Success in early treatment with lipid emulsion for antihypertension drug overdose patient.

Intravenous lipid emulsion (ILE) is typically applied as a rescue therapy after the use of conventional treatments for beta blocker (BBs) or calcium channel blocker (CCB) overdoses. We describe the case of a 72-year-old man who presented to our ED after attempting suicide by antihypertensive drug overdose. His blood pressure dropped upon arrival at the ED, and we consequently administered multitherapy including relatively early ILE to prevent prolonged hypotension. He regained stable hemodynamic status on the third day and was later discharged without major sequelae.

Impact of climate change on disaster events in metropolitan cities -trend of disasters reported by Taiwan national medical response and preparedness system.

BACKGROUND: Taiwan is geographically located in a zone that is vulnerable to earthquakes, typhoons, floods, and landslide hazards and has experienced various disasters. Six Regional Emergency Medical Operation Centers (REMOCs) are integrated and administered by the Ministry of Health and Welfare (MOHW) to be responsible for emergency situations during disastrous events, such as the emission of chemical toxicants, traffic accidents, industrial materials containment, and typhoons. OBJECTIVE: To analyze events reported by the six REMOCs during the 2014 to 2018 for the government policy reference. METHODS: Data were collected from injured and death toll reports provided by local designated hospitals in the emergency medical reporting system. Disaster events were categorized into three categories: natural disaster (NDs), disasters associated with technology (DTs), and disasters associated with security/violence/others (DSVOs). The three categories were further subdivided into sub-categories. Variables considered for trend analyses included the number of wounded and deaths, event characteristics, date/time, and triage. The frequency of disaster events among the six REMOCs was compared using the chi-square test. We used the global information system (GIS) to describe the distribution of events in Taiwan metropolitan cities. The α-level was set at 0.05. RESULTS: Of 580 events during the study period, the distribution of disaster characteristics in the jurisdictions of the six REMOCs were different. The majority of disaster events were DTs (64.5%), followed by NDs (24.5%) and DSVOs (11.0%). Events for the three disaster categories in the six REMOCs were different (χ2-test, p < 0.001). Furthermore, for the Taipei branch (Northern Taiwan), other NDs, especially heatwaves and cold spells, were most reported in New Taipei City (92.2%) and showed an increasing annual trend; for the Kaohsiung branch (Southern Taiwan), DT events were the most reported, especially in Kaohsiung City; and for the Taichung branch (Central Taiwan), DSVOs were the most reported, especially in Taichung City. CONCLUSION: Our data revealed that extreme weather precautions reported in the Taipei branch were increasing. Disaster characteristics were different in each metropolitan city. Upgrading the ability to respond to natural disasters is ineluctable.

Antimicrobial escalation is not beneficial for Gram-negative bacteremia in adults who remained critically ill after appropriate empirical therapy.

To study whether antimicrobial escalation is beneficial for the outcome of bacteremia patients receiving appropriate but less responsive antimicrobials as empirical therapy, adults with community-onset Gram-negative bacteremia and remained the critical illness after appropriate empirical therapy with third-generation cephalosporins were retrospective enrolled. Clinical outcomes included incidental nosocomial infections, breakthrough bacteremia, and in-hospital crude mortality were compared between patients receiving escalation and non-escalation therapy, after propensity-score (PS) matching at a ratio of 1:3 using independent predictors of 30-day mortality recognized by the multivariate regression model. Initially, the higher proportion of fatal comorbidities (McCabe classification) and 30-day mortality rates was exhibited in the escalation group (51 patients), compared to the non-escalation group (de-escalation, 81; non-switch, 95). After appropriate PS-matching, similar proportions of clinical variables between the escalation (45 patients) and no-escalation (135) groups, in terms of patient demographics, bacteremia severity at onset, severity and types of comorbidities, and bacteremia sources, were observed. Consequently, poorer clinical outcomes, such as the higher rate of incidental nosocomial infections and in-hospital crude mortality as well as the longer length of intravenous antimicrobial administration and hospitalization, were statistically evidenced in the escalation group, compared to the non-escalation group. Conclusively, for patients exhibiting poor responses to appropriate empirical therapy, antimicrobial escalation did not significantly result in improved outcomes; otherwise, clinicians should pay more attention to the strategy of supportive care or adequate control of septic complication.

