Models to predict bacteremia in the emergency department: a systematic review. / Modelos predictivos de bacteriemia en el servicio de urgencias: revisión sistemática.

OBJECTIVES: Blood cultures are ordered in emergency departments for 15% of patients with suspected infection. The diagnostic yield varies from 2% to 20%. Thirty-day mortality in patients with bacteremia is high, doubling or tripling the rate in patients with the same infection but without bacteremia. Thus, finding an effective model to predict bacteremia that is applicable in emergency departments is an important goal. Shapiro's model is the one traditionally used as a reference internationally. The aim of this systematic review was to compare the predictive power of bacteremia risk models published since 2008, when Shapiro's model first appeared. MATERIAL AND METHODS: We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, searching in the following databases for articles published between January 2008 and May 31, 2023: PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Trip Medical Database, and ClinicalTrials.gov. No language restrictions were specified. The search terms were the following Medical Subject Headings: bacteremia/bacteraemia/blood stream infection, prediction model/clinical prediction rule/risk prediction model, emergencies/emergency/emergency department, and adults. Observational cohort studies analyzing diagnostic yield were included; case-control studies, narrative reviews, and other types of articles were excluded. The Newcastle-Ottawa Scale was used to score quality and risk of bias in the included studies. The results were compared descriptively, without meta-analysis. The protocol was included in the PROSPERO register (CRD42023426327). RESULTS: Twenty studies out of a total of 917 were found to meet the inclusion criteria. The included studies together analyzed 33 182 blood cultures, which detected 5074 cases of bacteremia (15.3%). Eleven studies were of high quality, 7 of moderate quality, and 2 of low quality. The area under the receiver operating characteristic curve (AUC) of Shapiro's model varied from 0.71 to 0.83. Sensitivity was as high as 98%, and specificity ranged from 26% to 69%. Three models with high scores for quality were also supported by both internal and external validation studies: Lee's model (AUC, 0.81; sensitivity 68%; specificity, 81%), the 5MPB-Toledo model (AUC, 0.906 to 0.946), and the MPB-INFURG-SEMES model (AUC, 0.924; sensitivity, 97%; specificity, 76%. CONCLUSION: The 5MPB-Toledo and MPB-INFURG-SEMES are useful for assessing the true risk of bacteremia in patients attended in emergency departments.

OBJETIVO: La obtención de hemocultivos (HC) se realiza en el 15% de los pacientes atendidos con sospecha de infección en los servicios de urgencias (SU) con una rentabilidad diagnóstica variable (2-20%). La mortalidad a 30 días de estos pacientes con bacteriemia es elevada, doble o triple que el resto con el mismo proceso. Así, encontrar un modelo predictivo de bacteriemia eficaz y aplicable en los SU sería muy importante. Clásicamente, el modelo de Shapiro ha sido la referencia en todo el mundo. El objetivo de esta revisión sistemática (RS) es comparar la capacidad para predecir bacteriemia en los SU de los distintos modelos predictivos publicados desde el año 2008 (fecha de publicación del modelo de Shapiro). METODO: Se realiza una RS siguiendo la normativa PRISMA en las bases de datos de PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase y ClinicalTrials.gov desde enero de 2008 hasta 31 mayo 2023 sin restricción de idiomas y utilizando una combinación de términos MESH: "Bacteremia/Bacteraemia/Blood Stream Infection", "Prediction Model/Clinical Prediction Rule/Risk Prediction Model", "Emergencies/Emergency/Emergency Department" y "Adults". Se incluyeron estudios de cohortes observacionales (analíticos de rendimiento diagnóstico). Para valorar la calidad del método empleado y el riesgo de sesgos de los artículos incluidos se utilizó la Newcastle-Ottawa Scale (NOS). No se incluyeron estudios de casos y controles, revisiones narrativas y en otros tipos de artículos. No se realizaron técnicas de metanálisis, pero los resultados se compararon narrativamente. El protocolo de la RS se registró en PROSPERO (CRD42023426327). RESULTADOS: Se identificaron 917 artículos y se analizaron finalmente 20 que cumplían los criterios de inclusión. Los estudios incluidos contienen 33.182 HC procesados con 5.074 bacteriemias (15,3%). Once estudios fueron calificados de calidad alta, 7 moderada y 2 baja. El ABC-COR conseguida por el modelo de Shapiro varía de 0,71 a 0,83, con sensibilidad (Se) hasta del 98%, con especificidad (Es) (26% a 69%). Para los tres modelos que tienen validación interna y externa y una buena calidad metodológica, el modelo de Lee consigue un ABC-COR de 0,81 con Se: 68% y Es: 81%, el modelo 5MPB-Toledo consigue un ABC-COR entre 0,91 y 0,95, y el MPB-INFURG-SEMES obtiene una ABC-COR de 0,92 con una Se: 97% y Es: 76%. CONCLUSIONES: Los modelos 5MPB-Toledo y MPB-INFURG-SEMES representan herramientas útiles para la estratificación del riesgo real de bacteriemia en los pacientes atendidos en los SU.

The Guadalajara Declaration on sepsis: emergency physicians' constructive comments on the Surviving Sepsis Campaign's 2021 updated guidelines. / Declaración de Guadalajara: una visión constructiva desde el servicio de urgencias a partir de la Surviving Sepsis Campaign 2021.

