Delhi's network for surveillance of antimicrobial resistance: The journey, challenges and output from first year.

PURPOSE: Antimicrobial resistance [AMR] has emerged as a global and national priority and establishing an effective surveillance system for antimicrobial resistance is an essential prerequisite for generating evidence for informed policymaking at both national and state levels. METHODS: Twenty-four laboratories were enrolled after assessment in the WHO-IAMM Network for Surveillance of Antimicrobial Resistance in Delhi [WINSAR-D]. The NARS- NET standard operating procedures were adopted along with its priority pathogen lists and antibiotic panels. The members were trained to use WHONET software and monthly data files were collected, collated, and analyzed. RESULTS: Multiple logistic issues such as procurement, erratic supply of consumables, non-availability of standard guidelines, lack of automated systems, high workload and low manpower were reported by the majority of member laboratories. Microbiological challenges such as differentiation between colonization and pathogen in absence of patient details, lack of confirmation of resistance, identification of isolates and lack of dedicated computer and genuine windows software for data were common to most laboratories. The total number of isolates of priority pathogens in 2020 was 31,463. Of these, 50.1% isolates were from urine 20.6% were from blood and 28.3% were from pus aspirate and other sterile body fluids. High levels of resistance were observed for all antibiotics. CONCLUSION: There are many challenges in generating quality AMR data in lower-middle-income countries. There is a need for resource allocation and capacity building at all levels to ensure the collection of quality assured data.

Assessment of Knowledge, Attitude, Awareness, and Opinion of Patients on Routine Dental Services during COVID-19 Pandemic: A Cross-sectional Study

Background: The novel severe acute respiratory syndrome-coronavirus-2 virus has undoubtedly disrupted the life of every individual and created a global health and economic crisis. Health-care systems, including dental clinics, were affected and patients with dental pain suffered since they were unable to seek dental care at the right time. It has since become relevant to examine and understand the outlook and views of patients toward seeking routine dental services and their acceptance of alternative methods of dental practice through the COVID-19 pandemic. Hence, this cross-sectional questionnaire study was conducted to assess the knowledge, attitude, and opinion of patients visiting a dentist for routine dental services during the COVID-19 pandemic Methodology: A cross-sectional questionnaire-based survey was conducted among 200 patients who visited the dental college for their treatment. Their responses were recorded and descriptive analysis, Chi-square test, and multiple logistic regression analysis were carried out to evaluate their responses. Results: The participants were aware of the transmission of COVID-19 (91%), 64% believed it was safe to visit a dentist and 99.5% believed it necessary to take proper precautions before visiting the dentist. Participants (84%) preferred having dental consultations over phone/email/video calls compared to regular in-person consultations during the pandemic. Conclusion: Teledentistry has the potential to emerge as an effective mode of managing patients with dental needs to reduce the burden on dental clinics and hospitals. It can ensure the accessibility to dental care even in the remotest area by allowing patients to connect with dentists through appropriate digital and social media.

Severe acute respiratory infection-preparedness (Sari-Prep): A multicenter prospective study

OBJECTIVES: We designed a prospective cohort study to systematically study patients with severe acute respiratory infection (SARI) and improve hospital preparedness (SARI-PREP). The goal of this project is to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with SARI clinical outcomes and severity. METHODS: In collaboration with the Society of Critical Care Medicine Discovery Research Network and the National Emerging Special Pathogen Training and Education Center (NETEC), SARIPREP is an ongoing, prospective, observational, multi-center cohort study of hospitalized patients with respiratory viral infections. We collected patient demographics, signs, symptoms, and medications;microbiology, imaging, and other diagnostics;mechanical ventilation, hospital procedures, and other interventions;and clinical outcomes. Hospital leadership completed a weekly hospital stress survey. Respiratory, blood, and urine biospecimens were collected from patients on days 0, 3, 7-14 after study enrollment and at hospital discharge. MEASUREMENTS AND MAIN RESULTS: SARI-PREP enrollment began on April 4, 2020 and currently includes 674 patients. Here we report results from the first 400 patients: 216 are from the University of Washington Hospitals, Seattle WA, 142 from New York University, New York NY and 42 from University of Southern California, Los Angeles, CA. Almost all tested positive for SARS-CoV-2 infection (n=397), whereas 3 patients tested positive for an alternative viral pathogen. The mean (±SD) age of the patients was 57±16 years;72% were men, 62% were White, 14% were Asian, 12% were Black, and 31% were Hispanic. Most of the patients were admitted to the intensive care unit (96%). The median (interquartile range) hospital length of stay was 22 (9-46) days. Rates of invasive mechanical ventilation (72%) and renal replacement therapy (19%) were common and the rate of hospital mortality was 35%. CONCLUSIONS: Initial SARI-PREP analysis indicates enrollment of a diverse population of hospitalized patients primarily with SARSCoV-2 infection. The demographics and clinical outcomes of our cohort mirror other large critically ill cohorts of COVID-19 patients. Results of a concomitant, weekly, hospital stress assessment are reported separately.

