The Effect of Fluid Resuscitation Timing in Early Sepsis Resuscitation.

PURPOSE: The dose and timing of early fluid resuscitation in sepsis remains a debated topic. The objective of this study is to evaluate the effect of fluid timing in early sepsis management on mortality and other clinical outcomes. METHODS: Single-center, retrospective cohort study of emergency-department-treated adults (>18 years, n = 1032) presenting with severe sepsis or septic shock. Logistic regression evaluating the impact of 30 mL/kg crystalloids timing and mortality-versus-time plot controlling for mortality in emergency department sepsis score, lactate, antibiotic timing, obesity, sex, systemic inflammatory response syndrome criteria, hypotension, and heart and renal failures. This study is a subanalysis of a previously published investigation. RESULTS: Mortality was 17.1% (n = 176) overall and 20.4% (n = 133 of 653) among those in septic shock. 30 mL/kg was given to 16.9%, 32.2%, 16.2%, 14.5%, and 20.3% of patients within ≤1, 1 ≤ 3, 3 ≤ 6, 6 ≤ 24, and not reached within 24 h, respectively. A 24-h plot of adjusted mortality versus time did not reach significance, but within the first 12 h, the linear function showed a per-hour mortality increase (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.02-1.67) which peaks around 5h, although the quadratic function does not reach significance (P = .09). When compared to patients receiving 30 mL/kg within 1 h, increased mortality was observed when not reached within 24 h (OR 2.69, 95% CI 1.37-5.37) but no difference when receiving this volume between 1 and 3 (OR 1.11, 95% CI 0.62-2.01), 3 and 6 (OR 1.83, 95% CI 0.97-3.52), or 6 and 24 h (OR 1.51, 95% CI 0.75-3.06). Receiving 30 mL/kg between 1 and 3 versus <1 h increased the incidence of delayed hypotension (OR 1.83, 95% CI 1.23-2.72) but did not impact need for intubation, intensive care unit admission, or vasopressors. CONCLUSIONS: We observed weak evidence that supports that earlier is better for survival when reaching fluid goals of 30 mL/kg, but benefits may wane at later time points. These findings should be viewed as hypothesis generating.

The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis.

OBJECTIVE: Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. DATA SOURCES: Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. STUDY SELECTION: A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients ≥18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. DATA EXTRACTION: Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. DATA SYNTHESIS: From 1643 citations, five retrospective cohort studies were included (n = 20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio = OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR = 0.79 [0.62-1.02]; heterogeneity: I2 = 86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR = 0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR = 0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR = 0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR = 0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. CONCLUSION: This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely.

The Effect of Body Mass Index and Weight-Adjusted Fluid Dosing on Mortality in Sepsis.

PURPOSE: The Surviving Sepsis Campaign guidelines recommend 30 mL/kg of fluids within 3 hours (30by3) of sepsis-induced hypoperfusion, but a national mandate released an allowance for dosing based on ideal instead of actual body weight (IBW/ABW) for obese patients. This study aims to determine the dose-effect of 30by3 for patients with severe sepsis or septic shock (SS/SS) with respect to body mass index (BMI) categories and secondarily, examine the clinical impact of IBW vs. ABW-based dosing. METHODS: Retrospective cohort study of adults (≥18 years; n = 1,032) with SS/SS presenting to an urban, tertiary-care emergency department. Models include MEDS score, antibiotic timing, lactate, renal and heart failure, among others. RESULTS: The cohort was 10.2% underweight and 28.7% obese. Overall mortality was 17.1% with 20.4% shock mortality. An exponential increase in mortality was observed for each 5 mL/kg under 30by3 for underweight (p = 0.02), but not obese patients. ABW vs IBW-30by3 dosing was reached in 80.0 vs 52.4% (underweight), 56.4 vs 56.9% (normal/overweight), and 23.3 vs 46.0% (obese). Across all BMI categories, there was increased mortality for not reaching ABW-based 30by3 dosing (OR 1.78, 95% CI 1.18-2.69) with no significant impact for IBW (OR 1.28, 95% CI 0.87 -1.91). The increased mortality for failing to reach ABW-dosed 30by3 remained for underweight patients ABW (OR 5.82, 95% CI 1.32-25.57) but not obese patients. Longer ICU stays were observed for not reaching 30by3 based on ABW (ß = 2.40, 95% CI 0.84-3.95) and IBW dosing (ß = 1.58, 95% CI 0.07-3.08) overall. This effect remained for obese and underweight (except IBW dosing) patients. CONCLUSIONS: An exponential, dose-effect increase in mortality was observed for underweight patients not receiving 30by3. Therefore, the mortality impact of under-dosing may be amplified using ABW for underweight patients. Fluid dosing did not impact mortality for obese patients, but we caution against deviation from guidelines without further studies.

