Pantoprazole promotes sustained intestinal carriage of multidrug-resistant Escherichia coli in amoxicillin-treated mice.

AIMS: The main objective of this study was to compare extended-spectrum ß-lactamase (ESBL) Escherichia coli fecal titers during 12 days between two groups: mice who received proton pump inhibitors (PPIs) and those that did not. METHODS AND RESULTS: We tested three different in vivo models: model 1, high inoculum (106 CFU ml-1); model 2, low inoculum (102 CFU ml-1); and model 3, low inoculum and 2-day amoxicillin wash-out. There was no significant difference between the two groups in fecal ESBL E. coli titers in models 1 and 2. The fecal titers of ESBL E. coli were probably too high to show differences in colonization related to PPI treatment. By introducing a 2-day wash-out period after stopping amoxicillin (model 3), the fecal ESBL E. coli titers were higher in the PPI-treated mice during 12 days (3 log versus 11 log day CFU g-1; P < 0.05). This result highlighted that PPIs promote stable ESBL E. coli digestive carriage in mice. Fecal quantitative PCR showed that mice with low ESBL E. coli fecal titers had a much higher concentration of equol-producing bacteria, Muribaculum sp., and Adlercreutzia caecimuris. CONCLUSIONS: Pantoprazole treatment promotes sustained digestive carriage of ESBL E. coli in amoxicillin-treated mice.

In vitro and in vivo activity of new strains of Bacillus subtilis against ESBL-producing Escherichia coli: an experimental study.

AIMS: The gastro-intestinal tract is a major reservoir of extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. Bacillus spores may be used as probiotics to decrease digestive colonization by ESBL-E. coli. Our aim was to assess the in vitro and in vivo activity of new Bacillus strains against ESBL-E. coli. METHODS AND RESULTS: We screened the in vitro activity of 50 Bacillus strains against clinical isolates of ESBL-E. coli and selected B. subtilis strains CH311 and S3B. Both strains decreased ESBL-E. coli titers by 4 log10 CFU L-1 in an in vitro model of gut content, whereas the B. subtilis CU1 strain did not. In a murine model of intestinal colonization by ESBL-E. coli, CH311 and S3B did not decrease fecal titers of ESBL-E. coli. Ten sequences of putative antimicrobial peptides were identified in the genomes of CH311 and S3B, but not in CU1. CONCLUSIONS: Two new B. subtilis strains showed strong in vitro activity against ESBL-E. coli. SIGNIFICANCE AND IMPACT OF STUDY: Despite strong in vitro activities of new B. subtilis strains against ESBL-E. coli, intestinal colonisation was not altered by curative Bacillus treatment even if their spores proved to germinate in the gut. Thus, this work underlines the importance of in vivo experiments to identify efficient probiotics. The use of potential antimicrobial compounds identified by genome sequencing remains an attractive alternative to explore.

An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia.

BACKGROUND: The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. OBJECTIVE: This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician. METHODS: We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management. DISCUSSION: In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized ß2-agonists. CONCLUSIONS: Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.

US Immigration Is Associated With Rapid and Persistent Acquisition of Antibiotic Resistance Genes in the Gut.

Little is known about the effect of human migration on gut microbiome antibiotic resistance gene (ARG) carriage. Using deep shotgun stool metagenomics analysis, we found a rapid increase in gut microbiome ARG richness and abundance in women from 2 independent ethnic groups relocating from Thailand to the United States.

Modeling the risk of fluoroquinolone resistance in non-severe community-onset pyelonephritis.

