Models to predict bacteremia in the emergency department: a systematic review. / Modelos predictivos de bacteriemia en el servicio de urgencias: revisión sistemática.

OBJECTIVES: Blood cultures are ordered in emergency departments for 15% of patients with suspected infection. The diagnostic yield varies from 2% to 20%. Thirty-day mortality in patients with bacteremia is high, doubling or tripling the rate in patients with the same infection but without bacteremia. Thus, finding an effective model to predict bacteremia that is applicable in emergency departments is an important goal. Shapiro's model is the one traditionally used as a reference internationally. The aim of this systematic review was to compare the predictive power of bacteremia risk models published since 2008, when Shapiro's model first appeared. MATERIAL AND METHODS: We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, searching in the following databases for articles published between January 2008 and May 31, 2023: PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Trip Medical Database, and ClinicalTrials.gov. No language restrictions were specified. The search terms were the following Medical Subject Headings: bacteremia/bacteraemia/blood stream infection, prediction model/clinical prediction rule/risk prediction model, emergencies/emergency/emergency department, and adults. Observational cohort studies analyzing diagnostic yield were included; case-control studies, narrative reviews, and other types of articles were excluded. The Newcastle-Ottawa Scale was used to score quality and risk of bias in the included studies. The results were compared descriptively, without meta-analysis. The protocol was included in the PROSPERO register (CRD42023426327). RESULTS: Twenty studies out of a total of 917 were found to meet the inclusion criteria. The included studies together analyzed 33 182 blood cultures, which detected 5074 cases of bacteremia (15.3%). Eleven studies were of high quality, 7 of moderate quality, and 2 of low quality. The area under the receiver operating characteristic curve (AUC) of Shapiro's model varied from 0.71 to 0.83. Sensitivity was as high as 98%, and specificity ranged from 26% to 69%. Three models with high scores for quality were also supported by both internal and external validation studies: Lee's model (AUC, 0.81; sensitivity 68%; specificity, 81%), the 5MPB-Toledo model (AUC, 0.906 to 0.946), and the MPB-INFURG-SEMES model (AUC, 0.924; sensitivity, 97%; specificity, 76%. CONCLUSION: The 5MPB-Toledo and MPB-INFURG-SEMES are useful for assessing the true risk of bacteremia in patients attended in emergency departments.

OBJETIVO: La obtención de hemocultivos (HC) se realiza en el 15% de los pacientes atendidos con sospecha de infección en los servicios de urgencias (SU) con una rentabilidad diagnóstica variable (2-20%). La mortalidad a 30 días de estos pacientes con bacteriemia es elevada, doble o triple que el resto con el mismo proceso. Así, encontrar un modelo predictivo de bacteriemia eficaz y aplicable en los SU sería muy importante. Clásicamente, el modelo de Shapiro ha sido la referencia en todo el mundo. El objetivo de esta revisión sistemática (RS) es comparar la capacidad para predecir bacteriemia en los SU de los distintos modelos predictivos publicados desde el año 2008 (fecha de publicación del modelo de Shapiro). METODO: Se realiza una RS siguiendo la normativa PRISMA en las bases de datos de PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase y ClinicalTrials.gov desde enero de 2008 hasta 31 mayo 2023 sin restricción de idiomas y utilizando una combinación de términos MESH: "Bacteremia/Bacteraemia/Blood Stream Infection", "Prediction Model/Clinical Prediction Rule/Risk Prediction Model", "Emergencies/Emergency/Emergency Department" y "Adults". Se incluyeron estudios de cohortes observacionales (analíticos de rendimiento diagnóstico). Para valorar la calidad del método empleado y el riesgo de sesgos de los artículos incluidos se utilizó la Newcastle-Ottawa Scale (NOS). No se incluyeron estudios de casos y controles, revisiones narrativas y en otros tipos de artículos. No se realizaron técnicas de metanálisis, pero los resultados se compararon narrativamente. El protocolo de la RS se registró en PROSPERO (CRD42023426327). RESULTADOS: Se identificaron 917 artículos y se analizaron finalmente 20 que cumplían los criterios de inclusión. Los estudios incluidos contienen 33.182 HC procesados con 5.074 bacteriemias (15,3%). Once estudios fueron calificados de calidad alta, 7 moderada y 2 baja. El ABC-COR conseguida por el modelo de Shapiro varía de 0,71 a 0,83, con sensibilidad (Se) hasta del 98%, con especificidad (Es) (26% a 69%). Para los tres modelos que tienen validación interna y externa y una buena calidad metodológica, el modelo de Lee consigue un ABC-COR de 0,81 con Se: 68% y Es: 81%, el modelo 5MPB-Toledo consigue un ABC-COR entre 0,91 y 0,95, y el MPB-INFURG-SEMES obtiene una ABC-COR de 0,92 con una Se: 97% y Es: 76%. CONCLUSIONES: Los modelos 5MPB-Toledo y MPB-INFURG-SEMES representan herramientas útiles para la estratificación del riesgo real de bacteriemia en los pacientes atendidos en los SU.

