The prevalence and clinical context of antimicrobial resistance amongst medical inpatients at a referral hospital in Rwanda: a cohort study.

BACKGROUND: Antimicrobial resistance (AMR) is a growing global concern. AMR surveillance is a crucial component of the international response; however, passive surveillance of laboratory data is limited without corresponding patient-level clinical data. This study sought to examine the burden of AMR amongst medical inpatients in Rwanda, in the context of their clinical presentations and prior antibiotic exposures. METHODS: This cohort study was conducted over a 9-month period at a tertiary referral hospital in Kigali, Rwanda. We enrolled 122 adult medical inpatients with a history of fever and a positive microbiological culture result. Data were collected regarding the clinical and microbiological aspects of their admission. RESULTS: The most common diagnoses were urinary tract infection (n = 36, 30%), followed by pneumonia (n = 30, 25%) and bacteraemia (11 primary [9%] and 10 catheter-related [8%]). The most common pathogens were E. coli (n = 40, 33%) and Klebsiella pneumoniae (n = 36, 30%). The cohort were heavily antibiotic-exposed at the time of culture with 98% of patients (n = 119) having received an antibiotic prior to culture, with a median exposure of 3 days (IQR 2-4 days). Eighty patients (66%) were specifically prescribed ceftriaxone at the time of culture. Gram-negative organisms predominated (82% [100/122]) and exhibited high rates of resistance, with only 27% (21/77) being susceptible to ceftriaxone, 2.4% (2/82) susceptible to co-amoxiclav and 44% (8/18) susceptible to ciprofloxacin. Susceptibility amongst Gram-negatives was relatively preserved to amikacin (91%, 79/87) and imipenem (85%, 70/82). There were no cases of methicillin-resistant Staphylococcus aureus (0/12) or vancomycin-resistant enterococci (0/2). Discordant antibiotic therapy was significantly associated with in-hospital mortality (OR 6.87, 95%CI 1.80-45.1, p = 0.014). CONCLUSIONS: This cohort highlights high rates of resistance amongst Gram-negative organisms in Rwanda, including the presence of carbapenem resistance. Nonetheless, the detailed prescribing data also highlight the challenges of using routine laboratory data to infer broader AMR prevalence. The significant exposure to empiric broad-spectrum antibiotic therapy prior to culturing introduces a selection bias and risks over-estimating the burden of resistant organisms. Broadening access to microbiological services and active surveillance outside of teaching hospitals are essential to support national and international efforts to curb the growth of AMR in low-resource settings.

The impact of immunosuppressive therapy on secondary infections and antimicrobial use in COVID-19 inpatients: a retrospective cohort study.

BACKGROUND: Immunosuppressive therapies have become a cornerstone of the management of severe COVID-19. The impact of these therapies on secondary infections and antimicrobial prescribing remains unclear. We sought to assess antimicrobial use and the incidence of bacterial and fungal infections in patients with severe COVID-19, and to explore their associations with receipt of immunosuppressive therapies. METHODS: Our retrospective cohort study included 715 hospitalised, adult patients with severe COVID-19 admitted to St George's Hospital, London, UK, during the first UK pandemic wave (1st March-10th June 2020). Co-infections (occurring within 48 h of admission) and secondary infections (≥ 48 h) were defined as a positive microbiological culture with supporting clinical, radiological or laboratory data to suggest true infection. Cox regression models with time-dependent covariates were used to explore the association between immunosuppressant use and secondary infection. RESULTS: Microbiologically confirmed co-infection occurred in 4.2% (n = 30) and secondary infection in 9.3% (n = 66) of the cohort (n = 715) and were associated with in-hospital mortality (48% vs 35%, OR 1.8, 95%CI 1.1-2.7, p = 0.01). Respiratory (n = 41, 39%) and bloodstream infections (n = 38, 36%) predominated, with primarily Gram-negative pathogens. 606 (84.7%) patients received an antimicrobial, amounting to 742 days of therapy per 1000 patient-days (DOTs). In multivariable models, receipt of high-dose steroids (≥ 30 mg prednisolone or equivalent) or tocilizumab was significantly associated with increased antimicrobial consumption (+ 5.5 DOTs, 95%CI 3.4-7.7 days) but not secondary infection (HR 0.56, 95%CI 0.26-1.18). CONCLUSIONS: Bacterial and fungal infections in severe COVID-19 were uncommon. Receipt of steroids or tocilizumab was independently associated with antimicrobial consumption despite its lack of association with secondary infection. These findings should galvanise efforts to promote antimicrobial stewardship in patients with COVID-19.

Small-Group Teaching: Should It Be Recorded?

