COVID-19 triage in general adult in-patient psychiatry: perspectives from clinicians on a novel triage ward during the pandemic

SUMMARY Intra-hospital transmission of COVID-19 is a major concern. To mitigate this risk, ‘COVID-triage’ psychiatric wards were implemented by some in-patient service providers in the UK. Although the effectiveness of this model has not been investigated, there are questions about the benefits and detriments of this model of care for patients and staff. This reflection draws from the experiences of clinicians who were redeployed from their planned clinical posts (and training rotations, in the case of trainees) to staff a newly established COVID-triage ward at a large urban mental healthcare provider, between August 2020 and March 2021.

The burden and dynamics of hospital-acquired SARS-CoV-2 in England

Hospital-based transmission played a dominant role in MERS-CoV and SARS-CoV epidemics but large-scale studies of its role in the SARS-CoV-2 pandemic are lacking. Such transmission risks spreading the virus to the most vulnerable individuals and can have wider-scale impacts through hospital-community interactions. Using data from acute hospitals in England we quantify within-hospital transmission, evaluate likely pathways of spread and factors associated with heightened transmission risk, and explore the wider dynamical consequences. We show that hospital transmission is likely to have been a major contributor to the burden of COVID-19 in England. We estimate that between June 2020 and March 2021 between 95,000 and 167,000 patients acquired SARS-CoV-2 in hospitals with nosocomially-infected patients likely to have been the main sources of transmission to other patients. Increased transmission to patients was associated with hospitals having fewer single rooms and lower heated volume per bed. Moreover, we show that reducing hospital transmission could substantially enhance the efficiency of punctuated lockdown measures in suppressing community transmission. These findings reveal the previously unrecognised scale of hospital transmission, have direct implications for targeting of hospital control measures, and highlight the need to design hospitals better-equipped to limit the transmission of future high consequence pathogens.

Evaluation of methods for whole genome sequencing of Enterococcus faecium in a diagnostic laboratory

Enterococcus faecium is an important nosocomial pathogen associated with hospital transmission and outbreaks. Based on growing evidence that bacterial whole genome sequencing enhances hospital outbreak investigation of other bacterial species, our aim was to develop and evaluate methods for low volume clinical sequencing of E. faecium. Using a test panel of 22 E. faecium isolates associated previously with hospital transmission, we developed laboratory protocols for DNA extraction and library preparation, which in combination with the Illumina MiniSeq can generate sequence data within 24 hours. The final laboratory protocol took 3.5 hours and showed 98% reproducibility in producing sufficient DNA for sequencing. Repeatability and reproducibility assays based on the laboratory protocol and sequencing demonstrated 100% accuracy in assigning species, sequence type (ST) and (when present) detecting vanA or vanB, with all isolates passing the quality control metrics. Minor variation was detected in base calling of the same isolate genome when tested repeatedly due to variations in mapping and base calling, but application of a SNP cut-off (<15 SNPs) to assign isolates to outbreak clusters showed 100% reproducibility. An evaluation of contamination showed that controls and test E. faecium sequence files contained <0.34% and <2.12% of fragments matching another species, respectively. Deliberate contamination experiments confirmed that this was insufficient to impact on data interpretation. Further work is required to develop informatic tools prior to implementation into clinical practice.

981. An Investigation into Possible Nosocomial Clusters and On-Treatment Resistance Patterns in Candidemia

Background Candidemia has significant clinical implications, due to high rates of mortality and increasing resistance to antifungal drugs. Candida auris shows person-to-person transmission and survival on fomites. We aimed to determine if similar hospital transmission of Candida species, other than C. auris, is occurring. We analyzed candidemia infections for species, geographical, and temporal clusters, and clonality. We also aimed to study resistance patterns in individual patients on antifungal treatment. Here we present our current data from December 2019 – March 2021. Methods Patients with candidemia were identified with the help of the clinical microbiology lab serving an urban health system. Isolates were stored prospectively as glycerol stocks at -80 C. Data were collected by retrospective chart review and described in terms of frequency distributions and percentages. Patient locations within the hospital setting were traced by Infection Prevention. A cluster was defined as the same species being isolated from ≥ 2 patients in the same unit within a 90-day period. Genomic DNA was isolated and whole genome sequencing was performed. Genomic data were visualized using the Yeast Mapping Analysis Pipeline. The Minimum Inhibitory Concentration (MIC) was determined using broth microdilution. Results 105 patients were identified from six hospitals (Table 1). Seven clusters of candidemia were identified (Table 2). Genome sequencing supported that all isolates from an individual patient were genetically related. No clonality was observed for isolates from different patients, including those representing two of the seven clusters (Figure 1). Loss of heterozygosity was detected in isolates collected 15 minutes apart in the same patient, indicating distinct populations. MICs remained the same at 0.5 ug/ml over 6 days in Patients l and m (Table 1). For Patient n, MICs remained at 0.5-1 ug/ml Day 1-8, but increased to 4 ug/ml on Day 9. No copy number variation was observed in these isolates. Table 1. Species and resistance patterns of candidemia Table 2. Clusters of candidemia Figure 1. Yeast Mapping Analysis Pipeline for Clusters 3 and 4 – Candida albicans Conclusion We have not found evidence of hospital transmission of candida isolates in our investigations to date. We plan to evaluate clonality in the remaining 5 clusters. Future single nucleotide polymorphism analysis will determine if acquisition of point mutations is causing the increased MIC in Patient n. Disclosures All Authors: No reported disclosures

