Midregional proadrenomedullin safely reduces hospitalization in a low severity cohort with infections in the ED: a randomized controlled multi-centre interventional pilot study.

INTRODUCTION: The midregional fragment of proadrenomedullin (MR-proADM) is known to provide accurate short-, mid- and long term prognostic information in the triage and multi-dimensional risk assessment of patients in the emergency department (ED). In two independent observational cohorts MR-proADM values identified low disease severity patients without risk of disease progression in the ED with no 28 days mortality that wouldn´t require hospitalization. In this interventional study we want to show that the combination of an MR-proADM algorithm with clinical assessment is able to identify low risk patients not requiring hospitalization to safely reduce the number of hospital admissions. METHODS: A randomized-controlled interventional multicenter study in 4 EDs in Spain. The study protocol was approved by Ethics Committees. Control arm patients received Standard Care. MR-proADM guided arm patients with low MR-proADM value (≤0.87 nmol/L) were treated as out-patients, with high MR-proADM value (>0.87 nmol/L) were hospitalized. The hospitalization rate was compared between the study arms. RESULTS: Two hundred patients with suspicion of infection were enrolled. In the MR-proADM guided arm the hospital admission rate in the intention-to-treat (ITT) population was 17% lower than in the control arm (40.6% vs. 57.6%, p=0.024) and 20% lower in the per protocol (PP) population (37.2% vs. 57.6%, p=0.009). No deaths of out-patients and no significant difference for the safety endpoints readmission and representation rates were observed. The readmission rate was only slightly higher in the MR-proADM guided arm compared to the control arm (PP population: at 14 days 9.3% vs. 7.1%, difference 2.1% (95% CI: -11.0% to 15.2%); and at 28 days 11.1% vs. 9.5%, difference 1.6% (95% CI: -12.2% to 15.4%)). The rate of 28 days representation was slightly lower in the MR-proADM guided arm compared to the control arm (20.4% vs. 26.2%, difference -5.8% (95% CI: -25.0% to 13.4%); PP population). CONCLUSIONS: Implementing a MR-proADM algorithm optimizes ED workflows efficiently and sustainably. Hospitals can highly benefit from a reduced rate of hospitalizations by 20% using MR-proADM. The safety in the MR-proADM guided study arm was similar to the Standard Care arm. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03770533.

Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission.

BACKGROUND: The performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection. METHODS: A prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression. RESULTS: Six hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR [95% CI]: 5.8 [3.1 - 10.8]) and mortality (HR [95% CI]: 3.8 [2.2 - 6.5]). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 [0.25 - 5.0] days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment. CONCLUSIONS: Patients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.

Características de la prostatitis aguda en los pacientes ancianos atendidos en el servicio de urgencias / Characteristics of acute bacterial prostatitis in elderly patients attended in the Emergency Department

Objetivo: Comparar las características de la prostatitis aguda (PA) en los pacientes ancianos ≥75 años con los <75 años atendidos en un servicio de urgencias hospitalario (SU). Material y métodos: Estudio descriptivo observacional y prospectivo de los pacientes con PA atendidos de forma consecutiva durante un año en el SU de un hospital terciario. Se incluyen los datos relativos a la comorbilidad, episodios previos, clínica, microbiología, tratamiento, evolución a 30 días y se comparan los pacientes en función de la edad. Resultados: Se han incluido 241 episodios de PA con una edad media de 62,9+/-16 años y 64 (26,5%) con ≥75 años. Fueron positivos 104 de los 215 (48,4%) urocultivos y 25 de los 136 (18,4%) hemocultivos. El aislamiento más frecuente fue Escherichia coli con resistencias en los pacientes ancianos >30% para ciprofloxacino, amoxicilina-clavulánico y cotrimoxazol, y 15,4% de cepas productoras de beta-lactamasas de espectro extendido. En el análisis univariante la manipulación de la vía urinaria, los antecedentes de cáncer, la antibioterapia previa, la insuficiencia renal, la proporción de cepas de E. coli resistentes y el ingreso hospitalario resultaron más frecuentes en los pacientes ≥75 años. A pesar de ello, únicamente el tratamiento antibiótico inadecuado resultó significativamente más frecuente en los pacientes ancianos en el análisis multivariante (p=0,004). Conclusiones: Al establecer el tratamiento empírico inicial de la PA en el SU, especialmente en los pacientes ancianos, es importante tener en cuenta el patrón de resistencias a los antibióticos de uso más frecuente