Utility of bedside assessment to evaluate for cervical-spine fracture post ground-level fall for patients 65 years and older.

OBJECTIVES: The effectiveness of current assessment tools for cervical fracture are mixed with respect to elderly patients. We aim to examine utility of history and physical exam to assess for cervical fracture for elderly patients suffering a ground-level fall. METHODS: Retrospective cohort from a tertiary-care ED for patients ≥65 years, including dementia, after ground-level fall. Logistic regression was used to examine predictability of various clinical factors. Neurologic deficits were considered a hard sign for imaging and were not assessed. RESULTS: Of 1035 patient encounters analyzed, 683 had CT cervical-spine (C-spine) imaging (66.0%) and 16 (1.5%) had cervical fracture. C-spine tenderness (OR 4.7, 95% CI 1.5-14.1), neck pain (OR 10.5, 95% CI 3.4-32.5), altered mental status (AMS) (OR 5.1, 95% CI 1.7-15.6), and external trauma above the clavicles (ETC) (OR 3.8, 95% CI 1.2-12.3) predicted cervical fracture. C-spine tenderness and neck pain were collinear and run-in separate models. Dementia (OR 0.2, 95% CI 0.4-0.9) did not predict cervical fracture in this population. A combination of ETC, C-spine tenderness, and AMS had a sensitivity = 100% and specificity = 40.0% for detection of cervical fracture. ETC was found in all but two fractures requiring intervention with negative predictive value = 99.3%. CONCLUSIONS: Clinical assessment for elderly patients without neurologic signs, together with the absence of ETC, cervical tenderness, and AMS may be reliable in ruling out cervical fracture after a ground-level fall, including patients with history of dementia. Fractures requiring intervention were rare in patients without ETC. However, findings are retrospective and prospective validation is required.

Effect of a split-flow physician in triage model on abdominal CT ordering rate and yield.

OBJECTIVE: The objective of this study was to compare the rate and clinical yield of computed tomography (CT) imaging between patients presenting with abdominal pain initially seen by a physician in triage (PIT) versus those seen only by physicians working in the main emergency department (ED). METHODS: A retrospective study was conducted of all self-arrivals >18 years old presenting to a single ED with abdominal pain. Nine-hundred patients were randomly selected from both the PIT and traditional patient flow groups and rates and yields of CT imaging were compared, both alone and in a model controlling for potential confounders. Predetermined criteria for CT significance included need for admission, consult, or targeted medications. RESULTS: The overall rate of CT imaging (unadjusted) did not differ between the PIT and traditional groups, 48.7% (95% CI 45.4-51.9) vs. 45.1% (95% CI 41.8-48.4), respectively (p = .13). The CT yield for patients seen in in the PIT group was also similar to that of the traditional group: 49.1% (95% CI 44.4-53.8) vs. 50.5% (95% CI 45.6-55.4) (p = .68). In the logistic regression model, when controlling for age, gender, ESI-acuity, race and insurance payor, PIT vs. traditional was not a predictor of CT ordering (OR 1.14, 95% CI 0.94-1.38). CONCLUSIONS: For patients with abdominal pain, we found no significant differences in rates of CT ordering or CT yield for patients seen in a PIT vs. traditional models, suggesting the increased efficiencies offered by PIT models do not come at the cost of increased or decreased imaging utilization.

The effect of delays in second-dose antibiotics on patients with severe sepsis and septic shock.

BACKGROUND: Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. METHODS: ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. RESULTS: In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81-3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95-4.57; 12-h- OR 2.46, 95% CI 1.72-3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06-1.90), and renal failure (OR 2.57, 95% CI 1.50-4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58-1.29) or other outcomes. CONCLUSIONS: Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.

Effect of IV Push Antibiotic Administration on Antibiotic Therapy Delays in Sepsis.

