Comparison of Outpatient Department-Referred and Self-Referred Patients in the Emergency Department.

BACKGROUND: Patients present to emergency departments (EDs) from a variety of backgrounds, which may help inform decision making. OBJECTIVE: This study investigated the clinical characteristics and outcomes of outpatient department (OPD)-referred patients and self-referred patients in the ED. METHODS: We selected nontrauma ED adult patients from a tertiary teaching hospital in Taiwan between August 1, 2020, and October 31, 2020. The acuity levels were determined by dichotomizing the triage classification scores. After propensity score matching, we compared the hospitalization, mortality, and length of ED stay of OPD-referred and self-referred patients. We categorized the patients into "emergency" or "urgent" subgroups according to their triage information and then analyzed the effects of different severity levels. Statistical significance was set at p < 0.05. RESULTS: A total of 564 OPD-referred and 11,959 self-referred patients were included. After propensity score matching, the OPD-referred patients (n = 564), compared with self-referred patients (n = 564), had a higher admission rate (49.8% vs. 28.9%; p < 0.001; odds ratio [OR] 2.44). Among the emergency subgroup patients, there was no significant difference between OPD-referred patients (n = 131) and self-referred patients (n = 138) regarding the admission rate (p = 0.257) or the mortality rate (p = 0.253). Among the urgent subgroup patients, OPD-referred patients (n = 433), compared with self-referred patients (n = 426), had a significantly higher admission rate (46.0% vs. 20.2%; p < 0.001; OR 3.36), but not mortality rate (2.1% vs. 0.5%; p = 0.064). Regarding the length of ED stay, OPD-referred and self-referred patients had a significant difference only in the "urgent and discharged" subgroup (5.8 vs. 2.3 h; p < 0.001). CONCLUSIONS: OPD-referred ED patients might have more severe and complex conditions and need comprehensive care management.

Predictive models for short-term mortality and length of hospital stay among adults with community-onset bacteraemia before and during the COVID-19 pandemic: application of early data dynamics.

BACKGROUND: The development of scoring systems to predict the short-term mortality and the length of hospital stay (LOS) in patients with bacteraemia is essential to improve the quality of care and reduce the occupancy variance in the hospital bed. METHODS: Adults hospitalised with community-onset bacteraemia in the coronavirus disease 2019 (COVID-19) and pre-COVID-19 eras were captured as the validation and derivation cohorts in the multicentre study, respectively. Model I incorporated all variables available on day 0, Model II incorporated all variables available on day 3, and Models III, IV, and V incorporated the variables that changed from day 0 to day 3. This study adopted the statistical and machine learning (ML) methods to jointly determine the prediction performance of these models in two study cohorts. RESULTS: A total of 3,639 (81.4%) and 834 (18.6%) patients were included in the derivation and validation cohorts, respectively. Model IV achieved the best performance in predicting 30-day mortality in both cohorts. The most frequently identified variables incorporated into Model IV were deteriorated consciousness from day 0 to day 3 and deteriorated respiration from day 0 to day 3. Model V achieved the best performance in predicting LOS in both cohorts. The most frequently identified variables in Model V were deteriorated consciousness from day 0 to day 3, a body temperature ≤ 36.0 °C or ≥ 39.0 °C on day 3, and a diagnosis of complicated bacteraemia. CONCLUSIONS: For hospitalised adults with community-onset bacteraemia, clinical variables that dynamically changed from day 0 to day 3 were crucial in predicting the short-term mortality and LOS.

Predicting Bacteremia among Septic Patients Based on ED Information by Machine Learning Methods: A Comparative Study.

INTRODUCTION: Bacteremia is a common but life-threatening infectious disease. However, a well-defined rule to assess patient risk of bacteremia and the urgency of blood culture is lacking. The aim of this study is to establish a predictive model for bacteremia in septic patients using available big data in the emergency department (ED) through logistic regression and other machine learning (ML) methods. MATERIAL AND METHODS: We conducted a retrospective cohort study at the ED of National Cheng Kung University Hospital in Taiwan from January 2015 to December 2019. ED adults (≥18 years old) with systemic inflammatory response syndrome and receiving blood cultures during the ED stay were included. Models I and II were established based on logistic regression, both of which were derived from support vector machine (SVM) and random forest (RF). Net reclassification index was used to determine which model was superior. RESULTS: During the study period, 437,969 patients visited the study ED, and 40,395 patients were enrolled. Patients diagnosed with bacteremia accounted for 7.7% of the cohort. The area under the receiver operating curve (AUROC) in models I and II was 0.729 (95% CI, 0.718-0.740) and 0.731 (95% CI, 0.721-0.742), with Akaike information criterion (AIC) of 16,840 and 16,803, respectively. The performance of model II was superior to that of model I. The AUROC values of models III and IV in the validation dataset were 0.730 (95% CI, 0.713-0.747) and 0.705 (0.688-0.722), respectively. There is no statistical evidence to support that the performance of the model created with logistic regression is superior to those created by SVM and RF. DISCUSSION: The advantage of the SVM or RF model is that the prediction model is more elastic and not limited to a linear relationship. The advantage of the LR model is that it is easy to explain the influence of the independent variable on the response variable. These models could help medical staff identify high-risk patients and prevent unnecessary antibiotic use. The performance of SVM and RF was not inferior to that of logistic regression. CONCLUSIONS: We established models that provide discrimination in predicting bacteremia among patients with sepsis. The reported results could inspire researchers to adopt ML in their development of prediction algorithms.

