STATE-OF-THE-ART CLINICAL ARTICLE

Infectious Disease Issues in the Emergency Department

David A. Talan

Infectious disease management issues facing the emergencyphysician are frequently different from those confronted by theinfectious diseases specialist working in an office or as an in­hospital consultant. Community-acquiredinfections in both chil­dren and adults are evaluated primarily in the emergency depart­ment, where the spectrum of disease includes myriad benigninfections as well as occasional life-threatening conditions. Notunexpectedly, because culture and antimicrobial-susceptibilityfindings are not available during initial evaluation, emergencydepartment diagnoses are typically presumptive; thus, antimicro­bials are prescribed empirically or, for various types of trauma,prophylactically. Decisions regarding the need for hospitaliza­tion are routinely made in this setting. Emergency departmentpractitioners also have unusually high exposure to a number ofcommunicable infectious diseases.

Although emergency medicine is a field of great breadth,research focusing on infectious disease issues has created anew niche of growing depth. In this state-of-the-art clinicalarticle, infectious disease research with important bearing onemergency and outpatient care will be reviewed in order toacquaint the infectious diseases consultant with some of themany issues commonly confronted in this unique setting.

Occult Bacteremia and Serious Bacterial Infections in theNeonate, Young Child, and Adult

One of the most frequent presentations in the emergencydepartment is of a child with fever. Evaluation of young chil­dren is particularly problematic because they are at great riskfor potentially life-threatening infections. However, distin­guishing benign viral illness from more serious infections onthe basis of clinical evaluation can in many cases be extremelydifficult.

For febrile neonates and young infants, physical examinationcannot be relied upon in order to exclude serious bacterialinfections such as meningitis. Until recently, standard practice

Received 19 January 1996; revised 6 March 1996.Reprints or correspondence: Dr. David A. Talan, Olive View-UCLA Medi­

cal Center, Department of Emergency Medicine, 14445 Olive View Drive,Sylmar, California 91342.

Clinical Infectious Diseases 1996;23:1-14© 1996 by The University of Chicago. All rights reserved.1058-4838/96/2301-0001$02.00

From the Departments ofEmergency Medicine and Internal Medicine,Division of Infectious Diseases, Olive View- UCLA Medical Center,Sylmar; and the UCLA School of Medicine, Los Angeles, California

for these patients has been hospital admission and parenteralantibiotic treatment after culture of blood, urine, and CSF.Since the late 1980s, clinical and laboratory criteria have beenproposed to identify nontoxic febrile (defined by a rectal tem­perature of > 38°C) infants <3 months of age who are at lowrisk for serious bacterial infection and for whom outpatientmanagement is acceptable. These criteria, referred to as theRochester criteria, predict a likelihood of bacteremia, meningi­tis, and any serious bacterial infections of 1.1 %, 0.5%, and1.4%, respectively (table 1) [1].

The Rochester criteria have been best evaluated with regardto their applicability for infants 1-3 months of age and arenow employed in many venues to guide outpatient managementin this age group [2- 7]. Most physicians who have adoptedthis approach also do blood, urine, and CSF cultures (andstool cultures if clinically indicated), and they begin empiricaltherapy with an intramuscular injection of ceftriaxone. Othersmanage low-risk cases without antibiotics and lumbar puncture,as long as careful follow-up is ensured [7]. Febrile neonates< I month of age should undergo a full septic workup andbegin receiving parenteral antibiotics pending the results ofcultures as well as findings from observation in the hospital.

Clinical findings of serious focal bacterial infection are gen­erally more reliable with regard to children older than age 3months. However, unsuspected or occult bacteremia occurs in"""'3%-4% of non-toxic-appearing children who are 3 monthsto 3 years of age and have a temperature of > 39°C but noobvious focus of infection. In these patients occult bacteremiais mostly caused by Streptococcus pneumoniae (85%), Haemo­

phi/us infiuenzae (10%, prior to H. infiuenzae type b [Hib]vaccine), and Neisseria meningitidis (3%).

Although occult bacteremia will spontaneously clear in manychildren, it develops into serious focal infections in some. Forexample, among those not receiving antibiotics, ,....., 50%-70%will have fever persisting ~24 hours and 10%-20% will havepersistent bacteremia [7, 8]. The risk of subsequent meningitisfor patients with untreated occult bacteremia due to S. pneu­

moniae has been estimated to be 6% [9].For nontoxic febrile children who are 3 months to 3 years

of age and have no obvious source of infection, controversyexists with regard to the optimal management strategy. Factorsthat predict occult bacteremia in children include temperature,age (maternal antibodies may protect until 6 months of age,and the native immune defenses may be intact by 18 months),

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2 Talan em 1996;23 (July)

Table 1. The Rochester criteria for identifying nontoxic febrile in­fants <3 months of age who are at low risk for serious bacterialinfection and for whom outpatient management is acceptable [l].

Nontoxic appearance, previously healthy, born full-termNo current antibiotic use

No evidence of skin, soft-tissue, bone, joint, or ear infectionWBC count of 5,000-15,000/nun3 with ~ 1,500 band forms/mni'

WBC count in stool of ~5/high-power field, if diarrhea is presentWBC count in spun urine sediment of ~ 10/high-power fieldParents reliable and compliance with 24-hour follow-up likely

observational characteristics, and degree of WBC count eleva­tion, as well as other laboratory values (e.g., C-reactive proteinlevel and erythrocyte sedimentation rate) [7].

Unfortunately, these parameters do not completely distin­guish patients with occult bacteremia from those with benignviral illness. For example, the incidence of occult bacteremiaamong nontoxic children who are 3 months to 3 years of ageis 3%-4% when their temperature is >39°C and ,...,.,9% whentheir temperature is >41 oC. Among all nontoxic febrile chil­dren in this age range, the prevalence of occult bacteremia is3% among those whose WBC counts are <15,000/mm3 and13% among those whose counts are> l5,000/mm3

•

Observational scales also do not adequately distinguish chil­dren with occult bacteremia [10]. Therefore, strategies mustweigh the potential benefit of treating a subset of a few patientswith occult bacteremia to prevent infectious sequelae vs. therisk of unnecessarily treating the vast majority of children withbenign viral illness.

A meta-analysis of studies of occult bacteremia occurringin febrile children aged 3- 36 months before Hib vaccinationdemonstrated that either oral or parenteral antibiotic therapy(vs. no antibiotic therapy) decreased the frequency of subse­quent persistent fever (from 55.8% to 15.6%), persistent bacter­emia (from 20.9% to 3.8%), and meningitis (from 9.2% to4.5%) [7].

Two recent multicenter, randomized trials compared intra­muscular ceftriaxone to oral antibiotics. In one trial of 6,733children aged 3-36 months who had a temperature of >39°Cbut no focal findings (or otitis media, in 4%), ceftriaxone wasmore effective than amoxicillin in eradicating bacteremia, pre­venting definite focal infections (of which five occurred in theamoxicillin group and none in the ceftriaxone group), and ineradicating fever [11]. However, no significant difference be­tween treatment groups was found when probable as well asdefinite infections were included. Only two cases of culture­positive meningitis developed, both due to H. influenzae in theamoxicillin group.

