ABSTRACT
Background. Fungemia is associated with high rates of morbidity, mortality and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods. A retrospective cohort study was conducted at a tertiary healthcare system in Detroit, Michigan to evaluate the impact of the COVID-19 pandemic on incidence of candidemia. The "pre COVID-19" timeframe was defined as January - May 2019 while the "during COVID-19" timeframe was January - May 2020. To compare incidence and patient characteristics between cohorts, t-tests and chi-square analysis was used. Additional sub-analysis was performed in candidemia patients during COVID-19 timeframe comparing outcomes of patients based on COVID-19 status. A Fisher Exact and Satterthwaite Test were used for analysis of categorical and continuous variables, respectively. Results. Overall, 46 cases of candidemia were identified in both the pre COVID-19 and during COVID-19 periods. Pre COVID-19, the average number of cases was 3.0 ± 1.2 per month. The incidence more than doubled during COVID-19 to 6.2 ± 4.2 cases per month (p = 0.14) (Figure 1). No significant differences in patient demographics were detected between cohorts, however, patients in the COVID-19 cohort had higher rates of corticosteroid use, mechanical ventilation and vasopressors (Table 1). In the 2020 period, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. On average, COVID-19 patients developed candidemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative cohort (p = 0.340). Additionally, COVID-19 patients with candidemia coinfection were significantly more likely to expire;83.3% (n=10) COVID-19 patients expired compared to 36.8 (n=7) in the COVID-19 negative cohort (p = 0.025) (Table 2). Conclusion. The prevalence of fungemia markedly increased during the COVID-19 surge. Increased use of corticosteroids and broad spectrum antimicrobials, prolonged use of central venous catheters and prolonged ICU length of stay likely contributed to this increase. Patients who developed candidemia co-infection with COVID-19 were found to have poorer outcomes as compared to those who were SARS-CoV-2 negative or untested.
ABSTRACT
Background. Pseudomonas aeruginosa is one of the most common causes of healthcare-associated infections in critically ill patients and those with suboptimal immunity. However, the development of multidrug resistant Pseudomonas aeruginosa (MDR Pa) creates an even great disease burden and threat to both the hospital and local community health. The purpose of this study is to illustrate a descriptive analysis of a cluster of MDR Pseudomonas, during a local surge of SARS-CoV-2 (COVID 19) pandemic. The goal is to shed more light on the troublesome parallel during outbreaks, such as COVID-19 and consequential secondary outcomes. Methods. From November 2020 through February 2021, 16 patients exposed to the intensive care units of a tertiary healthcare system were infected or colonized with a multidrug-resistant strain of P. aeruginosa (Figure 1). Outbreak investigation was conducted via retrospective chart review of the first eight cases and prospective analysis of the latter eight cases. The isolates collected prospectively were analyzed for taxonomic identification, antimicrobial resistance profile, and phylogenetic analysis. Clinical characteristics of all patients were collected, and epidemiological investigation was carried out. MDR is defined as resistance to at least four classes of antibiotics: third-generation cephalosporins, fluoroquinolones, aminoglycosides, and carbapenems. Results. Of the 16 cases of MDR Pa infections, seven died within five months (Table 1). Antimicrobial resistance gene profiling detected blaOXA and blaPAO betalactamase genes in all the samples. One sample contained an additional blaVIM resistance gene, although this patient was colonized and not actively infected. The analysis suggests existence of two clusters demonstrating relatedness and possible horizontal transmission. Timing of this cluster of cases coincides with surge of COVID-19 cases. This highlights the importance of infection control measures and antimicrobial stewardship. Conclusion. Since early 2017 studies show there is a growing prevalence worldwide in transferable resistance, particularly for β-lactamases and carbapenemases, MDR Pseudomonas. This study emphasizes an irony paralleled during a pandemic, the needed efforts to prevent unintentional lapses in patient safety.
ABSTRACT
Introduction: IgA Vasculitis is one of the most common causes of primary glomerulonephritis, however there are very few cases reported in association with COVID-19. Approximately 20-50% of patients present with renal manifestations, such as IgA Nephropathy (IgAN). Here we present a case of rapidly progressing crescentic IgAN presenting after COVID-19 infection. Case Description: A 19-year-old male presented to the emergency department with elevated creatinine after being seen in the rheumatology clinic. A timeline of the patient's symptoms is presented in Figure 1. The renal biopsy showed a rapidly progressing IgAN with 15% crescents, hence he was placed on Mycophenolate mofetil and prednisone. He was also placed on Lisinopril and low-salt diet for better control of blood pressure and fish oil for dyslipidemia. Despite aggressive immunosuppression and risk factor modification, his renal function has not improved and he continues to have nephrotic range proteinuria. Discussion: COVID-19 is a coronavirus that enters the host cell via the ACE-2 receptor. In the kidney, ACE-2 is expressed in mesangial cells, podocytes, the parietal epithelium of Bowman's capsule, and the collecting ducts. Research suggests that the inflammatory environment from COVID-19 can activate or exacerbate immune mediated diseases in predisposed individuals. The mucosal immune response against COVID-19 might have contributed to the progression of IgAN in this patient. We plan on checking the SARS-CoV-2 anti-RBD IgA titer to see if there is a correlation between anti-RBD IgA levels and progression of kidney function. Also, the persistence of IgA antibody or memory B cells post-COVID 19 infections may have prognostic implications in advancing IgAN or even end-stage kidney disease. Although our patient has not been vaccinated, there have also been cases of patients with IgAN developing gross hematuria after receiving the mRNA COVID-19 vaccine. This suggests that the vaccine components may induce further activation of disease. This previously healthy patient is believed to have a severe and persistent case of IgAN in part due to his COVID-19 infection.
ABSTRACT
Background: Coronavirus Disease 2019 (COVID-19), an acute respiratory disease caused by novel coronavirus SARS-CoV-2, is particularly ominous to chronic dialysis patients as they are likely to experience more severe illness. However, these patients continue to require renal replacement therapy (RRT) during this time. To inform best practices for hemodialysis (HD) patients, we sought to determine the challenges regarding access placement during the pandemic era. Methods: This is a retrospective single-center study of adult patients who received chronic dialysis at one of the University of Virginia dialysis units. Prevalence of central venous catheter (CVC) use were assessed in patients receiving chronic HD between the months of February-April 2020 (during the pandemic in our area) and compared to the three months prior (October-December 2019). The patients' relevant clinical and laboratory information were reviewed and recorded monthly. All patients who received RRT on HD were included. Results: A total of 58 patients were evaluated, among whom 33 were male and 25 were female. The age range is 18-90 with a median age of 65. The number of patients using catheters in the pandemic months was 18 (31%), 19 (33%) and 22 (37%). The numbers pre-pandemic were 14 (25%), 19 (33%) and 17 (30%). The number of patients with central venous catheter for more than 90 days during the pandemic was 14 (24%), 16 (30%) and 16 (30%). The numbers pre-pandemic were 12 (22%), 15 (27%) and 15 (27%). Conclusions: This single-center study reveals the impact of the pandemic on HD catheter use in our area. There is a large population of ESRD patients in the United States on HD that require vascular access. An AVF is the desired access type as it has the most extended access survival, the best patient survival outcomes, the lowest cost, and requires the fewest interventions. Early referral for AVF is important;however, during the Covid-19 pandemic era patients and providers are hesitant to refer patients, wanting to avoid any exposure to the virus while resources remain scarce. This study identifies the inherent difficulty for access placement in this high-risk population of patients during times like this and raises questions in the literature on the best choice of access for these patients along with the optimal timing of fistula placement to provide safe care for the patients.