Microorganism Distributions and Antimicrobial Susceptibility in Community-Onset Bacteremia: A 6-Year Longitudinal Multicenter Cohort in Southern Taiwan.

Background: Prompt administration of appropriate antimicrobials has been correlated with improved prognoses in patients with bacteremia. Because the Clinical and Laboratory Standards Institute (CLSI) has numerously revised the interpretive criteria of susceptibility to numerous antimicrobials, the updated susceptibility is useful for empirical administration. Methods: In the multicenter retrospective cohort study consisting of adults with community-onset bacteremia in the emergency department (ED) during the period between January 2010 and December 2015, causative microorganisms were identified by the Vitek 2 system and prospectively collected. Antimicrobial susceptibility were respectively tested by the disk diffusion method for aerobes and the agar dilution method for anaerobes, in accordance with the contemporary CLSI criteria. Clinical information was retrospectively retrieved by reviewing the medical records. Results: Of the total 3,194 patients and 3,583 causative microorganisms, the leading source of bacteremia was the urinary tract infection (1,034 patients, 32.4%), and Escherichia coli accounted for the majority (1,332 isolates, 37.2%) of the total microorganisms. Overall, the lowest (58.2%) and highest (93.5%) susceptibility to cefazolin and piperacillin/tazobactam were, respectively, observed. In the leading five sources of bacteremia, in terms of the urinary tract infections, pneumonia, intraabdominal infections, skin and soft-tissue infections, and biliary tract infections, cefazolin or cefuroxime was only active against 49.3%-62.3% or 63.2%-74.1% of causative microorganisms, respectively. Notably, E. coli , Klebsiella species, and Proteus mirabilis (EKP) with the production of extended-spectrum beta-lactamases (ESBLs) accounted for 7.4% (142 isolates) of 1,908 EKP and 4.0% of all 3,583 microorganisms; and methicillin-resistant Staphylococcus aureus (MRSA) accounted for 37.7% (158 isolates) of S . aureus and 4.4% of all causative isolates. Conclusions: For adults with community-onset bacteremia, a low incidence (approximate 4%) of ESBL-producing EKP and MRSA among all causative microorganisms, but low susceptibility to cefazolin and cefuroxime were recognized. To achieve favorable prognoses by prompt administration of appropriate antimicrobials in EDs, our findings might offer useful information for the antimicrobial stewardship program.

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.

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 Antimicrobial Therapy in Older Persons Experiencing Bacteremia With or Without Initial Sepsis Presentations.

OBJECTIVES: To investigate the prognostic effects of delayed administration of appropriate antimicrobial therapy (AAT) in older persons experiencing bacteremia with and without initial sepsis syndrome, respectively. DESIGN: A 4-year multicenter cohort study. SETTING AND PARTICIPANTS: Older people (≥65 years of age) with community-onset bacteremia in the emergency department (ED) of 3 participating hospitals. METHODS: Clinical data were retrospectively collected and causative microorganisms were prospectively collected for susceptibilities to determine the period of delayed AAT for each bacteremia episode. Sepsis was defined based on the Sepsis-3 criteria. A multivariable regression model was used to investigate the prognostic effects of delayed AAT, after adjusting independent determinants of 30-day mortality. RESULTS: Of the total 2357 patients, their median (interquartile range) age was 78 (72-84) years and septic patients accounted for 48.4% (1140 patients) of the overall patients. Compared with nonseptic patients, septic individuals exhibited the shorter period of delayed AAT (median, 2.0 vs 2.5 hours; P < .001), longer hospitalization (median, 11 vs 9 days; P < .001), and higher crude mortality rates at 15 (28.9% vs 2.1%; P < .001) and 30 days (34.6% vs 4.0%; P < .001). In multivariable regression analyses, each hour of delayed AAT resulted in average increases in the 30-day crude mortality rates of 0.38% [adjusted odds ratio (AOR) 1.0038; P < .001), 0.42% (AOR 1.0042; P < .001), and 0.31% (AOR 1.0031; P = .04) among overall, septic, and nonseptic patients, respectively. CONCLUSIONS AND IMPLICATIONS: For older persons with community-onset bacteremia, irrespective of whether or not patients experiencing initial sepsis presentations, the prognostic impacts of delayed AAT have been evidenced. Notably, because of the longer period of delayed AAT in patients without fulfilling the Sepsis-3, adopting a stricter sepsis definition and/or early bacteremia predictor to avoid delayed AAT and unfavorable prognoses in patients with bacteremia is necessary.

