Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople)

Location planning, resource reallocation and patient assignment during a pandemic considering the needs of ordinary patients

During the initial phase of a pandemic outbreak, the rapid increase in the number of infected patients leads to shortages of medical resources for both pandemic-related and non-pandemic (ordinary) patients. It is crucial to efficiently utilize limited existing resources and strike a balance between controlling the pandemic and sustaining regular healthcare system operations. To tackle this challenge, we introduce and investigate the problem of optimizing the location of designated hospitals, reallocating beds within these hospitals, and assigning different types of patients to these hospitals. Designated hospitals isolate pandemic-related patients from ordinary patients to prevent cross-infection. Moreover, isolation beds can be converted into ordinary beds and vice versa. Considering the stochasticity and evolving nature of the pandemic, we formulate this problem as a multi-stage stochastic programming model, integrating a compartmental model with time-varying random parameters to enable dynamic resource allocation as the pandemic progresses. The model is then solved by a data-driven rolling horizon solution approach. We illustrate the effectiveness of our model using real data from the COVID-19 pandemic. Compared with two other approaches, our model demonstrates superior performance in controlling the spread of the pandemic while addressing the needs of both pandemic-related and ordinary patients. We also conduct a series of experiments to uncover managerial insights for policymakers to better utilize existing resources in response to pandemic outbreaks. Results indicate that admitting as many pandemic-related patients as possible during the initial phases of the outbreak can effectively flatten the pandemic peaks and alleviate strain on the healthcare system.

Nosocomial COVID-19 infection in the era of vaccination and antiviral therapy

BACKGROUND AND AIMS

Coronavirus disease 2019 (COVID-19) vaccination and antiviral therapies have altered the course of the COVID-19 pandemic through mitigating severe illness and death. However, immunocompromised, elderly and multimorbid patients remain at risk of poor outcomes and are overrepresented in hospital populations. The aim of this study was to describe the characteristics and outcomes of patients with nosocomial COVID-19 infection.

METHODS

This was a retrospective, observational study of patients who acquired COVID-19 after 7 days of hospital admission within the Southern Adelaide Local Health Network (SALHN) in South Australia between 1 June 2022 and 30 November 2022. Data were ascertained from the electronic medical record and the South Australian registry of births, deaths and marriages.

RESULTS

Of 1084 COVID-19 inpatient cases managed in SALHN, 295 (27%) were nosocomial, with 215 included in the study. The median age of patients was 80 years (interquartile range [IQR], 68-88 years), the median Charlson Comorbidity Index score was 5 (IQR, 4-7) and 6% were immunocompromised. Most nosocomial COVID-19 infections were of mild severity (81%). The 30-day all-cause mortality rate following COVID-19 infection was 6%, and, in most cases, a cause of death other than COVID-19 was recorded on the death certificate.

CONCLUSION

The majority of cases of nosocomial COVID-19 infection were mild, with a lower mortality rate than in earlier studies. This finding is likely attributable to immunity through vaccination and prior infection, early antiviral therapy and attenuated severity of the Omicron variant. The high proportion of nosocomial infections supports ongoing infection control measures.

Forensic Pathology and Legal Issues in COVID-19: Case Report and Literature Review

Autopsy investigations of deaths following nosocomial coronavirus disease 2019 (COVID-19) infection have enormous medical and social significance, as autopsies are essential for the correct statistical recording of COVID-19 deaths, presenting new lessons, which is important to policymakers and in the improvement of public health in general.  Our study is based on the presentation of a case of a road traffic accident involving an elderly 73-year-old female with a complication of nosocomial COVID-19 infection and death leading to forensic pathological investigation. This involved autopsy, histopathological examinations, and other tests, and highlighting the importance of medicolegal matters, including the legal and ethical practicalities encountered in healthcare. This article highlights the fact that patients who have sustained various traumatic injuries accompanied by nosocomial COVID-19 infection have higher risks of morbidity and mortality. The significance of the role of a Forensic Pathologist in dealing with the analysis of injuries and the performance of autopsies to determine the cause, mechanism, and manner of death. In addition, the important lesson of testing patients for COVID-19 more regularly during a long hospital admission period, to offer early treatment and isolation, including avoiding the further spread of the COVID-19 infection variants to patients and healthcare professionals, thereby minimising and preventing hospital-acquired infection and death is stressed.

A Bayesian approach to identifying the role of hospital structure and staff interactions in nosocomial transmission of SARS-CoV-2

Nosocomial infections threaten patient safety, and were widely reported during the COVID-19 pandemic. Effective hospital infection control requires a detailed understanding of the role of different transmission pathways, yet these are poorly quantified. Using patient and staff data from a large UK hospital, we demonstrate a method to infer unobserved epidemiological event times efficiently and disentangle the infectious pressure dynamics by ward. A stochastic individual-level, continuous-time state-transition model was constructed to model transmission of SARS-CoV-2, incorporating a dynamic staff-patient contact network as time-varying parameters. A Metropolis-Hastings Markov chain Monte Carlo (MCMC) algorithm was used to estimate transmission rate parameters associated with each possible source of infection, and the unobserved infection and recovery times. We found that the total infectious pressure exerted on an individual in a ward varied over time, as did the primary source of transmission. There was marked heterogeneity between wards; each ward experienced unique infectious pressure over time. Hospital infection control should consider the role of between-ward movement of staff as a key infectious source of nosocomial infection for SARS-CoV-2. With further development, this method could be implemented routinely for real-time monitoring of nosocomial transmission and to evaluate interventions.

Sarcopenic patients "get even": The impact of COVID-19 vaccination on mortality

BACKGROUND

Coronavirus Disease-2019 (COVID-19), driven by the SARS-CoV-2 virus, has disproportionately affected the elderly, with comorbidities like sarcopenia worsening prognosis. Considering the significant impact of RNA vaccines on survival rates in this population, our objective is to investigate the impact of vaccination on the survival of hospitalized elderly patients with COVID-19, considering the presence or absence of sarcopenia.

METHODS

Prospective study conducted on 159 patients aged>65 years from September 2021 to March 2022. Data about clinical and body composition, and mortality at 12-months after discharge were recorded. Sarcopenia was diagnosed according to the 2019 European Consensus criteria.

RESULTS

At the twelfth month post-discharge, vaccinated sarcopenic individuals exhibited a mortality risk similar to vaccinated non-sarcopenic individuals, and lower than unvaccinated non-sarcopenic patients. Cox regression analysis, adjusted for age, gender, comorbidity, functional and vaccinal status, showed that the presence of sarcopenia did not significantly impact the risk of death within 12-months post-discharge.

DISCUSSION

Vaccination emerges as a protective measure for sarcopenic patients, countering the potential adverse effects of sarcopenia on COVID-19 outcomes, underscoring the importance of immunization in the frail elderly with a call for meticulous monitoring of its benefits.

CONCLUSIONS

Our study represents the first attempt to analyze the vaccine's effect on survival in sarcopenic hospitalized older adults with COVID-19. The administration of vaccination to sarcopenic patients proves pivotal, as its omission could lead to notably unfavorable outcomes within this specific population.

Mortality amongst hospitalized COVID-19 cases by acquisition and pandemic wave in Wales, UK, February 2020-March 2022

BACKGROUND

Hospital populations are vulnerable to COVID-19, but the relative severity of hospital acquisition compared to community is unknown. We investigated differences in mortality between hospital and community acquired cases in Wales.

METHODS

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction tests from February 2020 to March 2022 were linked with hospital admissions to identify likely hospital-acquired cases. All-cause mortality within 28 days of a positive SARS-CoV-2 were measured by source of acquisition. Multi-variable logistic regression was used to compare mortality by source of acquisition, adjusting for confounders, computing adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

There were 25,263 hospital-acquired cases of COVID-19 and 5490 (22%) deaths in the study period. Although significant on univariate analysis, adjustment for confounding showed no association with increased mortality for hospital-acquired cases compared with cases admitted with COVID-19 (aOR 0.8, 95% CI 0.7-0.8). Vaccination (aOR 0.6, 95% CI 0.5-0.7) and infection in later pandemic waves (aOR 0.5, 95% CI 0.4-0.6) were associated with lower mortality; older age (≥85 vs <25 years: aOR 76.4, 95% CI 41.8-160.5) and male sex (aOR 1.5, 95% CI 1.4-1.6) were associated with higher mortality.

CONCLUSION

One in five hospitalised COVID-19 cases died within a month of infection. Mortality in nosocomial cases was not worse than those admitted with COVID-19, possibly reflecting early identification of nosocomial cases through screening.

Microbiological profile of multidrug resistant bacteria before and during COVID-19 in CHU Mohammed VI

Background and Objectives

A new type of corona virus has caused Corona virus disease-19 and, subsequently, a global pandemic. All individuals are prone to the disease, so drastic measures were taken to prevent its spread. This study aimed to evaluate the impact of COVID-19 on the progression of the antimicrobial resistance rate by comparing two periods: before and during COVID-19.

Materials and Methods

We used a cross-sectional design to investigate the Antimicrobial Resistance (AMR) rate before (03/2019 to 03/2020) and during COVID-19 (03/2020 to 03/2021) in a University Hospital in Marrakech. The data were analyzed using SPSS Version 25.0.

