Risk factors for contagious gastroenteritis in adult patients with diarrhoea in the emergency department - a prospective observational multicentre study.

BACKGROUND: Infectious gastroenteritis is common in the emergency department (ED). Patients infected with either Norovirus or toxigenic Clostridium difficile require special isolation procedures. The aims were to describe the aetiology of infectious gastroenteritis in the ED, evaluate whether current isolation procedures, based on clinical judgement are sufficient, and to identify information that might be used to identify patients requiring isolation. METHODS: Prospective, observational, multicentre study. We collected information on symptoms, vital signs, travel history, the recent use of antibiotics, and infectious contacts and tested faecal samples for Norovirus, C. difficile, and enteropathogenic bacteria. RESULTS: The study enrolled 227 patients, of whom 163 (71%) delivered a faecal sample for Norovirus analysis (13% positive), 171 (74%) for C. difficile (13% positive), and 173 (76%) for enteropathogenic bacteria (16% positive). In total 71% of the patients were isolated using strict precautions, 29% of the isolated patient and 14% of the patients who were not isolated had had a highly contagious GE. Risk factors for Norovirus included frequent vomiting (OR 5.5), recent admission of another patient with Norovirus (OR 2.6), and a short duration of diarrhoea. Risk factors for C. difficile infections included older age (OR 6.0), longer duration of diarrhoea (OR 5.2), mucus in stool (OR 3.5), and previous antibiotic use (OR 23.4). CONCLUSION: Highly contagious GE occurs in » of the GE patients in the EDs, isolation based on clinical judgement is not very efficient. Several risk factors can predict the presence of Norovirus or toxigenic Clostridium difficile. It is uncertain whether this knowledge can improve isolation practices in ED settings. TRIAL REGISTRATION: This study was retrospectively registered in the Clinical Trials Data Base ( NCT02685527 ) and prospectively approved by the Regional Committees on Health Research Ethics for Southern Denmark (project ID S20140200) and Ethics Committee at the Medical Association of Schleswig-Holstein ["Ethikkommission bei der Ärztekammer Schleswig-Holstein", project ID 120/15(I)] and registered with the Danish Data Protection Agency (project ID nr. 2008-58-0035/ 1608).

Ear measurement of temperature is only useful for screening for fever in an adult emergency department.

BACKGROUND: A new generation of ear thermometers with preheated tips and several measurements points should allow a more precise temperature measurement. The aim of the study was to evaluate if the ear temperature measured by this ear thermometer can be used to screen for fever and whether the thermometer is in agreement with the rectal temperature and if age, use of hearing devices or time after admission influences the temperature measurements. METHODS: Open cross-sectional clinical single site study patients, > 18 years old, who were acutely admitted to the short stay unit at the ED. A sample size of 99 patient per subgroup was recruited as random convenience series. As ear thermometer Braun Thermoscan Pro 4000® and as rectal thermometer Omron Flex Temp Smart ® was used. For different cut off of temperature the AUC was calculated and Bland-Altman analysis for calculation of 95% limits of agreement with rectal temperature, with subgroup analysis concerning age, time span from admission time and use of hearing aid. RESULTS: Among 599 patients the sensitivity to detect fever with an ear thermometer varied between 68 and 70% with AUC from 0.88-0.97. If the ear temperature was ≥37.5 oC, the sensitivity to detect patients with ≥38.0 oC rectally was 95% which raised to 100% for a rectal temperature of ≥38.3 oC. For the ear thermometer's ability to determine the exact temperature the 95% limits of agreement were +/- 0.8 oC. with no influence from age, duration of hospital stay or hearing aids. CONCLUSION: The examined ear thermometer is able to detect fever, defined as ≥38 oC rectally in an adult ED population by using an ear cut-point of 37.5 oC, but not to measure the exact temperature. Used in this way around a fifth of the patients will still be in need of a rectal temperature measurement, but less than 5% with fever ≥38.0 oC will remain undetected and none with fever ≥38.3 oC. Age, admission time and use of hearing aid did not influence the temperature measurements. TRIAL REGISTRATION: Clinical Trials: ID NCT02977481 , date 11/18/2016.

Evaluation of a new fast in-house Real-Time PCR assay for detecting both Norovirus and toxigenic Clostridium difficile using fecal sample and rectal swab.

BACKGROUND: Norovirus and toxigenic Clostridium difficile infections are the 2 most common causes of infectious gastroenteritis. Rapid and reliable detection of these to microorganisms is important to assess if contact precautions are indicated to prevent spreading and reduce cost of isolation. METHODS: This study determines sensitivity and specificity of a new fast in-house PCR assay used on BD MAX platform to detect both norovirus and C difficile in 1 turn-over in clinical context. Furthermore, fecal samples as well as rectal swabs were used as analysis material to determine the accuracy of the new assay on a fecal samples and rectal swabs compared with standard methods. RESULTS: From 227 included patients, 143 rectal swabs and 135 fecal samples obtained. The new in-house PCR showed a sensitivity of 73.3% and a specificity of 99.2% for norovirus on a fecal sample and a sensitivity of 57.1% and specificity 99.1% of for norovirus on a rectal swab. For C difficile a sensitivity of 100% and specificity of 100% on a fecal sample and a sensitivity of 90.9% and a specificity of 99.1% on a rectal swab was shown. The time consumption for detecting the 2 enteropathogens was reduced by half by using the new assay. CONCLUSIONS: The new assay shows an acceptable sensitivity and specificity for C difficile and an acceptable specificity for norovirus when analysis was done on fecal samples and reduces half of the time consumption. Further research is needed to improve the accuracy of the new in-house PCR before clinical implication.

Clinical information on admission is insufficient to determine the appropriate isolation regimen for acute gastroenteritis.

INTRODUCTION: The number of admissions for acute gastroenteritis (GE) is increasing. The majority of patients pass through a single high-flow emergency department (ED) area which increases the risk of spreading GE. The aim of this study was to determine the frequency and aetiology of GE for acutely admitted patients and to analyse their clinical information focusing on risk indicators of contagious aetiology and on the chosen isolation regime to determine if the GE required a contact precaution isolation regime. MATERIAL AND METHODS: This study included patients above 16 years of age who were admitted acutely within a one-year study period to a Danish hospital with a catchment population of 231,000 persons. The following items were analysed: information from the referring doctor, diarrhoea, nausea and vomiting and fever history, abdominal pain, prior antibiotics, co-morbidity, drugs, travel history, contagious contacts, general condition, vital values, isolation regime, final diagnosis and results of stool examination. RESULTS: Among 17,531 acute admissions, 1.6% had acute GE and 60% of these had stool examinations performed. Only 35% of the patients with GE had information about possible GE at referral. Short duration and vomiting may help to identify norovirus and antibiotic treatment within the last month to identify Clostridium difficile infections. All patients with highly infective GE were isolated under a contact precaution regime, but only one in four of the isolated patients were actually highly contagious. CONCLUSION: Acute GE is a prevalent condition in the ED; a number of patients are isolated unnecessarily, but it is difficult to assess correctly who should be isolated and who should not. We recommend that further studies be undertaken to define isolation criteria and to assess the usefulness of new rapid analysis modalities with a view to reducing the isolation period. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.