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Resumen Introduccion El diagnostico y el tratamiento precoces de la sepsis sigue siendo un reto en los servicios de urgencias hospitalarios. Objetivo El objetivo es evaluar el rendimiento de la escala quick Sequential related Organ Failure Assessment (qSOFA) para la activacion de un Codigo Sepsis en urgencias, respecto la aplicacion de los criterios previos basados en los parametros Systemic Inflammatory Response Syndrome (SIRS). Metodos Se incluyeron los pacientes ≥ 18 anos que consultaron en un servicio de urgencias de un hospital de tercer nivel durante dos periodos de tiempo (mayo-octubre de 2015) mediante criterios SIRS (grupo SIRS), y en los mismos meses de 2017 mediante criterios qSOFA (grupo qSOFA). Resultados Se analizaron 125 episodios: 70 correspondieron al grupo SIRS y 55 al grupo qSOFA. Los grupos fueron comparables respecto a antecedentes, con mayor presencia de enfermedad neoplasica en el grupo qSOFA. No se evidenciaron diferencias en la forma de presentacion, la actuacion realizada en urgencias, los ingresos en unidades de criticos, el uso de vasopresores o la estancia media hospitalaria entre los dos grupos. Si se objetivo una mayor tasa de mortalidad a 30 dias en el grupo qSOFA (21,81% vs 4,3%; p = 0,003). En el estudio multivariado destaca la enfermedad neoplasica como factor independiente de mal pronostico (OR: 5,36; p = 0,01), y la activacion mediante criterios SIRS como factor de buen pronostico (OR: 0,15; p = 0,021). Conclusiones La activacion del Codigo Sepsis mediante criterios qSOFA comporta una disminucion en la deteccion, con mayor mortalidad asociada. Es necesario buscar otras herramientas complementarias para la deteccion precoz de la sepsis en urgencias.

The early diagnosis and treatment of sepsis remains a challenge in hospital emergency departments.The objective was to evaluate the performance of the qSOFA (quick Sequential related Organ Failure Assessment) for activating a Sepsis Code in the emergency department, compared to applying previous criteria based on SIRS (Systemic Inflammatory Response Syndrome).Patients ≥18years were included who consulted an emergency department of a tertiary hospital over two periods of time (May-October 2015), using SIRS criteria (SIRS Group) and over the same months in 2017 using qSOFA criteria (qSOFA Group).One hundred and five episodes were analysed: 70 corresponded to the SIRS Group and 55 to the qSOFA Group. The groups were comparable in terms of history, with a greater presence of neoplastic disease in the qSOFA Group. No differences were observed in the form of presentation, the action taken in the emergency department, admissions to critical care units, use of vasopressors or mean hospital stay between the two groups. A higher 30-day mortality rate was observed in the qSOFA group (21.81% vs. 4.3%; P=.003). In the multivariate study, neoplastic disease was noteworthy as an independent factor of poor prognosis (OR 5.36; P=.01), and activation using the SIRS criteria as a factor of good prognosis (OR .15; P=.021).The activation of the Sepsis Code using qSOFA criteria results in a reduction in detection, with greater associated mortality. Other complementary tools need to be sought for the early detection of sepsis in the emergency department.

Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in the general population. Stroke prevention is one of the leading management objectives in the treatment of AF patients. The variables associated with the non-initiation of thromboprophylaxis in patients with thrombotic risk consulting for an episode of AF in Emergency Departments (ED) were investigated. This was a multipurpose, analytical, non-interventionist, multicenter Spanish study with a prospective 30-day follow-up. All patients >= 18 years of age consulting to the ED for the casual finding of AF in an electrocardiogram (ECG) performed 12 h prior to the consultation or with symptoms related to AF were enrolled from September 1, 2016 to February 28, 2017. Patients not previously received thromboprophylaxis were selected. Multivariate analysis was performed to calculate the odds ratio (OR) and the 95% confidence interval (CI). A total of 634 patients, not received thromboprophylaxis and at high thrombotic risk, were included. Of these, 251 (39.6%) did not receive thromboprophylaxis at ED discharge. In the multivariate analysis, non-initiation of anticoagulation at discharge from the ED was mostly related to cognitive impairment (OR 3.95; (95% CI 2.02-7.72), cancer history (OR 2.12; (95%CI 1.18-3.81), AF duration < 48 h (OR 2.49; (95% CI 1.48-4.21) and patients with re-establishment of sinus rhythm (OR 3.65; (95% CI 1.47-9.06). Reinforcement of the use of CHA(2)DS(2)-VASC as a stroke risk scale and empowerment of ED physicians is a must to improve this gap in care.