Results

Among the 7106 specimens, there was a significant increase in the multidrug-resistant bacterial from 27.38% to 35.87% during COVID-19 (p<0.001), particularly in blood culture, cerebrospinal fluid, catheter, and pus. However, there was a non-significant change in puncture fluid, expectoration, protected distal sampling, joint fluid, stool culture, and genital sampling. A decrease in Multidrug-resistant bacteria (MDRB) was observed only in cytobacteriological urine tests (p<0.05). According to species, there was an increase in extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus.

Conclusion

In our study, it is particularly noticeable that the MDRB has increased. These results highlight the importance that the pandemic has not been able to slow the progression.

Retrospective Analysis of Nosocomial SARS-CoV-2 Infections in Orthopedic and Traumatological Inpatients

SARS-CoV-2 has had a measurable impact on the field of orthopedic and traumatological surgery. To date, scarce data on intramural SARS-CoV-2 infections in orthopedic and traumatological patients have been reported. Therefore, the aim of our study was to investigate the effect of nosocomial SARS-CoV-2 infections in orthopedic and traumatological inpatients regarding symptoms of infection, mortality, duration of hospitalization, and other relevant patient-dependent factors. Patients admitted to hospital for an orthopedic or traumatological indication were screened retrospectively for nosocomial SARS-CoV-2 infections and included in this study. An age-, sex-, and ICD 10-matched control group was assigned and demographic data, clinical symptoms of a SARS-CoV-2 infection as well as mortality, length of hospital stays, time to surgery, pre-existing conditions, LKF-points representing the financial effort, and the Charlson Comorbidity Index were collected. A significantly higher length of stay was observed in the SARS-CoV-2 group (25 days; 4-60; SD 12.5) when compared to the control group (11 days; 2-36; SD 7; p < 0.05). LKF points were significantly higher in the SARS-CoV-2 group (13,939 points vs. 8542 points). No significant difference in mortality could be observed. An infection with SARS-CoV-2 in inpatients significantly increases length of hospital stay and cost of treatment. Although no significant difference in mortality was found, care should be taken to avoid intramural SARS-CoV-2 infections, resulting in prolonged hospitalization, higher costs, and potentially further individual risks.

Clinical characteristics and outcomes of nosocomial COVID-19 in Turkey: A retrospective multicenter study

Objective:

To identify the clinical characteristics and outcomes of hospital-acquired SARS-CoV-2 infection during the vaccination period nationwide in Turkey.

Methods:

COVID-19 patients followed in the pandemic services across Turkey between January 1, 2021, and March 31, 2022 were investigated retrospectively. Nosocomial COVID-19 was defined as a patient neither diagnosed with COVID-19 nor suspected COVID-19 at the hospital admission and was confirmed COVID-19 ≥5 days after hospital admission. The primary outcome of this study was in-hospital mortality; demographic features and vaccination status was compared between survivors and non-survivors.

Results:

During the study period, 15 573 COVID-19 patients were followed in 18 centers and 543 (3.5%) patients were nosocomial COVID-19. Most patients with nosocomial COVID-19 (80.4%) were transferred from medical wards. 162 (29.8%) of the patients with nosocomial COVID-19 admitted to the intensive care unit due to disease severity and 138 (25.4%) of the patients died during hospital stay. Advanced age (≥65 years) and number of comorbid diseases (≥2) was found to be associated with mortality in nosocomial COVID-19 (OR 1.74, 95% Cl 1.11-2.74 and OR 1.60, 95% Cl 1.02-2.56, respectively). Vaccination was associated with survival in nosocomial COVID-19 (OR 0.25, 95% Cl 0.16-0.38).

Conclusions:

Patients with nosocomial COVID-19 had increased admission to intensive care units and higher mortality rate. Vaccination can decrease the in-hospital mortality rate.

Vaccine effectiveness and the epidemiological characteristics of a COVID-19 outbreak in a tertiary hospital in Republic of Korea

BACKGROUND

Healthcare facilities are high-risk sites for infection. This study analyzed the epidemiological characteristics of a coronavirus disease 2019 (COVID-19) outbreak in a tertiary hospital after COVID-19 vaccination had been introduced in Republic of Korea. Vaccine effectiveness (VE) and shared anti-infection strategies are also assessed.

METHODS

The risk levels for 4,074 contacts were evaluated. The epidemiological characteristics of confirmed cases were evaluated using the chi-square test. The "1 minus relative risk" method was used to determine VE in preventing infection, progression to severe disease, and death. In the largest affected area (the 8th floor), a separate relative risk analysis was conducted. A multivariate logistic regression analysis (with 95% confidence interval [CIs]) was used to identify transmission risk factors with a significance level <10% via the backward elimination method.

RESULTS

In total, 181 cases of COVID-19 were confirmed, with an attack rate of 4.4%. Of those cases, 12.7% progressed to severe disease, and 8.3% died. In the cohort isolation area on the 8th floor, where 79.0% of the confirmed cases occurred, the adjusted odds ratio was 6.55 (95% CI, 2.99-14.33) and 2.19 (95% CI, 1.24-3.88) for caregivers and the unvaccinated group, respectively. VE analysis revealed that 85.8% of the cases that progressed to severe disease and 78.6% of the deaths could be prevented by administering a second vaccine.

CONCLUSION

Caregiver training for infection prevention and control is necessary to reduce infection risk. Vaccination is an important intervention to reduce the risk of progression to severe disease and death.

Nosocomial COVID-19 at a comprehensive cancer center during the first year of the pandemic: Lessons learned

BACKGROUND

The spread of coronavirus disease 2019 (COVID-19) in health care settings endangers patients with cancer. As knowledge of the transmission of COVID-19 emerged, strategies for preventing nosocomial COVID-19 were updated. We describe our early experience with nosocomial respiratory viral infections (RVIs) at a cancer center in the first year of the pandemic (March 2020-March 2021).

METHODS

Nosocomial RVIs were identified through our infection control prospective surveillance program, which conducted epidemiologic investigations of all microbiologically documented RVIs. Data was presented as frequencies and percentages or medians and ranges.

RESULTS

A total of 35 of 3944 (0.9%) documented RVIs were determined to have been nosocomial acquired. Majority of RVIs were due to SARS CoV-2 (13/35; 37%) or by rhinovirus/enterovirus (12/35; 34%). A cluster investigation of the first 3 patients with nosocomial COVID-19 determined that transmission most likely occurred from employees to patients. Five patients (38%) required mechanical ventilation and 4 (31%) died during the same hospital encounter.

CONCLUSIONS

Our investigation of the cluster led to enhancement of our infection control measures. The implications of COVID-19 vaccination on infection control policies is still unclear and further studies are needed to delineate its impact on the transmission of COVID-19 in a hospital setting.

Clinical characteristics and outcomes of hospital-manifested COVID-19 among Brazilians

OBJECTIVES

To analyze the clinical characteristics and outcomes of admitted patients with the hospital- versus community-manifested COVID-19 and to evaluate the risk factors related to mortality in the first population.

METHODS

This retrospective cohort included consecutive adult patients with COVID-19, hospitalized between March and September 2020. The demographic data, clinical characteristics, and outcomes were extracted from medical records. Patients with hospital-manifested COVID-19 (study group) and those with community-manifested COVID-19 (control group) were matched by the propensity score model. Logistic regression models were used to verify the risk factors for mortality in the study group.

RESULTS

Among 7,710 hospitalized patients who had COVID-19, 7.2% developed symptoms while admitted for other reasons. Patients with hospital-manifested COVID-19 had a higher prevalence of cancer (19.2% vs 10.8%) and alcoholism (8.8% vs 2.8%) than patients with community-manifested COVID-19 and also had a higher rate of intensive care unit requirement (45.1% vs 35.2%), sepsis (23.8% vs 14.5%), and death (35.8% vs 22.5%) (P <0.05 for all). The factors independently associated with increased mortality in the study group were increasing age, male sex, number of comorbidities, and cancer.

CONCLUSION

Hospital-manifested COVID-19 was associated with increased mortality. Increasing age, male sex, number of comorbidities, and cancer were independent predictors of mortality among those with hospital-manifested COVID-19 disease.

Clinical Outcome and Prognosis of a Nosocomial Outbreak of COVID-19

Nosocomial coronavirus disease 2019 (COVID-19) outbreaks have been reported despite widespread quarantine methods to prevent COVID-19 in society and hospitals. Our study was performed to investigate the clinical outcome and prognosis of a nosocomial outbreak of COVID-19. We retrospectively analyzed the medical records of patients diagnosed with nosocomial COVID-19 of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) at a university teaching hospital between 1 November 2021 and 31 April 2022. Nosocomial COVID-19 was defined as a positive SARS-CoV-2 polymerase chain reaction (PCR) test result 4 or more days after admission in asymptomatic patients who had a negative SARS-CoV-2 PCR test on admission. In this study, 167 patients were diagnosed with nosocomial COVID-19 (1.14%) among a total of 14,667 patients admitted to hospital during the study period. A total of 153 patients (91.6%) survived, but 14 patients (8.4%) died. The median time between admission and COVID-19 diagnosis was 11 days, and the median duration of hospital stay was 24 days. After adjusting for other factors, no vaccination (adjusted HR = 5.944, 95% CI = 1.626–21.733, p = 0.007) and chronic kidney disease (adjusted HR = 6.963, 95% CI = 1.182–41.014, p = 0.032) were found to increase mortality risk. Despite strict quarantine, a significant number of nosocomial COVID-19 cases with a relatively high mortality rate were reported. As unvaccinated status or chronic kidney disease were associated with poor outcomes of nosocomial COVID-19, more active preventive strategies and treatments for patients with these risk factors are needed.

