Hong Kong Journal of Emergency Medicine

Despite the paucity of supporting evidence, the use of antibiotics in the management of upper respiratory tract infections (URTI) remains a persistent and worrying trend worldwide. This survey study set out to examine the antibiotic prescribing profile of emergency physicians for patients diagnosed with URTI at a local tertiary hospital.

Patients seeking treatment for URTI at the emergency department in the year 2001 were identified by their ICD-9 code. The electronic medical records of a random sample of these patients were reviewed. Patients with the following documented findings were excluded: (a) a duration of more than 7 days between disease onset and date of consultation, (b) prior antibiotic usage or medical consultation, (c) presentation of purulent sputum and/or purulent nasal discharge, and (d) existing medical conditions requiring antibiotic treatment/prophylaxis. Chi-square and multivariate analyses were performed to assess the association of patient-related factors with antibiotic prescribing.

Of a random sample of 488 cases of URTI, inappropriate antibiotic prescribing was observed in 24% of cases (95% CI 20%, 28%). Significant associations were observed between antibiotic prescribing and month of consultation, patients' temperature and symptom of rhinorrhoea.

A substantial proportion of emergency department patients with URTI received antibiotics despite the lack of evidence supporting the drugs' effectiveness. Appropriate interventions to promote evidence-based prescribing amongst emergency physicians are required to reduce the extent of inappropriate antibiotic prescribing as well as to ensure the longevity of antibiotic effectiveness.

Urinary tract infection is a common problem in females encountered in the Accident & Emergency Department. The increasing prevalence of Escherichia coli and other urine isolates resistant to trimethoprim-sulfamethoxazole and ampicillin enhances the use of nitrofurantoin as the first line therapy. A guideline of 3-day antibiotic in presumed uncomplicated cystitis has been proved to be of improved cost-effectiveness.

To study the outcome and efficiency of 3-day antibiotic treatment in presumed acute uncomplicated cystitis in women in the Accident & Emergency Department.

This was a prospective study on women aged 18–55 years with presumed uncomplicated cystitis from January to June 2004. A telephone survey was conducted to assess the clinical response, adverse effect and compliance of the treatment.

Initially 83 patients were recruited in the study, but only 76 patients' outcomes could be traced by telephone survey and the computer system in public hospitals. Fifty-eight patients (76.3%) had good clinical response with symptoms resolved usually on day 2. Though 48.1% of the patients reported side effects with mainly gastrointestinal discomfort, most were mild and tolerable. The overall compliance was above 80%.

Three-day nitrofurantoin is an effective, inexpensive treatment for acute uncomplicated cystitis, which is a common disorder in females. Guidelines on the management of this large group of patients would help to conserve health care costs, improve compliance and reduce the emergence of resistance strains.

To characterise emergency department (ED) attendances for chronic obstructive airways disease (COAD) by patient demographics and severity, to determine treatment and disposition of patients and to determine use of diagnostic tests and treatment provided to different severity groups. A secondary aim was to compare treatment given to established treatment guidelines.

Prospective, observational cohort study of patients who presented to nine Australian ED with a primary diagnosis of acute exacerbation of COAD in October 2002. Information collected included demographics, duration of symptoms, co-morbidities, assessment findings, severity, treatment, disposition, tests, in-hospital mortality and length of stay.

A total of 137 patients were studied. Two-thirds (65%) of the group were male, and most (90%) were aged greater than 60 years. COAD severity was mild in 11%, moderate in 30% and severe in 59%, and 23% were receiving home oxygen therapy. As anticipated, patients with severe COAD were more likely to be admitted to hospital (mild: moderate: severe = 13%: 68%: 99%; p<0.0001) and to require ventilatory support (0%: 0%: 23%; p<0.002). There was under-utilisation of corticosteroids and antibiotics in the moderate and severe groups, and only 35% of the group had received influenza vaccination within the past year.

This study showed that adherence to best practice guidelines with respect to the use of corticosteroids and antibiotics for patients who presented to the ED with COAD was sub-optimal, as was the prevalence of prior influenza vaccination. Other aspects of treatment and investigation were consistent with available evidence. Efforts to address these deficiencies should be developed.

Pulmonary thromboembolism (PTE) still remains a diagnostic challenge to junior doctors working in emergency departments. Being aware of the condition and its associated risk factors can improve the diagnostic accuracy. Association between passenger travelling long-haul flight and PTE has been well documented; however its association with short-haul flight is very rare and controversial. This case report illustrates the possible linkages between short-haul air travel with the development of classic non-fatal PTE.

A young Indian gentleman after travelling four hours on a flight complained of progressive worsening of breathlessness when he arrived at Kuala Lumpur. Clinically he was tachypnoeic and tachycardiac. The electrocardiogram showed T inversion in leads III and aVF, and S wave in lead I. Oligaemia was shown on the chest X-ray and hypoperfused areas were seen on the spiral computed tomographic angiogram.

He was started on unfractionated heparin, switched to low molecular weight heparin, and then warfarin and subsequently admitted to the coronary care unit.

He was discharged well on day 7 after admission with warfarin and medical advice before returning to India.

Non-fatal PTE is at times difficult to diagnose and requires a high index of suspicion. Its association with healthy passengers of short-haul flight is not well established and this case report illustrates the possibility of linkages.