Estimating whether the individual probability of being infected by a fluoroquinolone resistant isolate is higher than 10% may help to choose the empirical treatment of pyelonephritis. We aimed to model the risk of fluoroquinolone resistance in women with community-onset pyelonephritis. Women with non-severe community-onset pyelonephritis were prospectively recruited in 4 French emergency departments of 2 districts. Adjusted odds ratios (aOR) and 95% confidence intervals were estimated through multivariate logistic regression. Among 190 patients, 19 (10%) were infected by a fluoroquinolone resistant isolate. Fluoroquinolone resistance was more frequent in district #2 (17%) than in district #1 (3%). Independent risk factors for fluoroquinolone resistance were district (adjusted OR, 7.0 (2.2-31.9)), and in the 6 previous months, urinary tract infection (UTI, aOR, 3.9 (1.3-11.5)) and vesical catheterization (aOR, 4.7 (0.5-33.3)). A specific model was derived to identify district #2 patients with a low (10% or lower) probability of being infected by a fluoroquinolone resistant isolate. Independent risk factors were residency in long-term care facility (aOR, 3.3 (0.7-13.5)), and in the 6 previous months, UTI (adjusted OR, 3.1 (0.9-10.7)) and home nursing care (aOR, 3.4 (0.6-17.0)). For 63 (67%) patients, the predicted probability of fluoroquinolone resistance was 0.10; among these patients, 6 (10%) actually had a fluoroquinolone resistant isolate. Locally derived predictive models may be used to identify patients with a low probability of fluoroquinolone resistance and guide the empirical antimicrobial therapy of non-severe community-onset pyelonephritis.

The effects of inulin on gut microbial composition: a systematic review of evidence from human studies.

BACKGROUND: Inulin, consisting of repetitive fructosyl units linked by ß(2,1) bonds, is a readily fermentable fiber by intestinal bacteria that generates large quantities of short-chain fatty acids (SCFA). In individuals with constipation, it was reported that inulin ingestion was associated with a significant increase in stool frequency, suggesting a potential impact of inulin on human gut microbiota composition. Progress in high-throughput technologies allow assessment of human-associated microbiomes in terms of diversity and taxonomic or functional composition, and can identify changes in response to a specific supplementation. Hence, to understand the effects of inulin on the human gut microbiome is pivotal to gain insight into their mechanisms of action. METHODS: Here, we conducted a systematic review of human studies in adult individuals showing the effects of inulin on the gut microbiome. We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until March 2019. We used multiple search terms capturing gut microbiome, gut microflora, intestinal microbiota, intestinal flora, gut microbiota, gut flora, microbial gut community, gut microbial composition, and inulin. RESULTS: Overall, nine original articles reported the effects of inulin on microbiome composition in adult humans, most of them being randomized, double-blind, placebo-controlled trials (n = 7). Studies varied significantly in design (3 studies associated inulin and oligofructose), supplementation protocols (from 5 to 20 gr per day of inulin consumed) and in microbiome assessment methods (16S sequencing, n = 7). The most consistent change was an increase in Bifidobacterium. Other concordant results included an increase in relative abundance of Anaerostipes, Faecalibacterium, and Lactobacillus, and a decrease in relative abundance of Bacteroides after inulin supplementation. CONCLUSIONS: Our systematic review assessed the evidence for the effects of inulin supplementation on the human gut microbiome. However, these in vivo studies did not confirm in vitro experiments as the taxonomic alterations were not associated with increase in short-chain fatty acids levels.

Trends and prediction of antimicrobial susceptibility in urinary bacteria isolated in European emergency departments: the EuroUTI 2010-2016 Study.

OBJECTIVES: To assess recent trends in susceptibility to antibiotics among urinary isolates isolated in European emergency departments (EDs) and to identify isolates with a high (90% or more) predicted probability of susceptibility to fluoroquinolones or third-generation cephalosporins (3GCs). METHODS: In this cross-sectional study, we included urine cultures obtained from adult patients between 2010 and 2016 in 24 European EDs. Temporal trends were assessed using time-series analysis and multivariate logistic models. Multivariate logistic models were also used to predict susceptibility to fluoroquinolones or 3GCs from patient age and sex, year, month and ED. RESULTS: We included 88242 isolates. Time-series analysis found a significant increase in susceptibility to fluoroquinolones and no significant trend for susceptibility to 3GCs. Adjusting for patient age and sex, ED and organism, multivariate models showed that susceptibility to 3GCs decreased from 2014 to 2016, while susceptibility to fluoroquinolones increased in 2015 and 2016. Among isolates from 2016, multivariate models predicted high probability of susceptibility to fluoroquinolones in 11% of isolates (positive predictive value 91%) and a high probability of susceptibility to 3GCs in 35% of isolates (positive predictive value 94%). CONCLUSIONS: Susceptibility of ED urinary isolates to fluoroquinolones increased from 2014, while susceptibility to 3GCs decreased from 2015. Predictive models identified isolates with a high probability of susceptibility to fluoroquinolones or 3GCs. The ability of such models to guide the empirical treatment of pyelonephritis in the ED remains to be determined.

