SARS-CoV-2 antigen detection in deceased bodies: implications for infection prevention.

Background & objectives: High transmissibility of the SARS-CoV-2 has significant implications on healthcare workers' safety, preservation, handling, transportation and disposal of the deceased bodies. The objective of this study was to detect SARS-CoV-2 antigen in nasopharyngeal samples and its implications in handling and care of COVID-19 deceased bodies. Methods: A study was conducted at a dedicated COVID-19 centre on deceased individuals from April to December 2020. Rapid antigen test (RAT) and reverse transcription (RT)-PCR was compared on all the SARS-CoV-2 positive cadavers recruited in the study. Results: A total of 115 deceased individuals were included in the study. Of these, 79 (68.7%) were male and 36 (31.3%) were female and majority were in the age group of 51-60 yr [31 (27%)]. SARS-CoV-2 antigen test was positive in 32 (27.8%) and negative in 83 (72.1%) individuals. The mean time interval between deaths to the sample collection was 13.2 h with interquartile range of eight to 20 h. Reverse transcription (RT)-PCR was used as the reference test and 24 (20.9%) cases were true positive; 93.6 per cent [95% confidence interval (CI) 88.8-98.4%] sensitivity, 45.2 per cent (95% CI 35.5-55%) specificity, 60.2 per cent (95% CI 50.6-69.8%) positive predictive value and 88.8 per cent (95% CI 82.7-95%) negative predictive value of antigen test was computed. Interpretation & conclusions: SARS-CoV-2 antigen test was positive beyond 19 h in COVID-19 deceased individuals. Antigen test was found to be highly sensitive in the deceased. Patients, suspected of having died due to COVID-19, can be screened by this method. As infectiousness of the virus in the deceased bodies cannot be directly concluded from either the antigen or RT-PCR test, yet possible transmission cannot be completely ruled out. Strict infection control measures need to be followed during the handling and clearance of COVID-19 cadavers.

Hand-hygiene compliance: The importance of WHO's "moment 1" in prevention of healthcare-associated infections.

BACKGROUND: Hand hygiene is the single most effective strategy for preventing healthcare associated infections (HCAI) but compliance is usually low and effective improvement strategies are needed. We assessed hand hygiene (HH) compliance with the World Health Organization (WHO) prescribed five moments of hand hygiene among health-care workers (HCW). METHODS: A retrospective analysis of one-year data on hand hygiene was done. WHO single observer direct observation technique was used and HH compliance was noted among HCWS. RESULTS: A total of 16,552 opportunities were recorded. Overall compliance as per WHO Guidelines was 69.2%. Sanitation worker had an adherence rate of 73.1% (95% confidence interval [CI]:70.6-75.4) followed by the nurses 71.2% (95% CI: 70.4-72.1). Physicians and technicians had a compliance rate of 64.9% (95% CI: 63.1-66.6) and 64% (95% CI: 60.1-67.9) respectively. Physiotherapists had a compliance rate of 62.2 (95% CI: 50.1-73.2) and the compliance of Phlebotomists was observed to be 23.1% (95% CI: 9.0-43.6). HCW stood best for WHO moment 5 and worst for moment 1 with compliance of 79.1% (95% CI:77.4-80.7) and 55.8% (95% CI:54.5-57.1) respectively. DISCUSSION: The moment 1 of the WHO's five moments is the most important for preventing the transmission of resistant pathogens between patients. Missed opportunities in moment 1 need to be focused on while planning new strategies to promote hand hygiene.

Eight year study on evolution of antimicrobial resistance in an antimicrobial-naïve trauma population.

PURPOSE: Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Moreover, the burden of HAIs is higher in ICU admitted patients. Long term studies are beneficial to evolution pattern of AMR. Therefore, this study aimed to evaluate the evolution of AMR pattern over the years in one of the ICUs of a level 1 Trauma Center. This will enable us to modify the prescribing practices according to emerging resistance patterns. METHODS: This study was conducted at one of the ICU of level-1 trauma center of tertiary care hospital. The study reports the findings of the AMR surveillance from January 2012 to December 2019. Standard definitions were used to define HAI (www.hais.com). The clinical records of the patients were maintained using ASHAIN indigenous software. Outbreak analysis was done by WHONET. RESULTS: From 1st January 2012-31st December 2019, 4305 isolates were obtained from 1969 patients. Most frequent occurring organism were gram negatives among which A. baumannii was common followed by K. pneumoniae, and P. aeruginosa. Retrospective analysis showed 7 outbreaks/clusters during the study period and all the outbreaks occurred from October to December in each year. The increasing trend of AMR pattern emphasizes to strengthen infection control practices and sustained AMR surveillance.

