Factors Affecting the Decision to Prescribe Antibiotics in the Emergency Department

Research Article

Austin J Emergency & Crit Care Med. 2015; 2(7): 1041.

Factors Affecting the Decision to Prescribe Antibiotics in the Emergency Department

Karacaer Z¹*, Salman N¹, Tezel O², Avci O³, Altun D4 and Eryilmaz M5

¹Department of Infectious Diseases and Clinical Microbiology, Etimesgut Military Hospital, Turkey

²Department of Emergency Medicine, Etimesgut Military Hospital, Turkey

³Department of Biochemistry, Etimesgut Military Hospital, Turkey

4Department of Pediatrics, Etimesgut Military Hospital, Turkey

5Gulhane Military Medical Academy, Department of Emergency Medicine, Turkey

*Corresponding author: Karacaer Zehra, Department of Infectious Diseases and Clinical Microbiology, Etimesgut Military Hospital, Asagi Dikmen mah, Ankara, Turkey

Received: November 26, 2015; Accepted: December 28, 2015; Published: December 30, 2015


Background: The aim of this study was to detect the factors affecting physician’s decisions to prescribe antibiotics for patients presenting to our hospital’s emergency department (ED) with symptoms of infectious disease.

Methods: This retrospective observational survey included the data of patients who presented to the ED with symptoms of infectious disease between January 1, 2014, and June 30, 2014. Statistical analysis was performed with SPSS version 22.0. P <0.05 was accepted as statistically significant.

Results: A total of 3,098 patients had symptoms relevant to infectious disease; 2,171 (70.1%) of them were male, and the mean age was 21 years (range 0–88). The most frequent symptom was sore throat (38.8%), and the most frequent initial diagnosis was acute pharyngitis (45.9%). The complete blood count (29.8%) was the most commonly used laboratory test. Of the treatments, 2,103 (86.2%) were empirical and 337 (13.8%) were laboratory-assisted. No culture-supported treatments were encountered. Antibiotics were included in 1,351 (64.2%) of the empirical treatments and in 252 (74.8%) of the laboratoryassisted treatments. It was identified that high fever, chest x-ray requests, signs of infection in stool, signs of infection on urinalysis, and leukocytosis affected the physicians’ decisions to prescribe antibiotics (p <0.001, p <0.001, p <0.001, p <0.001, p= 0.019, respectively).

Conclusion: High fever, chest x-ray requests, signs of infection in stool or on urinalysis, and leukocytosis significantly affected physicians’ decisions to prescribe antibiotics in the ED.

Keywords: Emergency department; Infectious diseases; Laboratory tests; Fever


SIRS: Systemic Inflammatory Response Syndrome; CBC: Complete Blood Count; ED: Emergency Department; ENT: Ear- Nose-Throat; CRP: C-reactive Protein; LAT: Laboratory-Assisted Treatment; UTI: Urinary Tract Infection; AGE: Acute Gastro Enteriti; ET: Empirical Treatment; STI: Soft Tissue Infection; URTI: Upper Respiratory Tract Infection


Infectious emergencies can create permanent tissue and organ damage if they are not treated appropriately, as these infections can transform into Systemic Immune Response Syndrome (SIRS) in a short time. Severe infections, such as meningitis, encephalitis, sepsis, septic shock, necrotizing soft tissue infections, pneumonia, complicated urinary tract infections, and severe forms of all other infections, may require urgent intervention [1]. In addition, certain diseases can be transmitted to health workers and can threaten the health of other sections of society [2].

Infectious diseases constitute an important part of emergency department (ED) admissions. Literature observing the ED admission rate of patients with infectious disease presents that this rate is about 11.3% to 14.2% in Turkey [3-5]. Donnelly et al. [6] reported that there were more than 12 million annual ED visits for acute respiratory tract infection in United States from 2001 to 2010, and antibiotics were used in the majority of these admissions. Complete Blood Count (CBC), peripheral blood smear, acute-phase reactants, urinalysis, and chest x-ray are essential studies done in the Emergency Department (ED) for the diagnosis of infectious diseases [2]. Appropriate treatment should be initiated as soon as possible after determination of a preliminary diagnosis through a detailed history, physical examination, and laboratory test results. Giving appropriate premature antibiotic treatment for infectious diseases that require emergency management prevents chronicity and complications, and increases the survival rate [7]. For successful and accurate treatment in the ED, the primary determination should be whether antibiotic therapy is necessary. Microorganisms should then be identified or cultures should be performed with infection-specific clinical material in order to choose the appropriate antibiotic. However, if there are no suitable laboratory facilities, the potential pathogens and antibiotic resistance should be considered. The final step of successful treatment involves the selection of appropriate antibiotics, as well as the appropriate dose and type of administration, and then monitoring the effectiveness of the treatment [7]. When we examined the current literature, we could find no another studies on the factors influencing physician’s decisions to prescribe antibiotics for infectious diseases in the ED.