Another study found ceftriaxone superior to amoxicillin/cla­vulanate in preventing persistent blood-culture positivity andfever but no difference in the associated frequency of focalinfections or meningitis [12]. Each of these series containedcases suggesting that a rare benefit of empirical antibiotic ther-

apy for fever of unknown origin is sterilization of the CSF,for patients with early subclinical bacterial meningitis (and/ormeningitis induced by lumbar puncture).

A meta-analysis including these studies demonstrated paren­teral antibiotics to be significantly more effective than oralantibiotics in reducing the mean risk of bacterial meningitisdue to all organisms, which was 9.8% without antibiotics, 8.2%with oral antibiotics, and 0.3% with parenteral antibiotics [9].However, the risk of pneumococcal meningitis was 0.4% inassociation with oral as well as parenteral antibiotics.

On the basis of these data, an expert panel of infectiousdisease, pediatric, and emergency medicine faculty developedpractice guidelines recommending two options, involving ad­ministration of empirical ceftriaxone (l) for all nontoxic chil­dren 3-36 months of age with fever (temperature of >39°C)of unknown origin or (2) for those patients with WBC countsof> l5,000/mm3 (in either case, after collection of blood andother appropriate culture specimens) [7]. Children should un­dergo a follow-up examination within 24 hours, and at thattime all bacteremic patients who are still febrile or who appearill, as well as children whose blood cultures are positive forH. influenzae or N. meningitidis, should have another bloodculture performed, undergo lumbar puncture, and be admittedfor parenteral antibiotic therapy (pending the results of thesecultures).

Despite the publication of these guidelines, a consensus hasnot emerged in practice, and the recommendations have beenchallenged on several grounds [13, 14]. First, to a great extent,infectious sequelae in these studies were due to H. influenzae,the incidence of which has markedly decreased since the intro­duction of the Hib vaccine. However, analyses ofoutcomes andadverse reactions associated with antibiotic treatment (based onthe assumption that risk of H inf/uenzae disease has beeneliminated by Hib vaccine) also favor administration of suchtreatment (table 2).

A recent study examining 382 childrenwith occultpneumococ­cal bacteremia found that those receiving antibiotic therapy weresignificantly less likely at follow-up to be febrile, require hospital­ization, have persistent bacteremia, or have any focal infection(nosignificant differences for meningitis werenoted) [8]. In light of theeffectiveness of Hib vaccine, oral amoxicillin may bean additionaloption, providedcompliance is ensuredand the frequency of drug­resistant S. pneumoniae (DRSP) is not significant.

Second, the frequency of the most important infectious out­come ofuntreated occult bacteremia, pneumococcal meningitis,has been questioned; one recent meta-analysis estimated therisk among patients with pneumococcal bacteremia to be <3%instead of 6% [15]. Therefore, even if parenteral antibioticseffectively reduce the risk of subsequent pneumococcal menin­gitis, which has yet to be definitely demonstrated, the degreeof benefit in a population of febrile children may not be asgreat as previously suggested.

For example, if one were to assume that the prevalence ofoccult bacteremia (90% of which is pneumococcal) is 3%,

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em 1996;23 (July) Infectious Diseases/Emergency Medicine

Table 2. Probabilities of outcome for children aged 3- 36 months with fever of unknown origin anda WBC count of ~ 15,OOO/mm3

•

No. of complications per

100,000 children

Risk per child receiving: receiving:

Risk per No Intramuscular No

Variable subgroup antibiotic antibiotic antibiotic Antibiotic

Outcome of bacteremia*

Persistent bacteremia' .10 .01100 .00275 1,100 275

Meningitis, t followed by .06 .00660 .00165 660 165

Death .15 .00099 .00025 99 25

Serious sequelae .17 .00112 .00028 112 28

Moderate sequelae .10 .00066 .00017 66 17

No sequelae .58 .00383 .00096 383 96

Antibiotic adverse reaction

Anaphylaxis, followed by .00000 .00006 0 6

Death .100 .00000 .00001 0 1

Serious sequelae .100 .00000 .00001 0 1

Recovery .800 .00000 .00005 0 5

Minor adverse reactions .00000 .05000 0 5,000

NOTE. Adapted by permission of Pediatrics, vol. 92, p. 8. Copyright 1993 [7]. Elimination of H. infiuenzaedisease by H. injiuenzae type b vaccine is assumed; data reflect risks and outcomes of S. pneumoniae bacteremiaonly.

*Probability of bacteremia: .11.tFor children with bacteremia, probability of persistent bacteremia: untreated, .1; antibiotic-treated, .025.tFor children with bacteremia, probability of meningitis: untreated, .06; antibiotic-treated, .015.

3

that meningitis will develop in 3% of the patients with occultbacteremia, and that antibiotics are 100% effective at pre­venting meningitis, then one would have to give antibioticsunnecessarily to '"" 1,000-2,000 children to prevent one caseof meningitis. To the extent that untreated children who subse­quently have meningitis would return for treatment and thecondition would be diagnosed sufficiently early to prevent com­plications, the benefit of early therapy for fever of unknownorigin would be even less.

Other concerns include the promotion of emergence of anti­biotic resistance and the possibility of more cases of partiallytreated meningitis due to broadened empirical antibiotic use.Thus, the approach to fever of unknown origin in the youngchild remains controversial and, to some extent, comes downto what one assumes the risk of meningitis to be, as well asthe risk one is willing to take. Ultimately, these issues maynot be resolved until there is a rapid test to detect the presenceof bacteremia (e.g., PCR) or else an effective conjugate pneu­mococcal vaccine that eliminates S. pneumoniae as a threat.

Although unsuspected or occult focal bacterial infectionsand bacteremia in adults presenting to emergency departmentshave not been as well studied as those in children, severalstudies shed some light on the subject. One study investigatedoccult bacterial infection (i.e., focal bacterial infection or bac­teremia not suspected on the basis of symptoms and signs)occurring in 880 adult patients in an emergency departmentwhose oral temperatures were ~37.9°C; 135 of these patientshad no symptoms or signs suggesting a focal infection [16].

Of this group, 48 (35%) had occult bacterial infection and44 (33%) were initially discharged (including four bacteremicpatients). Neither a toxic appearance nor a high temperaturewere associated with the presence of occult bacterial infection.An index of predictive findings included age of > 50 years,diabetes, a WBC count of ~ 15,000/rom3

, a neutrophil bandcount of ~ 1,500/mm3

, and an erythrocyte sedimentation rate(Wintrobe method) of ~30 mm/h.

