Not the sharpest of tools: Procalcitonin and bacterial co-infections in patients admitted with COVID-19

Background. The COVID-19 pandemic has caused record breaking hospitalizations due to respiratory failure. A major challenge in the management of COVID-19 is the difficulty distinguishing COVID-19 from other causes of lower respiratory tract infections (LRTIs) that may require antimicrobial use (AU). Procalcitonin (PCT) has been used to differentiate viral from bacterial causes of LRTIs and clinicians have relied on PCT to use or withhold antimicrobials. However, the utility of PCT in the setting of COVID-19 remains unclear. We seek to define the role of PCT in patients admitted with COVID-19. Methods. Retrospective cohort study of COVID-19 inpatients with PCT ordered at a 151-bed urban community hospital from March 2020-March 2022. Ranges of PCT were categorized as high ( >5 mug/L), medium (0.25-5 mug/L), and low (< 0.25 mug/L) risk of infection. Co-infection was defined as presence of clinical and microbiological evidence of infection in blood (BSI) or in sputum within 7 days of admission. Late infections were excluded Results. Of a total 262 cases, 154 (58%) were low-risk, 43 (16%) medium-risk, and 63 (24%) high-risk (Figure 1). AU in the low-risk category was 29% (45), followed by 29% in the moderate and 36% in high-risk categories. 1 BSI caused by Klebsiella pneumoniae in the low-risk category and 1 LRTI caused by Streptococcus pneumoniae in the high-risk category were found, representing 0.6% and 1.5% of samples in those categories. Total documented infection was 0.7% for all cases. Figure 1. Procalcitonin levels and co-infections in patients admitted with COVID-19 pneumonia. Conclusion. PCT has limited utility in COVID-19. Co-infection rates on admission are exceedingly rare, representing < 1% of our cohort. Only 2 documented infections were found, 1 of which was in the low-risk category. Thus, PCT was commonly elevated without documented infection. Though rare, a co-infection can occur without elevation of PCT. As described in the 2019 IDSA Community Acquired Pneumonia Guidelines, the use of PCT is of limited utility and may confound providers towards using or deferring antimicrobials inappropriately. This remains true in COVID-19. Antimicrobial stewardship programs should advise against its routine use.

Clinical, echocardiographic and electrocardiographic manifestations of COVID-19 multisystem inflammatory syndrome in children in the Dominican Republic

Background. The COVID-19 pandemic has spread globally and millions of infections have occurred. As cases mount, atypical manifestations of COVID-19 and post-infectious complications such as multisystem inflammatory syndrome in children (MIS-C) become more likely. MIS-C is a life threatening post-infectious complication of COVID-19. There is a paucity of data of MIS-C in the Dominican Republic (DR). We seek to understand the clinical manifestations of MISC-C in the DR. Methods. This is a retrospective review of cases admitted to a pediatric hospital in the Dominican Republic from March 2020 to December 2021. Patients with clinical findings and a diagnosis of MIS-C were included. Echocardiographic (Echo) and electrocardiographic (ECG) changes were reviewed. Results. A total of 16 patients were included in our study, of which 68.75 were male. Ages were 12.5% < 1 years old, 12.5% between 1-4, 62.5% 5-12 and 12.5% over 12. Fever and rash were the most common clinical findings (Figure 1), while 69% had a new abnormality on echo and 50% had new ECG abnormalities. Echocardiographic findings are listed in Figure 2. Clinical findings in patients admitted with MIS-C Echo findings ECG findings Conclusion. The clinical manifestation of MIS-C are primarily fever, conjunctivitis, rash and hypotension. Because these findings can be non-specific, a high level of suspicion is needed. With over two thirds of patients with MIS-C showing echocardiographic changes and more than 50% showing ECG changes, these two tests can add significant diagnostic value in the right clinical setting. Clinicians should consider early echocardiography and ECG in patients with possible or suspected MIS-C.

