists postintervention 2 (computer decision support) decision
analysis prescribing urban adult tertiary distribution of educational • Appropriateness of empirical antibiotics support,
hospital in Australia material) and a computerized   ○  61.9% vs 68.7% (P < 0.01) vs 89.7% (P = 0.01) academic
decision support system • Median length of stay (days) detailing
  ○  4 vs 4 vs 4 (P = 0.93) team
• Patients who received an antibiotic with known
allergy
  ○  26.2% vs 26.1% (P = 0.99) vs 14.3% (P = 0.33)
• Average cost of antibiotics per patient
  ○  $72.07 vs $94.47 vs $84.04
Percival et al, Before-and-after Assess the impact of Adult females Antibiogram development: Physicians and Preintervention vs postintervention ED pharmacist High
201536 study recommendations made (12-70 years old) provider educational pharmacists • Adherence to recommendations
from applying local discharged with intervention by pharmacists   ○  44.8% vs 83% (P < 0.001)
resistance patterns to an uncomplicated and reinforced by the • Cystitis agreement between empirical antibiotic
national guidelines for UTI from an ED at medical director on choice and isolated pathogen susceptibility
management of UTIs a tertiary teaching institutional-specific   ○  74% vs 89% (P = 0.05)
center in the United recommendations • Reevaluation in the ED or hospitalization within
States 30 days
  ○  4.6% vs 7.4% (P = 0.27)
Almatar et al, Before-and-after Evaluate success of general Adults with CAP General hospital-wide Physicians and Baseline vs general education vs ED-focused AMS team High
201647 study education and ED-specific presenting to a provider educational nurses intervention
AMS interventions on teaching hospital in intervention followed • Adherence to guidelines
prescriber concordance to Australia by an ED-specific clinical   ○  28.1% vs 31.2% vs 61.5% (P < 0.001)
guidelines pathway implementation
with audit and feedback for
management of CAP

(continued)
 Table 2. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Hecker et al, Before-and-after Assess the impact of Adult females Implementation of an Physicians and Baseline vs period 1 (electronic order set Pharmacist, ID High
201449 study implementing an electronic (18-65 years old) electronic order set and pharmacists implementation) vs period 2 (audit and feedback) physician,
order set along with presenting to the audit and feedback • Overall adherence to guidelines electronic
audit and feedback for ED with a UTI at   ○  44% vs 68% (P < 0.001) vs 82% (P = 0.015) order sets
management of UTIs an academic level 1 • Unnecessary antimicrobial use in days
trauma center in the   ○  250 vs 119 (P < 0.001) vs 52 (P < 0.001)
United States • Use of fluoroquinolones
  ○  44.4% vs 14.5% (P < 0.001) vs 12.9% (P = 0.70)
• Treatment failure
  ○  11.0% vs 7.0% (P = 0.16) vs 8.5% (P = 0.58)
• Primary adverse event
  ○  6% vs 8.5% (P = 0.66) vs 9.5% (P = 0.59)
Ostrowsky Before-and-after To assess the impact of a Adults with CAP at Development of a CAP Physicians, Preintervention vs postintervention Pyxis, AMS High
et al, study with ITS multidisciplinary AMS EDs of large, urban algorithm, education, pharmacists, • Appropriateness of antimicrobial prescribing team (ID
201352 intervention on improving hospitals in the Pyxis monitoring of and nurses   ○  Campus 1: 54.9% vs 93.4% (P < 0.001) specialists,
antimicrobial prescribing United States antimicrobial use, CAP kits   ○  Campus 2: 64.6% vs 91.3% (P = 0.004) pharmacist)
(prepackaged ceftriaxone
and azithromycin)
Culture review and follow-up
Baker et al, Before-and-after To compare days to culture Adults discharged Emergency medicine clinical Pharmacists and Preintervention vs postintervention Pharmacist High
201227 study follow-up, patient and from the ED of a pharmacist education physicians • Time to positive culture review (days)
provider notification, and university teaching to providers regarding   ○  3 vs 2 (P = 0.0001)
appropriate antimicrobial hospital in the appropriate antimicrobial • Time to patient and provider notification (days)
therapy before and after United States selection and culture review   ○  3 vs 2 (P = 0.01)
implementation of an ASP and follow-up of discharged • Appropriate empirical antimicrobial therapy
patients   ○  88.9% vs 87.0% (P = 0.75)
Randolph Before-and-after To assess the impact of Patients at an ED in Culture review by a pharmacist Pharmacists and Preintervention vs postintervention ED pharmacist Unclear
