COVID-19 patient and personal safety - lessons learnt for pandemic preparedness and the way to the next normal.

BACKGROUND: The COVID-19 pandemic has profoundly challenged societies and healthcare systems in particular. To prevent the spread of SARS-CoV-2, infection prevention and control (IPC) strategies had to be developed on the local, national and international level. The aim of this study is to provide details of the COVID-19 experience at the Vienna General Hospital (VGH) in the context of the national and international COVID-19 response for learning and improvement. METHODS: This is a retrospective report, outlining the evolution of IPC measures and challenges encountered at the health facility (VGH), the national (Austria) and global level between February 2020 and October 2022. RESULTS: The IPC strategy at the VGH has been continuously adapted to changes in the epidemiological setting, new legal directives and Austrian by-laws. The current strategy, nationally and internationally, focuses on endemicity rather than maximum transmission risk reduction. For the VGH, this has recently resulted in an increase in COVID-19 clusters. To protect our particularly vulnerable patients, many COVID-19 precautions have been maintained. Barriers to adequate IPC implementation at the VGH and other hospitals include a lack of sufficient isolation options and non-adherence with universal face mask regulations. Globally, misinformation on COVID-19 hampered an effective response. CONCLUSIONS: This retrospective analysis of the COVID-19 response at the VGH and international reports underline the need for pandemic preparedness, readiness and response by improving future hospital design and infrastructure, conducting regular trainings for protective attire and increasing health literacy as now recently published in a concise document by WHO.

Provision of safe patient care during the COVID-19 pandemic despite shared patient rooms in a tertiary hospital.

BACKGROUND: The COVID-19 pandemic has resulted in the disruption of healthcare systems. Vienna General Hospital (VGH), a tertiary hospital located in Austria, ran at almost full capacity despite high levels of community SARS-CoV-2 transmission and limited isolation room capacity. To ensure safe patient care, a bundle of infection prevention and control (IPC) measures including universal pre-admission screening and serial SARS-CoV-2 testing during hospitalization was implemented. We evaluated whether testing as part of our IPC approach was effective in preventing hospital outbreaks during different stages of the pandemic. METHODS: In this retrospective single center study, we analyzed the SARS-CoV-2 PCR test results of cases admitted to VGH between a low (15/05/2020-01/08/2020) and a high incidence period (15/09/2020-18/05/2021). Outcomes were the diagnostic yield of (a) admission screening, (b) the yield of serial testing during hospitalization and (c) the occurrence of healthcare-associated COVID-19 (HA-COVID-19) and SARS-CoV-2 related hospital outbreaks. RESULTS: The admission test positivity rate was 0.2% during the low and 2.3% during the high incidence phase. Regarding test conversions, 0.04% (low incidence phase) and 0.5% (high incidence phase) of initially negative cases converted to a positive test result within 7 days after admission The HA-COVID-19 incidence rate per 100,000 patient days was 1.0 (low incidence phase) and 10.7 (high incidence phase). One COVID-19 outbreak affecting eight patients in total could be potentially ascribed to the non-compliance with our IPC protocol. CONCLUSION: Testing in conjunction with other IPC measures enabled the safe provision of patient care at a hospital with predominantly shared patient rooms despite high case numbers in the community.

Routine Surveillance of Healthcare-Associated Infections Misses a Significant Proportion of Invasive Aspergillosis in Patients with Severe COVID-19.

Rates of invasive aspergillosis (IA) among COVID-19 ICU patients seem to reach over 30% in certain settings. At Vienna General Hospital (VGH), all rooms in COVID-19 ICUs were put under negative pressure as a protective measure, thus increasing the risk of exposure to environmental pathogens for patients. Even though all ICU patients are surveilled for healthcare-associated infections (HAI), there were concerns that the routine protocol might not be sufficient for IA detection. We reviewed the electronic patient charts of all patients with COVID-19 admitted to ICUs between 1 March 2020 and 31 July 2021 for fungal co- or superinfections, comparing four diagnostic algorithms based on different recommendations for the diagnosis of IA (according to EORTC/MSG, BM-AspICU, IAPA and CAPA) to our routine surveillance protocol. We found that out of 252 patients who were admitted to the ICU during the study period, 25 (9.9%) fulfilled the criteria of probable or possible IA of at least one algorithm. The IAPA definitions detected 25 and the CAPA definition 23 probable and 2 possible cases, out of which only 16 were classified as hospital-acquired IA by routine surveillance. In conclusion, adjustment of the routine protocol using a classification system especially designed for respiratory viral illness seems useful for the surveillance of IA in a highly vulnerable patient cohort.

Paracoccidioidomycosis Diagnosed in Europe-A Systematic Literature Review.

