Abstract
Background
Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) ...discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge.
Methods
A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection.
Results
293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio aHR, 2.32; 95% confidence interval CI, 1.41–3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62–1.62). Surgical source control (aHR, .57; 95% CI, .37–.87) and addiction medicine consultation (aHR, .57; 95% CI, .38–.86) were both associated with reduced readmissions.
Conclusions
Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.
We observed a reduction in 90-day readmission rates in PWID with invasive infections who left AMA who were prescribed oral antibiotic therapy, compared with those who were not. Readmission rates among those who received outpatient oral antibiotics were similar to those who completed inpatient IV antibiotic therapy.
Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the ...focus within the emergency medicine community has been on opioid prescribing—specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment—interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.
Invasive Fungal Infections Secondary to Traumatic Injury Kronen, Ryan; Liang, Stephen Y.; Bochicchio, Grant ...
International journal of infectious diseases,
September 2017, 2017-Sep, 2017-09-00, 20170901, 2017-09-01, Letnik:
62, Številka:
C
Journal Article
Recenzirano
Odprti dostop
•Invasive fungal infection is a potentially serious complication of traumatic injury.•Mucorales is the most common pathogen involved in post-traumatic IFI.•Risk factors include injury type, receipt ...of a blood transfusion, and rhabdomyolysis.•Early surgical debridement and antifungal therapy are the mainstays of treatment.
Invasive fungal infection (IFI) is a rare but serious complication of traumatic injury. The purpose of this article is to review the epidemiology, natural history, mycology, risk factors, diagnosis, treatment, and outcomes associated with post-traumatic IFI in military and civilian populations. The epidemiology of post-traumatic IFI is poorly characterized, but incidence appears to be rising. Patients often suffer from severe injuries and require extensive medical interventions. Fungi belonging to the order Mucorales are responsible for most post-traumatic IFI in both civilian and military populations. Risk factors differ between these cohorts but include specific injury patterns and comorbidities. Diagnosis of post-traumatic IFI typically follows positive laboratory results in the appropriate clinical context. The gold standard of treatment is surgical debridement in addition to systemic antifungal therapy. Patients with post-traumatic IFI may be at greater risk of amputation, delays in wound healing, hospital complications, and death as compared to trauma patients who do not develop IFI. More research is needed to understand the factors surrounding the development and management of post-traumatic IFI to reduce the significant morbidity and mortality associated with this disease.
Monkeypox is an emerging viral disease that has been declared a global health emergency. While this disease has been present for over 50 years, the recent surge in cases and expanding knowledge of ...this has prompted a need for a focused review for practicing clinicians.
This narrative review provides a focused overview of the epidemiology, presentation, evaluation, and management of monkeypox for emergency clinicians.
Monkeypox is an orthopoxvirus endemic to central and western Africa. An outbreak in May and June 2022 across Asia, Europe, North America, and South America was declared a global health emergency in July 2022. The disease can be transmitted via contact with an infected animal or human, as well as contact with a contaminated material. The disease presents with a prodromal flu-like illness and lymphadenopathy. A rash spreading in a centrifugal manner involving the oral mucosa, face, palms, and soles is typical. Lesions progress along various stages. Complications such as bacterial skin infection, pneumonitis, ocular conditions, and encephalitis are uncommon. Confirmation typically includes polymerase chain reaction testing. The majority of patients improve with symptomatic therapy, and as of July 2022, there are no United States Food and Drug Administration-approved treatments specifically for monkeypox. However, antiviral treatment should be considered for several patient populations at risk for severe outcomes.
An understanding of the presentation, evaluation, and management of monkeypox is essential for emergency clinicians to ensure appropriate diagnosis and treatment of this emerging disease.
The emergency department (ED) presents unique challenges to infection control and prevention. Hand hygiene, transmission-based precautions, environmental cleaning, high-level disinfection and ...sterilization of reusable medical devices, and prevention of health care-associated infections (catheter-associated urinary tract infection, ventilator-associated pneumonia, central line-associated bloodstream infection) are key priorities in ED infection prevention. Effective and sustainable infection prevention strategies tailored to the ED are necessary and achievable. Emergency clinicians can and already play an invaluable role in infection prevention.
Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and ...therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential Sepsis-related Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8-30.7%) and 97.3% specific (95% CI 92.1-99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1-73.0%) and decreased the specificity to 78.0% (95% CI 69.0-85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5-80.9) and specificity of 86.2% (95% CI 78.3-92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.
Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to ...diagnose and treat.
This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician.
TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations.
TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.
OBJECTIVE To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage. DESIGN Prospective ...pilot study. SETTING Tertiary-care hospital. PARTICIPANTS A total of 36 HCWs were included in this study: 18 donned/doffed contact precaution (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE. INTERVENTIONS HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped, and protocol deviations were recorded. RESULTS Overall, 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning, and 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (P=.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, versus 1 among CP PPE HCWs. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 EVD PPE HCWs (44%) and 5 CP PPE HCWs (28%), most commonly on hands. MS2 was recovered from 2 EVD PPE HCWs (11%) and 3 CP PPE HCWs (17%). CONCLUSIONS Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCW doffing assistant and/or the trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study. Infect Control Hosp Epidemiol 2017;38:1077-1083.
•Composition of the nutrient solution is critical for microbial communities gasifying coal to methane.•Different environmental parameters need to be evaluated regarding their effects on methane ...production.•A methane yield of 828.9ft3/ton was observed in 30days from bituminous coal.
Biostimulation through providing nutrients to microorganisms has been proven to be highly effective in enhancing methane yield from bituminous coals in the Illinois basin. In light of the extremely cheap natural gas price at present, it is critically important to decrease the cost of nutrient solutions used to stimulate microbial gasification of coal and improve the cost-effectiveness of the biostimulation approach. To lower cost of a nutrient solution reported in previous studies, the three most expensive components, yeast extract, peptone and mercaptoethanesulfonic acid (Coenzyme M, CoM) were evaluated. Regarding the first two, decreasing their concentrations resulted in decreased methane production. In terms of CoM, its concentration could be reduced to at least half without affecting methane yield negatively. Complete elimination of CoM led to a methane yield of 85% of those with the presence of this compound in the original medium. Two complex media, trypticase soy broth (TSB) and corn steep liquor (CSL) were intended to replace yeast extract and peptone. TSB had increasingly positive effect with increasing its concentration while CSL had opposite trend. TSB at 100% (v/v) was then investigated under different cultivation conditions. Among the four parameters tested, TSB concentration and agitation were found to exert positive effect while coal loading and temperature had negative impact on methane production. The highest methane yield of 828.9ft3/ton in 30days was obtained under temperature of 28°C with a coal loading of 200g/L and agitation at 100rpm. This yield is four-time higher than those observed with the original medium. These results clearly demonstrated that biostimulation is a viable method for enhancing methane production from coal and the ingredients of nutrient solutions need to be evaluated in detail in order to make biostimulation cost-effectively at commercial scales.
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