Editorial: Optimizing opioid prescriptions in the emergency department.

Optimizing opioid prescriptions in the emergency department is essential to address the opioid pandemic while ensuring patient wellbeing. This requires a comprehensive approach that includes exploring alternatives to opioids for pain management, identifying individuals at risk for opioid addiction, implementing evidence-based guidelines, and involving doctors in the management of opioid addiction.

Outcome of Immediate Versus Early Antibiotics in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Debate exists about the mortality benefit of administering antibiotics within either 1 or 3 hours of sepsis onset. We performed this meta-analysis to analyze the effect of immediate (0 to 1 hour after onset) versus early (1 to 3 hours after onset) antibiotics on mortality in patients with severe sepsis or septic shock. METHODS: This review was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searched databases included PubMed, EMBASE, Web of Science, and Cochrane Library, as well as gray literature. Included studies were conducted with consecutive adults with severe sepsis or septic shock who received antibiotics within each period and provided mortality data. Data were extracted by 2 independent reviewers and pooled with random effects. Two authors independently assessed quality of evidence across all studies with Cochrane's Grading of Recommendations Assessment, Development and Evaluation methodology and risk of bias within each study, using the Newcastle-Ottawa Scale. RESULTS: Thirteen studies were included: 5 prospective longitudinal and 8 retrospective cohort ones. Three studies (23%) had a high risk of bias (Newcastle-Ottawa Scale). Overall, quality of evidence across all studies (Grading of Recommendations Assessment, Development and Evaluation) was low. Pooling of data (33,863 subjects) showed no difference in mortality between patients receiving antibiotics in immediate versus early periods (odds ratio 1.09; 95% confidence interval 0.98 to 1.21). Analysis of severe sepsis studies (8,595 subjects) found higher mortality in immediate versus early periods (odds ratio 1.29; 95% confidence interval 1.09 to 1.53). CONCLUSION: We found no difference in mortality between immediate and early antibiotics across all patients. Although the quality of evidence across studies was low, these findings do not support a mortality benefit for immediate compared with early antibiotics across all patients with sepsis.

An overview of positive cultures and clinical outcomes in septic patients: a sub-analysis of the Prehospital Antibiotics Against Sepsis (PHANTASi) trial.

BACKGROUND: Sepsis remains one of the most important causes of morbidity and mortality worldwide. In approximately 30-50% of cases of suspected sepsis, no pathogen is isolated, disabling the clinician to treat the patient with targeted antimicrobial therapy. Studies investigating the differences in the patient outcomes between culture-positive and culture-negative sepsis patients have only been conducted in subgroups of sepsis patients and results are ambiguous. METHODS: This is a sub-analysis of the PHANTASi (Prehospital Antibiotics Against Sepsis trial), a randomized controlled trial that focused on the effect of prehospital antibiotics in sepsis patients. We evaluated the outcome of cultures from different sources and determined what the clinical implications of having a positive culture compared to negative cultures were for patient outcomes. Furthermore, we looked at the effect of antibiotics on culture outcomes. RESULTS: 1133 patients (42.6%) with culture-positive sepsis were identified, compared to 1526 (56.4%) patients with culture-negative sepsis. 28-day mortality (RR 1.43 [95% CI 1.11-1.83]) and 90-day mortality (RR 1.41 [95% CI 1.15-1.71]) were significantly higher in culture-positive patients compared to culture-negative patients. Culture-positive sepsis was also associated with ≥ 3 organ systems affected during the sepsis episode (RR 4.27 [95% CI 2.78-6.60]). Patients who received antibiotics at home more often had negative blood cultures (85.9% vs. 78%) than those who did not (p < 0.001). CONCLUSIONS: Our results show that culture-positive sepsis is associated with a higher mortality rate and culture-positive patients more often have multiple organ systems affected during the sepsis episode. TRIAL REGISTRATION: The PHANTASi trial is registered at ClinicalTrials.gov, number NCT01988428 . Date of registration: November 20, 2013.

Digital Health Training Programs for Medical Students: Scoping Review.

