David A. Talan

Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management—United States, 1998☆

From October 30 through December 23, 1998, CDC received reports of a series of bioterroristic threats of anthrax exposure. Letters alleged to contain anthrax were sent to health clinics on October 30, 1998, in Indiana, Kentucky, and Tennessee. During December 17-23 in California, a letter alleged to contain anthrax was sent to a private business, and three telephone threats of anthrax contamination of ventilation systems were made to private and public buildings. All threats were hoaxes and are under investigation by the Federal Bureau of Investigation (FBI) and local law enforcement officials. The public health implications of these threats were investigated to assist in developing national public health guidelines for responding to bioterrorism. This report summarizes the findings of these investigations and provides interim guidance for public health authorities on bioterrorism related to anthrax.

Analysis of emergency department management of suspected bacterial meningitis

Previous studies of emergency department management of bacterial meningitis have indicated that there are often long delays before initiation of antibiotics. The purpose of our study was to determine whether these delays were related to specific aspects of patient management. From 1981 through 1988, we retrospectively reviewed the medical records of 122 patients primarily evaluated in the ED and admitted for suspected bacterial meningitis at a university (55) and a community (67) hospital. The median time (interquartile range) from ED registration until initiation of antibiotics (time to antibiotics) was 3.0 hours (1.6 and 4.3 hours, respectively) (total range, 0.5 to 18 hours). The time to antibiotics was not significantly related to the time of ED registration. Ninety percent of the total time to antibiotics occurred after the initial physician encounter. Time to antibiotics was significantly (P less than .00005) longer for patients in whom computed tomography scan and/or laboratory analysis of cerebrospinal fluid preceded initiation of antibiotics compared with patients in whom antibiotic administration was not contingent on the results of these procedures (4.3 [3.2 and 6.0] versus 1.9 [1.2 and 3.4] hours, respectively). Also, time to antibiotics was significantly (P less than .00005) longer for patients in whom antibiotics were initiated on the ward as compared with in the ED (4.5 [3.5 and 6.8] versus 2.2 [1.4 and 3.5] hours, respectively). We conclude that long delays exist in the ED before initiation of antibiotics for cases of suspected bacterial meningitis, and that in general these delays appear to be physician generated and to a great extent potentially avoidable.

Compliance with universal precautions in a university hospital emergency department.

We investigated the compliance of emergency department health care workers with barrier precaution policies adapted from the Centers for Disease Controls Recommendations for Prevention of HIV Transmission in Health-Care Settings. One hundred sixty-nine health care worker encounters with 97 patients were observed. One hundred one observations were of noncritical ED patients undergoing IV catheter placement (35) or phlebotomy (66). Sixty-eight observations involved cardiac arrest or critical trauma patients. Observations in this latter group were of the use of needles, 22; physical examination, 18; patient handling, 17; endotracheal intubation, eight; and Foley catheter placement, three. For noncritical patients, only 52.5% of providers wore gloves for phlebotomy or IV catheter placement. For critical patients, gloves were worn by health care workers as follows: needle use, 64%; physical examination, 72%; intubation, 88%; physical handling of patients, 76%; and Foley catheter placement, 100%. Gowns, masks, and protective eyewear were used in encounters with critical patients by 28%, 1%, and 18% of workers, respectively. We conclude that there currently is a low rate of compliance with universal precaution policies by ED personnel.

Acute bacterial skin infections: developments since the 2005 Infectious Diseases Society of America (IDSA) guidelines.

