Elissa M. Schechter-Perkins

Prevalence and Predictors of Nasal and Extranasal Staphylococcal Colonization in Patients Presenting to the Emergency Department

STUDY OBJECTIVE Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of skin and soft tissue infections in patients presenting to the emergency department (ED). The prevalence of asymptomatic MRSA colonization in ED patients is less well described, particularly in the absence of a skin and soft tissue infection-related complaint. The goals of this study are to assess the prevalence of nasal and extranasal staphylococcal colonization in ED patients, evaluate risk factors, and molecularly characterize the strains. METHODS We performed active surveillance for methicillin-susceptible S aureus (MSSA) and MRSA colonization in 400 subjects presenting to an urban ED. Risk factor assessment was performed and culture testing was conducted on anterior nares, oropharynx, palms, groin, perirectal area, wounds, and catheter insertion sites. Multiplex polymerase chain reaction was used to identify the USA300/400 clonal types. RESULTS The prevalence of colonization with MSSA was 39% (95% confidence interval 34.2% to 44.0%), and prevalence of colonization with MRSA was 5% (95% confidence interval 3.1% to 7.6%). Among MRSA-colonized subjects, an extranasal site tested positive in 80% of subjects, and 45% had exclusive extranasal colonization. USA300 was identified in 55% of MRSA-colonized subjects. The main risk factors for MRSA colonization included HIV infection, diabetes, and participation in contact sports. CONCLUSION The overall prevalence of MRSA colonization in this ED population was lower than that reported in other high-risk ambulatory care settings. However, extranasal colonization was present in more than half of MRSA-colonized subjects, and USA300 was the predominant clonal type.

Multi-center evaluation of the cobas® Liat® Influenza A/B & RSV assay for rapid point of care diagnosis

Point of Care Testing (POCT) provides the capability for rapid laboratory test results in patient care environments where a traditional clinical laboratory is not available. POCTs have shorter turn-around times (TATs), they may be performed by non-laboratory personnel, and the need for transport time is eliminated. The Food and Drug Administration (FDA) recently granted Clinical Laboratory Improvements Amendment (CLIA) waiver status to the cobas® Influenza A/B & RSV assay, a rapid, accurate point-of-care test for Influenza and respiratory syncytial virus (RSV) performed on the Liat® System. The performance characteristics of this test were determined though a multi-site study consisting of different point of care testing environments. Prospectively collected Nasopharyngeal (NP) swabs from 1361 patients seen at 8 primary care clinics and 4 emergency departments (EDs) and 295 retrospectively identified specimens were tested for Influenza A/B and RSV on the cobas® Liat® platform. Performance characteristics were determined through comparison to ProFlu+, a laboratory-based PCR test for Influenza A/B and RSV (reference test). Discordant specimens were adjudicated following bi-directional sequencing. The cobas® Influenza A/B and RSV assay showed sensitivities of 99.6%, 99.3%, and 96.8% for Influenza A, Influenza B, and RSV, respectively as determined from percent positive agreement (PPA) following comparison to the reference test. Sequencing confirmed cobas® Influenza A/B and RSV results in 49.2% of reference test discordant specimens, while crossing threshold data suggest increased sensitivity compared to the reference test. The cobas® Influenza A/B and RSV assay was found to be a rapid, sensitive POCT for the detection of these viruses, and provides laboratory-quality PCR-based diagnostic results in point of care settings.

Treatment of Cases of Neisseria gonorrhoeae and Chlamydia trachomatis in Emergency Department Patients.

Background The aim of this study was to determine the proportion of patients treated appropriately, both presumptively in the emergency department (ED), and at follow-up, among those patients who ultimately tested positive for either Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT). Secondary aims were to characterize patients who received appropriate presumptive antibiotic treatment of both NG and CT at the time of ED visit and to compare them to patients who did not receive appropriate presumptive therapy. Methods A retrospective chart review was performed on 500 patients randomly chosen from those that had positive NG or CT test results performed in the ED between January 10 and June 11. The Center for Disease Control and Prevention 2010 STD Treatment Guidelines were used to determine appropriate antibiotics. Results We found 54% (95% confidence interval [CI], 49%–58%) of patients received appropriate antibiotics at ED visit and an additional 31% (95% CI, 27%–35%) were treated at our medical center on follow-up. Fifteen percent did not have documented treatment. Providers presumptively treated 46% (95% CI, 42%–50%) of patients studied with antibiotics appropriate for both NG and CT. The presence of behavioral risk factors and, for males, the presence of genital symptoms were the only factors independently associated with presumptive ED treatment. Conclusions Among patients diagnosed as having NG or CT in this ED, a portion were not documented to ever receive appropriate antibiotics, although a call-back system is in place. Presumptive treatment was not commonly used in this ED but may be necessary given the high number of patients who never got treated.

