key: cord-0748657-vmqmn306
authors: Dutta, Sourabh; Kumar, Praveen; Paulpandian, Rajarajan; Sajan Saini, Shiv; Sreenivasan, Priya; Mukhopadhyay, Kanya; Sundaram, Venkataseshan; Kumar, Jogender; Ray, Pallab
title: Relationship Between COVID-19 Lockdown and Epidemiology of Neonatal Sepsis
date: 2022-05-06
journal: Pediatr Infect Dis J
DOI: 10.1097/inf.0000000000003489
sha: bec37b6fc9e1adcabbb714aee15079c72c89200d
doc_id: 748657
cord_uid: vmqmn306

We compared the hospital-based epidemiology of neonatal sepsis after the coronavirus disease 2019 lockdown (LD) versus historical epochs and the LD period versus phases of unlocking. METHODS: This retrospective cohort study was conducted in a level 3 neonatal unit. We compared neonates born in three 24-week periods—Group LD: 22 March 2020 to 5 September 2020—the reference group, Group pre-LD: 29 September 2019 to 14 March 2020 and Group temporally corresponding to LD in 2019 (corres-LD): 24 March 2019 to 7 September 2019. We also studied linear trends from LD phase 1.0 until Unlock 4.0. The key outcome was culture-positive sepsis. RESULTS: There were 1622, 2744 and 2700 subjects in groups LD, pre-LD and corres-LD, respectively. The incidence of any culture-positive sepsis in pre-LD was higher than LD [odds ratio (95% CI) = 1.61 (1.02–2.56)]. This was mainly due to a statistically significant reduction in Acinetobacter baumannii sepsis, with incidence rate differences of pre-LD versus LD [0.67 (95% CI: 0.37–0.97), P = 0.0001] and corres-LD versus LD [0.40 (95% CI: 0.16–0.64), P = 0.0024]. Groups pre-LD and corres-LD had higher proportion of multi-drug resistant (MDR)/extreme drug resistance/pan drug resistance sepsis than LD [77%, 77% and 44%, respectively (P values of both groups vs. LD = 0.01)]. From LD 1.0 to unlock 4.0, there were fewer episodes of MDR sepsis (P(linear trends) = 0.047). On multivariable analysis, group pre-LD (vs. reference group LD), male sex, birth weight and Apgar score independently predicted culture-positive sepsis. CONCLUSIONS: LD favorably impacted the epidemiology of neonatal sepsis in a hospital setting, with less A. baumannii and MDR sepsis, which persisted during unlocking.

T he coronavirus disease 2019 (COVID-19) pandemic has directly afflicted millions globally. 1 The pandemic has also caused collateral damage from other diseases. [2] [3] [4] A recent meta-analysis identified increased stillbirths, maternal deaths and postnatal depression during the pandemic. 5 Conversely, COVID-19-related restrictions have decreased the incidence of several non-COVID-19 viral diseases. [6] [7] [8] [9] [10] [11] Respiratory viral infections decreased after the pandemic, despite more testing for viral illnesses. 12 To date, there are no reports regarding the effect of the COVID-19 pandemic on the changing epidemiology of neonatal sepsis.

Ours is a level III Neonatology Unit in a public-sector university hospital in northwest India. We deliver >6000 liveborn infants annually, of which ≈40% are preterm and ≈35% small for gestational age. Like other busy public-sector units in developing countries, neonatal sepsis is a major problem. 2%-3% of neonates in our unit develop culture-positive sepsis (unpublished 5-year unit data). Etiologic organisms include Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae and coagulase-negative Staphylococcus, in that order. Multi-drug resistant (MDR) sepsis is common, like other parts of South Asia. 13 In the absence of regionalized care, our center is overburdened with sick neonates. We have a 16-bedded neonatal intensive care unit (NICU) and a 24-bedded high dependency unit (HDU). We are often unable to immediately transfer neonates requiring NICU or HDU care to the respective facilities, owing to nonavailability of vacant beds, nor can we transfer out such patients. Consequently, we manage several neonates in the labor room stabilization unit-an interim high-dependency nursery-until such time that a transfer to the NICU or HDU is feasible. A surge in the delivery rate is a surrogate for overcrowding, and we have earlier anecdotally observed an increase in sepsis rates with overcrowding.

The government of India announced a public curfew on March 22, 2020, severe restrictions on March 23-24 and a stringent lockdown (LD) starting from March 25, 2020. The LD was extended until May 31, followed by unlocking in 1-month phases, during which restrictive measures were eased.