Molnupiravir-A Novel Oral Anti-SARS-CoV-2 Agent.

Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly resulted in a global pandemic with approximately 4 million deaths. Effective oral antiviral agents are urgently needed to treat coronavirus disease-2019 (COVID-19), block SARS-CoV-2 transmission, and prevent progression to severe illness. Molnupiravir (formerly EIDD-2801), a prodrug of beta-d-N4-hydroxycytidine (EIDD-1931) and an inhibitor of RNA-dependent RNA polymerase, possesses significant activity against SARS-CoV-2. Its prophylactic efficacy has been evidenced in a ferret model. Two phase-I trials (NCT04392219 and NCT04746183) have demonstrated that oral molnupiravir is safe and well-tolerated at therapeutic doses. After five-days of oral molnupiravir therapy, satisfactory efficacies, assessed by eliminating nasopharyngeal virus in patients with early and mild COVID-19, were disclosed in two phase-II trials (NCT04405739 and NCT04405570). Two phase-II/III trials, NCT04575597 and NCT04575584, with estimated enrollments of 1850 and 304 cases, respectively, are ongoing. The NCT04575597 recently released that molnupiravir significantly reduced the risk of hospitalization or death in adults experiencing mild or moderate COVID-19. To benefit individual and public health, clinical applications of molnupiravir to promptly treat COVID-19 patients and prevent SARS-CoV-2 transmission may be expected.

Is qSOFA Suitable for Early Diagnosis of Sepsis Among Bacteremia Patients in Emergency Departments? Time for a Reappraisal of Sepsis-3 Criteria.

Background: For early recognition of patients with sepsis, quick Sequential Organ Failure Assessment (qSOFA) was proposed by Sepsis-3 criteria as initial sepsis identification outside of intensive care units. However, the new definition has subsequently led to controversy and prompted much discussion for delayed treatment efforts. We aimed to validate Sepsis-3 criteria on bacteremia patients by investigating prognostic impacts of inappropriate administration of empirical antimicrobial therapy (EAT) and delayed source control (SC) compared to Sepsis-2 criteria. Methods: In the multicenter cohort of adults with community-onset bacteremia in emergency departments (EDs), adverse effects of delayed treatment efforts on 30-day mortality were examined in septic and non-septic patients by fulfilling the Sepsis-2 or Sepsis-3 criteria using the Cox regression model after adjusting independent determinants of mortality. Results: Of the 3,898 total adults, septic patients accounted for 92.8% (3,619 patients) by Sepsis-2 criteria (i.e., SIRS criteria). Using Sepsis-3 criteria, 1,827 (46.9%) patients were diagnosed with early sepsis (i.e., initial qSOFA scores ≥ 2) in EDs and 2,622 (67.3%) with sepsis during hospitalization (i.e., increased SOFA scores of ≥ 2 from ED arrival). The prognostic impacts of inappropriate EAT or delayed SC (for complicated bacteremia) were both significant in septic patients with fulfilling the Sepsis-2 or Sepsis-3 (i.e., SOFA) criteria, respectively. Meanwhile, these delayed treatment efforts trivially impact prognoses of non-septic patients recognized by the Sepsis-2 or Sepsis-3 (i.e., SOFA) definitions. Notably, prognostic effects of inappropriate EAT or delayed SC were disclosed for septic patients in EDs, specifically those with qSOFA scores of ≥ 2, and prognostic impacts of delayed treatment efforts remained significant for patients initially recognized early as being non-septic (i.e., initial qSOFA scores of <2). Conclusions: For patients with community-onset bacteremia, inappropriate EAT and delayed SC might result in unfavorable outcomes of patients early identified as being non-septic on ED arrival based on the qSOFA scores (by Sepsis-3 criteria). Accordingly, a more prudent diagnosis of sepsis adopted among bacteremia patients in the ED is necessary.