Another study looked at occult bacteremia (as opposed to allclinically occult bacterial infections) in 565 adults presenting toan emergency department with an oral temperature of>37.6°Cor a rectal temperature of>38.1"C. Among 401 patients whowere discharged, 124 had blood culture specimens taken, andonly 1 (from a patient with a tooth infection) was culture­positive [17].

Another study, of 411 adult patients in an emergency depart­ment from whom blood culture specimens were obtained, re­vealed that of 84 patients (21%) who were initially discharged,5 (5.8%) were bacteremic [18]. Two of these five cases ap­peared to involve endovascular infection (one patient had ahistory of rheumatic fever and the other was an intravenousdrug user; both histories included fever, and one of the patientshad a low-grade fever while in the department), and one caseinvolved significant comorbidity (a febrile diabetic patient un­dergoing renal dialysis). One of the five cases involved ahealthy young woman with acute uncomplicated pyelonephri­tis, and the last was a probable case of early, initially radio­graphically negative, pneumococcal pneumonia in a stable

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4 Talan em 1996;23 (July)

20

(/)15

'E(I)

~10C-

o0z 5

02 3 4 5 6 7 8 9 10 18

Time to initiation of antibiotic therapy (h)

Figure 1. The number of hours from emergency department regis­tration to administrationof antibiotics in 122cases of suspectedbacte­rial meningitis [19].

young adult who was prescribed ampicillin and refused to re­turn for reevaluation after being recontacted. Therefore, it isnot clear whether endocarditis and sepsis should have beeninitially suspected in the first three patients and whether bloodculture findings necessarily affected the outcome for the lasttwo patients.

In general, blood culture specimens are not routinely drawnfor patients who are well enough to be discharged from theemergency department. Further studies may be helpful in de­finitively determining the frequency, clinical indicators, andcomplications of bacteremia in non-ill-appearing febrile adultswith or without focal infections.

Meningitis

Acute bacterial meningitis is an infectious disease emergencyfor which prompt institution of parenteral antibiotic therapy isa high priority. Although textbooks contain recommendationsthat antibiotics be administered within 30 minutes after the diag­nosis is suspected, in actual clinical practice this textbook stan­dard is often not met [19-21]. A study analyzing the time totherapy for 122patients with presumed bacterial meningitis whowere admitted through the emergency department found that themedian time from registration of patients to initiation of paren­teral antibiotic therapy was 3 hours (figure 1).

Approximately 90% of this time occurred subsequent to theinitial physician encounter, so delays were not due to time spentin the waiting room. The most important factors associated withtherapeutic delays were management practices, as opposed tothe acuteness or specificity of the presentation [22]. Such prac­tices included withholding antibiotics until after CT imagingof the brain and in most cases a subsequent lumbar puncture(11% of cases), as well as awaiting results of formal CSFanalyses (26% of cases, even though the CSF was describedas grossly cloudy in 59% of this group).

In addition, in one-third of cases, antibiotics were not initi­ated in the emergency department, which resulted in a median

time to therapy of 4.5 hours (compared with 2.2 hours whenantibiotics were administered in the emergency department).

The need to perform CT imaging prior to lumbar puncturebecause of the potential risk of herniation in the face of unsus­pected mass lesions and intracranial hypertension has beendebated. It is clear that focal neurological findings and papil­ledema are not consistently found in patients with intracranialmass lesions. Nevertheless, the risk of deterioration is ex­tremely small for patients without either focal findings or severealteration in mental status, even if there is elevated intracranialpressure, as occurs typically in bacterial meningitis.

In the setting of possible acute CNS infection-in the ab­sence of focal neurological findings, papilledema, or severelyaltered mental status-CT should be reserved for patients whoare at risk for brain abscess (e.g., those with chronic sinusitis,history of congenital heart disease, or AIDS) or metastaticcancer. If lumbar puncture is delayed to perform CT scanningof the head, parenteral antibiotics should be administered im­mediately after blood culture specimens are drawn but beforeCT and lumbar puncture [23].

Even when antibiotics are administered before lumbar punc­ture, meningitis can be successfully diagnosed, as the CSFcytochemical profile is not altered over several hours. In addi­tion, the specific bacterial etiology can usually be identifiedbecause CSF cultures will often reveal growth as long as theyare performed within a few hours of a parenteral antibioticdose; furthermore, bacteremia can be detected in -50%-60%of cases of bacterial meningitis, and CSF gram staining, latexagglutination, and coagglutination will further increase diag­nostic sensitivity.

The potential benefit of early therapy would appear to out­weigh any small risk of obscuring the general or specific etio­logic diagnosis of bacterial meningitis or of leading to thefailure of empirical antibiotic therapy. Because of the emer­gence of DRSP, it may be prudent to screen for this pathogenby collecting a nasopharyngeal specimen prior to therapy incases in which antibiotics are administered before the CSF isobtained.

In a case involving a stable patient for whom the clinicallikelihood of bacterial meningitis is not high and who can beevaluated primarily with lumbar puncture, it may be appro­priate to await formal CSF analysis. However, gross CSF tur­bidity predicts a high likelihood ofbacterial etiology, and appli­cation of the dipstick analysis technique to the CSF may alsobe useful to rapidly predict bacterial disease [24]. In thesecases, antibiotics should not be withheld pending results of aformal CSF analysis.

Contact with the patient's physician and subsequent consul­tation with an infectious disease specialist are important butsometimes lead to long delays. Appropriate empirical antibiot­ics should be administered in the emergency department, beforethe patient is admitted.

Standard recommendations for empirical antibiotic therapyapply to the emergency setting: ceftriaxone or cefotaxime

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em 1996;23 (July) Infectious Diseases/Emergency Medicine 5

Figure 2. Pooled efficacy of antimicrobial drugs for the primarycontrol (acutesymptomatic relief)of acuteotitis mediain 5,400chil­dren evaluated in controlled and comparative trials (bars indicateranges and vertical marks indicate medians; ABX = antibiotic;aminoPen = aminopenicillin; Amox = amoxicillin; Amp = ampicil­lin; CA = clavulanic acid; Cfac = cefaclor; Cfix = cefixime; Em =erythromycin; Pen = penicillin; SSZ = sulfisoxazole; andTMP-SMZ= trimethoprim-sulfamethoxazole), Reprinted with permission from[32].

I I I

I I I

I I I

C

~C

Favors ~ ~ Favorscontrol ~ .............. treatment

Rate difference for primarycontrol of acute otitis media

302010o-20 -10

Cfac VS. Em/SSZCfac VS. Amox/CA

Cfac VS. Cfix

Control VS. treatment

No ABX vs. PenNo ABX VS. aminoPen

No ABX vs. any ABX

Amp vs. PenAmp VS. Pen/SSZaminoPen vs. Em

aminoPen VS. TMP/SMZAmox VS. CfacAmox VS. Cfix

should be administered, along with ampicillin for patients atrisk for listerial infection (i.e., neonates and immunocomprom­ised or elderly patients). Given the emerging problem ofDRSPin some areas, the addition of vancomycin should be consid­ered. Many trials have indicated a beneficial effect of earlytherapy with dexamethasone (ideally administered before anti­biotics to maximally prohibit the inflammatory burst) in reduc­ing neurological sequelae of H influenzae meningitis, and datathat support its effectiveness against pneumococcal meningitisare accumulating [25- 29].