BACKGROUNDnPatients with acute bacterial skin and skin structure infections (ABSSSI) commonly present to Emergency Departments (EDs) where physicians encounter a wide spectrum of disease severity. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has increased in the past decade, and CA-MRSA is now a predominant cause of purulent ABSSSI in the United States (US).nnnOBJECTIVESnThis article reviews significant developments since the most recent Infectious Diseases Society of America (IDSA) guidelines for the management of ABSSSI in the CA-MRSA era, focusing on recent studies and recommendations for managing CA-MRSA, newer antimicrobials with improved MRSA activity, new diagnostic technologies, and options for outpatient parenteral antimicrobial therapy (OPAT).nnnDISCUSSIONnThe increasing prevalence of CA-MRSA has led the IDSA and other organizations to recommend empiric coverage of CA-MRSA for purulent ABSSSI. The availability of rapid MRSA detection assays from skin and soft tissue swabs could potentially facilitate earlier selection of targeted antimicrobial therapy. Several newer intravenous antibiotics with expanded MRSA coverage, including ceftaroline fosamil, daptomycin, linezolid, and telavancin, may be utilized for treatment of ABSSSI. OPAT may be an option for intravenous administration of antibiotics in selected patients and may prevent or shorten hospitalizations, decrease readmission rates, and reduce nosocomial infections and complications.nnnCONCLUSIONnThe growing prevalence of CA-MRSA associated with ABSSSI in the US has a significant impact on clinical management decisions in the ED. Recent availability of new diagnostic testing and therapeutic options may help meet the demand for effective antistaphylococcal agents.

Relationship of clinical presentation to time to antibiotics for the emergency department management of suspected bacterial meningitis

STUDY HYPOTHESISnThe acuity and specificity of the clinical presentation of bacterial meningitis are significantly associated with the time to antibiotic administration.nnnDESIGNnRetrospective case series.nnnSETTINGnSeven hundred-bed university and 1,000-bed community hospital.nnnPARTICIPANTSnOne hundred twenty-two children and adults primarily evaluated in the emergency department and admitted with the diagnosis of suspected bacterial meningitis.nnnMETHODSnThe ED chart was reviewed for demographic, historical, physical examination, and time data and sequence of interventions. In addition, we categorized patient presentations as sick or not and as classic or not based on the following predetermined definitions. A sick presentation was defined as at least two of the following: temperature of more than 40 C, lethargic or comatose mental status, hypotension, or tachycardia. A classic presentation was defined as temperature of more than 39 C and at least one of the following: nuchal rigidity, bulging fontanelle, or abnormal mental status. Association of clinical variables and management practices to time to antibiotics was analyzed by analysis of variance and regression.nnnRESULTSnThe geometric mean time from ED registration until antibiotic initiation was 2.7 hours (range, 0.5 to 18 hours). Clinical factors that were associated independently with less time to antibiotics (hours less, P value) were a history of vomiting (0.5 hour, P = .06), no history of headache (0.8 hour, P = .01), hypotension (1.0 hour, P = .02), a bulging fontanelle (0.9 hour, P = .01), and a sick presentation (0.5 hour, P = .06). Management scenarios in which antibiotics were not administered until after return of results of computed tomography head scan or laboratory cerebrospinal fluid analysis and the practice of initiation of antibiotics on the ward compared with in the ED were associated independently with even greater delays (1.7 to 1.8 hours, P < .0001).nnnCONCLUSIONnCertain clinical factors, particularly those associated with acute illness compared with those that suggest the specific diagnosis, are associated with less time to antibiotics. Management practices, such as the order of interventions and the site of initiation of antibiotic therapy, appear to be of much greater importance in predicting antibiotic timeliness and represent an area of potentially avoidable delay for the ED management of suspected bacterial meningitis.

Erythromycin failure with subsequent Pasteurella multocida meningitis and septic arthritis in a cat-bite victim

We report the case of a 75-year-old woman who developed Pasteurella multocida meningitis and septic arthritis while being treated for a cat-bite wound infection with erythromycin. Review of the literature revealed that erythromycin has poor in vitro activity against this bacterium and has been associated with serious clinical failures. We recommend that erythromycin not be prescribed for empiric therapy of established animal-bite infections. Suggestions for optimal empiric therapy of animal-bite infections and the differential diagnosis of severe cat-bite-associated sepsis are discussed.

