Prof Sun Keyu
Vice President, Minhang Hospital Affiliated to Fudan University
Leader of National Key Clinical Specialist Departments
Director, Emergency Department, Minhang Hospital Affiliated to Fudan University
Chief Physician and Master’s Student Supervisor at Fudan University
Secretary and Committee Member of the Emergency Medicine Division, Shanghai Medical Association
Secretary and Committee Member of the Emergency Department Physicians Branch, Shanghai Medical Doctor Association
Committee Member of the Emergency Medicine Division, Shanghai Association of Integrated Traditional Chinese and Western Medicine
Committee Member of the Infectious Diseases Group, Emergency Division, Shanghai Medical Association
Member of the On-site Rescue Expert Committee, Chinese Ageing Well Association

Introduction: The emergency department encounters significant challenges stemming from infectious diseases and continually strives to enhance its capabilities in diagnosis and treatment.

As frontline healthcare providers, the emergency department serves as the primary facility for promptly attending to patients in critical conditions. According to the 2020 National Health Statistics Yearbook, nationwide visits to emergency departments reached as high as 270 million, among which infectious diseases accounted for approximately 15% of these visits, thus emerging as one of the primary challenges for emergency departments.¹ In this issue, Yixuejie is privileged to invite Chief Physician Dr Sun Keyu, Vice President of Minhang Hospital Affiliated to Fudan University and Director of the Emergency Department at the same hospital, to join us in exploring strategies for addressing the current surge in infectious diseases within emergency departments.

Race Against Time: The Emergency Department’s Battle Against Death
As the frontline defence in the hospital, the emergency department bears the responsibility of managing the sudden onset of various infectious diseases. Dr Sun Keyu stated that the array of diseases and pathogens encountered in the emergency department is diverse, and the age range of patients is notably wider, distinguishing it from other specialised departments. Patients with infectious diseases in the emergency department typically present with severe and rapidly progressing conditions requiring urgent intervention. Therefore, the primary objective of treating infectious diseases in the emergency department is the swift containment of the infection and stabilisation of the patient’s condition.

To achieve this objective, emergency department doctors need to be equipped with advanced emergency response techniques and a comprehensive understanding of infection management to make precise diagnosis and effective treatment decisions under pressing situations. However, due to the complex nature of patients’ disease and resource constraints within the department, emergency department doctors often find it challenging to conduct immediate comprehensive pathogen analysis, further complicating the diagnostic process.

In addition, Dr Sun Keyu noted that the normalisation in the aftermath of the COVID-19 pandemic and the high incidence of influenza have intensified pressures on diagnosis and treatment in the emergency department. This strain is evident in the increased workload of healthcare professionals, leading to shortages in medical resources such as bed space, medical equipment, medication, and manpower. Consequently, the diagnosis process for patients is prolonged, causing inconvenience and anxiety for both patients and their families, while also aggravating the psychological burdens on doctors and patients, further deepening the existing conflicts between them.

In the face of these formidable challenges, Dr Sun Keyu proposes a multifaceted strategy for the emergency department, advocating for collaboration with various stakeholders to navigate these turbulent times together. First and foremost, it is a need to strengthen the control of hospital-acquired infections, which is a critical public healthcare issue. Pathogens causing hospital-acquired infections mostly comprise Staphylococcus aureus and Bacillus, among others.² However, statistics reveal that up to 70% of such infections can be better controlled through improved prevention and control measures,³ including reinforcing training for healthcare professionals in infection control and prevention to elevate the department’s response to infectious diseases.

Secondly, the emergency department can enhance prevention efforts through public education initiatives, encouraging the public to undergo vaccinations and raising public awareness of health to mitigate infection risk. Furthermore, to optimize resource utilization, Dr Sun Keyu emphasised the importance of information sharing and collaboration with other departments to enhance diagnostic and treatment accuracy. Meanwhile, to alleviate patient and family anxieties, the emergency department should streamline workflows, prioritise key patient groups, and minimise waiting times to enhance treatment efficiency.

Wise Antibiotics Selection: Essential in Empirical Treatment Strategies
In the emergency department, a pivotal aspect of effectively controlling and treating infectious diseases lies in the timely and appropriate implementation of empirical treatment. In response to this, Dr Sun Keyu further elaborated on his principles regarding the selection of antibacterial medication.

First of all, emergency department doctors must refer to local antibiotic sensitivity monitoring reports or relevant guidelines to understand and familiarise themselves with the antibiotic susceptibility patterns of primary pathogens in the local area. Secondly, they must promptly  and effectively assess the patient’s condition and clinical presentation, identifying risk factors through attributes such as the patient’s age, gender, medical history, symptoms, physical examination findings and laboratory test results. These assessments helps determine the severity of their condition and predict possible pathogens for the infection, facilitating the selection of appropriate antibacterial medication.

