Clostridium difficile Infection Rates During the Pandemic in New York Capital Area: A Single-Center Study.

Introduction Clostridioides difficile (C. difficile) colonizes the large intestine, rendering healthy individuals asymptomatic carriers of the disease. In certain instances, C. difficile infection (CDI) occurs. Antibiotic use remains the leading risk factor for CDI. During the coronavirus disease 2019 (COVID-19) pandemic, multiple risk and protective factors for and against CDI were identified, and as such multiple studies tried to analyze the pandemic's overall effect on CDI incidence rates, with contradictory results. Our study's aim is to further characterize the CDI incidence rates trends, but for a longer period of 22 months in the pandemic. Methods We included only adult (>18 years) patients, diagnosed with CDI during their hospitalization for the following period: January 1, 2018, to December 31, 2021. Incidence was calculated as cases per 10,000 patient days. The period identified as the COVID-19 pandemic period was the following: March 1, 2020, to December 31, 2021. All analyses were performed by an expert statistician using Minitab software (Minitab Inc., State College, Pennsylvania, United States). Results The mean CDI incidence rate per 10,000 patient-days was 6.86 +/-2.1. The 95% confidence interval for the CDI incidence rate prior to the pandemic was found at 5.67 +/-0.35 while the interval during the pandemic was calculated at 8.06 +/- 0.41 per 10,000 patient days. Those results reveal a statistically significant increase in CDI incidence rates during the COVID-19 era. Conclusion Multiple risk and protective factors for and against hospital-acquired infections (including CDI) have been identified during the unprecedented COVID-19 healthcare crisis. In the literature, there is high controversy regarding the trends of CDI incidence during the pandemic. The current study analyzed an almost two-year period into the pandemic, identifying an increase in CDI rates when compared to the pre-pandemic era.

Influence of right ventricular structure and function on hospital outcomes in COVID-19 patients.

BACKGROUND: The impact of the right ventricular (RV) structure and function on the in-hospital outcomes in patients with COVID-19 infection has not been rigorously investigated. OBJECTIVES: The main aim of our study was to investigate in-hospital outcomes including mortality, ICU admission, mechanical ventilation, pressor support, associated with RV dilatation, and RV systolic dysfunction in COVID-19 patients without a history of pulmonary hypertension. METHODS: It was a single academic tertiary center, retrospective cohort study of 997 PCR-confirmed COVID-19 patients. One hundred ninty-four of those patients did not have a history of pulmonary hypertension and underwent transthoracic echocardiography at the request of the treating physicians for clinical indications. Clinical endpoints which included mortality, ICU admission, need for mechanical ventilation or pressor support were abstracted from the electronic charts. RESULTS: Patients' mean age was 68+/-16 years old and 42% of the study population were females. COPD was reported in 13% of the study population, whereas asthma was 10%, and CAD was 25%. The mean BMI was 29.8+/-9.5 kg/m2. Overall mortality was 27%, 46% in ICU patients, and 9% in the rest of the cohort. There were no significant differences in co-morbidities between expired patients and the survivors. A total of 19% of patients had evidence of RV dilatation and 17% manifested decreased RV systolic function. RV dilatation or decreased RV systolic function were noted in 24% of the total study population. RV dilatation was significantly more common in expired patients (15% vs 29%, p = 0.026) and was associated with increased mortality in patients treated in the ICU (HR 2.966, 95%CI 1.067-8.243, p = 0.037), who did not need require positive pressure ventilation, IV pressor support or acute hemodialysis. CONCLUSIONS: In hospitalized COVID-19 patients without a history of pulmonary hypertension, RV dilatation is associated with a 2-fold increase in inpatient mortality and a 3-fold increase in ICU mortality.

Clinical Characteristics of Hospitalized COVID-19 Patients Who Have Gastrointestinal Bleeds Requiring Intervention: A Case-Control Study.