However, the empirical use of dexamethasone is controver­sial for several reasons: (1) the rarity ofH. influenzae meningitis(owing to the Hib vaccine), (2) less secure evidence of benefitfrom corticosteroid therapy for S. pneumoniae meningitis vs.H influenzae meningitis, (3) the emergence of DRSP, and (4)concerns regarding corticosteroid-related delayed CSF steril­ization and impaired antibiotic penetration of the CSF (espe­cially with regard to vancomycin) [29].

Until further data are available, the use of dexamethasonein the emergency department for bacterial meningitis may bereasonably favored for children who have not undergone com­plete Hib vaccination, but it may be discouraged in areas wherevancomycin is recommended because of the significant preva­lence of DRSP.

Acute Otitis Media, Pharyngitis, and Bronchitis

Next to viral syndrome, acute otitis media (AOM) may bethe most common infectious disease diagnosis in emergencymedicine. Defined by the presence of fluid in the middle earin the setting of an acute illness, AOM can be difficult todiagnose since as many as one-third of children with the condi­tion lack fever or ear pain. A bacterial pathogen is isolatedfrom the middle ear fluid of approximately two-thirds of chil­dren with AOM [30].

Bacterial pathogens include S. pneumoniae (25%-50%),nontypeable H. influenzae (15%-30%), Moraxella catarrhalis(3%-20%), and (rarely) Streptococcus pyogenes and Staphylo­

coccus aureus. Approximately 20%-30% of H. influenzae iso­lates and 80% of M. catarrhalis isolates are ,B-Iactamase-pro­ducing.

Clinical resolution occurs in >90% of cases in which thereis bacterial eradication [31]. Clinical resolution also occurs inas many as two-thirds of treated cases in which the bacterialpathogen is not eradicated. Randomized controlled trials havedemonstrated an approximately 14% (95% CI, 8%-19%) over­all clinical-outcome advantage associated with the use ofantibi­otics vs. no antibiotic or placebo (respective absolute cure rates,95% vs. 81%) [32]. Unfortunately, it is impossible to clinicallydistinguish those patients whose illness will self-resolve fromthose who require therapy; therefore, antimicrobial treatmentis generally recommended for all cases of AOM.

Because of the preponderance of self-resolving bacterial andnonbacterial illness, for a study to demonstrate a 10% clinical-

outcome advantage of one antibiotic over another, >700 pa­tients with AOM would have to be enrolled (with an assumedsignificance level of0.05 and power of0.90). Most comparativetrials, such as those required by the U.S. Food and Drug Admin­istration for drug approval, include 100-200 patients. Not un­expectedly, these studies typically note the success of bothagents. The tendency of drugs with minimal antibacterial activ­ity to appear as clinically efficacious as more bacteriologicallyeffective drugs may lead to falsely optimistic results, a circum­stance referred to as the Pollyanna phenomenon [31].

Figure 2 summarizes the pooled outcome data for acutesymptomatic relief in 5,400 children with AOM evaluated incontrolled and comparative antibiotic trials [32]. Because of theinability to demonstrate consistent advantages of one antibioticover another, including broad-spectrum antimicrobials, stan­dard initial therapy for AOM is predicated on use of inexpen­sive, well-tolerated, and easily complied-with regimens ofagents such as amoxicillin, trimethoprim-sulfamethoxazole(TMP-SMZ), erythromycin/sulfisoxizole, and (recently ap­proved) azithromycin.

Other extended-spectrum antimicrobials (i.e., advanced-genera­tion cephalosporins and ,B-Iactam/,B-Iactamase-inhibitor antibiotics)are generally reserved for treatment failures. Recent research sug­gests that a single intramuscular dose of ceftriaxone may be aneffective therapeutic option that ensures compliance [33].

The present concern over DRSP does not justify a differentantibiotic approach [30]. This concept is based on the followinglogic: ~40% of AOM cases are due to S. pneunloniae, and if

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6 Talan em 1996; 23 (July)

one assumes that 20% of the isolates are intermediately orhighly resistant to penicillin and that -- 20% of these cases willclear spontaneously, then only --6%-7% of AOM-treatmentfailures will be due to DRSP. (Similar logic is employed tojustify the use of amoxicillin in cases where H. infiuenzae andM catarrhalis isolates are resistant.)

DRSP has emerged particularly among children with recur­rent otitis media and persistent effusions treated repetitivelywith ,8-lactam antibiotics. Shorter courses of therapy for somechildren with AOM and greater restraint in the administrationof antibiotics to children with persistent effusions and for pro­phylaxis of AOM have been suggested [34].

Acute bronchitis is characterized by productive cough inpatients without any underlying lung disease or evidence ofpneumonia or sinusitis. Surveys indicate that 50%-70% ofpatients with acute bronchitis will receive treatment with antibi­otics. However, there are descriptions in the literature of sevenrandomized placebo-controlled trials that demonstrated no con­sistent and important clinical benefit of antibiotics for healthyhosts with this acute condition [35, 36].

On the other hand, some evidence exists in support of treat­ment of acute exacerbations of chronic bronchitis. In a random­ized, double-blinded, crossover study of 173 patients>35 yearsof age for whom the clinical diagnosis was chronic obstructivepulmonary disease, 362 exacerbations were treated with eitherplacebo or antibiotic (doxycycline, TMP-SMZ, or amoxicillin)[37]. Resolution of symptoms within 21 days occurred in 68%of the antibiotic-treated group and 55% of the placebo-treatedgroup (P < .01).

Similarly, clinical deterioration was less frequent and peakflow measurements improved significantly faster in the antibi­otic-treated group. In light of these data and the diminishedrespiratory reserve of patients with chronic obstructive pulmo­nary disease, it is justifiable to treat acute exacerbations inthese patients with antibiotics.

The management of acute pharyngitis is an area of continuedcontroversy. While epidemiologic risk (i.e., for children 5-15years of age) and clinical correlates (i.e., fever, recent strepto­coccal exposure, pharyngeal exudate, tender cervical adenopa­thy, and absence of cough) of streptococcal etiology have beenidentified, no predictive model exists that reliably identifies orexcludes this entity in all individuals [38-40].

The practical "gold standard" for diagnosis, the routinethroat culture, has been questioned in light of certain factors.First is the recognition of asymptomatic carriers, symptomaticculture-positive nonseroconverters, and culture-negative sero­converters. In addition is the fact that the yield of group A ,8­hemolytic streptococci is greater with use of anaerobic culturemethods and in core tissue specimens [41-43].