Paracoccidioidomycosis is a systemic mycosis that is endemic in geographical regions of Central and South America. Cases that occur in nonendemic regions of the world are imported through migration and travel. Due to the limited number of cases in Europe, most physicians are not familiar with paracoccidioidomycosis and its close clinical and histopathological resemblance to other infectious and noninfectious disease. To increase awareness of this insidious mycosis, we conducted a systematic review to summarize the evidence on cases diagnosed and reported in Europe. We searched PubMed and Embase to identify cases of paracoccidioidomycosis diagnosed in European countries. In addition, we used Scopus for citation tracking and manually screened bibliographies of relevant articles. We conducted dual abstract and full-text screening of references yielded by our searches. To identify publications published prior to 1985, we used the previously published review by Ajello et al. Overall, we identified 83 cases of paracoccidioidomycosis diagnosed in 11 European countries, published in 68 articles. Age of patients ranged from 24 to 77 years; the majority were male. Time from leaving the endemic region and first occurrence of symptoms considerably varied. Our review illustrates the challenges of considering systemic mycosis in the differential diagnosis of people returning or immigrating to Europe from endemic areas. Travel history is important for diagnostic-workup, though it might be difficult to obtain due to possible long latency period of the disease.

Filamentous Fungal Infections in a Tertiary Care Setting: Epidemiology and Clinical Outcome.

Information on the distribution of filamentous fungal pathogens, which cause potential life-threatening invasive infections mostly in immunocompromised persons, is of great importance. The aim of this study was to evaluate the epidemiology and clinical outcome in patients with infections due to filamentous fungi at the University Hospital of Vienna, Austria. We conducted a retrospective observational study and consecutively included patients of any age with filamentous fungal infections between 2009 and 2017. The classification for probable and proven invasive filamentous fungal infections was based on the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC) criteria or the expert opinion of an experienced clinical mycologist. We included 129 patients (median age: 52 years; 47.3% female) with episodes of 101 proven and probable invasive and 35 localized filamentous fungal infections (16 sinus, 14 eye, one ear, and four deep cutaneous). Aspergillus fumigatus alone accounted for 50.3% of the fungi, which was followed by the Mucorales group (13.7%) and Fusarium spp. (8.5%). Diagnosis was mainly based on culture findings. The lung was the most frequent site of infection. The 30-day and 90-day overall mortality of invasive fungal infections was 30.2% and 42.7%, respectively. We observed a high all-cause mortality among patients with invasive filamentous fungal infections. Prospective data collection in a nationwide registry would be necessary to provide important information on surveillance to clinicians and other decision-makers.

Infection control and risk factors for acquisition of carbapenemase-producing enterobacteriaceae. A 5 year (2011-2016) case-control study.

Background: Carbapenemase-producing enterobacteriaceae (CPE) are a major threat for severely ill patients. However, only limited data on the epidemiology and on evidence-based infection prevention and control measures are available. The aim of this study was to investigate the epidemiology of patients with CPE, characterizing the CPE isolates by their resistance mechanisms and genetic similarity, to explore risk factors for their acquisition, and to evaluate the effectiveness of the current CPE infection control measures. Methods: A retrospective case-control study was performed using data from 2011 to 2016 in a 1800-bed academic hospital in Central Europe, where risk-based screening at patients´ admission is performed. Carbapenem resistance mechanisms of all carbapenem resistant enterobacteriaceae from patients admitted during this period were investigated. Clinical data of the CPE-positive patients were analysed and compared to a matched control group (case-control ratio of 1:3). We performed univariate and multivariate statistical analysis to identify risk factors for CPE acquisition. Results: Of 621,623 admitted patients in the study period, 75 patients with carriage of carbapenem resistant enterobacteriaceae were included (0.12/1000 admittances). Carbapenemase-encoding genes were detected in 77.3% (58/75) of patients with carbapenem-resistant enterobacteriaceae. The enzyme blaOXA-48 was found in 34.5% (20/58), blaKPC in 29.3% (17/58), blaNDM enzymes in 20.7% (12/58) and blaVIM in 8.6% (5/58) of the isolates. The overall mortality among CPE patients was 25.9% (15/58) and attributable mortality of CPE was 53.3% (8/15). Multivariate analysis revealed four risk factors to be independent predictors of CPE carriage: the length of hospital admission > 20 days (AOR: 4.9, 95% CI: 1.4-15.5; P <  0.001), hospital admission within the previous year (AOR: 22.3, 95% CI: 3.9-88.4; P <  0.001), exposure to a healthcare facility in a country with high or unknown carbapenem-resistant enterobacteriaceae prevalence 3 months before admission (AOR: 11.8, 95% CI: 2.2-63.2; P <  0.01) and the use of antibiotics longer than 10 days (AOR: 5.2, 95% CI: 1.4-35.9; P <  0.05). The current risk-based screening strategy at hospital admission could not identify 37 (63.8%) of the 58 CPE-positive patients. Epidemiological investigation and genotyping revealed that no outbreaks due to CPE occurred during this period. Conclusion: Overall, the CPE carriage rate in patients was very low, the attributable mortality, however, is alarming (53%). BlaOXA-48 and blaKPC were the main cause of carbapenem resistance in enterobacteriaceae. Although the strict application of standard infection control measures was effective for prevention of outbreaks in this setting, an enlarged risk based targeted screening strategy has to be implemented.

