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.

Chimney endovascular aortic repair is a viable salvage technique in a paravisceral pseudoaneurysm secondary to acute on chronic pancreatitis

BACKGROUND

Pseudoaneurysms of the abdominal aorta secondary to pancreatitis are an extremely rare clinical entity, however, can result in life threatening complications.

OBJECTIVE

To describe a chimney endovascular aneurysm repair (Ch-EVAR) for an acute pancreatitis related paravisceral aortic pseudoaneurym.

METHOD

Prospective data collected from subject.

RESULTS

We present a case of 23-year-old female who underwent a successful salvage Ch-EVAR for a ruptured paravisceral pseudoaneurysm secondary to acute on chronic pancreatitis.

CONCLUSION

Ch-EVAR may present a viable temporizing or definitive therapeutic treatment option for a paravisceral pseudoaneurysm, particularly in the setting of acute pancreatitis. Further studies are warranted to elucidate the long term viability of Ch-EVAR grafts in the suprarenal, paravisceral aortic position.

Avoiding the re-do sternotomy: treatment of an ascending aortic pseudoaneurysm using a percutaneous Amplatzer PFO closure device

PURPOSE

Ascending aortic pseudoaneurysms are a common phenomenon requiring surgical intervention but can pose high surgical risks in medically complex patients. We report a novel approach to percutaneous closure of ascending aortic pseudoaneurysms using an Amplatzer PFO closure device.

CASE REPORT

We present the case of a 65-year-old male with haemoptysis on a background of multiple cardiac surgeries and chronic kidney disease. Serial computerised tomography scans of the thoracic aorta demonstrated an enlarging ascending aortic pseudoaneurysm. Percutaneous closure was considered the safest treatment option. With angiography, the pseudoaneurysm was defined and a 25 mm Amplatzer PFO closure device was deployed. Repeat Computed Tomography aortography performed 43 days later confirmed stable device position and resolution of the pseudoaneurysm. The patient was clinically stable at this follow-up point.

CONCLUSION

The off-label use of the Amplatzer PFO device may provide a viable alternative treatment for ascending aortic pseudoaneurysms in medically complex patients to reduce morbidity and mortality.

Embolic phenomena to the limbs are an independent predictor of in-hospital mortality from infective endocarditis

BACKGROUND

Infective endocarditis (IE) is a morbid condition with high mortality. We investigated predictors of in-hospital mortality and embolic phenomena in a contemporary Australasian cohort.

METHODS

We identified all patients with IE admitted between January 2017 and 30th April 2020 (40 months). Patient characteristics, risk factors and clinical outcomes were retrospectively collected and analysed.

RESULTS

One hundred and seventy-two consecutive patients (mean age: 56.8 ± 17.9 years, male: 63%, 114/172) were included. Causative organisms were Staphylococcus aureus (44%, 75/172), Enterococcus faecalis (15%, 26/172), Streptococcus mitis (6%, 10/172) and Staphylococcus epidermidis (3%, 6/172). In-hospital mortality was 15% (25/172). Embolic complications were found among 57% (98/172) of patients, the most common being stroke (23%, 40/172), septic pulmonary emboli (17%, 29/172), splenic and/or renal emboli (17%, 26/172) and peripheral limb emboli (15%, 25/172). Sixty (35%, 60/172) patients underwent cardiac surgery. On multivariable analysis, independent predictors of in-hospital mortality were: increased age (odds ratio: 1.064, per year older, P = 0.001), ICU admission independent of cardiac surgery (OR 9.81, P < 0.001), moderate or severe LV impairment (OR 5.19, P = 0.012) and any sign of embolic phenomena to limbs (OR 5.02, P = 0.006). Multivariable predictors of embolic complications were S. aureus bacteraemia (OR 3.22, P = 0.001) and large vegetation >10 mm (OR 3.04, P = 0.002).

CONCLUSION

We demonstrate predictors of in-hospital mortality and embolic phenomena in our cohort. Though age remains a consistent predictor of mortality, surprisingly, signs of embolic phenomena to the limbs was established as an independent predictor of mortality. The mechanism of this is unclear and warrants further evaluation.

Occam's Razor and Managing Acute Thrombosis in the COVID-19 Era

The COVID-19 pandemic has profoundly influenced the practice of medicine in Australia over the last 24 months. Recently, the development of several vaccines to COVID-19 has been accompanied by reports of an associated rare syndrome of thrombosis and thrombocytopaenia (VITTS). The possibility of this rare disorder confronts all clinicians who deal with acute thrombosis, particularly given the prevalence of patients who have recently been immunised. However, VITTS remains rare, and we believe unnecessary focus on its potential diagnosis may distract from other more common causes of acute thrombosis. We discuss this with reference to a recent case at our institution.

A Case of Successful Endovascular Aortic Repair of Primary Aortoenteric Fistula Without Aortic Explantation

PURPOSE

The objective of this study is to report a case of a primary aortoenteric fistula successfully treated with endovascular repair without aortic explant.

CASE REPORT

A 48-year-old man presented with a 24-hour history of hematemesis and malena. A computed tomography (CT) abdomen and pelvis demonstrated a 6 cm infrarenal aortic aneurysm with periaortic stranding and contrast enhancement within the lumen of the third part of the duodenum. The patient underwent emergency Endovascular Aortic Repair (EVAR). The patient was discharged on day 8 of his admission on oral antibiotics. He returned 7 weeks postindex procedure and underwent a laparotomy with omental patch repair of the aortic defect. Intraoperative cultures grew candida albicans, and the patient was discharged on lifelong oral Fluconazole and Amoxycillin-Clavulanic Acid. At 18 months postoperatively, the patient was clinically stable with improved appearances on CT aortogram.