Penicillin, in comparison with placebo, appears to statisti­cally speed recovery from symptoms of streptococcal pharyngi­tis by about I day; this effect is limited to culture-positivecases and particularly those in which the patients present within24 hours of onset of symptoms [44]. However, this benefit is

diminished when standard antipyretic and analgesic agents arealso employed [45].

The need for case identification and treatment has beenvariously emphasized and discounted on the basis of spo­radic outbreaks of rheumatic fever and increasing reportsof invasive streptococcal syndromes, as well as the generaldecline in the incidence of rheumatic fever. The standardestimate of incidence in the United States is one case ofacute rheumatic fever for every 400 untreated cases ofstreptococcal pharyngitis.

In the original studies that demonstrated the efficacy of intra­muscular penicillin for prevention of rheumatic fever, therapywas given empirically (i.e., not on the basis of culture results),and both streptococcal pharyngitis (occurring in 70%-80% ofcases) and rheumatic fever (occurring in 2%-3% of untreatedpersons) were epidemic [46, 47]. The relative cost/benefit ofempirical or directed therapy may be vastly different in nonepi­demic vs. epidemic conditions, considering the potential insen­sitivity of throat cultures and the fact that, in some outbreaksof rheumatic fever in the United States, the majority ofpatientshad no history of significant sore throat or had only mild symp­toms [48].

Investigators of cost-effectiveness models based on variousassumptions have not concluded that there is a single bestapproach, but the models suggest that (1) clinical rules mayhelp identify a low-risk group (i.e., cases among which theprevalence of a streptococcal etiology is <5%), for whomtesting and treatment may be unnecessary, (2) the major advan­tage to testing is avoidance of adverse drug reactions, and (3)the cultures are less helpful for patients unlikely to appear forfollow-up [49-51].

Many emergency department patients do not have a continu­ing care physician and tend to be unreliable with regard tofollow-up. Therefore, rapid antigen detection testing, whichgenerally has high specificity (compared to that of routine cul­tures), would be potentially useful if it also had high sensitivity.Unfortunately, the sensitivity of current testing techniques isquite variable and in this setting has been exceptionally low(55%) [52].

The use ofpenicillin as the standard therapy for streptococcalpharyngitis has been challenged. Numerous reports have indi­cated relatively high bacteriologic failure rates with use ofpenicillin and the superiority of cephalosporins. However, itdoes not appear that penicillin's in vivo efficacy has diminishedover time, and careful studies with strain serotyping suggestthat the relative benefit of cephalosporins is small [53, 54].

In light of these many controversies, practical managementin the emergency department is empirical therapy based onthe patient's epidemiologic and clinical risk of streptococcalinfection and the local prevalence of rheumatic complications;cultures should be considered if the patient has mild symptomsand is likely to present for follow-up. Because of data sug­gesting some benefit of tonsillectomy or special antibiotic ther­apies (e.g., clindamycin) for patients with recurrent streptococ-

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em 1996;23 (July) Infectious Diseases/Emergency Medicine 7

cal pharyngitis, patients with frequent bouts of pharyngitisshould also have throat-swab specimens submitted for culture.

When no outbreak of rheumatic fever is occurring, patientswho have not had the condition and those who are at lowrisk of streptococcal etiology, such as adults with few clinicalcorrelates, should not be tested or treated. Penicillin remainsthe therapeutic mainstay. However, first-generation cephalo­sporins as well as macrolides and azalides are also reasonableoptions.

Outpatient Treatment of Inpatient Diseases: Pneumoniaand Pyelonephritis

The movement toward managed care has fostered furtherconsideration of cost-effective strategies and has led to thedevelopment of practice guidelines for the management of in­fectious diseases. Perhaps no one medical decision is moreimportant in this regard than whether to admit a patient to thehospital or to administer outpatient care. Whereas the costinvolved in the choice of an oral antibiotic may involve tensof dollars, effective outpatient management of would-be inpa­tients saves thousands of dollars.

Disposition decisions for infections such as pneumonia andpyelonephritis are routine in emergency practice. Recent out­comes-focused research has helped better predict outpatientsuccess and has provided data that challenge many previousnotions about the characteristics that mandate a need for hospi­tal admission.

A prospective cohort study of 280 adults with community­acquired pneumonia managed in emergency departments andmedical clinics identified risk factors associated with morbidcomplications and mortality among 170 patients who did nothave an indication for hospital admission (e.g., severe vitalsign abnormality, arterial hypoxemia, acute coexisting medicalproblem or laboratory abnormality, co-existent suppurative in­fection, or altered mental status) [55].

Independent predictors of a complicated course included ageof >65 years, presence of comorbidity or immunosuppressiveillness, temperature of >38.3°C, and an etiology associatedwith high risk (i.e., staphylococcal, gram-negative rod, aspira­tion, or postobstructive pneumonia). Approximately 90% ofthese patients had fewer than two risk factors and had infre­quent and generally minor complications (i.e., among themthere were no admissions to the intensive care unit and therewere no directly related deaths).

Another prospective study found that comorbidity, presumedaspiration etiology, multilobar involvement, history of lungdisease, and symptom duration of < I week or >4 weeks werepredictors of the need for hospitalization. Age was also associ­ated with morbidity; however, it correlated with comorbidity,which was a better predictor [56]. Although prospective ran­domized studies of inpatient vs. outpatient care have yet to becompleted, these data support broader consideration of outpa­tient management for patients with a stable home situation who

Table 3. Guidelines for outpatient treatment of community-acquiredpneumonia [57].

Age of <65 yearsAbsence of chronic lung disease or other compromising conditionsAbsence of clinical evidence (including high fever) and laboratory evidence

of severe sepsisWBC count of 4,000-30,000/mm3

Partial pressure (arterial) of O2 , >60 mm Hg; of CO2 , <50 mm Hg(while patient is breathing room air)

Chest radiograph shows ~ I lobe involved; no pleural effusionHematocrit, > 30%No suspicion of aspiration etiology

Patient able to take oral medicines and to comply with follow-up

are able to take oral medications and who are amenable toclose medical follow-up.

Table 3 indicates guidelines for outpatient management ofcommunity-acquired pneumonia in adults. Recommended oralagents for adults <60 years of age include erythromycin, clar­ithromycin, and azithromycin. For older patients, TMP-SMZ,a ,B-Iactam/,B-Iactamase inhibitor, or a second-generation ceph­alosporin is suggested [57].

In the past, cases ofacute uncomplicated pyelonephritis weremanaged in the hospital and treated with parenteral antibiotics.However, several studies have demonstrated that even moder­ate-to-severely ill but hemodynamically stable patients can beeffectively treated as outpatients [58-60]. In one prospectiveseries, initially 37% of patients had vomiting, 61% had nausea,and 23% had a temperature of ;?;38.8°C [60].

Emergency department strategies have included initial treat­ment with a parenteral dose of antibiotic (e.g., gentamicin,ceftriaxone, a fluoroquinolone, or TMP-SMZ), particularly forthose patients with nausea and vomiting, and extended observa­tion with concurrent fluid replacement and administration ofantiemetics and antipyretics.