Aims We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. Methods and Results We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. Conclusions PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Healthcare-related Legionnaires’ disease has a devastating impact on high risk patients, with a case fatality rate of 30-50%. Legionella prevention and control in hospitals is therefore crucial. To control Legionella water colonisation in a hospital setting we evaluated the effect of pipeline improvements and temperature increase, analysing 237 samples over a two-year period (first year: 129, second year: 108). In the first year, 25.58% of samples were positive for Legionella and 16.67% for amoeba. Assessing the distance of the points analysed from the hot water tank, the most distal points presented higher proportion of Legionella colonisation and lower temperatures (nearest points: 6.4% colonised, and temperature 61.4°C; most distal points: 50% and temperature 59.1°C). After the first year, the hot water system was repaired and the temperature stabilised. This led to a dramatic reduction in Legionella colonisation, which was negative in all the samples analysed; however, amoeba colonisation remained stable. This study shows the importance of keeping the temperature stable throughout the circuit, at around 60°C. Special attention should be paid to the most distal points of the circuit; a fall in temperature at these weak points would favour the colonisation and spread of Legionella, because amoeba (the main Legionella reservoir) are not affected by temperature.

Resumen Objetivos El objetivo de este trabajo fue evaluar el efecto de la vacunacion antigripal en la prevencion de casos graves asociados a gripe en pacientes adultos atendidos en un hospital de tercer nivel durante la temporada epidemica 2017-2018. Metodologia Se realizo un analisis descriptivo con toda la poblacion de sujetos con gripe confirmada por laboratorio en la temporada 2017-2018. Se definio caso grave como el ingreso en unidades de criticos o muerte. El efecto de la vacuna en la poblacion adulta se determino mediante analisis de regresion logistica multivariante. Resultados Entre las semanas epidemiologicas 44/2017 y 19/2018, el laboratorio del hospital detecto 706 muestras positivas de virus influenza. De los 551 pacientes confirmados de 18 anos o mas, cuarenta y tres fueron ingresados en alguna de las unidades de criticos del hospital y 26 fallecieron durante el ingreso. El modelo multivariante explicativo mostro la vacunacion de la gripe durante la temporada de estudio como factor protector del desarrollo de gravedad [OR: 0,27 (0,11-0,65), p = 0,004], ajustada por edad [1,03 (1,01-1,06), p = 0,04], sexo, tipo de virus (H1N1-pdm09, H3N2 o B) y el estar clasificado como Paciente Cronico Complejo o Enfermedad Avanzada Cronica. Conclusiones La vacuna de la gripe se muestra como factor protector frente al desarrollo de complicaciones en una temporada en la que la vacuna no contiene el virus que mas ha circulado entre la poblacion. Se debe recomendar la vacuna antigripal con periodicidad anual a los grupos de riesgo establecidos por las autoridades sanitarias.

Puntos para una lectura rapida • En los ultimos anos, la resistencia a los antibioticos se ha intensificado, y se ha convertido en una amenaza para la salud publica. • El consumo de antibioticos esta directamente relacionado con el desarrollo de resistencias. • La presion selectiva de los antibioticos sobre las bacterias se incrementa a medida que se alarga la duracion del tratamiento. • La duracion de los tratamientos es uno de los aspectos que hay que tener en cuenta en la valoracion de la idoneidad de la antibioticoterapia. • La disminucion de la duracion del tratamiento antibiotico es una de las estrategias clave de los programas de optimizacion del uso de antibioticos. • Los tratamientos cortos han demostrado ser eficaces, con menos efectos adversos y riesgo de seleccion de resistencias, ademas de ser mas economicos y favorecer la adherencia al tratamiento. • El elevado consumo de antibioticos y el importante porcentaje de tratamientos inapropiados en la atencion primaria ofrece una gran oportunidad para su optimizacion. • Gran parte de las infecciones atendidas a nivel de la atencion primaria pueden ser tratadas con cursos de tratamientos antibioticos iguales o inferiores a 7 dias. • Es necesario promover el cambio hacia la optimizacion de las duraciones de los tratamientos antibioticos lo mas cortas posible, segun la evidencia disponible. • Actualmente, no hay evidencia para indicar tratamientos cortos en pacientes con inmunosupresion, infecciones graves, infecciones quirurgicas con mal control del foco o infecciones protesicas.

