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Drug resistance or multidrug resistance is multidimensional and complex. Over the past decade and especially during the covid-19 pandemic, the incidence of drug resistant infections increased despite the implementation of infection control precautions. This was most commonly seen in low- and middle-income countries, due to the higher burden of infectious diseases, lack of proper infrastructure, unregulated antimicrobial prescriptions over the counter, limited surveillance of antimicrobial use and resistance patterns. This was further compounded by the dearth of healthcare personnel trained in appropriate infectious disease management. Strategies in high income countries to prevent and manage drug resistant infections are unfortunately, not implementable in LMICs due to differences in antimicrobial resistance (AMR) burden, access to newer antibiotics, limited infrastructure and human resources with requisite expertise with lack of economic investment by regulatory authorities to tackle AMR. During the covid-19 pandemic, the lack of therapeutic options and the similar clinical picture initially led to rampant antimicrobial use which in turn contributed to rise in multi-drug resistant infections (MDR). Along with inappropriate antimicrobial use, redistribution of staff assigned to enforce infection control practices, shortage of personnel protective equipment, overcrowded healthcare settings, use of prolonged broad-spectrum antimicrobials in patients requiring during intensive care and mechanical ventilation contributed to the rise in hospital transmission of multidrug resistant infections during the pandemic. To mitigate the effects of drug resistance, healthcare systems must ensure effective implementation of surveillance of antimicrobials, AMR patterns especially in MDR HAIs and antimicrobial stewardship interventions to promote optimal antimicrobial use. National level investment to improve diagnostics must be given priority as it can limit drug resistance and promote the role of biomarkers in streamlining antimicrobial use. These need to be planned to facilitate future integration with any future pandemic surveillance.Copyright © 2023
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Background: Non-invasive ventilation (NIV) has been tried in COVID-19 ARDS (CARDS), and its role is being increasingly recognised. If proven, it could be a game-changer in resource limited settings. We report our experience with administration of respiratory support using a tabletop NIV device in a respiratory intermediate care unit (RIMCU). Methodology: We retrospectively studied a cohort of hospitalised COVID-19 patients, who received protocolised management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy for deterioration despite low flow oxygen support. Treatment was commenced with continuous positive airway pressure (CPAP) mode up to a pressure of 10 cm H2O and if required inspiratory pressures were added with the bilevel positive airway pressure (BPAP) mode. Success was defined as weaning from NIV and stepping down to the ward. Failure was defined as escalation to the intensive care unit (ICU) or need for intubation or death. Result(s): In all, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were males. Diabetes Mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77%;of this, 41% was on CPAP alone and 36% after receiving increased inspiratory pressures on BPAP mode. Conclusion(s): Respiratory support using a tabletop NIV device is an effective, and economical treatment for CARDS. Further studies are required to assess the appropriate time of initiation for maximal benefit and judicious resource utilisation.
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Background. Geographical Information Surveillance (GIS) is an advanced digital technology tool that maps location-based data and helps in epidemiological modeling. During pandemics a rapid analysis of patterns of spread can help put in place strategies for containment and infection control. We applied GIS to analyze patterns of spread and hotspots of COVID-19 infected cases in Vellore district in Tamil Nadu, South India. Methods. Laboratory-confirmed COVID-19 patients from Vellore district and neighboring taluks from March 2020 to June 2021 were geo coded (based on addresses) and spatial maps generated. These were then layered as points on the base map to illustrate the distribution of all COVID-19 cases. Time trends exploring urban-rural burden with age-sex distribution of COVID-19 cases and other variables were correlated with outcomes of death, symptoms and complications. Map of undivided Vellore district showing rural and urban settlements. Results. A total of 45,401 cases of COVID-19 were detected between 28 March 2020 to 31 June 2021 with 20730 cases during the first wave (28 March 2020 to 31 March 2021) and 24671 cases during the second wave (1 April 2021 to 30 June 2021). The overall incidence rates of COVID-19 across the study region was 462.8 per 100,000 and 588.6 per 100,000 population during the first and second waves respectively. Pattern of spread revealed epicentres in densely populated urban areas with radial spread, sparing rural areas, Heat maps also confirmed higher densities at these epicentres, however, the second wave had more peri-urban and rural area involvement. Case fatality rate was 1.89% and 1.6% during the first and second waves and increased with advancing age, i.e., 7.38% were aged more than 60 years in the first wave and 5.02% in the second wave. Incidence was higher in men, 2.40%, and 1.76% as compared to women who had 1.16% and 1.38% in the first and second waves respectively. Overall, case fatality rates were the highest among those who had >2 comorbidities (9.52%). Subdistrict level incidence of COVID-19 during the first and second waves. Epidemic curve of the COVID-19 pandemic during the first and the second waves. Conclusion. Modern surveillance systems like GIS can accurately predict the trends of the outbreak and pattern of spread during future respiratory pandemics. Employing this in real time can help design risk mitigation strategies improving health care access and monitoring with prevention of spread to rural areas.
