Background Prospective review and feedback (PRF) of antibiotic prescriptions and compulsory computerized decision support system (CDSS) are 2 strategies of antimicrobial stewardship. There are limited studies investigating their combined effects. We hypothesized that the use of on-demand (voluntary) CDSS would achieve similar patient outcomes compared with automatically triggered (compulsory) CDSS whenever broad-spectrum antibiotics are ordered. Methods A parallel-group, 1:1 block cluster randomized crossover study was conducted in 32 medical and surgical wards from March to August 2017. CDSS use for piperacillin-tazobactam or carbapenem in the intervention clusters was at the demand of the doctor, while in the control clusters CDSS use was compulsory. PRF was continued for both arms. The primary outcome was 30-day mortality. Results Six hundred forty-one and 616 patients were randomized to voluntary and compulsory CDSS, respectively. There were no differences in 30-day mortality (hazard ratio [HR], 0.87; 95% CI, 0.67–1.12), re-infection and re-admission rates, antibiotic duration, length of stay, or hospitalization cost. The proportion of patients receiving PRF recommendations was not significantly lower in the voluntary CDSS arm (62 [10%] vs 81 [13%]; P = .05). Appropriate indication of antibiotics was high in both arms (351/448 [78%] vs 330/433 [74%]; P = .18). However, in geriatric medicine patients where antibiotic appropriateness was <50%, prescription via compulsory CDSS resulted in a shorter length of stay and lower hospitalization cost. Conclusions Voluntary broad-spectrum antibiotics with PRF via CDSS did not result in differing clinical outcomes, antibiotic duration, or length of stay. However, in the setting of low antibiotic appropriateness, compulsory CDSS may be beneficial.

Letter to the Editor Dear Editor, On 11 March 2020, the World Health Organization declared COVID-19 a global pandemic. 1 Since then, COVID-19 cases have risen exponentially in Singapore, 2 resulting in a corresponding need to rapidly increase our national treatment capacity, especially for patients requiring intensive care. With direction from Singapore's Ministry of Health (MOH), Tan Tock Seng Hospital (TTSH) worked together with its affiliated institution, National Centre of Infectious Diseases (NCID), to comprehensively plan to increase ICU capacity across the 2 institutions. NCID was purpose-built to treat patients with infectious diseases and to shoulder Singapore's outbreak response with peacetime capacity of 330 beds and flexibility to ramp-up to more than 500 beds. 3 NCID is located adjacent to TTSH-one of Singapore's largest tertiary hospitals, with a large capacity of over 1,500 beds. NCID is currently the frontline healthcare institution for the screening and treatment of COVID-19 patients in Singapore. 4 A decision was made from the onset to streamline all COVID-19 work processes within TTSH-NCID. Since January 2020, all COVID-19 patients requiring intensive care in TTSH-NCID were managed within NCID's 2 ICU wards. i TTSH's 4 ICU wards (Medical, Cardiac, Surgical and Neuroscience) continued to treat all non-COVID-19 'business-as-usual' (BAU) patients. As national cases steadily rose throughout March, and in anticipation of a potential exponential increase, TTSH-NCID (with direction from MOH) formulated an integrated plan to increase ICU capacity. Although TTSH-NCID's target ICU capacity was aligned to MOH's national objectives, TTSH-NCID planned to progressively ramp-up in phases according to realtime utilisation and demand. This plan was executed in April, as national cases started to rise exponentially. The ramp-up in Outbreak ICU (OICU) capacity to treat COVID-19 patients was achieved via 3 phases: (1) converting 2 BAU ICU wards in TTSH into OICU wards, (2) repurposing COVID-19 General Wards (GWs) in i NCID has a capacity of 38 ICU beds, of which only 10 are operational during peacetime.

The diagnosis of iron deficiency in hospital patients can be difficult in the presence of inflammation. A raised serum transferrin receptor (sTfR) level is useful as a marker of iron deficiency as it is unaffected by inflammation. However, diseases that cause an increase in erythropoietic activity can also result in a raised sTfR level. In South-East Asia, the prevalence of thalassaemia trait is high. As thalassaemia trait is associated with ineffective erythropoiesis and therefore an increase in the sTfR level, we studied the influence of thalassaemia trait on the diagnosis of iron deficiency in hospital patients. Among 431 patients with different combinations of iron deficiency, alpha- and beta-thalassaemia trait, we found that the sTfR level is an excellent diagnostic test for iron deficiency only in patients without thalassaemia trait. alpha-Thalassaemia trait worsened its diagnostic accuracy and beta-thalassaemia trait rendered it a non-diagnostic test. We conclude that in populations with a high prevalence of thalassaemia trait, the sTfR level is not useful in diagnosing iron deficiency unless the patient's thalassaemia status is known.

The success of solid organ transplantation in the treatment of end-stage organ failure has fuelled a growing demand for transplantable organs worldwide that has far outstripped the supply from brain dead heart-beating donors. In Singapore, this has resulted in long waiting lists of patients for transplantable organs, especially kidneys. The Human Organ Transplant Act, introduced in 1987, is an opt-out scheme that presumes consent to removal of certain organs for transplantation upon death. Despite this legislation, the number of deceased organ donors in Singapore, at 7 to 9 per million population per year, remains low compared to many other developed countries. In this paper, we reviewed the clinical challenges and ethical dilemmas encountered in managing and identifying potential donors in the neurological intensive care unit (ICU) of a major general hospital in Singapore. The large variance in donor actualisation rates among local restructured hospitals, at 0% to 56.6% (median 8.8%), suggests that considerable room still exists for improvement. To address this, local hospitals need to review their processes and adopt changes and best practices that will ensure earlier identification of potential donors, avoid undue delays in diagnosing brain death, and provide optimal care of multi-organ donors to reduce donor loss from medical failures. Key words: Brain death, End-of-life, Multi-organ donor, Organ procurement, Opt-out

Letter to the Editor Dear Editor, Prone positioning is an established treatment modality in acute respiratory distress syndrome (ARDS) and has been employed in the management of ARDS in severe 2019 novel coronavirus disease (COVID-19) in the intensive care unit (ICU) with varying clinical and physiological responses. 1,2 To date, Singapore has seen 44,122 COVID-19 patients, with the majority of inpatients managed at National Centre of Infectious Diseases (NCID). NCID ICU has managed 36 mechanically intubated patients thus far. We retrospectively examine the first 20 patients in NCID ICU and describe our early experience of prone positioning in COVID-19 ARDS including identifying potential early physiological indicators of poor response to prone positioning.