et al, study implementing a pharmacist- the United States or a physician physicians • Readmission to the ED within 96 hours of
201151 managed culture review discharge
program on patient care   ○  19% vs 7% (P < 0.001)
Miller et al, Before-and-after To assess the appropriateness Adults at an ED in the Culture review and follow-up Pharmacists, Preintervention vs postintervention ED pharmacist High
201453 study of antimicrobial prescribing United States of patients discharged nurses, and • Inappropriateness of antimicrobial prescribing
in patients followed up after from the ED by nurse in physicians   ○  46.6% vs 14.7% (P < 0.0001)
discharged from the ED consultation with a physician
compared with a nurse,
pharmacist, and physician
working collaboratively
Dumkow Before-and-after Assess the impact Adults with UTIs Computer decision support Physicians and Preintervention vs postintervention Computer High
et al, study of implementing a discharged from the alerted pharmacists to pharmacists • Appropriateness of therapy decision
201454 multidisciplinary culture ED at a teaching positive cultures (Monday   ○  63.1% vs 73% (P = 0.081) support, ED
follow-up program on ED hospital in the to Friday), therapy was • ED revisits within 72 hours and hospital admission pharmacy
revisits and hospitalizations United States reviewed by the pharmacist within 30 days resident and
and discussed with the ED   ○  16.9% vs 10.2% (P = 0.079) ED and ID
physician. ED physicians pharmacists
communicated with patients
(continued)

9
10
Table 2. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Davis et al Before-and-after Determine the value of Patients discharged Clinical pharmacist performed Nurses, Preintervention (nursing review) vs postintervention ED pharmacist High
201656 study pharmacist- vs nurse-driven from the ED in the daily culture review and physicians, and (pharmacist review)
culture follow-up United States follow-up and provided pharmacists • Frequency of intervening for inappropriate therapy
recommendation to ED   ○  50% vs 80% (P = 0.01)
physicians • Time to follow-up (days)
  ○  3.4 ± 1.9 vs 3.5 ± 1.2 (P = 0.81)
Santiago et al, Retrospective Evaluate the impact of ED Adults discharged ED pharmacist facilitated Nurses, Nurse vs pharmacist-driven intervention ED pharmacist High
201657 cohort study pharmacist culture review from an ED of an culture review of all positive physicians, and • Median time to initial review of positive culture
and follow-up as compared academic medical microbiological test results pharmacists (hours)
with a nurse-driven culture center in the United for the ED physician,   ○  2 vs 3, P = 0.35
review and follow-up States including patient assessment • Proportion of missed interventions
and recommendation. On   ○  47% vs 4%, P = 0.0004
weekends, nurses facilitated
the review and provided ED
physicians with culture and
sensitivity data
Clinical decision support system
Hall et al, Before-and-after Evaluate the use of an order Adults receiving Implementation and education Physicians Preintervention vs postintervention Electronic High
201538 study set on vancomycin dosing vancomycin in the of an electronic order set • Appropriateness of antibiotic dosing order
ED at a tertiary   ○  45.5% vs 67.4% (P < 0.05) entry with
care hospital in the physician
United States order entry
Faine et al, Before-and-after To assess the impact of Patients receiving Incorporation of an automatic Primary Preintervention vs postintervention Computer High
201546 study an EMR intervention on vancomycin in the dose calculation tool in educational • Proportion of appropriate first doses order entry
vancomycin dosing and 28- ED and admitted to computer order entry order target:   ○  24.0% vs 34.3% (P = 0.07) and EMR, IT
day mortality the intensive care and an educational campaign physicians; • 28-Day in-hospital mortality support
unit at an academic email   ○  10.0% vs 16.9% (P = 0.12)
level 1 trauma notification • Acute kidney injury
center in the United of the   ○  34.0% vs 31.5% (P = 0.66)
States intervention
also sent to all
ED staff
Demonchy Controlled before- To evaluate implementation of Adults with UTIs Computer decision support Physicians Period 1 (preintervention) vs period 2 (electronic PDF Specialist in High