TEXT: The Surviving Sepsis Campaign (SSC) published a 2021 update of its 2016 recommendations. The update was awaited with great anticipation the world over, especially by emergency physicians. Under the framework of the CIMU 2022 (33rd World Emergency Medicine Conference) in Guadalajara, Mexico in March, emergency physiciansreviewed and analyzed the 2021 SSC guidelines from our specialty's point of view. In this article, the expert reviewers present their consensus on certain key points of most interest in emergency settings at this time. The main aims of the review are to present constructive comments on 10 key points and/or recommendations in the SSC 2021 update and to offer emergency physicians' experience- and evidence-based proposals. Secondarily, the review's recommendations are a starting point for guidelines to detect severe sepsis in emergency department patients and prevent progression, which is ultimate goal of what has become known as the Guadalajara Declaration on sepsis.

TEXTO: En noviembre del año 2021, la Surviving Sepsis Campaign (SSC) publicó una actualización de sus recomendaciones y directrices de 2016. Estas fueron recibidas con una enorme expectativa en todo el mundo, especialmente entre los médicos de urgencias y emergencias (MUE). Recientemente, en el marco del CIMU 2022 (33 Congreso Mundial de Medicina de Urgencias celebrado en marzo de 2022 en Guadalajara ­ México) se ha revisado y analizado, desde la perspectiva del MUE, la Guía SSC de 2021. Los expertos que realizaron esa tarea y también consensuaron algunos de los puntos clave que más interesan y preocupan a los MUE en la actualidad han elaborado este documento. Su objetivo principal es analizar de forma constructiva diez de los puntos clave y recomendaciones de la SSC 2021 para complementarlas con argumentos y propuestas desde la experiencia, evidencia y perspectiva del urgenciólogo. Además, de forma secundaria, pretende ser el punto de partida de la elaboración de las guías para detectar, prevenir la progresión y atender a los pacientes con infección grave y sepsis en urgencias, que supone la meta final de lo que desde la MUE ya se conoce como "la Declaración de Guadalajara".

Models for bacteraemia risk prediction. Clinical implications

Bacteraemia has important consequences for the patient, as it is associated with worse clinical outcomes. On the other hand, unnecessarily obtaining samples for blood cultures increases costs and the workload in the microbiology laboratory. Its diagnosis implies a time delay, but decisions about start antibiotic treatment, discharge, or admits the patient must be taken during the first attention and, therefore, before known the blood cultures results. This manuscript reviews the different strategies based on clinical scores and biomarkers that are useful for predicting bacteraemia and improving initial decision-making. (AU)

Nuevos modelos predictivos de bacteriemia en el servicio de urgencias: un paso adelante / New predictive models of bacteremia in the emergency department: a step forward

La atención de pacientes con sospecha de un proceso infeccioso en los servicios de urgencias hospitalarios(SUH) se haincrementado en la última década hasta suponer alrededor del15-20% de todas las atenciones diarias. En la valoración inicialde estos enfermos se toman muestras para los distintos estudios microbiológicos en un 45% de los casos, donde predomina la obtención de hemocultivos (HC), en el 14,6% de todosellos. La rentabilidad diagnóstica de estos HC es muy variable(2-20%). Los focos o procesos infecciosos más frecuentes sospechados o confirmados de las bacteriemias verdaderas(BV) enlos SUH son la infección del tracto urinario (45%) y la infecciónrespiratoria (25%). Por todo ello, la sospecha y confirmaciónde la BV tiene un relevante significado diagnóstico, pronósticoy obliga a cambiar algunas de las decisiones más importantesa tomar en el SUH. Entre otras, indicar el alta o ingreso, extraer HC y administrar el antimicrobiano adecuado y precoz.La intención de esta revisión es poner de manifiesto las evidencias científicas publicadas en los últimos cinco años, aclararlas controversias existentes actuales y comparar la capacidadpara predecir bacteriemia de los últimos modelos predictivospublicados desde el año 2017 con los ya existentes en esa fecha, año en el que se publicó una revisión que dejaba abierta lapropuesta de seguir buscando un modelo con un rendimientoadecuado para los SUH. Y así, a partir de ella, generar distintasrecomendaciones que ayuden a definir el papel que pueden tener estos modelos o escalas en la mejora de la indicación deobtención de los HC, así como en la toma inmediata de otrasdecisiones diagnóstico-terapéuticas (administración precozy adecuada del tratamiento antibiótico, solicitud de estudios complementarios y otras muestras microbiológicas, intensidaddel soporte hemodinámico, necesidad de ingreso, etc.) (AU)

The care of patients with a suspected infectious processin hospital emergency department (ED) has increased in thelast decade to account for around 15-20% of all daily care.In the initial evaluation of these patients, samples are takenfor the different microbiological studies in 45% of the cases,where obtaining blood cultures (BC) predominates, in 14.6%of all of them. The diagnostic yield of these BC is highly variable (2-20%). The most frequent suspected or confirmed focior infectious processes of true bacteremia (TB) in the ED areurinary tract infection (45%) and respiratory infection (25%).For all these reasons, the suspicion and confirmation of TB hasa relevant diagnostic and prognostic significance and requireschanging some of the most important decisions to be made inthe ED. Among others, indicate discharge or admission, extractBC and administer the appropriate and early antimicrobial. Theintention of this review is to highlight the scientific evidencepublished in the last five years, clarify the current controversies and compare the ability to predict bacteremia of the latest predictive models published since 2017 with those alreadyexisting on that date, year in which a review was publishedthat left open the proposal to continue searching for a modelwith adequate performance for ED. And so, based on it, generate different recommendations that help define the role thatthese models or scales can have in improving the indicationfor obtaining BC, as well as in the immediate making of otherdiagnostic-therapeutic decisions (administration early andappropriate antibiotic treatment, request for complementary studies and other microbiological samples, intensity of hemodynamic support, need for admission, etc.) (AU)

