Hospitals' Collaborations Strengthen Pandemic Preparedness: Lessons Learnt from COVID-19

BACKGROUND

The COVID-19 pandemic strained healthcare systems around the world. This study aims to understand the preparedness of private remote hospitals in Lebanon to respond to the pandemic and evaluate the impact of inter-hospital collaborations on the hospitals' readiness.

METHODS

A multi-centered study was conducted between August 2020 and June 2021 in ten Lebanese private remote hospitals based on a mixed-methods embedded approach where the quantitative supported the qualitative. Through the AUB-USAID (American University of Beirut-United States Agency for International Development) COVID-19 project, these hospitals received personal protective equipment and medical equipment in addition to COVID-19-related training using the Train-the-Trainer model. The quantitative part used knowledge and evaluation questionnaires and a pre-post-intervention hospital preparedness checklist. The qualitative approach adopted semi-structured interviews with a purposive sample from key hospital personnel. Quantitative data were analyzed using SPSS version 27, and a p-value of <0.05 was considered to be statistically significant. For the qualitative data, a thematic analysis was performed by adopting the six-phase process described by Braun and Clarke.

RESULTS

Of the 393 healthcare workers who attended the training and completed the evaluation questionnaire, 326 completed the pre- and post-training knowledge questionnaire. A significant improvement was observed in mean knowledge scores following training for infection control, nursing, and polymerase chain reaction sampling staff (p-value < 0.001, p-value < 0.001, and p-value = 0.006, respectively), but not for housekeeping staff. More than 93% of the participants showed high trainer and content evaluation scores. As for the hospitals' preparedness assessments, there was a clear improvement in the pre- and post-assessment scores for each hospital, and there was a significant difference in the mean of the total scores of partner hospitals pre- and post-USAID-AUB project (p-value = 0.005). These findings were supported by the qualitative analysis, where nine hospitals expressed the positive impact of the USAID-AUB intervention in improving their preparedness to respond to the COVID-19 pandemic at a critical time when it was highly needed. Despite the intervention, persistent challenges remained.

CONCLUSIONS

A timely and proactive collaborative program between academic/tertiary care centers and remote community hospitals that includes sharing supplies and expertise is feasible and highly effective during public health emergencies.

Bacterial respiratory infections in patients with COVID-19: A retrospective study from a tertiary care center in Lebanon

BACKGROUND

Despite multiple reports of increased incidence of bacterial respiratory tract infections following COVID-19 globally, the microbiology is not yet fully elucidated. In this study, we describe the microbiology of bacterial infections and the prevalence of multidrug resistant organisms (MDROs) in hospitalized COVID-19 patients with community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP) which includes both non-ventilated hospital acquired pneumonia (NVHAP) and ventilator-associated pneumonia (VAP). To our knowledge, this is the first study that compares the microbiology of VAP and NVHAP in COVID-19 patients.

METHODS

This is a longitudinal retrospective cohort study conducted at the American University of Beirut Medical Center (AUBMC), a tertiary-care centre in Lebanon. Adult patients with confirmed COVID-19 and concurrent bacterial respiratory infections with an identifiable causative organism who were hospitalized between March 2020 and September 2021 were included. Bacterial isolates identified in hospital-acquired pneumonia (HAP) were divided into 3 groups based on the time of acquisition of pneumonia after admission: hospital day 3-14, 15-28 and 29-42.

RESULTS

Out of 1674 patients admitted with COVID-19, 159 (9.5%) developed one or more respiratory infections with an identifiable causative organism. Overall, Gram-negative bacteria were predominant (84%) and Stenotrophomonas maltophilia was the most common pathogen, particularly in HAP. Among 231 obtained isolates, 59 (26%) were MDROs, seen in higher proportion in HAP, especially among patients with prolonged hospital stay (> 4 weeks). Non-fermenter Gram-negative bacilli (NFGNB) (OR = 3.52, p-value<0.001), particularly S. maltophilia (OR = 3.24, p-value = 0.02), were significantly more implicated in VAP compared to NVHAP.

CONCLUSIONS

NFGNB particularly S. maltophilia were significantly associated with COVID-19 VAP. A high rate of bacterial resistance (25%), especially among Gram-negative bacteria, was found which may compromise patients' outcomes and has important implications in guiding therapeutic decisions in COVID-19 patients who acquire bacterial respiratory infections.