et al, and-after study computer decision support in the ED at 3 incorporated into an EMR of guidelines ED-A, computer decision support ED-B, public health
201458 to improve adherence to academic hospitals C) vs period 3 (computer decision support ED-A, no and health
guidelines for UTIs in France intervention ED-B, C) informatics
• Adherence to guidelines for empirical antimicrobial and ID
selection and duration specialists
  ○  ED-A: 27% vs 32% (P = 0.32) vs 24% (P = 0.16) to design
  ○  ED-B: 35% vs 34% (P = 0.91) vs 28% (P = 0.40) computer
  ○  ED-C: 33% vs 53% (P = 0.007) vs 38% (P = 0.07) decision
support
Carman et al, Before-and-after To determine if Patients with abscess Computer decision support Physicians Adherence to guidelines for antibiotic therapy EMR and Unclear
201159 study using time implementation of presenting to EDs tool for management of • Baseline = 86.8%, week 6 = 90.6%, week 12 = computer
series analysis computer decision support at a large trauma patients with abscess 96.7% (P = 0.000) decision
would improve adherence center, small support
to guidelines and improve community hospital,
patient outcomes and 2 freestanding
EDs in the United
States
(continued)
 Table 2. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Education alone
Metlay et al, Randomized To evaluate the impact of an Adults with acute Educational program for Physicians and Intervention vs control site N/A Unclear
200725 controlled trial educational program on respiratory tract clinicians (presentation patients • Adjusted change between year 1 and year 2 in
decreasing unnecessary infections at 16 and benchmarking of local antibiotic prescribing
antimicrobial use hospitals across the antimicrobial use with other   ○  −10% (95% CI = −18% to −2%) vs 0.5% (95% CI
United States sites and literature) and = −3% to 5%)
patients (posters, brochures, • Change in return visits per 100 persons between
video kiosk in the ED waiting year 1 and year 2
room)   ○  1.4 vs 4.6 (P = 0.48)
• Adjusted change in patient satisfaction between
year 1 and year 2
  ○  0.2 vs 0.2 (P = 0.71)
Celind et al, Before-and-after To evaluate adherence to Children with AOM at Information campaign on Physicians Adherence preintervention vs postintervention N/A High
201431 study guidelines and impact of an an ED in Sweden treatment of AOM • Choosing to use antibiotics
information campaign for   ○  79% vs 75% (P = 0.52)
management of AOM at a • Choice of antibiotic
pediatric ED   ○  76% vs 84% (P = 0.17)
• Dose per kg
  ○  70% vs 77% (P = 0.35)
• Duration of treatment
  ○  90% vs 94% (P = 0.49)
Palma et al, Before-and-after Assess the impact of Children with AOM Education of national guidelines Physicians Preintervention vs postintervention N/A Unclear
201534 study national guidelines on or acute mastoiditis for management of AOM • Antibiotics prescribed
appropriateness of presenting to an   ○  82% vs 81%
prescribing for AOM ED of an academic
tertiary care
pediatric hospital
in Italy
Prospective audit and feedback alone
Kiyatkin et al, Before-and-after To determine if Adults at a university Audit and feedback to Physician Preintervention vs postintervention AMS team High
201148 study implementation of audit medical center in individual physician assistants assistants • Inappropriate antimicrobial prescribing member to
and feedback interventions the United States for SSTIs, pneumonia,   ○  36% vs 18% (P = 0.001) complete
was effective in improving UTIs, and intra-abdominal audit and
appropriateness of infections provide
antimicrobial utilization feedback
Formulary restriction
Fagan et al, Controlled before- To reduce inappropriate use Patients with UTIs at 2 Formulary restriction of Physicians Preintervention vs postintervention N/A High
201450 and-after study of fluoroquinolones EDs in Norway ciprofloxacin and providing • Ciprofloxacin use
a preferred list of antibiotics   ○  Intervention site: 6.3% vs 3.4% (P = 0.0001)
with all urine dipstick results   ○  Control site: 2.3% vs 4.7% (P = 0.0001)

Abbreviations: AOM, acute otitis media; AMS, antimicrobial stewardship; ASP, antimicrobial stewardship program; CAP, community acquired pneumonia; DDD, defined daily dose; ED, emergency department; EMR, electronic
medical record; ID, infectious diseases; IT, information technology; ITS, interrupted time series; N/A, not applicable; NS, not significant; SSTIs, skin and soft-tissue infections; UTIs, urinary tract infections.