Ability of lactate, procalcitonin, and criteria defining sepsis to predict 30-day mortality, bacteremia, and microbiologically confirmed infection in patients with infection suspicion treated in emergency departments. / Capacidad del lactato, procalcitonina y de los criterios definitorios de sepsis para predecir mortalidad a 30 días, bacteriemia o infección confirmada microbiológicamente en los pacientes atendidos por sospecha de infección en urgencias.

OBJECTIVES: To evaluate lactate, procalcitonin, criteria defining systemic inflammatory response syndrome (SIRS), and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) and compare their ability to predict 30-day mortality, infection with microbiologic confirmation, and true bacteremia in patients treated for infection in hospital emergency departments. MATERIAL AND METHODS: Prospective multicenter observational cohort study. We enrolled a convenience sample of patients aged 18 years or older attended in 71 Spanish emergency departments from October 1, 2019, to March 31, 2020. Each model's predictive power was analyzed with the area under the receiver operating characteristic curve (AUC), and predetermined decision points were assessed. RESULTS: A total of 4439 patients with a mean (SD) age of 18 years were studied; 2648 (59.7%) were men and 459 (10.3%) died within 30 days. True bacteremia was detected in 899 (20.25%), and microbiologic confirmation was on record for 2057 (46.3%). The model that included the qSOFA score (2) and lactate concentration (0.738 mmol/L; 95% CI, 0.711-0.765 mmol/L) proved to be the best predictor of 30-day mortality, with an AUC of 0.890 (95% CI, 0.880-0.901). The model that included the SIRS score (2) and procalcitonin concentration (0.51 ng/mL) proved to be the best predictor of true bacteremia and microbiologic confirmation, with an AUC of 0.713 (95% CI, 0.698-0.728). CONCLUSION: A qSOFA score of 2 or more plus lactate concentration (0.738 mmol/L) predict 30-day mortality better than the combination of a SIRS score of 2 or more and procalcitonin concentration. A SIRS score of 2 or more plus procalcitonin concentration (0.51 ng/mL) predict true bacteremia and microbiologic confirmation.

OBJETIVO: Evaluar y comparar la capacidad del lactato, la procalcitonina (PCT) y de los criterios definitorios de sepsis (síndrome de respuesta inflamatoria sistémica ­SRIS­ y del quick Sepsis-related Organ Failure Assessment ­qSOFA­) para predecir mortalidad a 30 días, o infección ­con confirmación microbiológica o bacteriemia verdadera (BV)­ en los pacientes que acuden al servicio de urgencias hospitalario (SUH) por un episodio de sospecha de infección. METODO: Estudio observacional de cohortes, multicéntrico, prospectivo. Se incluyó por oportunidad a pacientes 18 años atendidos por sospecha de infección en 71 SUH españoles desde el 01/10/2019 al 31/03/2020. Se analizó la capacidad predictiva con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y puntos de decisión predeterminados. RESULTADOS: Se incluyeron 4.439 pacientes con edad media de 67 (18) años, 2.648 (59,7%) fueron hombres, fallecieron a los 30 días 459 (10,3%), se consideraron BV 899 (20,2%) y se consiguió confirmación microbiológica en 2.057 (46,3%). Para la mortalidad a 30 días la mejor ABC-COR fue la obtenida con el modelo qSOFA 2 más lactato 2 mmol/l con un ABC-COR de 0,738 (0,711-0,765). Para predecir BV y confirmación microbiológica el mejor rendimiento se obtuvo con el modelo de SRIS 2 más PCT 0,51 ng/ml, con un ABC-COR de 0,890 (0,880-0,901) y 0,713 (0,698-0,728), respectivamente. CONCLUSIONES: Para la predicción de mortalidad a 30 días, el qSOFA 2 es superior al SRIS 2 y el mejor rendimiento lo consigue el modelo qSOFA 2 más lactato 2 mmol/l. Para predecir BV y confirmación microbiológica, la PCT es superior al lactato y el mejor rendimiento lo obtiene el modelo SRIS 2 más PCT 0,51 ng/ml.

Utilidad del modelo 5MPB-Toledo para predecir bacteriemia en el paciente anciano / Usefulness of the 5MPB-Toledo model to predict bacteremia in the elderly patient