My colleagues and I are currently conducting a multicenter,randomized, double-blind study to determine if, after adminis­tration of an optional parenteral antibiotic dose, outpatient treat­ment for 7 days with ciprofloxacin is as effective as the standard14-day treatment with TMP-SMZ for moderately-to-severely illnonpregnant women with acute uncomplicated pyelonephritis.

Acute pyelonephritis during pregnancy is standardly man­aged in the hospital. Recent studies suggest that stable pregnantwomen with otherwise uncomplicated acute pyelonephritis canbe treated successfully on an outpatient basis [61, 62]. In arandomized trial, 120 women with acute pyelonephritis whowere <24 weeks pregnant and were hemodynamically stablewere either treated as outpatients with two intramuscular injec­tions of ceftriaxone (initially and I day later), followed by 10days oftherapy with cephalexin, or were hospitalized to receiveintravenous cefazolin until they were afebrile for 48 hours andthen were discharged (and continued receiving therapy withcephalexin) [61].

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8 Talan CID 1996;23 (July)

The outpatient group received careful follow-up, includinghome nursing visits. Clinical and bacteriologic cure rates weresimilar; one preterm delivery occurred in the inpatient group.In the future, more cases of pyelonephritis in pregnant womenmay be treated outside the hospital.

Outcome data such as these do not exist with regard tooutpatient management of pediatric pneumonia and pyelone­phritis. Standard recommended criteria for hospitalization in­clude evidence of toxicity or severe organ dysfunction (e.g.,respiratory failure in the case of pneumonia), age of < 1 year,immunocompromise, and lack of a sufficiently supportive fam­ily environment [63].

Fever in the Intravenous Drug User

Injection-drug users are particularly frequent municipal emer­gency department patients with well-known medical complica­tions. Fever in these patients may be the sole manifestation ofminor illness or life-threatening infections such as endocarditis.The potential for occult serious infectionhas led to the recommen­dation to hospitalize all febrile injection-drug users [64].

A prospective study with follow-up of 283 febrile injection­drug users who presented to a public hospital emergency de­partment found that 180 (64%) had an initial clinically apparentmajor illness (i.e., pneumonia, cellulitis, or abscess) [65]. How­ever, of the 103 (36%) without apparent major illness, '" 10%had occult major illness, mostly endocarditis.

Clinical characteristics and physicians' assessments were in­sufficient to reliably distinguish occult major illness from minorillness. Therefore, unless adequate follow-up exists, hospital­ization of febrile injection-drug users during the wait for bloodculture results appears necessary.

"Prophylactic," or Expectant, Antibiotic Therapy forSkin and Soft-Tissue Wounds and Bites

Traumatic wounds pose a risk for infection, and a logicalconsideration is that antibiotics administered prophylacticallywill decrease this risk. Whereas true prophylaxis involves theadministration of antibiotics before a wound is contaminated,prophylaxis of traumatic wounds is to prevent contaminationfrom becoming clinical infection. Therefore, the better term insuch cases is expectant antibiotic therapy.

There have been numerous prospective, randomized, pla­cebo-controlled studies of expectant antibiotic therapy for vari­ous types of wounds, including simple lacerations, open frac­tures, and dog, cat, and human bites. To a great extent,definitive conclusions have not resulted from this research be­cause of methodological problems such as inadequate samplesize, uncontrolled wound care and closure techniques, inade­quate assessment ofpatients , compliance, high subject dropoutrates, and nonexplicit outcome measures. However, despitethese limitations, an expert consensus has emerged in someareas.

Expectant antibiotic therapy does not appear to be justifiedfor simple lacerations. A meta-analysis of seven randomizedcontrolled trials of expectant antibiotic therapy for nonbite lac­erations involving 1,701 patients found no benefit in antibioticuse; this conclusion held true for double-blinded studies, su­tured and hand wounds, and studies with purulent drainage asan infection criterion [66]. Patients with puncture wounds onthe plantar surface of the feet are at risk for both soft-tissue andbone infection, particularly due to Pseudomonas aeruginosa;however, no reports of prospective placebo-controlled trialshave been published. Fluoroquinolones, which would be a logi­cal consideration for therapy, are not currently approved foruse by children who frequently acquire these types of wounds.

There have been no large prospective studies of human bitewounds. However, one small trial of human bite wounds tothe hand demonstrated a significant benefit from parenteral andoral cephalosporins in comparison with placebo [67].

Particularlyfor clenched-fistinjuries, expectant (and empirical)antibiotics with activity against anaerobes, S. aureus, Eikenellacorrodens, and streptococci (e.g., a ,B-Iactam/,B-lactamase inhibi­tor such as ampicillin/sulbactam) would appear appropriate [68].

While several trials of expectant antibiotic therapy for dogbites have been performed, they have been greatly limited bythe methodological problems noted above. A meta-analysis ofeight randomized studies revealed a benefit from antibiotics(vs. placebo), with a relative risk of infection of 0.56 (95% CI,0.38-0.82; absolute risk of infection in treated vs. untreatedpatients, 9% vs. 16%) [69]. For most uncomplicated open bitewounds, antibiotics are unnecessary and thorough irrigationand debridement are sufficient.

Most authorities favor expectant antibiotic therapy for high­risk dog bite wounds (such as deep and puncture-type wounds,which are not amenable to good irrigation and debridement,and those involving bone, tendon, joint, hands, or feet) or dogbite wounds in immunocompromised hosts. Data for cat bitesare inadequate, although the approach to dog bites has beenextended to these generally high-risk wounds.

Therapy with antibiotics that are active against Pasteurellamultocida, streptococci, and ,B-Iactamase producers such asS. aureus and many anaerobes should be initiated as soonas possible. Ampicillin/sulbactam , cefoxitin, or agents with asimilar spectrum of coverage are recommended both for expec­tant and empirical therapy [66].

There have been several placebo-controlled trials of expec­tant antibiotic therapy for open fractures [70]. In one double­blind trial, therapy with cloxacillin or placebo was initiatedas soon as possible after injury and continued for 10 days(intravenously for the first 4 days and orally thereafter) [71].All patients' fractures were internally fixated. Despite the factthat the antibiotic group had more high-risk fractures (i.e.,grade 3, defined as segmental fractures, those with extensivesoft-tissue damage, or those with neurovascular injury), theinfection rate was significantly lower than that for the placebogroup: two (5%) of 43 vs. 12 (27%) of 44 (P < .05).

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em 1996;23 (July) Infectious DiseaseslEmergency Medicine 9

Therapy with parenteral antibiotics that are active againstS. aureus is indicated and should be given as soon as possibleafter the open fracture; some authorities recommend additionalcoverage against aerobic gram-negative bacilli for grade 3 frac­tures.

The optimal duration ofexpectant antibiotic therapy for vari­ous traumatic wounds is unknown. Because single-dose regi­mens have been shown to be effective for true surgical prophy­laxis and because established skin and soft-tissue infectionsgenerally are treated for 7-14 days, an intermediate durationsuch as 3- 5 days is generally recommended.

