title: Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department.
abstract: BACKGROUND
  Antibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such as Clostridium difficile (C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers.
  
  
  OBJECTIVE
  To determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage.
  
  
  METHODS
  Interventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital's ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED.
  
  
  RESULTS
  There was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p<0.001) by 2.26 urine cultures per 100 ED patient visits.
  
  
  CONCLUSIONS
  FLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.
authors.affiliation: *Department of Emergency Medicine,Michael Garron Hospital,Toronto,ON.
authors.forename: Adam Jonathan
authors.identifier: http://orcid.org/0000-0003-2903-9307
authors.initials: AJ
authors.lastname: Kaufman
authors.affiliation: †Infectious Diseases Division,Department of Internal Medicine,Michael Garron Hospital,Toronto,ON.
authors.forename: Janine
authors.initials: J
authors.lastname: McCready
authors.affiliation: †Infectious Diseases Division,Department of Internal Medicine,Michael Garron Hospital,Toronto,ON.
authors.forename: Jeff
authors.initials: J
authors.lastname: Powis
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use*; D000073602:Antimicrobial Stewardship / Q000379:methods*; D004636:Emergency Service, Hospital / Q000592:standards*; D006786:Hospitals, Urban; D006801:Humans; D009864:Ontario; D010067:Ownership; D058996:Quality Improvement
chemical_list: D000890:Anti-Infective Agents
keywords: antimicrobial stewardship; emergency department; front-line ownership