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Background. Increased antibiotic usage during the COVID-19 pandemic and resultant infection control measures derailed the existing antimicrobial stewardship program which involved in person post prescription review and feedback. We performed a time series analysis using Procalcitonin as a tool for a remotely delivered antimicrobial stewardship program by a clinical pharmacist. Methods. This study was conducted in a tertiary care 3500 bedded teaching hospital in southern India. In the baseline phase, all COVID-19 in-patients receiving antibiotics > 48 hours were screened via the electronic records by a pharmacist and antimicrobial consumption indices like days of therapy (DOT) and length of therapy (LOT) were measured. In the intervention phase, if a patient was on antimicrobials, then a PCT was sent. An alert was sent to the treating team based on the procalcitonin levels and a screening of electronic records by a clinical pharmacist to either continue/ de-escalate or discontinue an antibiotic under supervision of an Infectious Diseases physician. Figure 1 Guideline for continuing or stopping antibiotics based on procalcitonin levels Figure 2 Guideline for continuing or stopping antibiotics based on procalcitonin levels Study Flow Results. About 481 patients were enrolled in the pre intervention phase of the study from July to October 2020 (peak of the pandemic) and 90 patients in the intervention phase December 2020 - March 2021 (decline of the pandemic. The baseline characteristics are shown in Figure3. The DOT/1000 patient days (PD) for all antibiotics was 9269 (DOT-6915) in the baseline and 2032 (DOT-886) in the intervention arm. The total length of therapy (LOT) for antimicrobial consumption significantly reduced from 3779 in the pre-intervention phase to 657 in the intervention phase (Figure 4). Out of the 90 recommendations given in the intervention phase, 82 (91.1%) were accepted by the treating team. For Azithromycin and Doxycycline, DOT significantly reduced from 3319 to 486 per 1000 PD and 602 to 158 per 1000 PD respectively. The DOT of the reserve antibiotics according to the WHO AWaRe classification like Polymyxins and Carbapenems decreased from 323 to 67 and 777 to 443 per 1000 PD days in the intervention phase. Conclusion. This study demonstrated the utility of a novel biomarker driven antimicrobial stewardship strategy by clinical pharmacists during the COVID pandemic when access to patients was restricted to both infection control physicians and pharmacists.
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Respiratory infections are among the most common and serious infections after solid organ transplantation (SOT). Infections within a month after transplant are usually donor-derived or bacterial infections related to surgical infections or ventilator associated. Infections between 1-6 months after SOT are mostly opportunistic due to various viruses, or fungal infections. After 6 months of transplantation usually community acquired infections predominate, however it is not uncommon to find opportunistic fungal and viral infections in this period. The signs and symptoms of these infections are often mitigated in SOT recipients, so a high index of suspicion is required along with microbiological or tissue diagnosis early in the course to timely treat these infections. Thorough screening for common infections and endemic infections is required in donor and recipients before transplantation to reduce the risk of infections in posttransplant period. Finally, a longer duration of treatment and prophylaxis is required for adequately treat these infections and prevent the relapse. Copyright © 2022 Indian Journal of Transplantation Published by Wolters Kluwer - Medknow.
