Changing epidemiology and management of infectious diseases in US EDs

Published:March 11, 2016DOI:



      The rise of antibiotic-resistant pathogens is believed to have influenced the emergency department (ED) epidemiology and management of infectious diseases (IDs) since 2000.


      Data from the National Hospital Ambulatory Medical Care Survey from 2000 to 2010 were used to examine temporal trends in the incidence of IDs presenting to EDs. Outcome measures included national visit rates, visit proportions, and antimicrobial prescriptions for all ID primary diagnoses, as well as for specific organ systems of interest (respiratory tract, skin/soft tissue, and urinary tract).


      An ID-related primary diagnosis was given in 18.3% (95% confidence interval, 17.9%-18.8%) of all ED visits during the study period. The hospitalization rate for these conditions is 7.8% (95% confidence interval, 7.3%-8.3%). The share of macrolide prescriptions for upper respiratory tract infections and lower respiratory tract infections increased by 34% and 46%, respectively, and that of quinolone prescription for lower respiratory tract infections doubled from 9% to 18.4% during the study period. Management of skin and soft tissue infections shifted from predominant use of cephalosporins to sulfonamides. For UTIs, quinolones were most commonly prescribed, with an increasing use of third-generation cephalosporins. Antibiotics were more frequently prescribed to patients who are white compared with (white: 60%, black: 57%, other races: 52%, P < .05).


      The changing epidemiology of IDs diagnosed in US EDs reflects national trends in emerging pathogens and drug resistance. Broad-spectrum antibiotics are being prescribed at increasing rates. There are significant demographic disparities in nationwide antibiotic prescription practices.
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        • Talan D.
        • Moran G.
        • Mower W.
        • et al.
        EMERGEncy ID NET: an emergency department-based emerging infections sentinel network. the EMERGEncy ID NET Study Group.
        Ann Emerg Med. 1998; 32: 703-711
        • Talan D.
        • Moran G.
        • Abrahamian F.
        Infectious disease emergencies, preface.
        Infect Dis Clin North Am. 2008; 22: ix-xi
        • May L.
        • Mullins P.
        • Pines J.
        Demographic and treatment patterns for infections in ambulatory settings in the United States, 2006-2010.
        Acad Emerg Med. 2014; 21: 17-24
        • Hyde T.
        • Gay K.
        • Stephens D.
        • Vugia D.
        • Pass M.
        • Johnson S.
        • et al.
        Whitney CG, Active Bacterial Core Surveillance/Emerging Infections Program Network. Macrolide resistance among invasive Streptococcus pneumoniae isolates.
        JAMA. 2001; 286: 1857-1862
        • McCaig L.
        • McDonald L.
        • Mandal S.
        • Jernigan D.
        Staphylococcus aureus–associated skin and soft tissue infections in ambulatory care.
        Emerg Infect Dis. 2006; 12: 1715-1723
        • Moran G.
        • Krishnadasan A.
        • Gorwitz R.
        • et al.
        Methicillin-resistant S. aureus infections among patients in the emergency department.
        N Engl J Med. 2006; 355: 666-674
        • Pallin D.
        • Egan D.
        • Pelletier A.
        • Espinola J.
        • Hooper D.
        • Camargo C.J.
        Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus.
        Ann Emerg Med. 2008; 51: 291-298
        • Qualls M.
        • Mooney M.
        • Camargo C.J.
        • Zucconi T.
        • Hooper D.
        • Pallin D.
        Emergency department visit rates for abscess versus other skin infections during the emergence of community-associated methicillin-resistant Staphylococcus aureus, 1997–2007.
        Clin Infect Dis. 2012; 55: 103-105
        • Karlowsky J.
        • Kelly L.
        • Thornsberry C.
        • Jones M.
        • Sahm D.
        Trends in antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States.
        Antimicrob Agents Chemother. 2002; 46: 2540-2545
        • Karlowsky J.
        • Thornsberry C.
        • Jones M.
        • Sahm D.
        Susceptibility of antimicrobial-resistant urinary Escherichia coli isolates to fluoroquinolones and nitrofurantoin.
        Clin Infect Dis. 2003; 36: 183-187
        • Fishman N.
        Antimicrobial stewardship.
        Am J Infect Control. 2006; 34: S55-S63
        • Thornsberry C.
        • Sahm D.
        • Kelly L.
        • et al.
        Regional trends in antimicrobial resistance among clinical isolates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States: results from the TRUST Surveillance Program, 1999-2000.
        Clin Infect Dis. 2002; 34: S4-S16
      1. National Center for Health Statistics. The National Ambulatory Medical Care Survey (NAMCS) description. [Accessed January 30, 2012].