Differential effects of inappropriate empirical antibiotic therapy in adults with community-onset gram-positive and gram-negative aerobe bacteremia.

Bacteremia is associated with high morbidity and mortality, which contribute substantially to health care costs. A beneficial influence of appropriate empirical antimicrobial therapy (EAT) on patient outcome is evidenced; However, the evidence highlighting a comparison of clinical manifestations and of the effects of inappropriate EAT between Gram-positive and Gram-negative bacteremia is insufficient. In a retrospective 6-year cohort study, the total 2053 adults (Gram-positive, 566; Gram-negative 1487) presenting with community-onset monomicrobial aerobes bacteremia were recruited. Inappropriate EAT was defined as the first dose of an appropriate antimicrobial agent not being administered within the first 24 h after blood cultures were drawn. Although the bacteremia severity (a Pitt bacteremia score) at onset, comorbidity severity (the McCabe-Johnson classification), and 28-day mortality rate were similar in the two groups. Furthermore, after adjustment of independent predictors of 28-day mortality respectively recognized by the multivariate regression model in Gram-negative and Gram-positive groups, the Kaplan-Meier curve and Cox regression analysis revealed a significant difference (adjust odds ratio [AOR], 2.68; P < 0.001) between appropriate and inappropriate EAT in the Gram-negative group, but not in the Gram-positive group (AOR, 1.54; P = 0.06). Conclusively, patients with Gram-positive and Gram-negative bacteremia exhibited the similar presentation in bacteremia severity, but a greater impact of inappropriate EAT on survival of patients with Gram-negative aerobe bacteremia was evidenced.

Differential impacts of inappropriate empirical therapy on ED patients with Staphylococcus aureus and streptococci bacteremia.

BACKGROUND: Staphylococcus aureus (S. aureus) and streptococci are leading Gram-positive pathogens causing community-onset bacteremia. The comparisons of initial presentations and impacts of inappropriate empirical antimicrobial therapy (EAT) on clinical outcomes between the two pathogens are lacking. METHODS: In a 6-year cohort study, adult patients with community-onset monomicrobial S. aureus or streptococci bacteremia in the emergency department (ED) were studied. Clinical variables were collected retrospectively from medical records; the primary outcome was 4-week mortality after ED arrival. The Cox regression model was studied for effects of inappropriate EAT on 4-week mortality, after adjustment of independent predictors of 4-week mortality recognized by the multivariate regression model. RESULTS: A difference of clinical manifestations between S. aureus (291 patients) and streptococci (223) bacteremia was exhibited, in terms of bacteremia sources and comorbidity types, but bacteremia and comorbidity severity at ED arrival were similar. Furthermore, a longer period of the time-to-defervescence and hospitalization as well as more frequencies of septic metastasis were disclosed in S. aureus bacteremia, compared to streptococcal bacteremia. Of note, a significant impact (adjusted odds ratio [ORa], 2.23; 95% confidence interval [CI], 1.25-3.96) of inappropriate EAT on 4-week mortality was evidenced in S. aureus bacteremia, but not in streptococcal bacteremia (ORa, 2.88; 95% CI, 0.85-9.86). CONCLUSIONS: For adults having community-onset monomicrobial bacteremia, the similarity of bacteremia and comorbidity severity at ED arrivals were observed between causative microorganisms of S. aureus and streptococci, but a crucial impact of inappropriate EAT on short-term mortality was only observed in S. aureus.

Validation of MEDS score in predicting short-term mortality of adults with community-onset bacteremia.

