Co-infections and antimicrobial use in hospitalized patients with moderate-severe COVID-19

Introduction/Aim: Coinfection in COVID-19 has been reported internationally, however, data on prevalence and outcomes in Australia is lacking. This study aimed to determine the prevalence and microbiology of coinfections, associated antimicrobial use, and outcomes in hospitalised patients with moderate-severe COVID-19 admitted to the Sunshine Coast University Hospital (SCUH). Method(s): A retrospective observational cohort study of adult patients admitted to the SCUH from February to July 2022 with moderate-severe COVID-19 was conducted. Demographics, comorbidities, laboratory, microbiological and radiological results, antimicrobial use, and hospital length of stay were collected. All-cause 30-day mortality and ICU admission were also collected, and incidence rate ratios (IRR) were calculated. Result(s): Sixty-six patients (57% male;median age 78.3) were captured. 13 coinfections occurred in 11 (16.7%) patients. Microbiological testing was performed in 94% of patients;respiratory viral PCR in 78.8%, blood cultures in 69.7%, sputum cultures in 25.8%, urinary antigens in 13.6% and atypical serology in 12.1%. Bacterial pathogens were most prevalent (53.8% of coinfections), whilst viral and fungal infections accounted for 30.8% and 15.4%, respectively. The most common pathogens were Streptococcus pneumoniae, Pseudomonas aeruginosa and influenza A. Most patients (74.2%) received empirical antibiotic therapy (mean = 5.5 days), with similar rates of use between those with coinfection (66.7%) and those without (75.9%). Overall patient mortality was 10.6%, with coinfections demonstrating a higher 30-day mortality (IRR = 2.0). Coinfected patients were seven times more likely to experience ICU admission (IRR = 7.5) compared to patients without coinfections. Conclusion(s): The prevalence of confirmed coinfection in hospitalised patients with moderate-severe COVID 19 was low;however, antimicrobial use was high. Importantly, patients with coinfections were twice as likely to die, and seven times more likely to be admitted to ICU. This study indicates the importance of developing improved diagnostic tools to identify coinfection and to help guide appropriate antimicrobial use.

Foreword

It had been a tough 15 months. Sharon had only been in the superintendent’s chair for a little over a year before the COVID-19 pandemic hit. Suddenly, everything was turned upside down. Schools were closed. Remote learning was rushed into place. Teachers were panicked and parents were upset. Now, in the past month, things had started returning to normal. However, normal for a superintendent was still a challenge. © 2022 selection and editorial matter, Jennifer Seydel, Cynthia L. Merse, Lisa A. W. Kensler, and David Sobel;individual chapters, the contributors.

Severe Rhabdomyolysis Temporally Associated with sars-cov-2 Vaccine in an Adolescent

Introduction: Serious pediatric systemic adverse events following receipt of the messenger ribonucleic acid (mRNA) vaccines such as Pfizer/BioNTech vaccine (BNT162b2-V) are rare, with the most common being myocarditis. We report a case of severe rhabdomyolysis following receipt of BNT162b2-V and review the literature for reports in children. To our knowledge, this is the first case of severe rhabdomyolysis temporally associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccine in a healthy adolescent without a predisposing cause. Case Description: A previously healthy16-year-old female developed extensive and severe myalgias and generalized weakness following dose two of BNT162b2-V. She had severe rhabdomyolysis with a peak creatinine kinase (CK) of 246,900 U/L at 92 hours post-vaccination. SARS-CoV-2 polymerase chain reaction (PCR) testing and antibody to nucleocapsid were negative. Extensive workup revealed no alternative causes. The patient was treated effectively with intravenous hyperhydration over a 3-day hospital admission. As of July 9th, 2021, four pediatric cases of rhabdomyolysis temporally associated with SARS-CoV-2 vaccination were identified in the Vaccine Adverse Event Reporting System (VAERS) database. Case 1 was a 17-yearold male with drug overdose (loratadine and doxylamine) 5 days post dose two of BNT162b2-V. He was found to have rhabdomyolysis and myocarditis. Case 2 was a 12-year-old female with bilateral arm weakness post dose two of BNT162b2-V and a peak CK of 7000 U/L. Rigorous exercise was implicated as a cause in this case. Case 3 was a 14-year-old female who accidently received a triple BNT162b2-V dose (undiluted dose) and developed chest pain, her CK was 7000 U/L. Case 4 was a 14-year-old male who developed myalgias post dose one of BNT162b2-V and had mild rhabdomyolysis with a CK of 1600 U/L. Discussion: Rhabdomyolysis has been reported following vaccines including BNT162b2-V but without a causal link. Although our case is the fifth adolescent reported, our case is unique given the absence of an identifiable trigger and the severity of rhabdomyolysis. The development of symptoms in close proximity to vaccine administration and in the absence of another identifiable trigger raises concerns about a potential link. Although exaggerated immune response in vaccine recipients who have had previous SARS-CoV-2 infection has been postulated, the absence of nucleocapsid antibodies does not support this in our patient. Immune mediated or aberrant autoimmune responses to adjuvants in the SARS-CoV-2 vaccine, as seen in the autoimmune inflammatory syndrome induced by adjuvants (ASIA) is another possibility. Post-vaccination autoimmune phenomena have been documented in connection to various vaccines. Conclusion: As more healthy adolescents with robust immune systems become vaccinated, it is important for clinicians to identify rhabdomyolysis post- SARS-CoV-2 vaccination to allow for timely intervention and prevent adverse outcomes such as acute kidney injury.

