Background and objectiveIt is crucial to make early differentiation between coronavirus disease 2019 (COVID-19) and seasonal influenza infections at the time of a patient's presentation to the emergency department (ED). In light of this, this study aimed to identify key epidemiological, initial laboratory, and radiological differences that would enable early recognition during co-circulation.MethodsThis was a retrospective, observational cohort study. All adult patients presenting to our ED at the Watford General Hospital, UK, with a laboratory-confirmed diagnosis of COVID-19 (2019/20) or influenza (2018/19) infection were included in this study. Demographic, laboratory, and radiological data were collected. Binary logistic regression was employed to determine features associated with COVID-19 infection rather than influenza.ResultsChest radiographs suggestive of viral pneumonitis and older age (>= 80 years) were associated with increased odds of having COVID-19 [odds ratio (OR): 47.00, 95% confidence interval (CI): 21.63-102.13 and OR: 64.85, 95% CI: 19.96-210.69 respectively]. Low eosinophils (<0.02 x 10(9)/L) were found to increase the odds of COVID-19 (OR: 2.12, 95% CI: 1.44-3.10, p<0.001).ConclusionsGaining awareness about the epidemiological, biological, and radiologic presentation of influenza-like illness can be useful for clinicians in ED to differentiate between COVID-19 and influenza. This study showed that older age, eosinopenia, and radiographic evidence of viral pneumonitis significantly increase the odds of having COVID-19 compared to influenza. Further research is needed to determine if these findings are affected by acquired or natural immunity.

Background Following a global shortage of piperacillin/tazobactam in 2017, a formulary decision was taken at a large District General Hospital in the East of England to partly replace piperacillin/tazobactam with either temocillin as monotherapy or as part of a combination regimen. A retrospective audit was then conducted to assess the clinical effectiveness of temocillin therapy. Methods Data from patients admitted to Watford General Hospital between May and August 2017 and treated with temocillin were reviewed retrospectively. Clinical characteristics of patients, data related to the episode of infection, clinical success, tolerance and mortality were analysed. Results Temocillin was used in 126 patients with median age of 73 years. Infection episodes mostly originated from the abdomen (n = 46), the lung (n = 40) and the urinary tract (n = 21). Seventy-seven patients received temocillin as first-line therapy and 106 received it empirically, with temocillin prescribed in combination with another antibiotic in 82% of the empirically treated cases. Clinical success was observed in 88.9% of cases with no difference between patients treated empirically and others (89.6% versus 85%) or in efficacy among abdominal (91%), pulmonary (87.5%) and urinary (81%) infections. One case of Clostridioides difficile infection was reported in a patient treated with four different antibiotics. During the shortage period, the hospital's standardized mortality ratio was significantly lower when compared with the same period of the preceding year (85 versus 96). Conclusions Using temocillin as part of an empirical strategy is feasible and safe as long as appropriate antibiotic combination is recommended based upon the indication and the likely bacterial pathogen.

ObjectiveProspectively validate prognostication scores, SOARS and 4C Mortality Score, derived from the COVID-19 first wave, for mortality and safe early discharge in the evolving pandemic with SARS-CoV-2 variants (B.1.1.7 replacing D614) and healthcare responses altering patient demographic and mortality.DesignProtocol-based prospective observational cohort study.SettingSingle site PREDICT and multisite ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts in UK COVID-19 second wave, October 2020 to January 2021.Participants1383 PREDICT and 20 595 ISARIC SARS-CoV-2 patients.Primary outcome measuresRelevance of SOARS and 4C Mortality Score determining in-hospital mortality and safe early discharge in the evolving UK COVID-19 second wave.Results1383 (median age 67 years, IQR 52–82; mortality 24.7%) PREDICT and 20 595 (mortality 19.4%) ISARIC patient cohorts showed SOARS had area under the curve (AUC) of 0.8 and 0.74, while 4C Mortality Score had AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore, effective in evaluating safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with SOARS of 0–1 were candidates for safe discharge to a virtual hospital (VH) model. SOARS implementation in the VH pathway resulted in low readmission, 11.8% (27/229) and low mortality, 0.9% (2/229). Use to prevent admission is still suboptimal, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0–1.ConclusionsSOARS and 4C Mortality Score remains valid, transforming complex clinical presentations into tangible numbers, aiding objective decision making, despite SARS-CoV-2 variants and healthcare responses altering patient demographic and mortality. Both scores, easily implemented within urgent care pathways for safe early discharge, allocate hospital resources appropriately to the pandemic’s needs while enabling normal healthcare services resumption.