The Guadalajara Declaration on sepsis: emergency physicians' constructive comments on the Surviving Sepsis Campaign's 2021 updated guidelines. / Declaración de Guadalajara: una visión constructiva desde el servicio de urgencias a partir de la Surviving Sepsis Campaign 2021.

TEXT: The Surviving Sepsis Campaign (SSC) published a 2021 update of its 2016 recommendations. The update was awaited with great anticipation the world over, especially by emergency physicians. Under the framework of the CIMU 2022 (33rd World Emergency Medicine Conference) in Guadalajara, Mexico in March, emergency physiciansreviewed and analyzed the 2021 SSC guidelines from our specialty's point of view. In this article, the expert reviewers present their consensus on certain key points of most interest in emergency settings at this time. The main aims of the review are to present constructive comments on 10 key points and/or recommendations in the SSC 2021 update and to offer emergency physicians' experience- and evidence-based proposals. Secondarily, the review's recommendations are a starting point for guidelines to detect severe sepsis in emergency department patients and prevent progression, which is ultimate goal of what has become known as the Guadalajara Declaration on sepsis.

TEXTO: En noviembre del año 2021, la Surviving Sepsis Campaign (SSC) publicó una actualización de sus recomendaciones y directrices de 2016. Estas fueron recibidas con una enorme expectativa en todo el mundo, especialmente entre los médicos de urgencias y emergencias (MUE). Recientemente, en el marco del CIMU 2022 (33 Congreso Mundial de Medicina de Urgencias celebrado en marzo de 2022 en Guadalajara ­ México) se ha revisado y analizado, desde la perspectiva del MUE, la Guía SSC de 2021. Los expertos que realizaron esa tarea y también consensuaron algunos de los puntos clave que más interesan y preocupan a los MUE en la actualidad han elaborado este documento. Su objetivo principal es analizar de forma constructiva diez de los puntos clave y recomendaciones de la SSC 2021 para complementarlas con argumentos y propuestas desde la experiencia, evidencia y perspectiva del urgenciólogo. Además, de forma secundaria, pretende ser el punto de partida de la elaboración de las guías para detectar, prevenir la progresión y atender a los pacientes con infección grave y sepsis en urgencias, que supone la meta final de lo que desde la MUE ya se conoce como "la Declaración de Guadalajara".

Ability of lactate, procalcitonin, and criteria defining sepsis to predict 30-day mortality, bacteremia, and microbiologically confirmed infection in patients with infection suspicion treated in emergency departments. / Capacidad del lactato, procalcitonina y de los criterios definitorios de sepsis para predecir mortalidad a 30 días, bacteriemia o infección confirmada microbiológicamente en los pacientes atendidos por sospecha de infección en urgencias.

