SG-APSIC1097: The impact of COVID-19 on the incidence of carbapenem-resistant Enterobacterales (CRE) in Singapore: An interrupted time-series analysis

Objectives: Over the past 2 years, many infection prevention and control (IPC) resources have been diverted to manage the COVID-19 pandemic. Its impact on the incidence of antimicrobial-resistant organisms has not been adequately studied. We investigated the impact of the pandemic on the incidence of carbapenem-resistant Enterobacterales (CRE) in Singapore. Methods: We extracted data on unique CRE isolates (clinical and/or surveillance cultures) and patient days for 6 public hospitals in Singapore from the carbapenemase-producing Enterobacteriaceae (CaPES) study group database, and we calculated the monthly incidence of CRE (per 10,000 patient days). Interrupted time-series (ITS) analysis was conducted with the pre–COVID-19 period defined as before February 2020, and the COVID-19 period defined as after February 2020. Statistical analyses were performed using Stata version 15 software. Results: From January 2017 to March 2021, 6,770 CRE isolates and 9,126,704 patient days were documented. The trend in CRE monthly incidence increased significantly during the pre–COVID-19 period (0.060;95% CI, 0.033–0.094;P < .001) but decreased during the COVID-19 period (−0.183;95% CI, −0.390 to 0.023;P = .080) without stepwise change in the incidence (−1.496;95% CI, −3.477 to 0.485;P = .135). The trend in monthly incidence rate of CRE clinical cultures increased significantly during the pre–COVID-19 period (0.046;95% CI, 0.028–0.064;P < .001) and decreased significantly during COVID-19 period (−0.148;95% CI, −0.249 to −0.048;P = .048) with no stepwise change in the incidence (−0.063;95% CI, −0.803 to 0.677;P = .864). The trend in monthly incidence rate of CRE surveillance cultures decreased during the pre–COVID-19 period (−0.020;95% CI, −0.062 to 0.022;P = .341) and the COVID-19 period (−0.067;95% CI, −0.291to 0.158;P = .552) without stepwise change in the incidence (−1.327;95% CI, −3.535 to 0.881;P = .233). Conclusions: The rate of CRE in clinical cultures decreased during COVID-19 but not the rate in surveillance cultures. Further studies are warranted to study the impact of COVID-19 on CREs.(DUPLICATE DELETED)

Predictive performance of emergency department-specific variables on COVID-19 pneumonia.

INTRODUCTION: The majority of patients with COVID-19 infection do not progress to pneumonia. We report emergency department (ED)-specific variables and evaluate their predictive performance on diagnosis of pneumonia, intensive care unit (ICU) admission and death. METHODS: This was a retrospective, single-centre cohort study of confirmed COVID-19 patients admitted to a Singapore tertiary hospital. Primary outcome was diagnosis of COVID-19 pneumonia. Secondary outcomes were ICU admission and/or death. Multivariate logistic regression was used to analyse the predictive performance of ED-specific variables. Accuracy of continuous variables was measured by area under receiver operating characteristic (ROC) curve. RESULTS: 294 patients were included. Patients with pneumonia were older (52.0 years, p < 0.001) and had higher C-reactive protein (CRP; 33.8 mg/L, p < 0.001). Patients with indeterminate chest radiograph (CRX) findings were at risk of pneumonia vs. patients with normal CRX (37.5% vs. 4.3%, p < 0.001). Patients admitted to ICU were older (60.0 years, p < 0.001) and had higher CRP (40.0 mg/L, p < 0.001). Diagnosis of COVID-19 pneumonia was associated with ICU admission and death (30.0% vs 0.39%, p < 0.001). Multivariate logistic regression analysis showed that age (aOR 1.07, p = 0.049), CRP (aOR 1.05, p = 0.006) and CRX findings (aOR 50.00, p < 0.001) had increased odds of pneumonia. ROC curve analysis showed that CRP of 23.3 mg/L was the optimal cut-off for predicting pneumonia. CONCLUSION: Older age, higher CRP and CRX findings are associated with COVID-19 pneumonia, ICU admission and death. Prospective studies should be undertaken to validate these findings.

Results from a systematic programme of evaluating COVID-19 reinfection cases in the early phase of the pandemic, Singapore.