Guideline-Based Clinical Assessment Versus Procalcitonin-Guided Antibiotic Use in Pneumonia: A Pragmatic Randomized Trial.

STUDY OBJECTIVE: Efforts to reduce unnecessary and unnecessarily long antibiotic treatment for community-acquired pneumonia have been attempted through use of procalcitonin and through guidelines based on serial clinical assessment. Our aim is to compare guideline-based clinical assessment- and procalcitonin algorithm-guided antibiotic use among patients with community-acquired pneumonia. METHODS: We performed a pragmatic, randomized, multicenter trial from November 2012 to April 2015 at 12 French hospitals. We included emergency department (ED) patients older than 18 years with community-acquired pneumonia. Patients were randomly assigned to either the procalcitonin-guided or clinical assessment group. In accordance with past studies, we hypothesized that serial clinical assessment would be superior to procalcitonin-guided care. The primary outcome was antibiotic duration, and secondary outcomes included rates of antibiotic duration less than or equal to 5 days, and clinical success and combined serious adverse outcomes at 30 days in the intention-to-treat population. RESULTS: Of 370 eligible patients, 285 (77%) were randomly assigned to either clinical assessment- (n=143) or procalcitonin-guided care (n=142). Median age was 67 years (range 18 to 93 years) and 40% of patients were deemed to have Pneumonia Severity Index class IV or V. Procalcitonin algorithm adherence was 76%. Antibiotic duration was not significantly different between clinical assessment- and procalcitonin-guided groups (median 9 versus 10 days, respectively). Clinical success rate was 92% in each group and serious adverse outcome rates were similar (15% versus 20%, respectively). CONCLUSION: Guideline-based serial clinical assessment did not reduce antibiotic exposure compared with procalcitonin-guided care among ED patients with community-acquired pneumonia. The strategies were similar in terms of duration of antibiotic use and clinical outcomes.

Antibiotics prescription and guidelines adherence in elderly: impact of the comorbidities.

BACKGROUND: Although the interest of antibiotics is well known, antibiotics prescription is associated with side effect, especially in patients with multiples comorbidities. One way to reduce the incidence of side effects is to respect antibiotics prescriptions guidelines. Our objective was to investigated the factors associated with guidelines adherence in elderly patients with multiples comorbidities. METHODS: From October 2015 to December 2016, antibiotics prescription and guidelines adherence were analyzed in two post-acute care and rehabilitation services of a 2600-bed, university-affiliated center. RESULTS: One hundred and twenty-eight patients were included, fifty-nine (46%) patients had antibiotics prescription according to guidelines. In Multivariable logistic regression analysis, prescription of 2 antibiotics or more (OR = 0.168, 95% IC = 0.037-0.758, p < 0.05), 85 years of age and more (OR = 0.375, 95% IC = 0.151-0.931, p < 0.05) and the Charlson comorbidity index score (OR = 0.750, 95% IC = 0.572-0.984, p < 0.05) were negatively associated with antibiotics prescriptions according to guidelines. CONCLUSIONS: High comorbidity in the elderly was negatively associated with the guidelines adherence of antibiotiсs prescriptions. These criteria should be considered to optimize antibiotics prescriptions in elderly patients.

Diagnostic performance of serum blood urea nitrogen to creatinine ratio for distinguishing prerenal from intrinsic acute kidney injury in the emergency department.

BACKGROUND: The blood urea nitrogen to creatinine ratio (BCR) has been used since the early 1940s to help clinicians differentiate between prerenal acute kidney injury (PR AKI) and intrinsic AKI (I AKI). This ratio is simple to use and often put forward as a reliable diagnostic tool even though little scientific evidence supports this. The aim of this study was to determine whether BCR is a reliable tool for distinguishing PR AKI from I AKI. METHODS: We conducted a retrospective observational study over a 13 months period, in the Emergency Department (ED) of Nantes University Hospital. Eligible for inclusion were all adult patients consecutively admitted to the ED with a creatinine >133 µmol/L (1.5 mg/dL). RESULTS: Sixty thousand one hundred sixty patients were consecutively admitted to the ED. 2756 patients had plasma creatinine levels in excess of 133 µmol/L, 1653 were excluded, leaving 1103 patients for definitive inclusion. Mean age was 75.7 ± 14.8 years old, 498 (45%) patients had PR AKI and 605 (55%) I AKI. BCR was 90.55 ± 39.32 and 91.29 ± 39.79 in PR AKI and I AKI groups respectively. There was no statistical difference between mean BCR of the PR AKI and I AKI groups, p = 0.758. The area under the ROC curve was 0.5 indicating that BCR had no capacity to discriminate between PR AKI and I AKI. CONCLUSIONS: Our study is the largest to investigate the diagnostic performance of BCR. BCR is not a reliable parameter for distinguishing prerenal AKI from intrinsic AKI.