BACKGROUND: The Mortality in Emergency Department Sepsis (MEDS) score can be used to stratify ED patients with suspected infections according to mortality risk. However, it has yet to be externally validated for patients having bloodstream infections. METHODS: We retrospectively computed clinical information for the MEDS score, Pitt bacteremia score (PBS), Charlson comorbidity index (CCI), and McCabe-Jackson comorbid classification (MJCC) for adults with community-onset bacteremia. The MEDS score was validated by the comparisons with the following scoring systems: the PBS, CCI, MJCC, PBS plus MJCC, and PBS plus CCI. We evaluated goodness-of-fit statistics and c-statistics as measures of model calibration and discrimination, respectively. RESULTS: Of 2328 adults, a good calibration for 28-day crude mortality was obtained only in the MEDS score and PBS plus MJCC; a higher c-statistic (0.870, P < 0.001) were achieved by the MEDS score, compared to the PBS, CCI MJCC, PBS plus MJCC, and PBS plus CCI. A high c-statistic was observed in two combinative scoring system: the PBS plus CCI (0.855, P < 0.001) and PBS plus MJCC (0.843, P < 0.001). According to the Kaplan-Meier curves, 28-day crude mortality significantly differed between patients with scores equal to or higher than selected cutoff values and those with scores lower than selected cutoff values: 10 in the MEDS score and 5 in the PBS plus MJCC, respectively. CONCLUSION: The MEDS score is an excellent predictor of short-term outcomes in patients with community-onset bacteremia because it provides estimates with higher calibration and discrimination than those of the other scoring systems.

Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia.

BACKGROUND: Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate. METHODS: In a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis. RESULTS: Of the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms. CONCLUSIONS: The delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.

Etiology of community-onset monomicrobial bacteremic pneumonia and its clinical presentation and outcome: Klebsiella and Pseudomonas matters.

To describe the difference of the clinical features, bacteremia severity, and outcome of patient with community-onset bacteremic pneumonia between Pseudomonas, Klebsiella, and other causative microorganisms, the total 278 adults with community-onset monomicrobial bacteremic pneumonia were studied in a retrospective cohort. Klebsiella (61 patients, 21.9%) and Pseudomonas (22, 7.9%) species was the leading and the fifth common pathogen, respectively. More patients having initial presentation with critical illness (a Pitt bacteremia score ≥ 4) and a fatal comorbidity (McCabe classification) as well as a higher short- (30-day) or long-term (90-day) mortality rate was evidenced in patients infected with Klebsiella or Pseudomonas species, compared to other causative microorganisms. Compared to patients in the Klebsiella group, more frequencies of recent chemotherapy and an initial presentation of febrile neutropenia, and less proportions of diabetes mellitus were disclosed among those in the Pseudomonas group. Of importance, a significantly differential survival curve between Klebsiella or Pseudomonas species and other species during 30-day or 90-day period after bacteremia onset but a similarity of Pseudomonas and Klebsiella species was evidenced, using the Cox-regression after adjusting the independent predictors of 30-day mortality. Conclusively, of pathogens causing community-onset bacteremic pneumonia, Klebsiella and Pseudomonas species should be recognized as the highly virulent pathogens and resulted in poor short- and long-term prognoses.

Clinical Benefit of Appropriate Empirical Fluoroquinolone Therapy for Adults with Community-Onset Bacteremia in Comparison with Third-Generation-Cephalosporin Therapy.

Both fluoroquinolones (FQs) and third-generation cephalosporins (3rd-GCs) are commonly prescribed to treat bloodstream infections, but comparative efficacies between them were rarely studied. Demographics and clinical characteristics of 733 adults with polymicrobial or monomicrobial community-onset bacteremia empirically treated by an appropriate FQ (n = 87) or 3rd-GC (n = 646) were compared. A critical illness (respectively, 8.0% versus 19.0%; P = 0.01), an initial syndrome with severe sepsis (33.3% versus 50.3%; P = 0.003), or a fatal outcome at 28 days (4.6% versus 10.5%; P = 0.08) was less common in the FQ group. A total of 645 (88.0%) patients were febrile at initial presentation, and the FQ group with (FQ group versus 3rd-GC group, respectively, 7.6 days versus 12.0 days; P = 0.04) and without (3.8 days versus 5.4 days; P = 0.001) a critical illness had a shorter time to defervescence than the 3rd-GC group. By the propensity scores, 87 patients with appropriate FQ therapy were matched with 435 treated by 3rd-GC therapy at a ratio of 1:5, and there were no significant differences in terms of bacteremia severity, comorbidity severity, major comorbidities, causative microorganisms, and bacteremia sources between groups. Moreover, crude mortality rates at 28 days (FQ group versus 3rd-GC group, respectively, 4.6% versus 7.8%; P = 0.29) did not differ significantly. However, the time to defervescence was shorter in the FQ group (4.2 ± 3.6 versus 6.2 ± 7.6 days; P < 0.001). Conclusively in the adults with community-onset bacteremia, appropriate empirical FQ therapy was related to shorter time to defervescence than with 3rd-GC therapy, at least for those without a critical illness.

