The burden of nosocomial covid-19: results from the Wales multi-centre retrospective observational study of 2518 hospitalised adults

Abstract

ObjectivesTo define the burden of nosocomial (hospital-acquired) novel pandemic coronavirus (covid-19) infection among adults hospitalised across Wales.DesignRetrospective observational study of adult patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection between 1st March – 1st July 2020 with a recorded hospital admission within the subsequent 31 days. Outcomes were collected up to 20th November using a standardised online data collection tool.SettingService evaluation performed across 18 secondary or tertiary care hospitals.Participants4112 admissions with a positive SARS-CoV-2 PCR result between 1st March to 1st July 2020 were screened. Anonymised data from 2518 participants were returned, representing over 60% of adults hospitalised across the nation of Wales.Main outcome measuresThe prevalence and outcomes (death, discharge) for nosocomial covid-19, assessed across of a range of possible case definitions.ResultsInpatient mortality rates for nosocomial covid-19 ranged from 38% to 42% and remained consistently higher than participants with community-acquired infection (31% to 35%) across a range of case definitions. Participants with nosocomial-acquired infection were an older, frailer, and multi-morbid population than those with community-acquired infection. Based on the Public Health Wales case definition, 50% of participants had been admitted for 30 days prior to diagnostic testing.ConclusionsThis represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date. These findings suggest that inpatient mortality rates from nosocomial-infection are likely higher than previously reported, emphasizing the importance of infection control measures, and supports prioritisation of vaccination for covid-19 negative admissions and trials of post-exposure prophylaxis in inpatient cohorts.Trial registrationThis project was approved and sponsored by the Welsh Government, as part of a national audit and quality improvement scheme for patients hospitalised covid-19 across Wales.Key MessagesWhat is already known on this topicWe searched PubMed and ISI Web of Science up until 31-December-2020 for studies reporting on patient outcomes following hospital-acquired infection due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We identified a range of case-definitions for hospital-acquired infection, based on timing of diagnostic testing 5 to 15 days following admission. The largest and only multi-centre study concluded individuals with nosocomial infection are at a lower risk of death from SARS-CoV-2 than those infected in the community, however, was performed early in the pandemic and utilised a conservative definition of nosocomial infection.What this study addsOur multi-centre observational study represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date, and suggests the burden of nosocomial SARS-CoV-2 infection has been underestimated. Nosocomial-infection occurred in older, frailer, and multi-morbid individuals, and was consistently associated with greater inpatient mortality than amongst those who were infected in the community across a spectrum of case-definitions. Our findings support implementation of enhanced infection control measures to reduce this burden during future waves, especially given the recent emergence of novel viral variants with enhanced transmissibility. Furthermore, roughly half of the patients meeting the Public Health Wales definition of definite nosocomial SARS-CoV-2 infection had been admitted for 30 days prior to diagnosis, highlighting a potential window of opportunity for inpatient pre-exposure and/or post-exposure prophylaxis.

Burden of nosocomial COVID-19 in Wales: results from a multicentre retrospective observational study of 2508 hospitalised adults

“…The methods and data sources relating to this work are described in detail elsewhere. 4 Briefly, positive SARS-CoV-2 PCR results recorded between 1 March 2020 and 1 July 2020 in adults with a recorded hospital admission were identified for retrospective notes review. Local clinical teams across 18 centres (online supplemental file S1) performed data entry using a standardised online tool.…”

Comparison of COVID-19 survival in relation to CPAP length of treatment and by comorbidity and transmission setting (community or hospital acquired) in a medium-sized UK hospital in 2020: a retrospective study

“…This mortality is much higher than the one found in other studies, 29 50 however, the similar mortality between both waves has been reported elsewhere as well. 29 The higher mortality in PHA patients than patients with community-acquired COVID-19 is also shown in recent studies, 50 although some literature has provided conflicting results. The data presented indicate that PHA infections were common during the outbreak.…”

A systematic review and meta-analysis of inpatient mortality associated with nosocomial and community COVID-19 exposes the vulnerability of immunosuppressed adults

“…A further 48 studies were excluded as they did not report mortality within both community and nosocomial-acquired COVID-19 patient groups. This left 21 studies for primary meta-analysis (9)(10)(11)(12)(13)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46), summarised in…”

“…We screened study quality through self-identified use of reporting standards. Three (14%) reports referenced the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement (9,12,36). Tables 2-4 show the formal risk of bias assessments.…”

“…The UK COVID-19 Clinical Information Network (CO-CIN) estimated 31,070 nosocomial COVID-19 infections occurred in England between February and July 2020, but made no assessment of the risk of mortality (8). We recently reported our initial experience from the first wave of the COVID-19 pandemic across the nation of Wales, using data collected from 2508 hospitalised adults (9).…”