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Study Objective: Many patients with pneumonia are admitted to respiratory isolation for possible tuberculosis (TB), but most do not have active TB. We created a decision instrument to predict which pneumonia patients do not need admission to a TB isolation bed., Methods: The design was a prospective case series conducted in 11 university-affiliated, urban, US emergency departments (EDs) (EMERGEncy ID NET). Participants were patients admitted to the hospital through the ED with a diagnosis of pneumonia or suspected TB. The main outcome measure was derivation and validation of a sensitive decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data and chest radiographs., Results: Of 5,079 pneumonia patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. The instrument derived to predict which patients did not have pulmonary TB included no TB history or previous positive tuberculin skin test result, nonimmigrant, not homeless, not recently incarcerated, no recent weight loss, and no apical infiltrate or cavitary lesion on plain chest radiograph. When tested on the validation subgroup, the decision instrument exhibited a negative predictive value of 99.7% (95% confidence interval [CI] 99.1% to 99.9%), and a sensitivity of 96.4% (95% CI 91.1% to 99.0%)., Conclusion: A decision instrument can accurately predict which patients with pneumonia do not require admission to TB isolation rooms.

Escherichia coli O157:H7 and other Shiga toxin-producing E. coli (STEC) infections have been associated with bloody diarrhea. The prevalence of enteropathogens among patients with bloody diarrhea was determined by a prospective study at 11 US emergency departments. Eligible patients had bloody stools, > or =3 loose stool samples per 24-h period, and an illness lasting <7 days. Among 873 patients with 877 episodes of bloody diarrhea, stool samples for culture were obtained in 549 episodes (62.6%). Stool cultures were more frequently ordered for patients with fever, >10 stools/day, and visibly bloody stools than for patients without these findings. Enteropathogens were identified in 168 episodes (30.6%): Shigella (15.3%), Campylobacter (6.2%), Salmonella (5.8%), STEC (2.6%), and other (1.6%). Enteropathogens were isolated during 12.5% of episodes that physicians thought were due to a noninfectious cause. The prevalence of STEC infection varied by site from 0% to 6.2%. Hospital admissions resulted from 195 episodes (23.4%). These data support recommendations that stool samples be cultured for patients with acute bloody diarrhea.

Context: Rabies postexposure prophylaxis (RPEP) treatments and associated costs have increased in the United States. The extent to which RPEP use is consistent with guidelines is not well understood., Objective: To characterize animal contacts and determine the frequency and factors associated with inappropriate RPEP use., Design, Setting, and Patients: Prospective case series study of patients presenting with an animal exposure-related complaint from July 1996 to September 1998 at 11 university-affiliated, urban emergency departments (the Emergency ID Net)., Main Outcome Measures: Exposure type, circumstances, and RPEP use (appropriateness defined by local public health departments)., Results: Of 2030 exposures, 1635 (81%) were to dogs; 268 (13%) to cats; 88 (4%) to rodents/rabbits; 10 (0. 5%) to raccoons; 5 (0.2%) to bats; and 24 (1.2%) to other animals. Among those exposed, 136 (6.7%) received RPEP after dog (95), cat (21), raccoon (8), bat (4), or other animal (8) exposures. Use of RPEP varied by site (range, 0%-27.7% of exposures), with most frequent use reported at sites in the eastern United States. Management was considered appropriate in 1857 exposures (91.5%). Use of RPEP was considered inappropriate in 54 cases (40% of those in which it was given), owing to factors including animal availability for observation and exposure in a low-endemicity area. Rabies postexposure prophylaxis was considered inappropriately withheld from 119 cases (6.3% of those not receiving RPEP), often because a domestic animal was unavailable for observation or testing., Conclusion: These results suggest that use of RPEP is often inappropriate. Greater compliance with current guidelines would increase RPEP use. Physician education, improved coordination with public health officials, and clarification of RPEP guidelines could optimize use of this expensive resource. JAMA. 2000;284:1001-1007