Original article clinicoepidemiological profile and outcome of COVID-19 positive health care workers in a tertiary care centre in south India microbiology section

Introduction: Coronavirus Disease 2019 (COVID-19) is rapidly spreading in India and all over the world. Being at the frontline in the battle against COVID-19, Health Care Workers (HCWs) are among the greatest groups at risk of COVID-19 infection. Therefore, it is very important to study the risk and sources of infection and clinical outcome of HCWs. Aim: To study the clinico-epidemiological profile and outcome of COVID-19 positive HCWs in Government Medical College Thrissur, Kerala, India. Materials and Methods: This was a hospital based cross-sectional study conducted during the time period from February 2020 to December 2020. A semi-structured telephonic interview schedule and hospital based records were used to collect the demographic, epidemiological and clinical information of 235 COVID-19 positive HCWs. Proportions along with 95% Confidence Interval was used to express the results. Results: Among 235 COVID-19 positive HCWs, 51% were either nurses or auxiliary nursing staff. Non-COVID-19 areas had 31.9% infections, while 17.1% of infections occured in COVID-19 areas. Around 57% acquired infection from health care settings. Common symptoms were fever (67.2%), myalgia (40.4%) and headache (39.6%). Around 21.3% subjects remained asymptomatic. Hand hygiene compliance was 96.6%. Among positive HCWs, 57% used N95 mask, 52.8% used gloves, 49.8% used apron and 48.9% used face shield in the hospital. Only 0.85% required Intensive Care Unit (ICU) admission. No mortality was reported in the present study. Conclusion: There is a considerable risk for COVID-19 infection among HCWs in hospital settings especially from non-COVID-19 areas. Present study findings show the risk of exposure and need of infection control measures even outside the health care settings. Early identification and isolation of cases is very important. This study will be useful for policy makers in planning control strategies and preventing COVID-19 infections among HCWs.

Persistence of symptoms after acute COVID-19 infection- An experience from a tertiary care centre in South India

Introduction: COVID-19 pandemic is posing a challenge not only with sheer number of people infected but also with the large number of patients with persistent symptoms of COVID-19 infection. A proper understanding of the magnitude and associated factors of persistent COVID-19 symptoms will go a long way in planning treatment and control strategies. Aim: To determine the proportion of patients who have persistent symptoms post-acute COVID-19 infection and to determine the factors associated with it, among those who have been discharged from Government Medical College, Thrissur. Materials and Methods: The current cross-sectional study was conducted among 335 patients who were admitted and discharged with COVID-19 infection in Government Medical College, Thrissur, Kerala, a tertiary care institution in southern India between December 2020 and February 2021. They were contacted through a telephonic interview 28 days from symptom onset through a semi-structured interview schedule. The questions included basic demographic details, symptomatology at admission, persistent symptoms at 28 days after onset and other clinical details including comorbidities. For defining post-COVID-19 symptom persistence National Institute for Health and Care (NICE) guidelines were used. Association between persistent symptoms and selected factors was done by Chi-square test. Results: Out of the 335 patients, the persistence of symptoms of COVID-19 infection after 28days of symptom onset was 221 (66%) C.I -60.7-70.8%). Persistence of two or more COVID-19 symptoms after 28 days of onset was seen in 120 (35.8%). The most common persistent symptoms among the patients were fatigue in 109 (32.5%) of people followed by dyspnoea in 77 (23%), cough in 45 (13.4%) and myalgia in 37 (11%) patients Highest persistence was seen in Category C patients where symptoms were persisting in 75%. Persistence was also higher in those with diabetes mellitus, those who received oxygen support and those who were in Intensive Care Unit (ICU) or ventilator and the association was statistically significant(p-value<0.05). Conclusion: The study shows that 2/3rd of patients still continues to have persistent symptoms even after 28 days of symptom onset. Health systems should be prepared to face the consequences of morbidities caused by post COVID-19 syndrome.

Icu visitor restriction policies and approaches to family engagement during the COVID-19 pandemic

INTRODUCTION: Communication with family members of ICU patients has changed dramatically during the COVID-19 pandemic. To investigate these changes, we interviewed site project leaders among ICUs that had participated in the Family Engagement Collaborative (FEC), a shared learning experience begun by SCCM in September 2019 that promoted ICU family engagement projects among participating sites before being cancelled in March 2020 due to COVID-19. METHODS: We developed a structured set of survey questions regarding the impact of COVID-19 on ICU family visitation and engagement and assessed content validity via an iterative process amongst FEC leadership. From June 9 to July 17, we contacted the site leader of all 27 ICUs that had participated in the FEC and administered the survey by phone. We also asked site leaders to provide a copy of their current visitor restriction policy. RESULTS: 22/27 (81.5%) site leaders participated. When asked about the peak of the pandemic in their respective ICUs, 2 sites (9.1%) reported having had a strict no-visitor policy without any exceptions. The remaining sites all reported a variety of exceptions, with a majority allowing visitation for patients at the end-of-life. Regarding current policies, all sites now have some visitor restriction exceptions in place, but with significant variability;at least half (12, 54.5%) of sites now permit at least 1 visitor for non-COVID patients during defined visitor hours. Four sites (21.1%) reported that their hospital did not provide PPE to visitors. 16 sites (84.2%) were unclear of their hospital's timeline for further relaxing visitor restrictions. All but 1 site (95.5%) reported now using video conferencing with families;however, 10 sites (47.6%) reported clinicians' using their own personal devices for conferencing. Among hospitals providing devices for staff, approximately 1 device had been provided on average for every 13 ICU beds. CONCLUSIONS: While ICU visitor policies have somewhat relaxed since the peak of the pandemic, there is considerable uncertainty about how policies might change moving forward. ICUs need additional resources to provide PPE for visitors and to ensure adequate video conferencing capabilities on hospital devices.