11
12
Table 3.  Abstracts, Letters to the Editor, and Conference Proceedings.
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Clinical pathway or guideline implementation with or without education

Julian-Jimenez Before-and-after To evaluate the impact Adults in the ED in Guideline implementation and guideline Physicians Preintervention vs postintervention N/A High
et al, 201040 study of guidelines on the Spain education • Appropriate empirical
management of CAP antimicrobial therapy
 ○  62% vs 97% (P < 0.05)
• Hospital length of stay (days)
 ○  8.6 vs 6.3 (P < 0.05)
• Revisit to ED within 30 days
 ○  17% vs 8% (P < 0.05)
• ED discharge rate
 ○  38% vs 42% (NS)
• 30-Day mortality
 ○  11% vs 8% (NS)
Mikulich et al, Before-and-after To assess the impact of Patients with signs Preintervention audit of guideline adherence Physicians Preintervention vs postintervention N/A High
201241 study intervention on guideline and symptoms of a was presented at grand rounds, guidelines • Appropriateness
adherence chest infection disseminated to providers and placed in  ○  21.9% vs 34.6%
ED
Sanchez et al, Before-and-after To assess the impact of Patients with upper- Guideline implementation, education, email ED staff Preintervention vs postintervention N/A High
201343 study guideline implementation respiratory-tract reminders, and patient information sheets • Appropriateness
on antibiotic prescribing infections in a  ○  22.4% vs 66.7% (P < 0.001)
patterns private ambulatory
ED in Ecuador
Gkentzi et al, Before-and-after To assess the impact of Children with Education (interactive group tutorials) Pediatric junior Preintervention vs postintervention N/A Unclear
201444 study education on antibiotic tonsillitis and with pre–education assessment and trainees • Prescribed antibiotics
prescribing AOM post–education assessment of prescribing  ○  Tonsillitis: 81% vs 50% (P =
attitudes, posters with recommendations, 0.007)
an educational website  ○  AOM: 82% vs 55% (NS)
Multifaceted intervention
Porco et al, Before-and-after To implement a quality Patients at a Antimicrobial education and implementation Physicians Preintervention vs postintervention N/A High
198739 study assurance program, which community of an antibiotic stamp (categorizing • Appropriate antibiotic prescribing
would modify physician hospital in the antibiotic as prophylactic, empirical, or  ○  57% vs 75%
prescribing and improve United States therapeutic)
appropriate culturing
(continued)
 Table 3. (continued)
Intervention Resource Bias
Reference Study Design Study Aim Patients and Setting Intervention and Comparator Target Outcomes Requirements Assessment

Sun et al, Before-and-after To evaluate the impact of a Adults with acute Patient education and personalized Patients and Preintervention vs postintervention N/A Unclear
201645 study stewardship intervention on respiratory prescriber feedback physicians • Rate of antibiotic prescription
inappropriate antimicrobial infections at a  ○  22% vs 14% (P < 0.0001)
prescribing tertiary ED in the • Odds of inappropriate antibiotic
United States prescription before intervention
 ○  OR = 1.8 (95% CI = 1.4-2.2; P
< 0.0001)
Culture review and follow-up
Kujawski et al, Nonrandomized To assess the impact of Adults in the ED Pharmacist providing culture follow-up as Pharmacists and Pharmacist vs other providers Pharmacist in High
201255 controlled incorporating an ED compared with other ED providers physicians • Appropriateness of antimicrobial the ED
trial pharmacist into culture prescribing
review and follow-up  ○  100% In both groups
• Readmission rates at 96 hours
 ○  18.8% vs 16.3%
Clinical decision support system
Frankel et al, Before-and-after To assess the impact of Patients admitted Computer order entry set for weight-based Physicians Preintervention vs postintervention Computerized Unclear
201342 study computerized order entry to a community vancomycin dosing • Adherence to dosing guidelines order entry
on appropriate dosing of academic ED in  ○  34.9% vs 51% (P < 0.001)
vancomycin the United States
Thomas et al, Before-and-after To assess the impact of Adults with Computerized order entry ED providers Preintervention vs postintervention Computerized High