Recognition and treatment of severe sepsis in the emergency department: retrospective study in two French teaching hospitals.

BACKGROUND: Sepsis management in the Emergency Department remains a daily challenge. The Surviving Sepsis Campaign (SSC) has released three-hour bundle. The implementation of these bundles in European Emergency Departments remains poorly described. The main objective was to assess the compliance with the Severe Sepsis Campaign 3-h bundle (blood culture, lactate dosage, first dose of antibiotics and 30 ml/kg fluid challenge). Secondary objectives were the analysis of the delay of severe sepsis recognition and description of the population. METHODS: In accordance with STROBE statement, we performed a retrospective study in two French University Hospital Emergency Departments from February to August 2015. Patients admitted during the study period were screened using the electronic files of the hospital databases. Patient's files were reviewed and included in the study if they met severe sepsis criteria. Demographics, comorbities, treatments were recorded. Delays from admission to severe sepsis diagnosis, fluid loading onset and antibiotics administration were calculated. RESULTS: One hundred thirty patients were included (76 men, mean age 71 ± 14 years). Blood culture, lactate dosage, antibiotics and 30 ml/kg fluid loading were performed within 3 hours in % [95% confidence interval] 100% [96-100%], 62% [54-70%], 49% [41-58%] and 19% [13-27%], respectively. 25 patients out of 130 (19% [13-27%]) fulfilled each criteria of the 3-h bundle. The mean fluid loading volume was 18 ± 11 ml/kg. Mean delay between presentation and severe sepsis diagnosis was 200 ± 263 min, from diagnosis to fluid challenge and first antibiotic dose, 10 ± 27 min and 20 ± 55 min, respectively. CONCLUSION: Compliance with SSC 3-h bundle and delay between admission and sepsis recognition have to be improved. If confirmed by other studies, an improvement program might be deployed.

High variability among Emergency Departments in 3rd-generation cephalosporins and fluoroquinolones use for community-acquired pneumonia.

OBJECTIVE: Fluoroquinolones and 3rd-generation cephalosporins that are prescribed for pneumonia may be avoided and replaced by a penicillin in some cases. We aimed to determine if the proportion of patients treated for pneumonia with a cephalosporin, a fluoroquinolone or both varies among Emergency Departments (EDs), and to estimate the proportion of avoidable prescriptions. METHODS: This was a retrospective study of patients treated for pneumonia in eight French EDs, and subsequently hospitalized in non-ICU wards. Third-generation cephalosporins or respiratory fluoroquinolones were presumed unavoidable if they met both criteria: (1) age ≥65 years or comorbid condition; and (2) allergy or intolerance to penicillin, or failure of penicillin, or previous treatment with penicillin, or for fluoroquinolones only, suspected legionellosis. RESULTS: We included 832 patients. Thirty-four percent (95 % CI, 31-38 %) of patients were treated with a cephalosporin, a respiratory fluoroquinolone or both (range among EDs 19-44 %). Four EDs were independent risk factors for prescription of a cephalosporin, a fluoroquinolone or both [adjusted OR, 2.27 (1.64-3.15)], as were immune compromise [aOR 2.54 (1.56-4.14)], antibacterial therapy started before arrival in the ED [aOR 3.32 (2.30-4.81)], REA-ICU class III or IV [aOR 1.93 (1.15-3.23)], PSI class V [aOR 1.49 (1.00-2.20)], fluid resuscitation [aOR 3.98 (2.49-6.43)] and non-invasive ventilation in the ED [aOR, 7.18 (1.7-50.1)]. Treatment with a cephalosporin, a fluoroquinolone or both was avoidable in 67 % (62-73 %) of patients. CONCLUSION: Cephalosporins and fluoroquinolones use in pneumonia is highly variable among EDs. The majority of these prescriptions are avoidable. Antibiotic stewardship programs should be implemented to restrict their use in EDs.