As expected, there were fewer neonates delivered in our center from March 22, 2020 onwards. A few months into the pandemic, we observed a decrease in episodes of culture-positive sepsis. In the absence of formal analysis of data, we were unsure about the validity of this observation and whether it was a consequence of fewer admissions, behavioral changes, administrative measures or a combination thereof. Improvements in the pattern of neonatal sepsis may hold useful lessons for a future non-pandemic situation.

Hence, we studied neonates delivered in 3 time periods, each lasting 6 months-the first starting with the LD in 2020, the second immediately prior to the LD and the third in 2019, temporally identical to the LD. We investigated trends across the phases of locking and unlocking. We hypothesized that the LD was associated with a lower incidence of neonatal sepsis, especially MDR sepsis and that unlocking was associated with a partial reversal of the same.

Group temporally corresponding to LD in 2019 (corres-LD): 24 March 2019 to 7 September 2019.

Group LD was the reference group. We included Group corres-LD to control for the possible impact of seasonal variations on demographics and sepsis.

To study the effect of stringency of measures, we included all liveborn infants delivered from 22 March 2020 to 30 September 2020 (see Figure, Supplemental Digital Content 1; http://links.lww. com/INF/E680). A composite objective measure of restrictions is the Government Stringency Index, ranging from 0 to 100, with 100 representing maximum stringency. 14 This part of the study included the following phases:

The time period of LD/unlocking was almost identical to Group LD, except that the former extended to 30 September 2020, whereas the latter ended on 5 September 2020. Detailed descriptions of the containment measures can be accessed elsewhere. 15 We recorded demographic data, admission to the NICU and/or HDU, duration of hospital stay, the final outcome and sepsis data during hospital stay. Antibiotic resistance was defined as "no MDR," MDR, extreme drug resistance (XDR) and pan drug resistance (PDR). 16 In Group LD, we performed a COVID-19 GeneXpert test in all laboring mothers and isolated the neonates from their mothers and other neonates until the mother was reported negative. We recorded the number of neonates thus isolated, and the number of neonates and mothers whose test was positive.

We used χ 2 test, Fisher exact test, Mann-Whitney U or Student t test as appropriate. We calculated incidence rate ratios of episodes of culture-positive, A. baumannii and antibiotic-resistant sepsis. We compared the phases of LD/unlocking by tests for linear trends [χ 2 for linear trends, Jonkheere-Terpstra or Analysis of Variance for trends, as appropriate] and without linear trends (χ 2 , Kruskal-Wallis test or Analysis of Variance, as appropriate). We performed a multivariable logistic regression to predict "any episode of culture-positive sepsis," with the following predictors selected a priori: Groups (Group LD: reference group), number of live births in the week that the subject was born (as a surrogate for overcrowding), sex, gestational age in weeks, birth weight in grams, 5-minute Apgar score and appropriateness for gestation. We tested for multi-collinearity using variance inflation factor and Eigenvalues. We included a constant and forced all variables into the model. We used SPSS v23 and Stata v14.2 for statistical analysis. As recruitment was based on time periods, we did not perform a formal sample size calculation.

There were 1622, 2744 and 2700 inborn neonates in groups LD, pre-LD and corres-LD, respectively (Table 1) . Fewer neonates in group pre-LD and corres-LD were admitted in the NICU and HDU and at significantly higher postnatal ages. Neonates with gestational age <32 weeks in group pre-LD and corres-LD had shorter hospital stay. Compared with group LD, a significantly lower proportion in group pre-LD was discharged home alive.

Group pre-LD had a significantly higher proportion of neonates with any episode of culture-positive sepsis compared with group LD [odds ratio = 1.61 (95% CI: 1.02-2.56)], but not so in the case of corres-LD (Table 2) . Group pre-LD had a significantly higher incidence rate ratio (IRR) of culture-positive sepsis compared with group LD [1.77 (95% CI: 1.13-2.85)], but not when corres-LD was compared with group LD. There were significant differences in etiologic organisms between the groups. Of note, there were no episodes of A. baumannii sepsis in Group LD, whereas there were 19 (24%) and 11 (20.7%) episodes in groups pre-LD and corres-LD, respectively. The IRR of A. baumannii sepsis in group pre-LD or corres-LD versus LD could not be calculated as the denominator was zero. Hence the incidence rate differences were calculated which were statistically significantly different for pre-LD versus LD There were significantly more episodes caused by MDR/ XDR/PDR organisms in group pre-LD and corres-LD compared with LD. The IRR of episodes caused by organisms that were MDR or worse when comparing group pre-LD versus LD [3.08 (95% CI: 1.64-6.29)] and group corres-LD versus LD [2.14 (95% CI: 1.11-4.48)] were statistically significant. Significantly more culture-positive episodes were treated with colistin in group pre-LD compared with group LD. Almost all isolates of A. baumannii were MDR/ XDR/PDR. The difference in MDR/XDR/PDR organisms between the phases was primarily driven by the difference in A baumannii. There were no significant differences in the proportion of non-A. baumannii MDR organisms (as a percentage of all sepsis) between LD, pre-LD and corres-LD.

