Sixty‐eight consecutive patients assessed for COVID‐19 infection: Experience from a UK Regional infectious diseases Unit

Abstract Background Assessment of possible infection with SARS‐CoV‐2, the novel coronavirus responsible for COVID‐19 illness, has been a major activity of infection services since the first reports of cases in December 2019. Objectives We report a series of 68 patients assessed at a Regional Infection Unit in the UK. Methods Between 29 January 2020 and 24 February 2020, demographic, clinical, epidemiological and laboratory data were collected. We compared clinical features between patients not requiring admission for clinical reasons or antimicrobials with those assessed as needing either admission or antimicrobial treatment. Results Patients assessed were aged from 0 to 76 years; 36/68 were female. Peaks of clinical assessments coincided with updates to the case definition for suspected COVID‐19. Microbiological diagnoses included SARS‐CoV‐2, mycoplasma pneumonia, influenza A, non‐SARS/MERS coronaviruses and rhinovirus/enterovirus. Nine of sixty‐eight received antimicrobials, 15/68 were admitted, 5 due to inability to self‐isolate. Patients requiring admission on clinical grounds or antimicrobials (14/68) were more likely to have fever or raised respiratory rate compared to those not requiring admission or antimicrobials. Conclusions The majority of patients had mild illness, which did not require clinical intervention. This finding supports a community testing approach, supported by clinicians able to review more unwell patients. Extensions of the epidemiological criteria for the case definition of suspected COVID‐19 lead to increased screening intensity; strategies must be in place to accommodate this in time for forthcoming changes as the epidemic develops.


SARS-CoV
Here, we describe our experience of the first 68 patients we have tested for SARS-CoV-2 at a Regional infectious diseases Unit (RIDU) in the UK. We present the spectrum of illness, alternative diagnoses made and management provided. This is of particular interest at this stage of the epidemic, where many individuals meeting the definition of a suspected case are returning travellers, where the differential diagnosis of respiratory or undifferentiated febrile illness may be broad.11 These findings have implications for the clinical and logistical support that may be required for roll-out of community testing to be a safe and effective replacement for the current predominantly hospital-based, physician-led system.

| Patients
The RIDU at Hull University Teaching Hospitals NHS Trust is based at Castle Hill Hospital, East Yorkshire, UK, and serves a population of 1.2 million people. Patients were predominately referred following telephone assessment by the national NHS 111 service, using Public Health England (PHE) case definitions. Patients were assessed by an infection clinician either in the infectious diseases ward, the ambulance or the patient's car that had transferred them to the unit, and in one instance in the emergency department of the trust. The first 68 consecutive cases are presented here.

| Clinical assessment and testing
All patients had symptoms recorded, together with a travel and exposure history for at least the 14 days preceding symptom onset.
Due to the use of personal protective equipment and in some cases assessment in the patient's car, clinical examination and observations varied between cases. Patients were managed as outpatients if clinically stable and able to self-isolate. All cases were tested for SARS2-CoV using a combined throat and nasopharyngeal (NP) swab, which were processed at the designated public health laboratory.
A separate NP swab was tested locally using the BioFire Film Array Respiratory Panel 2 plus (BioMérieux) which can detect 21 targets (17 viral and 4 bacterial). Blood samples were only performed on patients being admitted or where another serious diagnosis was being considered.

| Data collection, analysis and governance approval
Data were entered directly from clinical notes into a centrally held password-protected spreadsheet, to facilitate patient follow-up and data analysis. Clinical features, observations, investigations, management and outcomes are presented with descriptive statistics where relevant. Local clinical governance approval was granted to record the data as an ongoing service evaluation. As all care delivered to patients was routine, no ethical approval is necessary in keeping with UK national guidance that this is an evaluation of a current NHS service.

K E Y W O R D S
community assessment, COVID-19, respiratory infection, SARS-CoV-2

| Timeline of cases, countries visited and location of management
The timeline of cases seen is shown in Figure 1. With the change in case definition to include those returning from SE Asia, the number of cases markedly increased from an initial mean of 0.9 cases/d to

| Clinical features, patient demographics, antimicrobial usage/management and discharge diagnoses
Of the 68 patients seen, 36 were female (53%), with a mean age of 42.5 years (range 0.5-76). Table 1 shows the presenting features of the cases seen. In addition to the symptoms shown in the table, three cases (4%) had headache, three (4%) had ear pain, and nine (13%) had diarrhoea (two with vomiting as well). Table 2 shows the baseline physical observations, with seven patients (10%) having a temperature of 37.5° or greater on assessment. Antimicrobial therapy was prescribed to nine patients (1.3%), with doxycycline given to five patients (78%), moxifloxacin to three (4%) and oseltamivir to one     Table 4 shows the physiological and demographic features of those patients who were prescribed antimicrobial therapy or admitted for clinical reasons (as a group that represents those patients requiring medical input) compared to the other patients seen who were either managed as outpatients, or admitted due to being unable to selfisolate. Fever ≥ 37.5° and shortness of breath as a symptom were the only predictors of requiring antimicrobials or admission for a clinical need.

TA B L E 4 Differences between patients requiring medical admission and antimicrobials
a step-change in the number of suspected cases seen after the introduction of the third case definition on the evening of 6 February 2020 as a high number of people with respiratory symptoms and recent travel suddenly became suspected of having COVID-19. As there is further spread in the coming weeks, as is the case in Italy and Iran, and the epidemiological criteria of the case definition are notably extended again, infectious diseases clinicians will be unable to sustain a hospital-based screening service. The NHS is responding to this challenge by moving to a community provider screening model, which will deliver the majority of testing in the home.
Specialist input and assessment, supported by appropriate laboratory investigations, must be easily accessible to a COVID-19 testing service, especially if delivered by health care workers other than infectious diseases physicians. This is important for patients in the self-isolation periods both before and after receiving a test result as these individuals will not readily be able to access the usual healthcare services. This may apply particularly to patients with pre-existing lung disease, where respiratory viral illness, caused by SARS-CoV-2 or otherwise, may trigger clinical deterioration that could ordinarily be managed by early community intervention.
Infectious diseases physicians may be the group best placed to support patients in this situation for the short period of self-isolation,13 especially given the need for ongoing personal protective equipment use.14 Although we did not observe any imported "tropical" infections such as dengue, malaria, typhoid, rickettsiosis or leptospirosis, these remain important differential diagnoses in returning travel- The optimum configuration for such a service remains unclear and is likely to vary depending on local constraints, but during the containment phase of the epidemic response there may be time to pilot and compare a range of models before we are forced to move to delay and possibly mitigation strategies.