Since first identified in late 2019, the acute respiratory syndrome coronavirus (SARS-CoV2) and the resulting coronavirus disease (COVID-19) pandemic has overwhelmed healthcare systems worldwide, often diverting key resources in a bid to meet unprecedented challenges. To measure its impact on national antimicrobial stewardship (AMS) activities, a questionnaire was designed and disseminated to antimicrobialstewardship leads in the United Kingdom (UK). Most respondents reported a reduction in AMS activity with 64% (61/95) reporting that COVID-19 had a negative impact on routine AMS activities. Activities reported to have been negatively affected by the pandemic include audit, quality improvement initiatives, education, AMS meetings, and multidisciplinary working including ward rounds. However, positive outcomes were also identified, with technology being increasingly used as a tool to facilitate stewardship, e.g., virtual meetings and ward rounds and increased the acceptance of using procalcitonin tests to distinguish between viral and bacterial infections. The COVID-19 pandemic has had a significant impact on the AMS activities undertaken across the UK. The long-term impact of the reduced AMS activities on incidence of AMR are not yet known. The legacy of innovation, use of technology, and increased collaboration from the pandemic could strengthen AMS in the post-pandemic era and presents opportunities for further development of AMS.

ABSTRACTIntroductionRisk factors of adverse outcomes in COVID-19 are defined but stratification of mortality using non-laboratory measured scores, particularly at the time of pre-hospital SARS-CoV-2 testing, is lacking.MethodsMultivariate regression with bootstrapping was used to identify independent mortality predictors in a derivation cohort of COVID-19 patients. Predictions were externally validated in a large random sample of the ISARIC cohort (N=14,231) and a smaller cohort from Aintree (N=290).Results983 patients (median age 70, IQR 53-83; in-hospital mortality 29.9%) were recruited over an 11-week study period. Through sequential modelling, a 5-predictor score termed SOARS (SpO2, Obesity, Age, Respiratory rate, Stroke history) was developed to correlate COVID-19 severity across low, moderate and high strata of mortality risk. The score discriminated well for in-hospital death, with area under the receiver operating characteristic values of 0.82, 0.80 and 0.74 in the derivation, Aintree and ISARIC validation cohorts respectively. Its predictive accuracy (calibration) in both external cohorts was consistently higher in patients with milder disease (SOARS 0-1), the same individuals who could be identified for safe outpatient monitoring. Prediction of a non-fatal outcome in this group was accompanied by high score sensitivity (99.2%) and negative predictive value (95.9%).ConclusionThe SOARS score uses constitutive and readily assessed individual characteristics to predict the risk of COVID-19 death. Deployment of the score could potentially inform clinical triage in pre-admission settings where expedient and reliable decision-making is key. The resurgence of SARS-CoV-2 transmission provides an opportunity to further validate and update its performance.

