Treatment Outcome with High versus low-to-moderate Dosing of Corticosteroids in Early vis-a-vis Late-onset Hypoxic Cases of COVID-19: A Multicentric Retrospective Cohort Study.

Background: Corticosteroid dosing in COVID-19 cases associated with early-onset and late-onset hypoxia have not been separately explored. Methods: In this retrospective cohort study, we divided hypoxic COVID-19 cases into groups based on timing of initiation of corticosteroids relative to onset of symptoms; Group A (≤6th day), Group B (7th-9th day) and Group C (≥10th day), each group being sub-grouped into high and low-to-moderate dose corticosteroid recipients. Cox regression with propensity scoring was used to compare 28-day mortality between high and low-to-moderate dose recipients separately in Group A, Group B, Group C. Results: Among 505 patients included, propensity score matched Cox regression showed greater risk of all-cause mortality among high dose recipients in Group A [HR= 7.35, 95%CI 3.36-16.11, p-value<0·01, N=114] and Group B [HR=3.17, 95%CI 1.65-6.07, p-value<0·01, N=251]. In Group C, mortality was lowest [12.8% (18/140)] with no significant difference between sub-groups [HR=2.52, 95%CI 0.22-29.15, p-value=0.459, N=140]. Kruskal-Wallis Test between Group A, Group B and Group C for six pre-defined exposure variables showed significant differences for Neutrophil:Lymphocyte Ratio (NLR). Conclusion: When steroids were initiated early (owing to an earlier onset of hypoxic symptoms), a high dose of corticosteroid was associated with greater overall 28-day mortality compared to a low-to-moderate dose. NLR, a marker for individual immune response, varied between treatment groups.

Transfer Time from the Intensive Care Unit and Patient Outcome: A Retrospective Analysis from a Tertiary Care Hospital in India.

BACKGROUND AND AIMS: Patients' outcome after ICU transfer reflect hospital's post-ICU care status. This study assessed association of after-hour ICU transfer on patient outcome. SUBJECTS AND METHODS: Single-centre, retrospective analysis of data between March 2016 and April 2017 was performed at a tertiary-care hospital in India. Patient data were collected on all consecutive ICU admissions during study period. Patients were categorized according to ICU transfer time into daytime (08:00-19:59 hours) and after-hour (20:00-07:59 hours). Patients transferred to other ICUs/hospitals, died in ICU, or discharged home from ICU were excluded. Only ?rst ICU admission was considered for outcome analysis. Primary outcome-hospital mortality; secondary outcomes-ICU readmission and hospital length of stay (LOS). All analysis were adjusted for illness severity. RESULTS: Of 1857 patients admitted during study period,1356 were eligible for study; out of which 53.9% were males and 383(28%) patients transferred during after-hour. Mean age of two groups (daytime vs. after-hour 65.7±15.2 vs. 66.3±16.2 years) was similar (p = 0.7). Mean APACHE IV score was comparable between daytime vs. after-hour transfers (45.6±20.4 vs 46.8±22; p = 0.05). Unadjusted hospital mortality rate of after-hour-transfers was significantly higher compared to daytime-transfers (7.1% vs. 4.1%; p = 0.02). After adjustment with illness severity, after-hour-transfers were associated with significantly higher hospital mortality compared to daytime-transfers(aOR1.7, 95%CI 1.1,2.8; p = 0.04). Median duration of hospital LOS and ICU readmission though higher for after-hour-transfers, was not statistically significant in adjusted analysis (aORhospitalLOS1.1, 95% CI 0.8, 1.4, p = 0.5; aORreadmission 1.6, 95% CI 0.9,2.7; p = 0.06, respectively). CONCLUSION: After-hour-transfers from ICU is associated with significantly higher hospital mortality. Hospital LOS and readmission rates are similar for daytime and after-hour -transfers. HOW TO CITE THIS ARTICLE: Chatterjee S, Sinha S et al., Transfer Time from the Intensive Care Unit and Patient Outcome: A Retrospective Analysis from a Tertiary Care Hospital in India. Indian J Crit Care Med 2019;23(3):115-121.

The Chennai Declaration: a roadmap to tackle the challenge of antimicrobial resistance.