201260 study computerized order pneumonia in an • Appropriateness order entry
entry on compliance with academic ED  ○  59% vs 64.8% (P = 0.47)
guidelines

Abbreviations: AOM, acute otitis media; CAP, community acquired pneumonia; ED, emergency department; N/A, not applicable; NS, not significant; OR, odds ratio.

13
14 Annals of Pharmacotherapy 00(0)
successful delivery of these core interventions, include high
patient and staff turnover and the need for quick decision
making.15 In addition, guidelines for some conditions, includ-
ing the Surviving Sepsis Campaign recommendations for
rapid administration of broad-spectrum antibiotics within the
first 3 hours of presentation61 limit the feasibility of imple-
menting preauthorization. Despite these challenges, a small
number of studies have demonstrated successful implemen-
tation of prospective audit and feedback alone or in combina-
tion with other interventions, which led to improved
adherence to guidelines or appropriateness of prescrib-
ing.26,45,47-49 These findings are consistent with a Cochrane
review that evaluated audit and feedback in a variety of set-
tings and patient populations and demonstrated improved
adherence to desired practice by health care providers.62
ED stewardship interventions identified in our
review largely focused on guideline or clinical pathway
implementation alone or in combination with educa-
tion19-22,28-30,32,37,40,41,43,44 or other multifaceted interven-
tions.24,33,47,52 The majority of studies evaluating guideline or
pathway implementation with or without education (9/13) or
multifaceted interventions (4/4) demonstrated some positive
impact. However, most related to improved appropriateness
of therapy or decreased antimicrobial use.21,24,28,30,32,40,43,44,47,52
Antimicrobial use, whether appropriate or inappropriate has
been linked to antimicrobial resistance.4,5 Decreasing antimi-
crobial use may result in improved resistance rates. Improved
adherence to guidelines and best practices also has the poten-
tial to result in better health outcomes for patients. Because of
variability in study design and interventions, conclusions about
which interventions are most successful cannot be drawn.
Although there is a recognized need for pharmacists in
ED ASPs to improve antibiotic utilization,15,63 to our knowl-
edge, this is the first systematic review exploring their role.
Pharmacists were described as part of a multidisciplinary
team with specific roles in education and culture review and
follow-up. A recent review article by Bishop highlighted a
call to action for pharmacists to participate in ASPs and
indicated that pharmacists should provide leadership in the
development and implementation of ASPs in the ED.63 Our
review clearly highlights participation and important contri-
butions of pharmacists as part of multidisciplinary teams.
Although this review provides direction for EDs consid-
ering implementation or revisions of AMS programs, addi-
tional research in this setting is needed. Most studies
included in this review were uncontrolled before-and-after
studies. Further research is needed to evaluate recommended
AMS interventions in the ED, with better-quality study
designs as recommended by EPOC, including randomized
trials, nonrandomized trials, controlled before-after studies,
interrupted time series studies, and repeated-measures stud-
ies.17 Studies should be designed to evaluate evidence-based
interventions (prospective audit and feedback, passive edu-
cation to complement other stewardship activities) and
report on clinical outcome measures and antimicrobial utili-
zation (days of therapy, cost). In designing interventions,
researchers should consider use of theory. A recent system-
atic review of the use of theory in RCTs of audit and feed-
back concluded that design of interventions should be theory
informed in order to contribute to literature and increase
understanding.64 Finally, additional studies exploring the
impact of pharmacists on outcomes of interest would be of
value in supporting the role of pharmacists within the ED as
part of multidisciplinary teams.