In group LD, 425 neonates were briefly isolated from their mothers and other neonates until their mothers' COVID-19 report was available. One-hundred-eight severe acute respiratory syndrome coronavirus-2-positive mothers were isolated from other patients in a dedicated COVID building along with their neonates. Eight of these neonates were detected to be severe acute respiratory syndrome coronavirus-2 positive.

When comparing the phases of LD and unlocking, there were significant differences in gestational age and birth weight across phases, but no significant linear trends ( Table 3 ). The proportion of subjects with any episode of culture-positive sepsis declined from LD phase 1.0 to unlock phase 4.0 but was not statistically significant. The difference in the proportion of etiologic organisms did not show a linear trend. There were progressively fewer episodes of MDR sepsis (P linear trend = 0.047).

The candidate predictors in the multivariable analysis did not show multi-collinearity, hence all were included in the model. The Group (ie, LD, pre-LD and corres-LD), male sex, birth weight and Apgar score independently predicted the occurrence of any episode of culture-positive sepsis ( Table 4 ). The prediction accuracy was 97.9% (assuming cases with >50% predicted probability were true sepsis) and the C-statistic was 0.85 (95% CI: 0.81-0.89).

To better understand A. baumannii, which had disappeared in group LD, we pooled data of the first episode of Gram-negative sepsis from groups pre-LD and corres-LD and compared A. baumannii versus other Gram-negative sepsis (see Table, Supplementary Digital Content 2, http://links.lww.com/INF/E681). On univariable analysis, A baumannii sepsis was associated with male sex, lower gestational age, lower birth weight and more concurrent births in the week the subject was born. In a multivariable logistic regression analysis to predict A baumannii sepsis among all cases with Gram-negative sepsis in the full study population (see Table, Supplementary Digital Content 3, http://links.lww.com/INF/E682), the only independent predictor was the number of concurrent births.

The number of live births in group LD was only 60% of the numbers in group pre-LD and corres-LD. The reduced number of live births in group LD was probably due to difficulties encountered by patients in traveling to our hospital during the LD and the fear of contracting COVID-19 at our hospital. Many mothers may have preferred to deliver in a hospital closer to home. Neonates in group LD had better Apgar scores and were discharged with better outcomes. Greater proportions in group LD were admitted in the NICU and HDU, and at a younger postnatal age. There was an overall reduction in culture-proven sepsis following the LD primarily driven by a striking reduction in A. baumannii sepsis and sepsis due to MDR/XDR/PDR organisms. This led to lower usage of colistin. Patients in the pre-LD group (compared with group LD), male sex, lower birth weight and Apgar score were independent predictors of any episode of culture-positive sepsis. It was reassuring to find that there was no increase in the incidence of culture-proven sepsis with progressive unlocking.

There were no clinically meaningful differences in the average gestation between the three groups, although there was a statistically significant difference between LD and corres-LD. Our observation is contrary to previous reports, where the incidence of preterm births has declined during the pandemic. 5, 17 More neonates were admitted to the NICU and HDU after the LD possibly because the decrease in absolute number of live births made it easier to find a vacant bed in our NICU or HDU. The lower postnatal age of transfer to these areas supports the latter possibility. Similarly, the relatively longer hospital stay in the LD group can be attributed to the greater availability of vacant beds and hence less pressure on the physicians to discharge patients before schedule from the hospital. The decrease in hospital deliveries coupled with an increase in the need for NICU/HDU care has not been reported before. However, a 57% decrease in children's emergency visits has been documented during the peak of the pandemic. [18] [19] [20] [21] Like us, Goldman et al found that the acuity of sickness and admission rate among children was higher during the peak compared with preceding epochs. In a recent meta-analysis, Chmielewska et al did not observe significant differences in the mode of delivery, births <32 weeks gestation, perinatal asphyxia, low-birth-weight status, NICU admissions or neonatal deaths between the pandemic and pre-pandemic periods. 5 The incidence of preterm births <37 weeks gestation was significantly lower only among high-income countries. This meta-analysis did not evaluate neonatal sepsis.