16S rRNA gene pyrosequencing reveals shift in patient faecal microbiota during high-dose chemotherapy as conditioning regimen for bone marrow transplantation.

Gastrointestinal disturbances are a side-effect frequently associated with haematological malignancies due to the intensive cytotoxic treatment given in connection with bone marrow transplantation (BMT). However, intestinal microbiota changes during chemotherapy remain poorly described, probably due to the use of culture-based and low-resolution molecular methods in previous studies. The objective of our study was to apply a next generation DNA sequencing technology to analyse chemotherapy-induced changes in faecal microbiota. We included eight patients with non-Hodgkin's lymphoma undergoing one course of BMT conditioning chemotherapy. We collected a prechemotherapy faecal sample, the day before chemotherapy was initiated, and a postchemotherapy sample, collected 1 week after the initiation of chemotherapy. Total DNA was extracted from faecal samples, denaturing high-performance liquid chromatography based on amplification of the V6 to V8 region of the 16S ribosomal RNA (rRNA) gene, and 454-pyrosequencing of the 16 S rRNA gene, using PCR primers targeting the V5 and V6 hypervariable 16S rRNA gene regions were performed. Raw sequence data were screened, trimmed, and filtered using the QIIME pipeline. We observed a steep reduction in alpha diversity and significant differences in the composition of the intestinal microbiota in response to chemotherapy. Chemotherapy was associated with a drastic drop in Faecalibacterium and accompanied by an increase of Escherichia. The chemotherapy-induced shift in the intestinal microbiota could induce severe side effects in immunocompromised cancer patients. Our study is a first step in identifying patients at risk for gastrointestinal disturbances and to promote strategies to prevent this drastic shift in intestinal microbiota.

Efficacy of an inulin-based treatment on intestinal colonization by multidrug-resistant E. coli: insight into the mechanism of action.

Inulin, an increasingly studied dietary fiber, alters intestinal microbiota. The aim of this study was to assess whether inulin decreases intestinal colonization by multidrug resistant E. coli and to investigate its potential mechanisms of action. Mice with amoxicillin-induced intestinal dysbiosis mice were inoculated with extended spectrum beta-lactamase producing E. coli (ESBL-E. coli). The combination of inulin and pantoprazole (IP) significantly reduced ESBL-E. coli fecal titers, whereas pantoprazole alone did not and inulin had a delayed and limited effect. Fecal microbiome was assessed using shotgun metagenomic sequencing and qPCR. The efficacy of IP was predicted by increased abundance of 74 taxa, including two species of Adlercreutzia. Preventive treatments with A. caecimuris or A. muris also reduced ESBL-E. coli fecal titers. Fecal microbiota of mice effectively treated by IP was enriched in genes involved in inulin catabolism, production of propionate and expression of beta-lactamases. They also had increased beta-lactamase activity and decreased amoxicillin concentration. These results suggest that IP act through production of propionate and degradation of amoxicillin by the microbiota. The combination of pantoprazole and inulin is a potential treatment of intestinal colonization by multidrug-resistant E. coli. The ability of prebiotics to promote propionate and/or beta-lactamase producing bacteria may be used as a screening tool to identify potential treatments of intestinal colonization by multidrug resistant Enterobacterales.

Impact of emergency physician performed ultrasound in the evaluation of adult patients with acute abdominal pain: a prospective randomized bicentric trial.