Objective: To compare the characteristics of acute bacterial prostatitis between patients ≥75 years old with those <75 years old attended in the Emergency Department. Material and methods: A descriptive and observational study was conducted with a prospective follow-up including all consecutive patients with acute bacterial prostatitis that were admitted during one year to the Emergency Department of a tertiary-care hospital. Data were collected for demographic variables, comorbidities, clinical and microbiological findings, treatment, outcome, and re-consultation at 30 days follow-up. Patients were compared depending on age. Results: A total of 241 episodes of acute bacterial prostatitis were included. The mean age was 62.9+/-16 years, and 64 patients (26.5%) were ≥75 years old. In the microbiology findings, 104 out of 215 (48.4%) of urine cultures and 25 out of 136 (18.4%) blood cultures were positive. Escherichia coli was the most frequent isolation, with resistance rates in elderly patients above 30% for ciprofloxacin, amoxicillin-clavulanic, and cotrimoxazole, and 15.4% of extended spectrum beta-lactamase producing strains. In the univariate analysis, previous manipulation of the urinary tract, history of cancer, previous antibiotic treatment, resistant E. coli strains, renal impairment, and admission to the hospital were more frequent among patients ≥75 years. Nonetheless, in the multivariate analysis only inadequate empirical antibiotic treatment was found to be significantly more frequent in elderly patients (P=.004). Conclusions: Drug-resistance patterns to commonly used antibiotics should be considered when choosing empirical treatment for acute bacterial prostatitis in the Emergency Department setting, especially for patients ≥75 years

[Characteristics of acute bacterial prostatitis in elderly patients attended in the Emergency Department]. / Características de la prostatitis aguda en los pacientes ancianos atendidos en el servicio de urgencias.

OBJECTIVE: To compare the characteristics of acute bacterial prostatitis between patients ≥75 years old with those <75 years old attended in the Emergency Department. MATERIAL AND METHODS: A descriptive and observational study was conducted with a prospective follow-up including all consecutive patients with acute bacterial prostatitis that were admitted during one year to the Emergency Department of a tertiary-care hospital. Data were collected for demographic variables, comorbidities, clinical and microbiological findings, treatment, outcome, and re-consultation at 30 days follow-up. Patients were compared depending on age. RESULTS: A total of 241 episodes of acute bacterial prostatitis were included. The mean age was 62.9±16 years, and 64 patients (26.5%) were ≥75 years old. In the microbiology findings, 104 out of 215 (48.4%) of urine cultures and 25 out of 136 (18.4%) blood cultures were positive. Escherichia coli was the most frequent isolation, with resistance rates in elderly patients above 30% for ciprofloxacin, amoxicillin-clavulanic, and cotrimoxazole, and 15.4% of extended spectrum beta-lactamase producing strains. In the univariate analysis, previous manipulation of the urinary tract, history of cancer, previous antibiotic treatment, resistant E. coli strains, renal impairment, and admission to the hospital were more frequent among patients ≥75 years. Nonetheless, in the multivariate analysis only inadequate empirical antibiotic treatment was found to be significantly more frequent in elderly patients (P=.004). CONCLUSIONS: Drug-resistance patterns to commonly used antibiotics should be considered when choosing empirical treatment for acute bacterial prostatitis in the Emergency Department setting, especially for patients ≥75 years.