Resumen Objetivo: Analizar la utilidad del modelo predictivo de bacteriemia (5MPB-Toledo) en los mayores de 65 años atendidos por infección en el servicio de urgencias (SU). Material y Método: Estudio observacional prospectivo y multicéntrico de los hemocultivos (HC) obtenidos en pacientes mayores de 65 años atendidos por infección en 66 SU españoles desde el 1 de diciembre de 2019 hasta el 30 de abril de 2020. Se analizó la capacidad predictiva del modelo con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y se calculó el rendimiento diagnóstico de los puntos de corte (PC) del modelo elegido con los cálculos de la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo. Resultados: Se incluyeron 2.401 episodios de HC extraídos. De ellos, se consideró como bacteriemia verdadera a 579 (24,11%) y como HC negativo a 1.822 (75,89%). Entre los negativos, 138 (5,74%) se consideraron contaminados. Se categorizó a los pacientes en bajo (0-2 puntos), moderado (3-5 puntos) y alto (6-8 puntos) riesgo, con una probabilidad de bacteriemia de 1,2%, 18,1% y 80,7%, respectivamente. El ABC-COR del modelo tras remuestreo fue de 0,908 (IC 95%: 0,897-0,924). El rendimiento diagnóstico del modelo, considerando un PC ≥ 5 puntos, obtiene una sensibilidad de 94% (IC 95%:92-96), especificidad de 77% (IC 95%:76-79) y un valor predictivo negativo de 97% (IC 95%:96-98). Conclusión: El modelo 5MPB-Toledo es de utilidad para predecir bacteriemia en los mayores de 65 años atendidos en el SU por un episodio de infección.

Abstract Objective: To analyse a risk score to predict bacteremia (MPB5-Toledo) in the patients aged older 65 years seen in the emergency departments (ED) due to infections. Patients and Methods: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 66 Spanish ED for patients aged older 65 years seen from December 1, 2019, to April 30, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. Results: A total of 2.401 blood samples wered cultured. True cases of bacteremia were confirmed in 579 (24.11%). The remaining 1.822 cultures (75.89%) wered negative. And, 138 (5.74%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.2%, 18.1%, and 80.7%, respectively. The model´s area under the receiver ope rating characteristic curve was 0.908 (95% CI, 0.897-0.924). The prognostic performance with a model´s cut-off value of ≥ 5 points achieved 94% (95% CI: 92-96) sensitivity, 77% (95% CI: 76-79) specificity, and negative predictive value of 97% (95% CI: 96-98). Conclusion: The 5MPB-Toledo score is useful for predicting bacteremia in the patients aged older 65 years seen in the emergency departments due to infections.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections.

OBJECTIVE: To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections. METHODS: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0-2 points, intermediate risk by 3-5 points, and high risk by 6-8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70). CONCLUSION: The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

A bacteraemia risk prediction model: development and validation in an emergency medicine population.

OBJECTIVE: Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection. METHODS: This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value < 0.05 were introduced in the univariate analysis together with those of clinical significance. The final selection of variables for the scoring scale was made by logistic regression with selection by introduction. The results obtained were internally validated by dividing the sample in a derivation and a validation cohort. RESULTS: A total of 4,439 infectious episodes were included. Of these, 899 (20.25%) were considered as true bacteraemia. A predictive model for bacteraemia was defined with seven variables according to the Bacteraemia Prediction Model of the INFURG-SEMES group (MPB-INFURG-SEMES). The model achieved an area under the curve-receiver operating curve of 0.924 (CI 95%:0.914-0.934) in the derivation cohort, and 0.926 (CI 95%: 0.910-0.942) in the validation cohort. Patients were then split into ten risk categories, and had the following rates of risk: 0.2%(0 points), 0.4%(1 point), 0.9%(2 points), 1.8%(3 points), 4.7%(4 points), 19.1% (5 points), 39.1% (6 points), 56.8% (7 points), 71.1% (8 points), 82.7% (9 points) and 90.1% (10 points). Findings were similar in the validation cohort. The cut-off point of five points provided the best precision with a sensitivity of 95.94%, specificity of 76.28%, positive predictive value of 53.63% and negative predictive value of 98.50%. CONCLUSION: The MPB-INFURG-SEMES model may be useful for the stratification of risk of bacteraemia in adult patients with infection in EDs, together with clinical judgement and other variables independent of the process and the patient.

Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID 19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional CPAP devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for Pneumonia due to COVID 19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98% and 99% on average after 30 and 60 min with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122 respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040). CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

INTRODUCCIÓN: El uso de dispositivos que aportan presión positiva continua en la vía aérea ha demostrado mejoría en diversas patologías que producen insuficiencia respiratoria. En el episodio de pandemia por COVID 19 el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de CPAP, se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos dispositivos, así como su eficacia. MATERIAL Y MÉTODOS: Se recogen datos de pacientes ingresados por Neumonía por COVID 19 en el Hospital de campaña de IFEMA. Se recogen datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio. RESULTADOS: Estudio realizado sobre un total de 23 pacientes, con fecha ingreso en IFEMA. Se empleó CPAP alternativa en cinco pacientes (21,7%), mientras que en los 18 pacientes restantes (78,3%) se usó soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observa un aumento progresivo de la saturación en aquellos pacientes en los que se empleó CPAP alternativa (de 94% de promedio a 98% y 99% de promedio tras 30 y 60 minutos con la máscara, respectivamente), aunque este cambio no resultó significativo (p = 0,058 y p = 0,122 respectivamente). No se observó un cambio significativo de frecuencia respiratoria al inicio y final de la medición en pacientes que usaron CPAP alternativa (p = 0,423) pero si entre los que no la usaron (p = 0,001). Se observa una mejoría estadísticamente significativa en la variable Saturación de oxigeno / Fracción inspirado de oxígeno en los pacientes que usaron CPAP alternativa (p = 0,040). CONCLUSIÓN: El uso de estos dispositivos ha ayudado al trabajo ventilatorio de varios pacientes mejorando sus parámetros de oxigenación. Para observar mejor la evolución de los pacientes sometidos a esta terapia y compararlos con pacientes con otro tipo de soporte ventilatorio, son necesarios más estudios en los que se aleatorice su uso.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections. / Validación del modelo predictivo de bacteriemia (5MPB-Toledo) en los pacientes atendidos en el servicio de urgencias por infección.