Background Coronavirus disease 2019 (COVID-19) is widely recognized as a disease that affects the respiratory system, although it can also present with significant extrapulmonary symptoms. Very few studies have suggested an increased risk of gastrointestinal (GI) bleeding. This study aimed to elucidate the incidence, etiology, risk factors, and outcomes of clinically significant GI bleeding requiring endoscopic intervention in patients with COVID-19. Methods This is a case-control (1:2) retrospective analysis of all hospitalized adult patients with COVID-19 infection admitted between March 1, 2020, and January 5, 2021, in which we compared patients with upper and lower GI bleeds to those without. Cases are defined as patients hospitalized with COVID-19 who had a GI bleed requiring intervention while controls are defined as patients hospitalized with COVID-19 who did not have a GI bleed. Of 1002 patients admitted to the Albany Medical Center with COVID-19 infection, there were 76 confirmed cases of GI bleeding. These patients were compared to a control group composed of randomly selected patients with COVID-19 infection who were admitted to Albany Medical Center over the same time period. We assessed patients for in-hospital mortality, ventilator-free days on day 28, ICU-free days on day 28, and hospital-free days on day 28. Additional information collected included demographic information, comorbid conditions, COVID-19 treatments received, endoscopy findings, endoscopic treatment received, and if the patients required a packed red blood cell transfusion. Results Out of 1007 patients hospitalized with COVID-19, 76 (8%) had a GI bleed requiring endoscopic intervention. Peptic ulcer disease in the stomach or duodenum was the most common finding. The use of steroids, antiplatelet agents, and anticoagulation was not associated with an increased risk of GI bleed in COVID-19 patients. The GI bleed group required ICU care in 37% (28/76) compared with 21% (32/152) in the control group, which was statistically significant (p=0.012; chi-square test). Length of hospital stay was longer in the GI bleed group (median 16 days IQR: 8 to 29 versus 7 days, IQR:4 to 16; p<0.001, Mann Whitney test). Conclusion Length of hospital stay and ICU level of care was higher in the GI bleed group of patients with COVID-19. ICU level of care was noted to be associated with an increased risk of GI bleeding. A GI bleed in COVID-19 patients could be from the virus's direct effect on the gut mucosa or stress-induced bleeding like any other severely sick ICU patient; however, this needs to be explored in future studies.

Colonoscopy screening and surveillance disparities during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has increased barriers to accessing preventive healthcare. This study identifies populations disproportionately underrepresented in screening and surveillance colonoscopies during the COVID-19 pandemic. METHODS: In this single-center cohort study, colonoscopy procedures were reviewed during 6-month intervals before the pandemic (July 1, 2019 - December 31, 2019) and during the pandemic (July 1, 2020 - December 31, 2020 and January 1, 2021 - June 30, 2021). 7095 patients were categorized based on procedure indication, demographics, Charlson Comorbidity Index and Social Vulnerability Index (SVI). Statistics performed using VassarStats. RESULTS: 2387 (2019) colonoscopies pre-pandemic and 2585 (2020) and 2123 (2021) during the pandemic were identified. There was a decrease in colonoscopies performed during months when COVID-19 cases peaked. The total number of average CRC risk patients presenting for first colonoscopy declined during the pandemic: 232 (10 %) pre-pandemic to 190 (7 %) in 2020, 145 (7 %) in 2021 (p < 0.001). Fewer of these patients presented from highly vulnerable communities, SVI > 0.8, during the pandemic, 39 in 2019 vs 16 in 2020 and 22 in 2021. Of all screening and surveillance patients, fewer presented from communities with SVI > 0.8 during the pandemic, 106 in 2019 versus 67 in 2020 and 77 in 2021. CONCLUSION: It is important to address the decline in CRC preventive care during this pandemic among average CRC risk first-time screeners and vulnerable community patients. An emphasis on addressing social determinants of health and establishing patients in gastroenterology clinics is imperative to promote future health in these populations.

Corticosteroid Administration Is Associated With Improved Outcome in Patients With Severe Acute Respiratory Syndrome Coronavirus 2-Related Acute Respiratory Distress Syndrome.

OBJECTIVES: To compare the clinical outcome of mechanically ventilated patients with severe acute respiratory syndrome coronavirus 2-related acute respiratory distress syndrome, who received corticosteroid with those who did not. DESIGN: Retrospective analysis. SETTING: Intensive care setting. PATIENTS: All adult mechanically ventilated patients, who were admitted to the ICU between March 20, 2020, and May 10, 2020, for severe acute respiratory syndrome coronavirus 2-related acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cohort was divided into two groups based on corticosteroid administration. The primary outcome variable was ventilator-free days at day 28. Secondary outcome variable was ICU-free days at day 30, and hospital-free days at day 30. Consecutive 61 mechanically ventilated patients with severe acute respiratory syndrome coronavirus 2-related acute respiratory distress syndrome were analyzed. Patient in corticosteroid group as compared with noncorticosteroid group have higher 28-day ventilator-free days (mean, 10.2; median, 7 [interquartile range, 0-22.3] vs mean, 4.7; median, 0 [interquartile range, 0-11]; p = 0.01).There was no significant difference noted in secondary outcomes (ICU-free days at day 30 and hospital-free days at day 30). CONCLUSIONS: Among mechanically ventilated severe acute respiratory syndrome coronavirus 2-related acute respiratory distress syndrome patients, corticosteroids use was associated with significant improvement in 28-day ventilator-free days at day 28, but no significant improvement in ICU-free days at day 30, and hospital-free days at day 30.

Clinical Outcomes of Early Versus Late Intubation in COVID-19 Patients.

