Editorial
The challenge of infectious diseases in the emergency department: Presentation of 3 cases
El reto de la enfermedad infecciosa en los servicios de urgencias: a propósito de 3 estudios
Òscar Miró
Área de Urgencias, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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"contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 824 "Ancho" => 2105 "Tamanyo" => 114044 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Effects of inappropriate treatment on hospital stay, mortality and readmissions, both unadjusted and adjusted for demographic data, comorbidity, risk factors for resistant pathogens, sepsis in the ED and source of infection. <span class="elsevierStyleSup">a</span>Adjusted for admission<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>3 months, Charlson<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>3, chronic obstructive pulmonary disease, dementia, respiratory infection, sepsis in the ED, moderate-severe kidney failure, any risk factor for resistant microorganisms, nursing home resident, immunosuppression, peripheral vascular disease and antibiotic use for more than 7 days in the last month. <span class="elsevierStyleSup">b</span>Adjusted for diabetes, intra-abdominal infection and prior admission. <span class="elsevierStyleSup">c</span>Adjusted for admission<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>3 months, Charlson<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>3, chronic obstructive pulmonary disease, dementia, respiratory infection, sepsis in the ED, any risk factor for resistant microorganisms, tumour.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan González-del Castillo, Clara Domínguez-Bernal, María Cristina Gutiérrez-Martín, María José Núñez-Orantos, Francisco Javier Candel, Francisco Javier Martín-Sánchez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Juan" "apellidos" => "González-del Castillo" ] 1 => array:2 [ "nombre" => "Clara" "apellidos" => "Domínguez-Bernal" ] 2 => array:2 [ "nombre" => "María Cristina" "apellidos" => "Gutiérrez-Martín" ] 3 => array:2 [ "nombre" => "María José" "apellidos" => "Núñez-Orantos" ] 4 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Candel" ] 5 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Martín-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213005X15003778" "doi" => "10.1016/j.eimc.2015.10.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X15003778?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X17300825?idApp=UINPBA00004N" "url" => "/2529993X/0000003500000004/v1_201704140226/S2529993X17300825/v1_201704140226/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The challenge of infectious diseases in the emergency department: Presentation of 3 cases" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "207" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Òscar Miró" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Òscar" "apellidos" => "Miró" "email" => array:1 [ 0 => "omiro@clinic.cat" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Área de Urgencias, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El reto de la enfermedad infecciosa en los servicios de urgencias: a propósito de 3 estudios" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Infectious diseases are one of the most prevalent conditions treated in hospital emergency departments (EDs). However, they are also one of the most difficult to diagnose, as shown by the fact that more diagnostic errors occur with infectious diseases than with other conditions, and that 1 in 6 patients with fever discharged from EDs will be readmitted within 7 days of discharge.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2</span></a> Three research articles that underline the persistence of these diagnostic, treatment and prognostic challenges faced by ED physicians are presented in this issue of <span class="elsevierStyleItalic">Enfermedades Infecciosas y Microbiología Clínica</span>. While each article deals with a completely different condition, they are all studies conducted in hospital EDs by emergency department staff, hereinafter referred to as <span class="elsevierStyleItalic">emergency physicians</span>. This means that the questions that they pose and the solutions they recommend all fall under this particular remit.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In terms of diagnostic challenges, Morales-Casado et al. investigate the capacity of different biomarkers to establish a differential diagnosis between acute bacterial and viral meningitis.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> This is without a doubt one of the key unresolved problems of the 21st century, at least in terms of establishing a differential diagnosis during the patient's first consultation. In a retrospective series of 154 patients, the authors conclude that the biomarkers independently associated with acute bacterial meningitis diagnosis, in order of level of association, are: cerebrospinal fluid (CSF) lactate ≥33<span class="elsevierStyleHsp" style=""></span>mg/dl (odds ratio [OR]: 51), serum procalcitonin ≥0.8<span class="elsevierStyleHsp" style=""></span>ng/ml (OR: 46), glycorrhachia <60% blood glucose (OR: 21) and proportion of CSF polymorphonucleocytes >50% (OR: 20). Three aspects really stand out from the study's results. Firstly, according to the results of this and other studies,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,5</span></a> the classic glycorrhachia and leukocyte differential count parameters seem to have been superseded by CSF lactate and plasma procalcitonin. As other authors have also suggested,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> we are probably on the verge of a new paradigm in the differential diagnosis of meningitis in the ED. Before this can happen, however, certain deficiencies in hospital EDs will have to be addressed. While lactic acid availability is practically universal across EDs, the same cannot be said for procalcitonin. For example, only 20 of the 79 hospital EDs in Catalonia (25%) had the facility to measure procalcitonin 24<span class="elsevierStyleHsp" style=""></span>h a day in 2012, and in 58% this test was not available at any time of day.