OBJECTIVE: To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections. METHODS: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70). CONCLUSION: The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Puntos clave sobre la COVID-19 en los servicios de urgencias: propuestas de mejora para su atención en Latinoamérica / Key issues in emergency department management of COVID-19: proposals for improving care for patients in Latin America

La incidencia y el impacto de la COVID-19 (Coronavirus Disease 2019) en Latinoamérica y España, en particular en sus servicios de urgencias hospitalarios (SUH), independientemente de la diversidad de los conceptos y definiciones de casos confirmados o sospechosos empleados ha sido, es, y, desgraciadamente a medio plazo, va a seguir siendo enorme, sostenida e imprevisible. En este escenario global, un grupo multinacional de expertos y representantes del Grupo de Trabajo Latinoamericano para la mejora de la atención del paciente con Infección en Urgencias (GT-LATINFURG), compuesto por 13 Sociedades y Asociaciones Científicas que integran la Federación Latinoamericana de Medicina de Emergencias (FLAME), junto con la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES),ha elaborado diversos documentos técnicos y de opinión destinados a los profesionales de los Sistemas de Urgencias y Emergencias de nuestros países. El objetivo de este artículo es ofrecer unas pautas o recomendaciones consensuadas para facilitar la actuación de los SUH en relación los puntos que los miembros del grupo han considerado más interesantes o clave en relación a: la necesidad de reorganizar los SUH, triaje, disponibilidad de pruebas complementarias habituales y otras como biomarcadores, la identificación del paciente con COVID-19 a través de criterios clínicos, analíticos, radiológicos y microbiológicos, así como factores de riesgo, pronóstico y de mortalidad que puedan ayudara detectar rápidamente a los pacientes graves a su llegada a los dispositivos de Urgencias y Emergencias de los hospitales en nuestro entorno

The incidence of the coronavirus disease 2019 (COVID-19) in Latin America and Spain and its impact particularly on hospital emergency departments have been great, sustained, and unpredictable. Unfortunately, this situation will continue in the medium term, regardless of the diverse concepts and definitions used to identify cases or hypotheses about the role of staff. In the context of the worldwide pandemic, a multinational group of experts from the Latin American Working Group to Improve Care for Patients With Infection (GT-LATINFURG) has drafted various opinion papers for use by emergency care systems in the member countries. The GT-LATINFURG is comprised of representatives from the 13 scientific associations affiliated with the Latin American Federation for Emergency Medicine (FLAME). Experts from the Spanish Society of Emergency Medicine (SEMES) also participated. The present consensus statement offers protocols and recommendations to facilitate the work of hospital emergency departments with regard to key issues the group identified, namely, the need for reorganization, triage, and routine test availability. Additional issues discussed include biomarkers; clinical, laboratory, radiologic, and microbiologic criteria for identifying patients with COVID-19; and risk and prognostic factors for mortality that emergency staff can use to quickly detect severe cases in our settings

Key issues in emergency department management of COVID-19: proposals for improving care for patients in Latin America. / Puntos clave sobre la COVID-19 en los servicios de urgencias: propuestas de mejora para su atención en Latinoamérica.

The incidence of the coronavirus disease 2019 (COVID-19) in Latin America and Spain and its impact particularly on hospital emergency departments have been great, sustained, and unpredictable. Unfortunately, this situation will continue in the medium term, regardless of the diverse concepts and definitions used to identify cases or hypotheses about the role of staff. In the context of the worldwide pandemic, a multinational group of experts from the Latin American Working Group to Improve Care for Patients With Infection (GT-LATINFURG) has drafted various opinion papers for use by emergency care systems in the member countries. The GT-LATINFURG is comprised of representatives from the 13 scientific associations affiliated with the Latin American Federation for Emergency Medicine (FLAME). Experts from the Spanish Society of Emergency Medicine (SEMES) also participated. The present consensus statement offers protocols and recommendations to facilitate the work of hospital emergency departments with regard to key issues the group identified, namely, the need for reorganization, triage, and routine test availability. Additional issues discussed include biomarkers; clinical, laboratory, radiologic, and microbiologic criteria for identifying patients with COVID-19; and risk and prognostic factors for mortality that emergency staff can use to quickly detect severe cases in our settings.

La incidencia y el impacto de la COVID-19 (Coronavirus Disease 2019) en Latinoamérica y España, en particular en sus servicios de urgencias hospitalarios (SUH), independientemente de la diversidad de los conceptos y definiciones de casos confirmados o sospechosos empleados ha sido, es, y, desgraciadamente a medio plazo, va a seguir siendo enorme, sostenida e imprevisible. En este escenario global, un grupo multinacional de expertos y representantes del Grupo de Trabajo Latinoamericano para la mejora de la atención del paciente con Infección en Urgencias (GTLATINFURG), compuesto por 13 Sociedades y Asociaciones Científicas que integran la Federación Latinoamericana de Medicina de Emergencias (FLAME), junto con la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), ha elaborado diversos documentos técnicos y de opinión destinados a los profesionales de los Sistemas de Urgencias y Emergencias de nuestros países. El objetivo de este artículo es ofrecer unas pautas o recomendaciones consensuadas para facilitar la actuación de los SUH en relación los puntos que los miembros del grupo han considerado más interesantes o clave en relación a: la necesidad de reorganizar los SUH, triaje, disponibilidad de pruebas complementarias habituales y otras como biomarcadores, la identificación del paciente con COVID-19 a través de criterios clínicos, analíticos, radiológicos y microbiológicos, así como factores de riesgo, pronóstico y de mortalidad que puedan ayudar a detectar rápidamente a los pacientes graves a su llegada a los dispositivos de Urgencias y Emergencias de los hospitales en nuestro entorno.