Background The implications of intubation timing in COVID-19 patients remain highly debatable due to the scarcity of available evidence. Objectives Our study aims to assess the clinical characteristics and outcomes of COVID-19 patients undergoing early intubation compared to those undergoing late intubation. Methods This is a single-center retrospective study of adult COVID-19 patients admitted between March 1, 2020 and January 10, 2021. Early intubation was defined as intubation within 24 hours of a) hospital admission; b) respiratory status deterioration requiring FiO2 60% and higher; or c) moderate/severe acute respiratory distress syndrome (ARDS) diagnosis. Results Among the 128 COVID-19 patients included, 66.4% required early intubation, and 33.6% required late intubation. The 28-day all-cause mortality and other outcomes of mechanical ventilation duration, hospital and ICU length of stay were equal regardless of intubation timing. Clinical characteristics, inflammatory markers, COVID-19 therapies, PaO2/FiO2 ratio, and pH were comparable for both groups. Better lung compliance was observed during early intubation than late intubation based on plateau (mean 21.3 vs. 25.5 cmH2O; P < 0.01) and peak pressure (mean 24.1 vs. 27.4 cmH2O; P = 0.04). Conclusions In critically ill COVID-19 patients, the timing of intubation was not significantly associated with poor clinical outcomes in the setting of matching clinical characteristics. More research is needed to determine which subset of patients may benefit from intubation and the predictors for optimal intubation timing.

Clinical and Laboratory Profile of COVID-19 Pneumonia Patients With a Complicated Post-Intensive Care Unit Hospital Course.

BACKGROUND: Characteristics of intensive care unit (ICU) downgrades who experience a complicated post-ICU ward course (ICU return or floor death) and the incidence of this phenomenon have not been examined in ICU survivors of coronavirus disease 2019 (COVID-19) pneumonia. The aim of the present study was to establish the rate of a complicated post-ICU ward course among survivors of COVID-19 pneumonia and describe the associated patient, ICU management, and serum biomarker characteristics. An additional aim was to compare these parameters between those who experienced a complicated post-ICU course and those who did not. METHODS: This was a retrospective study of patients who were admitted to the ICU with COVID-19 pneumonia and were downgraded to a hospital floor at the end of their initial ICU stay. Patients were divided based on a complicated or uncomplicated post-ICU course. Groups were compared with respect to relevant clinical variables. Serum biomarker levels were compared on day of ICU exit and were trended in the days preceding the downgrade. Ward stay of patients who had a complicated course was examined for notable floor events surrounding their decompensation. RESULTS: Eighteen out of 99 downgraded patients (18%) experienced a complicated post-ICU course, among them there were 14 returns (14%) and four deaths (4%). They had higher Charlson Comorbidity Index, higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score, as well as higher D-dimer and C-reactive protein (CRP) at ICU departure. They were less likely to have received therapeutic anticoagulation and convalescent plasma during their ICU stay. On multivariable analysis, these parameters except D-dimer remained independently associated with a complicated course. Review of biomarker trends preceding ICU exit demonstrated an upward trajectory of D-dimer, CRP, and lactate dehydrogenase (LDH) in the complicated course group not mirrored by the uncomplicated course group. Examination of notable floor events leading up to decompensation revealed that in 50% the ward course was characterized by new cardiac disturbances. CONCLUSIONS: Our rate of ward death among ICU downgrades was similar to pre-COVID data, but the rate of ICU return was higher. Complicated post-ICU course patients were exhibiting upward biomarker trends at ICU exit, and their ward stay was punctuated by acute cardiac abnormalities.

Incidence, Risk Factors, and Outcomes of Rhabdomyolysis in Hospitalized Patients With COVID-19 Infection.

INTRODUCTION: There is a paucity of studies examining the prevalence and clinical characteristics of rhabdomyolysis in hospitalized patients with COVID-19 infection. The purpose of this study is to examine the incidence, clinical characteristics, and outcome of hospitalized patients with COVID-19 infection who develop rhabdomyolysis. METHODOLOGY: This is a single-center retrospective analysis of all hospitalized patients with COVID-19 admitted between March 8, 2020, and January 11, 2021. All patients with creatinine kinase (CK) levels available during the hospital admission were included. Rhabdomyolysis was defined as an elevation in CK level higher than five times the upper limit of normal (i.e., 1125 U/L). We compared clinical characteristics and outcomes of patients who developed rhabdomyolysis with patients who did not develop rhabdomyolysis. RESULTS: The incidence of rhabdomyolysis in hospitalized patients with COVID-19 infection was 9.2%. There was no significant difference noted in comorbidities and clinical characteristics between the two groups. Moreover, there was no significant difference noted in the presence of severe COVID-19 infection (72.7% vs 54.6%, p = 0.1), mortality (27.3% vs 23.9%, p = 0.72), acute kidney injury (59.1% vs 42.7%, p = 0.14), or need for intensive care unit (ICU) care (72.7% vs 51.4%, p = 0.051). However, a higher percentage of patients in the rhabdomyolysis group required physical rehabilitation after discharge (40.9% vs 19.3%, p = 0.02). CONCLUSION: The overall incidence of rhabdomyolysis in hospitalized patients with COVID-19 infection was high (9.2%). The presence of rhabdomyolysis was not associated with the increased severity of the disease. Patients with rhabdomyolysis more frequently required physical rehabilitation compared to those without rhabdomyolysis.

Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study.

BACKGROUND: The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. PURPOSE: To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. METHODS: This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. RESULTS: A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO2:FiO2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH2O vs 39ml/cmH2O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04). CONCLUSION: The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Incidence and risk factors for secondary pulmonary infections in patients hospitalized with coronavirus disease 2019 pneumonia.

BACKGROUND: Secondary pulmonary infections (SPI) have not been well described in COVID-19 patients. Our study aims to examine the incidence and risk factors of SPI in hospitalized COVID-19 patients with pneumonia. METHODS: This was a retrospective, single-center study of adult COVID-19 patients with radiographic evidence of pneumonia admitted to a regional tertiary care hospital. SPI was defined as microorganisms identified on the respiratory tract with or without concurrent positive blood culture results for the same microorganism obtained at least 48 h after admission. RESULTS: Thirteen out of 244 (5%) had developed SPI during hospitalization. The median of the nadir lymphocyte count during hospitalization was significantly lower in patients with SPI as compared to those without SPI [0.4 K/uL (IQR 0.3-0.5) versus 0.6 K/uL (IQR 0.3-0.9)]. Patients with lower nadir lymphocyte had an increased risk of developing SPI with odds ratio (OR) of 1.21 (95% CI: 1.00 to 1.47, p = 0.04) per 0.1 K/uL decrement in nadir lymphocyte. The baseline median inflammatory markers of CRP [166.4 mg/L vs. 100.0 mg/L, p = 0.01] and d-dimer (18.5 mg/L vs. 1.4 mg/L, p<0.01), and peak procalcitonin (1.4 ng/mL vs. 0.3 ng/mL, p<0.01) and CRP (273.5 mg/L vs. 153.7 mg/L, p<0.01) during hospitalization were significantly higher in SPI group. CONCLUSIONS: The incidence of SPI in hospitalized COVID-19 patients was 5%. Lower nadir median lymphocyte count during hospitalization was associated with an increased OR of developing SPI. The CRP and d-dimer levels on admission, and peak procalcitonin and CRP levels during hospitalization were higher in patients with SPI.

Correlation of Respiratory Physiologic Parameters in Mechanically Ventilated Coronavirus Disease 2019 Patients.

Acute respiratory distress syndrome secondary to severe acute respiratory syndrome coronavirus-2 pneumonia or coronavirus disease 2019-related acute respiratory distress syndrome is the primary cause of mortality in coronavirus disease 2019. Some studies have described the concept of "high and low" elastance coronavirus disease 2019-related acute respiratory distress syndrome and proposed individualized management for the acute respiratory distress syndrome, deviating from low tidal volume ventilation. We report simultaneously measured respiratory parameters (static lung compliance, alveolar dead space ventilation, and shunt fraction) in 14 patients with advanced coronavirus disease 2019-related acute respiratory distress syndrome. The results were consistent with typical acute respiratory distress syndrome and did not support the concept of high-type coronavirus disease 2019-related acute respiratory distress syndrome and low-type coronavirus disease 2019-related acute respiratory distress syndrome.

Unique inflammatory profile is associated with higher SARS-CoV-2 acute respiratory distress syndrome (ARDS) mortality.

The COVID19 pandemic has caused more than a million of deaths worldwide, primarily due to complications from COVID19-associated acute respiratory distress syndrome (ARDS). Controversy surrounds the circulating cytokine/chemokine profile of COVID19-associated ARDS, with some groups suggesting that it is similar to patients without COVID19 ARDS and others observing substantial differences. Moreover, although a hyperinflammatory phenotype associates with higher mortality in non-COVID19 ARDS, there is little information on the inflammatory landscape's association with mortality in patients with COVID19 ARDS. Even though the circulating leukocytes' transcriptomic signature has been associated with distinct phenotypes and outcomes in critical illness including ARDS, it is unclear whether the mortality-associated inflammatory mediators from patients with COVID19 are transcriptionally regulated in the leukocyte compartment. Here, we conducted a prospective cohort study of 41 mechanically ventilated patients with COVID19 infection using highly calibrated methods to define the levels of plasma cytokines/chemokines and their gene expressions in circulating leukocytes. Plasma IL1RA and IL8 were found positively associated with mortality, whereas RANTES and EGF negatively associated with that outcome. However, the leukocyte gene expression of these proteins had no statistically significant correlation with mortality. These data suggest a unique inflammatory signature associated with severe COVID19.