Introduction We aimed to develop and validate a prediction table for a simplified measure of rightward shift of the fetal oxyhaemoglobin saturation (SpO 2 ) versus inspired oxygen pressure ( P I O 2 ) curve as an objective marker of lung disease severity in very preterm infants, independent of unit altitude or oxygen prescribing policies. Methods Very preterm infants (n=219) had an oxygen reduction test at median (IQR) test age of 35 4 (34 5 –36 0 ) weeks’ postmenstrual age (PMA). Shift was derived from at least three paired SpO 2 versus P I O 2 measurements using a computer algorithm, using the fetal oxyhaemoglobin dissociation curve as the reference. Linear regression of resultant shift values enabled construction of a table to predict shift using a single paired SpO 2 versus P I O 2 measurement, validated subsequently in a separate infant cohort using Bland-Altman analysis. Receiver operating curve analysis provided threshold values equating to a clinical diagnosis of mild bronchopulmonary dysplasia (BPD) or moderate to severe BPD. Results The median (IQR) age of 63 infants in the validation cohort was 36 0 (35 6 –36 2 ) weeks’ PMA. Mean difference (95% CI) between predicted and measured shift was 2.1 (−0.8% to 4.9%) with wide limits of agreement (−20.7% to 24.8%). Predicted shift >10.1 kPa identified mild BPD with 71% sensitivity and 88% specificity while values>13.0 kPa identified moderate to severe BPD with 81% sensitivity and 100% specificity. Discussion Shift predicted from a single paired SpO 2 versus P I O 2 measurement using our validated table enables objective bedside screening of lung disease severity in very preterm infant cohorts at 36 weeks’ PMA.

ABSTRACTObjectiveProspectively validate two prognostic scores, pre-hospitalisation (SOARS) and hospitalised mortality prediction (4C Mortality Score), derived from the coronavirus disease 2019 (COVID-19) first wave, in the evolving second wave with prevalent B.1.1.7 and parent D614 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, in two large United Kingdom (UK) cohorts.DesignProspective observational cohort study of SOARS and 4C Mortality Score in PREDICT (single site) and multi-site ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts.SettingProtocol-based data collection in UK COVID-19 second wave, between October 2020 and January 2021, from PREDICT and ISARIC cohorts.Participants1383 from single site PREDICT cohort and 20,595 from multi-site ISARIC cohort.Main outcome measuresRelevance of SOARS and 4C Mortality Score derived from the COVID-19 first wave, determining in-hospital mortality and safe discharge in the UK COVID-19 second wave.ResultsData from 1383 patients (median age 67y, IQR 52-82; mortality 24.7%) in the PREDICT and 20,595 patients from the ISARIC (mortality 19.4%) cohorts showed both SOARS and 4C Mortality Score remained relevant despite the B.1.1.7 variant and treatment advances. SOARS had AUC of 0.8 and 0.74, while 4C Mortality Score had an AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore effective in evaluating both safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with a SOARS of 0-1 were potential candidates for home discharge to a virtual hospital (VH) model. SOARS score implementation resulted in low re-admission rates, 11.8% (27/229), and low mortality, 0.9% (2/229), in the VH pathway. Use is still suboptimal to prevent admission, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1.ConclusionSOARS and 4C Mortality Score remains valid, providing accurate prognostication despite evolving viral subtype and treatment advances, which have altered mortality. Both scores are easily implemented within urgent care pathways with a scope for admission avoidance. They remain safe and relevant to their purpose, transforming complex clinical presentations into tangible numbers, aiding objective decision making.Trial registrationNHS HRA registration and REC approval (20/HRA/2344, IRAS ID 283888).