Impact of a Midline Catheter Prioritization Project on Central Venous Access and Central Line Associated Bloodstream Infections at an Urban Safety-net Community Hospital

Background. The use of peripherally inserted central catheters (PICCs) has increased in the past decade. PICCs are central lines (CLs) commonly used for venous access. Midline catheters (MLs) can provide access when the need for a CL, such as vasopressors, is no longer present. MLs have a lower rate of BSI compared to PICCs and CLs, while providing dwell times comparable to PICCs. We established a project prioritizing ML use. Methods. This is a quasi-experimental study in a 151-bed safety net community hospital. The pre-intervention period was January-December 2018 and post period was January 2019-December 2021. MLs were prioritized when new PICCs are requested without CL indications, such as total parenteral nutrition, hyperosmolar solutions and vasopressors. PICCs and CLs are transitioned to a ML once indications are no longer met and peripheral IVs are not feasible. Data on utilization and complications, such as deep venous thrombus (DVT) and BSIs, were reviewed and compared. Results. A total of 63 peripherally inserted lines occurred prior to the intervention, of which 55 (87%) were PICC and 8 (13%) were ML (Figure 1). Post-intervention, 76 lines were placed the first year, of which 48 wereML (63%). This upward trend was sustained throughout the pandemic, with 116 lines in 2020 (80%ML) and 96 in 2021 (88% ML). No BSIs occurred during the pre-intervention and first post-intervention year. During the pandemic, 8 BSIs in MLs and 3 in PICCs occurred. The most common organismwas Candida (Figure 2). Themajority had COVID-19 (72%) and all (100%) BSIs were in the setting of shock. Case review demonstrated suspected secondary sources other than central venous catheters (CVCs). All BSIs with ML would have met NHSN criteria if CL present. No upper extremity DVTs were found. Conclusion. A midline prioritization project was successfully implemented and sustained during the COVID-19 pandemic. The decline of PICC use from 87% to 12% suggests use for access without CL needs. High acuity during the pandemic led to BSIs that were likely secondary to shock and complications of COVID-19. All cases would have met NHSN criteria for CLABSI. The cost of a CLABSI is estimated at $48,108. (Figure Presented).

Impact of a Culturally Sensitive Multilingual Community Outreach Model on COVID-19 Vaccinations at an Urban Safety-net Community Hospital

Background. The United States (US) is one of the most affected countries by the COVID-19 pandemic. A disproportionate burden of COVID-19 deaths is seen in Black, Asian, and Latinx groups. COVID-19 vaccines are the primary mitigation strategy to reduce morbidity and mortality. However, vaccine hesitancy is high in these communities due to factors such as low health literacy, language barriers, and other health inequities. Our objective was to implement a culturally sensitive, multi-lingual, community outreach model to promote vaccine education and facilitate vaccine administration. Methods. Community healthcare workers or "promotoras" were deployed to high traffic areas such as supermarkets, laundromats, churches, and commercial hubs from February-May 2021. The promotoras provided culturally sensitive vaccine counseling to individuals in their preferred language and facilitated vaccine appointments at our hospital. Our data was compared with publicly available data from other facilities organized by ZIP codes defined by the Department of Public Health as low, medium, or high-vulnerability to COVID-19. Results. A total of 109 outreach workers were hired, of which 67% (73) were Latinx, 27% (29) Black and 6% (7) Asian. Overall, 8,806 individual encounters led to 6,149 scheduled appointments and 3,192 completed first doses (Figure 1). A total of 14,636 individuals were vaccinated. Average age was 45.5 (range 12-98). Preferred language was 54% Spanish, 38% English, and 8% Chinese. Ethnicity was mostly Hispanic (66%) with race mostly white (54%) (Figure 2). High and medium-risk ZIP codes represented 69.4% of vaccinations at our facility (Figure 3). Conclusion. We successfully implemented a culturally sensitive community outreach model which resulted in higher vaccination rates from at risk ZIP codes when compared to other hospitals. Promotoras encouraged vaccination in native languages, thereby increasing vaccine awareness and appointment faciliation. Barriers to vaccine access remain in these vulnerable communities. This model educated the community via its own members and may help reduce barriers, increase vaccine awareness and vaccination rates.