Utilidad de la región medial de la pro-adrenomodulina para la detección de bacteriemia verdadera en pacientes mayores atendidos en urgencias por sospecha de infección / Utility of the medial region of pro-adrenomodulin for the detection of true bacteremia in elderly patients treated in the emergency department for suspected infection

Introducción. La predicción de bacteriemia en urgencias es importante para la toma de decisiones iniciales. La población mayor un reto diagnóstico. El objetivo fue evaluar la capacidad de la región medial de la pro-adrenomodulina (MR-proADM) para identificar bacteriemia verdadera (BV) en pacientes mayores atendidos en tres servicios de urgencias. Metodología. Estudio observacional incluyendo pacientes ≥75 años atendidos por sospecha de infección en los que se extrajo un hemocultivo (HC). Se recogieron variables sociodemográficas, comorbilidad, hemodinámicas, analíticas y biomarcadores [MR-proADM, procalcitonina (PCT), proteína C reactiva (PCR) y lactato]. La variable de resultado fue un verdadero positivo en el hemocultivo. Resultados. Se incluyeron 109 pacientes con edad media de 83 (DE 5,5) años. En 22 pacientes (20,2%) se obtuvo un diagnóstico final de BV. Las variables independientes para predecirla fueron PCT (OR13,9; IC95%: 2,702-71,703; p=0,002), MR-proADM (OR4,081; IC95%: 1,026-16,225; p=0,046) y temperatura (OR 2,171; IC95%: 1,109-4,248; p=0,024). Considerando el punto de corte con mayor rendimiento diagnóstico para el MR-proADM (2,13 mg/dl), se obtuvo una sensibilidad (Se) de 73%, una especificidad (E) de 71%, un valor predictivo positivo (VPP) de 39%, un valor predictivo negativo (VPN) de 91%, un coeficiente de verosimilitud positivo (LHR+) de 2,53 y un coeficiente de verosimilitud negativo (LHR-) de 0,38; para PCT (0,76 mg/dl) se obtuvo una Se de 90%, E de 65%, VPP de 40%, VPN de 96%, LHR+ 2,64 y un LHR– de 0,14. Al combinar ambos, se observó una Se de 69%, E de 84%, VPP de 52%, VPN de 91%, LHR+ de 4,24 y un LHR- de 0,38. Conclusión. Niveles elevados de PCT y MR-proADM se asocian a un riesgo incrementado de BV y la combinación de ambos mejora la capacidad para identificar estos pacientes. (AU)

Background. The prediction of bacteremia in the emergency department (ER) is important for initial decision-making. The elderly population is a diagnosis challenge. The objective was to evaluate the accuracy of mid regional pro-adrenomedullin (MR-proADM) to identify true bacteremia (BV) in elderly patients attended in 3 hospital emergency departments. Methods. Observational study including patients ≥75 years of age or older attended in the ER for suspected infection in whom a blood culture (BC) was extracted. Sociodemographic, comorbidity, hemodynamic and analytical variables, biomarkers [MR-proADM, procalcitonin (PCT), C-reactive protein (CRP) and lactate] and final diagnosis were collected. The primary outcome was a true positive on a blood culture. Results. A total of 109 patients with a mean age of 83 (SD: 5.5) years were included. A final diagnosis of BV was obtained in 22 patients (20.2%). The independent variables to predict it were PCT (OR: 13.9; CI95%: 2.702-71.703; p=0.002), MR-proADM (OR: 4.081; CI95%: 1.026-16.225; p=0.046) and temperature (OR: 2.171; CI95%: 1.109-4.248; p=0.024). Considering the cut-off point for MR-proADM (2.13 mg/dl), a sensitivity (Se) of 73%, specificity (E) of 71%, a positive predictive value (PPV) of 39%, a negative predictive value (NPV) of 91%, a positive likelihood ratio (LHR+) of 2.53 and a negative likelihood ratio (LHR-) of 0.38; for PCT (0.76 mg/dl) a Se of 90%, E of 65%, PPV of 40%, NPV of 96%, LHR+ 2,64 and a LHR- of 0.14 were obtained. When combining both, a Se of 69%, E of 84%, PPV of 52%, NPV of 91%, LHR+ of 4.24 and LHR- of 0.38 were observed. Conclusions. Elevated levels of PCT and MR-proADM were independently associated with an increased risk of BV and the combination of both improves the accuracy to identify these patients. (AU)

Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. / Diseño de un panel de indicadores para programas de optimización del uso de antimicrobianos en los Servicios de Urgencias.