        • Centers for Disease Control and Prevention
        Ambulatory care drug database system.
        Ambul Health Care Data. 2011; ([ Accessed June 16, 2015])
        • Centers for Disease Control and Prevention
        Trend analysis using NAMCS and NHAMCS drug data.
        Ambul Health Care Data. 2010; ([ Accessed June 16, 2015])
        • Armstrong G.
        • Conn L.
        • Pinner R.
        Trends in infectious disease mortality in the United States during the 20th century.
        JAMA. 1999; 281: 61-66
        • Pinner R.W.
        • Teutsch S.M.
        • Simonsen L.
        • et al.
        Trends in infectious diseases mortality in the United States.
        JAMA. 1996; 275: 189-193
        • Christensen K.
        • Holman R.
        • Steiner C.
        • Sejvar J.
        • Stoll B.
        • Schonberger L.
        Infectious disease hospitalizations in the United States.
        Clin Infect Dis. 2009; 49: 1025-1035
        • Yorita K.
        • Holman R.
        • Sejvar J.
        • Steiner C.
        • Schonberger L.
        Infectious disease hospitalizations among infants in the United States.
        Pediatrics. 2008; 121: 244-252
        • Donnelly J.
        • Baddley J.
        • Wang H.
        Antibiotic utilization for acute respiratory tract infections in U.S. emergency departments.
        Antimicrob Agents Chemother. 2014; 58: 1451-1457
        • Neuman M.
        • Shah S.
        • Shapiro D.
        • Hersh A.
        Emergency department management of childhood pneumonia in the United States prior to publication of national guidelines.
        Acad Emerg Med. 2013; 20: 240-246
        • Shapiro D.
        • Hicks L.
        • Pavia A.
        • Hersh A.
        Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09.
        J Antimicrob Chemother. 2014; 69: 234-240
        • Gonzales R.
        • Malone D.
        • Maselli J.
        • Sande M.
        Excessive antibiotic use for acute respiratory infections in the United States.
        Clin Infect Dis. 2001; 33: 757-762
        • Jung N.
        • Lehmann C.
        • Fätkenheuer G.
        The "choosing wisely": initiative in infectious diseases.
        Infection. 2015;
        • Maughan B.
        • Baren J.
        • Shea J.
        • Merchant R.
        Choosing wisely in emergency medicine: a national survey of emergency medicine academic chairs and division chiefs.
        Acad Emerg Med. 2015; 22: 1506-1510
        • Grijalva C.
        • Nuorti J.
        • Griffin M.
        Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.
        JAMA. 2009; 302: 758-766
        • Pallin D.
        • Espinola J.
        • Leung D.
        • Hooper D.
        • Camargo C.J.
        Epidemiology of dermatitis and skin infections in United States physicians' offices, 1993-2005.
        Clin Infect Dis. 2009; 49: 901-907
        • Popovich K.
        • Weinstein R.
        • Aroutcheva A.
        • Rice T.
        • Hota B.
        Community-associated methicillin-resistant Staphylococcus aureus and HIV: intersecting epidemics.
        Clin Infect Dis. 2010; 50: 979-987
        • Tattevin P.
        • Schwartz B.
        • Graber C.
        • et al.
        Concurrent epidemics of skin and soft tissue infection and bloodstream infection due to community-associated methicillin-resistant Staphylococcus aureus.
        Clin Infect Dis. 2012; 55: 781-788
        • Huang E.
        • Stafford R.
        National patterns in the treatment of urinary tract infections in women by ambulatory care physicians.
        Arch Intern Med. 2002; 162: 41-47
        • Sanchez G.
        • Master R.
        • Karlowsky J.
        • Bordon J.
        In vitro antimicrobial resistance of urinary Escherichia coli isolates among U.S. outpatients from 2000 to 2010.
        Antimicrob Agents Chemother. 2012; 56: 2181-2183
        • Baker M.
        • Barnard L.
        • Kvalsvig A.
        • et al.
        Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study.
        Lancet. 2012; 379: 1112-1119
        • Butler J.
        • Crengle S.
        • Cheek J.
        • et al.
        Emerging infectious diseases among indigenous peoples.
        Emerg Infect Dis. 2001; 7: 554-555
        • Institute of Medicine
        Unequal treatment: confronting racial and ethnic disparities in Health Care (full printed version).
        The National Academies Press, Washington DC2003
        • Hens J.
        • Heins A.
        • Grammas M.
        • Costello M.
        • Huang K.
        • Mishra S.
        Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.
        J Emerg Nurs. 2006; 32: 219-224
        • Tamayo-Sarver J.
        • Hinze S.
        • Cydulka R.
        • Baker D.
        Racial and ethnic disparities in emergency department analgesic prescription.
        Am J Public Health. 2003; 93: 2067-2073
        • Sidell D.
        • Shapiro N.
        • Bhattacharyya N.
        Demographic influences on antibiotic prescribing for pediatric acute otitis media.
        Otolaryngol Head Neck Surg. 2012; 146: 653-658
        • Fleming-Dutra K.E.
        • Shapiro D.J.
        • Hicks L.A.
        • Gerber J.S.
        • Hersh A.L.
        Race, otitis media, and antibiotic selection.
        Pediatrics. 2014; 134: 1059-1066
        • Frei C.
        • Mortensen E.
        • Copeland L.
        • et al.
        Disparities of care for African-Americans and Caucasians with community-acquired pneumonia: a retrospective cohort study.
        BMC Health Serv Res. 2010; 10: 143
        • Bach P.
        • Pham H.
        • Schrag D.
        • Tate R.
        • Hargraves J.
        Primary care physicians who treat blacks and whites.
        N Engl J Med. 2004; 351: 575-584
        • Boudreaux E.
        • Emond S.
        • Clark S.
        • Camargo C.J.
        Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status.
        Chest. 2003; 124: 803-812
        • Filbin M.R.
        • Arias S.A.
        • Camargo Jr., C.A.
        • Barche A.
        • Pallin D.J.
        Sepsis visits and antibiotic utilization in U.S. emergency departments*.
        Crit Care Med. 2014; 42: 528-535
        • Aronsky D.
        • Haug P.
        • Lagor C.
        • Dean N.
        Accuracy of administrative data for identifying patients with pneumonia.
        Am J Med Qual. 2005; 20: 319-328
        • Cadieux G.
        • Tamblyn R.
        Accuracy of physician billing claims for identifying acute respiratory infections in primary care.
        Health Serv Res. 2008; 43: 2223-2238