Healthcare-associated infections on the ICU in 21 Brazilian hospitals during the early months of the COVID-19 pandemic: an ecological study.

OBJECTIVE: The COVID-19 pandemic has caused a global health crisis and may have affected healthcare-associated infections (HAI) prevention strategies. This study aims to evaluate the impact of the COVID-19 pandemic on HAI incidence in Brazilian ICUs. METHODS: This ecological study compared adult patients admitted to the ICU from April through June 2020 (pandemic period) with the same period in 2019 (pre-pandemic period) in 21 Brazilian hospitals. The difference in microbiologically confirmed central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP) incidence density (cases per 1,000 patient days), the proportion of organisms that caused HAI, and antibiotic consumption (DDD) between the pandemic and the pre pandemic periods were compared in a pairwise analysis using the Wilcoxon signed rank sum test. RESULTS: We observed a significant increase in median CLABSI incidence during the pandemic (1.60 [0.44-4.20] vs. 2.81 [1.35-6.89], p = 0.002). There was no difference in VAP incidence between the two periods. In addition, there was a significant increase in the proportion of CLABSI caused by Enterococcus faecalis and Candida species during the pandemic, although only the latter retained statistical significance after correction for multiple comparisons. There was no significant change in ceftriaxone, piperacillin/tazobactam, meropenem, or vancomycin consumption between the studied periods. CONCLUSIONS: There was an increase in CLABSI incidence in Brazilian ICUs during the first months of COVID-19 pandemic. Additionally, we observed an increase in the proportion of CLABSI caused by E. faecalis and Candida species in this period. CLABSI prevention strategies must be reinforced in ICUs during the COVID-19 pandemic.

ANÁLISE DOS CASOS DE TRANSMISSÃO INTRA-HOSPITALAR DE COVID-19 NO HOSPITAL DO SERVIDOR PÚBLICO ESTADUAL DE SÃO PAULO

Introdução A transmissão intra-hospitalar de COVID-19 não é desprezível;pelo contrário, é necessária investigação dos casos suspeitos e rastreamento de contactantes para evitar a aquisição da doença no ambiente hospitalar. Objetivo Analisar a transmissão intra-hospitalar de COVID-19 num hospital geral, determinar a taxa de positividade dos casos suspeitos e dos contactantes e avaliar o desfecho de ambos. Método Estudo observacional, de coorte prospectivo, no qual todos os pacientes admitidos de Mar-2020 a Dez-2021 e que desenvolveram COVID-19 intra-hospitalar foram seguidos até a alta e/ou óbito, bem como seus respectivos contactantes intra-hospitalares. Estabeleceu-se um banco de dados e as características demográficas, enfermaria de origem, tempo para o desenvolvimento de sintomas, resultado de RT-PCR e desfecho do caso foram analisados. Resultados Foram internados 12.974 pacientes e identificados 405 casos suspeitos de aquisição intra-hospitalar de COVID-19, sendo 207 (51%) femininos e 198 (49%) masculinos, com idade média 69 anos e predominância na clínica médica, geriatria, cardiologia, cirurgia geral e ortopedia. O intervalo de tempo entre a internação e o início dos sintomas foi 7,1 dias. Encontrados 104 (25,7%) casos positivos, sendo 59 (32,8%) prováveis e 45 (25%) confirmados e observados 61 óbitos (58,6%) com intervalo entre a positividade do RT-PCR até o óbito de 18 dias. Identificados 565 contactantes, sendo 298 (52,7%) femininos e 267 (47,3%) masculinos, com idade média 67,8 anos e predominância na cardiologia, clínica médica, cirurgia geral, psiquiatria e geriatria. Destes, 26,8% (84/313) apresentaram RT-PCR positivo, sendo 66 (78,6%) sintomáticos e 18 (21,4%) assintomáticos. O intervalo de tempo entre o último contato com caso index e o aparecimento de sintomas foi 2 dias e a taxa de mortalidade dos contactantes foi de 44% (37/84), sendo o intervalo entre a positividade do RT-PCR até o óbito de 18 dias. A taxa de positividade geral dos casos de COVID-19 hospitalar foi de 1,3% (104/8.164). Conclusão A positividade geral de COVID hospitalar foi de 1,3%. A positividade foi de 25,7% para os casos suspeitos, sendo 59 (32,8%) prováveis e 45 (25%) confirmados e de 26,8% para os contactantes. A mortalidade hospitalar foi de 58,6% (casos) e de 44% (contactantes). Medidas de prevenção, como segregação, triagem, testagem e rastreamento dos pacientes e contactantes e uso correto de EPI's devem ser adotados para minimizar os riscos de aquisição.