Prediction of hospitalization using artificial intelligence for urgent patients in the emergency department.

Timely assessment to accurately prioritize patients is crucial for emergency department (ED) management. Urgent (i.e., level-3, on a 5-level emergency severity index system) patients have become a challenge since under-triage and over-triage often occur. This study was aimed to develop a computational model by artificial intelligence (AI) methodologies to accurately predict urgent patient outcomes using data that are readily available in most ED triage systems. We retrospectively collected data from the ED of a tertiary teaching hospital between January 1, 2015 and December 31, 2019. Eleven variables were used for data analysis and prediction model building, including 1 response, 2 demographic, and 8 clinical variables. A model to predict hospital admission was developed using neural networks and machine learning methodologies. A total of 282,971 samples of urgent (level-3) visits were included in the analysis. Our model achieved a validation area under the curve (AUC) of 0.8004 (95% CI 0.7963-0.8045). The optimal cutoff value identified by Youden's index for determining hospital admission was 0.5517. Using this cutoff value, the sensitivity was 0.6721 (95% CI 0.6624-0.6818), and the specificity was 0.7814 (95% CI 0.7777-0.7851), with a positive predictive value of 0.3660 (95% CI 0.3586-0.3733) and a negative predictive value of 0.9270 (95% CI 0.9244-0.9295). Subgroup analysis revealed that this model performed better in the nontraumatic adult subgroup and achieved a validation AUC of 0.8166 (95% CI 0.8199-0.8212). Our AI model accurately assessed the need for hospitalization for urgent patients, which constituted nearly 70% of ED visits. This model demonstrates the potential for streamlining ED operations using a very limited number of variables that are readily available in most ED triage systems. Subgroup analysis is an important topic for future investigation.

Blood Cultures and Appropriate Antimicrobial Administration after Achieving Sustained Return of Spontaneous Circulation in Adults with Nontraumatic Out-of-Hospital Cardiac Arrest.

We aimed to determine the incidence of bacteremia and prognostic effects of prompt administration of appropriate antimicrobial therapy (AAT) on nontraumatic out-of-hospital cardiac arrest (OHCA) patients achieving a sustained return of spontaneous circulation (sROSC), compared with non-OHCA patients. In the multicenter case-control study, nontraumatic OHCA adults with bacteremia episodes after achieving sROSC were defined as case patients, and non-OHCA patients with community-onset bacteremia in the emergency department were regarded as control patients. Initially, case patients had a higher bacteremia incidence than non-OHCA visits (231/2171, 10.6% vs. 10,430/314,620, 3.3%; p < 0.001). Compared with the matched control (2288) patients, case (231) patients experienced more bacteremic episodes due to low respiratory tract infections, fewer urosepsis events, fewer Escherichia coli bacteremia, and more streptococcal and anaerobes bacteremia. Antimicrobial-resistant organisms, such as methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase-producing Enterobacteriaceae, were frequently evident in case patients. Notably, each hour delay in AAT administration was associated with an average increase of 10.6% in crude 30-day mortality rates in case patients, 0.7% in critically ill control patients, and 0.3% in less critically ill control patients. Conclusively, the incidence and characteristics of bacteremia differed between the nontraumatic OHCA and non-OHCA patients. The incorporation of blood culture samplings and rapid AAT administration as first-aids is essential for nontraumatic OHCA patients after achieving sROSC.

A rapid clinic-based service for an emergency department of a tertiary teaching hospital during a dengue outbreak.

ABSTRACT: The 2015 dengue outbreak in southern Taiwan turned into a public health emergency, resulting in a large-scale mobilization of personnel from the emergency department (ED) services operating in and near full capacity to assist with the outbreak. This study aimed to assess a rapid independent clinic-based service (RCS), which was set up and designed to relieve the overcrowding of the regular ambulatory and emergency services during an epidemic of dengue.This is a retrospective cross-sectional study.National Cheng Kung University Hospital, Tainan, Taiwan.Patients with positive test results were enrolled and reviewed to evaluate the efficacy of RCS implementation between August and October 2015. The case-treatment rates stratified by length of stay (LOS) were used to examine the performance of the RCS that was set up outside the ED and designed to relieve the overcrowding of the regular ambulatory and emergency services.Patients with dengue-like illnesses may arrive at the hospital and require optimal ED triage and management thereafter. Although the outbreak resulted in a shortage of spare space in the ED, a proper response from the hospital administration would ameliorate the work overload of the staff and would not decrease the quality of care for critical patients.An early and restrictive intensive intervention was beneficial to health care facilities during a dengue outbreak. Further planning and training of the RCS could be crucial for hospital preparedness for infectious disease outbreaks.