Communicable Disease Threats: Blood-Borne Pathogensand Tuberculosis

The frequent acute management of major trauma placesemergency personnel among the groups of health care workersat highest risk for exposure to blood and body fluids. At oneinner-city hospital in 1988, among 2,523 emergency depart­ment patients from whom excess serum samples were available,seropositivity for hepatitis B, hepatitis C, and HIV was 5%,18%, and 6%, respectively [72].

In 1989, a study of 3,400 patients at three pairs of inner-cityand suburban emergency departments in high-AIDS-incidenceareas in the United States revealed an HIV seroprevalence of4.1-8.9 cases per 100 at inner-city hospitals and of 0.2-6.1per 100 in suburban emergency departments. The HIV infectionstatus of 69% of the infected patients was unknown to theemergency department staff.

Blood contact per 100 procedures was estimated at 11.2instances for ungloved workers and 1.3 for gloved workers[73]. Consequently, the practice of universal precautions andimplementation of new infection control technologies in theemergency department is especially emphasized.

Coincident with increased numbers ofcases of HIV infectionand AIDS, tuberculosis has also emerged as a communicabledisease threat in the emergency department. During 1992 and1993, one public hospital emergency department reported that25 (31%) of 81 previously PPD-negative employees had con­verted to seropositivity [74].

A study of pulmonary tuberculosis at a large public hospitalrevealed that the majority of these patients were initially evalu­ated in the emergency department [75]. Often there was aprolonged time until patients were isolated in the emergencydepartment, and occasionally patients were admitted to noniso­lation ward beds. Not infrequently, HIV-infected patients withradiographic infiltrates not characteristic of tuberculosis (i.e.,diffuse infiltrates as opposed to cavitary or apical disease) wereadmitted to nonisolation areas for treatment of Pneurnocystis

carinii pneumonia, only to have tuberculosis diagnosed.A 1993-1994 study of 305 United States municipal, Veter­

ans Affairs, university-affiliated, and other large hospitals re­vealed that tuberculosis-isolation rooms fulfilling guidelines ofthe Centers for Disease Control and Prevention (CDC) existed

in only 20% of emergency departments [76]. Of those depart­ments without isolation rooms, high-efficiency particulate fil­tration and ultraviolet germicidal radiation were employed inonly 19% and 10%, respectively. Despite the lack of appropri­ately ventilated areas, sputum induction was performed in~50% of departments.

Emergency departments are now encouraged to screen fortuberculosis at the triage area. Those patients with risk factorsand suspicious symptoms should be given a mask and immedi­ately undergo chest radiography, and isolation should be expe­dited for those with suggestive findings. In addition, risky pro­cedures such as sputum induction should not be performed inemergency departments without adequate facilities (i.e., boothsor other enclosures meeting ventilation requirements for tuber­culosis isolation) [77]. Establishment of proper isolation areasand adherence to other CDC recommendations should occurin high-risk departments.

Emergency Department Surveillance and EmergingInfections: Lyme Disease and Infections Due to E. coli0157:H7, Human Herpesvirus 6, and Helicobacter pylori

The emergence of newly recognized infections has effectedthe management of several emergency department infectioussyndromes. Fluoroquinolones have been demonstrated to sig­nificantly shorten the duration of illness of patients with acutedomestically acquired diarrhea (by 1-3 days) in some trials,regardless ofthe presence of fecal leukocytes, culture-positivityfor enteric pathogens, or severity of disease [78-80]. Theseresults may reflect the inadequate predictive value of the stoolleukocyte test as well as the lack of sensitivity of stool cultures.

Benefit from fluoroquinolone use in travel-related diseasehas also been demonstrated [81]. Empirical antibiotic therapyfor severe, presumed bacterial diarrhea has been advocatedfor both children (with TMP-SMZ, particularly for suspectedshigellal and enteroinvasive E. coli infections) and adults (withfluoroquinolones) [82].

However, the emergence of E. coli 0157:H7 (as well asother Shiga- and Shiga-like toxin-producing species) hasraised concerns about empirical therapy because of associationsbetween antibiotic therapy and the subsequent development ofhemolytic-uremic syndrome [83-86]. Until this issue is clari­fied, empirical antibiotic use for presumed bacterial diarrheacannot be recommended without reservation, particularly forchildren < 10 years of age, who are at greatest risk of hemo­lytic-uremic syndrome.

In certain areas of the country, patients frequently presentto emergency departments following tick bites to seek antibiotictreatment for preventing the development of Lyme disease. Adouble-blinded, placebo-controlled trial conducted in an areaof endemicity for the disease (southeastern Connecticut) ran­domized 387 patients to receive amoxicillin (205 patients) orplacebo (182) [87]. Fifteen percent of 344 submitted ticks wereinfected with Borrelia borgdorferi, as determined by PCR.

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10 Talan em 1996;23 (July)

Erythema migrans developed in two placebo-treated patients,

and no late complications or asymptomatic seroconversions oc­curred. The risk of infection in the placebo-treated group was

1.2% (95% CI, 0.1%-4.1%) and was not significantly different

than that in the amoxicillin-treated group. Therefore, it was con­cluded that prophylactic antibiotic treatment is not warranted.These data are consistent with those from other, smaller studies.

However, conclusions regarding proper management are limited

by the insufficient power of existing studies to detect relatively

rare disease and treatment complications [88, 89].

A cost-effectiveness model demonstrated that the fewestdrug and disease complications and the lowest costs were asso­

ciated with the strategy of treating all tick-bite victims when

the probability of infection following a tick bite was >3.6%.

Antibiotic therapy was marginally favored at a probability of

1%-3.6% because ofprevention ofthe fewest major complica­tions [90]. Below a probability of infection of 1%, empirical

therapy did not appear warranted.Since the rate of infection in published studies appears to

be ~ 1% and the rate ofserious late sequelae may be even lower

than assumed in the previous analysis, routine prophylaxis fordeer-tick bites to prevent Lyme disease does not appear to be

indicated. Whether these conclusions change with recognition

of the newest tick-transmitted disease, ehrlichiosis, is unclear.

A significant proportion of febrile illnesses, including febrile

seizures, among children presenting to emergency departmentsappear to be due to the recently identified cause of roseola

infantum-human herpesvirus type 6 (HHV-6). Approxi­

mately 10% of children < 3 years of age presenting to anemergency department with acute febrile illness had primaryHHV-6 infection (i.e., viremia and seroconversion); HHV-6

infection accounted for 20% of cases involving infants 6-12

months of age [91]. HHV-6 appeared to be the etiologic agentof one-third of all febrile seizures in children <2 years of age.