AVALIAÇÃO CLÍNICA, EPIDEMIOLÓGICA E MICROBIOLÓGICA DAS INFECÇÕES DA CORRENTE SANGUÍNEA (ICS) EM PACIENTES COM COVID-19 INTERNADOS EM UNIDADES DE TERAPIA INTENSIVA (UTI)

Introdução A COVID-19 é uma doença grave que pode necessitar de internação em UTI e por isso, os pacientes possuem maior risco de desenvolver infecções relacionadas à assistência à saúde. Existem poucos dados no Brasil sobre a epidemiologia das ICS em pacientes com COVID-19 internados em UTI. Objetivo Descrever a epidemiologia, a microbiologia e o desfecho clínico dos pacientes com COVID-19 que desenvolveram ICS internados nas UTIs. Método Estudo retrospectivo, observacional, realizado no período de Mar/20-Jul/21. Foram incluídos pacientes adultos, que apresentaram ICS (critérios ANVISA) e diagnóstico confirmado de COVID-19. Analisamos todos os casos de ICS notificados pela CCIH através de busca de prontuários para análise de: sexo, idade, data internação, data da 1ª hemocultura positiva, realização de hemodiálise, micro-organismos identificados, perfil de resistência, mortalidade em 14 dias, cálculo do Escore de Bacteremia de Pitt (PBS) e realizada análise uni e multivariada para mortalidade. Resultados Analisamos 174 episódios de ICS, sendo 92 (52,9%) do sexo masculino com média de idade de 64,3 anos. O tempo médio para positividade da hemocultura foi de 13 dias. O PBS variou de 0 a 14 pontos, com média de 7 e mediana de 8 pontos. No total, 158/174 (90,8%) dos casos apresentavam PBS ≥ 4 com pontuação do estado mental ajustada com escala de RASS e 125/174 (71,8%) dos casos apresentavam PBS ≥ 4 sem a pontuação do estado mental. Hemodiálise esteve presente em 89/174 (51,1%) dos casos. A distribuição dos patógenos demonstrou 21% de espécies de Pseudomonas sp (63% de R a carbapenêmico), 16% de Enterococcus sp (7,1% de R a vancomicina), 16% de Candida sp e 16% de Klebsiella pneumoniae (92% de R a carbapenêmico). A mortalidade em 14 dias foi de 49,4% e o PBS ≥ 4 foi o único fator de risco independente para a mortalidade. Conclusão As ICS ocorreram em pacientes masculinos, idosos, graves e submetidos a hemodiálise. Os agentes etiológicos isolados foram Pseudomonas sp, Enterococcus sp, Candida sp e Klebsiella pneumoniae. A mortalidade em 14 dias foi alta e o PBS ≥ 4 pode ajudar a estimar a mortalidade. O encontro destes patógenos reflete uma mudança na epidemiologia das ICS em UTIs com a COVID-19, pois houve um aumento de patógenos do trato gastrointestinal. Conhecer a epidemiologia local das infecções na COVID-19, faz-se necessário e urgente para guiar a terapia empírica, minimizar os riscos de desenvolvimento de infecções secundárias e melhorar as práticas de controle de infecção.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

Impact of the COVID-19 pandemic on the incidence of multidrug-resistant bacterial infections in an acute care hospital in Brazil.