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Secondly, and following on from the point above, procalcitonin may be the first accurate non-CSF biomarker that can support the decision-making process. In fact, a concentration ≥0.8<span class="elsevierStyleHsp" style=""></span>ng/ml yields a positive predictive value of 98.5%, according to the results presented in the study. This means that antibiotic treatment should be initiated immediately if a patient presents with clinical symptoms of acute meningitis plus a procalcitonin value ≥0.8<span class="elsevierStyleHsp" style=""></span>ng/ml, even if symptoms are suggestive of viral meningitis. Finally, the results generated by the study by Morales-Casado et al. do not solve the problem posed by partially-treated meningitis; that is, those patients in whom a fall in CSF glycorrhachia and an increase in CSF polymorphonucleocytes cannot be determined as a result of prior antibiotic use. As such, when the authors analyzed patients with possible partially-treated meningitis, the expected increases in plasma procalcitonin and CSF lactate observed in confirmed cases were not seen in this patient population.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study by González del Castillo et al., on the other hand, dealt with the complex topic of appropriate antibiotic prescribing in hospital EDs.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> As in many other areas of clinical practice, this decision must initially be taken empirically. The authors report that antibiotics are inappropriately prescribed in approximately 1 out of every 10 patients, and that inappropriate prescribing is correlated to an increased length of hospital stay. It is important to point out that empirical antibiotic prescribing in EDs can improve. This takes on particular relevance if we assume the authors’ premise that such an improvement would lead to more optimal outcomes. In this regard, Monclús Cols et al. studied antibiotics prescribed by EDs to both admitted and discharged patients and found that, while the antibiotic administered in the ED was adequately adjusted to renal function in 95% of patients and dosing intervals were correct in 94% of cases, 37% of patients with positive cultures had to switch antibiotic in accordance with the microbiological isolates.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> As such, the implementation of clinical guidelines, establishment of consensus statements and founding of infection control committees should be the best tools for ensuring increasingly appropriate antibiotic prescribing in hospital EDs.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10,11</span></a> The advantage of the series by González del Castillo et al. is that it is quite a representative sample, the patients having been consecutively recruited when the authors were on duty. However, this is somewhat offset by the fact that the study was conducted in a single hospital ED and only included hospitalised patients. It should be noted that it is vitally important for <span class="elsevierStyleItalic">emergency physicians</span> to identify those patients discharged who are at the greatest risk of bacteraemia, as the possibility of correcting antibiotic therapy is smaller and would probably happen later.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Until recently, blood cultures have been taken systematically in patients diagnosed in the ED with major infections, such as pneumonia, urinary tract infection, cellulitis and gastroenteritis. However, numerous studies have questioned this practice in recent years and the debate continues to rage.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, Julián-Jiménez et al. tackle the crucial subject of establishing a prognosis in patients who attend hospital EDs due to infection.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> As important as choosing the appropriate treatment, the <span class="elsevierStyleItalic">emergency physician</span> must decide whether to admit or discharge the patient. Knowing the short-term prognosis of the patient plays a crucial role in this decision. This is never an easy decision, and is even more complicated in elderly patients in whom identifying warning signs can often be more difficult.