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Perioperative prophylactic antibiotics following surgeries have been shown to reduce surgical site infections, and their administration is common practice. Despite clear guidelines regarding this being set forth by the Infectious Disease Society of America (IDSA), adherence to them is yet to translate to common practice in many parts of the world. A retrospective chart review of 409 patients who underwent elective surgeries over a period of 7 months at three different hospitals in India was performed. In-hospital antibiotic prescriptions of these patients were examined for any apparent inappropriateness (use of antibiotics with coverage broader than the target microbes and use of antibiotics with overlapping spectrum of target microbes). Four hundred ninety-five (48.9%) of the 1,012 patient intensive care unit (ICU) days had apparent inappropriateness in the choice of their prophylactic antibiotics and only 3.2% of the antibiotic units used were in accordance with the present IDSA guidelines. Injudicious use of broad-spectrum antibiotics for surgical prophylaxis is prevalent in low- and middle-income countries such as India. This poses the risk of emergence of resistant microorganisms in these areas and their potential spread across the borders. There is an acute need for diligent antibiotic stewardship programs in these areas to curb such practices.

A 24-year-old female with pneumonia two months prior presented with fever, cough and worsening dyspnea in the midst of a COVID-19 spike. Her initial episode was treated as COVID-19 pneumonia. On presentation, her chest CT was suggestive of bilateral lower zone organizing pneumonia with mild fibrosis and was attributed to post COVID sequelae with an infective exacerbation. Oral steroids and antibiotics were administered following which she had initial improvement and then subsequent deterioration requiring ICU care. A detailed clinical examination (in-person and virtually) at this point revealed the presence of pigmented rashes over the knuckles and weakness of hip muscles. Laboratory work showed elevated creatine kinase levels, positive anti-Ro and anti-Jo1 antibodies which pointed to a diagnosis of anti-synthetase syndrome (ASS). Unique attributes of this case include younger age of presentation in an atypical ethnic group and possibly incited by COVID-19 infection in the peak of a COVID-19 wave. The work-up, diagnosis and initial management of this patient was carried out through a hybrid ICU model which functioned as a traditional ICU in the day and a tele-ICU at night with an appropriate network of sub-specialists including Rheumatologists consulting, thus highlighting a collaborative model in a low resource setting capable of managing rare cases even in the midst of increasing critical care needs during the pandemic.

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