Is Early Oral Antimicrobial Switch Useful for Less Critically Ill Adults with Community-Onset Bacteraemia in Emergency Departments?

To compare prognoses and adverse events between bacteraemic patients in the emergency department (ED) who received an early antimicrobial IV-to-PO switch and those treated with late or no IV-to-PO switch, an 8-year multicentre cohort consisting of adults with community-onset bacteraemia was conducted. The clinical characteristics and outcomes were compared in matched cohorts by the closest propensity score calculated based on the independent determinants of 30-day mortality identified by the multivariate regression model. Of the 6664 hospitalised patients who received no or late IV-to-PO switch, 2410 were appropriately matched with 482 patients treated with early IV-to-PO switch and discharged from the ED. There were no significant differences between the two matched groups in their baseline characteristics, including the patient demographics, severity and types of comorbidities, severity and sources of bacteraemia, and the 15- and 30-day mortality rates. Notably, in addition to the shorter lengths of intravenous antimicrobial administration and hospital stay, less phlebitis and lower antimicrobial costs were observed in patients who received an early IV-to-PO switch. Similarity was observed in the clinical failure rates between the two groups. Furthermore, the inappropriate administration of empirical antibiotics and inadequate source control were identified as the only independent determinants of the post-switch 30-day crude mortality in patients who received an early IV-to-PO switch. In conclusion, for less critically ill adults with community-onset bacteraemia who received appropriate empirical antimicrobial therapy and adequate source control, an early IV-to-PO switch might be safe and cost-effective after a short course of intravenous antimicrobial therapy.

Implementation of a radiation injury management curriculum for health-care professionals in Taiwan.

AIM: Radiation-related injury in the general population due to accidents or incidents is a rare but significant event that merits serious study and planning in the health-care system. Therefore, we developed different levels of training courses targeting medical emergency response and treatment for radiation-related injury in patients, for different health-care professionals and medical students. METHODS: The curriculum, teaching instructions, and objectives were based on the working group consensus of first responders of radiation-related injury. The working group included different specialists from hospitals, medical schools, and government radiation emergency response agencies. RESULTS: Several different course levels, including lectures, group discussions, case and scenario discussions, hands-on practice, tabletop drills, and drills were included. The curriculums have shown that developing different levels of courses for medical students and health-care professionals was feasible. CONCLUSION: Through the cooperation of different specialties and different interactive courses, the training programs were able to meet the initial education goals for medical emergency and radiation-related injury for medical students and health-care professionals.

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.

The Outcome and Implications of Public Precautionary Measures in Taiwan-Declining Respiratory Disease Cases in the COVID-19 Pandemic.

With the rapid development of the COVID-19 pandemic, countries are trying to cope with increasing medical demands, and, at the same time, to reduce the increase of infected numbers by implementing a number of public health measures, namely non-pharmaceutical interventions (NPIs). These public health measures can include social distancing, frequent handwashing, and personal protective equipment (PPE) at the personal level; at the community and the government level, these measures can range from canceling activities, avoiding mass gatherings, closing facilities, and, at the extreme, enacting national or provincial lockdowns. Rather than completely stopping the infectious disease, the major purpose of these NPIs in facing an emerging infectious disease is to reduce the contact rate within the population, and reduce the spread of the virus until the time a vaccine or reliable medications become available. The idea is to avoid a surge of patients with severe symptoms beyond the capacity of the hospitals' medical resources, which would lead to more mortality and morbidity. While many countries have experienced steep curves in new cases, some, including Hong Kong, Vietnam, South Korea, New Zealand, and Taiwan, seem to have controlled or even eliminated the infection locally. From its first case of COVID-19 on the 21 January until the 12 May, Taiwan had 440 cases, including just 55 local infections, and seven deaths in total, representing 1.85 cases per 100,000 population and a 1.5% death rate (based on the Worldometer 2020 statistics of Taiwan's population of 23.8 million). This paper presents evidence that spread prevention involving mass masking and universal hygiene at the early stage of the COVID-19 pandemic resulted in a 50% decline of infectious respiratory diseases, based on historical data during the influenza season in Taiwan. These outcomes provide potential support for the effectiveness of widely implementing public health precaution measures in controlling COVID-19 without a lockdown policy.

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.