OBJECTIVES: Timeliness of antibiotic administration is recognized as an important factor in reducing mortality associated with sepsis. According to guidelines, antibiotics should be administered within 1 hour of sepsis presentation and the Centers for Medicare & Medicaid Services mandates administration within 3 hours. This study evaluates the difference in time from sepsis diagnosis to first-dose completion of ß-lactam antibiotics between IV push and IV piggyback administration. DESIGN: Single-center, retrospective analysis. SETTING: Urban, tertiary-care emergency department. PATIENTS: Inclusion criteria were as follows: 1) adult patients (n = 274) diagnosed with severe sepsis or septic shock per Sepsis-2 criteria from September to November 2016 and from September to November 2017 and 2) received ß-lactam antibiotic. INTERVENTIONS: Initial ß-lactam agent administered as either IV push or IV piggyback. MEASUREMENTS AND MAIN RESULTS: Median time (interquartile range) from sepsis diagnosis to administration of a ß-lactam antibiotic was 48 minutes (19-96 min) versus 72 minutes (8-180 min) and to administration of the complete broad-spectrum regimen was 108 minutes (66-144 min) versus 114 minutes (42-282 min) in the IV push (n = 143) versus IV piggyback (n = 131) groups, respectively. When controlling for time to sepsis diagnosis and other factors, IV push was associated with approximately 32-minute time savings to ß-lactam (ß = -0.60; 95% CI, -0.91 to -0.29) and approximately 32-minute time savings to broad-spectrum (ß = -0.32; 95% CI, -0.62 to -0.02) antibiotic administrations. The IV push group was less likely to fail the goal of ß-lactam antibiotics within 1 hour (44.6% vs 57.3%; odds ratio, 2.27; 95% CI, 1.34-3.86) and 3 hours (7.6% vs 24.5%; odds ratio, 4.31; 95% CI, 2.01-10.28) of sepsis diagnosis compared with IV piggyback. The IV push strategy did not affect mortality, need for ICU admission, or ICU length of stay. No adverse events, including infusion reactions, were found in either arm. CONCLUSIONS: Use of an IV push strategy may safely facilitate more rapid administration of ß-lactam antibiotics and may allow for better compliance with sepsis management guidelines.

Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock.

OBJECTIVES: Rapid fluid resuscitation has become standard in sepsis care, despite "low-quality" evidence and absence of guidelines for populations "at risk" for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived "at-risk" volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume "overload" by bedside examination. DESIGN: Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics. SETTING: Urban, tertiary care center between January 1, 2014, and May 31, 2017. PATIENTS: Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock. INTERVENTIONS: Administration of IV fluids by bolus. MEASUREMENTS AND MAIN RESULTS: In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46-0.83), male (odds ratio, 0.66; CI, 0.49-0.87), obese (odds ratio, 0.18; CI, 0.13-0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13-0.40), heart failure (odds ratio, 0.42; CI, 0.29-0.60), or documented volume "overload" (odds ratio, 0.30; CI, 0.20-0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03-2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02-1.99), and increased ICU stay (~2 d) (ß = 2.0; CI, 0.5-3.6), without differential effects for "at-risk" groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05). CONCLUSIONS: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.

Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department.

OBJECTIVES: The increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage. METHODS: This was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints. RESULTS: NEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5-86.5%), 86.1% (83.6-88.2%), and 28.5% (25.6-31.7%) and specificities were 85.0% (84.8-85.3%), 79.1% (78.9-79.3%), and 98.9% (98.8-99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively. CONCLUSIONS: NEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.

The Infant Aphakia Treatment Study Contact Lens Experience to Age 5 Years.

PURPOSE: To describe our experience treating a cohort of unilateral aphakic infants with contact lenses in the Infant Aphakia Treatment Study (IATS). MATERIALS AND METHODS: Fifty-seven of the 114 infants in the IATS were randomized to contact lens wear; all were followed until age 5 years, although a few had lapses in care. An examination under anesthesia, including keratometry, was performed at the time of enrollment and at approximately 1 year of age; keratometry was performed again at 5 years of age. A traveling examiner assessed visual acuity at approximately 1 year of age and again at 4.5 years of age. RESULTS: Twenty-four treated eyes (46%) wore silicone elastomer (SE) contact lenses, 11 eyes (19%) rigid gas permeable (GP) contact lenses and 17 eyes (29%) wore both lens types at various points of time. Median logMAR visual acuity was +0.70 (interquartile range (IQR), +0.30 to 1.20) in the SE group and 2.03 (IQR, +0.20 to 2.28) in the GP group at age 4.5 years. The mean (±SD) keratometric power of the treated eyes was 46.3±2.8 diopter (D) at baseline, 44.6±2.3 D at 1 year of age, and 44.3±1.7 D at 5 years of age. Keratometric astigmatism of treated eyes was 1.98±1.37 D at baseline, 1.62±0.98 D at 1 year of age, and 2.00±1.00 D at 5 years of age. Thirteen contact lens-related adverse events occurred among 7 patients after age 1 year. CONCLUSIONS: A cohort of infants with unilateral aphakia successfully wore contact lenses with relatively few adverse events.