Background There is ongoing uncertainty amongst clinicians on the use of prednisolone in acute pre-school wheeze. Some studies report that there is no positive effect by prescribing steroids for this cohort of children whilst others have shown a reduction in illness severity and duration of hospitalisation. Objectives In our emergency department a wheeze pathway with clinical proforma helps clinicians assess the severity of presentation (mild, moderate, severe, life-threatening) and directs them to an appropriate treatment course. For pre-school children (2–4 years) presenting with moderate severity acute wheeze, the pathway states ‘consider steroids’. This peer review examined the use of prednisolone in this group of patients. Methods Two paediatric registrars and two paediatric consultants independently performed a retrospective review of the notes of all pre-school children presenting with moderate severity acute wheeze over one month (n=23). In each case reviewers were asked to document whether or not they would give steroids and the justification for their decision. Results Of the 23 decisions made whether or not to give steroids, 9 children received steroids and 14 did not. The reviewers were in complete agreement with only 11 decisions (48%): 1 case where steroids were given, 10 when it was not. However, this value rose to 61% (14/23) where the majority of reviewers (3/4) agreed. Of the 9 who received steroids, in 4 of these cases reviewers felt steroids should not have been given. The steroids were prescribed within 15 minutes of the 1st chest assessment, and in one case steroids were even given before salbutamol. There was significant clinical improvement between 1st and 2nd chest assessments (approximately 20 mins time interval) more likely due to bronchodilator administration rather than the steroid. In the 14 children not receiving steroids, all reviewers agreed with 10 decisions (71%) not to give. In 1 instance all felt the child should have in fact received steroids due to the history of allergies and atopy, use of regular steroid inhaler, frequent admissions within the last year and poor response to bronchodilators. The remaining 3 decisions were split depending on the significance given to atopy by the reviewer and the impact of temperature on observations. Overall, the reviewers were less likely to give steroids than the clinicians who saw the patients 9% (2/23) vs 39% (9/23). Factors that impacted this discordance included timing of steroid dose (prior to reassessment after initial salbutamol), inaccurate scoring of severity, incomplete history taken and history of atopy. Conclusions This peer review illustrates that there is a potential overuse of steroids in acute pre-school wheeze in our emergency department. It is limited by retrospective bias contributed to by the accuracy of documentation in the medical records and any prior knowledge of the patient’s outcome by a reviewer. However, the grade of reviewer did not influence our findings. Appropriate prescribing of oral steroids in acute pre-school wheeze can be improved with ongoing education on emergency management of acute presentations. Clinical wheeze pathways should avoid vague statements and provide clearer guidance with regard to when steroids are indicated.

ObjectivesTo investigate whether calcium derangement was a specific feature of COVID-19 that distinguishes it from other infective pneumonias, and its association with disease severity.DesignA retrospective observational case–control study looking at serum calcium on adult patients with COVID-19, and community-acquired pneumonia (CAP) or viral pneumonia (VP).SettingA district general hospital on the outskirts of London, UK.Participants506 patients with COVID-19, 95 patients with CAP and 152 patients with VP.Outcome measuresBaseline characteristics including hypocalcaemia in patients with COVID-19, CAP and VP were detailed. For patients with COVID-19, the impact of an abnormally low calcium level on the maximum level of hospital care, as a surrogate of COVID-19 severity, was evaluated. The primary outcome of maximal level of care was based on the WHO Clinical Progression Scale for COVID-19.ResultsHypocalcaemia was a specific and common clinical finding in patients with COVID-19 that distinguished it from other respiratory infections. Calcium levels were significantly lower in those with severe disease. Ordinal regression of risk estimates for categorised care levels showed that baseline hypocalcaemia was incrementally associated with OR of 2.33 (95% CI 1.5 to 3.61) for higher level of care, superior to other variables that have previously been shown to predict worse COVID-19 outcome. Serial calcium levels showed improvement by days 7–9 of admission, only in survivors of COVID-19.ConclusionHypocalcaemia is specific to COVID-19 and may help distinguish it from other infective pneumonias. Hypocalcaemia may independently predict severe disease and warrants detailed prognostic investigation. The fact that decreased serum calcium is observed at the time of clinical presentation in COVID-19, but not other infective pneumonias, suggests that its early derangement is pathophysiological and may influence the deleterious evolution of this disease.Trial registration number20/HRA/2344.

Introduction Meropenem is a broad spectrum antibiotic used to treat a variety of bacterial infections. There are no clear standards nationally for the use of meropenem. The purpose of this study is to audit the appropriateness of Meropenem prescription at West Hertfordshire NHS trust METHODOLOGY Patients started on meropenem were identified via the hospital pharmacy in the period from 1st January 2019 to 31st March 2019. Patients’ clinical notes, drug charts and blood tests were reviewed. Appropriateness of meropenem prescription was judged based on the following: indication, penicillin allergy and its nature, pathogen antibiogram, microbiologists approval, indications for escalation and duration of treatment RESULTS forty-eight patients were identified during the study period. The main indications were hospital-acquired/community-acquired pneumonia and UTI. Penicillin allergy was documented in 31%, the nature of allergy was intolerance in 13% and not known in 20%. Of note, in 42% of these, treatment was not pathogen guided. In 45.5% of non-penicillin allergic patients, escalation to meropenem were neither supported by antibiogram nor by microbiologists. The main driver was raised inflammatory markers (62.5%). Of the 37 patients who completed their treatment during the study period, 21.6% had > 7 days with only 50% recommended by Microbiologists. CONCLUSION: In third of the patients, meropenem use was driven by penicillin allergy, however the nature of allergy did not justify its use in many of these cases. Lack of microbiology approval, failure to de-escalate and long courses of meropenem were additional areas identified to target in our antimicrobial stewardship programme