Lessons learned from the sccm family engagement collaborative prior to the COVID-19 pandemic

INTRODUCTION: The Family Engagement Collaborative (FEC) was a year-long shared learning experience begun by SCCM in September 2019 that utilized educational webinars, conference calls, listserv communications, and centralized family and clinician data collection to promote ICU family engagement projects among participating sites. We describe lessons learned from the FEC up to the point at which it was cancelled due to COVID-19, at a time when most sites had just begun local project implementation. METHODS: During an orientation period, sites reported on their selected local projects via scheduled conference calls and an online listserv. All sites also planned individual methods of assessing project impact via pre- and postimplementation data collection, with the option of utilizing an SCCM REDCap database for FS-ICU 24R and IPFCC Clinician Survey data starting in January 2020. After the FEC was cancelled in March 2020, each site leader was contacted to participate in a structured phone exit interview. RESULTS: Among 27 actively participating ICUs, the most common projects were creating ICU orientation videos, packets, or educational programs (12, 44.4%) promoting structured family care conferences (6, 22.2%), and implementing ICU diaries (5, 18.5%). 212 FS-ICU 24R surveys and 346 IPFCC Clinician Surveys collected across sites before project implementation highlighted a broad need for improving family support. After cancellation, 22 site leaders (81.5%) completed an interview. 20 sites (90.1%) reported stopping their project implementation due to the pandemic. The only 2 sites that continued projects were implementing (1) a standardized palliative extubation protocol and (2) daily written summaries for families of non-decisional patients. When all site leaders were asked to rate how helpful the FEC had been from a scale of 0-10, mean response was 8.0 (SD 2.5). Seven leaders (25.9%) suggested that a future FEC could benefit by focusing more on sites implementing a specific standardized project, as opposed to promoting a variety of different ideas. CONCLUSIONS: While the pandemic had a profound impact on sites' implementation of family-centered care projects that are of clear need, participants found value in the FEC's educational and communication model and provided actionable feedback for future iterations.

Home respiratory specimen collection in children with cystic fibrosis

Introduction: Collection of respiratory cultures for airway microbiology surveillance is an essential component of routine clinical care of individuals with CF. The COVID-19 global pandemic has necessitated an increase in the use of telehealth services to deliver care, but one limitation of telehealth is the inability to collect respiratory specimens. Therefore, we initiated a protocol for at-home collection of expectorated sputum (ES) and oropharyngeal (OP) swabs from children with CF followed at the Children's Hospital Colorado CF Center. Methods: Home respiratory specimen collection is offered by providers around the time of telehealth encounters. Respiratory specimen collection kits for either ES or OP swabs are mailed to participating families with instructions for specimen collection and return. The specimens are returned either by overnight mail or dropped off at a local Children's Colorado clinical laboratory for processing and culture according to a standard CF protocol. Data recorded include parental interest in receiving a kit, the number of kits sent and returned, and microbiology culture results. We plan to compare culture results from the home respiratory specimen to the most recent respiratory specimen collected in clinic for each patient to track concordance of the culture in the home environment, and to establish whether new pathogens were identified. We are also tracking the rate of Pseudomonas aeruginosa identification on home respiratory specimens to assess frequency with which the at-home specimen culture results impact clinical care decisions. Results: Home respiratory specimen collection kits have been sent to the families of 46 participating children with CF (patient age range 2-20 years), including 27 OP swab kits and 19 ES collection kits. Home respiratory specimen collection has only been declined by 4 families to whom it was offered (patient age range 2-11 years). To date, 13 specimens, including 11 OP swabs and 2 ES samples, have been returned for processing and culture. No growth or growth of upper respiratory flora alone was detected from 3 of the specimens, which was consistent with the most recent culture results from an in-clinic visit in each of these cases. One or more CF pathogens grew from 10 of the specimens. Of these, 5 grew the same CF pathogens that had previously grown from the patients' most recent in-clinic culture. CF pathogens were identified for 5 patients which had not been detected on the most recent in-clinic specimen. For 2 of these patients, the home collection specimen demonstrated growth of P. aeruginosa and resulted in initiation of eradication treatment with inhaled tobramycin. Conclusions: Home collection of respiratory specimens for bacterial culture is feasible in children with CF. Thus far, most specimens demonstrated growth of one or more CF pathogens, and most home cultures had results that were similar to recent in-clinic specimens, suggesting acceptable sample collection technique and sample integrity in the home setting. Anti-pseudomonal therapy was initiated for two children based on growth of P. aeruginosa from the home respiratory specimen.