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Background: N95 respirators have prevented transmission among health-care workers during the COVID-19 pandemic. During times of intense shortage of respirators and border closures during the pandemic, re-use strategies with available decontamination methods were necessitated. This in-house experimental study evaluated the effect of hydrogen peroxide gas-plasma sterilization on respirators and helped establish an evidence-based protocol for their re-use in a resource-poor setting. Materials and Methods: A three-dimensional experimental model using saline nebulization as the aerosol exposure and a particle counter to measure the filtration of particles through the mask pre- and post-sterilization was used. Multiple cycles of plasma sterilization were done till the physical integrity/fit was lost. Total filtration volume was used as a surrogate marker to assess the filtration efficiency (FE). Results: The total volume of particles filtered on a 3M respirator was 99.9%. Unused Halyard and Venus respirators were compared against 3M and found to have FE of 99.9% and 60.5%, respectively. After repeated sterilization cycles, the total volume of particles filtered was 59.3% for Halyard in the seventh cycle and 36.2% for Venus in the fifth cycle. When the physical integrity and fit was tested, the appropriate fit was lost after eight cycles of sterilization for Venus and was not lost for Halyard even after the tenth cycle. Conclusion: This low-cost experimental study helped implement an effective and safe decontamination strategy for safe re-use of N95 respirators in an emergent situation with no access to commercial testing in a resource poor health-care setting during the pandemic.
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Aim and background: COVID-19 was a new disease-causing a pandemic and hence generated uncertainty, and a great deal of anxiety with regard to appropriate therapeutic interventions. Many treatment regimens were tried with no evidence supporting the same. Critical and fatal COVID-19 due to immune dysregulation results in severe inflammation or a cytokine storm with markedly elevated pro-inflammatory cytokines like interleukin-6 (IL-6). Tocilizumab, an IL-6 receptor antagonist, is reported to prevent disease progression. However, since this is an expensive intervention, it is important that evidence is reviewed systematically regarding its utility. The India COVID guidelines is a group of experts and methodologists who came together to use a process of evidence synthesis to inform treatment guidelines using an evidence to decision framework (www.indiacovidguidelines.org). We report the data regarding tocilizumab in severe to critical COVID-19 infection. Objectives: To assess the efficacy and safety of tocilizumab in patients with COVID-19. Materials and methods: Search methods: We performed a systematic search till 15.10.2021 of the following databases: Pubmed, WHO ICTRP, L.OVE platform, Cochrane library, and COVID-NMA. Selection criteria: We selected only randomised controlled trials (RCT) evaluating tocilizumab use in COVID-19. Data collection and analysis: Two review authors independently screened and identified studies using Rayyan, did a risk of bias assessment using the Cochrane ROB 2 tool and extracted numerical data from studies for outcomes like all-cause mortality, disease progression, clinical improvement, and adverse events. Meta-analysis was performed using Review Manager 5.4. I2 statistics were used to measure residual heterogeneity. Certainty of evidence was evaluated using GRADE methodology. A group of experts then used the WHO evidence to decision framework to judge values and preferences, and a recommendation for tocilizumab applicable to a lower-middle-income country was generated. Results: Our search retrieved 1408 s from various databases. Twenty-three RCTs were included in this systematic review with 10,583 participants. All participants were hospitalised adults with moderate to severe disease with an average age of 54-65 years. Median C-reactive protein was ≥ 100 mg/L indicating significant systemic inflammation. Prevalence of comorbidities varied and tocilizumab was initiated in rapidly worsening patients within 24-48 hours of admission to intensive care in most trials. More than 80% of participants were administered corticosteroids. Tocilizumabtreated patients showed a significant reduction in mortality with RR 0.88 (95% CI 0.81, 0.94) and reduced disease progression with RR 0.87 (95% CI 0.72, 1.06) with moderate certainty of the evidence, increased clinical improvement with RR 1.04 (95% CI 1.00, 1.09), and reduced time to clinical improvement with HR 1.22 (95% CI 1.14, 1.30) with low certainty of evidence. There was very low certainty in the evidence for adverse events and serious adverse events. Secondary infections were uncommon in most trials with follow-up till 14 or 28 days, which may have been too early to detect the same. Conclusion: A systematic review and meta-analysis which generated efficacy data of tocilizumab was then applied to an evidence to decision framework by subject experts resulting in a robust evidence-informed guideline applicable to any Indian secondary or tertiary healthcare setting.
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Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the effects of molnupiravir in people with confirmed SARS-CoV-2 infection and mild-to-moderate symptoms, with or without risk factors for severe disease.
