Early experience with COVID-19 patients in a private tertiary hospital in the Philippines: Implications on surge capacity, healthcare systems response, and clinical care

Multidrug-resistant VAP before and during the COVID-19 pandemic among hospitalized patients in a tertiary private hospital

Background

There is limited data on ventilator-associated pneumonia (VAP) and multidrug-resistant VAP (MDR VAP) among COVID-19 patients.

Methods

A retrospective study in a single, tertiary, private hospital in the Philippines was conducted comparing the incidence, profile, and patient outcomes of MDR VAP during the pre-COVID-19 (2018-2019) and COVID-19 (2020-2021) periods.

Results

In total, 80/362 (22%) patients developed VAP, 27/204 (33.75%) from pre-COVID-19 and 53/158 (66.25%) from the COVID-19 period, respectively. The majority were male [20/27 (74%) vs 34/53 (64%)], with a median age of 66 (range 35-90) and 67 (range 32-92) years in each period, respectively. Comorbidities were similar, except cardiovascular disease (14/27 vs 11/53 patients, p-value 0.005) and chronic lung disease (14/27 vs 9/53 patients, p-value 0.0012). VAP incidence density was 19.3/1000 and 27.8/1000 ventilator days (p-value 0.9819)]; median length of stay before VAP for pre- and COVID-19 periods was 17 and 10 days, respectively (p-value <0.0001). Extended-spectrum β lactamase (ESBL)-producing resistance increased significantly [1/27 (3.7%) pre-COVID-19 vs 15/53 (28.3%)] during COVID-19, while Carbapenem-resistant Enterobacteriaceae resistance was higher in the pre-COVID-19 period (15/27 [56%] vs 10/53 [19%]). Mortality was high in both periods at 93% and 83%, respectively. On multivariate analysis, only female gender was associated with MDR VAP in the COVID-19 period (OR =3.47, [CI 1.019, 11.824], p-value < 0.047).

Conclusion

The frequency of VAP and MDR VAP increased during the COVID-19 period, despite a shorter duration of hospital stay. The mortality of VAP was extremely high. Factors associated with increased risk of VAP and COVID-19 need to be studied further, and preventive measures should be prioritized.

Emergency medicine research in the Philippines: A scoping review

Objectives

In this review, we aim to synthesize the current emergency medicine literature in the Philippines in order to determine the depth of research available in the country while delineating the gaps, helping to provide focus to future research in the field.

Methods

A literature review was done using 4 databases to identify emergency medicine studies in the Philippines. To explore the research trends among eligible studies, data on study type, countries, and institutions involved as well as study themes were collected and described.

Results

A total of 845 studies were screened, and 43 were included in this review. Results show that only 25% of emergency medicine studies were published before 2015. Most studies were observational (37.2%) or descriptive (37.2%) in nature with the University of the Philippines/Philippine General Hospital being the most common contributing institution (17.4%). Metro Manila was the most common study site with more than half of studies conducted in the area. Lastly, among the variety of study disciplines, disaster medicine was the most frequent topic comprising 30.2% of studies reviewed.

Conclusions

Compared to the global scene, Philippine emergency medicine research still has a long way to go. This study was able to provide a landscape of the current literature and highlight the study trends. Further, the findings here emphasize the need to expand the scope of emergency medicine studies in the country as it is still a young and growing field with studies tending to cluster around just a small number of institutions and regions.

Utilisation and Management of an Emergency Department in a Tertiary Hospital in the Philippines During the COVID-19 Pandemic

The Emergency Department (ED) plays the role of providing efficient and quality healthcare services to patients. During the COVID-19 pandemic, there were observed changes in the ED’s utilisation and management reflecting the underlying challenges faced by most tertiary hospitals in the Philippines. This study aims to describe the changes in the utilisation and management of ED in a major COVID-19 hospital in the Philippines, its implications for inpatient admissions, and effect on ED staff. Patient data from 2019 (pre-pandemic) and 2020 (pandemic) were compared. In addition, this study administered a COVID-19-specific psychometric tool to assess the pandemic’s effect on ED staff. Comparing the pre-pandemic and pandemic census, this study found a 59.0% and 67.6% decrease in ED consultations and hospital admissions, respectively. ED consultations significantly shifted to older patients, with longer length of stay, increased out-of-pocket payment, and mostly presenting with respiratory-related chief complaints. There is a decrease in general hospital unit utilisation, and the addition of a COVID-19 ward and an ICU. Despite the changes, 63.6% of the ED staff exhibited good emotional adjustment to the stress brought by the pandemic. This study reported the situation of Philippine ED amid the pandemic and indicated the important management changes in ED.

The association of the COVID-19 outbreak with in-hospital mortality: A single-centre study from Indonesia

Objective

The early outbreak period of Coronavirus Disease (COVID-19) has affected the emergency department (ED) and hospital services in many countries. This study aimed to investigate the association between COVID-19 outbreak and in-hospital mortality in Jakarta, Indonesia.

Methods

This retrospective cohort study was conducted in a single-centre referral hospital in Jakarta, Indonesia. Data were collected between May and October 2020. All patients who visited the ED and required inpatient care during the early COVID-19 outbreak period at the study location (March to April 2020) were included in the exposure group. All patients who visited the ED and required inpatient care during the non-outbreak period (March to April 2019) were included in the non-exposure group. In-hospital mortality was the primary outcome, whereas other variables, such as sex, age, triage categories, trauma cases, referral cases, and ED length of stay (LOS), were measured to identify confounding and effect modifications. Multivariate logistic regression analysis was performed to assess this association.