"A Roadmap to Tackle the Challenge of Antimicrobial Resistance - A Joint meeting of Medical Societies in India" was organized as a pre-conference symposium of the 2 nd annual conference of the Clinical Infectious Disease Society (CIDSCON 2012) at Chennai on 24 th August. This was the first ever meeting of medical societies in India on issue of tackling resistance, with a plan to formulate a road map to tackle the global challenge of antimicrobial resistance from the Indian perspective. We had representatives from most medical societies in India, eminent policy makers from both central and state governments, representatives of World Health Organization, National Accreditation Board of Hospitals, Medical Council of India, Drug Controller General of India, and Indian Council of Medical Research along with well-known dignitaries in the Indian medical field. The meeting was attended by a large gathering of health care professionals. The meeting consisted of plenary and interactive discussion sessions designed to seek experience and views from a large range of health care professionals and included six international experts who shared action plans in their respective regions. The intention was to gain a broad consensus and range of opinions to guide formation of the road map. The ethos of the meeting was very much not to look back but rather to look forward and make joint efforts to tackle the menace of antibiotic resistance. The Chennai Declaration will be submitted to all stake holders.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC).

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: We aimed to evaluate the impact of a multidimensional infection control strategy for the reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients hospitalized in adult intensive care units (AICUs) of hospitals which are members of the International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey. METHODS: We conducted a prospective before-after surveillance study of CAUTI rates on 56,429 patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance was performed. In Phase 2, we implemented a multidimensional infection control approach that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after interventions were implemented. RESULTS: We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2. In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase 2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk (RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction. CONCLUSIONS: Our study showed that the implementation of a multidimensional infection control strategy is associated with a significant reduction in the CAUTI rate in AICUs from developing countries.

Prospective observational evaluation of incidences and implications of drug-drug interactions induced adverse drug reactions in critically ill patients.

The primary aim of this study is to identify and analyze the importance of adverse drug reaction due to drug-drug interaction as a contributing factor towards drug safety. Patients more than 18 years of age admitted in multidisciplinary intensive care unit of a tertiary care hospital were included in this study. Patients who stayed less than 48 h and patients in whom all treatment modalities have been withdrawn and were on comfort measures only (no drugs were prescribed), were excluded. All the drugs that were given during intensive care unit stay were checked for presence of potential interactions which led to adverse drug reaction. Drug-drug interactions that were detected clinically or through investigations were recorded and also any therapeutic actions taken for drug-drug interactions were noted. From June 2006 to April 2007, 400 patients-prescriptions were analyzed. Adverse drug reactions due to drug-drug interactions were identified in 64% patients. Among those patients 38.67% had a single drug-drug interaction. Potential drug-drug interactions were 602. Clinically significant drug-drug interactions among the potential were 208 (34.55%). Clinically relevant drug-drug interactions were 103 (49.52% of 208 episodes). The adverse drug reactions due to drug-drug interactions in our sample were managed either by substituting another drug (50.48% of 103 episodes) or by adjusting the dose (1% of 103 episodes) or by omitting the drug (48.54% of 103 episodes). Among the 208 observed drug-drug interactions induced adverse drug reactions 21.63% was severe drug-drug interactions induced adverse drug reactions, 23.08% was moderate drug-drug interactions induced adverse drug reactions and 55.29% was minor drug-drug interactions induced adverse drug reactions. The interactions which were life threatening and/ or require medical intervention to minimize or prevent serious adverse effects were considered as severe drug-drug interactions and those interaction which resulted in an exacerbation of the patient's condition and/ or require an alteration in therapy were considered as moderate drug-drug interactions. The interactions which were limited clinical effects and manifestations may include an increase in the frequency or severity of side effects but generally would not require a major alteration in therapy were classified as minor drug-drug interactions. The correlation coefficient was 0.86 between the number of drugs given to the patient & number of average potential adverse drug reactions found among the patients. Increase in number of prescribed drug significantly (one way) increases number of potential adverse drug reaction due to drug-drug interaction (p<0.0001). Critically ill patients are more susceptible to drug-drug interactions due to the administration of multiple drugs and complex drug combinations. Several drug-drug interactions were clinically irrelevant.

Microalbuminuria: An inexpensive, non invasive bedside tool to predict outcome in critically ill patients.