BACKGROUND: The impact of COVID-19 on healthcare- associated infections (HCAI) caused by multidrug-resistant (MDR) bacteria that contribute to higher mortality is a growing area of study METHODS: This retrospective observational study compares the incidence density (ID) of HCAI caused by MDR bacteria (CRE, CRAB, CRP, MRSA and VRE) pre-COVID (2017-2019) and during the COVID-19 pandemic (2020) in overall hospitalized patients and in intensive care (ICU) units. RESULTS: We identified 8,869 HCAI, of which 2,641 (29.7%) were caused by bacterial MDR, and 1,257 (14.1%) were from ICUs. The overall ID of MDR infections increased 23% (P < .005) during COVID-19. The overall per-pathogen analysis shows significant increases in infections by CRAB and MRSA (+108.1%, p<0.005; +94.7%, p<0.005, respectively), but not in CRE, CRP, or VRE. In the ICU, the overall ID of MDR infections decreased during COVID, but that decline was not significant (-6.5%, P = .26). The ICU per-pathogen analysis of ID of infection showed significant increases in CRAB and MRSA (+42.0%, P = .001; +46.2%, P = .04), significant decreases in CRE and CRP (-26.4%, P = .002; -44.2%, P = 0.003, respectively) and no change in VRE. CONCLUSIONS: The COVID-19 pandemic correlates to an increase in ID of CRAB and MRSA both in ICU and non-ICU setting, and a decrease in ID of CRE and CRP in the ICU setting. Infection control teams should be aware of possible outbreaks of CRAB and MRSA and promote rigorous adherence to infection control measures as practices change to accommodate changes in healthcare needs during and after the pandemic.

Procalcitonin as a biomarker for ventilator associated pneumonia in COVID-19 patients: Is it an useful stewardship tool?

Ventilator associated pneumonia(VAP) is a severe complication that can lead to high mortality when not early identified or when therapy is delayed. The aim of this study was to evaluate procalcitonin(PCT) as a biomarker for VAP development. In total, 73 hospitalized patients with COVID-19 were analyzed. PCT levels greater than 0.975ng/mL were more related to VAP. No association was found for C-reactive protein (CRP). The results show that procalcitonin may be a pertinent biomarker for VAP diagnosis and can be a helpful tool for antibiotic withdrawal.

Decontamination and re-use of surgical masks and respirators during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 pandemic increased global demand for personal protective equipment (PPE) and resulted in shortages. The study evaluated the re-use of surgical masks and respirators by analysing their performance and safety before and after reprocessing using the following methods: oven, thermal drying, autoclave, and hydrogen peroxide plasma vapour. METHODS: In total, 45 surgical masks and 69 respirators were decontaminated. Visual integrity, air permeability, burst resistance, pressure differential and particulate filtration efficiency of new and decontaminated surgical masks and respirators were evaluated. In addition, 14 used respirators were analysed after work shifts before and after decontamination using reverse transcription polymerase chain reaction (RT-PCR) and viral culturing. Finally, reprocessed respirators were evaluated by users in terms of functionality and comfort. RESULTS: Oven decontamination (75 °C for 45 min) was found to be the simplest decontamination method. Physical and filtration assays indicated that all reprocessing methods were safe after one cycle. Oven decontamination maintained the characteristics of surgical masks and respirators for at least five reprocessing cycles. Viral RNA was detected by RT-PCR in two of the 14 used respirators. Four respirators submitted to viral culture were PCR-negative and culture-negative. Reprocessed respirators used in work shifts were evaluated positively by users, even after three decontamination cycles. CONCLUSION: Oven decontamination is a safe method for reprocessing surgical masks and respirators for at least five cycles, and is feasible in the hospital setting.

Approach to Endoscopic Procedures: A Routine Protocol from a Quaternary University Referral Center Exclusively for Coronavirus Disease 2019 Patients

