An outbreak within an outbreak: The impact of Infection Prevention and Control strategies on hospital-acquired infections and the occurrence of multi-drug resistant organisms during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic placed an unprecedented strain on intensive care units (ICUs) in South Africa. Infection prevention and control (IPC) strategies were highlighted to minimise the risk to healthcare workers and for the protection of patients from contracting hospital-acquired infections (HAIs). During the third wave, our institution adopted a shift system to address severe burnout among ICU personnel. We noted an upstroke in the occurrence of HAIs, specifically carbapenem-resistant Enterobacterales (CRE) and multidrug-resistant (MDR) Acinetobacter baumannii.

OBJECTIVES

To report these outbreaks, compare the rate of CRE and A. baumannii infections with the first COVID-19 wave and to analyse its impact on patient outcomes.

METHOD

We retrospectively analysed data from a prospectively collected registry involving all adult patients with severe COVID-19 admitted to the dedicated COVID-19 ICU from May 2021 to September 2021. Information from the admission database, including the patients' demographics, comorbidities, laboratory results and length of ICU stay were extracted.

RESULTS

Ninety patients were admitted with severe COVID-19 during the third wave. There was an outbreak of both CRE (the majority Klebsiella pneumoniae) and A. baumannii. Furthermore, 18 patients cultured the same CRE organism, and 25 patients cultured the environmental organism A. baumannii. The HAI rate was significantly higher compared with the first wave published data: 59/90 (65.6%) v. 73/363 (20.1%, p<0.01). Patients with any HAI had a longer mean stay in ICU (10.1 days v. 6.7 days (p<0.01) and a higher mortality of 48/59 (81%) v. 19/31 (61%) (p=0.05).

CONCLUSION

We observed a very significant rise in HAIs in the COVID-19 ICU during the third wave compared with the first, with almost three times as many patients developing HAIs. Unsurprisingly, it was associated with a longer mean stay in ICU and a higher mortality. The outbreak of both CRE and A. baumannii, and the fact that many patients cultured the same CRE organism and A. baumannii, strongly suggests that a critical breakdown in IPC measures had occurred.

A point-prevalence study of body mass indices in HIV-positive and HIV-negative patients admitted to hospital with COVID-19 in South Africa

Background

Obesity is now well recognised as a risk factor for severe COVID-19, but the true prevalence of obesity in hospitalised adults with COVID-19 remains unclear because formal body mass indices (BMIs) are not routinely measured on admission.

Objectives

To describe the true prevalence of obesity measured by the BMI, and associated comorbidities, in patients hospitalised with severe COVID-19, including people with HIV (PWH).

Methods

We conducted a point-prevalence study of measured BMI in consecutive patients with severe COVID-19 admitted to the medical COVID-19 wards in a tertiary academic hospital in Cape Town, South Africa (SA). Patients were enrolled over a 2-week period during the peak of the first COVID-19 wave in SA.

Results

We were able to measure the BMI in 122 of the 146 patients admitted during the study period. The prevalence of HIV was 20% (n=24/122). Most of the participants were overweight or obese (n=104; 85%), and 84 (68.9%) met criteria for obesity. The mean (standard deviation) BMI was 33 (7.5), and 34.5 (9.1) in PWH. Of PWH, 83% (n=20/24) were overweight or obese and 75% (n=18) met criteria for obesity. Multimorbidity was present in 22 (92%) of PWH.

Conclusion

We found that most patients, including PWH, met criteria for being overweight or obese. The high prevalence of obesity in PWH and severe COVID-19 reinforces the need for targeted management of non-communicable diseases, including obesity, in PWH.

Study synopsis

What the study adds. We found that the true prevalence of obesity, including in people with HIV (PWH), measured with the formal body mass index in hospitalised patients with severe COVID-19 was much higher than reported previously.Multimorbidity was present in over half of all patients, and in 92% of PWH. Implications of the findings. Urgent public health measures are required to tackle the rise in obesity, including in low- and middle-income countries.HIV care must integrate management of non-communicable diseases, including obesity.The pathogenic mechanism of the link between obesity and severe COVID-19 needs further research.

Bleeding and thrombosis outcomes in hospitalised COVID-19 patients on low-molecular-weight heparin and antiplatelet therapy

BACKGROUND

An increased incidence of thromboembolic events in hospitalised COVID‑19 patients has been demonstrated despite the use of low-molecular-weight heparin (LMWH). Antiplatelet therapy prior to admission and early in the disease course has been hypothesised to be protective against thrombosis.

OBJECTIVES

To describe the bleeding and thrombosis outcomes in hospitalised patients with confirmed COVID‑19 receiving LMWH, with and without concomitant antiplatelet therapy. Secondary objectives were to explore predictors of bleeding and thrombosis outcomes, and dosing practices of antiplatelet therapy and LMWH.

