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