Age-Related Trends in Adults with Community-Onset Bacteremia.

To understand the epidemiological variation in bacteremia characteristics among differently aged populations, adults with community-onset bacteremia during a 6-year period were studied in a retrospective cohort. A total of 2,349 bacteremic patients were stratified into four age categories: young adults (18 to 44 years old; 196 patients; 8.3%), adults (45 to 64 years old; 707 patients; 30.1%), the elderly (65 to 84 years old; 1,098 patients; 46.7%), and the oldest old (≥85 years old; 348 patients; 14.8%). Age-related trends in critical illness (a Pitt bacteremia score of ≥4) at bacteremia onset, antibiotic-resistant pathogens (extended-spectrum ß-lactamase [ESBL]-producing Escherichia coli, Klebsiella species, and Proteus mirabilis [EKP]; methicillin-resistant Staphylococcus aureus [MRSA]; and levofloxacin nonsusceptible EKP), inappropriate empirical antibiotic therapy (EAT), and 4-week mortality rate were observed. Using a multivariate regression model, critical illness at bacteremia onset (adjusted odds ratio [AOR], 9.03; P < 0.001) and inappropriate EAT (AOR, 2.67; P < 0.001) were the two leading predictors of 4-week mortality. Moreover, ESBL-producing EKP (AOR, 12.94; P < 0.001), MRSA (AOR, 8.66; P < 0.001), and levofloxacin-nonsusceptible EKP (AOR, 4.27; P < 0.001) were linked to inappropriate EAT. In conclusion, among adults with community onset bacteremia, significant positive age-related trends were noted in antibiotic-resistant pathogens and bacteremia severity, which were related to the increasing incidence of inappropriate EAT and 4-week mortality with age. Thus, different empirical antimicrobial regimens should be considered for distinct age groups.

Timing of appropriate empirical antimicrobial administration and outcome of adults with community-onset bacteremia.

BACKGROUND: Early administration of appropriate antimicrobials has been correlated with a better prognosis in patients with bacteremia, but the optimum timing of early antibiotic administration as one of the resuscitation strategies for severe bacterial infections remains unclear. METHODS: In a retrospective cohort study, adults with community-onset bacteremia at the emergency department (ED) were analyzed. Effects of different cutoffs of time to appropriate antibiotic (TtAa) administration after arrival at the ED on 28-day mortality were examined, after adjustment for independent predictors of mortality identified by multivariate regression analysis. RESULTS: Among 2349 patients, the mean (interquartile range) TtAa was 2.0 (<1 to 12) hours. All selected cutoffs of TtAa, ranging from 1 to 96 hours, were significantly associated with 28-day mortality (adjusted odds ratio (AOR), 0.54-0.65, all P < 0.001), after adjustment of the following prognostic factors: fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score (PBS) ≥4) on arrival at the ED, polymicrobial bacteremia, extended-spectrum beta-lactamase-producer bacteremia, underlying malignancies or liver cirrhosis, and bacteremia caused by pneumonia or urinary tract infections. The adverse impact of TtAa on 28-day mortality was most evident at the cutoff of 48 hours, as the lowest AOR was identified (0.54, P < 0.001). In subgroup analyses, the most evident TtAa cutoff (i.e., the lowest AOR) remained at 48 hours in mildly ill (PBS = 0; AOR 0.47; P = 0.04) and moderately ill (PBS = 1-3; AOR 0.55; P = 0.02) patients, but shifted to 1 hour in critically ill patients (PBS ≥4; AOR 0.56; P < 0.001). CONCLUSIONS: The time from triage to administration of appropriate antimicrobials is one of the primary determinants of mortality. The optimum timing of appropriate antimicrobial administration is the first 48 hours after non-critically ill patients arrive at the ED. As bacteremia severity increases, effective antimicrobial therapy should be empirically prescribed within 1 hour after critically ill patients arrive at the ED.