Resumen Objetivos Evaluar el impacto de la implantacion de un codigo sepsis (CS) en la evolucion de pacientes con sepsis grave (SG)/shock septico (SS). Determinar los factores independientes asociados a mortalidad. Metodo Estudio de cohortes de pacientes con diagnostico de SG/SS que consultaron en urgencias de un hospital terciario durante 6 meses. Se analiza el cumplimiento de las recomendaciones de la Surviving Sepsis Campaign, la estancia media, el ingreso en criticos y la mortalidad a 30 dias. Se comparan 2 grupos: activacion CS (A) y no activacion (NA). Resultados Se detectaron 114 episodios, 61,4% del grupo A y 38,6% del NA. El grupo A presenta con mayor frecuencia presion arterial sistolica 3 mmol/l (48,3% vs 80%; p = 0,01) y foco abdominal (34,3% vs 13%; p = 0,01). En el grupo A mas frecuentemente se cursaron hemocultivos en la primera hora (95% vs 41,7%; p Una determinacion de proteina C reactiva > 200 mg/l (odds ratio 33,7; p Conclusiones La implantacion de un CS mejora el cumplimiento de las recomendaciones y se asocia a una reduccion de los ingresos en unidades de criticos, estancia media y mortalidad. La elevacion de la proteina C reactiva y la no activacion del codigo son factores independientes asociados a mortalidad. Existe un gran margen de mejora en la deteccion de los pacientes con SG/SS, asi como en la optimizacion del tratamiento inicial en urgencias.

Introduction Influenza vaccination rates in risk groups remain suboptimal. Evidence supporting a significant association between influenza vaccination and severe illness is limited. Methods We retrospectively analyzed the epidemiological characteristics of out- and inpatients with laboratory-confirmed influenza infection attended during the 2018–19 epidemic season. Influenza vaccination coverage by indication was analyzed. Logistic regression was used to compare the odds of vaccination between severe and non-severe influenza-positive patients. Severe cases were defined as presenting pneumonia, admission to critical care units and/or death. Results The overall vaccination coverage among influenza-positive patients was 30.4%. In subjects with ≥ 1 indication for vaccination, the vaccination coverage was 42.4%. By indication, coverage rates were: 52.5% in patients aged ≥ 59 years, 42.2% in obese patients, 29.2% in immunosuppressed subjects and 6.5% in pregnant women. In patients with underlying chronic diseases, a higher coverage was found in patients with cognitive impairment (77%), muscular dystrophy (63.6%) and renal disease (60.4%). The multivariate logistic regression model showed severe influenza-related illness was associated with a lack of influenza vaccination before seeking care during the 2018–2019 season [0.59 (95%CI 0.36–0.97); p = 0.038], older age [1.01 (95%CI 1.00–1.02); p = 0.009] and current or former smoking status [1.63 (95%CI 0.84–3.18) and 2.03 (95%CI 1.16–3.57); p = 0.031], adjusted by underlying disease. Conclusion Adjusting by age, smoking status and underlying disease, a moderate association between the influenza vaccine and severe laboratory-confirmed influenza-related illness was found in an epidemic season in which there was matching between the vaccine and circulating strains. Protection against complications, especially in older subjects and in those with underlying disease is postulated as one of the strengths of annual influenza vaccination. However, influenza vaccination is a pending issue in these groups, especially in pregnant women and obese people. To avoid suboptimal vaccination coverages, health professionals should recommend the seasonal influenza vaccination according to the annual instructions of the health authorities.

Objective Amiodarone is a widely used drug in the emergency department (ED) for control of atrial fibrillation, but it has a delayed onset of action and slow metabolism, leading to longer length of ED stay. The aim of this study was to compare the length of ED stay of atrial fibrillation patients who were treated with or without amiodarone. Methods We undertook a multicenter, observational, cohort study of the URGFAICS registry of older adults with atrial fibrillation who presented to five Spanish EDs and compared patients who had received amiodarone with those who had not. Afterward, we performed a propensity score matched analysis of atrial fibrillation to determine the ED length of stay related to amiodarone. Results Of the 1199 patients included in the registry, 225 patients (18.8%) were treated with amiodarone while 974 (81.2%) were not. We performed a univariate study depending on amiodarone administration followed by propensity score calculation according to the 14 statistically different features found previously and six significant variables, obtaining 150 patients (75 for each group) suitable for the analysis. The length of ED stay was analyzed using box plot, with a P

Objective: We investigated the incidence, risk factors, clinical characteristics and outcome of spontaneous pneumothorax (SP) in COVID-19 patients attended in emergency departments (ED) before hospitalization. Methods: We retrospectively reviewed all COVID patients diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs), during the first two months of the COVID outbreak and compared them with two control groups: COVID patients without SP (control group A) and non-COVID patients with SP (control group B). Relative frequencies of SP were estimated in cases and control group B. Unadjusted comparisons between cases and controls included 52 clinical, analytical and radiological characteristics and 4 outcomes. Results: We identified 40 SP in 71,904 patients with COVID-19 attending EDs (0.56‰, 95%CI=0.40-0.76‰). This incidence was higher than that observed in non-COVID patients (387/1,358,134, 0.28‰, 95%CI=0.26-0.32; OR=1.93, 95%CI=1.41-2.71). In COVID patients the characteristics associated with a higher risk of SP were: male sex, shorter symptom length, less fever, greater dyspnea, tachycardia, tachypnea and hypoxia, higher hemoglobin, leukocyte count, D-dimer and LDH, and lower lymphocyte count. Compared to control group B, case group patients were older, more frequently had obesity, asthma, dyspnea, tachycardia, tachypnea, hypoxia and analytical disturbances, and less frequently diabetes mellitus, hypertension, smoker habit, and chest pain. All the outcomes measured, including in-hospital death, were worse in cases than in control groups A and B. Conclusions: SP as a form of COVID presentation is unusual (