OBJECTIVES: To evaluate lactate, procalcitonin, criteria defining systemic inflammatory response syndrome (SIRS), and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) and compare their ability to predict 30-day mortality, infection with microbiologic confirmation, and true bacteremia in patients treated for infection in hospital emergency departments. MATERIAL AND METHODS: Prospective multicenter observational cohort study. We enrolled a convenience sample of patients aged 18 years or older attended in 71 Spanish emergency departments from October 1, 2019, to March 31, 2020. Each model's predictive power was analyzed with the area under the receiver operating characteristic curve (AUC), and predetermined decision points were assessed. RESULTS: A total of 4439 patients with a mean (SD) age of 18 years were studied; 2648 (59.7%) were men and 459 (10.3%) died within 30 days. True bacteremia was detected in 899 (20.25%), and microbiologic confirmation was on record for 2057 (46.3%). The model that included the qSOFA score (2) and lactate concentration (0.738 mmol/L; 95% CI, 0.711-0.765 mmol/L) proved to be the best predictor of 30-day mortality, with an AUC of 0.890 (95% CI, 0.880-0.901). The model that included the SIRS score (2) and procalcitonin concentration (0.51 ng/mL) proved to be the best predictor of true bacteremia and microbiologic confirmation, with an AUC of 0.713 (95% CI, 0.698-0.728). CONCLUSION: A qSOFA score of 2 or more plus lactate concentration (0.738 mmol/L) predict 30-day mortality better than the combination of a SIRS score of 2 or more and procalcitonin concentration. A SIRS score of 2 or more plus procalcitonin concentration (0.51 ng/mL) predict true bacteremia and microbiologic confirmation.

OBJETIVO: Evaluar y comparar la capacidad del lactato, la procalcitonina (PCT) y de los criterios definitorios de sepsis (síndrome de respuesta inflamatoria sistémica ­SRIS­ y del quick Sepsis-related Organ Failure Assessment ­qSOFA­) para predecir mortalidad a 30 días, o infección ­con confirmación microbiológica o bacteriemia verdadera (BV)­ en los pacientes que acuden al servicio de urgencias hospitalario (SUH) por un episodio de sospecha de infección. METODO: Estudio observacional de cohortes, multicéntrico, prospectivo. Se incluyó por oportunidad a pacientes 18 años atendidos por sospecha de infección en 71 SUH españoles desde el 01/10/2019 al 31/03/2020. Se analizó la capacidad predictiva con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y puntos de decisión predeterminados. RESULTADOS: Se incluyeron 4.439 pacientes con edad media de 67 (18) años, 2.648 (59,7%) fueron hombres, fallecieron a los 30 días 459 (10,3%), se consideraron BV 899 (20,2%) y se consiguió confirmación microbiológica en 2.057 (46,3%). Para la mortalidad a 30 días la mejor ABC-COR fue la obtenida con el modelo qSOFA 2 más lactato 2 mmol/l con un ABC-COR de 0,738 (0,711-0,765). Para predecir BV y confirmación microbiológica el mejor rendimiento se obtuvo con el modelo de SRIS 2 más PCT 0,51 ng/ml, con un ABC-COR de 0,890 (0,880-0,901) y 0,713 (0,698-0,728), respectivamente. CONCLUSIONES: Para la predicción de mortalidad a 30 días, el qSOFA 2 es superior al SRIS 2 y el mejor rendimiento lo consigue el modelo qSOFA 2 más lactato 2 mmol/l. Para predecir BV y confirmación microbiológica, la PCT es superior al lactato y el mejor rendimiento lo obtiene el modelo SRIS 2 más PCT 0,51 ng/ml.