The improvement in the epidemiology of neonatal sepsis in our study may be partly explained by earlier transfer of neonates to the NICU and HDU than what was possible prior to the LD. This 

is reflected in fewer episodes of sepsis in the labor room stabilization unit. The changes can also be attributed to behavioral factors. Unfortunately, we do not have data that can quantify these behavioral changes, so our observations are necessarily anecdotal and subjective. Prior to the LD, healthcare workers (HCW) and family members were expected to wash hands at entry to all patient care areas and HCWs were expected to follow hand hygiene measures at the 5 moments of hand hygiene prescribed by the World Health Organization but wearing a face mask was not mandatory. During the LD, compliance to hand hygiene measures increased substantially and there was universal usage of face masks by HCWs and family members. Before the LD, housekeeping measures included regular disinfection of equipment and surfaces, but during the LD these were followed more assiduously, with disinfection of highcontact surfaces such as door handles, telephones, etc. performed at least twice in every nursing shift. Instructions for disinfection of mobile phones were provided to all HCWs. Patients were distributed across more areas because those awaiting COVID reports were isolated in a separate 12-bedded isolation ward for mothers and a 6-bedded isolation ward for neonates, and proven cases were managed in a separate building. HCWs working in the isolation wards with suspected or proven cases of COVID-19 donned N-95 masks, caps, goggles, impervious gowns, shoe covers and gloves. There were no changes in the water sources or frequency of surveillance cultures for MDR organisms in the unit. Academic activities and meetings went online, and HCWs practiced social distancing.

A. baumannii is an important cause of neonatal sepsis in developing countries. 22 The decrease in A. baumannii sepsis disproportionate to other Gram-negative sepsis in group LD is puzzling. The only independent risk factor we could identify was less overcrowding (see Table, Supplemental Digital Content 4, http://links.lww.com/INF/E683), but it is unclear why it should preferentially impact one species. A. baumannii is known to behave differently than other Gram-negative bacteria, characterized by more rapid acquisition of MDR, and resistance to desiccation and disinfectants. 23 Compared with E. coli or Klebsiella, neonates with A. baumannii sepsis have lower birth weight. 24 It is possible that infection control measures may have differential effects on A. baumannii sepsis and other Gram-negative sepsis. In a systematic review and network meta-analysis of 42 studies on adult ICU patients, compared with standard treatment alone, the addition of environmental cleaning to standard treatment plus antibiotic stewardship program or the addition of source control to standard treatment and environmental cleaning significantly reduced MDR A. baumannii sepsis. 25 On the other hand, infection control strategies that mandatorily included antibiotic stewardship programs significantly reduced sepsis due to MDR extended-spectrum beta-lactamase producing Gram-negative infections. In a study from China, the authors reported the effect of relocation of the NICU and introduction of a care bundle for prevention of ventilator-acquired pneumonia (VAP). 26 The incidence of VAP due to A. baumannii decreased from 79% to 36%, whereas VAP due to K. pneumoniae increased from 17% to 18%. Infection control measures rapidly control outbreaks of A. baumannii in neonatal units. 27, 28 Our study was not specifically designed to evaluate the effect of infection control measures on the decline of MDR sepsis or organism-wise sepsis and we were unable to quantify the infection control measures. Although augmentation in infection control measures was an important feature of the LD epoch, apart from infection control measures there were several other differences between the 3 epochs. Authors of a study on older patients in the United Kingdom reported differential effects of the pandemic on etiologic organisms: Enterobacteriaceae reached an all-time low and coagulase-negative Staphylococcus an all-time high. 29 The absolute decline in MDR sepsis was not merely a consequence of overall decline in sepsis, as MDR sepsis as a proportion of all sepsis declined significantly in group LD. Our data shows that the decrease in MDR sepsis was driven by the decline in A. baumannii, which is frequently multi-drug resistant.

As early-onset neonatal sepsis is attributed to maternal risk factors that are unlikely to be altered by the pandemic, and lateonset neonatal sepsis is environmentally acquired, we expected to see a greater proportion of early-onset neonatal sepsis in group LD. We observed this difference, but it was not statistically significant.

