Have you ever had this happen? Send a resident to the ER, the resident diagnosed with dehydration and sent back to you on an antibiotic? If not, you are rare, most everyone in post-acute care has had this experience. We are not doubting that the laboratory values obtained in the ER aren’t accurate and reflect dehydration, however, frail elders tend to have abnormal lab values when it comes to evaluating hydration and what about the antibiotic?

An interesting article was published in the Cambridge University Press that discussed the use of antibiotics in U.S. emergency departments. Although not focused on the elderly exclusively, an analysis from 2016-2021 reflected 27.6% of visits resulted in inappropriate antibiotic prescribing. 14.9% of these orders had diagnosis codes plausibly antibiotic-related (e.g., acute bronchitis), suggesting actual inappropriate prescribing, and 12.6% had diagnosis codes not plausibly antibiotic-related (e.g., hypertension), suggesting poor coding quality.

These findings suggest that ED antibiotic stewardship initiatives should focus on both reducing antibiotic prescribing for infections, antibiotic-inappropriate conditions, and on improving coding quality for antibiotic prescriptions. In fairness, the patient in the ER is a snapshot in time. The medical staff rely solely on lab values, the patient’s complaints and possibly x-rays. When that resident comes back to you on antibiotics, consider having a full medical assessment by the attending physician or physician extender to confirm that the symptoms are infectious related. If it is determined that the antibiotic is warranted, continue the medication. If not, discuss options with the attending to determine the risk/benefit of continuing the medication. Antibiotic Stewardship, priceless! Stay well and stay informed!