BACKGROUND: Medical schools worldwide are accelerating the introduction of digital health courses into their curricula. The COVID-19 pandemic has contributed to this swift and widespread transition to digital health and education. However, the need for digital health competencies goes beyond the COVID-19 pandemic because they are becoming essential for the delivery of effective, efficient, and safe care. OBJECTIVE: This review aims to collate and analyze studies evaluating digital health education for medical students to inform the development of future courses and identify areas where curricula may need to be strengthened. METHODS: We carried out a scoping review by following the guidance of the Joanna Briggs Institute, and the results were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. We searched 6 major bibliographic databases and gray literature sources for articles published between January 2000 and November 2019. Two authors independently screened the retrieved citations and extracted the data from the included studies. Discrepancies were resolved by consensus discussions between the authors. The findings were analyzed using thematic analysis and presented narratively. RESULTS: A total of 34 studies focusing on different digital courses were included in this review. Most of the studies (22/34, 65%) were published between 2010 and 2019 and originated in the United States (20/34, 59%). The reported digital health courses were mostly elective (20/34, 59%), were integrated into the existing curriculum (24/34, 71%), and focused mainly on medical informatics (17/34, 50%). Most of the courses targeted medical students from the first to third year (17/34, 50%), and the duration of the courses ranged from 1 hour to 3 academic years. Most of the studies (22/34, 65%) reported the use of blended education. A few of the studies (6/34, 18%) delivered courses entirely digitally by using online modules, offline learning, massive open online courses, and virtual patient simulations. The reported courses used various assessment approaches such as paper-based assessments, in-person observations, and online assessments. Most of the studies (30/34, 88%) evaluated courses mostly by using an uncontrolled before-and-after design and generally reported improvements in students' learning outcomes. CONCLUSIONS: Digital health courses reported in literature are mostly elective, focus on a single area of digital health, and lack robust evaluation. They have diverse delivery, development, and assessment approaches. There is an urgent need for high-quality studies that evaluate digital health education.

Towards Understanding the Effective Use of Antibiotics for Sepsis.

BACKGROUND: The benefits of early antibiotics for sepsis have recently been questioned. Evidence for this mainly comes from observational studies. The only randomized trial on this subject, the Prehospital Antibiotics Against Sepsis (PHANTASi) trial, did not find significant mortality benefits from early antibiotics. That subgroups of patients benefit from this practice is still plausible, given the heterogeneous nature of sepsis. RESEARCH QUESTION: Do subgroups of sepsis patients experience 28-day mortality benefits from early administration of antibiotics in a prehospital setting? And what key traits drive these benefits? STUDY DESIGN AND METHODS: We used machine learning to conduct exploratory partitioning cluster analysis to identify possible subgroups of sepsis patients who may benefit from early antibiotics. We further tested the influence of several traits within these subgroups, using a logistic regression model. RESULTS: We found a significant interaction between age and benefits of early antibiotics (P = .03). When we adjusted for this interaction and several other confounders, there was a significant benefit of early antibiotic treatment (OR, 0.07; 95% CI, 0.01-0.79; P = .03). INTERPRETATION: An interaction between age and benefits of early antibiotics for sepsis has not been reported before. When validated, it can have major implications for clinical practice. This new insight into benefits of early antibiotic treatment for younger sepsis patients may enable more effective care.

Timeliness of antibiotics for patients with sepsis and septic shock.

For many years, sepsis guidelines have focused on early administration of antibiotics. While this practice may benefit some patients, for others it might have detrimental consequences. The increasingly shortened timeframes in which administration of antibiotics is recommended, have forced physicians to sacrifice diagnostic accuracy for speed, encouraging the overuse of antibiotics. The evidence supporting this practice is based on retrospective data, with all the limitations attached, while the only randomized trial on this subject does not show a mortality benefit from early administration of antibiotics in a population of patients with sepsis as often seen in the emergency department (ED). Physicians are challenged to treat patients suspected of having sepsis within a short period of time, while the real challenge should be to identify patients who would not be harmed by withholding treatment with antibiotics until the diagnosis of infection with a bacterial origin is confirmed and the appropriateness of a course of antibiotics can be evaluated more adequately. Therefore, in the general population of patients with sepsis, taking the time to gather additional data to confirm the diagnosis should be encouraged without a specific timeframe, although physicians should be encouraged to perform an adequate work-up as soon as possible. Patients with suspected sepsis and signs of shock should immediately be treated with antibiotics, as there is no margin for error.

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.

BACKGROUND: Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care. METHODS: After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428. FINDINGS: 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone. INTERPRETATION: In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity. FUNDING: The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).