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SESSION TITLE: Tobacco Use, Risk Factors, and Managing Patients with Pulmonary Diseases SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: COVID-19 disproportionately affects patients who are Hispanic or Black. Risk factors for COVID-19 progression to critical illness – defined as a composite outcome of ICU transfer, need for invasive or non-invasive mechanical ventilation, or in-hospital mortality – have not been fully identified in this patient population. The Harris Health System (HHS) in Houston, Texas serves a unique patient population who are underserved and predominantly Hispanic or Black. We examined the clinical characteristics of adults admitted with COVID-19 to HHS affiliated county hospitals and examined risk factors that predicted progression to critical illness. METHODS: This was an observational cohort study of adult patients with COVID-19 infection admitted from the emergency room between March 2020 and December 2020. We excluded patients who were pregnant or admitted to primary surgical services. We additionally excluded patients who - within the first 24 hours of presentation to the ED - were admitted to the ICU, required mechanical ventilation, or expired. We captured clinical characteristics from the first 24 hours of presentation. We used Lasso logistic regression for variable selection, and included those variables that remained significant in a multiple logistic model predicting progression to critical illness. Discrimination of the model was assessed using 10-fold cross-validated area under the receiver operator characteristic (AUROC) curve. RESULTS: 1777 patients were included in the final analysis. 211 patients progressed to critical illness – 91 (5.1%) died, 148 (8.3%) required invasive or non-invasive mechanical ventilation, and 164 (9.2%) were transferred to the ICU. Several notable risk factors for progression to COVID critical illness included age (adj OR 1.04, 95% CI: 1.02, 1.05), body mass index (adj OR 1.04, 95% CI: 1.02, 1.06), chronic pulmonary disease (adj OR = 2.07, 95% CI: 1.15, 3.72), renal disease (adj OR 2.08, 95% CI: 1.28, 3.37), and active malignancy (adj OR 2.20, 95% CI: 1.11, 4.37). Compared to patients who did not require oxygen support within the first 24h, those who required high flow nasal cannula were more likely to progress to critical illness (adj OR 4.10, 95% CI: 2.39, 7.02). The prediction model demonstrated a 10-fold cross-validated AUROC of 0.79 (95% CI: 0.76, 0.81). CONCLUSIONS: In this unique population of underserved and majority Hispanic and Black patients, we identified multiple risk factors that predict patients with COVID-19 at risk of progression to critical illness. CLINICAL IMPLICATIONS: We believe that this prediction model has the ability to identify patients with COVID-19 at risk of progression to critical disease and who may benefit from closer monitoring and/or timely initiation of novel interventions. DISCLOSURES: No relevant relationships by Hana El Sahly No relevant relationships by Casey Graziani Advisory Committee Member relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Advisory Committee Member relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Removed 08/02/2022 by Nicola Hanania Research support relationship with Boehringer Ingelheim, GSK, Novartis Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support Research support relationship with Sanofi Genzyme and Genentech Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support No relevant relationships by Ang Li No relevant relationships by Dharani Kumari Narendra No relevant relationships by Shital Patel No relevant relationships by Krist n Staggers
ABSTRACT
TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Inhaled amikacin is FDA approved in the treatment of pulmonary Mycobacterium avium complex (MAC). Here we present a case of acute hypersensitivity pneumonitis after initiating therapy with inhaled amikacin. CASE PRESENTATION: An 82 year old male with a history of pulmonary MAC infection and chronic hypoxemia on 2L oxygen presented with progressive non-productive cough and dyspnea. He had been diagnosed with pulmonary MAC three years prior to presentation and had been treated with azithromycin, rifampin, and ethambutol. CT chest imaging demonstrated multifocal bronchiectasis, tree in bud nodules, and cavitary lesions. Respiratory AFB cultures were positive for MAC. He was prescribed oral rifampin and azithromycin. Intravenous amikacin was considered given cavitary disease but deferred in light of age and comorbidities. Inhaled amikacin was prescribed but unable to be started as an outpatient. One week later, he was admitted with new fevers, progressive dry cough, dyspnea, and increased oxygen requirement. CT chest was negative for pulmonary embolism and showed new multifocal ground glass opacities (Image #1). He was admitted for suspected superimposed bacterial or viral pneumonia. COVID-19 and respiratory viral testing were negative. Sputum culture was unable to be obtained due to non-productive cough. Rifampin and azithromycin were continued and nebulized amikacin was initiated. Broad spectrum antibiotics were started to cover for bacterial pneumonia. He initially defervesced but on hospital day #5, his dyspnea and hypoxemia worsened. He required up to 15 liters 100% oxygen via non-rebreather mask. He was empirically diuresed and antibiotic coverage was broadened without improvement. Echocardiogram showed unchanged cardiac function. CT chest imaging on hospital day #7 demonstrated progressive multifocal ground glass opacities with intralobular and interlobular septal thickening (Image #2). Clinical picture was concerning for drug induced pneumonitis. Amikacin was discontinued and oral prednisone was started. His respiratory symptoms improved and he was weaned to 2L via nasal cannula prior to discharge. Nebulized amikacin was not restarted. DISCUSSION: In this patient, initiation of inhaled amikacin was temporally related to the development of an acute hypersensitivity pneumonitis associated with significant hypoxemia which improved promptly with the discontinuation of inhaled amikacin and initiation of corticosteroids. Trial data investigating inhaled liposomal amikacin in pulmonary MAC has reported a 3% incidence of hypersensitivity pneumonitis. CONCLUSIONS: Inhaled amikacin is a useful adjunctive therapy in the treatment of refractory pulmonary MAC infection. The development of hypersensitivity pneumonitis should prompt immediate discontinuation of the drug and consideration for corticosteroid therapy in severe cases. REFERENCE #1: Griffith DE, Eagle G, Thomson R, et al. CONVERT Study Group Amikacin liposome inhalation suspension for treatment-refractory lung disease caused by Mycobacterium avium complex (CONVERT): A prospective, open-label, randomized study. Am J Respir Crit Care Med 2018;198:1559–69. REFERENCE #2: Swenson, C, Lapinel NC, and Ali J. Clinical Management of Respiratory Adverse Events Associated With Amikacin Liposome Inhalation Suspension: Results From a Patient Survey. Open Forum Infect Dis. 2020 Apr;7(4): ofaa079 DISCLOSURES: No relevant relationships by Casey Graziani, source=Web Response No relevant relationships by Ali Jiwani, source=Web Response