METHODS

We conducted a descriptive, cross-sectional study of bleeding and thrombosis outcomes at Tygerberg Academic Hospital, Cape Town, South Africa, during the first COVID‑19 wave, in 808 hospitalised patients with confirmed COVID‑19 receiving LMWH with and without concomitant antiplatelet therapy. Multivariate logistic regression analysis was performed if predictors were deemed statistically and clinically significant.

RESULTS

Patients receiving both LMWH and antiplatelet therapy had similar bleeding outcomes compared with patients only receiving LMWH (odds ratio (OR) 1.5; 95% confidence interval (CI) 0.6 - 4.0). Patients receiving both LMWH and antiplatelet therapy had increased odds of developing thrombosis compared with patients only receiving LMWH (OR 4.8; 95% CI 2.1 - 10.7).

CONCLUSION

The bleeding risk in COVID‑19 patients receiving both LMWH and antiplatelet therapy was not significantly increased. A potentially higher risk of thrombosis in patients receiving LMWH and antiplatelet therapy was observed. However, this could reflect confounding by indication. Randomised studies are required to further evaluate the use of antiplatelet therapy to treat hospitalised patients with COVID‑19.

Clinical features and outcomes of COVID-19 admissions in a population with a high prevalence of HIV and tuberculosis: a multicentre cohort study

BACKGROUND

There is still a paucity of evidence on the outcomes of coronavirus disease 2019 (COVID-19) among people living with human immunodeficiency virus (PWH) and those co-infected with tuberculosis (TB), particularly in areas where these conditions are common. We describe the clinical features, laboratory findings and outcome of hospitalised PWH and human immunodeficiency virus (HIV)-uninfected COVID-19 patients as well as those co-infected with tuberculosis (TB).

METHODS

We conducted a multicentre cohort study across three hospitals in Cape Town, South Africa. All adults requiring hospitalisation with confirmed COVID-19 pneumonia from March to July 2020 were analysed.

RESULTS

PWH comprised 270 (19%) of 1434 admissions. There were 47 patients with active tuberculosis (3.3%), of whom 29 (62%) were PWH. Three-hundred and seventy-three patients (26%) died. The mortality in PWH (n = 71, 26%) and HIV-uninfected patients (n = 296, 25%) was comparable. In patients with TB, PWH had a higher mortality than HIV-uninfected patients (n = 11, 38% vs n = 3, 20%; p = 0.001). In multivariable survival analysis a higher risk of death was associated with older age (Adjusted Hazard Ratio (AHR) 1.03 95%CI 1.02-1.03, p < 0.001), male sex (AHR1.38 (95%CI 1.12-1.72, p = 0.003) and being "overweight or obese" (AHR 1.30 95%CI 1.03-1.61 p = 0.024). HIV (AHR 1.28 95%CI 0.95-1.72, p 0.11) and active TB (AHR 1.50 95%CI 0.84-2.67, p = 0.17) were not independently associated with increased risk of COVID-19 death. Risk factors for inpatient mortality in PWH included CD4 cell count < 200 cells/mm3, higher admission oxygen requirements, absolute white cell counts, neutrophil/lymphocyte ratios, C-reactive protein, and creatinine levels.

CONCLUSION

In a population with high prevalence of HIV and TB, being overweight/obese was associated with increased risk of mortality in COVID-19 hospital admissions, emphasising the need for public health interventions in this patient population.

Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation

Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.

Opportunities to enhance antibiotic stewardship: colistin use and outcomes in a low-resource setting

Background

Colistin use is increasing with the rise in MDR Gram-negative infections globally. Effective antibiotic stewardship is essential to preserve this antibiotic of last resort.

Objectives

This study investigated stewardship and safety errors related to colistin use to identify opportunities for improvement.

Patients and methods

A prospective descriptive study involving all patients 13 years and older treated with colistin at a tertiary hospital in Cape Town, South Africa, between August 2018 and June 2019. We collected clinical, laboratory and outcome data and assessed provided treatment for stewardship and safety errors.

Results

We included 44 patients. Treatment errors were identified for 34 (77%) patients (median = 1), most commonly inadequate monitoring of renal function (N = 16, 32%). We also identified no rational indication for colistin (N = 9, 20%), loading dose error (N = 12, 27%); maintenance dose error (N = 10, 23%); no prior culture (N = 11, 25%); and failure to de-escalate (2 of 9) or adjust dose to changes in renal function (6 of 15). All cause in-hospital mortality was 47%. Amongst survivors, median ICU stay was 6 days and hospital stay more than 30 days. Eight (18%) patients developed renal injury or failure during treatment. Three (7%) patients in this study were found to have colistin-resistant organisms including two prior to colistin exposure.