BACKGROUND: Abdominal pain is common in patients visiting the emergency department (ED). The aim of this study was to assess the diagnostic contribution of point-of-care ultrasound (POCUS) in patients presenting to the ED with acute abdominal pain. METHODS: We designed an interventional randomized, controlled, open label, parallel-group, trial in two French EDs. We included adult patients presenting to the ED with acute abdominal pain. Exclusion criteria were a documented end-of-life, an immediate need of life-support therapy and pregnant or breast-feeding women. Patients were randomized in the experimental group (i.e., workup including POCUS) or control group (usual care). The primary objective of the study was to assess the added value of POCUS on diagnostic pathway in the ED, according to the diagnostic established a posteriori by an adjudication committee. The primary endpoint was the proportion of exact preliminary diagnosis between the 2 groups. The preliminary diagnosis made after clinical examination and biological results with POCUS (intervention arm) or without POCUS (usual care) was considered exact if it was similar to the adjudication committee diagnosis. RESULTS: Between June 2021 11th and June 2022 23th, 256 patients were randomized, but five were not included in the primary analysis, leaving 125 patients in the POCUS group and 126 patients in the usual care group (130 women and 121 men, median [Q1-Q3] age: 42 [30;57]). There was no difference for exact diagnosis between the two groups (POCUS 70/125, 56% versus control 78/126 (62%), RD 1.23 [95% CI 0.74-2.04]). There was no difference in the accuracy for the diagnosis of non-specific abdominal pain nor number of biological or radiological exams. Diagnostic delays and length of stay in the ED were also similar. CONCLUSIONS: In this trial, systematic POCUS did not improve the rate of diagnostic accuracy in unselected patients presenting to the ED with acute abdominal pain. However, as it was a safe procedure, further research should focus on patients with suspected etiologies where POCUS is particularly useful. TRIAL REGISTRATION:  This trial was registered on ClinicalTrials.gov on 2022/07/20 ( https://clinicaltrials.gov/study/NCT04912206?id=NCT04912206&rank=1 ) (NCT04912206).

Base excess is an accurate predictor of elevated lactate in ED septic patients.

BACKGROUND: Prior studies showed that lactate is a useful marker in sepsis. However, lactate is often not routinely drawn or rapidly available in the emergency department (ED). OBJECTIVE: The study aimed to determine if base excess (BE), widely and rapidly available in the ED, could be used as a surrogate marker for elevated lactate in ED septic patients. METHODS: This was a prospective and observational cohort study. From March 2009 to March 2010, consecutive patients 18 years or older who presented to the ED with a suspected severe sepsis were enrolled in the study. Lactate and BE measurements were performed. We defined, a priori, a clinically significant lactate to be greater than 3 mmol/L and BE less than -4 mmol/L. RESULTS: A total of 224 patients were enrolled in the study. The average BE was -4.5 mmol/L (SD, 4.9) and the average lactate was 3.5 mmol/L (SD, 2.9). The sensitivity of a BE less than -4 mmol/L in predicting elevated lactate greater than 3 mmol/L was 91.1% (95% confidence interval, 85.5%-96.6%) and the specificity was 88.6% (95% confidence interval, 83.0%-94.2%). The area under the curve was 0.95. CONCLUSION: Base excess is an accurate marker for the prediction of elevated lactate in the ED. The measurement of BE, obtained in a few minutes in the ED, provides a secure and quick method, similar to the electrocardiogram at triage for patients with chest pain, to determine the patients with sepsis who need an early aggressive resuscitation.

Identification of potential organ donors of advanced age in EDs.

OBJECTIVE: In France and in Belgium, as in many countries, there is a shortage of organs for transplantation, which has led to strategies to recruit older potential donors who may die of stroke. METHODS: We conducted a post hoc analysis to identify potential organ donors with cardiac function among a population of dying patients in emergency departments. This population had been selected for a separate multicenter prospective observational study. We identified patients who died of a neurologic cause but had no clinical findings affecting their donor status. RESULTS: Of 2420 patients in the study, 407 died of a neurologic cause; and 233 of these were excluded because of clinical factors that made them ineligible as organ donors. The remaining 174 patients (7.2% of dying patients) could be considered potential organ donors. Their mean age was 75.2 ± 11 years. Sixty-eight (39%) were intubated, and 60 of these (34.5%) were mechanically ventilated. In addition, 94 patients (54%) died within 12 hours (median, 9.3 hours) after admission; and 13 (7%) died while receiving a maximum level of care. No diagnostic procedures were performed to assess brain death. CONCLUSION: A significant number of patients who die in emergency departments could be organ donors, including approximately 7% between 60 and 85 years of age with life-threatening neurologic diseases. However, this percentage may be reduced by family opposition. Emergency physicians should collaborate with intensive care units and local organ donation teams to optimize end-of-life care and maximize the number of potential donors.

Outcome of chest pain patients discharged from a French emergency department: a 60-day prospective study.

