Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom

Background Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. Objective We assess the relative cost-effectiveness of screening programmes compared with no- screening. Methods A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. Results In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. Conclusion The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.

Admission of a Terminally Ill Lung Cancer Patient With the Accidental Diagnosis of SARS-CoV-2 to a Palliative Care Unit Resulting in a SARS-CoV-2 Outbreak

The COVID-19 pandemic poses challenges for palliative care. Terminal patients cannot wear masks and may demonstrate unspecific symptoms reminiscent of those caused by COVID-19. This report is about a terminally ill patient with lung cancer who displayed fever, cough, and fatigue. During hospital admission screening, the patient tested negative for SARS-CoV-2. When admitting his wife to stay with him, she also had to test for SARS-CoV-2 and displayed a positive test result. Until the positive results were reported, six staff members were infected with SARS-CoV-2, even though they were routinely wearing respirators. This resulted in the palliative care unit having to be closed. Hospitals need strict and adequate testing and re-testing strategies even for intra-hospital transfers. Workers must strictly adhere to recommended respirator practices. Ventilation of patient rooms is essential due to the possible enrichment of particle aerosols containing viruses, as negative pressure rooms are not recommended in all countries.

Medical Image of the Month: COVID-19-Associated Pulmonary Aspergillosis in a Post-Liver Transplant Patient

No abstract available. Article truncated after first 150 words. A previously healthy, 48-year-old woman, admitted with a working diagnosis of acute-on-chronic liver failure (Grade III) secondary to an autoimmune etiology, was found to be SARS COV-2 RTPCR positive on routine admission screening. She was initially managed with standard medical care for COVID, including steroids. She required invasive ventilation for worsening encephalopathy and when her antigen test was negative 10 days later, she underwent an urgent liver transplantation. Her preoperative infection screen (culture of blood, bronchoalveolar lavage, urine) was negative and computerized tomography (CT) of the chest was normal (Figure 1). She was extubated on day 3 after liver transplantation. Her recovery was uneventful until the 10th postoperative day when she developed cough and desaturation. A repeat CT chest showed multiple multilobular consolidatory nodules with central breakdown involving both lung (Figure 2). Her bronchoalveolar lavage culture grew Aspergillus fumigatus (azole sensitive) which fulfilled criteria for proven COVID-19 Associated pulmonary aspergillosis …

COVID-19 in Children at the National Teaching Hospital of Cotonou: Epidemiology, Clinic, and Therapy

Objective: The description of COVID-19 in children has evolved over time. We report here its epidemiological, clinical and evolutionary aspects in a hospital setting in sub-Saharan Africa. Methods: The study was prospective cross sectional, from January 1 to June 30, 2021. It included all children from 1 month to 18 years of age, admitted to the pediatric emergency ward of the CNHU HKM of Cotonou, tested positive for SARS-CoV-2 by RT-PCR on nasopharyngeal swabs. At admission, screening of children was targeted, based on symptoms common in children with COVID-19 according to the literature. Results: A total of 93 children were screened during the period, among which 18 were positive for SARS-CoV-2. The hospital frequency was 2% (18/895). The median age was 11 months. The most common symptoms were fever, cough, and shortness of breath. Half of the children had comorbidities, including heart disease, sickle cell disease, and nephrotic syndrome. The moderate form was the most frequent with pneumonia (10/18). The severe form was present in 2 children. Malaria was associated in 2 cases. The evolution was favorable in 17 children, after a mean hospitalization time of 5.81±2.74 days. One 4-month-old infant, with suspected multisystem inflammatory syndrome (MIS-C) died. Conclusion: The evolution of COVID-19 in children is benign, but severe forms are possible. A systematic screening should be proposed to all febrile children admitted to the emergency room.