Interhospital Transmission of Vancomycin-resistant Enterococcus Faecium in Aomori, Japan

A series of vancomycin-resistant Enterococcus faecium (VREf) outbreaks caused by clonal propagation due to inter-hospital transmission occurred in six general hospitals in Aomori prefecture, Japan. This was the first multi-jurisdictional outbreak of VREf sequence type 1421 in Japan. It took almost three years for VREf prevalence to return to pre-outbreak levels. The duration and size of outbreaks differed between hospitals according to the countermeasures available at each hospital. Prompt and strong countermeasures including patient isolation and repetitive screening of all inpatients were required to control the outbreaks. In addition to strict infection control measures, continuous monitoring of VREf prevalence in local medical regions and smooth and immediate communication among hospitals are required to prevent VREf outbreaks.

Risk Groups for SARS-CoV-2 Infection among Healthcare Workers: Community Versus Hospital Transmission

Background: We aimed to detect the risk factors for SARS-CoV-2 infection among healthcare workers (HCWs) in 2020 before the vaccination era. Methods: We surveyed SARS-CoV-2 infection among the HCWs in a hospital through screening for antibody levels and the detection of viral RNA by RT-PCR between May 2020 and December 2020. Occupational and non-occupational potential predictors of disease were surveyed for the HCWs included in this study. Results: Among 1925 personnel in the hospital, 1732 were included to the study with a response rate of 90%. The overall infection rate of HCWs was 16.3% at the end of 2020, before vaccinations started. In the multivariate analysis, being janitorial staff (OR: 2.24, CI: 1.21–4.14, p = 0.011), being a medical secretary (OR: 4.17, CI: 2.12–8.18, p < 0.001), having at least one household member with a COVID-19 diagnosis (OR: 8.98, CI: 6.64–12.15, p < 0.001), and number of household members > 3 (OR: 1.67, CI: 1.26–2.22, p < 0.001) were found to be significantly associated with SARS-CoV-2 infection. Conclusions: Medical secretaries and janitorial staff were under increased risk of SARS-CoV-2 infection. The community-hospital gradient can explain the mode of transmission for infection among HCWs. In the setting of this study, community measures were less strict, whereas hospital infection control was adequate and provided necessary personal protective equipment. Increasing risk in larger households and households with diagnosed COVID-19 patient indicates the community-acquired transmission of the infection.

Patient adherence with infection control measures on a novel ‘COVID-19 triage’ psychiatric in-patient ward

Background Intra-hospital transmission of coronavirus disease 2019 (COVID-19) is a major concern. Psychiatric in-patient units pose unique challenges for the prevention of transmission. ‘COVID-triage’ wards with strict infection control procedures have been implemented to prevent the spread of infection, but little is known about the extent to which psychiatric in-patients adhere to these procedures. Aims To examine patient adherence with infection control measures on a novel ‘COVID-triage’ psychiatric in-patient ward in London, England. Method This was an observational study of adherence with infection control measures. The proportion of patients who were adherent with infection control measures was calculated. The association of adherence with demographic and clinical factors was examined. Results The majority of patients (n = 138/176, 78.4%) were not adherent with infection control measures. However, adherence did improve when patients who were non-adherent were given direct instructions by staff during clinical contact. Patients with diagnoses of psychotic disorders, personality disorders and substance use disorders were less likely to be adherent than those without these diagnoses. Conclusions Psychiatric in-patients show poor adherence with infection control measures. Proactive engagement by staff is key to improving patients’ adherence. Urgent efforts are needed to identify and implement other effective methods of improving adherence in acute settings.

Diversity of sequence types and impact of fitness cost among carbapenem-resistant Acinetobacter baumannii isolates from Tripoli, Libya

We investigated the molecular epidemiology of 21 carbapenem-resistant A. baumannii from Libya, and assessed their relative fitness. Core-genome MLST revealed five inter-hospital transmission clusters. Three clusters were associated with the international clones (IC) IC1, IC2, and IC7. Carbapenem-resistance was associated with bla OXA-23, bla GES-11 , or bla NDM-1 . Compared to A. baumannii DSM 30008, the doubling time was similar over 10 hours, but after 16 hours, half the isolates grew to higher densities, suggesting a fitness advantage.