The comparative efficacy and risk of harms of the intravenous and subcutaneous formulations of trastuzumab in patients with HER2-positive breast cancer: a rapid review.

BACKGROUND: Trastuzumab is a monoclonal antibody for patients with HER2 (human epidermal growth factor receptor 2)-positive breast cancer, which is added to regular treatment and reduces mortality. Originally, trastuzumab had to be administered intravenously (IV) over 30 min every 3 weeks for 1 year. Since 2012, a formulation for the subcutaneous (SC) administration of trastuzumab has been available, which has not yet been approved in the USA. Advocates claim that the SC formulation saves time and money, despite higher costs. The purpose of this study is to review existing literature concerning the comparative efficacy and risk of harms of trastuzumab IV and SC concerning patient-relevant health outcomes. METHODS: We conducted searches in the Cochrane Library and MEDLINE for articles published through May 2018 in English or German. In addition, we searched ClinicalTrials.gov to identify unpublished studies. We dually reviewed the abstracts and full-text articles based on a priori defined inclusion criteria, rated the risk of bias of included studies, and assessed the strength of the evidence for each outcome of interest. Because data was insufficient for quantitative synthesis, we summarized results narratively. RESULTS: We identified three RCTs (randomized controlled trials) meeting our eligibility criteria, which included data on 1003 patients. We found moderate evidence for similar event rates (20.05% vs. 18%, HR (hazard ratio) 0.88, CI 95% = 0.62-1.27), and mortality rates (10% vs. 8%, HR 0.76, CI 95% = 0.44-1.32) after 1.7 years for patients receiving trastuzumab IV and for patients receiving SC. Results remained similar after 3.3 years, though evidence lacked strength due to a high dropout rate. All trials reported more adverse events among the SC group than in the IV group. Evidence for these findings was of moderate strength. Nevertheless, more than 85% of the patients preferred trastuzumab SC over IV. Results concerning serious adverse events appeared to be heterogeneous. CONCLUSION: Results of studies indicate similar efficacy between the two routes of administration. The higher rates of adverse events for SC administration were mainly attributable to injection site-related events. The clinical decision of whether to administer trastuzumab SC or IV requires the consideration of several factors and should be determined individually.

Comparing Indicators of Suicidality Among Users in Different Types of Nonprofessional Suicide Message Boards.

BACKGROUND: Little is known about linguistic differences between nonprofessional suicide message boards that differ in regard to their predominant attitude to suicide. AIMS: To compare linguistic indicators potentially related to suicidality between anti-suicide, neutral, and pro-suicide message boards, and between the types of posters (primary posters, who initiate the thread, and the respective respondents). METHOD: In all, 1,200 threads from seven German-language nonprofessional suicide message boards were analyzed using the software Linguistic Inquiry and Word Count (LIWC) with regard to wording related to suicidal fantasies, aggression, and indicators of so-called suicidal constriction. Data were analyzed with ANOVA. RESULTS: There were fewer words related to affective, social, cognitive, and communicative processes in pro-suicide message boards than in other boards. Death-related wording and aggression as well as tentative wording appeared more prevalent in pro-suicide boards. LIMITATIONS: Complex language structures cannot be analyzed with LIWC. CONCLUSION: The results suggest fewer emotion words and wording related to social circumstances among primary posters and respondents in pro-suicide boards as compared with other boards, and a higher use of death- and aggression-related words. These findings might signal a higher degree of suicidality or sheer differences in matters of interest or social desirability. The differences require attention in practice and research.

[Criterion Validity of the German Version of the CES-D in the General Population]. / Kriteriumsvalidität der deutschsprachigen Version der CES-D in der Allgemeinbevölkerung.

OBJECTIVE: The "Center of Epidemiologic Studies - Depression scale" (CES-D) is a well-known screening tool for depression. Until now the criterion validity of the German version of the CES-D was not investigated in a sample of the adult general population. METHODS: 508 study participants of the Austrian general population completed the CES-D. ICD-10 diagnoses were established by using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Receiver Operating Characteristics (ROC) analysis was conducted. Possible gender differences were explored. RESULTS: Overall discriminating performance of the CES-D was sufficient (ROC-AUC 0,836). Using the traditional cut-off values of 15/16 and 21/22 respectively the sensitivity was 43.2 % and 32.4 %, respectively. The cut-off value developed on the basis of our sample was 9/10 with a sensitivity of 81.1 % und a specificity of 74.3 %. There were no significant gender differences. CONCLUSION: This is the first study investigating the criterion validity of the German version of the CES-D in the general population. The optimal cut-off values yielded sufficient sensitivity and specificity, comparable to the values of other screening tools.