Impact of surgical site infection on unplanned hospital readmissions, initiation of adjuvant treatment following surgery, and disease-free survival on patients with upper aerodigestive tract squamous cell carcinoma.

INTRODUCTION: Unplanned hospital readmission (UHR) is an important indicator of the quality of the healthcare system in place. It has various implications for the patients and the healthcare system at large. In this article, we have attempted to understand the various factors influencing UHR and the start of adjuvant treatment following cancer surgery. PATIENTS & METHODS: In this study adult patients above 18 years of age with upper aerodigestive tract squamous cell carcinoma who underwent surgery at our center between July 2019 to December 2019 were included in the study. Various factors influencing UHR and delay in receiving adjuvant treatment were analyzed. RESULTS: A total of 245 patients satisfied the inclusion criteria. Surgical site infection (SSI) was the factor that had the maximum influence on the UHR (p < 0.002, OR: 5.6, 95% CI: [1.911-16.4]) and delaying the start of adjuvant treatment (p = 0.008, OR: 3.786, 95% CI: [1.421-10.086]) on multivariate analysis. Surgery lasting for >4 h and patients who had received prior treatment tended to develop SSI postoperatively. The presence of SSI also seemed to have had a negative influence on disease-free survival (DFS) as well. CONCLUSIONS: SSI is an important postoperative complication having major implications in terms of increased UHR and delays in starting adjuvant treatment which in turn is reflected as a poorer DFS among patients who develop SSI postoperatively.

A self-reported survey on the implementation of infection prevention and control elements in Indian hospitals, part of a HAI surveillance network: Results from 23 hospitals conducting a standardized IPC assessment.

BACKGROUND: Healthcare-associated infections (HAIs) are one of the most common adverse events in patient care that account for substantial morbidity and mortality. We evaluate the existing Infection Prevention and Control (IPC) practices in hospitals participating in the nationally representative HAI Surveillance network. METHODS: This cross-sectional survey was conducted in 23 hospitals across 22 states of India from October-2015 to September-2018 in the HAI surveillance network. The World Health Organization (WHO) IPC core components assessment tool for health-care facility level (IPCAT-H) was adapted from IPC assessment tool developed by US Centers for Disease Control and Prevention (US CDC) under the Epidemiology and Laboratory Capacity (ELC) Infection Control Assessment and Response (ICAR) Program. Mann-Whitney U test was used to calculate the significant difference between scores (P < .05). RESULTS: Amongst the participating hospitals, 7 were private sectors and 16 were public health care facilities. Infection IPCAT-H average score per multimodal strategy was less than 50% for programmed IPC activities (45.7); implementation of health care workers (HCWs) immunization programme (43.5%); monitoring and evaluation component (38.30%). CONCLUSIONS: There is potential for improvement in Human Resources, Surveillance of HAIs as well as Monitoring and Evaluation components.

Clinical Validation of Standard Q COVID-19 Antigen and IgM/IgG Combo Kit Assay at a Tertiary Care Center in Northern India.

Background Expansion of the testing capacities for severe acute respiratory syndrome-coronavirus-2 is an important issue in the face of ever-increasing case load. So, there is need of point-of-care diagnostic tests in the existing laboratory capacities for early treatment, isolation, and clinical decision making, especially in resource limited settings. Materials and Methods This prospective cohort study was conducted at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi. Nasopharyngeal samples and blood samples were collected for antigen and antibody testing. Rapid antigen test was performed as per the kit's instructions. The performance of the kit was compared with the gold standard reverse transcription polymerase chain reaction (RT-PCR) testing. Results Eighty-eight out of 110 patients tested positive by RT-PCR for coronavirus disease 2019 in last 48 to 72 hours were included in the study. Overall, the sensitivity of combined antibody test was 52%, antigen test 26%, and combined sensitivity of both antigen and antibody was 72.7%, respectively. Conclusion The combo kit needs to be used with caution in low prevalence settings, where cases may be missed.

Rate of shed of SARS COV-2 viral RNA from COVID-19 cadavers.

