Journal of General and Family Medicine
2015, vol. 16, no. 4, p. 281–287.
Original Articles
Inappropriate Antibiotic Use for Acute Asthma in Japanese Emergency Departments Kenzo Tanaka, MD,1 Koichiro Gibo, MD,2 Hiroko Watase, MD, MPH,3 Masaki Oohashi, MD,1 Carlos A. Camargo Jr., MD, DrPH,4 and Kohei Hasegawa, MD, MPH4,5 on behalf of the Japanese Emergency Medicine Network Investigators 1
Emergency and Trauma Center, Kameda Medical Center, 929 Higashi, Kamogawa, Chiba 2968602, Japan
2
Department of Emergency Medicine, Okinawa Prefectural Chubu Hospital Department of Radiology, University of Washington
3 4
Harvard Medical School
5
Department of Emergency Medicine, Massachusetts General Hospital
Background : Little is known about the extent that acute asthma is inappropriately treated with antibiotics in Japanese emergency departments (EDs). Objectives : We examined the proportion and predictors of inappropriate antibiotic use for adults with acute asthma in the Japanese EDs. Methods : We conducted a chart review study in 23 Japanese EDs. Subjects were ED patients aged 18 to 54 years with acute asthma between 2009 and 2011. To examine predictors of inappropriate antibiotic use, we performed multi-level logistic regression analysis at both the patient- and ED-level modeling EDs as a random variable. Results : Among 1380 patients in the overall study, the analytic cohort comprised 1311 patients. Overall, antibiotics were inappropriately prescribed for 4.4% (95% confidence interval [CI], 3.4%–5.7%). In the multi-level logistic regression analysis, higher annual ED asthma visit volume was significantly associated with a lower proportion of inappropriate antibiotic use (odds ratio per 100-visit increase, 0.3 ; 95%CI, 0.2–0.6). Conclusions : In this large multicenter study in Japan, we found that approximately 4% of ED patients with acute asthma were inappropriately treated with antibiotics. We also demonstrated that the inappropriate use of antibiotics
Corresponding author : Kenzo Tanaka, MD Emergency and Trauma Center, Kameda Medical Center, 929 Higashi, Kamogawa, Chiba 296-8602, Japan E-Mail :
[email protected] Received for publication 24 March 2015 and accepted in revised form 16 April 2015 © 2015 Japan Primary Care Association
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largely differed across the EDs and was less common in EDs with a more annual ED asthma visits. Organized knowledge translation initiatives are warranted to address this gap in emergency asthma care. Keywords : emergency department, acute asthma, antibiotics, multicenter study
Background Asthma is an important public health problem in Japan, affecting approximately one million individuals.1 The international guidelines recommend treatment of acute asthma using inhaled ¢-agonists, systemic corticosteroids, inhaled anticholinergics agent, and intravenous magnesium without the use of antibiotics.2,3 However, a previous study from North America reported a high frequency (18%–22%) of inappropriate antibiotic use for patients with acute asthma in the ED.4 It is well documented in the literature that microbial resistance to antibiotic therapy poses a significant threat to public safety.5 As injudicious use of antibiotics substantially contributes to this problem, there is an urgent need to reduce unnecessary antibiotic use for populations, such as patients with uncomplicated acute asthma. Despite the public heath importance, there have been no efforts that investigate the proportion of inappropriate antibiotic use for ED patients with acute asthma in Japan. To address the knowledge gap in the literature, we conducted a multi-center study to investigate the proportion, characteristics, and predictors of inappropriate antibiotic use for adults with acute asthma in Japanese EDs.
geographic regions across Japan. Throughout the study
Methods Study design and setting We performed a secondary analysis of the data from the 3rd Japanese Emergency Airway Study (JEAN-3 Study). The study setting, methods of data collection, and measured variables of the JEAN-3 study have been reported elsewhere.6 Briefly, the JEAN-3 was a multicenter chart review study that was designed to characterize the acute asthma management in Japanese EDs. The JEAN-3 was coordinated by the Japanese Emergency Medicine Network (JEMNet) in collaboration with the US-based Emergency Medicine Network (www.emnet-usa.org). JEMNet is a consortium of 23 academic and community EDs from different
viewers abstracted the patient- and ED-level informa-
period, all 23 EDs were staffed by ED-based attending physicians. All patients were managed by at the discretion of the treating physician. The institutional review board of each participating hospital approved the study with a waiver of written informed consent. Study subjects Using a primary discharge diagnosis of asthma, each ED first identified all ED visits for acute asthma during 2009 and 2011 that were made by adults aged 18 to 54 years with a history of physician-diagnosed asthma. Next, onsite chart abstractors reviewed 60 randomlyselected ED charts ; we created a cohort of 1380 ED patients with acute asthma. For the purpose of this analysis, among 1380 patients in the JEAN-3, we excluded patients with potential indication for antibiotic use (e.g., patients with coexisting bacterial infection, such as COPD, pneumonia, or sinusitis) and those who were transferred to another hospital after the index ED visit. We also excluded patients without the information on coexisting medical illness. Measurements Using standardized data collection form, chart retion. All chart abstractors were emergency physicians or emergency medicine residents. Abstractors were trained with a 1-hour lecture, and then the abstractors completed practice charts, which were assessed with a “criterion standard.” If an abstractor’s accuracy was 0.05), although patients with inappropriate antibiotic use were more likely to have a
Discussion In this large multicenter study of ED patients with acute asthma, approximately 4% of the patients were treated with antibiotics inappropriately in the ED. We also found a wide variation in the proportion of inappropriate antibiotic use across the 23 participating EDs, The independent predictors of inappropriate use were history of hospital admission for acute asthma and lower asthma-related ED visit volume.
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Table 1. Demographic and clinical characteristics of patients with acute asthma who received inappropriate antibiotics and those who did not in emergency department
Demographics Age (y), median (IQR) Sex Male Female Current smoking Chronic asthma factors Admitted for asthma in past year ED visit for asthma in past year Ever intubated for asthma Current use of inhaled corticosteroids Current use of leukotriene modifiers Current use of oral methylxanthines Duration of symptoms