Utilidad del modelo 5MPB-Toledo para predecir bacteriemia en el paciente anciano / Usefulness of the 5MPB-Toledo model to predict bacteremia in the elderly patient

Resumen Objetivo: Analizar la utilidad del modelo predictivo de bacteriemia (5MPB-Toledo) en los mayores de 65 años atendidos por infección en el servicio de urgencias (SU). Material y Método: Estudio observacional prospectivo y multicéntrico de los hemocultivos (HC) obtenidos en pacientes mayores de 65 años atendidos por infección en 66 SU españoles desde el 1 de diciembre de 2019 hasta el 30 de abril de 2020. Se analizó la capacidad predictiva del modelo con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y se calculó el rendimiento diagnóstico de los puntos de corte (PC) del modelo elegido con los cálculos de la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo. Resultados: Se incluyeron 2.401 episodios de HC extraídos. De ellos, se consideró como bacteriemia verdadera a 579 (24,11%) y como HC negativo a 1.822 (75,89%). Entre los negativos, 138 (5,74%) se consideraron contaminados. Se categorizó a los pacientes en bajo (0-2 puntos), moderado (3-5 puntos) y alto (6-8 puntos) riesgo, con una probabilidad de bacteriemia de 1,2%, 18,1% y 80,7%, respectivamente. El ABC-COR del modelo tras remuestreo fue de 0,908 (IC 95%: 0,897-0,924). El rendimiento diagnóstico del modelo, considerando un PC ≥ 5 puntos, obtiene una sensibilidad de 94% (IC 95%:92-96), especificidad de 77% (IC 95%:76-79) y un valor predictivo negativo de 97% (IC 95%:96-98). Conclusión: El modelo 5MPB-Toledo es de utilidad para predecir bacteriemia en los mayores de 65 años atendidos en el SU por un episodio de infección.

Abstract Objective: To analyse a risk score to predict bacteremia (MPB5-Toledo) in the patients aged older 65 years seen in the emergency departments (ED) due to infections. Patients and Methods: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 66 Spanish ED for patients aged older 65 years seen from December 1, 2019, to April 30, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. Results: A total of 2.401 blood samples wered cultured. True cases of bacteremia were confirmed in 579 (24.11%). The remaining 1.822 cultures (75.89%) wered negative. And, 138 (5.74%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.2%, 18.1%, and 80.7%, respectively. The model´s area under the receiver ope rating characteristic curve was 0.908 (95% CI, 0.897-0.924). The prognostic performance with a model´s cut-off value of ≥ 5 points achieved 94% (95% CI: 92-96) sensitivity, 77% (95% CI: 76-79) specificity, and negative predictive value of 97% (95% CI: 96-98). Conclusion: The 5MPB-Toledo score is useful for predicting bacteremia in the patients aged older 65 years seen in the emergency departments due to infections.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections.

OBJECTIVE: To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections. METHODS: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0-2 points, intermediate risk by 3-5 points, and high risk by 6-8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70). CONCLUSION: The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

A bacteraemia risk prediction model: development and validation in an emergency medicine population.

OBJECTIVE: Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection. METHODS: This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value < 0.05 were introduced in the univariate analysis together with those of clinical significance. The final selection of variables for the scoring scale was made by logistic regression with selection by introduction. The results obtained were internally validated by dividing the sample in a derivation and a validation cohort. RESULTS: A total of 4,439 infectious episodes were included. Of these, 899 (20.25%) were considered as true bacteraemia. A predictive model for bacteraemia was defined with seven variables according to the Bacteraemia Prediction Model of the INFURG-SEMES group (MPB-INFURG-SEMES). The model achieved an area under the curve-receiver operating curve of 0.924 (CI 95%:0.914-0.934) in the derivation cohort, and 0.926 (CI 95%: 0.910-0.942) in the validation cohort. Patients were then split into ten risk categories, and had the following rates of risk: 0.2%(0 points), 0.4%(1 point), 0.9%(2 points), 1.8%(3 points), 4.7%(4 points), 19.1% (5 points), 39.1% (6 points), 56.8% (7 points), 71.1% (8 points), 82.7% (9 points) and 90.1% (10 points). Findings were similar in the validation cohort. The cut-off point of five points provided the best precision with a sensitivity of 95.94%, specificity of 76.28%, positive predictive value of 53.63% and negative predictive value of 98.50%. CONCLUSION: The MPB-INFURG-SEMES model may be useful for the stratification of risk of bacteraemia in adult patients with infection in EDs, together with clinical judgement and other variables independent of the process and the patient.

Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID 19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional CPAP devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for Pneumonia due to COVID 19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98% and 99% on average after 30 and 60 min with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122 respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040). CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

INTRODUCCIÓN: El uso de dispositivos que aportan presión positiva continua en la vía aérea ha demostrado mejoría en diversas patologías que producen insuficiencia respiratoria. En el episodio de pandemia por COVID 19 el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de CPAP, se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos dispositivos, así como su eficacia. MATERIAL Y MÉTODOS: Se recogen datos de pacientes ingresados por Neumonía por COVID 19 en el Hospital de campaña de IFEMA. Se recogen datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio. RESULTADOS: Estudio realizado sobre un total de 23 pacientes, con fecha ingreso en IFEMA. Se empleó CPAP alternativa en cinco pacientes (21,7%), mientras que en los 18 pacientes restantes (78,3%) se usó soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observa un aumento progresivo de la saturación en aquellos pacientes en los que se empleó CPAP alternativa (de 94% de promedio a 98% y 99% de promedio tras 30 y 60 minutos con la máscara, respectivamente), aunque este cambio no resultó significativo (p = 0,058 y p = 0,122 respectivamente). No se observó un cambio significativo de frecuencia respiratoria al inicio y final de la medición en pacientes que usaron CPAP alternativa (p = 0,423) pero si entre los que no la usaron (p = 0,001). Se observa una mejoría estadísticamente significativa en la variable Saturación de oxigeno / Fracción inspirado de oxígeno en los pacientes que usaron CPAP alternativa (p = 0,040). CONCLUSIÓN: El uso de estos dispositivos ha ayudado al trabajo ventilatorio de varios pacientes mejorando sus parámetros de oxigenación. Para observar mejor la evolución de los pacientes sometidos a esta terapia y compararlos con pacientes con otro tipo de soporte ventilatorio, son necesarios más estudios en los que se aleatorice su uso.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections. / Validación del modelo predictivo de bacteriemia (5MPB-Toledo) en los pacientes atendidos en el servicio de urgencias por infección.

OBJECTIVE: To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections. METHODS: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70). CONCLUSION: The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Key issues in emergency department management of COVID-19: proposals for improving care for patients in Latin America. / Puntos clave sobre la COVID-19 en los servicios de urgencias: propuestas de mejora para su atención en Latinoamérica.

The incidence of the coronavirus disease 2019 (COVID-19) in Latin America and Spain and its impact particularly on hospital emergency departments have been great, sustained, and unpredictable. Unfortunately, this situation will continue in the medium term, regardless of the diverse concepts and definitions used to identify cases or hypotheses about the role of staff. In the context of the worldwide pandemic, a multinational group of experts from the Latin American Working Group to Improve Care for Patients With Infection (GT-LATINFURG) has drafted various opinion papers for use by emergency care systems in the member countries. The GT-LATINFURG is comprised of representatives from the 13 scientific associations affiliated with the Latin American Federation for Emergency Medicine (FLAME). Experts from the Spanish Society of Emergency Medicine (SEMES) also participated. The present consensus statement offers protocols and recommendations to facilitate the work of hospital emergency departments with regard to key issues the group identified, namely, the need for reorganization, triage, and routine test availability. Additional issues discussed include biomarkers; clinical, laboratory, radiologic, and microbiologic criteria for identifying patients with COVID-19; and risk and prognostic factors for mortality that emergency staff can use to quickly detect severe cases in our settings.

