The spatial and temporal distribution of SARS-CoV-2 from the built environment of COVID-19 patient rooms: A multicentre prospective study.

BackgroundSARS-CoV-2 can be detected from the built environment (e.g., floors), but it is unknown how the viral burden changes over space and time surrounding an infected patient. Characterising these data can help advance our understanding and interpretation of surface swabs from the built environment. MethodsWe conducted a prospective study at two hospitals in Ontario, Canada between January 19, 2022 and February 11, 2022. We performed serial floor sampling for SARS-CoV-2 in rooms of patients newly hospitalized with COVID-19 in the past 48 hours. We sampled the floor twice daily until the occupant moved to another room, was discharged, or 96 hours had elapsed. Floor sampling locations included: 1m from the hospital bed, 2m from the hospital bed, and at the rooms threshold to the hallway (typically 3 - 5m from the hospital bed). The samples were analyzed for the presence of SARS-CoV-2 using qPCR. We calculated the sensitivity of detecting SARS-CoV-2 in a patient with COVID-19, and we evaluated how the percentage of positive swabs and the cycle threshold of the swabs changed over time. We also compared the cycle threshold between the two hospitals. ResultsOver the 6-week study period we collected 164 floor swabs from the rooms of 13 patients. The overall percentage of swabs positive for SARS-CoV-2 was 93% and the median cycle threshold (for positive swabs) was 33.7 (IQR: 30.9, 37.5). On day 0 of swabbing the percentage of swabs positive for SARS-CoV-2 was 81.1% and the median cycle threshold was 33.7 (IQR: 32.1, 38.3) compared to swabs performed on day 2 or later where the percentage of swabs positive for SARS-CoV-2 was 98.1% and the cycle threshold was 33.4 (IQR: 30.7, 35.7). We found that viral detection did not change with increasing time (since the first sample collection) over the sampling period, OR 1.65 per day (95% CI 0.68, 4.02; p = 0.27). Similarly, viral detection did not change with increasing distance from the patients bed (1m, 2m, or 3m), OR 0.85 per metre (95% CI 0.38, 1.88; p = 0.69). The cycle threshold was lower (e.g. more virus) in The Ottawa Hospital (median Cq 30.8) where the floors are cleaned once daily rather than the Toronto hospital (median Cq 37.3) where floors were cleaned twice daily. ConclusionsWe were able to detect SARS-CoV-2 on the floors of rooms of patients with COVID-19 and the viral burden did not vary over time or by distance from the bed. These results suggest floor swabbing for the detection of SARS-CoV-2 in a built environment such as a hospital room is both accurate and robust to variation in sampling location and duration of occupancy.

Heparin for Moderately Ill Patients with Covid-19

BackgroundHeparin, in addition to its anticoagulant properties, has anti-inflammatory and potential anti-viral effects, and may improve endothelial function in patients with Covid-19. Early initiation of therapeutic heparin could decrease the thrombo-inflammatory process, and reduce the risk of critical illness or death. MethodsWe randomly assigned moderately ill hospitalized ward patients admitted for Covid-19 with elevated D-dimer level to therapeutic or prophylactic heparin. The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation or ICU admission. Safety outcomes included major bleeding. Analysis was by intention-to-treat. ResultsAt 28 days, the primary composite outcome occurred in 37 of 228 patients (16.2%) assigned to therapeutic heparin, and 52 of 237 patients (21.9%) assigned to prophylactic heparin (odds ratio, 0.69; 95% confidence interval [CI], 0.43 to 1.10; p=0.12). Four patients (1.8%) assigned to therapeutic heparin died compared with 18 patients (7.6%) assigned to prophylactic heparin (odds ratio, 0.22; 95%-CI, 0.07 to 0.65). The composite of all-cause mortality or any mechanical ventilation occurred in 23 (10.1%) in the therapeutic heparin group and 38 (16.0%) in the prophylactic heparin group (odds ratio, 0.59; 95%-CI, 0.34 to 1.02). Major bleeding occurred in 2 patients (0.9%) with therapeutic heparin and 4 patients (1.7%) with prophylactic heparin (odds ratio, 0.52; 95%-CI, 0.09 to 2.85). ConclusionsIn moderately ill ward patients with Covid-19 and elevated D-dimer level, therapeutic heparin did not significantly reduce the primary outcome but decreased the odds of death at 28 days. Trial registration numbers: NCT04362085; NCT04444700

