JAC Advance Access published online on June 26, 2007
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm233
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Appropriateness of antibiotic therapy on weekends versus weekdays
1 Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa 49100, Israel 2 Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel 3 Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, Israel 4 Department of Emergency Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, Israel
* Corresponding author. Tel: +972-3-937-7511; Fax: +972-3-937-7513; E-mail: jihadb{at}clalit.org.il or bishara{at}netvision.net.il
Received 18 April 2007; returned 14 May 2007; revised 19 May 2007; accepted 5 June 2007
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Abstract |
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Objectives: To compare the appropriateness of antibiotic treatment prescribed in an emergency department (ED) of a tertiary medical centre on weekdays and weekends.
Methods: During a 1 month period, medical charts of 1029 ED visits for patients who were discharged from the ED were reviewed. Data of patients who were discharged with antibiotics were blind evaluated by two infectious disease specialists, and an ‘appropriateness score’ was given to the antibiotic prescription.
Results: Antibiotics were prescribed at discharge for 182 (17.7%) patients. Appropriate antibiotic treatment was administered significantly less frequently on weekends when compared with weekdays (P = 0.004). Appropriateness scores were higher for the surgical and urological wings (P = 0.011) and for diagnoses of pneumonia and urinary tract infection (P = 0.005). Time of the day and patient's age and sex did not have a significant effect on the appropriateness score. Adjusting for all variables, only weekends remained significantly associated with less appropriate antibiotic treatment, odds ratio 0.35 and 95% confidence intervals 0.16–0.78.
Conclusions: This study shows less appropriate antibiotic prescription in an ED on weekends than weekdays. More studies are required to clarify measures to improve appropriate antibiotic therapy at weekends.
Key Words: antibiotic prescriptions , weekly variation , prescribing
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Introduction |
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Data from a few clinical trials suggest that hospitals function less effectively on weekends than weekdays. Neonatal mortality is marginally higher among babies born on weekends than among those born on weekdays. In addition, the management of acute myocardial infarction, stroke and drug overdose may be worse for patients presenting on weekends than for those presenting on weekdays.1–3
Physicians in the emergency department (ED) are expected to decide within a relatively short period of time whether the patient requires hospitalization or discharge. A significant percentage of patients arriving at the ED complain of symptoms suggestive of infectious diseases. As many patients seen at the ED are discharged and recommendations given in the hospital are respected in the community, the impact of the ED physician on the community use of medications in general and antibiotics in particular is significant.
Antimicrobial resistance is a growing and almost universal problem. The intensive use and excessive abuse of antibiotics have resulted in the selection of bacteria that are resistant to many antimicrobials.
Measures to counter the threat of rapidly escalating antimicrobial resistance include surveillance of susceptibility to and consumption of and rational use of antibiotics.4
Previous reports have described the injudicious prescription of antibiotics in a number of EDs.5–7 There have also been a number of studies describing the epidemiological characteristics of patients discharged from the ED with infectious diagnosis.4–7 However, the percentage and appropriateness of antibiotic prescription to patients discharged from the ED and its daily and weekly variations have not been widely studied. In this study, we attempted to evaluate the appropriateness of antimicrobial prescription and its temporal variation during the week.
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Methods |
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The study took place at the Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, Israel, a 900 bed university hospital. The centre serves an urban population of approximately 1 000 000 persons as both a first-line and tertiary facility. The ED consists of Internal Medicine, Surgical, Dermatological, Urological, Ear, Nose and Throat (ENT) and Orthopaedic wings. There are approximately 83 000 visits to the ED each year. During the month of April, there were 6886 patients with 6922 visits. Thirty-six patients had more than one visit. Among the 6992 visits, patients of 1895 visits were admitted to the hospital and 5027 were discharged.
Charts of 1029 randomly selected patients discharged from the ED were reviewed. From each chart, we noted demographic patient's characteristics, the time and day of the week of arrival, previous antibiotic therapy prior to admission to the ED and the presence of antibiotic hypersensitivity. We also documented diagnosis, as well as type, dosage and duration of the recommended antibiotic. Two infectious disease specialists, familiar with the local antibiotic susceptibility patterns of microorganisms, evaluated blindly and independently the data of the patients to whom antibiotic was prescribed. The two infectious disease specialists were blinded to the time of day and day of the week of antibiotic prescription. Each case received from each infectious disease specialist a score from 0 to 2, according to the appropriateness of the prescription (0, inappropriate treatment; 1, doubtful and 2, appropriate treatment). The appropriateness of antibiotic treatment was given for the diagnoses and then applied to each patient. We then summed the two values to give a composite score from 0 to 4 for each case. For the purpose of the study, ad hoc criteria for the appropriateness of antibiotic prescription were established and utilized by the two infectious disease specialists (Table 1).
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Statistical analysis
We analysed the association of weekends (Friday–Saturday in Israel) versus weekdays and other variables with appropriate antibiotic treatment. Univariate associations were assessed using the 
2 test. Variables found significant on univariate analysis (P < 0.1) were entered into a multivariable analysis using block entry of variables. Analyses were performed using SPSS version 14.0.