The risk factors of the 72-h unscheduled return visit admission to emergency department in adults below 50 years old.

BACKGROUND: An unscheduled return visit (URV) to the emergency department (ED) within 72-h is an indicator of ED performance. An unscheduled return revisit (URV) within 72-h was used to monitor adverse events and medical errors in a hospital quality improvement program. The study explores the potential factors that contribute to URV to the ED within 72-h and the unscheduled return revisit admission (URVA) in adults below 50 years old. METHODS: The case-control study enrolled 9483 URV patients during 2015-2020 in National Cheng-Kung University Hospital. URVA and URV non-admission (URVNA) patients were analyzed. The Gini impurity index was calculated by decision tree (DT) to split the variables capable of partitioning the groups into URVA and URVNA. Logistic regression is applied to calculate the odds ratio (OR) of candidate variables. The α level was set at 0.05. RESULTS: Among patients under the age of 50, the percentage of females in URVNA was 55.05%, while in URVA it was 53.25%. Furthermore, the average age of URVA patients was 38.20 ± 8.10, which is higher than the average age of 35.19 ± 8.65 observed in URVNA. The Charlson Comorbidity Index (CCI) of the URVA patients (1.59 ± 1.00) was significantly higher than that of the URVNA patients (1.22 ± 0.64). The diastolic blood pressure (DBP) of the URVA patients was 85.29 ± 16.22, which was lower than that of the URVNA (82.89 ± 17.29). Severe triage of URVA patients is 21.1%, which is higher than the 9.7% of URVNA patients. The decision tree suggests that the factors associated with URVA are "severe triage," "CCI higher than 2," "DBP less than 86.5 mmHg," and "age older than 34 years". These risk factors were verified by logistic regression and the OR of CCI was 2.42 (1.50-3.90), the OR of age was 1.84 (1.50-2.27), the OR of DBP less than 86.5 was 0.71 (0.58-0.86), and the OR of severe triage was 2.35 (1.83-3.03). CONCLUSIONS: The results provide physicians with a reference for discharging patients and could help ED physicians reduce the cognitive burden associated with the diagnostic errors and stress.

Risk factors and outcome of Pseudomonas aeruginosa bacteremia among adults visiting the ED.

OBJECTIVES: The aim of this study was to determine the clinical characteristics of, antibiotic therapy for, and clinical outcome of Pseudomonas aeruginosa infection among bacteremic adults who visit the emergency department (ED). METHODS: Bacteremic adults who visited the ED were identified retrospectively from January 2007 to December 2007. Demographic characteristics, underlying illnesses, severity, bacteremic pathogens, antimicrobial agents, and outcome were determined from chart records. RESULTS: The records of 340 eligible bacteremic adults were analyzed; their mean age was 66.2 years, and major comorbidities included hypertension (175 patients, or 51.5%), diabetes mellitus (124, or 36.5%), and malignancy (87, or 25.6%). Among the 379 bacteremic isolates, Escherichia coli (139 isolates, or 6.6%) and Klebsiella pneumoniae (63, or 16.6%) were the major pathogens, whereas P aeruginosa (15, or 4.0%) was the third-leading gram-negative isolate. Of note, both 30-day mortality (33.3% vs 8.9%, P = .01) and the proportion of empirically inappropriate antibiotics (86.7% vs 31.4%, P < .001) were higher in bacteremia caused by P aeruginosa than in bacteremia not caused by P aeruginosa in univariate analysis. Moreover, multivariate analysis identified 3 independent factors related to P aeruginosa bacteremia: surgery during the 4 weeks before ED arrival (adjusted odds ratio [AOR], 12.7; 95% confidence interval [CI], 1.68-95.7; P = .01), malignancy (AOR, 4.57; 95% CI, 1.27-16.3; P = .02), and community onset (AOR, 0.14; 95% CI, 0.04-0.47; P = .002). CONCLUSIONS: For bacteremic adults who visited the ED, P aeruginosa was associated with a high mortality rate and a high proportion of empirically inappropriate antibiotic therapy. Identification of clinical predictors of P aeruginosa bacteremia would improve the quality of care and the use of appropriate antibiotics in the ED.

