Predictors and outcomes of hospitalized COVID-19 patients with liver injury

Objective@#To determine incidence, predictors, and impact of liver injury among hospitalized COVID-19 patients@*Methods@#This is a retrospective cohort study of hospitalized COVID-19 patients at the University of the PhilippinesPhilippine General Hospital. Liver injury (LI) was defined as ALT elevation above institutional cut-off (>50 u/L) and was classified as mild (>1x to 3x ULN), moderate (>3x to 5x ULN), or severe (>5x ULN). Significant liver injury (SLI) was defined as moderate to severe LI. Univariate analysis of SLI predictors was performed. The impact of LI on clinical outcomes was determined and adjusted for known predictors -age, sex, and comorbidities.@*Results@#Of the 1,131 patients, 565 (50.04%) developed LI. SLI was associated with male sex, alcohol use, chronic liver disease, increasing COVID-19 severity, high bilirubin, AST, LDH, CRP, and low lymphocyte count and albumin. An increasing degree of LI correlated with ICU admission. Only severe LI was associated with the risk of invasive ventilation (OR: 3.54, p=0.01) and mortality (OR: 2.76, p=0.01). Severe LI, male sex, cardiovascular disease, and malignancy were associated with longer hospital stay among survivors.@*Conclusion@#The liver injury occurred commonly among COVID-19 patients and was associated with important clinicodemographic characteristics. Severe liver injury increases the risk of adverse outcomes among hospitalized patients.

A prospective cohort study of the Quick Sequential Organ Failure Assessment (qSOFA) score versus Systemic Inflammatory Response Syndrome (SIRS) criteria in the determination and prognostication of sepsis in a Philippine Tertiary Hospital

@#<p style="text-align: justify;"><strong>Background:</strong> Sepsis is a leading cause of mortality both locally and worldwide. Despite this, early diagnosis of sepsis remains challenging, with a significant number not fulfilling SIRS (Systemic Inflammatory Response Syndrome) criteria. In 2016, the Sepsis-3 guidelines modified its definition to include the qSOFA (Quick Sequential Organ Failure Assessment) score in an attempt to include a significant number of SIRS-negative septic patients.</p><p style="text-align: justify;"><strong>Methods:</strong> To compare the two, 295 adult patients in the emergency room with suspected infection were included in the study and simultaneously determined their qSOFA score and SIRS criteria. Three infection specialists adjudicated the presence of sepsis, and outcomes within the first 48 hours were acquired. Sensitivity, specificity, positive predictive and negative predictive values for qSOFA and SIRS were computed using constructed confusion matrices, and overall predictive accuracy was measured by the Area under the Receiver Operating Characteristic (AUROC) curve.</p><p style="text-align: justify;"><strong>Results:</strong> Of the 295 patients included in the study, 95 (32.2%) were deemed sepsis positive via adjudication. The qSOFA score was a specific (95.5%) but a poorly sensitive (46.3%) test compared to the SIRS criteria (sensitivity 73.7% and specificity 60%). Both qSOFA and the SIRS criteria significantly correlated with sepsis positivity, but the qSOFA score had superior overall predictive accuracy at 70.9% compared to the SIRS criteria. The adjudicators had moderate strength in agreement (Fleiss' kappa = 0.39) and a percentage agreement of 60%.</p><p style="text-align: justify;"><strong>Conclusion:</strong> We concluded that the qSOFA score was a more accurate predictor of sepsis and a reliable pre-dictor of in-hospital mortality, but should not be used as a sepsis screening tool due to the low sensitivity. We recommend that the SIRS criteria be maintained as a screening tool and to use the qSOFA score concurrently for time management.</p><p style="text-align: justify;"><strong>Key Words:</strong> Sepsis, qSOFA, SIRS</p>

Characteristics and factors associated with mortality of 200 COVID-19 patients at a Philippine COVID-19 tertiary referral center