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In the past 20 years, several viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 and 2003, H1N1 influenza in 2009, and Middle East Respiratory Coronavirus in 2012 have been recorded. The COVID-19 pandemic caused by SARS-CoV-2 has infected millions across the globe and has been a unique public health challenge with its increased rates of contagion and transmission. This outbreak was likely to have started from a zoonotic transmission event associated with a large sea-food market that also traded live wild animals. An exponential increase in the number of nonzoonotic cases in late December 2019, pointed toward the risk of human-to-human transmission. This led to a faster spread of infection and made the outbreak difficult to contain. The situation was unique in the busy Emergency Department (ED) of our institution, where regular emergency care could not be halted but had to be modified to accommodate COVID-19 confirmed and suspect patients. The ED needed to develop standard operating protocols to isolate and manage these patients, without putting other patients and health-care workers at risk of infection. This is a story of evolving practices in the ED of a leading tertiary care center of South India. © 2022 Medical Journal of Dr. D.Y. Patil Vidyapeeth ;Published by Wolters Kluwer - Medknow
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Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To determine the efficacy and safety of favipiravir in patients with COVID-19 as compared to standard of care without favipiravir. Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Background. Remdesivir (RDV), was included for the treatment of mild to moderate COVID-19 since July 2020 in our institution, following the initial results from ACTT-1 interim analysis report. With the adoption of RDV, there seems to be anecdotal evidence of efficacy as evidenced by early fever defervescence, quick recovery when on oxygen with decreased need for ventilation and ICU care. We aimed to study the impact of RDV on clinical outcomes among patients with moderate to severe COVID -19. Methods. Nested case control study in the cohort of consecutive patients with moderate to severe COVID - 19. Cases were patients initiated on RDV and age and sex- matched controls who did not receive RDV were included. The primary outcome was in-hospital mortality. Secondary outcomes were, duration of hospital stay, need for ICU, duration of oxygen therapy and need for ventilation. Results. A total of 926 consecutive patients with COVID - 19 were included, among which 411 patients were cases and 515 controls. The mean age of the cohort was 57.05±13.5 years, with male preponderance (75.92%). The overall in-hospital mortality was 22.46%(n=208). On comparison between cases and controls there was no statistically significant difference with respect to primary outcome [22.54% vs. 20.78%, (p value: 0.17)]. Progression to non-invasive ventilation (NIV) was higher among the controls [24.09% vs. 40.78% (p value: < 0.001∗)]. Progression to invasive ventilation was also higher among the controls [5.35% vs. 9.71% (p value: 0.014∗)]. In subgroup analysis among critically ill patients, the use of RDV showed decrease in mortality (OR 0.32 95% CI;0.13 - 0.75 p value - 0.009∗). Conclusion. RDV did not decrease the in-hospital mortality among moderate to severe COVID - 19. However, there seems to be a significant reduction in mortality in critically ill patients.
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In late 2019, an epidemic of Novel Corona Virus infection later named SARS-CoV2 hit China followed by rapid spread of infections across the World. Notwithstanding Government mandated measures like lockdown, rigorous testing, universal masking and COVID-19 screening camps, it is important for hospitals to be prepared to face the pandemic. A proper triaging facility with appropriate infection control precautionary measures, adequate supply of Personal Protective Equipment (PPE), rational usage of disinfectants and PPE, protection of health care workers and prevention of cross transmission of infection in a health care setting needs to be implemented through appropriate guidance and experts. In this review article, we share our experience and key areas that need to be addressed by any institution during a pandemic situation.
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Background and Objectives: The COVID-19 pandemic has highlighted the risk of airborne transmission of infections in health-care facilities such as dental clinics. In this experimental study, methods to control airborne particles in a simulated dental clinic setting were measured and compared using a low cost and convenient technique. Materials and Methods: Particles representing inhalable airborne particles were generated using smoke from incense sticks and their concentration measured by handheld particle sensors whereas using different engineering controls for the particle removal in dental clinic equivalent settings. Measurements were made at short (<3 ft) and intermediate (between 3 and 6 ft) distance from the source. The particle filtration through surgical masks and N95 masks was also studied. Results: Natural ventilation, by keeping windows open, can reduce intermediate range particles (removal of 4.7% of ambient particles/min). However, in closed facilities without natural ventilation, particle removal by air purifier combined with overhead fan or with high volume evacuators was found most suitable for intermediate range particles (25.9%/min) and for short range particles (27.6%/min), respectively. N95 masks were found to filter out 99.5% of the generated PM 2.5 particles. Conclusions: Potentially inhalable airborne particles can persist in the air of a dental clinic. The use of N95 masks and environmental controls is essential for the dental team's safety. The choice of an engineering control is governed by multiple factors explained in the study. Smoke particles generated by incense sticks and measurement by handheld particle sensors are low-cost methods to estimate the effectiveness of airborne particle controls.