For example, patients who are immunocompromised or have underlying conditions may require broad-spectrum antibacterial medications. Additionally, precise localisation of the infected area and targeted medication selection can enhance treatment precision and effectiveness.

Besides the empirical selection of antibacterial medication, Dr Sun Keyu emphasised that doctors must consider the effects and toxic side-effects of such medication, as well as the patient’s tolerance and history of allergies, when making treatment decisions. A comprehensive assessment of these factors is required to weigh out the pros and cons and make informed decisions.

The emergence of a new-generation fluoroquinolone drugs, exemplified by sitafloxacin, has equipped the emergency department with a powerful tool for emergency antimicrobial therapy. Sitafloxacin demonstrates excellent in vitro activity against a variety of bacteria, including Gram-positive, Gram-negative, anaerobic and atypical pathogens⁵. According to the National Antibacterial Drug Susceptibility Survey Study (2011–2022), sitafloxacin exhibits superior antibacterial activity against Pseudomonas aeruginosa and Escherichia coli compared to ciprofloxacin and levofloxacin.

Dr Sun Keyu also highlighted that sitafloxacin is currently the preferred medication for emergency patients with unknown aetiology, high-risk condition, or suspected severe infections, owing to its excellent antibacterial activity, high tissue penetration, superior pharmacokinetic profile, and proven tolerance and safety. Dr Sun Keyu also mentioned the oral administration and the longer half-life of sitafloxacin, enabling once-daily dosing. Tailored adjustments can also be made based on individual patient condition, which greatly reduces the medication burdens on both patients and doctors, leading to more efficient utilisation of manpower resources.

Meanwhile, Dr Sun Keyu emphasised the crucial role of expert clinical judgment in treatment decisions, stressing the need to consider individual patient conditions and local antibiotic susceptibility patterns. Consultation with infectious disease specialists or clinical pharmacists may be required to make comprehensive judgment and ensure the precision and effectiveness of antibacterial treatment.

Moreover, with the implementation of the national centralised procurement policies, innovator drugs have been replaced by generic drugs. Based on his clinical experience, Dr Sun Keyu outlined the differences between innovator and generic drugs.

Firstly, in terms of drug quality and the drug manufacturing process, innovator drugs are developed and manufactured by their original manufacturers with strict monitoring and control over their quality. In comparison, while the composition and effects of generic drugs are similar to that of innovator drugs, the manufacturing process and quality may differ. Secondly, in terms of support from research data, innovator drugs require extensive clinical trial data before market approval to validate their efficacy and safety. They must also undergo stringent review and assessment by professional regulatory authorities before approval can be granted. However, generic drugs are typically approved based on existing data from innovator drugs, hence their clinical trial data may be relatively limited.

Nevertheless, whether using innovator or generic drugs, it is imperative for both doctors and patients to adhere to objective data and assess the efficacy, safety, and indications of medications, and ensure that medications are administered at the correct dosage according to the prescribed treatment regimen.

Conclusion
In the current situation of post-COVID-19 normalisation, the high incidence of infectious diseases poses tremendous burdens and challenges for the emergency department. Healthcare personnel in the emergency department should prioritise both prevention and treatment. The emergence of sitafloxacin provides strong support for the treatment of infectious diseases in the emergency department. Meanwhile, emergency department doctors should continually improve their professional competence and make comprehensive judgments to develop treatment plans that are more suitable for their patients.

References:
1. National Bureau of Statistics. 2020 China Health and Health Statistical Yearbook [R], 2020.

2. XIA J, GAO J, TANG W. Nosocomial infection and its molecular mechanisms of antibiotic resistance [J]. Biosci Trends, 2016, 10(1): 14-21.

3. CARTER E J, POUCH S M, LARSON E L. Common infection control practices in the emergency department: a literature review [J]. Am J Infect Control, 2014, 42(9): 957-62.

4. MORAN G. Approaches to treatment of community-acquired pneumonia in the emergency department and the appropriate role of fluoroquinolones [J]. J Emerg Med, 2006, 30(4): 377-87.

5. CHEN C K, CHENG I L, CHEN Y H, et al. Efficacy and Safety of Sitafloxacin in the Treatment of Acute Bacterial Infection: A Meta-analysis of Randomized Controlled Trials [J]. Antibiotics (Basel), 2020, 9(3).

6. LI Y, ZHENG B, XUE F, et al. China Antimicrobial Resistance Surveillance Trial (CARST) 2021–2022: Gram-negative Bacteria Surveillance Report [J]. Chinese Journal of Clinical Pharmacology, 2023, 39(23): 3525-44.