It was interesting to note that there were no major differences from LD 1.0 to unlock 4.0. This could be due to the small sample sizes in each phase. The easing of restrictions may have had little impact on hospital functioning. It did not alter important predictors of sepsis, for example, gestational age, birth weight and appropriateness for gestational age. A closer look at the government stringency index shows that there was very little objective decline in the stringency of restrictions during the various phases of unlocking. We do not have data to quantify any change in behavior or infection control measures during the phases of unlocking.

In the multivariable analysis, Group pre-LD independently doubled the odds of an episode of culture-positive sepsis compared with group LD. Our analysis suggests that the overall changes after the LD were associated with less culture-positive sepsis rather than overcrowding specifically around the time of birth.

Groups LD and corres-LD covered virtually identical dates exactly a year apart whereas group pre-LD covered a different time of the year. Since the differences in most outcomes were larger between groups LD and pre-LD compared with groups LD and corres-LD, it suggests that seasonal differences may have accentuated the differences between Groups LD and pre-LD. We studied the incidence of sepsis, particularly A. baumannii sepsis, for 4 years prior to 2019, to evaluate the possibility that a downward sloping trend may have exaggerated the effect of the LD. However, no such trend could be observed from the year 2015 through 2018 (see Table, Supplemental Digital Content 4, http://links.lww.com/ INF/E683).

The strengths of our study were a large sample size and two comparison groups. Being retrospective, it was prone to several biases. There may have been unmeasured differences in patient characteristics, clinical practices, and rigor of data collection between the time periods. We limited our observation to hospital stay and may have missed cases of sepsis after transfer or discharge. Our results may not be generalizable to centers with fewer resource constraints, and less MDR sepsis. Weekly births are a sub-optimal surrogate for overcrowding. We were unable to quantify behavioral changes and infection control measures following the LD and during unlocking. We do not have data about the harm caused to neonates whose mothers were not able to reach our center due to the pandemic. Improvement in sepsis parameters may have occurred at the expense of worse outcomes among those who delivered elsewhere.

From the limited experience accrued from our center, we conclude that the LD may be associated with a decrease in culture-proven neonatal sepsis, primarily due to A. baumannii sepsis and antibiotic-resistant sepsis in settings like ours. Efforts must be made to consolidate the gains achieved during the pandemic by reinforcing the desirable administrative and infection control practices.

Since the eradication of smallpox, monkeypox has assumed the role of the most prominent orthopoxvirus affecting human communities. Formerly a rare disease native to Africa, monkeypox is now endemic to countries in western and central Africa, which have faced a resurgence of monkeypox outbreaks over the past decade. Nigeria is in the midst of an ongoing monkeypox outbreak, as of October 2021, a total of 502 cases and 8 deaths from this disease had been reported. Outside Africa, cases of monkeypox remain rare, but are increasing: 7 international cases have been diagnosed since 2018. In the United States, a case was recently identified in Texas in a traveler returning from Nigeria. Before that case, the last confirmed monkeypox cases in the United States were in an outbreak involving 47 persons across 6 states; those cases were associated with contact of prairie dogs infected by imported rats from the Gambia. A case of imported monkeypox in Maryland, United States, and the infection control measures used to prevent additional disease transmission is described.

A 28-year-old man sought care for a diffuse vesicular rash that had developed over the preceding 24-48 hours. He had traveled on a flight from Lagos, Nigeria, and arrived in the United States the day he sought care. While in Nigeria, he visited relatives, stayed in hotel lodging without travel to rural regions and had no interactions with animals or animal carcasses. During his flight from Lagos, he noticed a burning sensation on his skin, followed by development of discrete vesicles on his forehead and nose, which spread to his arms, trunk and inner thighs over several hours. He denied having associated symptoms, including fever, chills or headache. On physical examination, right cervical lymphadenopathy and numerous 2-4 mm pustules on an erythematous base were noted. Some of the pustules had central umbilication and were present with acrofacial propensity.

The patient was given intravenous acyclovir for empiric treatment of disseminated varicella zoster virus infection, admitted and placed on contact and airborne isolation precautions. Within 24 hours of admission, no new lesions developed, and there was noticeable crusting of several existing vesicles. A 4-mm punch biopsy specimen from an intact pustule on the abdomen of the patient showed epidermal necrosis, reticular degeneration and vesiculation by staining with hematoxylin and eosin.

