Hostname: page-component-7c8c6479df-fqc5m Total loading time: 0 Render date: 2024-03-29T11:20:57.767Z Has data issue: false hasContentIssue false

Hospital infection and COVID-19: Do not put all your eggs on the “swab” tests

Published online by Cambridge University Press:  27 May 2020

Francesco Chirico*
Affiliation:
Postgraduate School of Occupational Medicine, Università Cattolica del Sacro Cuore, Rome, Italy Health Service Department, State Police, Ministry of Interior, Milan, Italy
Gabriella Nucera
Affiliation:
Faculty of Nursing, University of Milan, Italy Fatebenefratelli Sacco, FatebeneFratelli Hospital, Milan, Italy
Nicola Magnavita
Affiliation:
Postgraduate School of Occupational Medicine, Università Cattolica del Sacro Cuore, Rome, Italy Department of Woman/Child and Public Health, Fondazione Policlinico “A.Gemelli” IRCCS, Rome, Italy
*
Author for correspondence: Prof Francesco Chirico, E-mail: medlavchirico@gmail.com
Rights & Permissions [Opens in a new window]

Abstract

Type
Letter to the Editor
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

To the Editor—In healthcare settings, including long-term care facilities, hospital administrators have a legal obligation to set up a risk assessment strategy to carry out effective prevention and control measures during the management of suspected and confirmed cases of COVID-19 infection. 1 Hospitalized inpatients and residents in care homes are often elderly and immune-depressed patients with comorbidities; thus, they are at high risk of infection and mortality. Special attention and efforts to protect or reduce transmission should be also applied in healthcare providers because depletion of the healthcare workforce not only will affect health care but also will contribute to the spread of the outside hospitals.

According to European Centres for Disease Control and Prevention (EU-CDC) guidelines, 1 each hospital should constitute a ‘COVID-19 preparedness and response committee’ and should prepare a specific plan, including a number of administrative and structural measures for patient and healthcare management. Undoubtedly, the most important measure in reding the likelihood of nosocomial infection is early isolation of patients with COVID-19, or at least maintaining a safe distance between those who are awaiting diagnosis. However, a number of recent studies showed that patients with mild or nonspecific symptoms can escape isolation and thus introduce SARS-CoV-2 into hospitals, leading to clusters of nosocomial infections. Reference Klompas2

To minimize the risk of spreading, mass testing with nasopharyngeal and oropharyngeal (NP/OP) swab of all patients has been proposed, Reference Klompas2,Reference Gandhi, Yokoe and Havlir3 associated with mass testing of both symptomatic and asymptomatic healthcare workers. Reference Black, Bailey, Przewrocka, Dijkstra and Swanton4 Even the use of these expensive and demanding mass strategies, however, cannot be considered a measure of absolute guarantee.

Indeed, Xie et al Reference Xie, Zhong, Zhao, Zheng, Wang and Liu5 observed typical COVID-19 chest lesions via computed tomography (CT) scans in 5 patients with a negative or weakly positive swab test (RT-PCR test). Another patient with a chest X-ray showing interstitial pneumonia but with a negative RT-PCR test was reported by Winichakoon et al. Reference Winichakoon, Chaiwarith and Liwsrisakun6 Kumar et al Reference Kumar, O’Neill, Johnston, Grant and Sweet7 reported the case of a patient with pneumonia and negative nasopharingeal swab who tested positive some days later with a bronchial lavage sample. Bandirali et al Reference Bandirali, Scofienza and Serra8 found that asymptomatic or minimally symptomatic patients may have abnormalities in chest x-rays after 14 days of quarantine, with a sensitivity of RT-PCR testing of 59%. Reference Bandirali, Scofienza and Serra8

Cao et al Reference Cao, Tang and Yang9 observed that patients with negative to RT-PCR tests may have specific IgG and/or IgM for SARS-CoV-2 at recovery stage. Reference Cao, Tang and Yang9 In reality, the sensitivity of an NP/OP swab in the course of disease ranges between 42% and 71% Reference Winichakoon, Chaiwarith and Liwsrisakun6 and depends on sampling technique, timing within the clinical course of COVID-19, and viral loads detected in the swab. Reference Winichakoon, Chaiwarith and Liwsrisakun6