Conclusions

This study has identified opportunities to enhance colistin stewardship and improve efficacy and safety of prescription. The appearance of colistin-resistant organisms reinforces the urgent need to ensure effective and appropriate use of colistin.

Staff testing for COVID-19 via an online pre-registration form

Background

Healthcare workers are at increased risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and potentially causing institutional outbreaks. Staff testing is critical in identifying and isolating infected individuals, whilst also reducing unnecessary workforce depletion. Tygerberg Hospital implemented an online pre-registration system to expedite staff and cluster testing. We aimed to identify specific presentations associated with a positive or negative result for SARS-CoV-2.

Methods

A retrospective descriptive study design involving all clients making use of the hospital's pre-registration system during May 2020.

Results

Of 799 clients, most were young and females with few comorbidities. Nurses formed the largest staff contingent in the study, followed by administrative staff, doctors and general assistants. Doctors tested earlier compared with other staff (median: 1.5 vs. 4 days). The most frequent presenting symptoms included headache, sore throat, cough and myalgia. Amongst those testing positive (n = 105), fever, altered smell, altered taste sensation, and chills were the most common symptoms. Three or more symptoms were more predictive of a positive test, but 12/145 asymptomatic clients also tested positive.

Conclusion

Staff coronavirus testing using an online pre-registration form is a viable and acceptable strategy. Whilst some presentations are less likely to be associated with SARS-CoV-2 infection, no symptom can completely exclude it. Staff testing should form part of a bundle of strategies to protect staff, including wearing masks, regular handwashing, buddy screening, physical distancing, availability of personal protective equipment and special dispensation for coronavirus disease 2019 (COVID-19)-related leave.

Bacterial infection, antibiotic use and COVID-19: Lessons from the intensive care unit

BACKGROUND

Empirical broad-spectrum antibiotics are frequently prescribed to patients with severe COVID-19, motivated by concern about bacterial coinfection. There is no evidence of benefit from such a strategy, while the dangers of inappropriate antibiotics are well described.

OBJECTIVES

To investigate the frequency, profile and related outcomes of infections by bacterial pathogens in patients admitted to an intensive care unit (ICU) with severe COVID-19 pneumonia.

METHODS

This was a prospective, descriptive study in a dedicated COVID-19 ICU in Cape Town, South Africa, involving all adult patients admitted to the ICU with confirmed COVID-19 pneumonia between 26 March and 31 August 2020. We collected data on patient comorbidities, laboratory results, antibiotic treatment, duration of admission and in-hospital outcome.

RESULTS

We included 363 patients, who collectively had 1 199 blood cultures, 308 tracheal aspirates and 317 urine cultures performed. We found positive cultures for pathogens in 20 patients (5.5%) within the first 48 hours of ICU admission, while 73 additional patients (20.1%) had positive cultures later during their stay. The most frequently isolated pathogens at all sites were Acinetobacter baumannii (n=54), Klebsiella species (n=13) and coagulase-negative staphylococci (n=9). Length of ICU stay (p&lt;0.001) and intubation (p&lt;0.001) were associated with positive cultures on multivariate analysis. Disease severity (p=0.5), early antibiotic use (p=0.5), diabetes mellitus (p=0.1) and HIV (p=0.9) were not associated with positive cultures. Positive cultures, particularly for tracheal aspirates (p&lt;0.05), were associated with longer ICU length of stay and mortality. Early empirical antibiotic use was not associated with mortality (odds ratio 2.5; 95% confidence interval 0.95 - 6.81).

CONCLUSIONS

Bacterial coinfection was uncommon in patients at the time of admission to the ICU with severe COVID-19. Avoiding early empirical antibiotic therapy is therefore reasonable. Strategies to avoid coinfection and outbreaks in hospital, such as infection prevention and control, as well as the strict use of personal protective equipment, are important to improve outcomes.

Implementing a video call visit system in a coronavirus disease 2019 unit

The lockdown and physical distancing strategies imposed to combat COVID-19 have caused seismic shifts at all levels of society. Hospitals have been particularly affected. Healthcare workers (HCW’s) wore PPE during all patient interactions and visitors were prohibited. Life for a patient became lonelier and for those with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) measures were even more severe. HCW’s must treat patients following a biopsychosocial approach and promote communication between patients and loved ones. We implemented a low cost Video Call Visit system at Tygerberg Hospital, Cape Town. In this article we discuss the elements of a successful implementation and potential pitfalls in the context of a pandemic, notably cross-infection and privacy. Rapid but responsible innovation using 21st century tools was required to address the many challenges of the pandemic, including improving the lived experience for patients and families. These should be intended to last after the pandemic has passed.