La incidencia y el impacto de la COVID-19 (Coronavirus Disease 2019) en Latinoamérica y España, en particular en sus servicios de urgencias hospitalarios (SUH), independientemente de la diversidad de los conceptos y definiciones de casos confirmados o sospechosos empleados ha sido, es, y, desgraciadamente a medio plazo, va a seguir siendo enorme, sostenida e imprevisible. En este escenario global, un grupo multinacional de expertos y representantes del Grupo de Trabajo Latinoamericano para la mejora de la atención del paciente con Infección en Urgencias (GTLATINFURG), compuesto por 13 Sociedades y Asociaciones Científicas que integran la Federación Latinoamericana de Medicina de Emergencias (FLAME), junto con la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), ha elaborado diversos documentos técnicos y de opinión destinados a los profesionales de los Sistemas de Urgencias y Emergencias de nuestros países. El objetivo de este artículo es ofrecer unas pautas o recomendaciones consensuadas para facilitar la actuación de los SUH en relación los puntos que los miembros del grupo han considerado más interesantes o clave en relación a: la necesidad de reorganizar los SUH, triaje, disponibilidad de pruebas complementarias habituales y otras como biomarcadores, la identificación del paciente con COVID-19 a través de criterios clínicos, analíticos, radiológicos y microbiológicos, así como factores de riesgo, pronóstico y de mortalidad que puedan ayudar a detectar rápidamente a los pacientes graves a su llegada a los dispositivos de Urgencias y Emergencias de los hospitales en nuestro entorno.

[Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19]. / Métodos alternativos de CPAP para el tratamiento de insuficiencia respiratoria grave secundaria a neumonía por COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

A multidrug-resistant microorganism infection risk prediction model: development and validation in an emergency medicine population.

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p < 0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74-0.78) in the derivation cohort and 0.72 (CI 95% 0.70-0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0-2 points), 16% (3-5 points), 24% (6-9 points), 33% (10-14 points), 47% (15-21 points), and 71% (> 21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Sepsis in the emergency department: key points, controversies, and proposals for improvements in Latin America. / Puntos clave y controversias sobre la sepsis en los servicios de urgencias: propuestas de mejora para Latinoamérica.

EN: Although infection rates and the impact of infection on hospital emergency departments (EDs) are known or can be reliably estimated, the incidence and prevalence of sepsis vary in relation to which definitions or registers used. Sepsis is also well known to be under-diagnosed by physicians in general and by ED physicians in particular. Over half of sepsis cases are community-acquired, and 50% to 60% of patients in intensive care units (ICUs) with sepsis or septic shock are admitted directly from the ED. Pneumonia and urinary tract infections are the most common points of focus in sepsis, septic shock, bacteremia, and ED admissions to the ICU for infectious processes. For this article a multinational group of experts representing Latin American emergency medicine associations reviewed and analyzed similarities and differences in the epidemiology of sepsis in different geographic locations. We consider key aspects and geographic similarities and differences in the early identification of patients with severe sepsis; criteria that define the diagnosis; appropriate early antibiotic and fluid therapy; the roles of triage systems and multidisciplinary sepsis code units; and the use of biological markers in this time-dependent disease. We also discuss key points and strategies for improving the diagnosis, prognosis, and care of sepsis patients in the ED.

ES: En los servicios de urgencias hospitalarios (SUH), la incidencia y la prevalencia de la sepsis dependen de las definiciones y registros que se utilicen. Además, en general existe un infradiagnostico. Un grupo internacional de expertos y representantes de sociedades y asociaciones latinoamericanas de urgencias y emergencias ha revisado y analizado las coincidencias y diferencias en la situación actual epidemiológica, así como los problemas y puntos clave (con sus similitudes y diferencias según el entorno geográfico) en relación a: la detección inmediata del paciente con infección grave-sepsis, los criterios para su definición, la administración de la antibioterapia y fluidoterapia precoces y adecuadas, y el papel que juegan los sistemas de triaje, las unidades multidisciplinares de sepsis (conocidas como "código sepsis") o los biomarcadores en esta enfermedad tiempo-dependiente. Además, señalan algunos puntos clave y estrategias de mejora para el diagnóstico, pronóstico y atención en los SUH de estos pacientes.