Impact of a multipronged approach to reduce the incidence of Clostridioides difficile infections in hospitalized patients.

BACKGROUND: Effective approaches to reduce Clostridioides difficile infections (CDI) in hospitalized patients are needed. We report data from 3 years preceding and 3 years following interventions that proved successful, with detailed analysis of all cases the first year after implementation. METHODS: Interventions included a nursing protocol to identify cases present on admission by asking if the patient had 1 or more liquid stools in the last 24 hours, and a 2-step testing algorithm with samples positive by polymerase chain reaction (PCR) for the C. difficile toxin gene reflexing to an enzyme immunoassay (EIA) for the toxin antigen. RESULTS: Healthcare-associated infections due to CDI fell from ∼160 in each of the preceding 3 years to <65 in each of the subsequent 3 years (P < .001), while the ratio of observed-to-expected hospital-onset cases diminished to ∼0.50 (P < .02). In the first year, 395 samples were PCR(+), but only 118 (29.9%) of these were EIA(+). 55 (46.6%) of the PCR(+)/EIA(+) samples were from hospital day 1 or 2 and classified as present on admission. The mean time from stool collection to report of PCR results was ∼7.5 hours, and the EIA took on average only 68 additional minutes to be reported. CONCLUSIONS: The number of incident CDI cases can be dramatically decreased by implementing an admission screening question and a 2-step testing algorithm.

The infant aphakia treatment study contact lens experience: one-year outcomes.

PURPOSE: We describe our experience correcting a cohort of infants with contact lenses in the Infant Aphakia Treatment Study. MATERIALS AND METHODS: Fifty-seven infants 1-6 months of age were randomized to contact lens wear. An examination under anesthesia was performed at the time of enrollment and at approximately 1 year of age. A traveling examiner assessed visual acuity at approximately 1 year of age. RESULTS: Forty-two treated eyes (74 %) were fitted with silicone elastomer (SE) contact lenses; 12 eyes (21 %) with rigid gas permeable (RGP) contact lenses, and 3 eyes (5%) wore both lens types. Median visual acuity was +0.80 logMAR in both lens type-wearing groups. The mean (± SD) keratometric power of the treated eyes was 46.3±2.8 D at baseline and 44.6±2.3 D at 1 year of age for a mean decrease of 0.2±0.2 D/mo. Keratometric astigmatism of treated eyes was 1.98±1.37 D at baseline and 1.62±0.98 D at 1 year of age for a mean decrease of 0.05±0.2 D/mo. The mean RGP lens base curve at baseline was 47.62 D±2.62 D versus 47.00 D±3.50 D at 12 months after surgery. Children wearing SE lenses required a mean of 10.9 replacements (range 2-24) compared to 16.8 replacements (range 8-32) for children wearing RGP lenses. Three adverse events occurred. CONCLUSIONS: Contact lenses were worn successfully with relatively few adverse events by a cohort of infants with unilateral aphakia. The visual acuity results were identical independent of the contact lens material or modality. RGP lenses needed replacement more often than SE lenses.

Potential resistant morphotypes of Acanthamoeba castellanii expressed in multipurpose contact lens disinfection systems.

OBJECTIVES: The free-living amoeba Acanthamoeba castellanii is a rare cause of contact lens-associated microbial keratitis. The cyst stage of this amoeba is noted for its resistance to disinfection by multipurpose contact lens solutions (MPS). This report examines and reviews the potential survival modes of A. castellanii in MPS. METHODS: Trophozoites of A. castellanii (ATCC 30234) at densities from 10 to near 10 were incubated in 3 different MPS in a laminar flow hood for 24 hours at ambient temperatures. The dried films of MPS and phosphate-buffered saline (PBS) controls were examined before and after the addition of a peptone-yeast extract-glucose recovery broth (PYG) for the presence of amoeboid trophozoites and resistance stages over at least 7 days. The parallel exposure of trophozoites to MPS without evaporation or addition of PYG was similarly examined. RESULTS: Amoeboid trophozoites were not recovered in PYG nor were cyst-like structures observed in any MPS with near 10 densities. Progressively with 10 to 10 trophozoites, varied survival modes, particularly aggregates of trophozoites associated with cyst-like structures and occasional amoeboid forms and double-walled cysts with ostioles, became more evident. These morphotypes were most prominent after evaporation and typically first observed in the PYG. CONCLUSIONS: Trophozoites of A. castellanii near 10 and progressively to 10 densities are capable of expressing a variety of "short-term" survival modes in MPS, notably with the added stress of evaporation. Expression of these alternate survival modes in MPS may relate, in part, to contamination of contact lens cases and difficulties in developing standardized MPS efficacy tests.