Based on the travel history of the patient and histopathologic findings, monkeypox was suspected, likely acquired by human contact in the absence of any animal exposures. Additional specimens of the skin lesions were identified by the Maryland Department of Health as nonvariola orthopox by real-time reverse transcription polymerase chain reaction and the Centers for Disease Control and Prevention (CDC) Laboratory Response Network protocol. CDC used viral culture and real-time reverse transcription polymerase chain reaction to confirm the diagnosis of monkeypox, further identifying the specimen as part of the West African clade, which has driven the outbreak in Nigeria since 2017.

Upon confirmation of the monkeypox diagnosis, all healthcare workers (HCWs) involved in the case were identified and 40 were classified as contacts by CDC guidelines. No HCW met the criteria for high-risk exposure, and no doses of preventive smallpox vaccine were administered. Disease transmission was not detected at the conclusion of the 21-day surveillance period.

Comment: Monkeypox has an overall case-fatality rate of up to 11%, and increasing human populations have no immunity to poxvirus; therefore, future progress in understanding monkeypox is critical. The World Health Organization Research and Development Blueprint in 2018 classified monkeypox as an emergent disease requiring accelerated research, development and public health action. Although the public health experience addressing monkeypox in the United States has been limited, this case illustrates the effectiveness of the basic principles of infection control; rapid identification and isolation of the index patient; use of personal protective equipment by HCWs; and thorough contact tracing, including monitoring for secondary cases throughout the incubation period.

Although vaccination was not required in this case, public health recommendations to prevent secondary disease transmission of monkeypox include the smallpox vaccine. The 2 Food and Drug Administrationapproved vaccines are ACAM2000 and JYNNEOS; this second vaccine is a nonreplicating, live virus vaccine, licensed specifically for monkeypox prevention. In addition to smallpox vaccine, vaccinia immune globulin is available and can be used as prophylaxis for severely immunocompromised patients when smallpox vaccine should be avoided. The Food and Drug Administration-approved drugs to treat smallpox are tecovirimat and brincidofovir, which can also be used to treat monkeypox, but there are no monkeypox-specific antiviral drugs for treatment or postexposure prophylaxis.

Multiple appearances beyond disease-endemic countries indicate that monkeypox has become a relevant travel-related disease and physicians should remain vigilant in diagnosing and preventing transmission of this virus.

The indirect impact of COVID-19 on women

Collateral damage of COVID-19 pandemic: delayed medical care

Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and metaanalysis

Seasonal influenza activity during the SARS-CoV-2 outbreak in Japan

Evaluation of seasonal respiratory virus activity before and after the statewide COVID-19 shelter-in-place order in Northern California

Coronavirus disease 2019 pandemic: impact caused by school closure and national lockdown on pediatric visits and admissions for viral and nonviral infections-a time series analysis

Effect of social distancing due to the COVID-19 pandemic on the incidence of viral respiratory tract infections in children in finland during early 2020

Impact of public health interventions on seasonal influenza activity during the COVID-19 outbreak in Korea

Impact of social distancing and travel restrictions on Non-Coronavirus Disease 2019 (Non-COVID-19) respiratory hospital admissions in young children in Rural Alaska

Reduction in healthcare-associated respiratory viral infections during a COVID-19 outbreak

Neonatal sepsis in South Asia: huge burden and spiralling antimicrobial resistance

Covid-19 government response tracker

Covid-19 lockdown in India. Available at

Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance

What is driving the decreased incidence of preterm birth during the coronavirus disease 2019 pandemic?

Emergency department use during COVID-19 as described by syndromic surveillance

Delayed access or provision of care in Italy resulting from fear of COVID-19

Impact of the COVID-19 pandemic on an emergency traumatology service: experience at a Tertiary Trauma Centre in Spain

Paediatric patients seen in 18 emergency departments during the COVID-19 pandemic

Investigators of the Delhi Neonatal Infection Study c. Characterisation and antimicrobial resistance of sepsis pathogens in neonates born in tertiary care centres in Delhi, India: a cohort study

Case-control analysis of endemic Acinetobacter baumannii bacteremia in the neonatal intensive care unit

Prevention and control of multidrug-resistant gram-negative bacteria in adult intensive care units: a systematic review and network meta-analysis

Efficacy of an infection control program in reducing ventilator-associated pneumonia in a Chinese neonatal intensive care unit

Successful control of an Acinetobacter baumannii outbreak in a neonatal intensive care unit

Successful management of an outbreak due to carbapenem-resistant Acinetobacter baumannii in a neonatal intensive care unit

Bacteraemia variation during the COVID-19 pandemic; a multi-centre UK secondary care ecological analysis

Current Abstracts Edited By

Emerg Infect Dis