@# Objectives: To describe the clinical profile and factors associated with mortality among the first 200 patients confirmed to have COVID-19 infection admitted in the University of the Philippines – Philippine General Hospital (UP-PGH) Methodology: We conducted a retrospective review of adult patients with confirmed COVID-19 infection admitted in PGH, a designated COVID-19 referral center. Demographic, clinical data, and clinical outcomes were extracted from medical records. Frequencies and distributions of various clinical characteristics were described, and factors associated with mortality were investigated. Results: Of the 200 patients in our cohort, majority were male (55.5%), and more than half (58%) were over 60 years old. Underlying co-morbid illnesses (67.5%) included hypertension (49.5%), diabetes mellitus (26.5%), and cardiovascular disease (20.5%). Most frequent presenting symptoms were cough (69.0%), fever (58.5%), or shortness of breath (53.0%). Most patients presented with mild (n=41, 20.5%) to moderate illness (n=99, 49.5%) and only 60 were considered severely (n=32, 16.0%) or critically ill (n=28, 14.0%). Many (61%) received empiric antibiotics, while 44.5% received either repurposed drugs or investigational therapies for COVID-19. Bacterial co-infection was documented in 11%, with Klebsiella pneumoniae commonly isolated. In-hospital mortality was 17.5%, which was highest for critical COVID-19 (71.4%). Mortality was observed to be higher among patients age 60 and above, those requiring oxygen, ventilatory support and ICU admission, and among those who developed acute kidney injury, acute stroke, sepsis, and nosocomial pneumonia. Conclusion: Our study confirms that COVID-19 affects males, older individuals and those with underlying co-morbid conditions. Empiric antimicrobial treatment was given for majority of patients, despite documentation of bacterial infection in only 11%. K. pneumoniae was commonly isolated, reflecting local epidemiology. Mortality rate during this early period of the pandemic was high and comparable to other institutions. Factors associated with mortality were related to critical COVID-19 and are similar to other studies.

Oral versus Intravenous Antibiotic treatment for Osteomyelitis in Adults: A Systematic Review and Meta-Analysis

@#BACKGROUND: The worldwide incidence of osteomyelitis is approximately 21.8 cases per 100,000 person-years. The cornerstone of treatment is prolonged (4-6 weeks) intravenous antibiotic administration. This entails additional cost, inconvenience, and added manpower from the healthcare system. Thus, studies have explored the possible use of oral antibiotics as alternatives to improve patient compliance and reduce costs. Our meta-analysis aimed to compare the efficacy of oral versus intravenous antibiotics in treating adult patients with osteomyelitis. MATERIALS AND METHODS: Electronic databases (PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate) from 1966 to April 2020 were searched using the terms “oral antibiotics”, “osteomyelitis”, “randomized controlled trial”. Only studies that directly compared oral versus intravenous antibiotics and confirmed osteomyelitis through biopsy and/or imaging were included. Primary outcome is remission (resolution of symptoms with no relapse and bacteriologic eradication); secondary outcomes, (a) relapse (persistence of the pathogen after treatment) and (b) adverse events. The validity of included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We performed a random-effects model in Review Manager Version 5.3 with 95% confidence interval. The I 2 test was used to assess heterogeneity. RESULTS: Seven of 89 trials comprised of 1,282 patients were included in the final analysis. All studies included patients with osteomyelitis of the lower extremities. Oral antibiotics used were Ciprofloxacin, Ofloxacin, and Co-trimoxazole; intravenous antibiotics used were deemed appropriate by the infectious disease specialist. Patients were only given either oral or intravenous antibiotics. Results showed an 8% increase in remission rates [RR 1.08 (0.81 to 1.44, 95% CI, Z = 0.52, p=0.60)] with no heterogeneity (I2 = 0%) in the intravenous antibiotics group. However, this was not statistically significant. Furthermore, there was a 62% decrease in relapse rates in the intravenous antibiotics group [RR 1.62 (0.85 to 3.07, 95% CI, Z = 1.47, p = 0.14)] with no heterogeneity (I2 = 0%) but was not statistically significant. CONCLUSION: Oral are comparable to intravenous antibiotics in treating osteomyelitis in terms of remission and relapse rates. However, larger and double-blinded trials should be done to generate more robust data to validate these claims.