This study was conducted to evaluate whether microalbuminuria on admission and after 24 hrs of admission to intensive care unit (ICU) predicts outcome as well as the Acute Physiology and Chronic Health Evaluation (APACHE) II severity illness score, the current accepted method of doing so. The study was carried out in a 20 bed mixed medical-surgical ICU of a tertiary care hospital. Of 525 consecutive adult patients with ICU stay of more than 24 hrs, 238 were included for the study. Patients with pregnancy, menstruation, anuria, macroscopic hematuria, urinary tract infection, marked proteinuria due to renal and post-renal structural diseases, were excluded. Spot urine samples were collected on admission to ICU and 24 hrs thereafter. Urine albumincreatinine ratio (ACR) was measured on ICU admission (ACR1) and after 24 hrs (ACR2) and expressed in mg/g. Patient demographics were noted on admission. For disease severity scoring, APACHE II scores were calculated. Each patient was followed up throughout their ICU stay for a maximum of 28 days and the following outcome data were obtained: ICU length of stay and ICU mortality. Of the 238 patients, 196 survived while 42 patients died in the ICU. Non-survivors had a significantly higher median ACR2 [162.7 mg/g (IQR 69.5-344.3)] in comparison to the survivors who had a median ACR2 = 54.4 mg/g (IQR 19.0-129.1) (P< 0.0001). The median ACR1 [161.0 mg/g (IQR 29.0-369.3)] of non-survivors was higher than the median ACR1 [80.4 mg/g (IQR 35.1-167.6)] of survivors but failed to reach statistical significance (P= 0.0948). In a receiver operating characteristic curve (ROC) analysis, ACR2 emerged as the best indicator of mortality [(area under curve (AUC) of ACR2 = 0.71 > AUC (ACR1) =0.58 > AUC (ΔACR) =0.55] similar to the currently used APACHE II scores (AUC = 0.78) (P=0.3). At a cutoff of 101 mg/g, ACR2 had a sensitivity of 69%, specificity of 67%, positive predictive value of 31% and a negative predictive value of 91% for predicting mortality in the critically ill patients. Absence of significant microalbuminuria at 24 hrs of ICU admission may help to predict survival in the ICU.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC).

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

Thrombotic thrombocytopenic purpura associated with Human Immunodeficiency Virus infection.

Thrombotic thrombocytopenic purpura (TTP) belongs to the group of diseases called Thrombotic microangiopathies (TMA). While several triggering conditions are known, often none is apparent in the individual case. We report a patient presenting with TTP that was associated with a Human Immunodeficiency Virus (HIV) infection, with its consequent diagnostic, therapeutic and prognostic implications. Further, our case had individual clinical features that were of interest within the TTP-HIV subgroup.

Validation of an inexpensive B-mode ultrasound device for detection of deep vein thrombosis.

OBJECTIVE: To validate a portable, inexpensive, real-time, B-mode ultrasound device compared with duplex ultrasound in the detection of proximal lower extremity deep vein thrombosis in hospitalized patients clinically suspected of having deep vein thrombosis. DESIGN: Prospective cohort study. SETTING: Tertiary care community teaching hospital. PATIENTS: Medical-surgical hospitalized patients undergoing duplex ultrasonography for clinically suspected lower extremity deep vein thrombosis. INTERVENTIONS: Hospitalized patients who underwent duplex ultrasound examinations were enrolled in the study. Blinded from the duplex ultrasound results, the investigators utilized the study ultrasound device to perform compression ultrasonography of the common femoral, superficial femoral, and popliteal veins within 48 h of the duplex examinations. The results of the study ultrasound device were recorded as normal (compressible) or abnormal (noncompressible). RESULTS: Of the 198 lower limbs evaluated, duplex ultrasonography documented 34 proximal lower extremity deep vein thrombi. The study ultrasound device detected 32 of the 34 proximal thrombi detected by duplex ultrasonography. One false-positive result of an examination occurred with the study ultrasound device. Compared with duplex ultrasonography, the study ultrasound device had a sensitivity of 94%, specificity of 99%, positive predictive value of 97%, and negative predictive value of 98%. CONCLUSIONS: The results of this investigation document that the study ultrasound device has an acceptable sensitivity, specificity, and diagnostic accuracy for clinical use in detection of proximal lower extremity deep vein thrombosis. Further evaluation and validation of this ultrasound device are warranted.