[Profile and initial management of infection in elderly patients in an Emergency Department]. / Perfil y manejo inicial de los ancianos atendidos por infección en los servicios de Urgencias hospitalarios.

OBJECTIVE: To determine the clinical profile and the initial management of elderly patients with acute infections attending Spanish Emergency Departments (EDs), and to analyse whether there are any differences compared to younger adults. MATERIAL AND METHODS: A descriptive, cross-sectional, multicentre study using the data recorded in the INFURG-SEMES register. It included a total of 79,654 of 15 years or over treated for an acute infection in 49 Spanish EDs between 10 October 2010 and 20 September 2011. Demographic variables, clinical profile, and care in the ED, were collected. The classifying variable was to be 65 years or over. RESULTS: Of the total of 11,399 cases, 4,255 (37.3%) were 65 years or over. Statistically significant differences were found on comparing the elderly with the younger adults as regards the presence of a high comorbidity (P<.001), of at least one risk factor for multidrug resistance (P<.001), or septic syndrome (P<.001), type of infection (P<.001), taking of the specimen for blood culture (P<.001), determination of antigens in urine (P<.001), the antibiotic prescribed in the ED (P<.001), and final destination (P<.001). CONCLUSIONS: There are significant age-dependent differences in the profile and management of patients with infections that attend Spanish EDs, which must be taken into account when developing strategies for improving quality, as well as for future lines of research.

[Usefulness of inflammation and infection biomarkers in the Emergency Department]. / Utilidad de los biomarcadores de inflamación e infección en los servicios de urgencias.

Infectious processes account for 10% of patient seen in the emergency department. To administer antibiotics early, and before any other therapeutic-diagnostic decisions (complementary tests, microbiological samples, intensity of hemodynamic support, need for admission, etc.) have direct repercussions on the survival of patients with severe bacterial infections (bacteremia, severe sepsis or septic shock). In this context, the emergency department represents a critical level where the suspicion of infection and it diagnosis is made and treatment is started, and the progression and prognosis will be determined by the speed of this action. However, the clinical manifestations of infectious diseases are often non-specific and variable which makes early recognition of these patients and situations difficult. Inflammation and infection biomarkers have been around for years as helpful tools for improving emergency medical diagnoses and management of infection in the emergency department. The aim of this review is to summarize the published scientific evidence, in order to clarify the existing controversies, comparing the usefulness of the major biomarkers of inflammation and infection. It will alas suggest recommendations for their use in order to improve diagnosis, prognostic evaluation and management of infected patients in the emergency department.

[Daptomycin in the context of antimicrobial resistance in Gram-positive bacteria]. / Daptomicina en el contexto de la resistencia a los antimicrobianos en bacterias grampositivas.

Infection by antimicrobial-resistant Gram-positive bacteria (GPB) is highly prevalent, especially in the hospital setting. The increase in the use of glycopeptides has a microbiological cost: vancomycin-resistant strains (scarce), strains with intermediate sensitivity, heteroresistant and glycopeptide-tolerant strains and glycopeptide-sensitive strains but with a higher minimal inhibitory concentration require a higher dose of vancomycin, increasing toxicity. Because of its pharmacodynamics profile, linezolide has allowed more effective treatment of localized GPB infections in areas with complex spread and in ischemic tissues with little cost in terms of the selection of resistant strains. Similarly, because of its broad spectrum, tigecycline can be used to treat complex mixed infections caused by resistant pathogens. However, because linezolide and tigecycline are bacteriostatic agents, their use in the initial management of bacteremia, endocarditis and infection in immunocompromised hosts is limited. Because daptomycin has potent early bactericidal activity and has not been affected by heteroresistance or tolerance, this drug is an effective alternative against these severe GPB infections.