Background: Recording large-group lectures is commonplace in higher education, allowing students to access content asynchronously and remotely. With the move towards online learning during the COVID-19 pandemic, recording of small-group teaching sessions has also become increasingly common; however, the educational value of this practice is unknown. Methods: All medical students rotating through the Acute Medicine Department of a large teaching hospital were invited to enrol in the study. Consenting students were recorded for the second half of an online case-based learning (CBL) session. The recording was available for 6 months; viewing patterns were analysed. Students were sent a questionnaire after the session, asking them to reflect on the recorded and unrecorded halves of the session. Findings: Thirty-three students underwent recording in 12 separate groups; 31 students (94%) completed the questionnaire. All 31 respondents (100%) described the session as "useful" or "very useful". Twenty-four respondents (77%) recommended continuing to record small-group sessions and 17 (55%) reported being "likely" or "very likely" to watch the recording. Six respondents (19%) reported a negative impact of being recorded. During 6 months of follow-up, no students returned to view the recording for more than 1 minute. Conclusion: Despite positive feedback for the session and high student demand for ongoing recording, no students viewed the recording for any significant duration. One-fifth of students reported a negative impact of being recorded. The findings from this study do not support routine recording of small-group CBL sessions, even where demand for this may exist. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01837-5.

Grass-roots junior doctor communication network in response to the COVID-19 pandemic: a service evaluation.

BACKGROUND: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions. LOCAL PROBLEM: A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature. METHODS: This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical-bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical-top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken. RESULTS: Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration. CONCLUSIONS: This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

Clinical Characteristics and Predictors of Outcomes of Hospitalized Patients With Coronavirus Disease 2019 in a Multiethnic London National Health Service Trust: A Retrospective Cohort Study.

BACKGROUND: Emerging evidence suggests ethnic minorities are disproportionately affected by coronavirus disease 2019 (COVID-19). Detailed clinical analyses of multicultural hospitalized patient cohorts remain largely undescribed. METHODS: We performed regression, survival, and cumulative competing risk analyses to evaluate factors associated with mortality in patients admitted for COVID-19 in 3 large London hospitals between 25 February and 5 April, censored as of 1 May 2020. RESULTS: Of 614 patients (median age, 69 [interquartile range, 25] years) and 62% male), 381 (62%) were discharged alive, 178 (29%) died, and 55 (9%) remained hospitalized at censoring. Severe hypoxemia (adjusted odds ratio [aOR], 4.25 [95% confidence interval {CI}, 2.36-7.64]), leukocytosis (aOR, 2.35 [95% CI, 1.35-4.11]), thrombocytopenia (aOR [1.01, 95% CI, 1.00-1.01], increase per 109 decrease), severe renal impairment (aOR, 5.14 [95% CI, 2.65-9.97]), and low albumin (aOR, 1.06 [95% CI, 1.02-1.09], increase per gram decrease) were associated with death. Forty percent (n = 244) were from black, Asian, and other minority ethnic (BAME) groups, 38% (n = 235) were white, and ethnicity was unknown for 22% (n = 135). BAME patients were younger and had fewer comorbidities. Although the unadjusted odds of death did not differ by ethnicity, when adjusting for age, sex, and comorbidities, black patients were at higher odds of death compared to whites (aOR, 1.69 [95% CI, 1.00-2.86]). This association was stronger when further adjusting for admission severity (aOR, 1.85 [95% CI, 1.06-3.24]). CONCLUSIONS: BAME patients were overrepresented in our cohort; when accounting for demographic and clinical profile of admission, black patients were at increased odds of death. Further research is needed into biologic drivers of differences in COVID-19 outcomes by ethnicity.

In-hospital mortality is associated with inflammatory response in NAFLD patients admitted for COVID-19.

BACKGROUND & AIMS: Although metabolic risk factors are associated with more severe COVID-19, there is little evidence on outcomes in patients with non-alcoholic fatty liver disease (NAFLD). We here describe the clinical characteristics and outcomes of NAFLD patients in a cohort hospitalised for COVID-19. METHODS: This study included all consecutive patients admitted for COVID-19 between February and April 2020 at Imperial College Healthcare NHS Trust, with either imaging of the liver available dated within one year from the admission or a known diagnosis of NAFLD. Clinical data and early weaning score (EWS) were recorded. NAFLD diagnosis was based on imaging or past medical history and patients were stratified for Fibrosis-4 (FIB-4) index. Clinical endpoints were admission to intensive care unit (ICU)and in-hospital mortality. RESULTS: 561 patients were admitted. Overall, 193 patients were included in the study. Fifty nine patients (30%) died, 9 (5%) were still in hospital, and 125 (65%) were discharged. The NAFLD cohort (n = 61) was significantly younger (60 vs 70.5 years, p = 0.046) at presentation compared to the non-NAFLD (n = 132). NAFLD diagnosis was not associated with adverse outcomes. However, the NAFLD group had higher C reactive protein (CRP) (107 vs 91.2 mg/L, p = 0.05) compared to non-NAFLD(n = 132). Among NAFLD patients, male gender (p = 0.01), ferritin (p = 0.003) and EWS (p = 0.047) were associated with in-hospital mortality, while the presence of intermediate/high risk FIB-4 or liver cirrhosis was not. CONCLUSION: The presence of NAFLD per se was not associated with worse outcomes in patients hospitalised for COVID-19. Though NAFLD patients were younger on admission, disease stage was not associated with clinical outcomes. Yet, mortality was associated with gender and a pronounced inflammatory response in the NAFLD group.