Cancer Patients' Prehospital Emergency Care: Post Hoc Analysis from the French Prospective Multicenter Study EPICANCER.

BACKGROUND: Very little data are available concerning the prehospital emergency care of cancer patients. The objective of this study is to report the trajectories and outcomes of cancer patients attended by prehospital emergency services. METHODS: This was an ancillary study from a three-day cross-sectional prospective multicenter study in France. Adult patients with cancer were included if they called the emergency medical dispatch center Service d'Aide Médicale Urgente (SAMU). The study was registered on ClinicalTrials.gov (NCT03393260, accessed on 8th January 2018). RESULTS: During the study period, 1081 cancer patients called the SAMU. The three most frequent reasons were dyspnea (20.2%), neurological disorder (15.4%), and fatigue (13.1%). Among those patients, 949 (87.8%) were directed to the hospital, among which 802 (90.8%) were directed to an emergency department (ED) and 44 (5%) were transported directly to an intensive care unit (ICU). A mobile intensive care unit (MICU) was dispatched 213 (31.6%) times. The decision to dispatch an MICU seemed generally based on the patient's reason for seeking emergency care and the presence of severity signs rather than on the malignancy or the patient general health status. Among the patients who were directed to the ED, 98 (16.1%) were deceased on day 30. Mortality was 15.4% for those patients directed to the ED but who were not admitted to the ICU in the next 7 days, 28.2% for those who were admitted to ICU in the next 7 days, and 56.1% for those patients transported by the MICU directly to the ICU. CONCLUSION: Cancer patients attending prehospital emergency care were most often directed to EDs. Patients who were directly transported to the ICU had a high mortality rate, raising the question of improving triage policies.

No significant difference between ceftriaxone and cefotaxime in the emergence of antibiotic resistance in the gut microbiota of hospitalized patients: A pilot study.

BACKGROUND: Ceftriaxone and cefotaxime share a similar antibacterial spectrum and similar indications but have different pharmacokinetic characteristics. Ceftriaxone is administered once daily and 40% of its clearance is by biliary elimination, whereas cefotaxime requires three administrations per day and shows less than 10% biliary elimination. The high biliary elimination of ceftriaxone suggests a greater impact of this antibiotic on the gut microbiota than cefotaxime. The objective of this study was to compare the impact of ceftriaxone and cefotaxime on the gut microbiota. METHODS: A prospective clinical trial was performed that included 55 patients treated with intravenous ceftriaxone (1 g/24 h) or cefotaxime (1 g/8 h) for at least 3 days. Three fresh stool samples were collected from each patient (days 0, 3, and 7 or at the end of intravenous treatment) to assess the emergence of third-generation cephalosporin (3GC)-resistant Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa, toxigenic Clostridioides difficile, and vancomycin-resistant enterococci. RESULTS: The emergence of 3GC-resistant gram-negative enteric bacilli (Enterobacteriaceae) (5.9% vs 4.7%, p > 0.99), Enterococcus spp, and non-commensal microorganisms did not differ significantly between the groups. Both antibiotics reduced the counts of total gram-negative enteric bacilli and decreased the cultivable diversity of the microbiota, but the differences between the groups were not significant. CONCLUSION: No significant difference was observed between ceftriaxone and cefotaxime in terms of the emergence of resistance.

Plasmatic presepsin (sCD14-ST) concentrations in acute pyelonephritis in adult patients.

INTRODUCTION: Presepsin (sCD14-ST) is an emerging biomarker for infection. We hypothesized that presepsin could specifically increase during acute pyelonephritis and correlate with severity. METHODS: We compared presepsin values in patients with acute pyelonephritis and controls, and we assessed its capacity to predict bacteraemia and admission in patients. RESULTS: In 312 patients with acute pyelonephritis (median age 33years), presepsin concentrations were higher than in controls (476 vs 200ng/L, p<0.001). ROC curve indicated an AUC at 0.90 [for presepsin (vs. 0.99 and 0.98 for CRP and PCT, respectively; p<0.05) and an optimal threshold at 340ng/L (74% sensitivity, 94% specificity). Presepsin concentrations increased in acute pyelonephritis patients with bacteraemia (614 vs. 461ng/L, p,=0.001) and in those requiring admission (614ng/L vs. 320ng/L, p<0.001). Performance of presepsin to predict bacteraemia [AUC=0.63, 95%CI: 0.55-0.72] was similar to CRP (AUC=0.64, p=0.87) and less accurate than PCT (AUC=0.78, p<0.001). AUC for presepsin to detect the need for admission was 0.67, and comparable to CRP (p=0.26) and PCT (p=0.18). CONCLUSION: Presepsin is a valuable biomarker to detect patients with acute pyelonephritis. However, it presents mild performance to predict bacteraemia and the need for admission, and offers no advantage as compared to CRP and PCT.

Presepsin (sCD14-ST) in emergency department: the need for adapted threshold values?

Presepsin is elevated in patients developing infections and increases in a severity-dependent manner. We aimed to evaluate circulating values of this new biomarker in a population free of any acute infectious disorder. We recruited 144 consecutive patients presenting at the emergency department (ED) without acute infection or acute/unstable disorder, and 54 healthy participants. Presepsin plasmatic concentrations were measured on the PATHFAST point-of-care analyzer. The 95th percentile of presepsin values in the ED population is 750ng/L. Presepsin was significantly increased in patients aged ≥70years vs. younger patients (470 [380-601] ng/L vs. 300 [201-457] ng/L, p<0.001). Prevalence of elevated presepsin values was increased in patients in comparison to controls (80% vs.13%, p<0.001), and in patients aged ≥70years in comparison to younger patients (87% vs. 47%, p<0.001). Presepsin concentrations were significantly increased in patients with kidney dysfunction. Aging was an independent predictor of an elevated presepsin value. In conclusion, presepsin concentrations increase with age and kidney dysfunction. Therefore interpretation of presepsin concentrations might be altered in the elderly or in patients with impaired renal function. Adapted thresholds are needed for specific populations.

Decisional procalcitonin thresholds are not adapted to elderly patients admitted to the emergency room.

CONTEXT: Diagnosis of sepsis in elderly is challenging. OBJECTIVES: We investigated whether procalcitonin concentrations in elderly differed from values for the general population. METHODS: Procalcitonin measurement was assessed prospectively in 307 apyretic patients ≥75 years visiting the emergency department. RESULTS: Median age was 86 years [IQR81-90] and 222 (72%) were female. Procalcitonin concentration was 0.057 µg/L [0.040-0.092]; 99th percentile was 0.661 µg/L. Patients with procalcitonin concentrations above decisional thresholds had lower glomerular filtration rate and higher C-reactive protein concentrations. CONCLUSIONS: Baseline procalcitonin levels are increased in elderly. Elevated values are common and associated to low-grade inflammation and lower eGFR.