- Email: [email protected]
258 The Optic Nerve Sheath Diameter in Cerebral Infections
Research Forum Abstracts UTI visits account for 1.6 billion dollars per year. In response to IDSA guidelines, fluoroquinolones have become the preferred empiric treatment for uncomplicated UTI in many EDs where TMP-SMX resistance is greater than 20%. Recent surveys of antimicrobial susceptibility patterns in outpatient urinary isolates have revealed a fivefold increase in quinolone resistance over the course of several years. Most hospital antibiograms fail to differentiate between blood, sputum, and urine sources and do not provide patterns of bacterial susceptibilities specific to the ED. While several studies have examined outpatient and inpatient susceptibilities, little data exists regarding emergency and immediate care (IC) settings. Study Objectives: To examine and compare the causative bacteria and antimicrobial susceptibility rates in urinary isolates obtained in the ED and IC setting and consider implications for site-specific antibiotic selection. Methods: A retrospective query was performed to obtain susceptibility patterns in urine isolates obtained from all-comers at a Level 1 urban ED and 3 satellite IC sites during the 2013 calendar year. Prevalence of causative bacteria and antibiotic resistance rates were compared. Results: A total of 1258 urinary isolates were obtained in the ED and 757 urinary isolates were obtained in the 3 IC settings during the 2013 calendar year. The most common bacteria in the ED were E-coli (58%), Klebsiella (13%), Proteus (.08%), and Staph aureus (.03%). The most common bacteria in the IC setting were E-coli (80%), Klebsiella (10%), Proteus (.05%), and Staph aureus (.017%). Zero cases of MRSA were reported in IC setting versus 17 cases in the ED. The ED susceptibilities for E-coli were 96% to Nitrofurantoin, 82% to Cefazolin, 71% to Ciprofloxacin, and 69% to TMP-SX. IC susceptibilities were 98% to Nitrofurantoin, 90% to Cefazolin, 80% to Ciprofloxacin, and 79% to TMP-SX. Conclusion: Without considering other independent variables, there appear to be some general differences between causative bacteria and antimicrobial susceptibility patterns in emergency department and immediate care patients at our institution. E-coli is more likely to be present in IC isolates than in ED isolates. E-coli resistance to TMPSX and Ciprofloxacin both exceed the 20% benchmark used by the IDSA in ED patients, however, 87% of E-coli species in the IC setting remain susceptible to Ciprofloxacin. E-coli species in both settings exceed 96% susceptibility to Nitrofurantoin. While previous studies have demonstrated the value of considering comorbid conditions and prior antibiotic use for resistance risk stratification in the ED, this data suggests that there may be value in tailoring UTI therapy based on emergency versus IC setting.
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The Optic Nerve Sheath Diameter in Cerebral Infections
Bhatt S, Sangani S, Roberts J, Salway J, Mallon W/LAC+USC Medical Center, Los Angeles, CA; BJ Civil Medical Center, Ahmedabad, India
Background: Tuberculosis and malaria constitute large global burdens of disease. CNS tuberculosis can manifest as meningitis, arachnoiditis, and a tuberculoma. The rupture of a tubercle can lead to an elevation of the intracranial pressure and hydrocephalus. Meanwhile, in cerebral malaria, rupture of the blood-brain barrier may lead to hemorrhage and subsequent increases in intracranial pressure. In cerebral infections, while various measurements of intracranial pressure have been directly correlated with patient morbidity and outcome, little is known regarding the optic nerve sheath diameter (ONSD) measurement in cerebral infections. As the clinical outcome depends on the stage at which therapy is initiated, early detection and treatment may be of significant importance. Study Objectives: The aim of this study was to determine whether patients with cerebral infections, specifically tuberculosis meningitis and cerebral malaria, have a dilated optic nerve sheath as measured by bedside ultrasound performed by the emergency department (ED) provider. A secondary outcome of the study was to evaluate for differences in ONSD between Tuberculosis and Malaria. Methods: We conducted a prospective, blinded observational study on adult ED patients with suspected cerebral infections at the BJ Civil Medical Center in Ahmedabad, India. All patients with AMS and 2 of 4 SIRS criteria initially underwent ultrasound measurements of the optic nerve followed by an MRI and peripheral smear. The diagnosis of tuberculosis meningitis was made when an MRI showed basilar meningeal enhancement and hydrocephalus. When safe and in the setting of a normal peripheral smear and normal MRI, a lumbar puncture was performed to further evaluate for tuberculosis meningitis. The diagnosis of cerebral malaria was made with a positive peripheral smear. In total, 8 cases of confirmed cerebral malaria and 15 cases of
S92 Annals of Emergency Medicine
tuberculosis meningitis were identified and measured. These measurements were compared with 120 control patients. Results: Control data suggested that the upper limit of normal for optic nerve sheath diameter is 4.37 mm. Those patients with tuberculosis meningitis have a mean ONSD of 5.87 mm (SD 0.49) and those with cerebral malaria have a mean ONSD of 6.09 mm (SD 0.42). These results confirm that patients with cerebral malaria and tuberculosis meningitis have an ONSD in excess of the control data. (P<.001). Conclusions: The evaluation of the optic nerve sheath diameter is a simple noninvasive procedure, which is a potentially useful tool in the assessment of adults suspected of having cerebral infections including tuberculosis meningitis and cerebral malaria.