OBJECTIVES: The present coronavirus disease (COVID-19) pandemic has ushered in an unprecedented era of quality control that has necessitated advanced safety precautions and the need to ensure the adequate protection of healthcare professionals (HCPs). Endoscopy units, endoscopists, and other HCP may be at a significant risk for transmission of the virus. Given the immense burden on the healthcare system and surge in the number of patients with COVID-19, well-designed protocols and recommendations are needed. We aimed to systematically characterize our approach to endoscopic procedures in a quaternary university hospital setting and provide summary protocol recommendations. METHOD: This descriptive study details a COVID-19-specific protocol designed to minimize infection risks to patients and healthcare workers in the endoscopy unit. RESULTS: Our institution, located in São Paulo, Brazil, includes a 900-bed hospital, with a 200-bed-specific intensive care unit exclusively designed for patients with moderate and severe COVID-19. We highlighted recommendations for infection prevention and control during endoscopic procedures, including appropriate triage and screening, outpatient management and procedural recommendations, role and usage of personal protective equipment (PPE), and role and procedural logistics involving COVID-19-positive patients. We also detailed hospital protocols for reprocessing endoscopes and cleaning rooms and also provided recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission. CONCLUSION: This COVID-19-specific administrative and clinical protocol can be replicated or adapted in multiple institutions and endoscopy units worldwide. Furthermore, the recommendations and summary protocol may improve patient and HCP safety in these trying times.

COVID-19 and dental sleep medicine: risks, precautions and patient guidance.

COVID-19 is the offcial name for the disease caused by SARS-CoV-2, which has become a pandemic, infecting more than 5 million people worldwide. Transmission occurs by inhaling droplets generated when an infected person coughs, sneezes or exhales, or by touching contaminated surfaces and then rubbing their hands over their eyes, nose or mouth. Some infected people become seriously ill, while others have no symptoms, but even though they are asymptomatic, they can still transmit the virus. As vaccines and effective medications do not yet exist, the only way to handle the devastating consequences of the pandemic is prevention. Quality of sleep is essential for the immune system to be prepared to receive, fight and restore itself after a viral infection. Therefore, patients with obstructive sleep apnea (OSA) should continue treatment, and only suspend or change the therapeutic modality under the guidance of a sleep physician. In the era of COVID-19, due to the high probability of contamination promoted by CPAP, the mandibular repositioning device has been considered as the first choice for patients with OSA. However, as the dental approach is at high risk of contamination, due to the proximity of the dental surgeon to the patient, it is essential that the professional who works in this field knows the risks to which they are exposed. Precautions must be adopted and patients should be guided in order to control and use of their intraoral devices.

Disinfection of 3D-printed protective face shield during COVID-19 pandemic.

This study assessed the disinfection using 70% ethanol; H2O2-quaternary ammonium salt mixture; 0.1% sodium hypochlorite and autoclaving of four 3D-printed face shields with different designs, visor materials; and visor thickness (0.5-0.75 mm). We also investigated their clinical suitability by applying a questionnaire to health workers (HW) who used them. Each type of disinfection was done 40 times on each type of mask without physical damage. In contrast, autoclaving led to appreciable damage.

Approach to Endoscopic Procedures: A Routine Protocol from a Quaternary University Referral Center Exclusively for Coronavirus Disease 2019 Patients.

OBJECTIVES: The present coronavirus disease (COVID-19) pandemic has ushered in an unprecedented era of quality control that has necessitated advanced safety precautions and the need to ensure the adequate protection of healthcare professionals (HCPs). Endoscopy units, endoscopists, and other HCP may be at a significant risk for transmission of the virus. Given the immense burden on the healthcare system and surge in the number of patients with COVID-19, well-designed protocols and recommendations are needed. We aimed to systematically characterize our approach to endoscopic procedures in a quaternary university hospital setting and provide summary protocol recommendations. METHOD: This descriptive study details a COVID-19-specific protocol designed to minimize infection risks to patients and healthcare workers in the endoscopy unit. RESULTS: Our institution, located in São Paulo, Brazil, includes a 900-bed hospital, with a 200-bed-specific intensive care unit exclusively designed for patients with moderate and severe COVID-19. We highlighted recommendations for infection prevention and control during endoscopic procedures, including appropriate triage and screening, outpatient management and procedural recommendations, role and usage of personal protective equipment (PPE), and role and procedural logistics involving COVID-19-positive patients. We also detailed hospital protocols for reprocessing endoscopes and cleaning rooms and also provided recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission. CONCLUSION: This COVID-19-specific administrative and clinical protocol can be replicated or adapted in multiple institutions and endoscopy units worldwide. Furthermore, the recommendations and summary protocol may improve patient and HCP safety in these trying times.