OBJECTIVE: To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS: A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS: 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS: The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Mapa de la situación actual de la atención a la sepsis en los servicios de urgencias españoles / Current situation of sepsis care in Spanish emergency departments

Objetivo. Describir el abordaje que se realiza a los pacientescon sospecha de sepsis en los servicios de urgencias hospitalarios (SUH) españoles y analizar si existen diferencias atendiendoal tamaño del hospital y la afluencia a urgencias en el territorio.Método. Encuesta estructurada a los responsables de los282 SUH públicos que atienden adultos 24 horas/día, 365 días/año. Se preguntó sobre asistencia y manejo en urgencias en laatención a pacientes con sospecha de sepsis. Los resultados secomparan según tamaño del hospital (grande ≥ 500 camas vsmedio-pequeño < 500) y afluencia en urgencias (alta ≥ 200visitas/día vs media-baja < 200).Resultados. Respondieron 250 SUH españoles (89%). En163 (65%) SUH se dispone de protocolos de sepsis. La medianade sepsis semanales atendidas variaban desde 0-5 por semana en 39 (71%) SUH, 6-10 por semana en 10 (18%), 11-15por semana en 4 (7%), y más de 15 activaciones por semanaen 3 centros (3,6%). Los criterios utilizados para la activacióndel código sepsis (CS) fueron el qSOFA/SOFA en 105 (63,6%) delos hospitales, SIRS en 6 (3,6%), mientras que en 49 (29,7%)utilizaban ambos criterios de forma simultanea. En 79 centrosel CS estaba informatizado y en 56 existían herramientas deayuda a la toma de decisiones. Un 48% (79 de 163) de los SUHdisponían de datos de cumplimiento de medidas. En el 61%(99 de 163) de SUH existía formación en sepsis y en el 56% (55de 99) ésta era periódica. Atendiendo al tamaño del hospital,los hospitales grandes participaban más frecuentemente comoreceptores de enfermos con CS y disponían de servicio/unidadde infecciosas, de sepsis y de corta estancia, microbiólogo einfectólogo de guardia.Conclusión. la mayoría de los SUH disponen de protocolos de CS, pero existe margen de mejora. La informatización ydesarrollo de alertas para el diagnóstico y tratamiento tienenaún un gran recorrido en los SUH. (AU)

Objective. To describe the approach to the patients withsuspected sepsis in the Spanish emergency department hospitals (ED) and analyze whether there are differences according to the size of the hospital and the number of visits to theemergency room.Method. Structured survey of those responsible for the282 public EDs that serve adults 24 hours a day, 365 days ayear. It was asked about assistance and management in theemergency room in the care of patients with suspected sepsis.The results are compared according to hospital size (large ≥500 beds vs medium-small <500) and influx to the emergencyroom (discharge ≥ 200 visits / day vs medium-low <200).Results. A total of 250 Spanish EDs responded (89%).Sepsis protocols are available in 163 (65%) EDs median weekly sepsis treated ranged from 0-5 per week in 39 (71%) ED,6-10 per week in 10 (18%), 11-15 per week in 4 (7%), andmore than 15 activations per week in 3 centers (3.6%). Thecriteria used for sepsis diagnosis were the qSOFA/SOFA in 105(63.6%) of the hospitals, SIRS in 6 (3.6%), while in 49 (29.7%)they used both criteria simultaneously. In 79 centers, the sepsis diagnosis was computerized, and in 56 there were tools tohelp decision-making. 48% (79 of 163) of the EDs had dataon bundles compliance. In 61% (99 of 163) of EDs there wastraining in sepsis and in 56% (55 of 99) it was periodic. Considering the size of the hospital, large hospitals participated more frequently as recipients of patients with sepsis and hadan infectious, sepsis and short-stay unit, a microbiologist andinfectious disease specialist on duty.Conclusion. Most EDs have sepsis protocols, but there isroom for improvement. The computerization and developmentof alerts for diagnosis and treatment still have a long way togo in EDs (AU)