259
Use of Antibiotics for Acute Rhinosinusitis in the Emergency Department
Dresden SM, Kuhns M, Dearing E, Smith SS/Northwestern University Feinberg School of Medicine, Chicago, IL
Study Objective: Acute rhinosinusitis (ARS) is a common condition encountered by physicians in outpatient clinics and emergency departments (EDs). Recent literature suggests that antibiotics in cases of ARS do not offer a clinical advantage and routine use of antibiotics in such cases is not recommended; however, studies have shown that antibiotics are still prescribed in 82-88% of office visits for ARS. Our goal is to describe the rate of antibiotic prescription, the most commonly prescribed antibiotics, and variations in antibiotic prescribing patterns antibiotics for ARS in the ED on a national level. Methods: This is a nationally representative cross sectional study performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED files from 2006 to 2010. The study sample included ED visits by adults (age 18+) who received a primary, secondary, or tertiary diagnosis of ARS (ICD-9-CM code 461.x). The number and proportion of ED visits resulting in antibiotic prescription were calculated using sample weighting to provide a nationally representative estimate. Antibiotics are reported by pharmacological class. Using a classification strategy consistent with previous investigations broad spectrum antibiotics were defined as beta lactamaseinhibiting penicillins, second to fourth generation cephalosporins, quinolones, azithromycin, and clarithromycin. Chi-square tests were performed to compare proportions of antibiotic prescriptions by age category, sex, race, ethnicity, geographic region, median household income group, and expected source of payment. Results: ARS accounted for an estimated 1.4 million (standard error: 0.2 million) ED visits from 2006-2010. No patients diagnosed with ARS in the ED were admitted. There were no statistically significant differences in the rate of antibiotic prescription based on patient factors. Antibiotics were prescribed in 87.4% (se: 2.1%) Of the 1.2 million (se: 0.1 million) antibiotic prescriptions, macrolides were the most commonly prescribed - 22.8% (se: 3.3%), followed by amoxicillin - 22.6% (se: 3.2%), amoxicillin/clavulanate - 18.9% (se: 3.0%), quinolones - 11.2% (se: 2.0%), and 2nd/ 3rd generation cephalosporins - 4.9% (se: 3.0%). Broad spectrum antibiotics accounted for 58.0% (se: 4.1%) of all antibiotic prescriptions for ARS. Conclusion: Despite literature that suggests antibiotics do not offer a clinical advantage in ARS, antibiotics are still prescribed in the vast majority of cases of ARS diagnosed in the ED. This is consistent with other outpatient practice settings. Additionally, macrolides, the most commonly prescribed antibiotics for ARS in the ED, are not recommended for treatment of ARS because of high bacterial resistance. Familiarity with consensus guidelines, concern for patient follow-up, and perceived patient expectations may play a role in the overuse of antibiotics and inappropriate choice of class of antibiotics in the ED.
260
Inappropriate Initial Antimicrobial Therapy in the Emergency Department and Mortality in Severe Sepsis and Septic Shock
Kobayashi S, Tomaszewski C, Fedullo P/University of California, San Diego, San Diego, CA
Study Objectives: To analyze the impact of an “inappropriate” first dose of antimicrobials in patients presenting to the emergency department with severe sepsis or septic shock. Methods: This historical cohort study focused on patients presenting with severe sepsis or septic shock and bacteremia to either of two emergency departments (12 miles apart) which are part of the same tertiary, academic medical center over a 2-year period from January 1, 2012 to December 31, 2013. To be
Volume 64, no. 4s : October 2014
257 258
Withdrawn
The Optic Nerve Sheath Diameter in Cerebral Infections
Bhatt S, Sangani S, Roberts J, Salway J, Mallon W/LAC+USC Medical Center, Los Angeles, CA; BJ Civil Medical Center, Ahmedabad, India
Background: Tuberculosis and malaria constitute large global burdens of disease. CNS tuberculosis can manifest as meningitis, arachnoiditis, and a tuberculoma. The rupture of a tubercle can lead to an elevation of the intracranial pressure and hydrocephalus. Meanwhile, in cerebral malaria, rupture of the blood-brain barrier may lead to hemorrhage and subsequent increases in intracranial pressure. In cerebral infections, while various measurements of intracranial pressure have been directly correlated with patient morbidity and outcome, little is known regarding the optic nerve sheath diameter (ONSD) measurement in cerebral infections. As the clinical outcome depends on the stage at which therapy is initiated, early detection and treatment may be of significant importance. Study Objectives: The aim of this study was to determine whether patients with cerebral infections, specifically tuberculosis meningitis and cerebral malaria, have a dilated optic nerve sheath as measured by bedside ultrasound performed by the emergency department (ED) provider. A secondary outcome of the study was to evaluate for differences in ONSD between Tuberculosis and Malaria. Methods: We conducted a prospective, blinded observational study on adult ED patients with suspected cerebral infections at the BJ Civil Medical Center in Ahmedabad, India. All patients with AMS and 2 of 4 SIRS criteria initially underwent ultrasound measurements of the optic nerve followed by an MRI and peripheral smear. The diagnosis of tuberculosis meningitis was made when an MRI showed basilar meningeal enhancement and hydrocephalus. When safe and in the setting of a normal peripheral smear and normal MRI, a lumbar puncture was performed to further evaluate for tuberculosis meningitis. The diagnosis of cerebral malaria was made with a positive peripheral smear. In total, 8 cases of confirmed cerebral malaria and 15 cases of
