La saturation de la structure des urgences (SU) est un tueur silencieux. En effet, plusieurs auteurs dans différents pays ont décrit une augmentation de la mortalité, une diminution de la qualité des soins et un séjour hospitalier prolongé associés à la saturation de la SU. Les causes de la saturation sont multiples : l'organisation de l'amont et en particulier l'accès pour la médecine de ville aux examens complémentaires et aux hospitalisations, l'organisation de la SU et les tâches inutiles ou chronophages et l'organisation de l'aval en particulier la disponibilité en lits d'hospitalisation pour les malades non programmés. La principale cause de saturation de la SU est l'attente de lits disponibles dans les unités, appelé « boarding ». Les solutions pour résoudre ce boarding sont organisationnelles et nécessitent une coopération de l'ensemble de l'établissement à travers un bed management efficace et l'implication de tous les acteurs. Les patients polypathologiques et ceux pour lesquels sont intriquées des difficultés sociales sont souvent les patients qui attendent le plus longtemps en SU. La médecine interne, de par son expérience et son savoir-faire, est la discipline idéale pour ces patients complexes qui nécessitent du temps d'observation et d'évaluation. Un partenariat entre SU et médecine interne pourrait concourir à diminuer la saturation de la SU en améliorant les parcours de soins.Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

319 children with clinical data indicating a probably severe bacterial infection were randomly studied during 9 months in 33 French center. They were treated either with a single daily injection of ceftriaxone at 50 mg/kg/d (100 mg/kg/d for meningitis or typhoid fever) or with 3 to 4 injections of cefotaxime at 100 to 200 mg/kg/d. An aminoglycoside or an imidazole compound could be used as associated therapy according to the severity of infection as well as ampicillin in neonates. The clinical severity criteria and the biological parameters (PCR) were assessed before antibiotic treatment. 233 cases were selected for the comparative study: 22 new-borns, 117 infants, 94 children. 118 were given ceftriaxone and 115 cefotaxime. The infections were documented for 221/233 patients (95 %): E. coli (54 %). H. influenzae (14 %). N. meningitidis (6 %), Proteus mirabilis (3,5 %), S. pneumoniae (6 %), Streptococci (2.6 %). Pseudomonas (2.2 %) Enterobacter (1.7 %). Salmonella typhi (6.7 %). miscellaneous (3.3 %). The infections treated were pyelonephritis (131), meningitis (36), septic fever (35), and other infections (31). The groups were comparable in age and sex. Results showed no difference for efficacity or bacterial eradication, in any pathology. Tolerance was excellent for the two groups, adverse reactions were rare: 9 for the ceftriaxone group, 10 for the cefotaxime group (no significant difference). The total dose (mg/kg x days of treatment) of cefotaxime was three time higher than the total dose of ceftriaxone used. This trial stressed thr easier management and the potential lower cost of ceftriaxone, thanks to 3 single daily administration.