Treatment of life-threatening hyperkalemia with peritoneal dialysis in the ED

Severe hyperkalemia (serum potassium N 7.0 mmol/L) is an uncommon electrolyte abnormality in patients undergoing maintenance peritoneal dialysis (PD). Hemodialysis (HD) has been suggested as the definitive therapy for severe hyperkalemia in this population,although there is limited data regarding renal replacement options.We report a case of life-threatening hyperkalemia with electrocardiogram changes in a nonadherent PD patient who was successfully treated with standard medical therapy and manual exchanges initiated by emergency department (ED) personnel. The patient did not require HD. This case demonstrates the potential utility of PD as a treatment option for severe hyperkalemia in established dialysis patients when EDs are prepared to deliver exchanges. This report maybe particularly relevant due to the increasing prevalence rate of PD and for centers with limited HD access.

Implementation of a rapid HIV testing programme favourably impacts provider opinions on emergency department HIV testing

Objective To assess staff knowledge of Centers for Disease Control (CDC) guidelines, attitudes and barriers towards emergency department (ED) HIV testing before and after implementing an ED rapid HIV testing programme (EDRHTP). Methods We conducted a cross-sectional pre/post survey at an urban academic medical centre. In March 2009, ED registered nurses (RNs) and doctors (MDs) participated in an anonymous survey. An EDRHTP was established in September 2009, and in March 2011, the survey was redistributed to ED staff. Differences before and after programme implementation were assessed using χ2 statistics or Fishers exact test. Results Respondents reported greater familiarity with CDC guidelines after programme implementation (44% vs 59%, p=0.04) and more believed that HIV testing should be offered to all ED patients (44% vs 79%, p<0.0001). Prior to programme implementation, RNs and MDs differed in attitudes towards ED HIV testing across most questions, and differences disappeared post programme. Conclusions Overall support for ED HIV testing increased after establishment of a rapid testing programme.

The evaluation of acute vision loss: central serous chorioretinopathy

Acute vision loss is frightening to patients and may represent serious pathology that is irreversible if not intervened upon quickly. We present a case of a 36-year-old man with sudden onset of unilateral painless central visual disturbance described as flashes of light. His emergency department examination was normal, and an ophthalmologic consult found fluid accumulation in the subretinal space on optical coherence tomography, confirming a diagnosis of central serous chorioretinopathy. Central serous chorioretinopathy is a poorly understood disease associated with type A personality and elevated glucocorticoids. Although there is no proven treatment regimen for acute disease, vision problems usually resolve. Some patients have recurrent episodes that can lead to permanent visual loss

Case report: Topical use of tranexamic acid for the management of post-procedural rectal bleeding

Tranexamic acid (TXA) is increasingly used in the Emergency Department (ED). While the intravenous form has been extensively studied and used, its utility in a topical formulation is not as widespread. Its reported use in the ED is mostly for control of epistaxis. We present a case of a 61 year old male with post-procedural rectal bleeding, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.

Point-of-care influenza testing does not significantly shorten time to disposition among patients with an influenza-like illness

Introduction: Availability of anti‐viral agents and need to isolate infected patients increases the need to confirm the diagnosis of influenza before determining patient disposition. Objectives: We sought to determine if time‐to‐disposition (TTD) was shorter among patients tested for influenza using an Emergency Department (ED) Point‐of‐care (POC) test compared to core laboratory (lab) test and to determine difference in antibiotic use between groups. Methods: We prospectively enrolled a convenience sample of ED patients for whom influenza testing was ordered during influenza season 2017. Participants were randomized to POC or lab. Data collected included demographics, chief complaint, influenza test results, turnaround time (TAT), whether antibiotics were given, and TTD. Descriptive statistics were calculated and group comparisons conducted using chi squared and Wilcoxon Rank Sum tests. Results: Study population included 100 in the POC group and 97 in the lab group. Demographics were similar between POC and lab participants. More flu positive results were reported in the POC group compared to the lab group (51.0% vs. 33.0% p = 0.01). The median TTD was 146.5 min (IQR 98.5) for POC group and 165.5 min (IQR 127) for lab group (p = 0.26). The median TAT was 30.5 min (IQR 7.5) for POC group and 106.0 min (IQR 55) for core lab group (p = 0.001). Antibiotics were given to 14.0% of POC participants and 14.4% of lab participants (p = 0.93). Conclusions: Although use of a POC influenza test provided more rapid TAT than use of a core lab test, there was no significant difference in TTD or antibiotic use between groups.

Why do patients refuse HIV testing in the emergency department? Perspectives from a qualitative study

ABSTRACT Despite support for routine testing in all health care settings, including emergency departments (EDs), there are challenges to implementing ED-based HIV testing and high refusal rates. We conducted qualitative interviews to examine reasons for refusal with 30 testing refusers in the ED of a safety net hospital. Key themes included: routine testing is positive, importance of privacy and respectful approach, ED atmosphere and environment discourage testing acceptance, importance of HIV counseling, desire to see an MD before testing staff, and who should offer testing. Results provide useful information for programs and policies of routine ED-based HIV testing to encourage testing uptake.

Peritoneal dialysis and potassium: pains and gains in ED—the authors' reply

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