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED.

OBJECTIVES: To investigate the clinical impact of inappropriate empirical antibiotics on patient outcome and determine the risk factors for mortality in bacteremic adults who visited the emergency department (ED). METHODS: Bacteremic adults visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcomes were determined from chart records. RESULTS: The total of 454 eligible bacteremic adults were included in the analysis; excluded from the study were another 261 patients with contaminated blood cultures and 64 patients with ED stays of less than 24 hours. Among the included individuals, the mean age was 64.6 years, with a small predominance of males (230 patients, 50.7%). Of a total 494 bacteremic isolates, Escherichia coli (206, 41.7%) and Klebsiella species (81, 16.4%) were the most frequently encountered microorganisms. A lower 28-day mortality rate was demonstrated in bacteremic patients treated with appropriate antibiotics than that in those with inappropriate antibiotics or that in those with no antibiotic therapy, as judged by Kaplan-Meier survival curves (P = .01). Moreover, the differences among these three groups achieved higher significance (P = .002) in critically ill patients (Pittsburgh bacteremia scores of ≥ 4 points). In multivariate analyses, inappropriate antibiotic therapy in the ED was associated independently with mortality at 28 days (odds ratio, 2.26; 95% confidence interval, 1.01-5.13; P = .04). CONCLUSIONS: For bacteremic adults visiting the ED, their outcomes were favorable following appropriate antibiotics, compared to treatment with inappropriate antibiotics or no antibiotics.

Prognostic Effects of Inappropriate Empirical Antimicrobial Therapy in Adults With Community-Onset Bacteremia: Age Matters.

Background: Studies have reported the effects of delayed administration of appropriate antimicrobial therapy (AAT) on the short-term prognosis of patients with bloodstream infections; however, whether there is an age-related difference in these effects remains debated. Methods: In this 4-year multicenter case-control study, patients with community-onset bacteremia were retrospectively categorized into the "middle-aged" (45-64 years), "old" (65-74 years), and "very old" (≥75 years) groups. Two methods were adopted to investigate the prognostic effects of delayed AAT in each age group. First, its effects were, respectively, investigated, after adjustment for the independent predictors of 30-day mortality. Second, patients in each age group were matched by the closest propensity-score (PS), which was calculated by independent predictors of mortality; the survival curves and Pearson chi-square tests were adopted to disclose its effects in each PS-matching group. Results: Each hour of delayed AAT resulted in an average increase in the 30-day crude mortality rate of 0.2% (P = 0.03), 0.4% (P < 0.001), and 0.7% (P < 0.001) in middle-aged (968 patients), old (683), and very old (1,265) patients, after, respectively, adjusting the independent predictors of mortality in each group. After appropriate PS-matching, no significant proportion differences in patient demographics, bacteremia characteristics, severity of bacteremia and comorbidities, and 15-day or 30-day crude mortality rates were observed between three matched groups (582 patients in each group). However, significant differences in survival curves between patients with delayed AAT > 24 or >48 h and those without delayed administration were demonstrated in each age group. Furthermore, the odds ratios of 30-day mortality for delayed AAT > 24 or >48 h were 1.73 (P = 0.04) or 1.82 (P = 0.04), 1.84 (P = 0.03) or 1.95 (P = 0.02), and 1.87 (P = 0.02) or 2.34 (P = 0.003) in the middle-aged, old, and very old groups, respectively. Notably, the greatest prognostic impact of delayed AAT > 24 or >48 h in the very old group and the smallest impact in the middle-aged group were exhibited. Conclusion: For adults (aged ≥45 years) with community-onset bacteremia, the delayed AAT significantly impacts their short-term survival in varied age groups and the age-related differences in its prognostic impact might be evident.

