Infection control and antibiotic prescribing have been high on the list of priorities for clinicians working in acute medicine over recent years. Concerns about antibiotic resistance have encouraged many hospital-based and speciality society guidelines to take a broad spectrum approach to the septic patient. However, this approach risks exacerbating the problems of resistance and increasing the incidence of Clostridium Diffi cile diarrhoea, particularly amongst our elderly patients. Finding the appropriate balance is a key priority for physicians working at the hospital’s ‘front door’. Three of our review articles highlight some of the issues involved in this area. In an extensively researched review, Lille and Barlow provide a microbiological perspective on the topic of antibiotic resistance. Their approach suggests a mechanism for risk assessment in relation to the likelihood of antibiotic resistance, while the results of cultures are awaited. Although most hospitals have their own specifi c prescribing guidelines, the algorithms in this article should provide a useful reference guide. Two other reviews deal specifi cally with issues around management of acute respiratory illness. Distinction between community acquired pneumonia (CAP) and exacerbation of COPD remains a signifi cant area of confusion in relation to antibiotic prescribing. Inappropriate use of CAP severity scoring for patients with COPD frequently leads to over-use of intravenous antibiotics, for a condition which is often non-infective in origin. The medical complications of cocaine use are not as common a cause of hospital admission as pneumonia or COPD. However, the increasing recreational use of this drug, highlighted in the review by Irvine and Penston, requires that acute physicians are familiar with its consequences and their treatment. Cardiac-type chest pain and arrhythmias are the most likely complications to present on the acute medical take, but pneumothorax and pneumomediastinum are also well recognised. Consideration of cocaine as a cause for ST segment elevation is important, given that thrombolysis is generally contraindicated; pressure to administer thrombolytic drugs within 30 minutes for patients with STEMI requires that the appropriate questions are asked at the time of admission. Issues around acute medicine training and the interface with emergency medicine continue to cause controversy. In an article submitted in response to a Viewpoint article published last year, Gallitelli and colleagues imply that the approach in Italy is progressing towards the development of combined training in acute and emergency medicine. Although the development of Acute Care Common Stem rotations in the UK may suggest a step in a similar direction, there remains a need to fi nd ways in which specialist trainees in both areas can work more closely together to attain necessary competencies in management of acutely unwell adults.
Acute and General Medicine on Opposite Sides of the World