S92 Annals of Emergency Medicine
tuberculosis meningitis were identified and measured. These measurements were compared with 120 control patients. Results: Control data suggested that the upper limit of normal for optic nerve sheath diameter is 4.37 mm. Those patients with tuberculosis meningitis have a mean ONSD of 5.87 mm (SD 0.49) and those with cerebral malaria have a mean ONSD of 6.09 mm (SD 0.42). These results confirm that patients with cerebral malaria and tuberculosis meningitis have an ONSD in excess of the control data. (P<.001). Conclusions: The evaluation of the optic nerve sheath diameter is a simple noninvasive procedure, which is a potentially useful tool in the assessment of adults suspected of having cerebral infections including tuberculosis meningitis and cerebral malaria.
259
Use of Antibiotics for Acute Rhinosinusitis in the Emergency Department
Dresden SM, Kuhns M, Dearing E, Smith SS/Northwestern University Feinberg School of Medicine, Chicago, IL
Study Objective: Acute rhinosinusitis (ARS) is a common condition encountered by physicians in outpatient clinics and emergency departments (EDs). Recent literature suggests that antibiotics in cases of ARS do not offer a clinical advantage and routine use of antibiotics in such cases is not recommended; however, studies have shown that antibiotics are still prescribed in 82-88% of office visits for ARS. Our goal is to describe the rate of antibiotic prescription, the most commonly prescribed antibiotics, and variations in antibiotic prescribing patterns antibiotics for ARS in the ED on a national level. Methods: This is a nationally representative cross sectional study performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED files from 2006 to 2010. The study sample included ED visits by adults (age 18+) who received a primary, secondary, or tertiary diagnosis of ARS (ICD-9-CM code 461.x). The number and proportion of ED visits resulting in antibiotic prescription were calculated using sample weighting to provide a nationally representative estimate. Antibiotics are reported by pharmacological class. Using a classification strategy consistent with previous investigations broad spectrum antibiotics were defined as beta lactamaseinhibiting penicillins, second to fourth generation cephalosporins, quinolones, azithromycin, and clarithromycin. Chi-square tests were performed to compare proportions of antibiotic prescriptions by age category, sex, race, ethnicity, geographic region, median household income group, and expected source of payment. Results: ARS accounted for an estimated 1.4 million (standard error: 0.2 million) ED visits from 2006-2010. No patients diagnosed with ARS in the ED were admitted. There were no statistically significant differences in the rate of antibiotic prescription based on patient factors. Antibiotics were prescribed in 87.4% (se: 2.1%) Of the 1.2 million (se: 0.1 million) antibiotic prescriptions, macrolides were the most commonly prescribed - 22.8% (se: 3.3%), followed by amoxicillin - 22.6% (se: 3.2%), amoxicillin/clavulanate - 18.9% (se: 3.0%), quinolones - 11.2% (se: 2.0%), and 2nd/ 3rd generation cephalosporins - 4.9% (se: 3.0%). Broad spectrum antibiotics accounted for 58.0% (se: 4.1%) of all antibiotic prescriptions for ARS. Conclusion: Despite literature that suggests antibiotics do not offer a clinical advantage in ARS, antibiotics are still prescribed in the vast majority of cases of ARS diagnosed in the ED. This is consistent with other outpatient practice settings. Additionally, macrolides, the most commonly prescribed antibiotics for ARS in the ED, are not recommended for treatment of ARS because of high bacterial resistance. Familiarity with consensus guidelines, concern for patient follow-up, and perceived patient expectations may play a role in the overuse of antibiotics and inappropriate choice of class of antibiotics in the ED.
260
Inappropriate Initial Antimicrobial Therapy in the Emergency Department and Mortality in Severe Sepsis and Septic Shock
Kobayashi S, Tomaszewski C, Fedullo P/University of California, San Diego, San Diego, CA
Study Objectives: To analyze the impact of an “inappropriate” first dose of antimicrobials in patients presenting to the emergency department with severe sepsis or septic shock. Methods: This historical cohort study focused on patients presenting with severe sepsis or septic shock and bacteremia to either of two emergency departments (12 miles apart) which are part of the same tertiary, academic medical center over a 2-year period from January 1, 2012 to December 31, 2013. To be
Volume 64, no. 4s : October 2014