Admission screening and cohort care decrease carbapenem resistant enterobacteriaceae in Vietnamese pediatric ICU’s

Objectives To assess if admission screening for Carbapenem Resistant Enterobacteriaceae (CRE) and cohort care can reduce CRE acquisition (CRE colonization during hospital stay), Hospital Acquired Infections (HAI), hospital-stay, mortality, and costs in three Intensive Care Units (ICU’s) at the Vietnamese National Children’s Hospital. Method CRE screening using rectal swabs and ChromIDCarbas elective culture at admission and if CRE negative, once weekly. Patients were treated in cohorts based on CRE colonization status. Results CRE colonization at baseline point-prevalence screening was 76.9% (103/134). Of 941 CRE screened at admission, 337 (35.8%) were CREpos. 694 patients met inclusion criteria. The 244 patients CRE negative at admission and screened > 2 times were stratified in 8 similar size groups (periods), based on time of admission. CRE acquisition decreased significant (OR − 3.2, p < 0.005) from 90% in period 2 (highest) to 48% in period 8 (last period). Patients with CRE acquisition compared to no CRE acquisition had a significantly higher rate of culture confirmed HAI, n = 20 (14%) vs. n = 2 (2%), longer hospital stays, 3.26 vs. 2.37 weeks, and higher total treatment costs, 2852 vs. 2295 USD. Conclusion Admission CRE screening and cohort care in pediatric ICU’s significantly decreased CRE acquisition, cases of HAI and duration of hospital-stay.

COVID-19 Admission Screening, and Assessment of Infectiousness at an Academic Medical Center, Iowa 2020

Objective: Patients admitted to the hospital may unknowingly carry SARS-CoV-2 and hospitals have implemented SARS-CoV-2 admission screening. However, because SARS-CoV-2 RT-PCR may remain positive for months after infection, positive results may represent active or past infection. We determined the prevalence and infectiousness of patients who were admitted for reasons unrelated to COVID-19 but tested positive on admission screening. Methods: We conducted an observational study at the University of Iowa Hospitals & Clinics from July 7 to October 25, 2020. All patients admitted without suspicion of COVID-19 infection were included and medical records of those with a positive admission screening test were reviewed. Infectiousness was determined using patient history, PCR cycle threshold (Ct) value, and serology. Results: A total of 5,913 patients were screened and admitted for reasons unrelated to COVID-19. Of these, 101 had positive admission RT-PCR results. Thirty-six patient were excluded because they had respiratory signs/symptoms on admission on chart review. Sixty-five patients (1.1%) did not have respiratory symptoms. A total of 55 patients had Ct values available and were included in this analysis. The median age was 56 years, and (51%) were male. Our assessment revealed that 23 patients (42%) were likely infectious. The median duration of in-hospital isolation was five days for those likely infectious and two days for those deemed non-infectious. Conclusions: COVID-19 infection was infrequent among patients admitted for reasons unrelated to COVID-19. An assessment of the likelihood of infectiousness using clinical history, RT-PCR Ct values, and serology may help discontinue isolation and conserve resources.

Increasing routine HIV testing in low and medium secure forensic settings

AimsThere remain a number of barriers to patients taking HIV tests, and prevalence of HIV in patients with severe mental illness can be higher than those without. Patients in forensic settings may be at even greater risk. National standards state that in areas of high and extremely high prevalence of HIV, testing should be offered routinely on admission to hospital. A review of compliance with these standards took place across low and medium secure male forensic wards in West London, followed by implementation of targeted interventions to increase testing rates. A reaudit was later completed to assess if changes had resulted in lasting effectsMethodA retrospective review of computer records took place to identify all inpatients residing on the low and medium secure wards on the day of data collection. Their pathology records were checked to ascertain if HIV test results were available. If no test was documented here, then patient psychiatric records were searched for documentation of the test being offered.After the initial audit, education of patients and staff regarding the benefits of HIV testing took place, HIV testing was incorporated into primary healthcare routine admission screening and separate consent forms were eradicated.The reaudit took place with data collection occurring in an identical manner.Result183 patients were initially identified across 5 low and 7 medium secure male wards, and 184 on reaudit. The initial audit found that only 30.6% (56/183) of patients had either been offered an HIV test or had a result recorded on the pathology system, but this rose to 82.6% (154/184) on reaudit. After the interventions, 43.4% of all patients had HIV test results available, compared to 23.5% initially. Even where no test result existed, the number of tests offered rose from 7.1% to 39.1% of all patients.ConclusionThis study shows that simple measures to normalise HIV testing and make it part of routine admission screening had dramatic implications for the number of patients being offered an HIV test.There is still room for improvement, however, with 17.4% of patients having neither test results available, nor documentation that a test was offered. This could be a result of poor general engagement with health care services, and would benefit from thorough documentation and assertive outreach.