BACKGROUND: At what rate does the RNA of SARS CoV-2 shed from cadavers? Although, there have been numerous studies which have demonstrated the persistence of the virus on dead bodies, there is a lack of conclusive evidence regarding the variation of viral RNA content in cadavers. This has led to a knowledge gap regarding the safe handling/management of COVID-19 decedents, posing a barrier in forensic investigations. METHODS: In this study, we report the presence of RNA of SARS CoV-2 by real time RT-PCR, in nasopharyngeal swabs collected after death from two groups of bodies - one who died due to COVID-19 and the other who died due to other diagnoses. A prospective study on 199 corpses, who had tested positive for COVID-19 ante-mortem, was conducted at a tertiary care center. RNA testing was conducted at different time intervals (T1-T5). RESULTS: 112(56.3%) died primarily due to COVID-19 and 87(43.7%) died due to other diagnoses. 144(72.4%) were male and 55(27.6%) were female. A total of 115 (57.8%) tested positive for COVID-19 after death at different time points. The mean age was 50.7 ± 18.9 years and the length of hospitalization ranged from 1 to 50 days with a mean of 9.2 ± 7.6 days. Realtime RT-PCR positivity of SARS CoV-2 RNA decreases with time. CONCLUSION: We observed that real time RT-PCR positivity, indicating viral RNA detection, decreases with time. Therefore, it is advisable to follow appropriate COVID-19 precautions to carry out scientific studies, medico-legal investigations and mortuary services on suspected/confirmed COVID-19 corpses.

Secondary Bacterial Infections in Mucormycosis-COVID-19 Cases: Experience during the Second COVID-19 Wave in India.

In the second wave of COVID-19 in India, there was a new challenge in the form of mucormycosis. Coinfection with mucormycosis was perilous as both conditions required a prolonged hospital stay, thus serving as an ideal platform for secondary infections. Using a retrospective observational study, we studied secondary infections and their impact on the outcome in COVID-19 patients with mucormycosis. The outcome in these patients was evaluated and compared with COVID-19 patients with mucormycosis but without any secondary infection. SPSS V-20 was used for data analysis. Fifty-five patients tested positive for mucormycosis (55/140; 39.28). Twelve out of these 55 (21.8%) developed secondary infections during their hospital stay. Bloodstream infection was the most common (42.86%) secondary infection. The Gram-negative (GN) organisms were more common (11/16; 68.75%) compared with the Gram-positives (GP) (5/16; 31.25%). But the most common isolate was Enterococcus faecium (5/16; 31.25%). A high percentage of microorganisms isolated were multidrug-resistant (15/16; 93.75%). Two out of five (40%) isolates of Enterococcus faecium were vancomycin-resistant (VRE). High resistance to carbapenems was noted in the GN isolates (9/11; 81.81%). The comparison of length of stay in both subgroups was statistically significant (P value <0.001). When compared, the length of stay in people with adverse outcomes was also statistically significant (P value <0.001). Procalcitonin (PCT) had a positive predictive value for the development of secondary bacterial infections (P value <0.001). Antimicrobial stewardship and strict infection control practices are the need of the hour. IMPORTANCE Although our knowledge about COVID-19 and secondary infections in patients is increasing daily, little is known about the secondary infections in COVID-19-mucormycosis patients. Thus, we have intended to share our experience regarding this subgroup. The importance of this study is that it brings to light the type of secondary infections seen in COVID-19-mucormycosis patients. These secondary infections were partially responsible for the mortality and morbidity of the unfortunate ones. We, as health care workers, can learn the lesson and disseminate the knowledge so that in similar situations, health care workers, even in other parts of the world, know what to expect.

SARS-CoV-2 Rapid Antigen Detection in Respiratory and Nonrespiratory Specimens in COVID-19 Patients.

Rapid antigen testing for coronavirus disease 2019 (COVID-19) available at present provides immediate results at low cost with less expertise and without any need of sophisticated infrastructure. Most of these test kits available are for nasopharyngeal samples. This is a novel study to detect the presence of COVID antigen in samples other than throat and oropharyngeal. Various samples received from patients admitted in the COVID-19 dedicated center were tested for the presence of antigen. Same procedure was followed as done for the nasopharyngeal sample. A total of 150 samples were tested, which included ascitic fluid, pleural fluid, drain fluid, bile, bronchoalveolar lavage, cerebrospinal fluid, endotracheal tube aspirate, sputum, tissue, and urine. Out of 150, 11 (7.33%) were positive and 138 (92.66%) were negative for the antigen test. The COVID-19 antigen test kit, though designed for nasopharyngeal samples, was able to detect the presence of antigen in other clinical samples.

Surveillance for surgical site infections in orthopedic trauma surgeries at an Indian hospital.