Same day discharge for robot-assisted radical prostatectomy: a prospective cohort study documenting an Australian approach

BACKGROUND

The introduction of robotic surgical systems has significantly impacted urological surgery, arguably more so than other surgical disciplines. The focus of our study was length of hospital stay - patients have traditionally been discharged day 1 post-robot-assisted radical prostatectomy (RARP), however, during the ongoing COVID-19 pandemic and consequential resource limitations, our centre has facilitated a cohort of same-day discharges with initial success.

METHODS

We conducted a prospective tertiary single-centre cohort study of a series of all patients (n = 28) - undergoing RARP between January and April 2021. All patients were considered for a day zero discharge pathway which consisted of strict inclusion criteria. At follow-up, each patient's perspective on their experience was assessed using a validated post-operative satisfaction questionnaire. Data were reviewed retrospectively for all those undergoing RARP over the study period, with day zero patients compared to overnight patients.

RESULTS

Overall, 28 patients 20 (71%) fulfilled the objective criteria for day zero discharge. Eleven patients (55%) agreed pre-operatively to day zero discharge and all were successfully discharged on the same day as their procedure. There was no statistically significant difference in age, BMI, ASA, Charlson score or disease volume. All patients indicated a high level of satisfaction with their procedure. Median time from completion of surgery to discharge was 426 min (7.1 h) in the day zero discharge cohort.

CONCLUSION

Day zero discharge for RARP appears to deliver high satisfaction, oncological and safety outcomes. Therefore, our study demonstrates early success with unsupported same-day discharge in carefully selected and pre-counselled patients.

Transmission dynamics and associated mortality of nosocomial COVID-19 throughout 2021: a retrospective study at a large teaching hospital in London

BACKGROUND

The impact of nosocomial SARS-CoV-2 infections has changed significantly since 2020. However, there is a lack of up-to-date evidence of the epidemiology of these infections which is essential in order to appropriately guide infection control policy.

AIMS

To identify the secondary attack rate of SARS-CoV-2 infection and associated mortality across different variants of concern.

METHODS

A single-centre retrospective study of all nosocomial SARS-CoV-2 exposure events was conducted between 31^st December 2020 and 31^st December 2021. A secondary attack rate was calculated for nosocomial acquisition of SARS-CoV-2 infection and time to positivity. Positive contacts were assessed for all-cause 30-day mortality.

RESULTS

A total of 346 sequential index exposure events were examined, and 1378 susceptible contacts identified. Two hundred susceptible contacts developed SARS-CoV-2 infection (secondary attack rate of 15.5%). The majority of index cases (59%) did not result in any secondary SARS-CoV-2 infection. Where close contacts developed SARS-CoV-2 infection, 80% were detected within the first five days since last contact with the index case. The overall associated mortality among positive contacts across 2021 was 9%, with an estimated reduction of 68% when comparing periods of high Omicron versus Alpha transmission.

CONCLUSION

Our findings describe that most SARS-CoV-2 infections are detected within five days of contact with an index case; we have also demonstrated a considerably lower mortality rate with the Omicron variant in comparison to previous variants. These findings have important implications for informing and supporting infection control protocols to allow movement through the hospital, and ensure patients access care safely.

Predictors of mortality in patients with COVID-19 infection in different health-care settings: A retrospective analysis from a CORACLE study group

BACKGROUND

Despite the large number of hospitalized patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, few data are available about risk factors and mortality in subjects with nosocomially acquired respiratory infection of Coronavirus Disease 2019 (COVID-19).

METHODS

We retrospectively evaluated in a multicentric study -during the pre-vaccination era-all patients admitted with confirmed diagnosis of nosocomial COVID-19 (NC). Patients were classified according to provenance: hospital-acquired NC or long-term care (LTC) facilities.

RESULTS

Among overall 1047 patients evaluated with COVID-19, 137 had a confirmed diagnosis of NC (13%). 78 (56.9%) patients had hospital-acquired NC and 59 (43%) had LTC NC. Overall mortality was 35.8%, in hospital-acquired NC 24.4%, in LTC NC 50.8% (p < 0.001) (Log Rank test: p = 0.001). Timing of diagnosis was significantly different between hospital acquired and LTC NC (3.5 vs 10 days, p < 0.001). In multivariate analysis age, intensive-care unit admission, LTC provenance and sepsis were significant predictors of mortality in patients with NC infection.

CONCLUSION

Patients with NC are at higher risk of mortality (especially for LTC NC) and required preventive strategies, early diagnosis, and treatment to avoid COVID-19 cluster.

The Italian policy of mandating SARS-CoV-2 vaccination for healthcare workers: Analysis of the policy processes and preliminary outcomes

BACKGROUND

Italy experienced the first outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Europe, and was among the most hardly hit European countries. Growing evidence suggests healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection. Infection in HCWs can lead to cross-transmission and increase community transmission. Italy was the first country in Europe to introduce mandatory vaccinations against SARS-CoV-2 for HCWs, on April 1, 2021.

AIM

To describe the policy processes and preliminary results of the introduction of compulsory vaccination against SARS-CoV-2 for HCWs in Italy.

RESULTS AND CONCLUSION

In Italy, the adoption of the policy was possible in the context of the public health and economic crisis resulting from the pandemic, with support from the scientific community and among favorable political conditions. Preliminary data suggest the policy has so far had a positive impact on increasing vaccine uptake and lowering infection rates among HCWs. Hopefully, the lack of serious vaccine-related adverse events and the growing evidence on vaccine effectiveness will progressively strengthen vaccine confidence among HCWs. In the context of a global pandemic, the Italian experience could provide insight for policymakers in other countries considering similar policies. Further, the ethical, legal, and policy challenges raised by the current public health emergency could be used to inform future pandemic preparedness plans.

How SARS-CoV-2 Infection Impacts the Management of Patients with Vulvar Cancer: Experience in a Third-Level Hospital of Southern Italy

Background: Since February 2020, the spread of Coronavirus Disease 2019 (COVID-19) in Italy has induced the government to call for lockdown of any activity apart from primary needs, and changing the lives of each of us. All that has dramatically impacted the management of patients affected by cancer. Patients with vulvar cancer (VC) represent a particularly frail population because they are elderly and affected by multiple comorbidities. The aim of this study is to evaluate the clinical impact of the SARS-CoV-2 infection on VC patients in terms of delay or impossibility of carrying out the scheduled treatment. Methods: The medical records of patients affected by vulvar tumors, referred to "DAI Materno-Infantile" of AOU Federico II of Naples between February 2020 and January 2022 were retrospectively analyzed. The presence of a positive reverse transcription-polymerase chain reaction (RT-PCR) in nasopharyngeal swab defined the positivity to SARS-CoV-2. Results: Twenty-four patients with VC were analyzed and scheduled for treatment. The median age was 70.7 years (range: 59-80). Seven (29.2%) patients were diagnosed with SARS-CoV-2 infection: In three (42.8%) patients, the treatment was delayed with no apparent consequences, in four (57.2%), the treatment was delayed or changed due to cancer progression and, of these four, one died due to respiratory complications of COVID-19, and one died due to oncologic disease progression. Conclusion: COVID-19 caused, in most cases, significant delays in oncologic treatments and high mortality in our series of patients affected by VC.

Nosocomial COVID-19: A Nationwide Spanish Study

INTRODUCTION

SARS-CoV-2 is a highly contagious virus, and despite professionals' best efforts, nosocomial COVID-19 (NC) infections have been reported. This work aimed to describe differences in symptoms and outcomes between patients with NC and community-acquired COVID-19 (CAC) and to identify risk factors for severe outcomes among NC patients.

METHODS

This is a nationwide, retrospective, multicenter, observational study that analyzed patients hospitalized with confirmed COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry) from March 1, 2020, to April 30, 2021. NC was defined as patients admitted for non-COVID-19 diseases with a positive SARS-CoV-2 test on the fifth day of hospitalization or later. The primary outcome was 30-day in-hospital mortality (IHM). The secondary outcome was other COVID-19-related complications. A multivariable logistic regression analysis was performed.

RESULTS

Of the 23,219 patients hospitalized with COVID-19, 1,104 (4.8%) were NC. Compared to CAC patients, NC patients were older (median 76 vs. 69 years; p < 0.001), had more comorbidities (median Charlson Comorbidity Index 5 vs. 3; p < 0.001), were less symptomatic (p < 0.001), and had normal chest X-rays more frequently (30.8% vs. 12.5%, p < 0.001). After adjusting for sex, age, dependence, COVID-19 wave, and comorbidities, NC was associated with lower risk of moderate/severe acute respiratory distress syndrome (ARDS) (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.59-0.87; p < 0.001) and higher risk of acute heart failure (aOR: 1.40; 1.12-1.72; p = 0.003), sepsis (aOR: 1.73; 1.33-2.54; p < 0.001), and readmission (aOR: 1.35; 1.03-1.83; p = 0.028). NC was associated with a higher case fatality rate (39.1% vs. 19.2%) in all age groups. IHM was significantly higher among NC patients (aOR: 2.07; 1.81-2.68; p < 0.001). Risk factors for increased IHM in NC patients were age, moderate/severe dependence, malignancy, dyspnea, moderate/severe ARDS, multiple organ dysfunction syndrome, and shock; odynophagia was associated with lower IHM.