Métodos alternativos de CPAP para el tratamiento de insuficiencia respiratoria grave secundaria a neumonía por COVID-19 / Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19

Introducción: El uso de dispositivos que aportan presión positiva continua en la vía aérea ha demostrado mejoría en diversas patologías que producen insuficiencia respiratoria. En el episodio de pandemia por COVID-19, el uso de estos dispositivos se ha generalizado, pero, debido a la escasez de dispositivos convencionales de presión positiva continua en la vía aérea (CPAP), se han fabricado dispositivos alternativos. El objetivo de este estudio es describir el uso de estos, así como su eficacia.Material y métodosSe recogen datos de pacientes ingresados por neumonía por COVID-19 en el Hospital de Campaña de IFEMA, así como datos de pacientes con insuficiencia respiratoria y necesidad de soporte ventilatorio.ResultadosEstudio realizado sobre un total de 23 pacientes, con fecha de ingreso de entre el 24 de marzo y el 28 de abril en IFEMA. Se empleó CPAP alternativa en cinco pacientes (21,7%), mientras que, en los 18 restantes (78,3%) se usó un soporte ventilatorio con mascarilla reservorio o Ventimask efecto Venturi. Se observó un aumento progresivo de la saturación en aquellos pacientes en los que se empleó CPAP alternativa (de 94% de promedio a 98 y 99% de promedio, tras 30 y 60 minutos con la máscara, respectivamente), aunque este cambio no resultó significativo (p = 0,058 y p = 0,122, respectivamente). De igual manera, no se observó un cambio significativo de frecuencia respiratoria al inicio y al final de la medición en pacientes que usaron CPAP alternativa (p = 0,423) pero sí entre los que no la usaron (p = 0,001). Se observó una mejoría estadísticamente significativa en la variable de saturación de oxígeno/fracción inspirado de oxígeno en los pacientes que usaron CPAP alternativa (p = 0,040). (AU)

Introduction: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy.Material and methodsData are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support.ResultsStudy carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040)ConclusionThe use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary. (AU)

[Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19]. / Métodos alternativos de CPAP para el tratamiento de insuficiencia respiratoria grave secundaria a neumonía por COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

Utility of lateral flow tests in SARS-CoV-2 infection monitorization / Utilidad de los test lateral Flow en la monitorización de la infección por SARS-CoV-2

INTRODUCTION: The diagnosis of SARS-CoV-2 infection is crucial for medical and public health reasons, to allow the best treatment of cases and the best control of the pandemic. Serology testing allows for the detection of asymptomatic infections and 19-COVID cases once the virus has been cleared. We analyzed the usefulness of the SARS-CoV-2 rapid test of Autobio and tried to correlate its pattern with the severity of COVID19 infection. MATERIAL AND METHOD: We analyzed the accuracy and clinical usefulness of a point-of-care IgM and/or IgG test for SARS-CoV-2 in 35 COVID-19 patients [12 (34.3%) mild-moderate and 23 (65.7%) severe-critical] admitted to a field hospital in Madrid, as well as in 5 controls. RESULTS: The mean time from the first day of symptoms to the antibody test was 28 days (SD: 8.7), similar according to the severity of the disease. All patients with SARS-CoV-2 PCR+ showed the corresponding IgG positivity, while these results were negative in all control individuals. A total of 26 (74%) cases also presented with positive IgM, 19 (83%) were severe-critical cases and 7 (58%) were mild-moderate cases. The IgM response lasted longer in the severe critical cases (mean: 29.7 days; SD: 8.4) compared to the moderate cases (mean: 21.2 days; SD: 2.0). CONCLUSIONS: Rapid serology tests are useful for the diagnosis of patients with COVID-19 (mainly IgG detection) and may also be correlated with the severity of the infection (based on IgM detection)