Prognostic Effects of Delayed Administration of Appropriate Antimicrobials in Bacteraemic Adults Initially Presenting with Various Body Temperatures.

Purpose: To investigate the different impact of delayed administration of appropriate antimicrobial therapy (AAT) on short-term mortality of bacteraemia patients initially presenting with various body temperatures (BTs). Materials and Methods: A six-year, two-center cohort consisting of adults with community-onset bacteraemia in emergency departments (EDs) was retrospectively collected. Through the multivariable analyses, clinical impacts of delayed AAT, assessed by the time gap between the first dose of AAT and ED arrival, on 30-day mortality (primary outcomes) were respectively examined in the different groups of initial BTs (iBTs). Results: Of the 3171 adults, despite the similarities of delayed AAT in six iBT categories, hourly AAT delay was associated with an average increase in 30-day mortality rates of 0.24% in the group of iBT <36.0℃, 0.40% in the 36.0℃-36.9℃ group, 0.48% in the 37.0℃-37.9℃ group, 0.59% in the 38.0℃-38.9℃ group, 0.58% in the 39.0℃-39.9℃ group, and 0.71% in the ≥40.0℃ group, after respective adjusting independent predictors of mortality. Furthermore, for 589 patients who inappropriately received empirical antimicrobial treatment (ie, delayed AAT ≥ 24 hours), with a cutoff of 34.0℃, each 1℃ increase in iBTs was independently associated with an average increase in 30-day mortality rates of 42%. Conclusion: For adults with community-onset bacteraemia, the iBT-related differences in the prognostic impacts of delayed administration of appropriate antimicrobials might be evident.

Toxicity of tetramethylammonium hydroxide: review of two fatal cases of dermal exposure and development of an animal model.

To document two cases of patients who were fatally exposed to tetramethylammonium hydroxide (TMAH) on the skin and to establish a rat model to investigate the effects of dermal exposure to TMAH. The charts of two workers who died from occupational accidental exposure to TMAH were reviewed. The 4-hour lethal dose (LD50) of TMAH was determined by applying solutions mimicking the two most common industrially used concentrations (2.38% and 25%) of TMAH to the skin of Sprague-Dawley rats. Exposure of the rat's skin to 2.38% or 25% TMAH generated LD50 values of 85.9 mg/kg and 28.7 mg/kg, respectively. Application of either concentration of TMAH to the skin produced a rapid, significant increase in the rate of respiration. The serum concentrations of tetramethylammonium (TMA) also changed significantly with time of exposure to both concentrations of TMAH. The level of blood urea nitrogen decreased significantly in rats exposed to the 2.38% TMAH, and rats exposed to the 25% solution had a significant decrease in the serum concentration of sodium. Injection of atropine after 5 minutes of exposure did not significantly overcome any of the toxic effects observed with either solution of TMAH. The preliminary results in the rat model indicated that the lethality of TMAH cannot be fully explained by the severity of the patients' chemical burns, and the physiologic effects on respiratory and kidney functions were probably involved.

Definitive Cefazolin Therapy for Stabilized Adults with Community-Onset Escherichia coli, Klebsiella Species, and Proteus mirabilis Bacteremia: MIC Matters.

BACKGROUND: Cefazolin is in vitro active against wild isolates of Escherichia coli, Klebsiella species, and Proteus mirabilis (EKP), but clinical evidence supporting the contemporary susceptibility breakpoint issued by the Clinical and Laboratory Standards Institute (CLSI) are limited. METHODS: Between 2010 and 2015, adults with monomicrobial community-onset EKP bacteremia with definitive cefazolin treatment (DCT) at two hospitals were analyzed. Cefazolin minimum inhibitory concentrations (MICs) were correlated with clinical outcomes, including primary (treatment failure of DCT) and secondary (30-day mortality after bacteremia onset, recurrent bacteremia, and mortality within 90 days after the end of DCT) outcomes. RESULTS: Overall, 466 bacteremic episodes, including 340 (76.2%) episodes due to E. coli, 90 (20.2%) Klebsiella species, and 16 (3.6%) P. mirabilis isolates, were analyzed. The mean age of these patients was 67.8 years and female-predominated (68.4%). A crude 15- and 30-day mortality rate was 0.7% and 2.2%, respectively, and 11.2% experienced treatment failure of DCT. A significant linear-by-linear association of cefazolin MICs, with the rate of treatment failure, 30-day crude mortality, recurrent bacteremia or 90-day mortality after the DCT was present (all γ = 1.00, p = 0.01). After adjustment, the significant impact of cefazolin MIC breakpoint on treatment failure and 30-day crude mortality was most evident in 2 mg/L (>2 mg/L vs. ≤2 mg/L; adjusted hazard ratio, 3.69 and 4.79; p < 0.001 and 0.02, respectively). CONCLUSION: For stabilized patients with community-onset EKP bacteremia after appropriate empirical antimicrobial therapy, cefazolin might be recommended as a definitive therapy for cefazolin-susceptible EKP bacteremia, based on the contemporary CLSI breakpoint.