CONCLUSIONS

NC is associated with greater mortality and complications compared to CAC. Hospital strategies to prevent NC must be strengthened.

COVID-19 among health care workers and their impact on the health care system in a teaching hospital in Pakistan: A cross sectional observational study

Background and Aims

Health care workers (HCWs) are thought to be high-risk population for acquiring coronavirus disease (COVID-19). The COVID-19 emergence has had a profound effect on healthcare system. We sought to investigate the COVID-19 among HCWs and their effects on the healthcare system.

Methods

A cross sectional observational study was conducted at Timergara teaching hospital. The study included HCWs with positive real time polymerase chain reaction (Q-PCR) for severe acute respiratory syndrome coronavirus (SARS-CoV-2). The study duration was from April to September, 2020. The demographic profile of each recruited subject was collected through structured interview. The patient's admissions to hospital were collected for the 5 months before (October 2019-February 2020) and 5 months after lockdown (March-July 2020).

Results

A total of 72 out of 689 (10%) HCWs were tested positive for SARS-CoV-2, of whom 83% were front-liners. The majority were male (72%), with comorbidities (14%) and no mortality. The structured interview of all participants showed that the healthcare setting was the major possible source of infection (97%). The patient admissions into the hospital were reduced by 42% during lockdown than prelockdown period. The patients admission was significantly decreased in the medical ward during lockdown (60% decrease; p < 0.01) with slightly similar trends in other departments.

Conclusion

In conclusion, we found increased risk of COVID-19 for front-line HCWs. Lack of mortality was the favorable outcome. Lack of replacing the infected HCWs possibly explained the marked decrease in hospital admissions, and potential inadequate healthcare delivery during the lockdown. Understanding SARS-CoV-2 among HCWs and their impact on health-care system will be crucial for countries under COVID-19 crises or in case of future pandemic to deliver proper health services.

Management of the Medico-Legal Dispute of Healthcare-Related SARS-CoV-2 Infections: Evaluation Criteria and Case Study in a Large University Hospital in Northwest Italy from 2020 to 2021

Healthcare-related SARS-CoV-2 infection is an issue of particular concern during the pandemic. It has important repercussions on the National Health System, which represents a source of medical-legal health disputes. In the healthcare context, there are reports of negative screening at hospital admission (via nasopharyngeal swabs) and subsequent diagnosis of SARS-CoV-2 infection during hospitalization. Such cases cannot be considered a priori of healthcare-related infections but require extensive in-depth evaluation. In this study, we propose an empirical classification to frame cases of SARS-CoV-2 infection diagnosed in the hospital (first negative admission swab, with subsequent positive test during hospitalization). The classification is based on five categories: nosocomial, probably nosocomial, indeterminate, probably community, and community cases. We analyzed patients who died after testing positive for SARS-CoV-2 during hospitalization (with initial negative screening) in the largest hospital in Northwest Italy from February 2020 to 31 December 2021. A total of 383 cases were tracked and are listed as follows: 41 cases (11%) were classified as nosocomial (i.e., 3.2% of COVID-19 deaths). In contrast, 71 cases (19%) were classified as probably nosocomial, 69 (18%) were indeterminate (i.e., the clinical, radiological, and laboratory characteristics did not provide information on the genesis of the infection), 166 (43%) were classified as probably community cases, and 36 (9%) were defined as community cases. Deceased patients with nosocomial SARS-CoV-2 infection constituted the following: 3.23% (41/1266) with respect to the total number of COVID-19 deaths, 1.1% (41/3789) with respect to those who entered the hospital with a negative swab and 0.82% (41/4672) with respect to the total of deaths from any cause of death. In this paper we discuss the topic and issues of nosocomial COVID-19 in hospitalized patients and address the medicolegal implications.

Nosocomial infection and spread of SARS-CoV-2 infection among hospital staff, patients and caregivers

BACKGROUND

There are difficulties in diagnosing nosocomial transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in hospital settings. Furthermore, mortality of cases of nosocomial infection (NI) with SARS-CoV-2 is higher than that of the general infected population. In the early stage of the pandemic in Taiwan, as patients were not tested for SARS-CoV-2 at admission, NIs often go undetected. Strictly applying the systematic polymerase chain reaction (PCR) screening, as a standard infection control measure was subsequently implemented to reduce NI incidence. However, evidence on risk factors for SARS-CoV-2 NIs among healthcare workers (HCWs) and caregivers is limited.

AIM

To assess NI incidence of SARS-CoV-2 among hospital staff, hospitalized patients, and caregivers, and the transmission routes of clusters of infection.

METHODS

This descriptive retrospective analysis at our hospital from May 15 to August 15, 2021 included data on 132 SARS-CoV-2 NIs cases among hospital staff, inpatients, and caregivers who previously tested negative but subsequently identified with a positive SARS-CoV-2 reverse transcriptase-PCR (RT-PCR) test results, or a hospital staff who tested positive following routine SARS-CoV-2 RT-PCR test. Chi-square tests were performed to compare the differences between hospital staff and private caregivers, and between clusters and sporadic infections.

RESULTS

Overall, 9149 patients and 2005 hospital staff members underwent routine SARS-CoV-2 RT-PCR testing, resulting in 12 confirmed cluster and 23 sporadic infections. Among the index cases of the clusters, three (25%) cases were among hospital staff and nine (75%) cases were among other contacts. Among sporadic infections, 21 (91%) cases were among hospital staff and two (9%) cases were among other contacts (P < 0.001). There was an average of 8.08 infections per cluster. The secondary cases of cluster infection were inpatients (45%), hospital staff (30%), and caregivers (25%). Private caregivers constituted 27% and 4% of the clusters and sporadic infections, respectively (P = 0.024); 92.3% of them were infected in the clusters. The mortality rate was 0.0%.

CONCLUSION

The incidence of SARS-CoV-2 infection was relatively high among private caregivers, indicating a need for infection control education in this group, such as social distancing, frequent hand-washing, and wearing PPE.

Hospital-acquired coronavirus disease 2019 (COVID-19) among patients of two acute-care hospitals: Implications for surveillance

OBJECTIVES

We quantified hospital-acquired coronavirus disease 2019 (COVID-19) during the early phases of the pandemic, and we evaluated solely temporal determinations of hospital acquisition.

DESIGN

Retrospective observational study during early phases of the COVID-19 pandemic, March 1-November 30, 2020. We identified laboratory-detected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) from 30 days before admission through discharge. All cases detected after hospital day 5 were categorized by chart review as community or unlikely hospital-acquired cases, or possible or probable hospital-acquired cases.

SETTING

The study was conducted in 2 acute-care hospitals in Chicago, Illinois.

PATIENTS

The study included all hospitalized patients including an inpatient rehabilitation unit.

INTERVENTIONS

Each hospital implemented infection-control precautions soon after identifying COVID-19 cases, including patient and staff cohort protocols, universal masking, and restricted visitation policies.

RESULTS

Among 2,667 patients with SARS-CoV-2, detection before hospital day 6 was most common (n = 2,612; 98%); detection during hospital days 6-14 was uncommon (n = 43; 1.6%); and detection after hospital day 14 was rare (n = 16; 0.6%). By chart review, most cases after day 5 were categorized as community acquired, usually because SARS-CoV-2 had been detected at a prior healthcare facility (68% of cases on days 6-14 and 53% of cases after day 14). The incidence rates of possible and probable hospital-acquired cases per 10,000 patient days were similar for ICU- and non-ICU patients at hospital A (1.2 vs 1.3 difference, 0.1; 95% CI, -2.8 to 3.0) and hospital B (2.8 vs 1.2 difference, 1.6; 95% CI, -0.1 to 4.0).

CONCLUSIONS

Most patients were protected by early and sustained application of infection-control precautions modified to reduce SARS-CoV-2 transmission. Using solely temporal criteria to discriminate hospital versus community acquisition would have misclassified many "late onset" SARS-CoV-2-positive cases.

Challenges in hospital-acquired coronavirus disease 2019 (COVID-19) surveillance and attribution of infection source

We performed surveillance for hospital-acquired COVID-19 (HA-COVID-19) and compared time-based, electronic definitions to real-time adjudication of the most likely source of acquisition. Without real-time adjudication, nearly 50% of HA-COVID-19 cases identified using electronic definitions were misclassified. Both electronic and traditional contact tracing methods likely underestimated the incidence of HA-COVID-19.

A Simulation-Based Cost-Effectiveness Analysis of Severe Acute Respiratory Syndrome Coronavirus 2 Infection Prevention Strategies for Visitors of Healthcare Institutions

OBJECTIVES

The aim is to quantitatively evaluate different infection prevention strategies in the context of hospital visitor management during pandemics and to provide a decision support system for strategic and operational decisions based on this evaluation.

