Defining a clinical prediction rule to diagnose bacterial gastroenteritis requiring empirical antibiotics in an emergency department setting: A retrospective review.

BACKGROUND: Gastroenteritis (GE) is a non-specific term for various pathologic states of the gastrointestinal tract. Infectious agents usually cause acute GE. At present, there are no robust decision-making rules that predict bacterial GE and dictate when to start antibiotics for patients suffering from acute GE to the emergency department (ED). We aim to define a clinical prediction rule to aid in the diagnosis of bacterial GE, requiring empirical antibiotics in adult patients presenting to the emergency department with acute GE. METHODS: A two-year retrospective case review was performed on all cases from July 2015 to June 2017 that included patients with acute GE symptoms referred to the ED, after which their stool cultures were performed. The clinical parameters analyzed included patient with comorbid conditions, physical examination findings, historical markers, point-of-care and radiographic tests and other laboratory work. We then used multi-variate logistic regression analysis on each group (bacterial culture-positive GE and bacterial culture-negative GE) to elucidate clinical criteria with the highest yield for predicting bacterial gastroenteritis (BGE). RESULTS: A total of 756 patients with a mean age of 52 years, 52% female and 48% male, respectively, were included in the study. On the basis of the data of these patients, we suggested using a scoring system to delineate the need for empirical antibiotics in patients with suspected bacterial GE based on six clinical and laboratory variables. We termed this the BGE score. A score 0 - 2 points suggests low risk (0.9%) of bacterial GE. A score of 3 - 4 points confers an intermediate risk of 12.0% and a score of 5 - 8 points confers a high risk of 85.7%. A cut-off of  ≥ 5 points may be used to predict culture-positive BGE with a 75% sensitivity and 75% specificity. The area under the receiver operating characteristic (AUROC) for the scoring system (range 0 - 8) was 0.812 (95% CI: 0.780-0.843) p-value < 0.001. CONCLUSION: We suggest using the BGE scoring system (cut-off ≥ 5 points) to delineate the need for empirical antibiotics in patients diagnosed with gastroenteritis. While this is a pilot study, which will require further validation with a larger sample size, our proposed decision-making rule will potentially serve to improve the diagnosis of BGE and thus reduce unnecessary prescription of antibiotics, which will in turn reduce antibiotic-associated adverse events and save on costs worldwide.

Performance of the modified HEART score in an Asian population.

INTRODUCTION: Chest pain is the most common potentially life-threatening presentation to the emergency department (ED). Furthermore, the identification of acute coronary syndrome (ACS) including its risk stratification and subsequent disposition can be challenging. The original HEART score was derived as a predictive tool to risk stratify patients presenting with undifferentiated chest pain (CP) and aid physician decision-making. However, it utilized conventional troponins as its cardiac biomarker component. Our study aims to assess the utility of the modified HEART score with highly sensitive troponins in an Asian setting with mixed ethnicity to determine if it corroborates the findings of another recent Chinese study by Chun-Peng et al. (Journal of Geriatric Cardiology 13:64-69, 2016). METHODS: Clinical data from 413 patients presenting to the ED for evaluation of chest pain were analyzed. The predictive value of the modified HEART score for determining major adverse cardiac events (MACE) was then evaluated. RESULTS: A total of 49 patients (11.9%) had a MACE: 31 patients (7.5%) underwent PCI and 1 patient (0.2%) underwent CABG. There were 17 (4.1%) deaths. Three risk groups were elucidated based on MACE. In the low-risk group (0-2), there were 72 patients (17.4%), with a MACE rate of 1.4%. In the intermediate-risk group (3-5), there were 233 patients (56.4%), with a MACE rate of 5.2%. In the high-risk group (6-10), there were 108 patients (26.2%), with a MACE rate of 33.3%. CONCLUSION: The modified HEART score is an effective risk stratification tool in an ethnically diverse Asian population. Furthermore, it identifies low-risk patients who are candidates for early discharge from a local emergency department.

Effectiveness of a post-emergency department discharge multidisciplinary bundle in reducing acute hospital admissions for the elderly.

OBJECTIVE: We evaluated the effectiveness of the Subacute Ambulatory care for the Functionally challenged and Elderly (SAFE) programme, a post-emergency department (ED) discharge intervention for elderly and functionally challenged patients, in reducing acute hospital admissions. METHODS: This study was a 32-month retrospective quasi-experimental study comparing patients with at least one of six diagnostic classifications who underwent SAFE intervention with those who were eligible but declined and received usual ED care (control). The primary outcomes were rates of first acute hospital admission at 30 and 60 days post-ED discharge. Secondary outcomes were 20-day withdrawal rate and 60-day mortality. The difference in primary outcome between the two groups was compared using a Cox proportional hazards model. We reported adjusted hazard ratios (HRs) with their 95% confidence intervals (CIs) adjusting for predefined factors of age, sex, triage risk assessment tool scores and baseline ED utilization and acute hospital admission rates in the past year. RESULTS: There were 438 and 209 patients in the intervention and control groups, respectively. The intervention group had reduced risk of first acute hospital admission at 30 days (10 vs. 27%, HR=0.34, 95% CI: 0.22-0.52) and 60 days (18 vs. 33%, HR=0.48, 95% CI: 0.34-0.69) compared with the control. The 20-day withdrawal rate was 3.2%. Both groups did not differ in 60-day mortality rates. CONCLUSION: The SAFE programme was effective in reducing first acute hospital admissions in selected elderly and functionally challenged patients after ED discharge at 30 and 60 days compared with usual ED discharge care.