OBJECTIVES: The objectives of this study were to describe the coronavirus disease caused by SARS-CoV-2 (COVID-19) reinfection evaluation algorithm used in the early phase of the pandemic in Singapore and analyze the clinical and laboratory characteristics of the cases evaluated. METHODS: We performed a retrospective case-control analysis including all COVID-19 cases evaluated for possible reinfection under the local COVID-19 reinfection evaluation programme between 1 June 2020-30 June 2021. Whole genome sequencing (WGS) was used as confirmatory testing. We compared all reinfection ("RI") cases against those who were evaluated but eventually assessed not to be reinfection ("non-RI"). RESULTS: There were 74 possible reinfection cases evaluated through the programme, of which 32 were subsequently classified as RI. There was strong statistical evidence that RI cases had a longer interval between 1st and 2nd episode (mean 297 days; 95%-confidence interval (CI) 267-327) compared to non-RI cases (mean 186 days; 95%-CI 144-228). The cycle threshold (Ct) value of initial polymerase chain rection (PCR) at 2nd episode was also found to be significantly lower in RI cases (mean 23; 95%-CI 20-26) compared to non-RI cases (mean 34; 95%-CI 32-36). There was no significant difference in the proportion of individuals who had fever, acute respiratory symptoms or asymptomatic in both groups. Delta and beta variants were most commonly identified from WGS and provide indication of re-infection as these were not 'wild-type' and were not circulating during the time period of the index infection. CONCLUSIONS: Using a combination of serologic, microbiologic and genomic criteria to evaluate possible reinfection cases is useful and can provide a framework for evaluation that may be modified for future similar situations.

Diabetes predicts severity of COVID-19 infection in a retrospective cohort: A mediatory role of the inflammatory biomarker C-reactive protein.

Diabetes is a risk factor for developing severe COVID-19, but the pathogenesis remains unclear. We investigated if the association of diabetes and COVID-19 severity may be mediated by inflammation. We also hypothesized that this increased risk may extend to prediabetes. Hospitalized patients in Singapore with COVID-19 were subdivided into three groups in a retrospective cohort: normoglycemia (HbA1c: ≤5.6%), prediabetes (HbA1c: 5.7%-6.4%) and diabetes (HbA1c: ≥6.5%). The primary outcome of severe COVID-19 was defined by respiratory rate ≥30, SpO2 ≤93% or intensive care unit admission. The association between clinical factors on severe COVID-19 outcome was analyzed by cox regression. Adjusted mediation analysis of C-reactive protein (CRP) on the relationship between diabetes and severe COVID-19 was performed. Of 1042 hospitalized patients, mean age 39 ± 11 years, 13% had diabetes, 9% prediabetes and 78% normoglycemia. Severe COVID-19 occurred in 4.9% of subjects. Compared to normoglycemia, diabetes was significantly associated with severe COVID-19 on both univariate (hazard ratio [HR]: 9.94; 95% confidence interval [CI]: 5.54-17.84; p < .001) and multivariate analysis (HR: 3.99; 95% CI: 1.92-8.31; p < .001), while prediabetes was not a risk factor (HR: 0.94; 95% CI: 0.22-4.03; p = .929). CRP, a biomarker of inflammation, mediated 32.7% of the total association between diabetes and severe COVID-19 outcome. In conclusion, CRP is a partial mediator of the association between diabetes and severe COVID-19 infection, confirming that inflammation is important in the pathogenesis of severe COVID-19 in diabetes.

Antivirals With Adjunctive Corticosteroids Prevent Clinical Progression of Early Coronavirus 2019 Pneumonia: A Retrospective Cohort Study.

This is a retrospective cohort study of hospitalized adults with coronavirus disease 2019 (COVID-19). Fifty-seven patients received treatment alone, and 35 patients received treatment with adjunctive prednisolone. A combination of corticosteroids and antivirals was associated with lower risk of clinical progression and invasive mechanical ventilation or death in early COVID-19 pneumonia.

Age and chest radiography as possible parameters for rapid triage in COVID-19 outbreak surge (preprint)

BackgroundTo evaluate the utility of age and chest radiography(CXR) in triaging COVID-19 patients for hospitalization versus isolation in non-hospital facilities, we examined how age and CXR at diagnosis were associated with clinical needs from late-January to early-April. MethodsClinical status of all COVID-19 cases was monitored for national disease surveillance. Cases were isolated in hospitals until SARS-CoV-2 RNA was undetectable on PCR. Age and CXR results on admission were analysed for association with oxygen supplementation and mechanical ventilation, the outcomes of interest.ResultsTill 4 April 2020, there were 1,481 COVID-19 cases in Singapore. Overall, 11.4% required supplemental oxygen while 4.8% required mechanical ventilation and intensive care. The respective proportions increased to 40.9% and 16.5% for cases aged ≥70 years. As a predictor of subsequent mechanical ventilation, age had an area under the receiver operator characteristic curve(AUROC) of 0.772 (95%CI:0.699-0.845). A combined criterion of either an abnormal CXR or age≥55 years had a sensitivity of 86.7% and specificity of 58.0% for the same outcome. A similar performance was observed for predicting oxygen supplementation needs.ConclusionsAge and CXR at diagnosis may be valuable in excluding severe disease, allowing safe triage for isolation in non-hospital facilities.