Small bowel perforation secondary to fish bone ingestion managed non-operatively.

BACKGROUND: The presurgical diagnosis of foreign body (FB)-induced bowel perforation is exceedingly difficult. Perforation most commonly occurs in the ileocecal region and typically mimics diagnoses more common to the right lower quadrant (RLQ), including appendicitis and diverticulitis. OBJECTIVES: This report will discuss the events of this particular case of fish bone ingestion and subsequent small bowel perforation and the epidemiology, diagnosis, and management of FB ingestions. CASE REPORT: This case describes a 28-year-old man who presents with a 4-h history of sharp, stabbing abdominal pain localized to the RLQ. Abdominal computed tomography revealed a 1.5-cm curvilinear foreign body traversing through a loop of small bowel in the RLQ. Upon further questioning, the patient recalled eating northern pike 2 days before. During his hospital stay, the patient noted improvement of his symptoms and thus was managed non-operatively without complication. The patient was discharged after complete resolution of his abdominal pain on hospital day number 2. CONCLUSION: This represents a rare case of small bowel perforation secondary to fish bone ingestion that was managed non-operatively without complication.

Diagnostic Accuracy of a Bacterial and Viral Biomarker Point-of-Care Test in the Outpatient Setting.

Importance: Acute respiratory infections (ARIs) account for most outpatient visits. Discriminating bacterial vs viral etiology is a diagnostic challenge with therapeutic implications. Objective: To investigate whether FebriDx, a rapid, point-of-care immunoassay, can differentiate bacterial- from viral-associated host immune response in ARI through measurement of myxovirus resistance protein A (MxA) and C-reactive protein (CRP) from finger-stick blood. Design, Setting, and Participants: This diagnostic study enrolled adults and children who were symptomatic for ARI and individuals in a control group who were asymptomatic between October 2019 and April 2021. Included participants were a convenience sample of patients in outpatient settings (ie, emergency department, urgent care, and primary care) who were symptomatic, aged 1 year or older, and had suspected ARI and fever within 72 hours. Individuals with immunocompromised state and recent vaccine, antibiotics, stroke, surgery, major burn, or myocardial infarction were excluded. Of 1685 individuals assessed for eligibility, 259 individuals declined participation, 718 individuals were excluded, and 708 individuals were enrolled (520 patients with ARI, 170 patients without ARI, and 18 individuals who dropped out). Exposures: Bacterial and viral immunoassay testing was performed using finger-stick blood. Results were read at 10 minutes, and treating clinicians and adjudicators were blinded to results. Main Outcomes and Measures: Bacterial- or viral-associated systemic host response to an ARI as determined by a predefined comparator algorithm with adjudication classified infection etiology. Results: Among 520 participants with ARI (230 male patients [44.2%] and 290 female patients [55.8%]; mean [SD] age, 35.3 [17.7] years), 24 participants with missing laboratory information were classified as unknown (4.6%). Among 496 participants with a final diagnosis, 73 individuals (14.7%) were classified as having a bacterial-associated response, 296 individuals (59.7%) as having a viral-associated response, and 127 individuals (25.6%) as negative by the reference standard. The bacterial and viral test correctly classified 68 of 73 bacterial infections, demonstrating a sensitivity of 93.2% (95% CI, 84.9%-97.0%), specificity of 374 of 423 participants (88.4% [95% CI, 85.0%-91.1%]), positive predictive value (PPV) of 68 of 117 participants (58.1% [95% CI, 49.1%-66.7%), and negative predictive value (NPV) of 374 of 379 participants (98.7% [95% CI, 96.9%-99.4%]).The test correctly classified 208 of 296 viral infections, for a sensitivity of 70.3% (95% CI, 64.8%-75.2%), a specificity of 176 of 200 participants (88.0% [95% CI, 82.8%-91.8%]), a PPV of 208 of 232 participants (89.7% [95% CI, 85.1%-92.9%]), and an NPV of 176 of 264 participants (66.7% [95% CI, 60.8%-72.1%]). Conclusions and Relevance: In this study, a rapid diagnostic test demonstrated diagnostic performance that may inform clinicians when assessing for bacterial or viral etiology of ARI symptoms.