Clinical features and outcomes of COVID-19 admissions in a population with a high prevalence of HIV and tuberculosis: a multicentre cohort study.

BACKGROUND: There is still a paucity of evidence on the outcomes of coronavirus disease 2019 (COVID-19) among people living with human immunodeficiency virus (PWH) and those co-infected with tuberculosis (TB), particularly in areas where these conditions are common. We describe the clinical features, laboratory findings and outcome of hospitalised PWH and human immunodeficiency virus (HIV)-uninfected COVID-19 patients as well as those co-infected with tuberculosis (TB). METHODS: We conducted a multicentre cohort study across three hospitals in Cape Town, South Africa. All adults requiring hospitalisation with confirmed COVID-19 pneumonia from March to July 2020 were analysed. RESULTS: PWH comprised 270 (19%) of 1434 admissions. There were 47 patients with active tuberculosis (3.3%), of whom 29 (62%) were PWH. Three-hundred and seventy-three patients (26%) died. The mortality in PWH (n = 71, 26%) and HIV-uninfected patients (n = 296, 25%) was comparable. In patients with TB, PWH had a higher mortality than HIV-uninfected patients (n = 11, 38% vs n = 3, 20%; p = 0.001). In multivariable survival analysis a higher risk of death was associated with older age (Adjusted Hazard Ratio (AHR) 1.03 95%CI 1.02-1.03, p < 0.001), male sex (AHR1.38 (95%CI 1.12-1.72, p = 0.003) and being "overweight or obese" (AHR 1.30 95%CI 1.03-1.61 p = 0.024). HIV (AHR 1.28 95%CI 0.95-1.72, p 0.11) and active TB (AHR 1.50 95%CI 0.84-2.67, p = 0.17) were not independently associated with increased risk of COVID-19 death. Risk factors for inpatient mortality in PWH included CD4 cell count < 200 cells/mm3, higher admission oxygen requirements, absolute white cell counts, neutrophil/lymphocyte ratios, C-reactive protein, and creatinine levels. CONCLUSION: In a population with high prevalence of HIV and TB, being overweight/obese was associated with increased risk of mortality in COVID-19 hospital admissions, emphasising the need for public health interventions in this patient population.

Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation.

Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.

Opportunities to enhance antibiotic stewardship: colistin use and outcomes in a low-resource setting.

BACKGROUND: Colistin use is increasing with the rise in MDR Gram-negative infections globally. Effective antibiotic stewardship is essential to preserve this antibiotic of last resort. OBJECTIVES: This study investigated stewardship and safety errors related to colistin use to identify opportunities for improvement. PATIENTS AND METHODS: A prospective descriptive study involving all patients 13 years and older treated with colistin at a tertiary hospital in Cape Town, South Africa, between August 2018 and June 2019. We collected clinical, laboratory and outcome data and assessed provided treatment for stewardship and safety errors. RESULTS: We included 44 patients. Treatment errors were identified for 34 (77%) patients (median = 1), most commonly inadequate monitoring of renal function (N = 16, 32%). We also identified no rational indication for colistin (N = 9, 20%), loading dose error (N = 12, 27%); maintenance dose error (N = 10, 23%); no prior culture (N = 11, 25%); and failure to de-escalate (2 of 9) or adjust dose to changes in renal function (6 of 15). All cause in-hospital mortality was 47%. Amongst survivors, median ICU stay was 6 days and hospital stay more than 30 days. Eight (18%) patients developed renal injury or failure during treatment. Three (7%) patients in this study were found to have colistin-resistant organisms including two prior to colistin exposure. CONCLUSIONS: This study has identified opportunities to enhance colistin stewardship and improve efficacy and safety of prescription. The appearance of colistin-resistant organisms reinforces the urgent need to ensure effective and appropriate use of colistin.

Staff testing for COVID-19 via an online pre-registration form.

BACKGROUND: Healthcare workers are at increased risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and potentially causing institutional outbreaks. Staff testing is critical in identifying and isolating infected individuals, whilst also reducing unnecessary workforce depletion. Tygerberg Hospital implemented an online pre-registration system to expedite staff and cluster testing. We aimed to identify specific presentations associated with a positive or negative result for SARS-CoV-2. METHODS: A retrospective descriptive study design involving all clients making use of the hospital's pre-registration system during May 2020. RESULTS: Of 799 clients, most were young and females with few comorbidities. Nurses formed the largest staff contingent in the study, followed by administrative staff, doctors and general assistants. Doctors tested earlier compared with other staff (median: 1.5 vs. 4 days). The most frequent presenting symptoms included headache, sore throat, cough and myalgia. Amongst those testing positive (n = 105), fever, altered smell, altered taste sensation, and chills were the most common symptoms. Three or more symptoms were more predictive of a positive test, but 12/145 asymptomatic clients also tested positive. CONCLUSION: Staff coronavirus testing using an online pre-registration form is a viable and acceptable strategy. Whilst some presentations are less likely to be associated with SARS-CoV-2 infection, no symptom can completely exclude it. Staff testing should form part of a bundle of strategies to protect staff, including wearing masks, regular handwashing, buddy screening, physical distancing, availability of personal protective equipment and special dispensation for coronavirus disease 2019 (COVID-19)-related leave.

Implementing a video call visit system in a coronavirus disease 2019 unit.

The lockdown and physical distancing strategies imposed to combat COVID-19 have caused seismic shifts at all levels of society. Hospitals have been particularly affected. Healthcare workers (HCW's) wore PPE during all patient interactions and visitors were prohibited. Life for a patient became lonelier and for those with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) measures were even more severe. HCW's must treat patients following a biopsychosocial approach and promote communication between patients and loved ones. We implemented a low cost Video Call Visit system at Tygerberg Hospital, Cape Town. In this article we discuss the elements of a successful implementation and potential pitfalls in the context of a pandemic, notably cross-infection and privacy. Rapid but responsible innovation using 21st century tools was required to address the many challenges of the pandemic, including improving the lived experience for patients and families. These should be intended to last after the pandemic has passed.