Coronavirus-19 and coagulopathy: A Systematic Review

BackgroundUnderstanding the association between Coronavirus Disease 2019 (COVID-19) and coagulopathy may assist clinical prognostication, and influence treatment and outcomes. We aimed to systematically describe the relationship between hemostatic laboratory parameters and important clinical outcomes among adults with COVID-19. MethodsA systematic review of randomized clinical trials, observational studies and case series published in PubMed (Medline), EMBASE, and CENTRAL from December 1, 2019 to March 25, 2020. Studies of adult patients with COVID-19 that reported at least one hemostatic laboratory parameter were included. ResultsData were extracted from 57 studies (N=12,050 patients) that met inclusion criteria. The average age of patients was 52 years and 45% were women. Of the included studies, 92.7% (N=38/41 studies) reported an average platelet count [≥] 150 x 109/L, 68.2% (N=15/22 studies) reported an average prothrombin time (PT) between 11-14 s, 55% (N=11/20 studies) reported an average activated partial thromboplastin time (aPTT) between 25-35 s, and 34.4% (N=11/32 studies) reported a D-dimer concentration above the upper limit of normal (ULN). Eight studies (7 cohorts and 1 case series) reported hemostatic lab values for survivors versus non-survivors. Among non-survivors, D-dimer concentrations were reported in 4 studies and all reported an average above the ULN. InterpretationMost patients had a normal platelet count, elevated D-dimer, PT and aPTT values in the upper reference interval; D-dimer elevation appeared to correlate with poor outcomes. Further studies are needed to better correlate these hemostatic parameters with the risk of adverse outcomes such as thrombosis and bleeding.

Patient characteristics, clinical care, resource use, and outcomes associated with hospitalization for COVID-19 in the Toronto area

BackgroundPatient characteristics, clinical care, resource use, and outcomes associated with hospitalization for coronavirus disease (COVID-19) in Canada are not well described. MethodsWe described all adult discharges from inpatient medical services and medical-surgical intensive care units (ICU) between November 1, 2019 and June 30, 2020 at 7 hospitals in Toronto and Mississauga, Ontario. We compared patients hospitalized with COVID-19, influenza and all other conditions using multivariable regression models controlling for patient age, sex, comorbidity, and residence in long-term-care. ResultsThere were 43,462 discharges in the study period, including 1,027 (3.0%) with COVID-19 and 783 (2.3%) with influenza. Patients with COVID-19 had similar age to patients with influenza and other conditions (median age 65 years vs. 68 years and 68 years, respectively, SD<0.1). Patients with COVID-19 were more likely to be male (59.1%) and 11.7% were long-term care residents. Patients younger than 50 years accounted for 21.2% of all admissions for COVID-19 and 24.0% of ICU admissions. Compared to influenza, patients with COVID-19 had significantly greater mortality (unadjusted 19.9% vs 6.1%, aRR: 3.47, 95%CI: 2.57, 4.67), ICU use (unadjusted 26.4% vs 18.0%, aRR 1.52, 95%CI: 1.27, 1.83) and hospital length-of-stay (unadjusted median 8.7 days vs 4.8 days, aRR: 1.40, 95%CI: 1.20, 1.64), and not significantly different 30-day readmission (unadjusted 8.6% vs 8.2%, aRR: 1.01, 95%CI: 0.72, 1.42). InterpretationAdults hospitalized with COVID-19 during the first wave of the pandemic used substantial hospital resources and suffered high mortality. COVID-19 was associated with significantly greater mortality, ICU use, and hospital length-of-stay than influenza.

Cohorting of Non-Critically Ill COVID-19 Patients: A Multicenter Survey Study (COVID-COHORT)

The COVID-19 pandemic has posed novel infection-control challenges for hospitals around the globe. One infection-control strategy that has been widely used in the context of other outbreaks is patient cohorting. This strategy refers to the placement of all patients exposed to the same laboratory-confirmed infectious agent in one location within the hospital. Little is known about the current utilization of this strategy with non-critically ill COVID-19 patients. An international multicenter, survey study was conducted to identify what strategies are planned or in place for patients with COVID-19 who are not critically ill. The survey was distributed from March 23-29th, 2020 to GIM physicians in Canada, USA, Denmark, Singapore, Hong Kong, and England. Of the 31 hospitals, 29 (94%) indicated that they plan on cohorting all GIM patients with COVID-19 to one location in the hospital. Among these 29 hospitals, 23 (79%) had implemented the plan at the time of the survey. The primary reasons for this decision were to limit the spread of COVID-19 and conserve PPE use. In conclusion, in the face of a novel virus there is near unanimity in the practice of patient cohorting as a potential mitigation strategy.