METHODS

A simulation-based cost-effectiveness analysis is applied to the data of a university hospital in Southern Germany and published COVID-19 research. The performance of different hospital visitor management strategies is evaluated by several decision-theoretic methods with varying objective functions.

RESULTS

Appropriate visitor restrictions and infection prevention measures can reduce additional infections and costs caused by visitors of healthcare institutions by >90%. The risk of transmission of severe acute respiratory syndrome coronavirus 2 by visitors of terminal care (ie, palliative care) patients can be reduced almost to 0 if appropriate infection prevention measures are implemented. Antigen tests do not seem to be beneficial from both a cost and an effectiveness perspective.

CONCLUSIONS

Hospital visitor management is crucial and effectively prevents infections while maintaining cost-effectiveness. For terminal care patients, visitor restrictions can be omitted if appropriate infection prevention measures are taken. Antigen testing plays a subordinate role, except in the case of a pure focus on additional infections caused by visitors of healthcare institutions. We provide decision support to authorities and hospital visitor managers to identify appropriate visitor restriction and infection prevention strategies for specific local conditions, incidence rates, and objectives.

Consenting patients for elective procedures during the pandemic: Are we consenting for risk of nosocomial COVID-19 infection

Introduction: Nosocomial COVID-19 increases morbidity and mortality in patients undergoing surgical procedures. This study assesses the consenting process in patients admitted for surgical procedures with regard to risks of contracting nosocomial COVID-19 infection during the three lockdown periods in the United Kingdom.Methods: Retrospective review of consecutive surgical patients admitted to our tertiary referral centre for surgical procedures during the lockdown periods in the United Kingdom. Data from our hospital's electronic theatre database cross-referenced with the online surgical operative, admission and discharge records were reviewed by three independent reviewers.Discussion: A total of 180 patients (104 males and 76 females) were studied. No patients tested positive perioperatively for COVID-19. The first lockdown had a significantly larger proportion of consultants consenting (P < 0.001). Surgeons consented patients for risk of COVID-19 infection in 34.4% of cases, COVID-19-related illness in 33.9%, inpatient Intensive Care Unit (ITU) admission secondary to COVID-19 infection and risk of death due to COVID-19 in 0.0% and risk of death secondary to inpatient COVID infection in 1.1%.Conclusion: As surgical activity continues and COVID-19 persists, surgeons should be vigilant and ensure proper documentation for consent regarding COVID-19-related complications in line with the Royal College of Surgeons of England guidelines.

Investigation of healthcare-associated COVID-19 in a large French hospital group by whole-genome sequencing

OBJECTIVES

Despite the quick implementation of infection prevention and control procedures and the use of personal protective equipment within healthcare facilities, many cases of nosocomial COVID-19 transmission have been reported. We aimed to estimate the frequency and impact of healthcare-associated COVID-19 (HA-COVID-19) and evaluate the contribution of whole-genome sequencing (WGS) in cluster investigation.

METHODS

We estimated the frequency and mortality of HA-COVID-19 infections from September 1 to November 30, 2020, with a focus on the evolution of hospitalized community-associated COVID-19 (CA-COVID-19) cases and cases detected among healthcare workers (HCWs) within the Sorbonne University Hospital Group (Paris, France). We thoroughly examined 12 clusters through epidemiological investigations and WGS.

RESULTS

Overall, 209 cases of HA-COVID-19 were reported. Evolution of HA-COVID-19 incidence closely correlated with the incidence of CA-COVID-19 and COVID-19 among HCWs. During the study period, 13.9 % of hospitalized patients with COVID-19 were infected in the hospital and the 30-day mortality rate of HA-COVID-19 was 31.5 %. Nosocomial transmission of SARS-CoV-2 led to clusters involving both patients and HCWs. WGS allowed the exclusion of one-third of cases initially assigned to a cluster.

CONCLUSIONS

WGS analysis combined with comprehensive epidemiological investigations is essential to understand transmission routes and adapt the IPC response to protect both patients and HCWs.

COVID-19 Vaccine Uptake among Healthcare Workers: A Systematic Review and Meta-Analysis

The vaccine-induced immunity of healthcare workers (HCWs) is crucial to controlling the COVID-19 pandemic. Therefore, we conducted a systematic review and meta-analysis to assess the COVID-19 vaccine uptake among HCWs worldwide and to identify predictors of vaccination. We searched Scopus, Web of Science, Medline, PubMed, ProQuest, CINAHL, and medRxiv up to 25 August 2022. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We found 25 studies including 491,624 vaccinated HCWs, while the full sample included 555,561 HCWs. The overall proportion of vaccinated HCWs was 77.3%. Vaccine uptake for studies that were conducted in North America (85.6%) was higher than the proportion for studies that were conducted in Asia (79.5%), Europe (72.8%), and Africa (65.6%). The overall prevalence of COVID-19 vaccine uptake was 83.6% and 77.4% for physicians and nurses, respectively. Older age, white race, physicians' profession, seasonal influenza vaccine, direct COVID-19 patient care, and confidence in COVID-19 vaccine safety and effectiveness were positive predictors of vaccine uptake, while history of SARS-CoV-2 infection was a negative predictor. Deep understanding of the factors that influence HCWs' decisions to receive a COVID-19 vaccine is critical to implementing tailored communication strategies for HCWs who are at risk for not getting vaccinated.

State-controlled epidemic in a game against a novel pathogen

The pandemic reminded us that the pathogen evolution still has a serious effect on human societies. States, however, can prepare themselves for the emergence of a novel pathogen with unknown characteristics by analysing potential scenarios. Game theory offers such an appropriate tool. In our game-theoretical framework, the state is playing against a pathogen by introducing non-pharmaceutical interventions to fulfil its socio-political goals, such as guaranteeing hospital care to all needed patients, keeping the country functioning, while the applied social restrictions should be as soft as possible. With the inclusion of activity and economic sector dependent transmission rate, optimal control of lockdowns and health care capacity management is calculated. We identify the presence and length of a pre-symptomatic infectious stage of the disease to have the greatest effect on the probability to cause a pandemic. Here we show that contrary to intuition, the state should not strive for the great expansion of its health care capacities even if its goal is to provide care for all requiring it and minimize the cost of lockdowns.

Preventive measures significantly reduced the risk of nosocomial infection in elderly inpatients during the COVID-19 pandemic

In December 2019, there was an outbreak of pneumonia of unknown causes in Wuhan, China. The etiological pathogen was identified to be a novel coronavirus, named severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). The number of infected patients has markedly increased since the 2019 outbreak and COVID-19 has also proven to be highly contagious. In particular, the elderly are among the group of patients who are the most susceptible to succumbing to COVID-19 within the general population. Cross-infection in the hospital is one important route of SARS-CoV-2 transmission, where elderly patients are more susceptible to nosocomial infections due to reduced immunity. Therefore, the present study was conducted to search for ways to improve the medical management workflow in geriatric departments to ultimately reduce the risk of nosocomial infection in elderly inpatients. The present observational retrospective cohort study analysed elderly patients who were hospitalised in the Geriatric Department of the First Affiliated Hospital with Nanjing Medical University (Nanjing, China). A total of 4,066 elderly patients, who were admitted between January and March in 2019 and 2020 and then hospitalised for >48 h were selected. Among them, 3,073 (75.58%) patients hospitalised from January 2019 to March 2019 were allocated into the non-intervention group, whereas the remaining 933 (24.42%) patients hospitalised from January 2020 to March 2020 after the COVID-19 outbreak were allocated into the intervention group. Following multivariate logistic regression analysis, the risk of nosocomial infections was found to be lower in the intervention group compared with that in the non-intervention group. After age stratification and adjustment for sex, chronic disease, presence of malignant tumour and trauma, both inverse probability treatment weighting and standardised mortality ratio revealed a lower risk of nosocomial infections in the intervention group compared with that in the non-intervention group. To rule out interference caused by changes in the community floating population and social environment during this 1-year study, 93 long-stay patients in stable condition were selected as a subgroup based on 4,066 patients. The so-called floating population refers to patients who have been in hospital for <2 years. Patients aged ≥65 years were included in the geriatrics program. The incidence of nosocomial infections during the epidemic prevention and control period (24 January 2020 to 24 March 2020) and the previous period of hospitalisation (24 January 2019 to 24 March 2019) was also analysed. In the subgroup analysis, a multivariate analysis was also performed on 93 elderly patients who experienced long-term hospitalisation. The risk of nosocomial and pulmonary infections was found to be lower in the intervention group compared with that in the non-intervention group. During the pandemic, the geriatric department took active preventative measures. However, whether these measures can be normalised to reduce the risk of nosocomial infections among elderly inpatients remain unclear. In addition, the present study found that the use of an indwelling gastric tube is an independent risk factor of nosocomial pulmonary infection in elderly inpatients. However, nutritional interventions are indispensable for the long-term wellbeing of patients, especially for those with dysphagia in whom an indwelling gastric tube is the most viable method of providing enteral nutrition. To conclude, the present retrospective analysis of the selected cases showed that enacting preventative and control measures resulted in the effective control of the incidence of nosocomial infections.