A Simple Scoring Algorithm That Predicts Abscesses in Adults with Community-Onset Klebsiella pneumoniae Bacteremia: Hypermucoviscosity Matters.

INTRODUCTION: Klebsiella pneumoniae is a pathogen commonly found in community-onset bacteremia. It causes an invasive syndrome that is frequently presented by metastatic infections and abscesses elsewhere and that is necessary for surgical or drainage intervention. To achieve a scoring algorithm to identify patients with community-onset K. pneumoniae bacteremia (CoKPB) who are at risk for abscess occurrences, a retrospective cohort study consisting of adults with CoKPB was conducted. METHODS: A 6-year cohort study consisting of adults having community-onset monomicrobial K. pneumoniae bacteremia was conducted. In addition to clinical variables collected from medical records, the hypermucoviscosity (HMV)-related gene (rmpA and magA) and an HMV phenotype were integrated into the proposed scoring algorithm. RESULTS: Of the 258 eligible adults, only 79 (30.6%) had abscesses related to bacteremia. Besides the presence of magA (ie, capsular serotype K1) and the HMV-phenotype, five clinical predictors were significantly associated with abscesses in a multivariate analysis: male gender, comorbidities with diabetes mellitus or neurological disorders, recent chemotherapy, and high c-reactive protein levels. Together, these predictors were used to calculate the CoKPB abscess score. Based on the scoring algorithm, a cut-off value of +2 yielded the high sensitivity (93.7%) and the acceptable specificity (50.8%); the area under the ROC curve was 0.83. CONCLUSION: A simple scoring algorithm that has substantial sensitivity and satisfactory specificity was proposed and the importance of the HMV phenotype or capsular K1 serotype was emphasized. The proposed predictive model needs external validation, but this scoring algorithm might be convenient and useful for clinicians.

The Hypotension Period after Initiation of Appropriate Antimicrobial Administration Is Crucial for Survival of Bacteremia Patients Initially Experiencing Severe Sepsis and Septic Shock.

Bacteremia is linked to substantial morbidity and medical costs. However, the association between the timing of achieving hemodynamic stability and clinical outcomes remains undetermined. Of the multicenter cohort consisted of 888 adults with community-onset bacteremia initially complicated with severe sepsis and septic shock in the emergency department (ED), a positive linear-by-linear association (γ = 0.839, p < 0.001) of the time-to-appropriate antibiotic (TtAa) and the hypotension period after appropriate antimicrobial therapy (AAT) was exhibited, and a positive trend of the hypotension period after AAT administration in the 15-day (γ = 0.957, p = 0.003) or 30-day crude (γ = 0.975, p = 0.001) mortality rate was evidenced. Moreover, for every hour delay of the TtAa, 30-day survival dropped an average of 0.8% (adjusted odds ratio [AOR], 1.008; p < 0.001); and each additional hour of the hypotension period following AAT initiation notably resulted in with an average 1.1% increase (AOR, 1.011; p < 0.001) in the 30-day crude mortality rate, after adjusting all independent determinants of 30-day mortality recognized by the multivariate regression model. Conclusively, for bacteremia patients initially experiencing severe sepsis and septic shock, prompt AAT administration might shorten the hypotension period to achieve favourable prognoses.