PURPOSE: Surgical site infections (SSIs) are one of the most common, causing substantial morbidity, mortality and are highly cost-effective means of reducing healthcare associated infections rates in health care set-ups. In India, there is no existing system for systematic surveillance of SSIs, encompassing post-discharge period. METHODS: An indigenous SSI e-surveillance software was developed. Patients developing SSI as per standard definitions were included in the study. A denominator form and a case report form were filled for each case of SSI detected. The microbiological diagnosis was done as per standard methods. Logistic regression analysis was used to test for association of SSI and risk factors and determining the prevalence odds ratios. RESULTS: Of the total of 850 patients enrolled in the SSI surveillance, 47 (5.5%) developed SSI. Most patients (490/850, 58%) underwent the open reduction internal fixation (ORIF) and also developed an SSI (33/490, 6.7%). Clean contaminated wound class and Dressing were found to be associated with increased risk of SSI significantly, Also increase in the length of stay was found to be associated with increased risk of SSI significantly. High antimicrobial resistance was observed in the microbial isolates recovered from SSIs. Patients who developed SSI had longer hospital stays. CONCLUSIONS: Our study has been the first systematic surveillance effort in India, where patients were followed up till six months post surgeries. This pilot study was later expanded to other Indian hospitals. This network of SSI-Surveillance will lay the foundation for initiation of SSI-surveillance across the country.

High Prevalence of Fungal and NDM-OXA Producing Gram-Negative Bacterial Superinfections in the Second Wave of Coronavirus Disease 2019 in India: Experience from a Dedicated Coronavirus Disease 2019 Hospital in North India.

Introduction: During the second wave of coronavirus disease 2019 (COVID-19), superinfection caused by fungus and multidrug-resistant bacteria worsened the severity of illness in COVID-19 patients. Limited studies from India reported the antimicrobial resistance pattern of secondary infections. In this study, we aim to study the epidemiology of pathogens causing superinfections and genotyping of Gram-negative isolates in COVID-19 patients. Methods: This retrospective study was conducted at a dedicated COVID-19 center, India. The identification of bacteria/fungi was done by Vitek2® and matrix-assisted laser desorption/ionization-time of flight mass spectrometry system. Identification of beta-lactamase genes was done using thermal cycler. The diagnosis of mucormycosis was based on 10% potassium hydroxide direct microscopy. Statistical analyses were performed using STATA version 15.1 (StataCorp., College Station, TX, USA). For continuous variables, mean and standard deviation were computed. For comparing proportions of secondary infections across admission location and outcomes, the Chi-squared test of independence was used. To compare the mean and median between intensive care units and outcomes, an independent t-test and a Mann-Whitney test were used. Results: Of all the clinical samples, 45.4% of samples were cultured positive for secondary infections. Acinetobacter baumannii (35%) was the most common Gram-negative pathogen, while among Gram positive, it was Enterococcus faecium (40%). Among fungus, Candida spp. (61%) predominates followed by molds. Colistin and tigecycline proved effective against these pathogens. blaNDM was the most prevalent gene followed by the blaOX among the carbapenemase genes. Conclusions: The mortality rate among COVID-19 patients with secondary infection was significantly higher compared to the overall mortality rate in COVID-19 patients.

Self-reported survey on infection prevention and control structures in healthcare facilities part of a national level healthcare associated infection surveillance network in India, 2019.

BACKGROUND: Healthcare associated infections (HAIs) are prevalent and difficult to treat worldwide. Most HAIs can be prevented by effective implementation of Infection Prevention and Control (IPC) measures. A survey was conducted to assess the existing IPC practices across a network of Indian Hospitals using the World Health Organization designed self-assessment IPC Assessment Framework (IPCAF) tool. METHODS: This was a cross sectional observation study. Thirty-two tertiary care public and private facilities, part of the existing Indian HAI surveillance network was included. Data collected was analyzed by a central team at All India Institute of Medical Sciences, New Delhi, a tertiary care hospital of India. The WHO questionnaire tool was used to understand the capacity and efforts to implement IPC practices across the network. RESULTS: The overall median score of IPCAF across the network was 620. Based on the final IPCAF score of the facilities; 13% hospitals had basic IPC practices, 28% hospitals had intermediate and 59% hospitals had advanced IPC practices. The component multimodal strategies had the broadest range of score while the component IPC guidelines had the narrowest one. CONCLUSIONS: Quality improvement training for IPC nurses and healthcare professionals are needed to be provided to health facilities.