INTRODUCCIÓN: El diagnóstico de la infección por SARSCoV-2 es crucial por razones médicas y de salud pública, para permitir el mejor tratamiento de los casos y el mejor control de la pandemia. Las pruebas de serología permiten la detección de infecciones asintomáticas y de casos de COVID-19 una vez que se ha logrado la eliminación del virus. El objetivo fue analizar la utilidad del test rápido SARS-CoV-2 de Autobio e intentar correlacionar su patrón con la gravedad de la infección por COVID19. MATERIAL Y MÉTODOS: Hemos analizado la precisión y la utilidad clínica de un test de IgM y/o IgG en el punto de atención para el SARS-CoV-2 en 35 pacientes COVID-19 [12 (34,3%) leves-moderados y 23 (65,7%) severos-críticos] ingresados en un hospital de campaña en Madrid, así como en 5 controles. RESULTADOS: El tiempo medio desde el primer día de síntomas hasta la prueba de anticuerpos fue de 28 días (DE: 8,7), similar según la gravedad de la enfermedad. Todos los pacientes con SARS-CoV-2 PCR+ mostraron la correspondiente positividad de IgG, mientras que estos resultados fueron negativos en todos los individuos de control. Un total de 26 (74%) casos también se presentaron con IgM positiva, 19 (83%) fueron casos severos-críticos y 7 (58%) fueron casos leves-moderados. La respuesta a la IgM duró más tiempo en los casos críticos severos (media: 29,7 días; DE: 8,4) en comparación con los casos moderados (media: 21,2 días; DE: 2,0). CONCLUSIONES: Las pruebas de serología rápida son de utilidad para el diagnóstico de los pacientes con COVID-19 (principalmente la detección de IgG) y también pueden estar correlacionadas con la gravedad de la infección (basada en la detección de IgM)

A multidrug-resistant microorganism infection risk prediction model: development and validation in an emergency medicine population.

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p < 0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74-0.78) in the derivation cohort and 0.72 (CI 95% 0.70-0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0-2 points), 16% (3-5 points), 24% (6-9 points), 33% (10-14 points), 47% (15-21 points), and 71% (> 21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid / Consensus document for sepsis code implementation and development in the Community of Madrid

Se presenta aquí el documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid, cuya redacción se completó en abril de 2017. Este documento ha sido adoptado por la Consejería de Sanidad madrileña como base de trabajo para la puesta en marcha del Código Sepsis, tanto en el ámbito hospitalario (hospitales de agudos y de media y larga estancia) como en Atención Primaria y los Servicios de Emergencia Extrahospitalaria. Se publica ahora sin modificaciones con respecto a la versión original, añadiendo únicamente las referencias bibliográficas más significativas. El documento se estructura en cuatro partes: introducción, detección y valoración iniciales, tratamiento inicial y organización asistencial. En las partes segunda a cuarta se proponen 25 recomendaciones, consensuadas por los autores después de varias reuniones presenciales y una extensa discusión "online". Se incluyen nueve tablas que pretenden servir de guía práctica para la activación y aplicación del código sepsis. Tanto el contenido de las recomendaciones como su redacción formal se han realizado teniendo en cuenta su aplicabilidad en todos los ámbitos a los que se dirigen, que cuentan con recursos y características estructurales y funcionales muy dispares, por lo que deliberadamente se ha huido de un mayor grado de concreción: el objetivo no es que el código sepsis se organice y se aplique de forma idéntica en todos ellos, sino que los recursos sanitarios trabajen de forma coordinada alineados en la misma dirección

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive «online» discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction

Sepsis in the emergency department: key points, controversies, and proposals for improvements in Latin America. / Puntos clave y controversias sobre la sepsis en los servicios de urgencias: propuestas de mejora para Latinoamérica.

EN: Although infection rates and the impact of infection on hospital emergency departments (EDs) are known or can be reliably estimated, the incidence and prevalence of sepsis vary in relation to which definitions or registers used. Sepsis is also well known to be under-diagnosed by physicians in general and by ED physicians in particular. Over half of sepsis cases are community-acquired, and 50% to 60% of patients in intensive care units (ICUs) with sepsis or septic shock are admitted directly from the ED. Pneumonia and urinary tract infections are the most common points of focus in sepsis, septic shock, bacteremia, and ED admissions to the ICU for infectious processes. For this article a multinational group of experts representing Latin American emergency medicine associations reviewed and analyzed similarities and differences in the epidemiology of sepsis in different geographic locations. We consider key aspects and geographic similarities and differences in the early identification of patients with severe sepsis; criteria that define the diagnosis; appropriate early antibiotic and fluid therapy; the roles of triage systems and multidisciplinary sepsis code units; and the use of biological markers in this time-dependent disease. We also discuss key points and strategies for improving the diagnosis, prognosis, and care of sepsis patients in the ED.

ES: En los servicios de urgencias hospitalarios (SUH), la incidencia y la prevalencia de la sepsis dependen de las definiciones y registros que se utilicen. Además, en general existe un infradiagnostico. Un grupo internacional de expertos y representantes de sociedades y asociaciones latinoamericanas de urgencias y emergencias ha revisado y analizado las coincidencias y diferencias en la situación actual epidemiológica, así como los problemas y puntos clave (con sus similitudes y diferencias según el entorno geográfico) en relación a: la detección inmediata del paciente con infección grave-sepsis, los criterios para su definición, la administración de la antibioterapia y fluidoterapia precoces y adecuadas, y el papel que juegan los sistemas de triaje, las unidades multidisciplinares de sepsis (conocidas como "código sepsis") o los biomarcadores en esta enfermedad tiempo-dependiente. Además, señalan algunos puntos clave y estrategias de mejora para el diagnóstico, pronóstico y atención en los SUH de estos pacientes.