Results

A total of 2,808 patients during the outbreak period and 2,423 patients during the non-outbreak period participated in the study. The odds of in-hospital mortality increased during the outbreak period compared to that during the non-outbreak period (odds ratio [OR], 1.41; 95%CI 1.04-1.91; p = 0.01) after adjusting for age, sex, triage categories, trauma case, ED LOS, and interaction between the outbreak period and ED LOS.

Conclusion

COVID-19 outbreaks have been associated with an increased risk of in-hospital mortality in referral hospitals in Jakarta, Indonesia.

Clinical characteristics of patients with asymptomatic and symptomatic COVID-19 admitted to a tertiary referral centre in the Philippines

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Asymptomatic infection is common.

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Bimodal age distribution of coronavirus disease 2019 (COVID-19) was observed at the University of the Philippines–Philippine General Hospital.

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Universal testing impacts infection control measures in resource-limited settings.

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Further blood testing is likely to be unnecessary for mild and asymptomatic cases of COVID-19.

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Symptom-based isolation protocol reduces length of hospitalization.

Objectives

To describe the clinical profile and outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19) across the spectrum of disease severity.

Methods

This retrospective study included adult patients with confirmed COVID-19 infection admitted to a referral hospital. Descriptive statistics, tests for trend, Kaplan–Meier curve and log-rank test were used to compare characteristics and outcomes across disease severity categories.

Results

Of 1500 patients with COVID-19, 14.8% were asymptomatic, 13.5% had mild disease, 36.6% had moderate disease, 12.3% had severe disease and 22.7% had critical disease. Asymptomatic patients were admitted for a concurrent condition or for isolation. Patients aged >60 years, male gender and with co-morbidities had more severe disease. Fever, cough, shortness of breath, malaise, gastrointestinal symptoms and decreased sensorium were more common in patients with severe disease. Bilateral pulmonary infiltrates were common (51.1%), with sicker patients having more abnormal findings. The overall mortality rate was 15.1%. Adopting a symptom-based strategy reduced the length of hospitalization from a median of 13 [interquartile range (IQR) 7–21] days to 9 (IQR 5–14) days.

Conclusion

The clinical profile and outcomes for this cohort of patients with COVID-19 was consistent with published reports. Asymptomatic infection was common, and universal testing may be a valuable strategy in the correct context, given the implications for infection control. A symptom-based strategy was found to reduce the length of hospitalization considerably.

COVID-19 in Pediatric Patients: A Systematic Review

INTRODUCTION

The coronavirus disease (COVID)-19 pandemic has been an enormous global health burden, resulting in hundreds of millions of documented infections and more than 3 million deaths. Increasing reports characterizing the effects of COVID-19 in pediatric populations have been published during the course of the pandemic. We performed a systematic review to assess the scope of diagnosis, treatment, and management of COVID-19 in pediatric patients.

MATERIALS AND METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed, CINAHL, and Embase for studies published between January 1, 2020, and May 1, 2021. Each result was screened by 2 authors independently, and discordant findings were adjudicated by a third party. Data extracted included demographic data, symptom data, and clinical data including mortality, severe illness, laboratory data, radiologic data, and treatment. Bias assessment was performed using the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies.

RESULTS

We found a total of 16,266 search results, and we accepted 63 manuscripts into the review. The quality of evidence was low. It was difficult to estimate the risk of mortality in pediatric patients with COVID-19 given the quality of the evidence, but overall it is likely below 1%. The most common symptoms in symptomatic pediatric COVID-19 patients were fever (58%) and cough (50%). There was a high proportion of asymptomatic infection (65%).

DISCUSSION

Pediatric COVID-19 infection is mild and frequently asymptomatic. There is a low risk of severe illness or death in children who contract COVID-19. High-quality studies should be conducted to develop best practices for prevention, diagnosis, and management of symptomatic illness.

Clinical Outcomes of Older Persons and Persons with Dementia Admitted for Coronavirus Disease 2019: Findings from the Philippine CORONA Study

INTRODUCTION

The Philippine CORONA Study was a multicenter, retrospective, cohort study of 10,881 coronavirus disease 2019 (COVID-19) admissions between February and December 2020.

METHODS

Subgroup analysis was done on clinical outcomes of mortality, respiratory failure, duration of ventilator dependence, intensive care unit (ICU) admission, length of ICU stay, and length of hospital stay among older persons and persons with dementia.

RESULTS

The adjusted hazard ratios for mortality among the mild and severe cases were significantly higher by 3.93, 95% CI [2.81, 5.50] and by 1.81, 95% CI [1.43, 2.93], respectively, in older persons compared to younger adults. The adjusted hazard ratios for respiratory failure in older persons were increased by 2.65, 95% CI [1.92, 3.68] and by 1.27, 95% CI [1.01, 1.59] among the mild and severe cases, respectively. The adjusted hazard ratio for ICU admission in older persons was higher by 1.95, 95% CI [1.47, 2.59] among the mild cases. The adjusted hazard ratios for mortality and ICU admission in persons with dementia were higher by 7.25, 95% CI [2.67, 19.68] and by 4.37, 95% CI [1.08, 17.63], respectively, compared to those without dementia.

CONCLUSION

Older age and dementia significantly increased the risk of mortality, respiratory failure, and ICU admission among COVID-19 patients.