Better cardioprotection in atrial septal defect patients treated with cardiopulmonary bypass beating heart technique without the application of aortic cross clamp

Background and objectives: Creatine phosphokinase-myocardial band fraction (CPK-MB) and cardiac troponin I (cTnI) are cardiac specific biochemical markers which are raised in myocardial ischemia. The aim of this study was to determine cardiac injury by comparing the levels of cardiac enzymes CPK-MB and cTnI in atrial septal defect (ASD) patients whose operative repair was done under cardiopulmonary bypass (CPB) using beating heart technique with and without the application of aortic cross clamp. Materials and Methods: This study was carried out in the Department of Cardiothoracic and Vascular Surgery in a Tertiary Care Hospital over a period of 2 years. A total of 60 atrial septal defect (ASD) patients were operated and repair of the defect was done under the CPB using beating heart technique. Aortic cross clamp was applied in 22 patients (Group-A) while 38 patients were operated without cross clamp (Group-B) during the procedure. Blood samples were collected 24 hours prior and 12 hours post procedure for the estimation of CPK MB and cTnI levels. Results: Mean age of the atrial septal defect patients was 23.83±10.97 years and 60% and 40% of the patients were females and children (age < 18 years) respectively. Serum CPK-MB and cTnI l levels were in the normal range in all the patients before surgery and increased significantly post procedure. Twelve hours after surgery, the mean CPK-MB and cTnI levels were significantly low in Group-B patients compared to Group-A patients (CPK-MB: 56.39±23.55 U/L vs. 34.38±15.97U/L , p= 0.0004; cTnI: 9.37±4.97 ng/ml vs. 5.92±4.17ng/ml, p = 0.009). Conclusion: Post surgery CPK-MB and cTnI levels were significantly higher in ASD patients who underwent CPB surgery with aortic cross clamp compared to those in whom aortic cross clamp was not applied. Therefore, application of aortic cross clamp during the procedure induces greater levels of ischemic injury to the heart. IMC J Med Sci. 2023; 17(1): 001. DOI: https://doi.org/10.55010/imcjms.17.001 *Correspondence: Feroze Mohammad Ganai, Department of CVTS, Superspeciality Hospital, Shireen Bagh, Srinagar, Jammu and Kashmir, India. Email address: ferose999@yahoo.com

Barriers to hand hygiene compliance in intensive care units during the COVID-19 pandemic: A qualitative study

BACKGROUND

The practice of hand washing is an effective way to prevent contamination and disease transmission. Following the COVID-19 pandemic, hand washing has become increasingly important. Therefore, this qualitative study aimed to understand barriers to hand hygiene compliance among healthcare workers during the COVID-19 pandemic.

MATERIALS AND METHODS

Twenty-five healthcare workers from intensive care units were sampled using purposive sampling in a qualitative content analysis study. Data were collected through a semi-structured interview and field notes. Based on the Lundman and Graneheim approach, the data were analyzed. COREQ checklist was used to report the research.

RESULTS

According to the findings, there are three main categories of barriers to hand hygiene practice: barriers related to individuals (including two subcategories of lack of knowledge of healthcare workers and healthcare workers' improper attitude), barriers related to management (including two subcategories of wrong behavioral patterns and unsuitable training and planning), and barriers related to organizations (including four subcategories of heavy workloads, improperly designed wards, a lack of equipment, and lack of quality equipment).

CONCLUSIONS

This research indicates that hand washing practice increased during the COVID-19 pandemic. Nevertheless, some barriers persist, resulting in a decline in hand washing compliance among health care workers. This finding can help managers and policymakers remove barriers to hand washing compliance and improve healthcare workers' adherence to hand washing.

Risk of air and surface contamination of SARS-CoV-2 in isolation wards and its relationship with patient and environmental characteristics

Air and surface contamination of the SARS-CoV-2 have been reported by multiple studies. However, the evidence is limited for the change of environmental contamination of this virus in the surrounding of patients with COVID-19 at different time points during the course of disease and under different conditions of the patients. Therefore, this study aims to understand the risk factors associated with the appearance of SARS-CoV-2 through the period when the patients were staying in the isolation wards. In this study, COVID-19 patients admitted to the isolation wards were followed up for up to 10 days for daily collection of air and surface samples in their surroundings. The positivity rate of the environmental samples at different locations was plotted, and multiple multi-level mixed-effect logistic regressions were used to examine the association between the positivity of environmental samples and their daily health conditions and environmental factors. It found 6.6 % of surface samples (133/2031 samples) and 2.1 % of air samples (22/1075 samples) were positive, and the positivity rate reached to peak during 2-3 days after admission to the ward. The virus was more likely to present at bedrail, patients' personal items and medical equipment, while less likely to be detected in the air outside the range of 2 m from the patients. It also revealed that higher positivity rate is associated with lower environmental temperature, fever and cough at the day of sampling, lower Ct values of latest test for respiratory tract samples, and pre-existing respiratory or cardiovascular conditions. The finding can be used to guide the hospital infection control strategies by identifying high-risk areas and patients. Extra personal hygiene precautions and equipment for continuously environmental disinfection can be used for these high-risk areas and patients to reduce the risk of hospital infection.

Establishing a Learning Model for Correct Hand Hygiene Technique in a NICU

The ability of healthcare workers to learn proper hand hygiene has been an understudied area of research. Generally, hand hygiene skills are regarded as a key contributor to reduce critical infections and healthcare-associated infections. In a clinical setup, at a Neonatal Intensive Care Unit (NICU), the outcome of a multi-modal training initiative was recorded, where objective feedback was provided to the staff. It was hypothesized that staff at the NICU are more sensitive towards applying increased patient safety measures. Outcomes were recorded as the ability to cover all hand surfaces with Alcohol-Based Handrub (ABHR), modelled as a time-series of measurements. The learning ability to rub in with 1.5 mL and with 3 mL was also assessed. As a secondary outcome, handrub consumption and infection numbers were recorded. It has been observed that some staff members were able to quickly learn the proper hand hygiene, even with the limited 1.5 mL, while others were not capable of acquiring the technique even with 3 mL. When analyzing the 1.5 mL group, it was deemed an insufficient ABHR amount, while with 3 mL, the critical necessity of skill training to achieve complete coverage was documented. Identifying these individuals helps the infection control staff to better focus their training efforts. The training led to a 157% increase in handrub consumption. The setting of the study did not allow to show a measurable reduction in the number of hospital infections. It has been concluded that the training method chosen by the staff greatly affects the quality of the outcomes.

Integration of Sequencing and Epidemiologic Data for Surveillance of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infections in a Tertiary-Care Hospital

BACKGROUND

The ongoing coronavirus disease 2019 pandemic significantly burdens hospitals and other healthcare facilities. Therefore, understanding the entry and transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is critical for effective prevention and preparedness measures. We performed surveillance and analysis of testing and transmission of SARS-CoV-2 infections in a tertiary-care hospital in Germany during the second and third pandemic waves in fall/winter 2020.

METHODS

Between calendar week 41 in 2020 and calendar week 1 in 2021, 40%, of all positive patient and staff samples (284 total) were subjected to full-length viral genome sequencing. Clusters were defined based on similar genotypes indicating common sources of infection. We integrated phylogenetic, spatial, and temporal metadata to detect nosocomial infections and outbreaks, uncover transmission chains, and evaluate containment measures' effectiveness.

RESULTS

Epidemiologic data and contact tracing readily recognize most healthcare-associated (HA) patient infections. However, sequencing data reveal that temporally preceding index cases and transmission routes can be missed using epidemiologic methods, resulting in delayed interventions and serially linked outbreaks being counted as independent events. While hospital-associated transmissions were significantly elevated at a moderate rate of community transmission during the second wave, systematic testing and high vaccination rates among staff have led to a substantial decrease in HA infections at the end of the second/beginning of the third wave despite high community transmissions.

CONCLUSIONS

While epidemiologic analysis is critical for immediate containment of HA SARS-CoV-2 outbreaks, integration of genomic surveillance revealed weaknesses in identifying staff contacts. Our study underscores the importance of high testing frequency and genomic surveillance to detect, contain and prevent SARS-CoV-2-associated infections in healthcare settings.

A retrospective cohort study of risk factors and outcomes in older patients admitted to an inner-city geriatric unit in London during first peak of COVID-19 pandemic

PURPOSE

Compared to younger patients, coronavirus disease 2019 (COVID-19) clinical presentation in older people can be more heterogeneous and fatal. We aim to describe a cohort of older adults admitted in an inner-city London hospital during the first peak of the pandemic.

METHODS

A retrospective observational study that enrolled older adults consecutively admitted into two geriatric wards with suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We collected socio-demographic data, comorbidities, symptoms at presentation and/or during admission, biochemical and radiological data and outcomes at 28 days.

RESULTS

One hundred twenty-four patients were included, and 75% were > 80 years old. 19.5% of COVID-19 cases were judged to be hospital-acquired. More than half presented or developed typical symptoms, respiratory failure or fatigue. 46.8% were diagnosed with delirium, 24.2% with falls and dysphagia was present in 13.7%. The mortality rate was 29.8% and was higher among males, those > 80 years, patients with a higher grade of frailty, a history of dementia or chronic kidney disease, as well as those diagnosed with respiratory failure, acute kidney injury or hypernatremia. Independent predictors of mortality were male sex, age > 80 years, respiratory failure and hypernatremia.