“My child has ADHD…am I ok?” The Psychological Burden of Caring for an ADHD child in Lebanon and its association to Caregivers’ Mental Health

Objectives: Previous studies have indicated that caregivers of ADHD children consider this disorder to be a psychological burden on their lives in all its aspects: social, occupational, and financial. As a result, these caregivers are marked with psychological morbidities including stress, anxiety and depression. While there have been reports of ADHD in Lebanon, there are no studies in Lebanon or in the Middle East that measure the psychological burden of ADHD on caregivers or its association to mental health. Therefore, this study aims to inspect the psychological burden of ADHD and assess the variation in stress, depression, and anxiety among caregivers of ADHD children. Methods: The study involves 120 Lebanese caregivers, 48 of which are caregivers of ADHD children and 72 are those of normally developing children. Caregivers are presented with three scales to report: DASS-21, SDQ and a CAPPA-adapted survey. Results: After analyzing the responses, we can infer that caregivers of ADHD children worry, avoid outside activities with their child, consider their child to be a strain on their family, on their occupation, and on their finances more than caregivers of normally developing children with ORs= 15.8, 20.3, 3.5, 13, and 3.7 respectively. Moreover, more caregivers of ADHD children reported depression (58% vs 26%) and anxiety (31% vs 14%) with higher mean scores on DASS-21 (mean= 14.98+/-6.2, p<0.001) for depression and (mean= 15.67+/- 5.02, p<0.001) for anxiety compared with caregivers of normally developing children. ORs= 4.7 and 3.7 for depression and anxiety respectively. In addition, mental health seems to be positively associated with each of the psychological burden and severity of the child’s ADHD. And in turn, the caregivers’ psychological burden is also positively associated to the child’s ADHD severity. Finally, mental health seems to be discriminant in caregiver gender, where more mothers show depression (64%), anxiety (75%) and stress (68%) than fathers of ADHD children. Conclusion: This study affirms that caring for a child with ADHD impacts the mental health of caregivers and their lives. Therefore, there are strong grounds to contemplate ways to help such a vulnerable group of caregivers in the Lebanese population.

Incidence, outcome, and risk factors for recurrence of nosocomial Clostridioides difficile infection in adults: A prospective cohort study

BACKGROUND

Nosocomial Clostridioides difficile infection (CDI) complicates up to 1% of all hospital admissions and is associated with considerable health burden.

AIMS

To determine the incidence and outcomes of nosocomial CDI at a major University Medical Center.

METHODS

Consecutive adult nosocomial CDI cases were prospectively identified. Stool samples were collected for ribotyping and antibiotic resistance testing. Patients were followed for eight weeks after discharge for relapse.

RESULTS

Over a 2-year period, 215 patients developed nosocomial CDI (incidence 2:1000) and 200 (mean age 62.2±19.6 years) gave informed consent. Mean hospital stay was 23.3±28.9 days (range 0-278). Infection was diagnosed within 7 days of admission (range 0-95) in 129 patients (64.5%). More than two-thirds (69.0%) were previously hospitalized within 12 weeks of the index hospitalization. Twenty five percent received prior antibiotics within eight weeks. Fifty-two patients (26.0%) did not receive antibiotics prior to diagnosis. Considerable comorbidities (Charlson Comorbidity Index ≥8) were noted in 33.5% of patients. Recurrence occurred in 43 patients (21.5%). On multivariate logistic regression, fluoroquinolone exposure was the only predictor of recurrence (OR=2.9, 95%CI 1.1-7.7). Overall mortality was 14.0% and CCI ≥8 was the only predictor on multivariate analysis (p=0.004). Genotyping did not identify any known hypervirulent strains and all isolates were susceptible to metronidazole and vancomycin.

CONCLUSION

Antibiotic exposure, comorbidities, and prior hospitalization constitute the major risk factors for nosocomial CDI. Recurrence is common and is associated with fluoroquinolones exposure. High baseline comorbidity score was the only predictor of increased mortality in this prospective cohort.

Modulation of anterior cingulate cortex reward and penalty signalling in medication-naive young-adult subjects with depressive symptoms following acute dose lurasidone

BACKGROUND

Aberrations in reward and penalty processing are implicated in depression and putatively reflect altered dopamine signalling. This study exploits the advantages of a placebo-controlled design to examine how a novel D2 antagonist with adjunctive antidepressant properties modifies activity in the brain's reward network in depression.

METHODS

We recruited 43 medication-naïve subjects across the range of depression severity (Beck's Depression Inventory-II score range: 0-43), including healthy volunteers, as well as people meeting full-criteria for major depressive disorder. In a double-blind placebo-controlled cross-over design, all subjects received either placebo or lurasidone (20 mg) across two visits separated by 1 week. Functional magnetic resonance imaging with the Monetary Incentive Delay (MID) task assessed reward functions via neural responses during anticipation and receipt of gains and losses. Arterial spin labelling measured cerebral blood flow (CBF) at rest.