In conclusion, given the fact that negative NP/OP swabs do not rule out COVID-19 diagnosis, we propose that all the patients hospitalized with pneumonia be subjected to swab obtained by deep tracheal aspirate, which has a lower risk of aerosolization. Reference Alhazzani, Møller and Arabi10 We further recommend that suspected infection be checked with a combination of repeated RT-qPCR tests and chest CT scan. All patients hospitalized without respiratory symptoms should also be checked with repeated RT-qPCR tests and chest X ray before admission in hospital wards.

Moreover, healthcare providers should be tested regularly with serological test and swabs and symptom monitoring. Finally, a policy of universal masking and eye shielding for all healthcare providers involved in direct patient care is needed.

Acknowledgments

None.

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References

Infection prevention and control and preparedness for COVID-19 in healthcare settings - third update. EU-CDC European Centre For Disease Prevention and Control. https://www.ecdc.europa.eu/en/publications-data/infection-prevention-and-control-and-preparedness-covid-19-healthcare-settings. Accessed May 22, 2020.Google Scholar
Klompas, M. Coronavirus disease 2019 (COVID-19): protecting hospitals from the invisible. Ann Intern Med 2020 Mar 11 [Epub ahead of print]. doi:10.7326/M20-0751.CrossRefGoogle ScholarPubMed
Gandhi, M, Yokoe, DS, Havlir, DV. Asymptomatic transmission, the Achilles’ heel of current strategies to control COVID-19. N Engl J Med 2020 Apr 24 [Epub ahead of print]. doi:10.1056/NEJMe2009758.CrossRefGoogle ScholarPubMed
Black, JRM, Bailey, C, Przewrocka, J, Dijkstra, KK, Swanton, C. COVID-19: the case for health-care worker screening to prevent hospital transmission [published correction appears in Lancet 2020 Apr 17]. Lancet 2020;395:14181420.CrossRefGoogle Scholar
Xie, X, Zhong, Z, Zhao, W, Zheng, C, Wang, F, Liu, J. Chest CT for typical 2019-nCoV pneumonia: relationship to negative RT-PCR testing. Radiology 2020 Feb 12 [Epub ahead of print]. doi:10.1148/radiol.2020200343.CrossRefGoogle ScholarPubMed
Winichakoon, P, Chaiwarith, R, Liwsrisakun, C, et al. Negative nasopharyngeal and oropharyngeal swab does not rule out COVID-19. J Clin Microbiol 2020. doi: 10.1128/JCM.00297-20.CrossRefGoogle Scholar
Kumar, DS, O’Neill, SB, Johnston, JC, Grant, JM, Sweet, DD. SARS-CoV-2 infection in a 76-year-old man with negative results for nasopharyngeal swabs and possible nosocomial transmission. CMAJ 2020 Apr 24 [Epub ahead of print]. doi:10.1503/cmaj.200641.CrossRefGoogle Scholar
Bandirali, M, Scofienza, LM, Serra, R, et al. Chest X-ray findings in asymptomatic and minimally symptomatic quarantined patients in Codogno, Italy. Radiology 2020 Mar 27 [Epub ahead of print. doi:10.1148/radiol.2020201102.CrossRefGoogle ScholarPubMed
Cao, G, Tang, S, Yang, D, et al. One nosocomial cluster following with a familial cluster of COVID-19 cases: the potential transmission risk in patients with negative swab tests. 2020 Mar [Preprint]. doi:10.21203/rs.3.rs-17879/v1.CrossRefGoogle Scholar
Alhazzani, W, Møller, MH, Arabi, YM, et al. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med 2020 Mar 28 [Epub ahead of print]. doi: 10.1007/s00134-020-06022-5.CrossRefGoogle Scholar