CONCLUSION

We have described a cohort of patients with SARS-CoV-2 infection in the first UK peak of the global pandemic. We found that these patients had significant frailty with multiple comorbidities. There was a high mortality and increased dependency and greater social care need in survivors.

Management strategy for control and prevention of SARS-CoV-2 infection in hospital settings - a brief review

The current pandemic of COVID-19 has spread worldwide rapidly. Many countries are struggling with the third pandemic wave despite having the vaccine distribution to frontline workers and people at high risk. Several studies have suggested a high possibility of hospital-acquired COVID-19. Therefore, it is vital to have proper recommendations and guidelines to prevent COVID-19 transmission in hospitals. Eliminating hospital-acquired infection is impossible, but reducing the rate and severity is possible by following appropriate guidelines. This paper reviews the strategies and recommendations that can be helpful for a hospital authority to control and prevent SARS-CoV-2 infection among the patients and healthcare workers. IMC J Med Sci 2022; 16(2): 006. DOI: https://doi.org/10.55010/imcjms.16.016 *Correspondence: Akash Ahmed, Department of Mathematics & Natural Sciences, BRAC University, Dhaka, Bangladesh. Email: akash.ahmed@bracu.ac.bd

Investigation of healthcare-associated SARS-CoV-2 infection: Learning outcomes from an investigative process in the initial phase of the pandemic

Background

Healthcare-associated (HCA) SARS-CoV-2 infection is a significant contributor to the spread of the 2020 pandemic. Timely review of HCA cases is essential to identify learning to inform infection prevention and control (IPC) policies and organisational response.

Aim

To identify key areas for improvement through rapid investigation of HCA SARS-CoV-2 cases and to implement change.

Methods

Cases were identified based on date of first positive SARS-CoV-2 PCR sample in relation to date of hospital admission. Cases were reviewed using a structured gap analysis tool to identify key learning points. These were discussed in weekly multidisciplinary meetings to gain consensus on learning outcomes, level of harm incurred by the patient and required actions. Learning was then promptly fed back to individual teams and the organisation.

Findings

Of the 489 SARS-CoV-2 cases admitted between 10^th March and 23^rd June 2020, 114 suspected HCA cases (23.3%) were reviewed; 58/489 (11.8%) were ultimately deemed to be HCA. Five themes were identified: individual patient vulnerability, communication, IPC implementation, policy issues and organisational response. Adaptations to policies based on these reviews were completed within the course of the initial phase of the pandemic.

Conclusion

This approach enabled timely learning and implementation of control measures and policy development.

Efficacy of Combining an Extraoral High-Volume Evacuator with Preprocedural Mouth Rinsing in Reducing Aerosol Contamination Produced by Ultrasonic Scaling

The coronavirus disease pandemic has afforded dental professionals an opportunity to reconsider infection control during treatment. We investigated the efficacy of combining extraoral high-volume evacuators (eHVEs) with preprocedural mouth rinsing in reducing aerosol contamination by ultrasonic scalers. A double-masked, two-group, crossover randomized clinical trial was conducted over eight weeks. A total of 10 healthy subjects were divided into two groups; they received 0.5% povidone-iodine (PI), essential oil (EO), or water as preprocedural rinse. Aerosols produced during ultrasonic scaling were collected from the chest area (PC), dentist's mask, dentist's chest area (DC), bracket table, and assistant's area. Bacterial contamination was assessed using colony counting and adenosine triphosphate assays. With the eHVE 10 cm away from the mouth, bacterial contamination by aerosols was negligible. With the eHVE 20 cm away, more dental aerosols containing bacteria were detected at the DC and PC. Mouth rinsing decreased viable bacterial count by 31-38% (PI) and 22-33% (EO), compared with no rinsing. The eHVE prevents bacterial contamination when close to the patient's mouth. Preprocedural mouth rinsing can reduce bacterial contamination where the eHVE is positioned away from the mouth, depending on the procedure. Combining an eHVE with preprocedural mouth rinsing can reduce bacterial contamination in dental offices.

Nosocomial COVID-19 Infection in a Long-Term Hospital in Spain: Retrospective Observational Study

Background and Objectives. The aim of this study is to compare clinical and epidemiological characteristics and outcomes in patients with versus without nosocomial COVID-19 after exposure to SARS-CoV-2 and to analyze the risk factors for severe outcomes of COVID-19 in a long-term hospital in Spain. Materials and methods. This retrospective, single-center observational study included all inpatients in a long-term hospital during a COVID-19 outbreak from 21 January to 15 March 2021. Results. Of 108 admitted patients, 65 (60.2%) were diagnosed with nosocomial COVID-19 disease (n = 34 women (52.3%), median age 77 years). In the univariable analysis, risk factors associated with nosocomial COVID-19 were dementia (OR 4.98 95% CI 1.58–15.75), dyspnea (OR 5.34 95% CI 1.69–16.82), asthenia (OR 5.10, 95% CI 1.40–18.60) and NECesidades PALiativas (NECPAL) (OR 1.28 95% CI 1.10–1.48). In the multivariable analysis, risk factors independently associated with nosocomial COVID-19 infection were dyspnea (aOR 7.39; 95% CI 1.27–43.11) and NECPAL (aOR 1.25; 95% CI 1.03–1.52). Of the 65 patients diagnosed with nosocomial COVID-19, 29 (44.6%) died, compared to 7/43 (16.2%) non-infected patients (OR 4.14, 95% CI 1.61–10.67). Factors associated with mortality in nosocomial COVID-19 were confusion (aOR 3.83; 95% CI 1.03–14.27) and dyspnea (aOR 7.47; 95% CI 1.87–29.82). The NECPAL tool played an important predictive role in both nosocomial COVID-19 infection and mortality (aOR 1.19, 95% CI: 1.00–1.41). Conclusions. In a long-term hospital, nosocomial COVID-19 main clinical characteristics associated with infection were dyspnea and NECPAL. Mortality was higher in the group with nosocomial COVID-19; risk factors were confusion and dyspnea. The NECPAL tool may help to predict progression and death in COVID-19.

COVID-19 Autopsies Reveal Underreporting of SARS-CoV-2 Infection and Scarcity of Co-infections

Coronavirus disease 2019 (COVID-19) mortality can be estimated based on reliable mortality data. Variable testing procedures and heterogeneous disease course suggest that a substantial number of COVID-19 deaths is undetected. To address this question, we screened an unselected autopsy cohort for the presence of SARS-CoV-2 and a panel of common respiratory pathogens. Lung tissues from 62 consecutive autopsies, conducted during the first and second COVID-19 pandemic waves in Switzerland, were analyzed for bacterial, viral and fungal respiratory pathogens including SARS-CoV-2. SARS-CoV-2 was detected in 28 lungs of 62 deceased patients (45%), although only 18 patients (29%) were reported to have COVID-19 at the time of death. In 23 patients (37% of all), the clinical cause of death and/or autopsy findings together with the presence of SARS-CoV-2 suggested death due to COVID-19. Our autopsy results reveal a 16% higher SARS-CoV-2 infection rate and an 8% higher SARS-CoV-2 related mortality rate than reported by clinicians before death. The majority of SARS-CoV-2 infected patients (75%) did not suffer from respiratory co-infections, as long as they were treated with antibiotics. In the lungs of 5 patients (8% of all), SARS-CoV-2 was found, yet without typical clinical and/or autopsy findings. Our findings suggest that underreporting of COVID-19 contributes substantially to excess mortality. The small percentage of co-infections in SARS-CoV-2 positive patients who died with typical COVID-19 symptoms strongly suggests that the majority of SARS-CoV-2 infected patients died from and not with the virus.

Patient-level and hospital-level variation and related time trends in COVID-19 case fatality rates during the first pandemic wave in England: multilevel modelling analysis of routine data

BACKGROUND

A report suggesting large between-hospital variations in mortality after admission for COVID-19 in England attracted much media attention but used crude rates. We aimed to quantify these variations between hospitals and over time during England's first wave (March to July 2020) and assess available patient-level and hospital-level predictors to explain those variations.

METHODS

We used administrative data for England, augmented by hospital-level information. Admissions were extracted with COVID-19 codes. In-hospital death was the primary outcome. Risk-adjusted mortality ratios (standardised mortality ratios) and interhospital variation were calculated using multilevel logistic regression. Early-wave (March to April) and late-wave (May to July) periods were compared.

RESULTS

74 781 admissions had a primary diagnosis of COVID-19, with 21 984 in-hospital deaths (29.4%); the 30-day total mortality rate was 28.8%. The crude in-hospital death rate fell in all ages and overall from 32.9% in March to 13.4% in July. Patient-level predictors included age, male gender, non-white ethnic group (early period only) and several comorbidities (obesity early period only). The only significant hospital-level predictor was daily COVID-19 admissions in the late period; we did not find a relation with staff absences for COVID-19, mechanical ventilation bed occupancies, total bed occupancies or bed occupancies for COVID-19 admissions in either period. Just 4 (3%) and 2 (2%) hospitals were high, and 5 (4%) and 0 hospitals were low funnel plot mortality outliers at 3 SD for early and late periods, respectively, after risk adjustment. We found no strong correlation between early and late hospital-level mortality (r=0.17, p=0.06).