CONCLUSION

We discuss the use of EVAR without aortic explant as a possible treatment option in the management of patient with primary aortoenteric fistulae. This may potentially avoid the significant morbidity and mortality associated with aortic explant in suitable candidates without perioperative signs of sepsis.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Renocaval Bypass for Acute Renal Failure and Haematuria Following Left Renal Vein Ligation During Aorto-Bifemoral Bypass

Ligation of the left renal vein is an accepted manoeuvre where it is difficult to access the pararenal abdominal aorta for the open treatment of aortic occlusive or aneurysmal disease. There is some controversy regarding the long-term effect of this on renal function. We describe the case of a 37-year-old gentleman who underwent an elective aorto-bifemoral bypass for aorto-iliac occlusive disease with symptoms of short distance claudication, with intra-operative ligation of the left renal vein. This was complicated by post-operative acute renal failure and haematuria, with CT findings of left renal venous dilatation and peri-renal stranding. The patient underwent successful left renocaval bypass with reversed great saphenous vein, with subsequent resolution of haematuria and improvement in renal function. The syndrome of acute renal failure and haematuria is a rare but possible complication of left renal vein ligation during aortic surgery, and restoration of renal venous outflow via renocaval bypass in this instance was an effective method of treating this complication.

Penetrating angle grinder injury to the neck causing subclavian artery injury

Penetrating injuries to the neck present a unique challenge due to the confined space of the thoracic outlet for haemorrhage control and repair. This results in high mortality rates when the major vascular structures of the neck are transected, as well as potential neurological compromise. We present the case of a penetrating injury to the proximal subclavian artery from a broken angle grinder disc which is a unique mechanism of injury that can have fatal consequences. The patient described in this case underwent an emergent median sternotomy for proximal control of the brachiocephalic trunk and ligation of the right vertebral artery to facilitate a primary repair of the injured vessel segment. Post operatively the patient made a complete recovery with no central or peripheral neurologic deficits and requiring no further interventions. The key points from this case are that angle grinders pose a significant injury burden and early specialised medical attention should be sought, rapid control of the proximal neck vessels can be obtained via a median sternotomy and that the vertebral artery can be ligated in an emergent situation without neurological consequence.

Cystic Adventitial Disease Presenting as Occlusion of the External Iliac Artery: A Rare Manifestation

Cystic adventitial disease (CAD) is a rare, non-atherosclerotic cause of peripheral arterial disease characterized by mucinous cyst formation in the adventitial layer of arteries; with approximately 80% to 90% of cases involving the popliteal artery. We describe a case of CAD presenting in a female with left external iliac artery occlusion and intermittent claudication, for whom an intra-operative diagnosis of CAD of the ilio-femoral segment was made. A 37-year-old mother-of-two was referred to a Vascular Surgeon with a 3 to 4-year history of progressive intermittent claudication. A computed tomography (CT) angiogram demonstrated a left external iliac artery occlusion. Given the location of the lesion, the absence of cardiovascular risk factors and the patient's history of cycling, a diagnosis of left external iliac artery occlusion secondary to arterial endofibrosis or spontaneous arterial dissection was thought to be likely. A left Rutherford-Morrison incision was made and an extraperitoneal approach used to expose the left iliac system. A cyst was opened and marsupialized along the superior aspect of the external iliac artery, releasing gelatinous material. A provisional intra-operative diagnosis of CAD was made. The patient was systemically heparinized and an external iliac to common femoral artery bypass was performed using reversed ipsilateral greater saphenous vein. CAD primarily involves the popliteal artery. Under 40 cases of CAD with iliofemoral involvement have been reported. Our case is unusual given the location of CAD, as well as its occurrence in a female. Management options for similar cases have been described in the literature ranging from cyst excision and arterial patching, to interposition bypass and even exclusion bypass, in the case of longer segment occlusions. In our case, an exclusion bypass was deemed the most appropriate treatment given the extensive length and complete occlusion of the external iliac artery.

Two and a half years on: data and experiences establishing a 'Virtual Clinic' for joint replacement follow up

BACKGROUND

We use a 'Virtual Clinic' for follow up of hip and knee replacement patients. The aim of this study was to investigate patient compliance, pain and function, revision rates and surgeon experience using this system.

METHODS

All hip and knee replacements conducted from 2000 onwards were suitable for 'Virtual Clinic' review. Between July 2014 and December 2016, all patients due for follow up (at 1, 5 and 7 years post-operatively, or biennially thereafter) were mailed an Oxford Hip or Knee Score and a request for a radiograph. A surgeon reviewed the questionnaire and radiograph and decided whether face-to-face review was necessary. We calculated compliance as the percentage of eligible patients who completed the 'Virtual Clinic'. We used retrospective review of medical records for all clinic participants to analyse Oxford scores, disposition following appointment, and revision rates. We reviewed all clinic participants in December 2017 to identify any further revisions. Surgeon feedback was assessed by emailed survey.

RESULTS

A total of 2076 patients were due for follow up. 1405 patients were contactable, and 710 completed the process. We calculated a 36% compliance rate. Surgeons decided 162 (23%) patients with a mean Oxford score of 24.2 required face-to-face assessment. This identified 13 patients needing revision. One other patient was revised for loosening which developed between 'Virtual Clinic' appointments. Surgeon feedback indicated the inclusion of a 'comment' section on the questionnaire as particularly useful.

DISCUSSION

We describe our adoption of a 'Virtual Clinic' for joint replacement follow up. We recommend this system as a practical method of following up patients.