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In this scenario, the study by Julián-Jiménez et al. has special merit. The authors propose a scale, known as LIBPAS, comprising serum lactate concentration, the Barthel index and systolic blood pressure, which offers extremely high diagnostic performance to predict 30-day mortality, with an area under the ROC curve of 0.971. On this basis, the authors propose certain cut-off points to separate groups with vastly differing mortality: from 4.5% in the low-risk group (0 points on the LIBPAS scale) to 95.5% in the high-risk group (5 points on the LIBPAS scale). These spectacular results require deeper analysis, both in terms of internal validation (not presented by the authors) as well as external validation in general clinical practice in hospital EDs. The LIBPAS scale was conceived from an observational study in 8 Spanish EDs for patients aged 75 years and above. One aspect that the study fails to clarify is the percentage of patients for whom treatment was withheld or limited, as it would appear that this option was chosen for a significant number of patients with a low Barthel index and low systolic blood pressure. If this were the case, the high mortality associated with a high LIBPAS score would be a reflection of the medical practice (palliative) rather than the severity of the condition, at least exclusively. Equally, the recommendation to admit patients with a high LIBPAS score to the intensive care unit, as proposed by the authors, could have limited scope in the specific target population. In any event, the study by Julián-Jiménez et al. underlines the importance of agreeing an approach to treating infectious disease in hospital EDs. In this light, the recent publication of the PIPA project (infection in elderly patients project) could represent the first step on this journey.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">I could not let this unique occasion pass, upon which 3 ED-based infection studies conducted by <span class="elsevierStyleItalic">emergency physicians</span> have been published in <span class="elsevierStyleItalic">Enfermedades Infecciosas y Microbiología Clínica</span>, without acknowledging the combined research efforts of both <span class="elsevierStyleItalic">infectologists</span> and <span class="elsevierStyleItalic">emergency physicians</span>; 2 medical specialties with no tradition thus far of contributing to medical research in Spain. Hospital emergency departments are a unique setting that play host to the first hours of acute conditions, including infections and, in exceptional cases, sepsis.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14,16,17</span></a> As such, there are certain aspects that can only be approached in this setting and the collaboration of both specialties is vital. This has been going on for some time in the field of cardiovascular disease, with promising results.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18–20</span></a> Multidisciplinary research is undoubtedly the key to advancing our knowledge of infectious diseases in the future, and this collaboration between the different specialties can only benefit the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest with regards to this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miró Ò. El reto de la enfermedad infecciosa en los servicios de urgencias: a propósito de 3 estudios. Enferm Infecc Microbiol Clin. 2017;35:205–207.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Error diagnóstico en urgencias: relación con el motivo de consulta, mecanismos y trascendencia clínica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Tudela" 1 => "J.M. Mòdol" 2 => "M.J. Rego" 3 => "M. Bonet" 4 => "B. Vilaseca" 5 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 8 | 2 | 10 |
| 2024 September | 6 | 4 | 10 |
| 2024 August | 12 | 3 | 15 |
| 2024 July | 12 | 1 | 13 |
| 2024 June | 13 | 4 | 17 |
| 2024 May | 13 | 3 | 16 |
| 2024 April | 20 | 4 | 24 |
| 2024 March | 26 | 6 | 32 |
| 2024 February | 8 | 1 | 9 |
| 2024 January | 16 | 0 | 16 |
| 2023 December | 20 | 3 | 23 |
| 2023 November | 7 | 1 | 8 |
| 2023 October | 19 | 1 | 20 |
| 2023 September | 6 | 2 | 8 |
| 2023 August | 18 | 3 | 21 |
| 2023 July | 6 | 4 | 10 |
| 2023 June | 16 | 0 | 16 |
| 2023 May | 41 | 7 | 48 |
| 2023 April | 35 | 0 | 35 |
| 2023 March | 20 | 1 | 21 |
| 2023 February | 8 | 3 | 11 |
| 2023 January | 57 | 5 | 62 |
| 2022 December | 11 | 2 | 13 |
| 2022 November | 17 | 7 | 24 |
| 2022 October | 9 | 8 | 17 |
| 2022 September | 14 | 3 | 17 |
| 2022 August | 9 | 7 | 16 |
| 2022 July | 10 | 5 | 15 |
| 2022 June | 9 | 8 | 17 |
| 2022 May | 18 | 7 | 25 |
| 2022 April | 6 | 6 | 12 |
| 2022 March | 13 | 6 | 19 |
| 2022 February | 26 | 3 | 29 |
| 2022 January | 15 | 7 | 22 |
| 2021 December | 15 | 10 | 25 |
| 2021 November | 9 | 10 | 19 |
| 2021 October | 38 | 9 | 47 |
| 2021 September | 16 | 7 | 23 |
| 2021 August | 7 | 5 | 12 |
| 2021 July | 9 | 6 | 15 |
| 2021 June | 13 | 4 | 17 |
| 2021 May | 15 | 8 | 23 |
| 2021 April | 30 | 9 | 39 |
| 2021 March | 13 | 12 | 25 |
| 2021 February | 7 | 6 | 13 |
| 2021 January | 8 | 8 | 16 |
| 2020 December | 11 | 6 | 17 |
| 2020 November | 9 | 2 | 11 |
| 2020 October | 12 | 4 | 16 |
| 2020 September | 15 | 7 | 22 |
| 2020 August | 6 | 6 | 12 |
| 2020 July | 1 | 0 | 1 |
| 2020 June | 9 | 3 | 12 |
| 2020 May | 14 | 8 | 22 |
| 2020 April | 8 | 3 | 11 |
| 2020 March | 7 | 5 | 12 |
| 2020 February | 5 | 3 | 8 |
| 2020 January | 6 | 2 | 8 |
| 2019 December | 11 | 9 | 20 |
| 2019 November | 8 | 1 | 9 |
| 2019 October | 12 | 6 | 18 |
| 2019 September | 8 | 2 | 10 |
| 2019 August | 2 | 1 | 3 |
| 2019 July | 7 | 13 | 20 |
| 2019 June | 15 | 3 | 18 |
| 2019 May | 34 | 18 | 52 |
| 2019 April | 9 | 2 | 11 |
| 2019 March | 6 | 1 | 7 |
| 2019 February | 6 | 5 | 11 |
| 2019 January | 4 | 1 | 5 |
| 2018 December | 0 | 2 | 2 |
| 2018 November | 4 | 1 | 5 |
| 2018 October | 0 | 8 | 8 |
| 2018 September | 4 | 0 | 4 |
| 2018 August | 5 | 0 | 5 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 2 | 1 | 3 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 2 | 0 | 2 |
| 2018 January | 6 | 0 | 6 |
| 2017 December | 10 | 2 | 12 |
| 2017 November | 8 | 1 | 9 |
| 2017 October | 8 | 0 | 8 |
| 2017 September | 5 | 0 | 5 |
| 2017 May | 3 | 0 | 3 |
| 2017 April | 12 | 1 | 13 |
| 2017 March | 0 | 1 | 1 |
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