Assessing the prudent use of antibiotics in the ED may provide opportunities to correct application mistakes and prevent antibiotic resistance. It is a significant problem to identify the most common types of infection in the ED, and to determine the laboratory tests and treatments required for these infections. At our centre, there have been no previous studies dealing with this subject. The aim of the present study was to investigate the factors that influence physicians’ decisions to prescribe antibiotics to patients presenting to our ED with infectious disease symptoms.

Materials and Methods

We performed a retrospective observational study, analyzing the written and digital records of patients admitted to our ED with complaints of infectious diseases between January 1, 2014, and June 30, 2014. Patients with incomplete data were excluded from the study. In our hospital, emergency medicine specialists serve in the ED during working hours (8:00 a.m. to 5:00 p.m.). Outside of working hours (5:00 p.m. to 8:00 a.m. and on weekends), two specialists from other fields serve in the ED. In this study, we did not perform any individual assessments or personal comparisons of the physicians. During a six-month period, 32 different specialists worked ED shifts. These included three emergency medicine specialists, two Ear/ Nose/Throat (ENT) specialists, three infectious disease specialists, one Cardiologist, two Paediatricians, three general surgeons, three neurologists, two urologists, one neurosurgeon, one dermatologist, one pulmonologist, one psychiatrist, two physical medicine and rehabilitation specialists, one gastroenterology specialist, one family medicine specialist, one gynaecologist, one plastic surgeon, one medical microbiology specialist, one ophthalmologist, and one internal medicine specialist. The physicians belonged to three groups: the emergency medicine group, the internist group, and the surgeon group. One specialist from medical microbiology was included in the internist group.

Each patient’s age, gender, symptoms, body temperature, x-ray results, CBC, sedimentation rate, C-Reactive Protein (CRP), urinalysis, stool analysis, physician’s specialty, initial diagnosis, treatment approach (empirical, laboratory-assisted, or culturesupported), antibiotics group, and conclusion (discharge, dispatch, or hospitalization) were recorded.

Our ED facilities include X-ray, CBC, sedimentation, CRP, urinalysis, stool analysis, blood and urine cultures. According to the reference values of our laboratory, the following were considered normal: CBC with leukocytes of 3.5–10.5 x 103/μl, sedimentation rate of =20 mm/h, CRP of =5 mg/dl, and urinalysis showing < 3 erythrocytes and < 4 leukocytes in all microscopic fields. Stool samples with a macroscopic appearance of soft-liquid consistency with blood and/or mucus, or microscopically involving leukocytes, erythrocytes, or any kind of parasite, were considered pathological [8]. X-rays performed in the ED were not reported by a radiologist, so we could not include the X-ray results in this study. However, the effects on decision-making for antibiotic prescriptions with regard to chest X-ray requests (in patients with fever, cough, sputum production, dyspnea, or chest pain) were investigated. The patient’s body temperatures were evaluated with a tympanic thermometer (Covidien 303000 Genius 2 Tympanic Thermometer, ear mode); < 37°C was considered normal, 37°C – 37.9°C was subfebrile, and =38°C was febrile.

Treatment decisions that used CBC, X-ray, sedimentation rate, or CRP results were designated Laboratory-Assisted Treatment (LAT). These included Urinary Tract Infection (UTI) treatments based on urinalysis and CBC, and Acute Gastro Enteritis (AGE) treatments based on stool analysis. Treatments performed according to culture results were considered the culture-supported approach, and all others were defined as Empirical Treatment (ET).

Statistical analysis was performed with SPSS software version 22.0. Data distribution was assessed with the Kolmogorov-Smirnov test. Definitive statistics were calculated, and since they were not suited to normal distribution, the scale data expressed the median (minimum-maximum) and categorical data were expressed as numbers and percentages. For comparisons among groups, the Pearson’s chi-square test was used, and a p-value of <0.05 was considered significant. Approval for the study was obtained from our hospital’s local ethics committee.


During the study period, 9,042 patients were admitted to the ED, and 3,098 (34.26%) of them had symptoms associated with infectious disease. Of these patients, 2,171 (70.1%) were male and 927 (29.9%) were female, with a mean age of 21 years (range 0–88 years). Seven hundred thirty-five (23.7%) of the patients were under 18 (411 males, 324 females), 6.1% were younger than 5 years, and 1.3% were over 65.

Within the study period, the most common symptom was sore throat (38.8%) (Table 1), and acute pharyngitis was the most common preliminary diagnosis for the infectious diseases (45.9%) (Table 2).