Low SARS-CoV-2 seroprevalence and no active infections among dogs and cats in animal shelters with laboratory-confirmed COVID-19 human cases among employees

Human-to-animal and animal-to-animal transmission of SARS-CoV-2 has been documented;however, investigations into SARS-CoV-2 transmission in congregate animal settings are lacking. We investigated four animal shelters in the United States that had identified animals with exposure to shelter employees with laboratory-confirmed COVID-19. Of the 96 cats and dogs with specimens collected, only one dog had detectable SARS-CoV-2 neutralizing antibodies;no animal specimens had detectable viral RNA. These data indicate a low probability of human-to-animal transmission events in cats and dogs in shelter settings with early implementation of infection prevention interventions.

Bringing our heeadsss together-prioritising the voices of children and young people Collaborators

Background Children and young people (CYP) are increasingly attending acute paediatric services due to mental health difficulties. 50% of all mental health problems are established by 14 years of age and 75% by 24 years. Underinvestment in mental health has been a longstanding concern, amplified by the COVID-19 pandemic through extra stress caused by prolonged school closures, social isolation and a lack of access to usual support services. In 2020, the Royal College of Paediatrics and Child Health highlighted that suicide is now the leading cause of death in England and Wales for children aged 5-19 years, emphasising the need to prioritise and improve mental health. Paediatricians must develop the knowledge and skills to identify, support and make appropriate referrals for common mental health problems. HEEADSSS is a well-known psychosocial screening tool with eight domains, used to identify potential or actual harm. Objectives Establish whether CYP within the West Midlands, UK are receiving adequate psychosocial assessments on hospital admission and whether healthcare professionals are signposting to relevant services. The primary outcome was the percentage of CYP with documented evidence of being offered a HEEADSSS assessment. Methods A regional prospective audit across nine hospitals was performed for three days per week from 4st -31st January 2021. A standardised proforma was used to gather information from medical records of all CYP aged >12 years admitted to paediatric wards. Pooled data were analysed using Microsoft Excel. Results 231 patients were included. The median age was 14 years old (range 12-17 years). 163(71%) were female. 202 (87%) had no known communication difficulties. 53(23%) were known to CAMHS and 43(19%) to social care. 78/231 (34%) were admitted with mental health as the presenting complaint. 35/231(15%) were documented to be given the opportunity to be spoken to alone;29(82%) accepted. No department had a psychosocial screening tool embedded in the admission document. 158/231(69%) had less than half of the eight domains completed. The median was 1.5 (range 0-8). Home and education/ employment were most frequently asked (37-42%). Eating/exercise, drugs, safety, sexual activity and other activities were the least frequently asked (14-27%). The proportion of those with a concern identified when asked ranged from 18%-39%. However, in self-harm, depression and suicide, only 85/231 (37%) were asked, with concern identified in 87%. 78 patients were admitted for mental health;28(39%) had less than half the domains completed (median 5, range 0-8). Drug use 46/78(59%), safety and sexual activity (both 38/78 (49%)) were inconsistently documented in this group, with concerns identified in 20-26% of those asked. 90/231(39%) were referred to CAMHS, social care, counselling, online or other support services. 16/77(21%) patients with a concern documented in at least one domain were not referred onwards. Conclusions This study demonstrates poor implementation of the HEEADSSS tool on admission, across a wide geographical area. Increased utilisation of a psychosocial screening tool would provide more opportunities to CYP to discuss their psychosocial health and receive appropriate support, in line with national guidance standards. Further work is underway addressing barriers to using HEEADSSS, considering electronic or embedded tools and signposting to relevant services.

The impact of the COVID-19 pandemic on African American cancer survivors living in metropolitan Detroit

Background: COVID-19 has had profound direct and indirect effects on population health to date and long-term effects are anticipated. Vulnerabilities to the most serious consequences of infection include older age, obesity, African American race and the presence of comorbid conditions. African American cancer survivors represent a particularly high-risk group, therefore understanding the impact of the virus and our strategies to prevent its spread on this patient population is important. Methods: The Detroit Research on Cancer Survivors (ROCS) cohort is a unique effort to understand the determinants of poor outcomes in African American cancer survivors. Eligible participants were diagnosed with breast, prostate, colorectal, or lung cancer on or after 1/1/2013, or with endometrial or any other cancer before age 50 on or after 01/01/2016 and were identified through the Metropolitan Detroit Cancer Surveillance System cancer registry. To date, we have enrolled 4173 survivors. Full participation includes completion of a baseline survey, and collection of biospecimens, medical records and tumor tissue, if available. Participants are also followed annually for outcomes and changes in history. A supplemental survey focused on the impact of COVID-19 was offered to enrolled participants beginning in the spring of 2020. The results presented here include data from 890 survivors who also completed the ROCS COVID survey. Results: Nearly all ( > 99%) survivors reported some change in their daily activities in an effort to reduce the risk of infection. At the time of survey, just over 1/3 of participants reported being tested for the virus and among those, 12% reported positive results. More than 40% of survivors reported some disruption in their access to medical care. A substantial ( > 40%) proportion of survivors reported feeling anxious, depressed and/or isolated during the COVID-19 pandemic. Approximately 40% of patients reported changes in health behaviors as a direct result of the pandemic that are known to negatively affect survivorship outcomes (physical inactivity, smoking, alcohol use). Notably, 30% of survivors reported declines in physical activity and these declines were significantly associated with increased anxiety (p = 0.008), depression (p = 0.005) and poorer healthrelated quality of life (p < 0.001). Conclusions: The influence of the COVID- 19 pandemic on African American cancer survivors has been substantial, affecting both their physical and mental health and access to needed medical care. Coupled with changes in health behaviors as a direct result of the pandemic, these factors will likely affect outcomes in this high-risk patient population making further study and interventions necessary to mitigate the long-term impact of the pandemic on cancer outcomes.