Background: Influenza pneumonia can be challenging to treat particularly in critically ill patients. The aim of this study is to review the risk factors for severe influenza infection, the course of the disease, the choice of antivirals and the management outcome in patients admitted with complicated influenza illness to ICU Method Sixteen patients who were admitted to ICU at West Hertfordshire hospitals NHS Trust with severe influenza illness were reviewed between 20th December 2018 and 14th February 2019. Data on Demographics, vaccination status, viral strain and clinical outcome were collected and analysed. Results High proportion of patients were below the age of 65 (n=9).The predominant strain was A(H1N1) pdm09 (n=10), followed by A(H3N2) (n=5) and 1 patient had no strain reported. All patients were initiated on Oseltamivir. Six patients developed multi-organ failure and were switched to IV Zanamivir. None of the latter were severely immunosuppressed. 56.25% (n=9) were not vaccinated and third with unknown status (n=5). 66% of the patients below the age of 65 were not vaccinated and had to switch to Zanamavir. Fourteen patients made good recovery and 2 died while on Zanamavir Conclusion: Our result suggest that the majority of patients admitted to ICU did not carry risk factor for complications and were below the age of 65, but were unvaccinated and infected with A(H1N1)pdm09 strain. Larger study is required to fully understand the risk factors for ICU admission including vaccination status in this group of patients and the optimum antiviral choice.

Context: The significant global upsurge in antimicrobial resistance, particularly among Enterobacteriaceae, represents a serious threat to health care systems. The implications for urologic practice are of particular concern.Objective: To review trends in antibiotic resistance in urologic practice.Evidence acquisition: We report current European trends of resistance in Gram-negative uropathogens.Evidence synthesis: In addition to beta-lactam resistance, Gram-negative pathogens are often resistant to multiple drug classes, including aminoglycosides, fluoroquinolones, and carbapenems, commonly used to treat urologic infections. Interest is renewed in old antibiotics, and several new antibiotics are in the pipeline to meet the challenge of treating these infections. In this review, we summarise emerging trends in antimicrobial resistance and its impact on urologic practice. We also review current guidelines on the treatment and prevention of urologic infections with these organisms, and some key antibiotics in the era of resistance.Conclusions: Increasing antimicrobial resistance represents a challenge to urologic practice for both treatment and prophylaxis. Antibiotic choice should be determined according to risk factors for multidrug resistance. Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy.Patient summary: Antimicrobial resistance represents a challenge in urology. We summarise emerging trends in antimicrobial resistance and review current guidelines on the treatment and prevention of urologic infections, as well as some key antibiotics in the era of resistance. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

For reference [[56]Bou-Antoun S. Davies J. Guy R. Johnson A.P. Sheridan E.A. Hope R.J. Descriptive epidemiology of Escherichia coli bacteraemia in England, April 2012 to March 2014.Euro Surveill. 2016; 21 (www. eurosurveillance.org/images/dynamic/EE/V21N35/art22569.pdf): 1-9Crossref Scopus (66) Google Scholar], the name of the first author of the paper is missing. The correct reference is as follows: Trends in Antibiotic Resistance in Urologic PracticeEuropean Urology FocusVol. 2Issue 4PreviewTake Home Message Increasing antimicrobial resistance presents a challenge to urologic practice for both treatment and prophylaxis. It is essential that antibiotic choice is determined according to risk factors for multidrug resistance (MDR). Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy. As MDR Gram-negative uropathogens increases in prevalence, further studies are required to investigate the utility of prebiopsy screening for resistant pathogens and the role of individualised decision-making. Full-Text PDF