Resumen: Antecedentes: Poder aprender de sus errores supone para los clínicos un elemento de gran interés. Esta función la plantea la retroinformación clínica en sentido formativo (feedback), reconocida como un elemento útil en la mejora de la calidad asistencial y la seguridad clínica. Objetivos: Describir nuestra experiencia en feedback formativo, analizando las características de los casos clínicos incorporados, así como la opinión de los profesionales que recibieron la formación. Material y métodos: Estudio descriptivo, que recoge la experiencia de un año, en la práctica de feedback formativo sobre incidentes clínicos. Se determinó: fuente de notificación, descripción del incidente e impacto clínico, mensajes clave y tipo de feedback (grupal y/o individual). Así mismo, se planteó una encuesta de opinión al grupo de facultativos. Resultados: Se incluyeron 27 casos, que suponen un 0,06% de las asistencias. Las fuentes de notificación fueron: el propio SUH en 19 (70,3%) casos, unidad de atención a la ciudadanía en 3 (11,1%), dirección de calidad en 2 (7,4%), unidad de admisiones en 2 (7,4%) y servicio de microbiología en uno (3,7%). Los casos correspondían en un 7,4% a aspectos de carácter diagnóstico, 40,7% terapéutico, y 55,5% de ambos. La encuesta a los profesionales, aunque con una participación del 36%, mostró unas valoraciones positivas en todos los aspectos planteados. Conclusiones: Incorporar el feedback formativo para los profesionales resulta factible, parece ser bien recibido y podría representar una herramienta útil en la mejora de la seguridad clínica. Abstract: Background: To learn from one's mistakes is an element of great interest for clinicians. This strategy is proposed as clinical feedback in a training sense, recognized as a useful element for the improvement of healthcare quality and clinical safety. Objectives: To describe our experience in training feedback, analysing the characteristics of the clinical cases included, as well as the opinion of the professionals who received the training. Material and methods: A descriptive study, which gathers the experience of one year in the practice of educational feedback on clinical incidents. Source of notification, description of the incident and clinical impact, key messages and type of feedback (individual and / or group level) were determined. In addition, an opinion survey was proposed to all the doctors. Results: 27 cases were included, which represent .06% of the total medical care provided. The sources of notification were the emergency department in 19 (70.3%) cases, citizenship unit 3 (11.1%), quality management 2 (7.4%), admissions unit 2 (7.4%) and microbiology department 1 (3.7%). Of the cases, 7.4% corresponded to aspects related to diagnosis, 40.7% to therapy, and 55.5% to both. The survey for professionals showed a predominance of positive assessments in all aspects raised, although participation was 36%. Conclusions: Incorporating training feedback for professionals is feasible, seems to be well accepted and could prove a useful tool for improving clinical safety. Palabras clave: Feedback formativo, Seguridad clínica, Urgencias, Keywords: Training feedback, Clinical safety, Emergency

To evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality.All patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients' average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA).A total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs 34.4%; P=.005). Patients in group NA more frequently had lactate levels of3mmol/L (48.3% vs 80%; P=.01), and abdominal focus of sepsis (34.3% vs 13%; P=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs 41.7%; P.001), early antibiotic was administered (76.9% vs 25%; p=.005) and fluid replacement carried out (54.5% vs 18.2%; P=.01). Global achievement of CS objectives was higher in group A (31.4% vs 9.1%; P=.006). In group NA more patients were admitted to the intensive care unit (10% vs 36.4%; P.001), had longer average stays (10.2 days SD 6.9 vs 14.4 days SD 5.8; P.001) and a higher mortality rate (4.3% vs 34.1%; P.001). CRP200mg/l (OR 33.7; P.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality.The implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.