This review included a comprehensive search and critical
appraisal of the current available literature on AMS services in
the ED. Although this review summarizes numerous interven-
tions and evaluation of a wide range of outcomes, a number of
limitations should be considered. The majority of included
studies were small and lacked randomization. In addition, most
studies were rated as having unclear or high risk of bias.
Finally, few studies evaluated core stewardship interventions
or reported on metrics as recommended by the IDSA.6,7
In summary, a variety of AMS interventions have been
successfully implemented in the ED. The AMS initiatives
and ASP determinants of success summarized in this review
may be used to improve new and existing programs in the
ED. The importance of physician and pharmacist leader-
ship, need for infectious diseases expertise, and necessity
for a multidisciplinary team are emphasized as critical com-
ponents of ASPs by the IDSA guidelines6,7 and were identi-
fied as utilized resources in included studies. IT’s role in
ASPs is apparent in the recommendation to include IT per-
sonnel as team members and the incorporation of computer-
ized clinical decision support at the time of prescribing as
an intervention in ASPs.6,7 Despite successful implementa-
tion, a number of weaknesses in study design limit our abil-
ity to draw firm conclusions based on the available literature.
Findings do highlight need for additional research.
Appendix
MEDLINE Search.
Search
Number Search Terms
1 Emergency Treatment/ or Emergency Medicine/
or emergency medical services/ or emergency
service, hospital/ or trauma centers/ or triage/
or exp Evidence-Based Emergency Medicine/
or exp Emergency Nursing/ or Emergencies/
or emergicent*.mp. or ((emergenc* or ED)
adj1 (room* or accident or ward or wards
or unit or units or department* or physician*
or doctor* or nurs* or pharmacist* or
treatment*or visit*)).mp. or (triage or critical
care or (trauma adj1 (cent* or care))).mp.
(continued)
Losier et al 15
Appendix (continued)
Search
Number Search Terms
2 exp Policy Making/ or exp Organizational Policy/
or exp Policy/ or exp Quality Assurance,
Health Care/ or exp Quality Control/ or exp
“Guideline Adherence”/ or exp “Utilization
Review”/ or exp “Quality Indicators, Health
Care”/ or exp “Quality Improvement”/ or
exp “Quality Assurance, Health Care”/ or exp
“Program Evaluation”/ or exp “Peer Review,
Health Care”/ or exp “Process Assessment
(Health Care)”/ or exp “Outcome and Process
Assessment (Health care)”/
3 exp Anti-Bacterial Agents/ or exp Anti-Infective
Agents/ or exp Drug Resistance, Microbial/
4 2 AND 3
5 ((antibiotic* or antimicrobi* or antibacteri* or
“anti-bacterial” or “anti-microbial” or “anti-
biotic” or “anti-infective” or antiinfect*) and
(steward* or program* or polic* or pathway*
or audit or formular* or guideline* or “order
form” or “order forms” or streamlin* or
educat* or optimiz* or optimis* or “quality
improvement” or “quality assurance” or
“quality indicator” or “quality indicators” or
preauthorization* OR ‘pre authorization*’ OR
preauthorisation* OR ‘pre-authorisation*’)).mp.
6 4 OR 5
7 1 AND 6
Acknowledgments
The authors of this article would like to acknowledge Melissa
Helwig, Information Services Librarian, for her support in devel-
oping and completing the literature search. They would also like to
acknowledge assistance from Megan Harrison (pharmacy student)
for her support in data extraction.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported in part by a grant from the Canadian Society
of Hospital Pharmacists (CSHP) Foundation Research Grant.
Funding to provide a student research salary for Mia Losier was
provided by an internal grant from the Dalhousie University,
Faculty of Health Professions.
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