Puntos clave y controversias sobre la sepsis en los servicios de urgencias: propuestas de mejora para Latinoamérica / Sepsis in the emergency department: key points, controversies, and proposals for improvements in Latin America

En los servicios de urgencias hospitalarios (SUH), la incidencia y la prevalencia de la sepsis dependen de las definiciones y registros que se utilicen. Además, en general existe un infradiagnostico. Un grupo internacional de expertos y representantes de sociedades y asociaciones latinoamericanas de urgencias y emergencias ha revisado y analizado las coincidencias y diferencias en la situación actual epidemiológica, así como los problemas y puntos clave (con sus similitudes y diferencias según el entorno geográfico) en relación a: la detección inmediata del paciente con infección grave-sepsis, los criterios para su definición, la administración de la antibioterapia y fluidoterapia precoces y adecuadas, y el papel que juegan los sistemas de triaje, las unidades multidisciplinares de sepsis (conocidas como "código sepsis") o los biomarcadores en esta enfermedad tiempo-dependiente. Además, señalan algunos puntos clave y estrategias de mejora para el diagnóstico, pronóstico y atención en los SUH de estos pacientes

Although infection rates and the impact of infection on hospital emergency departments (EDs) are known or can be reliably estimated, the incidence and prevalence of sepsis vary in relation to which definitions or registers used. Sepsis is also well known to be under-diagnosed by physicians in general and by ED physicians in particular. Over half of sepsis cases are community-acquired, and 50% to 60% of patients in intensive care units (ICUs) with sepsis or septic shock are admitted directly from the ED. Pneumonia and urinary tract infections are the most common points of focus in sepsis, septic shock, bacteremia, and ED admissions to the ICU for infectious processes. For this article a multinational group of experts representing Latin American emergency medicine associations reviewed and analyzed similarities and differences in the epidemiology of sepsis in different geographic locations. We consider key aspects and geographic similarities and differences in the early identification of patients with severe sepsis; criteria that define the diagnosis; appropriate early antibiotic and fluid therapy; the roles of triage systems and multidisciplinary sepsis code units; and the use of biological markers in this time-dependent disease. We also discuss key points and strategies for improving the diagnosis, prognosis, and care of sepsis patients in the ED

Recomendaciones para la atención del paciente con neumonía adquirida en la comunidad en los Servicios de Urgencias / Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department

La incidencia de la neumonía adquirida en la comunidad (NAC) oscila entre 2-15 casos/1.000 habitantes/año, siendo más elevada en los mayores de 65 años o en pacientes con co-morbilidades. En los servicios de urgencias hospitalarios (SUH) supone hasta el 1,35% de las atenciones. Aproximadamente el 75% de todas las NAC diagnosticadas son atendidas en los SUH. La NAC representa el origen de la mayoría de sepsis y shock sépticos diagnosticados en los SUH, la principal causa de muerte y de ingreso en la unidad de cuidados intensivos (UCI) por enfermedad infecciosa. Se le atribuye una mortalidad global del 10-14% según la edad y factores de riesgo asociados. El 40-60% de las NAC requerirán ingreso hospitalario, incluyendo las áreas de observación (con rangos muy variables del 22-65% según centros, época del año y características de los pacientes), y de ellos entre el 2-10% será en la UCI. De todo lo dicho se traduce la importancia que tiene la NAC en los SUH, y también del "impacto de la atención en urgencias sobre el enfermo con NAC", al ser el dispositivo donde se toman las decisiones iniciales, pero fundamentales, para la evolución del proceso. Es conocida la gran variabilidad entre los clínicos en el manejo de los aspectos diagnóstico-terapéuticos en la NAC, lo que constituye una de las razones que explican las grandes diferencias en las tasas de ingreso, de consecución del diagnóstico microbiológico, solicitud de estudios complementarios, la elección de la pauta antimicrobiana o la diversidad de cuidados aplicados. En este sentido, la implementación de las guías de práctica clínica con el uso de las escalas pronósticas de gravedad y las nuevas herramientas disponibles en los SUH como lo son los biomarcadores pueden mejorar la atención del paciente con NAC en los SUH. Por ello, a partir de un grupo multidisciplinar de profesionales de urgencias y especialistas que participan en el proceso asistencial de la NAC, se ha diseñado esta guía clínica con diversas recomendaciones para las decisiones y momentos clave en proceso de atención del paciente con NAC en Urgencias

The incidence of community-acquired pneumonia (CAP) ranges from 2-15 cases / 1,000 inhabitants / year, being higher in those older than 65 years and in patients with high co-morbidity. Around 75% of all CAP diagnosed are treated in the Emergency Department (ED). The CAP represents the main cause for sepsis and septic shock in ED, and the most frequent cause of death and admission to the Intensive Care Unit (ICU) due to infectious disease. Overall mortality is 10-14% according to age and associated risk factors. Forty to 60% of CAP will require hospital admission, including observation units (with very variable ranges from 22-65% according to centers, seasonal of the year and patients' characteristics). Between the admissions, 2-10% will be in the ICU. All of previously mentioned reflects the importance of the CAP in the ED, as well as the "impact of the emergency care on the patient with CAP", as it is the establishment where the initial, but key decisions, are made and could condition the outcome of the illness. It is known the great variability among physicians in the diagnostic and therapeutic management of CAP, which is one of the reasons that explains the great differences in the admission rates, achievement of the microbiological diagnosis, request for complementary studies, the choice of antimicrobial treatment, or the diversity of applied care. In this sense, the implementation of clinical practice guidelines with the use of the severity scores and the new tools available, such as biomarkers, can improve patient care with CAP in ED. Therefore, a multidisciplinary group of emergency professionals and specialists involved in the care process of CAP has designed a guideline with several recommendations for decisions-making during the key moments in patients with CAP attended in the ED