Recent years have seen a range of measures deployed to curb crowding in hospital emergency departments, but as episodes of overcrowding continue to occur the discussion of causes and possible solutions remains open. The problem is universal, and efforts to revamp health care systems as a result of current socioeconomic circumstances have put emergency services in the spotlight. Consensus was recently achieved on criteria that define emergency department overcrowding. The causes are diverse and include both external factors and internal ones, in the form of attributes specific to a department. The factors that have the most impact, however, involve hospital organization, mainly the availability of beds and the difficulty of assigning them to emergency patients requiring admission. Crowding is associated with decreases in most health care quality indicators, as departments see increases in the number of patients waiting, the time until initial processing, and the time until a physician or nurse intervenes. Crowding is also associated with risk for more unsatisfactory clinical outcomes. This situation leads to dissatisfaction all around-of patients, families, and staff-as aspects such as dignity, comfort, and privacy deteriorate. Proposals to remedy the problem include assuring that the staff and structural resources of a facility meet minimum standards and are all working properly, facilitating access to complementary tests, and providing observation areas and short-stay units. The response of hospitals to the situation in emergency departments should include alternatives to conventional admission, through means for rapid diagnosis, day hospitals, and home hospitalization as well as by offering a clear response in cases where admission is needed, granting easier access to beds that are in fact available. For its part, the health system overall, should improve the care of patients with chronic diseases, so that fewer admissions are required. It is also essential to search for ways to bring the supply of necessary social and health care services more in step with demand.En los últimos años hemos asistido al despliegue de diferentes medidas de desarrollo de los SUH, pero a pesar de ello los episodios de saturación siguen sucediéndose y el debate en cuanto a sus causas y posibles soluciones sigue abierto. Se trata de un problema universal y en el momento actual las circunstancias socioeconómicas comportan un replanteamiento del sistema sanitario, en el que los SUH tendrán un papel crucial. Recientemente se han consensuado los criterios concretos que definen una situación de saturación en los SUH. Las causas de la saturación son diversas e implican aspectos tanto externos a los SUH como intrínsecos a la propia unidad. Pero los más determinantes son propios de la dinámica hospitalaria, fundamentalmente la dificultad en adjudicación de cama para ingreso y en su disponibilidad real. Esta saturación se asocia a un descenso de la mayoría de indicadores de calidad. Así mismo, se incrementan el número de pacientes que esperan ser atendidos, el tiempo de espera para el inicio de la asistencia y el tiempo de actuación médico-enfermería. Además conlleva un alto riesgo de peores resultados clínicos. Esta situación conduce a la insatisfacción de pacientes, familiares y personal sanitario y a deterioro de aspectos como la dignidad, la comodidad o la confidencialidad. Las propuestas de mejora pasan por asegurar unos mínimos recursos estructurales y de personal, y agilizar algunas exploraciones complementarias, así como implementar áreas de observación y unidades de corta estancia. La respuesta de los centros a los SUH debería incluir alternativas a la hospitalización convencional con dispositivos de diagnóstico rápido, hospitales de día y hospitalización domiciliaria, así como acciones de respuesta bien definidas a las necesidades de ingreso hospitalario, con agilización de la disponibilidad real de camas. El sistema sanitario por su parte debería mejorar el control de los pacientes crónicos para reducir las necesidades de ingreso, y adecuar la oferta a las necesidades reales de atención sociosanitaria.

Purpose To assess the correlation of procalcitonin (PCT), C-reactive protein (CRP), neopterin, mid-regional pro-atrial natriuretic peptide (MR-proANP), and mid-regional pro-adrenomedullin (MR-proADM) with severity risk scores: severe CAP (SCAP) and SMART-COP in patients with community-acquired pneumonia (CAP), as well as short term prognosis and to determine the correlation with mortality risk scores. Methods Eighty-five patients with a final diagnosis of pneumonia were consecutively included during a two month period. Epidemiological, clinical, microbiological, and radiological data were recorded. Patients were stratified according to the PSI, CURB-65, SCAP and SMART-COP. Complications were defined as respiratory failure/shock, need of ICU, and death. Plasma samples were collected at admission. Results MR-proANP and MR-proADM showed significantly higher levels in high risk SCAP group in comparison to low risk. When considering SMART-COP none of the biomarkers showed statistical differences. MR-proADM levels were high in patients with high risk of needing intensive respiratory or vasopressor support according to SMRT-CO. Neopterin and MR-proADM were significantly higher in patients that developed complications. PCT and MR-proADM showed significantly higher levels in cases of a definite bacterial diagnosis in comparison to probable bacterial, and unknown origin. MR-proANP and MR-proADM levels increased statistically according to PSI and CURB-65. Conclusions Biomarker levels are higher in pneumonia patients with a poorer prognosis according to SCAP and SMART-COP indexes, and to the development of complications.