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Results |
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Patients' characteristics and pre-defined variables assessed for their association with the appropriateness of antibiotic treatment are shown in Table 2. The study group comprised 492 males (48%) and 537 females (52%). The age of the patients ranged from 2 to 98 years (mean 48.5 years, SD ±21.6). The total number of patients prescribed antibiotic treatment on discharge from the ED was 182 (17.69%). Full data were available for 177 of these cases. Most patients visiting the ED were treated in the internal medicine (46%), orthopaedic (20.7%) and surgical wings (14.9%). The antibiotic prescription scoring was not significantly different between patients with different gender or from different age groups. Comparisons of appropriate and inappropriate antibiotic prescription in the morning and night shifts showed no significant differences between these two groups. However, the percentage of appropriate antibiotic prescription was highest for the urology and surgery wings and lowest for the ENT wing (Table 2). During the week, there was significant variability in the appropriateness of antibiotic treatment (P = 0.025), declining from 71% on Sundays (first day of the week in Israel) to 33% on Saturdays (Figure 1). Patients diagnosed as having pneumonia or urinary tract infection (UTI) received better treatment, with regard to the appropriateness of antibiotic therapy, than patients with less common diagnoses (Table 2, P = 0.005).
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On multivariate analysis including the variables weekend, diagnosis and wing, only weekends remained significantly associated with inappropriate antibiotic treatment, odds ratio 0.35, 95% confidence intervals 0.16–0.78, P = 0.010 (Hosmer–Lemeshow
2 = 6.000, df = 8. P = 0.647). |
Discussion |
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The most intriguing finding of our study was the significant variation between weekdays and weekends in the appropriateness of antibiotic therapy.
During weekends, significantly less appropriate antibiotic treatment was prescribed when compared with weekdays, independent of all other risk factors for inappropriate antibiotic treatment. Our institution and other hospitals in Israel provide routine care on weekdays and only emergency or urgent care on weekends. Hospital staffing is reduced on weekends, both numerically and in terms of available expertise on site. In previous studies, it has been shown that this difference in staffing may result in different outcomes for patients with acute conditions such as myocardial infarction, depending on whether they are admitted on weekends or weekdays.8 In their study, Kostis et al.8 showed that the mortality because of myocardial infarction was higher among patients admitted on weekends than among those admitted on weekdays. Patients admitted on weekends were less likely to undergo invasive cardiac procedures than those admitted on weekdays. Previous works reported a lower appropriateness of treatment prescribed when performed on duty compared with during normal working time.4 Other reports have emphasized the role of fatigue and sleep deprivation in physicians' performances and decision-making.9,10 In the current study the continuous decline in performance as the week went by might be attributed to increased fatigue among the ED physicians. However, additional studies are required in order to explore the possible correlation between fatigue and the appropriateness of physicians' decisions.
In this study, we found a higher rate of appropriate antibiotic prescription for pneumonia and UTI than for less common infections. This can be explained, in part, by the fact that physicians are less likely to make incorrect decisions about antibiotic treatment of infections they meet on a daily basis, although they might choose inappropriate treatment for infections they encounter less commonly.
Physicians and especially ED practitioners should be made aware of increasing bacterial resistance. The injudicious and excessive prescription of antibiotics in ambulatory practice is a major contributor to the development of antibiotic-resistant bacteria.11,12
Excessive prescription of antibiotics has numerous causes. In the USA, 75% of the ambulatory antibiotic prescriptions are for the treatment of acute respiratory infections, which are predominantly of viral aetiology.13 It has been shown that antibiotic prescription for these infections accounts for a large proportion of the unnecessary treatment.14–16 Patients' pressure on the physician to prescribe antibiotic therapy is another factor in the overuse of antibiotics and the subsequent emergence of antibiotic resistance. It is possible that pressure by patients or their relatives on prescribing physicians becomes greater during weekends. This can be attributed to greater anxiety expressed by patients and their families during days with less available healthcare services.
Our results are based on the evaluation of two independent infectious disease specialists who were blinded to the time of day and day of the week. Evaluators based their decisions on explicit definitions for appropriate antibiotic treatment (Table 1) based on the available evidence and adapted to local antibiotic resistance patterns. However, several limitations of our study are noteworthy. First, our results were derived from a single institution and our findings and conclusions may vary in other centres and geographical areas. Secondly, although our sample was selected randomly, we did not include all consecutive patients discharged from the ED for the study period. Finally, we did not assess patient-related outcomes. We selected inappropriate antibiotic treatment as an outcome because it has been shown to correlate with adverse outcomes, mainly induction of antibiotic resistance.
Further studies are required to explore whether our findings are replicated in other institutions. In addition, whether more appropriate staffing of EDs during weekends can prevent some of these inappropriate prescriptions should be clarified.
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None to declare.
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Acknowledgements |
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This paper was presented in part at the Twenty-fifth International Congress of Chemotherapy (ICC) and Seventeenth European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), Munich, Germany, 2007.
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References |
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