Safe return to elective surgery following a COVID-19 outbreak: an observational study

Background It is a challenging task to resume suspended surgical services following coronavirus disease 2019 (COVID-19) outbreaks. We aimed to investigate the results of the pre-admission screening for patients awaiting surgery during the COVID-19 pandemic. Methods This retrospective study enrolled consecutive 100 patients who underwent surgical procedures under general anesthesia at a single institution in May 2020. For 2 weeks prior to admission, patients were required to avoid nonessential outings and record symptoms and temperatures every day. On the day before admission, real-time polymerase chain reaction (PCR) and chest computed tomography (CT) were performed. Results Pre-admission PCRs were all negative, and no CT imaging suggested COVID-19 infection, combined with clinical information. As a result, all surgeries were performed as scheduled. No virus was detected from the extubated tracheal tubes in operating rooms. No patients developed COVID-19 infection postoperatively. No nosocomial infection was reported through the study period and for 1 month thereafter. Conclusions With 2-week avoidance of nonessential outings before admission for surgery, combined with reverse transcriptase PCR and chest CT shortly before admission, we successfully resumed elective surgeries, confirmed by PCR of extubated tracheal tube swabs, at a hospital that experienced a COVID-19 outbreak.

N06 Patient perspectives on the role of the IBD nurse and telemedicine during COVID-19 pandemic: results from a Belgian tertiary IBD unit

Background Many inflammatory bowel disease (IBD) patients experienced additional stress due to the COVID-19 pandemic. Concerns for COVID-19 disease increased the risk of immunomodulatory or biologic treatment discontinuation. Furthermore, lockdown threatened the continuity of chronic care delivery. To guarantee the continuity of care our IBD unit rapidly adapted and developed new ways of remote communication. This included telephonic clinics and telephonic pre-admission screening before every appointment at the dayclinic. In this process the IBD nurse played a pivotal role. The aim was to assess patients’ concerns during the first COVID-19 wave and their acceptance of telemedicine. Methods A cross-sectional study was performed using an anonymous electronic questionnaire (REDCap®) to assess IBD patients’ satisfaction regarding care delivery at the IBD unit of the Ghent University Hospital during the first COVID-19 wave. Results A total of 274 patients participated. Mean age was 47.5 years (SD ± 15.4). According to patients’ answers, 57.2% had Crohn’s disease, 34.5% ulcerative colitis and 8.3% reported ‘other’. During the first wave, 43.6% of patients contacted their IBD nurse; usually questions regarding medication (20.6%), appointments (18.4%) or SARS-CoV2 infection risk (6%). For the majority of patients (96.5%) these contacts were sufficient. In person follow-up consultation was scheduled for 178 patients. From those, 31 considered cancelling their consultation due to the pandemic and 18 effectively cancelled (Fig 1). Half of the population (51.6%) received intravenous therapy at the day clinic. Telephonic pre-admission screening the day before was done for all patients and well received in most of them (98.5%). During the first wave, endoscopy was planned in 31.5% of the responding patients. A minority (11.1%) postponed or cancelled endoscopic appointments. From those, 55.6% reported that the main reason was fear of the coronavirus. Ninety-four (39.2%) of responders had a telephonic consultation during the first wave. Different aspects regarding satisfaction and acceptance of telemedicine were also assessed (Fig 2–3). For further follow-up, 60.2% preferred balanced combination of telephonic and face-to-face consultations. Conclusion Remote ways of care delivery were generally well received during the first wave of the pandemic. Only a minority of patients cancelled appointments without discussion with the medical team. The most frequent patient concerns were about medications and appointments. The challenges in continuity of care during the pandemic created a window for new ways of care delivery in the future.