Resumen Fundamento y objetivos Valorar la relacion entre algunas variables clinicas y analiticas, y la existencia de bacteriemia para establecer un modelo predictivo. Pacientes y metodo Se analizaron durante 2 meses los casos atendidos en Urgencias con muestras para hemocultivos. Se elaboro con el grupo de derivacion un modelo predictivo de bacteriemia y se valido en el grupo restante. Las variables significativas del analisis univariado se sometieron a regresion logistica y de esta se derivo una puntuacion. Se calculo la prevalencia de bacteriemia para cada puntuacion en ambos grupos. Se evaluo la calibracion del modelo por la prueba de Hosmer-Lemeshow, se calcularon las curvas de eficacia diagnostica y el rendimiento del modelo. Resultados Se incorporaron al estudio 412 casos, los hemocultivos fueron positivos en el 12,8 %. Las variables significativas en el analisis multivariado fueron un indice de Charlson superior o igual a 2 y una procalcitonina superior a 0,4 ng/ml. Con el sistema de puntuacion (1 y 2 puntos, respectivamente) se establecieron 4 grupos de probabilidad creciente de bacteriemia; del 0–35% en el grupo de derivacion y del 2,9–27,2% en el de validacion. En la curva de eficacia diagnostica, el area bajo la curva fue de 0,80 en el grupo de derivacion y de 0,74 en el de validacion. El modelo presento un valor predictivo negativo del 95,2% en el grupo de derivacion y del 95,3% en el de validacion. Conclusiones Se propone un modelo de prediccion con las variables indice de Charlson y procalcitonina que permite delimitar un grupo con muy baja probabilidad de bacteriemia.

Fundamento y objetivo En el ano 2001 tuvo lugar en Murcia un brote de enfermedad del legionario (EL) con una de las tasas de mortalidad mas bajas conocidas. Los objetivos de este estudio fueron describir la presentacion clinica y los resultados de los estudios molecular y de virulencia de los aislamientos clinicos de Legionella para correlacionar la baja mortalidad de la serie con la virulencia de la cepa. Pacientes y metodo Estudio prospectivo y descriptivo de un brote de EL en un subgrupo de 86 pacientes. Se analizan datos demograficos, factores de riesgo y evolucion clinica. Se ha practicado subtipificacion molecular mediante electroforesis en campo pulsatil y estudio de citopatogenicidad de los aislamientos clinicos y se han comparado con los de aislamientos procedentes de otros brotes. Resultados La edad media fue de 58,2 anos, con predominio del sexo masculino (77,9%). El tabaquismo fue el factor de riesgo mas frecuente (71,7%). El 70,2% de los pacientes presentaba enfermedades de base. Las manifestaciones clinicas, los datos de laboratorio y la radiologia fueron compatibles con un cuadro de neumonia atipica. La mortalidad fue del 3,2%. Todos los aislamientos clinicos de Legionella pneumophila mostraron el mismo subtipo molecular. En el estudio de citopatogenicidad, las cepas de Legionella procedentes del brote se incluyeron dentro del grupo de menor virulencia. Conclusiones En este subgrupo de pacientes predominaron el sexo masculino, el tabaquismo, la presentacion clinica compatible con neumonia atipica y la baja mortalidad. La baja virulencia de este genotipo molecular de L. pneumophila podria ser causante, en parte, de la baja mortalidad observada en el brote de Murcia.

Fundamento y objetivo Analizar la relacion entre motivo de consulta y error diagnostico, los mecanismos clinicos de este, y la trascendencia clinica del error, en pacientes atendidos en un area medica de urgencias. Pacientes y metodo Se analizan los ingresos en el area medica comparando los diagnosticos en urgencias y al alta para detectar los casos con error. Se compararon las variables edad, sexo, horario y motivo de consulta, estancia y mortalidad, entre los grupos con y sin error. Los casos con error diagnostico se analizaron para determinar los mecanismos del error y su trascendencia clinica. Resultados Se detectaron 42 casos (6,2%) con error diagnostico. No se encontraron diferencias significativas en cuanto a la distribucion de edad, sexo, horario, dias de estancia y mortalidad, pero si en cuanto a los diferentes motivos de consulta, siendo la fiebre la que presento una mayor y significativa frecuencia de error (p Conclusiones Los errores diagnosticos en urgencias son mas frecuentes en los pacientes que consultan por fiebre. Se producen mayoritariamente en relacion con una anamnesis sobre los sintomas actuales o exploracion fisica insuficientes, o con una interpretacion erronea de la radiologia. Aunque a menudo implican retrasos en el inicio de tratamientos especificos, no incrementan la estancia hospitalaria ni la mortalidad.

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

Nasopharyngeal aspirates, collected during outbreaks, of the novel influenza A (H1N1) virus in Barcelona, were used to compare the accuracy of a rapid antigen-based test (Binax) with the real-time RT-PCR assay developed by the CDC. The sensitivity, specificity and positive predictive value of the rapid test are higher in patients less than 18 years old and during the acute stage of the epidemic than in adult patients.