BACKGROUND: Chest pain (CP) is a common complaint among patients presenting to the emergency department (ED). Previous studies suggest that between 2% and 5% of ED patients who present with CP and are sent home develop an acute coronary syndrome within 30 days. In France, no prospective data are available concerning the outcome of CP patients discharged from the ED. OBJECTIVE: The objective of our study was to determine the rate of adverse cardiac events (ACE) within a period of 60 days after discharge from the ED. METHODS: From October 2007 to February 2008, consecutive patients aged 25 years or more who presented to the ED with CP were prospectively included. Patients discharged from the ED were contacted by phone at 60 days to determine their clinical course and the occurrence of an ACE. RESULTS: There were 322 CP patients enrolled, representing 3.9% of all medical admissions to the ED; 40.4% of these patients were hospitalized and 59.6% were discharged. Three patients (1.6%) could not be contacted for follow-up, leaving 189 patients eligible for the study. The rate of ACE was 3.7%: one ST-segment elevation myocardial infarction and six non-ST-segment elevation myocardial infarctions. Follow-up revealed that 39.1% of patients saw a cardiologist and that 14.2% were readmitted for CP. CONCLUSION: We found that CP is a frequent complaint in patients who present to our ED, and that a small proportion (3.7%) is mistakenly discharged and presents with an ACE during the 60-day follow-up period.

Palliative care for patients who died in emergency departments: analysis of a multicentre cross-sectional survey.

OBJECTIVES: A growing number of patients die each year in hospital emergency departments (EDs). Decisions to withhold or to withdraw life-support therapies occur in 80% of patients as described in a multicentre cross-sectional survey including 2420 patients. Palliative care has not been explored in patients dying in this setting. The aim of this study was to assess the incidence of palliative care and to describe this population. METHODS: The authors conducted a post-hoc analysis on a cohort of 2420 patients who died in 174 French and Belgian EDs. The authors identified patients who benefited from palliative care and described this population and the palliative care. RESULTS: Palliative therapies were administered to 1373 patients (56.7%). These therapies included administration of analgesics, sedation, mouth care, repositioning for comfort (as appropriate) and provision of emotional support to the patient and his/her relatives. These palliative measures were provided more frequently in the observation unit of the ED (n=908, 66.2%) than in an examination room (n=465, 33.8%). Median time interval between ED admission and death was longer in patients who received palliative care (n=1373) (median, 15 h; first quartile, 6 h; third quartile, 34 h) than in those who did not (n=1047) (median, 4 h; first quartile, 1 h; third quartile, 10 h) (p<10(-4)). CONCLUSIONS: Palliative care is administered to about half of the patients who die in EDs. This is insufficient as the majority of the patients who died in EDs actually died after a decision to withhold or withdraw life-support therapies. End-of-life management must be improved in EDs.

Comparison of the global prevalence and trend of human intestinal carriage of ESBL-producing Escherichia coli between healthcare and community settings: a systematic review and meta-analysis.

Objectives: The widespread intestinal carriage of ESBL-producing Escherichia coli (ESBL E. coli) among both patients and healthy individuals is alarming. However, the global prevalence and trend of this MDR bacterium in healthcare settings remains undetermined. To address this knowledge gap, we performed a comparative meta-analysis of the prevalence in community and healthcare settings. Methods: Our systematic review included 133 articles published between 1 January 2000 and 22 April 2021 and indexed in PubMed, EMBASE or Google Scholar. A random-effects meta-analysis was performed to obtain the global pooled prevalence (community and healthcare settings). Subgroup meta-analyses were performed by grouping studies using the WHO regions and 5 year intervals of the study period. Results: We found that 21.1% (95% CI, 19.1%-23.2%) of inpatients in healthcare settings and 17.6% (95% CI, 15.3%-19.8%) of healthy individuals worldwide carried ESBL E. coli in their intestine. The global carriage rate in healthcare settings increased 3-fold from 7% (95% CI, 3.7%-10.3%) in 2001-05 to 25.7% (95% CI, 19.5%-32.0%) in 2016-20, whereas in community settings it increased 10-fold from 2.6% (95% CI, 1.2%-4.0%) to 26.4% (95% CI, 17.0%-35.9%) over the same period. Conclusions: The global and regional human intestinal ESBL E. coli carriage is increasing in both community and healthcare settings. Carriage rates were generally higher in healthcare than in community settings. Key relevant health organizations should perform surveillance and implement preventive measures to address the spread of ESBL E. coli in both settings.