RESULTS

Lurasidone altered fronto-striatal activity during anticipation and outcome phases of the MID task. A significant three-way Medication-by-Depression severity-by-Outcome interaction emerged in the anterior cingulate cortex (ACC) after correction for multiple comparisons. Follow-up analyses revealed significantly higher ACC activation to losses in high- v. low depression participants in the placebo condition, with a normalisation by lurasidone. This effect could not be accounted for by shifts in resting CBF.

CONCLUSIONS

Lurasidone acutely normalises reward processing signals in individuals with depressive symptoms. Lurasidone's antidepressant effects may arise from reducing responses to penalty outcomes in individuals with depressive symptoms.

Ten-year surveillance study of ventilator-associated pneumonia at a tertiary care center in Lebanon

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with significant adverse outcomes in critically-ill patients admitted to the Intensive Care Unit (ICU). Systematic data from Lebanon on VAP are not available and large epidemiological studies from the region are scarce.

METHODS

We conducted a retrospective study over a 10-year period at the American University of Beirut Medical Center (AUBMC), a tertiary referral center in Lebanon in order to describe the incidence, microbiology, and temporal trends of VAP in the medical/surgical ICU.

RESULTS

A total of 162 patients developed VAP over the study period and the overall incidence of VAP was 7.9 per 1000 ventilator-days. There was a statistically significant decrease over time in the incidence of VAP, from 13.1 in 2008 to 1.1 per 1000 ventilator-days in 2017. Multidrug-resistant (MDR) Acinetobacter spp. was the predominant pathogen, both in early- as well as late-onset VAP, followed by Pseudomonas aeruginosa.

CONCLUSIONS

Following significant efforts from the Infection Control and Prevention Program, a considerable reduction in the incidence of VAP was achieved at AUBMC. The predominance of MDR Acinetobacter spp. should be taken into consideration when deciding on empirical therapy in patients with VAP.

Atypical presentation of Middle East respiratory syndrome coronavirus in a Lebanese patient returning from Saudi Arabia

Around 2090 confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) from 27 countries have been reported to the World Health Organization (WHO) between September 2012 and October 2017, the majority of whom occurring in countries in the Arabian Peninsula, mainly in Saudi Arabia. MERS- CoV can have atypical and misleading presentations resulting in delays in diagnosis and is associated with a high mortality rate especially in elderly patients with multiple comorbidities. Herein, we present the first case of confirmed MERS-CoV infection diagnosed at the American University of Beirut Medical Center (AUBMC) - Lebanon in June 2017 presenting without any respiratory symptoms. This is the second confirmed case of MERS-CoV infection in Lebanon since 2014. The first case presented with a febrile respiratory infection with persistent symptoms despite antibiotic treatment.

Non-Antidepressant Treatment of Generalized Anxiety Disorder

INTRODUCTION

Generalized anxiety disorder (GAD) is a prevalent and very disabling anxiety disorder. First-line medications are antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and noradrenalin reuptake inhibitors (SNRIs). However, a substantial number of patients do not reach remission while on antidepressants and they may develop troublesome side effects, which highlights the necessity of new therapeutic options for GAD.

METHODS

The purpose of this review is to discuss all non-antidepressant treatments studied in GAD. We searched MedLine for English articles published between 1980 and 2012, containing the following keywords: "generalized (or generalised) anxiety disorder" OR "anxiety disorder", AND "drug therapy" OR "herbal medicine". 76 articles were finally selected.

RESULTS

Pregabalin is the anticonvulsant with the most robust level of evidence in GAD. It rapidly reduces anxiety, has a safe side effect profile and presents a low potential for abuse. Among antipsychotics, quetiapine is the one of choice in GAD, with similar efficacy to SSRIs in low dosages, yet with lower overall tolerability. Benzodiazepines, buspirone and hydroxyzine are Food and Drugs administration (FDA) approved for GAD and have relatively good evidence of efficacy. Other drugs (betablockers, zolpidem, riluzole, etc.) and natural remedies (e.g. Piper methysticum) could be potential treatment options, yet additional research is warranted.

CONCLUSION

Pregabalin and quetiapine are the two most promising non-antidepressant treatments for GAD.

Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon

40 million female domestic workers worldwide experience the inhumane conditions associated with this unregulated occupation, a situation that induces psychiatric morbidities in many. The case in Lebanon is not any better where it is estimated that one foreign domestic worker (FDW) commits suicide weekly. 33 female FDW and 14 female Lebanese (control group, CG) were enrolled. Brief Psychotic Rating Scale (BPRS) and Clinical Global Impression (CGI) scales were administered on admission and discharge and socio-demographic, living conditions, mental health care data and phenomenological observations were collected. Sexual, physical, and verbal abuses were detected in FDW (12.5, 37.5, and 50.0 %. respectively). 66.7 % of them were diagnosed with brief psychotic episode. The mean duration of hospital stay (13.1 days) was significantly lower in the FDW group. The mean cumulative antipsychotic dose of the FDW was 337.1 mg of chlorpromazine equivalent and the mean BPRS total pre-score of FDW was 66.4 with a much improved state on the CGI global improvement scale, all of which were nonsignificantly different from the CG. Striking phenomenological findings among FDW were acute anorexia (39.4 %), nudity (30.3 %), catatonic features (21.2 %), and delusion of pregnancy (12.1 %). Inpatient FDW are more diagnosed with psychotic than affective disorders and receive approximately similar treatment as controls in spite of the trend to rapidly discharge and deport the worker to limit the costs. Both groups presented with similar severity, although the FDW had peculiar phenomenological observations.

Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International Nosocomial Infection Control Consortium (INICC) findings

OBJECTIVE

The objective of this study was to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) in an adult intensive care unit (ICU) of a hospital member of the International Nosocomial Infection Control Consortium (INICC) in Lebanon.

METHODS

A before-after prospective active surveillance study was carried out to determine rates of CAUTI in 1506 ICU patients, hospitalized during 10 291 bed-days. The study period was divided into two phases: phase 1 (baseline) and phase 2 (intervention). During phase 1, surveillance was performed applying the definitions of the US Centers for Disease Control and Prevention National Healthcare Safety Network (CDC/NHSN). In phase 2, we adopted a multidimensional approach that included: (1) a bundle of infection control interventions, (2) education, (3) surveillance of CAUTI rates, (4) feedback on CAUTI rates, (5) process surveillance, and (6) performance feedback. We used random effects Poisson regression to account for clustering of CAUTI rates across time-periods.

RESULTS

We recorded a total of 9829 urinary catheter-days: 306 in phase 1 and 9523 in phase 2. The rate of CAUTI was 13.07 per 1000 urinary catheter-days in phase 1, and was decreased by 83% in phase 2 to 2.21 per 1000 urinary catheter-days (risk ratio 0.17; 95% confidence interval 0.06-0.5; p=0.0002).

CONCLUSIONS

Our multidimensional approach was associated with a significant reduction in the CAUTI rate.

International nosocomial infection control consortium findings of device-associated infections rate in an intensive care unit of a lebanese university hospital

OBJECTIVES

To determine the rates of device-associated healthcare-associated infections (DA-HAI), microbiological profile, bacterial resistance, length of stay (LOS), excess mortality and hand hygiene compliance in one intensive care unit (ICU) of a hospital member of the International Infection Control Consortium (INICC) in Beirut, Lebanon.

MATERIALS AND METHODS

An open label, prospective cohort, active DA-HAI surveillance study was conducted on adults admitted to a tertiary-care ICU in Lebanon from November 2007 to March 2010. The protocol and methodology implemented were developed by INICC. Data collection was performed in the participating ICUs. Data uploading and analyses were conducted at INICC headquarters on proprietary software. DA-HAI rates were recorded by applying the definitions of the National Healthcare Safety Network (NHSN) at the US Centers for Disease Control and Prevention (CDC). We analyzed the DA-HAI, mechanical ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CAUTI) rates, microorganism profile, excess LOS, excess mortality, and hand hygiene compliance.

RESULTS

A total of 666 patients hospitalized for 5,506 days acquired 65 DA-HAIs, an overall rate of 9.8% [(95% confidence interval (CI) 7.6-12.3], and 11.8 (95% CI 9.1-15.0) DA-HAIs per 1000 ICU-days. The CLA-BSI rate was 5.2 (95% CI 2.8-8.7) per 1000 catheter-days; the VAP rate was 8.1 (95% CI 5.5-11.7) per 1000 ventilator-days; and the CAUTI rate was 4.1 (95% CI 2.6-6.2) per 1000 catheter-days. LOS of patients was 7.3 days for those without DA-HAI, 13.8 days for those with CLA-BSI, 18.8 days for those with VAP. Excess mortality was 40.9% [relative risk (RR) 3.14; P 0.004] for CLA-BSI. Mortality of VAP and CAUTI was not significantly different from patients without DA-HAI. Escherichia coli was the most common isolated microorganism. Overall hand hygiene compliance was 84.9% (95% CI 82.3-87.3).

CONCLUSIONS

DA-HAI rates, bacterial resistance, LOS and mortality were moderately high, below INICC overall data and above CDC-NHSN data. Infection control programs including surveillance and antibiotic policies are essential and continue to be a priority in Lebanon.