Álvaro Eloy Monje-López

Background: Asymptomatic bacteriuria (ASB) is frequently overtreated in emergency departments (ED), contributing to antimicrobial resistance without improving clinical outcomes. Rapid decision-making and high patient turnover in the ED increase the risk of unnecessary antibiotic use. Methods: A quasi-experimental study was conducted in the ED of a tertiary hospital in Barcelona, Spain, from January 2024 to June 2025. The intervention included targeted education for ED staff and daily audit-feedback on antibiotic prescriptions for suspected ASB. Outcomes were compared with a six-month pre-intervention period. The primary outcome was 30-day return visit to the ED for Urinary Tract Infection (UTI) with the same microbiological isolate. Secondary outcomes included 30-day all-cause mortality, overall UTI return visit to the ED, antimicrobial consumption (Daily Defined Dose/1,000 admissions), and urine culture requests. Results: A total of 130 patients in the pre-intervention period and 127 patients in the intervention period were included. In the intervention period, antibiotic discontinuation was recommended in 96 (75.6%) patients; acceptance rate was 29.2%. Despite limited acceptance, antimicrobial consumption declined, with cefalosporins reduced by 21% and carbapenems by 24%. Urine culture requests fell by 16.1%, and uropathogen isolates decreased by 15.9%. Clinical outcomes were similar between both periods: 30-day return visit to the EDs for UTI with the same isolate dropped from 6.2% to 1.6% (p-value=0,103), overall UTI return visit to the EDs from 8.5% to 4.7% (p-value=0.316), and 30-day mortality remained stable (6.2% vs. 3.9%, p-value=0.571), no statistically significant differences across all variables. Conclusions: This program reduced inappropriate antibiotic use and unnecessary urine testing in the ED without compromising patient safety. These results highlight educational and audit-feedback intervention as a safe, practical, and impactful antimicrobial stewardship strategy in high-pressure clinical settings as the ED.

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.