In the past, patients with dyspepsia and presumed ulcer dis­ease were treated with an empirical course of antisecretorytherapy. It is now evident that treatment effective at eradicating

H. pylori results in significantly lower ulcer-recurrence ratesthan are achieved with acid suppression, a circumstance sug­gesting an important etiologic role for this emerging pathogen.A recent cost-effectiveness analysis compared the use ofempir­

ical therapy directed against H. pylori with empirical antisecre­

tory therapy, serological testing, and initial endoscopic strate­

gies for patients who were clinically suspected of having ulcer

disease that was not related to nonsteroidal antiinflammatory

drugs [92]. Antibiotic therapy alone was determined to be most

cost-effective.

Empirical therapy directed against H. pylori is recommended

for those with confirmed ulcers as well as those with a historyof confirmed ulcers and recurrent symptoms. This treatmentshould also be considered in place of Hj-receptor-blocker regi­mens for patients with symptoms suggestive of ulcer disease.

The CDC recently issued a strategic plan to address thethreat of emerging infections in the United States [93]. The

proposed strategies included the establishment of sentinel net­

works of laboratories and practitioners in various health care

environments, including emergency departments. Surveillanceand research of acute infectious presentations in at-risk popula­tions may be especially effective in this setting.

In 1995 the CDC issued two grants for cooperativeagreements in order to establish new sentinels; one was issued

to a group of 10 university-affiliated emergency departments

directed by Olive View-UCLA and the other to the Infectious

Diseases Society of America [94]. The establishment of these

sentinels represents an important opportunity for collaborationbetween the specialties of emergency medicine and infectious

diseases and for each discipline to learn from the other's unique

perspective in order to address the problem of emerging infec­

tious diseases.

Conclusions

In the future, there may be many new diagnostic and thera­

peutic modalities that change the nature of infectious disease

management in the emergency department. With the mounting

problem of resistance among community-acquired bacteria,

ways to limit broad use of empirical antibiotics to treat minor

infections or to prevent their rare major sequelae may need to

be reexamined. The development of rapid and accurate antigendetection tests such as polymerase and ligase chain reaction

may shift emergency department treatment from mostly empiri­

cal to a more pathogen-specific approach.If biological-response modifiers are indeed effective for

treatment of sepsis, it would be expected that their benefit

would be greatest if administered as soon as possible. Expedi­

tious diagnosis and initiation of these therapies may furtheremphasize the importance of this front line of medical care, as

we have seen in other areas, such as the use of thrombolytictherapy for acute myocardial infarction.

Finally, with the continued emphasis on cost-effectiveness,

the emergency department will likely be a pivotal area forinitiation of creative strategies to manage increasingly seriousinfections at home.

Acknowledgment

The author thanks Drs. Jerome O. Klein, Matthew B. Goetz,Ellie 1. C. Goldstein, Gregory J. Moran, Jerome R. Hoffman, andMichael A. Newdow for their review and suggestions in preparingthis manuscript.

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13

OFFICE OF CONTINUING MEDICAL EDUCATIONUCLA SCHOOL OF MEDICINE

This test affords you the opportunity to assess your knowl­edge and understanding ofthe material presented in the preced­ing clinical article, "Infectious Disease Issues in the Emer­gency Department," by David A. Talan, and to earn continuingmedical education (CME) credit.

The Office of Continuing Medical Education, UCLA Schoolof Medicine, is accredited by the Accreditation Council forContinuing Medical Education to sponsor continuing medicaleducation for physicians. The Office of Continuing MedicalEducation, UCLA School of Medicine, certifies that this contin­uing medical education activity meets the criteria for 1 credithour in Category I of the Physician's Recognition Award ofthe American Medical Association and the California MedicalAssociation Certificate in Continuing Medical Education.

To earn credit, read the State-of-the-Art Clinical Article care­fully and answer the following questions. Mark your answersby circling the correct responses on the answer card (usuallyfound toward the front of the issue), and mail the card afteraffixing first-class postage. To earn credit, a minimum scoreof 80% must be obtained.

Certificates of CME credit will be awarded on a per-volume(biannual) basis. Each answer card must be submitted within3 months of the date of the issue.

This program is made possible by an educational grant fromRoche Laboratories.

1. Non-toxic-appearing infants who are 1-3 months of ageand have a rectal temperature of >38°C should

A. all be admitted to the hospital and receive parenteralantibiotics.

B. be discharged to the home, solely on the basis of physi­cal examination.

C. undergo clinical and laboratory evaluations to deter­mine if they are at low risk for septic complicationsand, if so, may be discharged (with close follow-up).

D. receive oral or parenteral antibiotics and be followedup as determined by the care-givers.

2. The most common cause of occult bacteremia in children3-36 months of age is

A. Streptococcus pneumoniae.

B. Haemophilus injiuenzae.

C. Neisseria meningitidis.

D. Salmonella species.

3. The factor(s) found most responsible for therapeutic delaysin cases of suspected bacterial meningitis presenting to theemergency department is/are

A. prolonged time spent in the waiting room.

B. diagnostic uncertainty for patients with nonspecific pre­sentations.

C. the withholding of antibiotics when lumbar punctureis delayed and deferring antibiotic administration untilthe patient is admitted to the ward.

D. difficulty in performing lumbar puncture.

4. The high rate of clinical cure of acute otitis media inchildren treated with amoxicillin, despite resistance ofmany middle-ear pathogens to this drug, is due to the

A. concentration of amoxicillin in the middle-ear fluid.

B. significant frequency of nonbacterial etiologies, self­resolving illness, and prominence of S. pneumoniae.

C. predominance of viral etiologies.

D. beneficial effect of co-administered decongestants.

5. Clinical studies support the use of oral antibiotics for thetreatment of

A. acute bronchitis.

B. acute exacerbations of chronic bronchitis.

C. both

D. neither

6. All of the following are predictors of a complicated courseof community-acquired penumonia except

A. advanced age.

B. presence of comorbidity or immunosuppressive illness.

C. aspiration etiology.

D. absence of fever.

7. Clinical studies suggest outpatient treatment of womenwith acute uncomplicated pyelonephritis can be successfulin cases involving

A. nonpregnant women.

B. pregnant women.

C. both

D. neither

8. Expectant antibiotic therapy is indicated for the followingtraumatic skin and soft-tissue wounds except

A. deep dog or cat bites to the hand.

B. simple nonbite lacerations.

C. open extremity fractures.

D. human bites from clenched-fist injuries.

9. When a patient presents to the emergency department withcommunity-acquired pneumonia, diagnostic sputum col­lection

A. should always be done in the emergency department.

B. should only be done within the isolation areas of theemergency department that meet CDC requirements.

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14 CME Test cm 1996;23 (July)

c. nearly always provides information that changes casemanagement.

D. is particularly important because of the emergence ofdrug-resistant S. pneumoniae.

10. Patients with tick bites who present for treatment to preventdevelopment of Lyme disease

A. should always be treated with antibiotics.

B. should not generally be treated with antibiotics.

C. should undergo a workup for cardiovascular complica­tions of Lyme disease.

D. should have serology performed for Lyme disease.

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