CONCLUSIONS

There was modest variation in mortality following admission for COVID-19 between English hospitals after adjustment for risk and random variation, in marked contrast to early media reports. Early-period mortality did not predict late-period mortality.

Healthcare-associated COVID-19 outbreaks: a nationwide population-based cohort study

Background

Aim

Methods

Findings

Conclusion

Evaluation of Bi-Lateral Co-Infections and Antibiotic Resistance Rates among COVID-19 Patients

In addition to the pathogenesis of SARS-CoV-2, bacterial co-infection plays an essential role in the incidence and progression of SARS-CoV-2 infections by increasing the severity of infection, as well as increasing disease symptoms, death rate and antimicrobial resistance (AMR). The current study was conducted in a tertiary-care hospital in Lahore, Pakistan, among hospitalized COVID-19 patients to see the prevalence of bacterial co-infections and the AMR rates among different isolated bacteria. Clinical samples for the laboratory diagnosis were collected from 1165 hospitalized COVID-19 patients, of which 423 were found to be positive for various bacterial infections. Most of the isolated bacteria were Gram-negative rods (n = 366), followed by Gram-positive cocci (n = 57). A significant association (p < 0.05) was noted between the hospitalized COVID-19 patients and bacterial co-infections. Staphylococcus aureus (S. aureus) showed high resistance against tetracycline (61.7%), Streptococcus pyogenes against penicillin (100%), E. coli against Amp-clavulanic acid (88.72%), Klebsiella pneumoniae against ampicillin (100%), and Pseudomonas aeruginosa against ciprofloxacin (75.40%). Acinetobacter baumannii was 100% resistant to the majority of tested antibiotics. The prevalence of methicillin-resistant S. aureus (MRSA) was 14.7%. The topmost symptoms of >50% of COVID-19 patients were fever, fatigue, dyspnea and chest pain with a significant association (p < 0.05) in bacterial co-infected patients. The current study results showed a comparatively high prevalence of AMR, which may become a severe health-related issue in the future. Therefore, strict compliance of antibiotic usage and employment of antibiotic stewardship programs at every public or private institutional level are recommended.

Family caregiving during the COVID-19 pandemic: factors associated with anxiety and depression of carers for community-dwelling older adults in Hong Kong

Background

The COVID-19 pandemic disrupts the daily routine and increases the caregiving load of the family carers of older adults. This study examined how the pandemic may impact mental health and investigated the prevalence of anxiety and depressive symptoms in family carers of older people.

Methods

Two hundred and thirty-six family carers of older adults participated in this cross-sectional survey study. Outcome measures included their symptoms of anxiety and depression, pandemic-related psychosocial factors, external factors, and the practice of preventive behaviours.

Results

Caseness prevalence of anxiety and depression among family carers was 25 and 56% respectively. Working carers were more depressed than non-working, while younger carers reported more anxiety and depression symptoms than older. Hand hygiene and getting drugs from the hospital positively predicted depression while healthy lifestyle negatively predicted depression. These variables, together with perceived risk and severity and the worry of getting infected, predicted anxiety.

Conclusions

The prevalence of mental health symptoms was alarming. Telemedicine practice, including online pharmaceutical services and the Internet Hospital plus Drug Delivery platform, could be a solution in alleviating the burden and worry of infection of family carers. Tailored-made interventions by age and working status of the family carers are recommended.

Prognostic value of estimated glomerular filtration rate in hospitalised older patients (over 65) with COVID-19: a multicentre, European, observational cohort study

Background

The reduced renal function has prognostic significance in COVID-19 and it has been linked to mortality in the general population. Reduced renal function is prevalent in older age and thus we set out to better understand its effect on mortality.

Methods

Patient clinical and demographic data was taken from the COVID-19 in Older People (COPE) study during two periods (February–June 2020 and October 2020–March 2021, respectively). Kidney function on admission was measured using estimated glomerular filtration rate (eGFR). The primary outcomes were time to mortality and 28-day mortality. Secondary outcome was length of hospital stay. Data were analysed with multilevel Cox proportional hazards regression, and multilevel logistic regression and adjusted for individual patient clinical and demographic characteristics.

Results

One thousand eight hundred two patients (55.0% male; median [IQR] 80 [73–86] years) were included in the study. 28-day mortality was 42.3% (n = 742). 48% (n = 801) had evidence of renal impairment on admission. Using a time-to-event analysis, reduced renal function was associated with increased in-hospital mortality (compared to eGFR ≥ 60 [Stage 1&2]): eGFR 45–59 [Stage 3a] aHR = 1.26 (95%CI 1.02–1.55); eGFR 30–44 [Stage 3b] aHR = 1.41 (95%CI 1.14–1.73); eGFR 1–29 [Stage 4&5] aHR = 1.42 (95%CI 1.13–1.80). In the co-primary outcome of 28-day mortality, mortality was associated with: Stage 3a adjusted odds ratio (aOR) = 1.18 (95%CI 0.88–1.58), Stage 3b aOR = 1.40 (95%CI 1.03–1.89); and Stage 4&5 aOR = 1.65 (95%CI 1.16–2.35).

Conclusion

eGFR on admission is a good independent predictor of mortality in hospitalised older patients with COVID-19 population. We found evidence of a dose-response between reduced renal function and increased mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02782-5.

Hospital acquired COVID-19 infections amongst patients before the rollout of COVID-19 vaccinations, a scoping review

BACKGROUND

Hospital settings are at increased risk of spreading Coronavirus Disease 2019 (COVID-19) infections, hence non-pharmaceutical prevention interventions (NPPIs) and prioritized vaccination of healthcare workers and resident patients are critical. The status of COVID-19 hospital acquired infections (HAIs) in low-income settings is unclear. We aimed to identify and summarize the existing evidence on COVID-19 HAIs amongst patients, prior to the rollout of vaccines in countries worldwide.

METHODS

We conducted a scoping review of English peer-reviewed literature in PubMed, Web of Science and Scopus using a combination of selected search terms. Full texts articles presenting results on COVID-19 HAIs in hospitalised patients before the rollout of vaccines in countries worldwide were eligible. Data extracted from eligible articles included estimates of COVID-19 HAIs, country, and type of hospital setting, and was summarized narratively. Quality assessment of included articles was not possible.

RESULTS

Literature searches generated a total of 5920 articles, and 45 were eligible for analysis. Eligible articles were from Europe, North America, Asia, and Brazil and none were from low-income countries. The proportion of COVID-19 HAIs ranged from 0% when strict NPPIs were applied, to 65% otherwise. The estimates of COVID-19 HAIs did not differ by country but were lower in studies conducted after implementation of NPPIs and in specialized hospital settings for operative surgery. Studies conducted before the implementation of NPPIs or in long-term care and psychiatric wards often reported high estimates of HAI. Although there was no clear trend in general wards, those situated in academic hospitals managed to reduce HAI rates under strict NPPI protocols. Operative surgery settings, unlike psychiatric settings, effectively prevented COVID-19 HAI using tailored NPPIs.

CONCLUSION

The available evidence shows a high risk of COVID-19 HAIs, the feasibility of preventing HAIs in different healthcare settings and the importance of appropriately tailored NPPIs. There were no data from low-income settings, therefore, it is unclear whether the reported NPPI approaches could be equally effective elsewhere. We recommend routine monitoring of COVID-19 HAIs in countries with low vaccination coverage, to identify and close gaps in NPPIs and understand gains made from vaccinating healthcare workers and hospitalized patients.

Descriptive comparison of admission characteristics between pandemic waves and multivariable analysis of the association of the Alpha variant (B.1.1.7 lineage) of SARS-CoV-2 with disease severity in inner London

BACKGROUND

The Alpha variant (B.1.1.7 lineage) of SARS-CoV-2 emerged and became the dominant circulating variant in the UK in late 2020. Current literature is unclear on whether the Alpha variant is associated with increased severity. We linked clinical data with viral genome sequence data to compare admitted cases between SARS-CoV-2 waves in London and to investigate the association between the Alpha variant and the severity of disease.

METHODS

Clinical, demographic, laboratory and viral sequence data from electronic health record systems were collected for all cases with a positive SARS-CoV-2 RNA test between 13 March 2020 and 17 February 2021 in a multisite London healthcare institution. Multivariate analysis using logistic regression assessed risk factors for severity as defined by hypoxia at admission.

RESULTS

There were 5810 SARS-CoV-2 RNA-positive cases of which 2341 were admitted (838 in wave 1 and 1503 in wave 2). Both waves had a temporally aligned rise in nosocomial cases (96 in wave 1 and 137 in wave 2). The Alpha variant was first identified on 15 November 2020 and increased rapidly to comprise 400/472 (85%) of sequenced isolates from admitted cases in wave 2. A multivariate analysis identified risk factors for severity on admission, such as age (OR 1.02, 95% CI 1.01 to 1.03, for every year older; p<0.001), obesity (OR 1.70, 95% CI 1.28 to 2.26; p<0.001) and infection with the Alpha variant (OR 1.68, 95% CI 1.26 to 2.24; p<0.001).

CONCLUSIONS

Our analysis is the first in hospitalised cohorts to show increased severity of disease associated with the Alpha variant. The number of nosocomial cases was similar in both waves despite the introduction of many infection control interventions before wave 2.