Sabado 1 Diciembre 2007. Volumen 129 - Numero 20 p. 770 - 772 Texto completo Descargar PDF Buscar en medline articulos de: Pere Tudela Josep Maria Modol Montserrat Gimenez Cristina Prat Blanca Vilaseca Jordi Tor Buscar: en Medicina Clinica en Vol. 129, Num. 20 Busqueda avanzada Originales breves Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los ultimos 10 anos Pere Tudelaa Josep Maria Modola Montserrat Gimenezb Cristina Pratb Blanca Vilasecac Jordi Tord aUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. bServicio de Microbiologia. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. cUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. dServicio de Medicina Interna. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. Fundamento y objetivo: Conocer la incidencia anual de bacteriemia en pacientes no hospitalizados (BPNH), analizar sus caracteristicas clinicas y epidemiologicas, asi como sus tendencias evolutivas. Pacientes y metodo: Se analizo un periodo de 10 anos, durante el cual se contabilizaron el porcentaje de hemocultivos positivos y, de estos, el porcentaje de BPNH. Se recogieron los siguientes parametros: ano, mes, edad, sexo, diagnostico inicial, factores de riesgo para la bacteriemia, microorganismo, diagnostico final, concordancia entre ambos y necesidad de ingreso. Se clasificaron en: infeccion urinaria, respiratoria, abdominal, de cateter venoso (ICV), cutanea, endocarditis, bacteriemia sin focalidad aparente (BSFA) y un grupo miscelanea. Se compararon las variables edad, sexo, ano y mes entre los grupos con y sin diagnostico concordante. Resultados: Se registraron 283 episodios. El porcentaje de hemocultivos positivos se mantuvo constante, mientras que el de BPNH tendio a descender. El microorganismo mas frecuente fue Escherichia coli (56,5%), y los principales focos, el urinario (59,7%) y la BSFA (19,7%). Los diagnosticos inicial y final no eran concordantes en el 37,1% de los casos. Preciso ingreso el 30,3%. Se detecto infeccion urinaria en el 93,5% de los casos, ICV solo en el 6,2% y ninguna BSFA. La presencia de los principales factores de riesgo para la bacteriemia a lo largo de los anos mostro un descenso de la infeccion por el virus de la inmunodeficiencia humana, mientras que se advertia un ascenso de las enfermedades neoplasicas. Conclusiones: La BPNH, en nuestra experiencia, tiende a un descenso progresivo. La de origen urinario no parece preocupante, mientras que es mejorable la sospecha de ICV. La BSFA constituye el grupo mas preocupante y supone un reto diagnostico para el futuro

Achieving a rapid microbiological diagnosis is crucial for decreasing morbidity and mortality of patients with a bloodstream infection, as it leads to the administration of an appropriate empiric antimicrobial therapy. Molecular methods may offer a rapid alternative to conventional microbiological diagnosis involving blood culture. In this study, the performance of a new technology that uses broad-spectrum PCR coupled with mass spectrometry (PCR/ESI-MS) was evaluated for the detection of microorganisms directly from whole blood. A total of 247 whole blood samples and paired blood cultures were prospectively obtained from 175 patients with a suspicion of sepsis. Both sample types were analyzed using the PCR/ESI-MS technology, and the results were compared with those obtained by conventional identification methods. The overall agreement between conventional methods and PCR/ESI-MS performed in blood culture aliquots was 94.2% with 96.8% sensitivity and 98.5% specificity for the molecular method. When comparing conventional methods with PCR/ESI-MS performed in whole blood specimens, the overall agreement was 77.1% with 50% sensitivity and 93.8% specificity for the molecular method. Interestingly, the PCR/ESI-MS technology led to the additional identification of 13 pathogens that were not found by conventional methods. Using the PCR/ESI-MS technology the microbiological diagnosis of bloodstream infections could be anticipated in about half of the patients in our setting, including a small but significant proportion of patients newly diagnosed. Thus, this promising technology could be very useful for the rapid diagnosis of sepsis in combination with traditional methods.

Fundamento Conocer la concordancia diagnosticaentre urgencias y hospitalizacion, analizandoel indice de error, sus caracteristicasepidemiologicas y motivos fundamentales. Pacientes y metodo Se analizaron los ingresosen el area medica, estableciendo tres nivelesde concordancia: coincidente (A), sindromica(B) y erronea (C). Se compararon lasvariables edad, sexo, horario y estancia, enlos grupos A + B y C. En el grupo C se determinoel motivo fundamental del error. Resultados La concordancia fue nivel A enel 88,1%, B en el 7,3% y C en el 4,6%. Nohubo diferencias significativas en la distribucionde las variables analizadas. Los motivosde error mas frecuentes fueron una valoracionclinica insuficiente (50%) y la interpretacionde la radiografia de torax (28,6%). Conclusiones La concordancia diagnosticafue mayoritaria, con un indice de error inferioral 5%. No hallamos un perfil epidemiologiconi clinico caracteristico del error. Elmotivo mas frecuente de error fue una insuficientevaloracion clinica.