Staphylococcus aureus Colonization and Strain Type at Various Body Sites among Patients with a Closed Abscess and Uninfected Controls at U.S. Emergency Departments

ABSTRACT Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a prevalent cause of skin and soft tissue infections (SSTI), but the association between CA-MRSA colonization and infection remains uncertain. We studied the carriage frequency at several body sites and the diversity of S. aureus strains from patients with and without SSTI. Specimens from the nares, throat, rectum, and groin of case subjects with a closed skin abscess (i.e., without drainage) and matched control subjects without a skin infection (n = 147 each) presenting to 10 U.S. emergency departments were cultured using broth enrichment; wound specimens were cultured from abscess cases. Methicillin resistance testing and spa typing were performed for all S. aureus isolates. S. aureus was found in 85/147 (57.8%) of abscesses; 49 isolates were MRSA, and 36 were methicillin-susceptible S. aureus (MSSA). MRSA colonization was more common among cases (59/147; 40.1%) than among controls (27/147; 18.4%) overall (P < 0.001) and at each body site; no differences were observed for MSSA. S. aureus-infected subjects were usually (75/85) colonized with the infecting strain; among MRSA-infected subjects, this was most common in the groin. The CC8 lineage accounted for most of both infecting and colonizing isolates, although more than 16 distinct strains were identified. Nearly all MRSA infections were inferred to be USA300. There was more diversity among colonizing than infecting isolates and among those isolated from controls versus cases. CC8 S. aureus is a common colonizer of persons with and without skin infections. Detection of S. aureus colonization, and especially MRSA, may be enhanced by extranasal site culture.

The management of HIV-related illness in the emergency department

As the AIDS epidemic progresses, the number of ED patients with HIV-related illness will continue to increase. As reviewed in this article, much of the existing clinical research in HIV-related illness has an impact on the diagnostic and management issues that arise in the ED. Many of the patterns of disease, subtleties of diagnosis, and therapies unique to AIDS patients have already been greatly elucidated. However, as the recognition of this disease goes into only its second decade, many questions remain. Further studies are needed, for example, to improve physician assessment of HIV risk, to further identify discriminators of PCP and bacteremia, and to optimize strategies for disposition and outpatient management. In the future, in the areas of research and clinical care, emergency medicine will play an increasing important role in the front-line attack on this modern epidemic.

Phenotypic and Molecular Characterization of Solobacterium moorei Isolates from Patients with Wound Infection

ABSTRACT Though seldom reported, Solobacterium moorei, which was first described in 2000, has been identified in specimens from patients with root canals, periradicular lesions, periodontal disease, dentoalveolar abscesses, bacteremia, septic thrombophlebitis, and halitosis. In the present study, we describe 9 cases of mixed wound infection, from a pool of 400 surgical wound infections that we have studied, in which S. moorei was isolated or found in a clone library. All isolates of S. moorei were identified by 16S rRNA gene sequence analysis, and then six were examined for their physiological and biochemical characteristics and for antimicrobial susceptibility. The results of the present study indicate that Solobacterium moorei may be a significant component in some mixed surgical wound infections and that surgical management and antimicrobial therapy may be indicated when these bacteria are identified in significant situations.

New concepts in antimicrobial therapy for emergency department infections

This state-of-the art review addresses advances in the understanding of infectious disease management that have practical implications for emergency care. The associations of decreased mortality and shorter length of hospital stay with the timely administration of antimicrobial agents for various types of serious infections underscore the importance of emergency department diagnosis and management. Treatment of patients presenting with infectious diseases to the ED continues to present challenges because of emerging bacterial resistance, the introduction of new antimicrobial drugs, and greater emphasis on cost-effectiveness and outpatient care. The emergence of drug-resistant Streptococcus pneumoniae has resulted in changes to empirical therapy for various respiratory tract infections and meningitis. Higher doses of amoxicillin are recommended for treatment of children with acute otitis media, fluoroquinolones with enhanced pneumococcal activity are new treatment options for adults with community-acquired pneumonia, and vancomycin is now added to a third-generation cephalosporin for treatment suspected bacterial meningitis in infants and adults. Recently recognized resistance of uropathogenic Escherichia coli to trimethoprim-sulfamethoxazole will lead to greater reliance on fluoroquinolones for nonpregnant women with urinary tract infection. The need for expensive in-hospital care for many presumed serious infectious presentations is increasingly questioned. Low-risk groups have been identified among patients with pneumonia, pyelonephritis, pelvic inflammatory disease, and fever and neutropenia who may be managed as outpatients. In the future, we will see the introduction of protein-conjugate pneumococcal vaccine for young children, new antimicrobial agents with enhanced activity against increasingly resistant gram-positive bacteria, and further efforts to limit antimicorbial treatment to patients with diagnoses clearly associated with benefit from these agents so as to forestall further development of bacterial resistance.