Patients with Bacteraemia Discharged from the Department of Emergency Medicine: Distribution of Organisms and Associated Characteristics

Introduction

Although blood cultures are commonly used to investigate febrile patients presenting to an emergency department, treatment decisions usually have to be made before the results are available.

Methods

We performed a retrospective analysis of consecutive patients presenting with community-acquired bacteraemia at the emergency department of Nambour Hospital, Queensland, Australia between 2000 and 2008. We determined their clinical characteristics, the distribution of organisms and also assessed patient characteristics associated with discharge from the emergency department.

Results

A total of 885 patients with 915 presentations of community-acquired bacteraemia were included. While having bacteraemia, 33 patients (3.6%) were discharged from the emergency department. Age, mode of presentation, altered mental state, presence of immunocompromise, presence of respiratory distress, C reactive protein, Charlson score, age score and estimated 10 years survival were significant factors discriminating the admitted from discharged patients. The most commonly found organism in blood cultures of discharged patients was Staphylococcus aureus (27.3%), whereas in admitted patients it was E. coli (27.7%). Methicillin-resistant Staphylococcus aureus accounted for 1.7% of cases of community-acquired bacteraemia.

Conclusions

Emergency physicians only rarely discharge patients with community-acquired bacteraemia using current assessment tools and decision-making rules. However, they tend to discharge younger self-presenting patients with good baseline function.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Coccidioidomycosis in returned Australian travellers

Coccidioidomycosis is a fungal infection caused by Coccidioides species. The disease has wide clinical presentation and a distinct geographical distribution. We describe two cases of coccidioidomycosis in returned Australian travellers who presented to Nambour Hospital. Knowledge of the international geographical distribution of endemic fungal infections and their clinical manifestations can assist in earlier diagnosis and appropriate management.

Osteomyelitis due to Mycobacterium haemophilum in a patient with AIDS

A case of osteomyelitis resulting from infection with Mycobacterium haemophilum in a patient with the Acquired Immunodeficiency Syndrome (AIDS) and Hodgkin's disease is described. The clinical features and response to therapy are examined and compared to previous reported cases. Mycobacterium haemophilum infection in immunocompromised patients usually results in cutaneous lesions but osteomyelitis may be the presenting feature. Tissue samples should be obtained early for microbiological examination and treatment should consist of surgical debridement and appropriate antimicrobial therapy.

Medullary thyroid carcinoma

Medullary thyroid carcinoma is an infrequent and unusual malignancy. Since its description 15 years ago, many new features have developed. Many biologically active compounds which are directly related to the different symptoms of the disease have been recovered from the tumors. A familial incidence is noted, and there is an increased association with other tumors and their behavior. The cell of origin is the parafollicular cell, which secretes calcitonin and is responsible for the unusual behavior of medullary thyroid carcinoma. Treatment is primiarily surgical. Four cases are presented and the syndrome reviewed.