Fundamento Conocer la frecuencia con que se realizala puncion lumbar (PL) en urgencias y susindicaciones, asi como su rendimiento diagnosticoen la sospecha de infeccion del sistema nerviosocentral (ISNC). Pacientes y metodo Se analizaron las puncionespracticadas durante dos anos en un servicio de urgencias,comparando las caracteristicas clinicasde los casos en que la PL confirmo o no la sospechade infeccion. Se revisaron los casos de ISNCno sospechados en urgencias. Resultados En el 0,4% de las urgencias medicasse practico un PL. En el 76% la indicacion fuesospecha de ISNC, de las cuales se confirmaron el30%. Fiebre, cefalea, rigidez de nuca y antecedentesde otitis o sinusitis cronica fueron las variablesasociadas a ISNC. Un 11% de las ISNC nose sospecharon en urgencias, y de ellas el 80%tenian el antecedente de infeccion por el VIH. Conclusiones La PL se realiza frecuentemente enurgencias, fundamentalmente por sospecha deISNC, que se confirma en un tercio de los casos.La ISNC no sospechada en urgencias correspondemayoritariamente a meningitis subagudas en pacientescon infeccion por el VIH.

Fundamento El uso del tratamiento antirretroviral de gran actividad (TARGA) (highly active antiretroviral therapy) ha conducido probablemente a la reduccion de las infecciones hematogenas en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Pacientes y metodo Se han estudiado todas las infecciones hematogenas, incluidas micobacteriemias y fungemias, ocurridas en pacientes infectados por el VIH y se han estratificado en dos periodos ( I: 1995-1996, y II: 1997-1998) para evaluar los cambios atribuibles al TARGA. Resultados Se atendieron 226 episodios (incidencia: 38,8 en el periodo I y 15,3 en el periodo II; p Conclusiones La infeccion hematogena en pacientes infectados por el VIH ha disminuido de forma significativa tras el uso generalizado del TARGA.

To evaluate the relationship between some clinical and analytical data and the presence of bacteremia in order to establish a clinical decision rule.All the patients with blood cultures obtained from the emergency room in a two months period were analyzed. Patients were randomly assigned to derivation or validation sets. A logistic regression of the significant values in the univariate analysis was performed and a score obtained. The prevalence of bacteraemia for every score was calculated. The diagnostic efficacy curves and the performance of the predictive model were calculated.412 patients were enrolled. The blood cultures were positive in 12.8% of them. The significant values in the univariate analysis were Charlson index ≥2 and PCT0.4ng/ml. Four groups of increasing risk of bacteraemia were designed, from 0 to 35% in the derivation set and from 2.9% to 27.2% in the validation set. In the diagnostic efficacy curve, the AUC was 0.8 in the derivation set and 0.74 in the validation set. The model presented a negative predictive value of 95.2% in the derivation set and 95.3% in the validation set.A model that includes Charlson index and PCT makes possible to define a group of patients with a very low risk of bacteremia.

To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution.We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance.We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period.In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF.

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

The purpose of this study was to know the concordance of diagnosis between emergency rooms amd hospitalization wards and to analyze the mistake index, the epidemiological characteristics and the main reasons for the mistakes.We analyzed hospitalized patients and used a three-level concordance: exact diagnosis (A), syndromical concordance (B) and mistake (C). We compared age, sex, time and days of hospitalization between the groups A+B and C. We also analyzed the causes of mistakes in group C.We found 88.1% of patients in level A, 7.3% in level B and 4.6% in level C. There were no significant differences in the variables analyzed. Main mistakes were a deficient clinical evaluation (50%) and X-ray interpretation (28.6%).Concordance of diagnoses was the rule, with less than 5% mistakes. There is no clinical or epidemiological pattern for the mistake. The most frequent cause for it was a deficient clinical evaluation.

To know the frequency, indications and diagnosis efficiency of lumbar puncture (LP) in the Emergency Department (ED) when suspecting a central nervous system (CNS) infection.We analyzed all the LP performed over a 2-year period in the ED. We compared the clinical characteristics of patients with and without CNS infection. We also reviewed all the cases of CNS infection diagnosed in the hospital in the same period.A LP was performed in 0.4% of emergencies. In 76% of cases, it was performed because of CNS infection suspicion, which was confirmed in 30% of cases. Fever, headache, nuchal rigidity and chronical otitis were all clinical variables associated with CNS infection. An 80% of CNS infections that were not diagnosed in the ED corresponded to HIV-infected patients.Lumbar puncture is frequently performed in the ED, mostly for suspicion of CNS infection, which is eventually confirmed in one third of cases. CNS infection cases which have not been suspected in the ED usually correspond to a subacute meningitis in a HIV-infected patient.

The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age > or =60 years (28% vs. 13%, P = 0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs. 9%, P = 0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests.