ABSTRACT
Background. Coinfection with COVID-19 and a secondary pathogen contributes to morbidity and mortality. Despite its contribution to outcomes, diagnosing coinfection is challenging and no predictive tools have been established. To better assess risk factors for coinfection, we performed a review of all patients hospitalized for COVID-19 in our institution and evaluated them for candidate predictors of coinfection. Methods. Medical records were reviewed in all patients admitted with COVID-19 at University of Chicago Medical Center between March 1, 2020 and April 18, 2020. Those identified as having coinfection were compared to those without coinfection. Secondary review was performed for characteristics of the coinfection, including diagnosis, microbiology, drug resistance, and nosocomial acquisition. Results. 401 patients were included in the study, the mean age was 60 years (SD-17), 29% had severe disease, and 13% died. At least one test for coinfection was performed in 99% of patients. Coinfection was identified in 15% (72/401) of patients. Coinfection was associated with older age, disease severity, and hospital complications, such as DVT/PE, AKI, and delirium. [Table 1] No symptom, non-microbiologic test, radiograph, or preexisting condition was associated with coinfection. Dyspnea, chest pain, and obesity were more common in those without coinfection. 74% received antibiotics. The most common sites for coinfection were urinary 33%, lower respiratory 26%, and blood 24%. [Table2] Bacteria were most frequently recovered (82%). The most commonly recovered pathogens were Enterobacterales (42%), Staphylococcus aureus (12%), and Pseudomonas (4%). 42% of the infections were hospital acquired, 16% caused by MDRO, and 13% were catheter or ventilator associated. Conclusion. Coinfection in COVID-19 was most closely associated with age, COVID-19 disease severity, and complicated hospitalization. No presenting symptoms, non-microbiologic test, or radiograph was associated with coinfection, underscoring the challenge in diagnosing coinfection. A remarkable number of infections were hospital acquired, MDRO, and catheter/ventilator associated. Further prospective study on coinfection in COVID-19 is needed to guide diagnosis and treatment.
ABSTRACT
Study Objective: The COVID-19 pandemic caused by the severe acute respiratory coronavirus 2 (SARS-CoV-2) has significantly affected the provision of routine and acute medical care. The aim of this report is to characterize patients with cancer presenting to EDs in the United States and COVID-19 mortality risk according to tumor subtype. Methods: The RECOVER registry represents a collaboration between 45 EDs spanning 27 states. This retrospective registry enrolled patients from each study site who received molecular diagnostic testing as part of ED care due to clinical suspicion for COVID-19 disease. Clinical characteristics pertaining to a patient’s cancer status were obtained from medical record review, specifically cancer type, active versus remission status, metastatic versus isolated tumor, and hematologic versus solid tumor status. Cancer type was further classified as solid/hematologic tumor localized or metastatic based on documented diagnoses and/or past medical history. Results: There are a total of 2865 patients who have a reported history of cancer, 1899 (66.3%) were negative for COVID-19 and 33.7% were positive on COVID-19 testing. There are higher percentages of minority-identifying patients in the COVID-19 positive cohort as compared to the negative cohort, namely Black or African American (33.9% vs 13.5%, respectively, p<0.001), and unknown/other (20.5% vs. 7.1%, p<0.001). Breast cancer was the most common solid tumor presenting in this cohort, with 19.6% of the COVID-positive cohort compared to 9.6% of the COVID-negative cohort (p=0.099). The next most common cancers in the cohort were colorectal (7.5%) and prostate (6.9%), however there were no statistical differences between the cohorts. The mortality rate for COVID-19 positive patients was 24.2% versus 9.9% for the COVID-19 negative rate (p<0.001, OR 1.96). Patients with breast cancer had a much higher mortality rate when associated with a COVID-19 positive test (26.4% versus 10.2%, p<0.001, OR 3.27). Similarly, colorectal cancer, prostate cancer, and leukemias experienced higher mortality rates for COVID-19 positive patients, 31.4% versus 13.2%, 31% versus 12.4%, and 30.8% versus 16.4% (all p<001). For patients with a documented history of cancer in remission, they also experienced higher mortality rates when associated with a positive COVID-19 test, namely 21.3% versus 7.2%. Conclusion: This study represents one of the largest COVID-19 cancer-related studies with 966 patients with a history of active cancer and SARS-CoV-2 infection. Patients with cancer present to the ED with diverse symptoms, treatment regimens, and having a diagnosis of COVID-19 is associated with higher mortality rates. Because of the high mortality rates observed for several of the cancer types in this study, initial evaluation of patients in the ED, subsequent ED therapies, and close communication with treating oncologists is of the utmost importance. [Formula presented]
ABSTRACT
Study Objective: We hypothesize that placing a piece of surgical tape at the bridge of the nose over the mask, creating a physical deterrent to mask removal, will improve proper mask use among emergency department (ED) patients. Methods: 123 patients were enrolled in a randomized controlled trial at Eskenazi Hospital from April 2020 until October 2020. We permitted participants to either use their own mask (due to low resources institutionally) or we provided a surgical/cloth mask (early on relied on donated cloth masks for patients). Participants were randomized to a control (no tape over the mask/nose) or to the intervention (placing tape over the bridge of the nose of the face mask). The primary outcome of this study is the frequency at which participants correctly wear their masks in the intervention and control groups at 60 minutes into their ED visit. Results: At 60- minutes in the no-tape control group, 31.1% participants were incorrectly wearing the masks, compared to 100% of the intervention group correctly wearing their masks. Subjects who were observed wearing their masks incorrectly (91.1%) exhibited some combination of either their mask removed or their nose and/or mouth exposed. Conclusions: Applying a piece of tape to the bridge of the nose affords a simple, low-cost, low-risk solution that improved the rate of proper mask usage to 100%.
ABSTRACT
Background: Morbidity and mortality due to coronavirus disease 2019 (COVID-19) may in part be due tointerleukin-6 (IL-6)-mediated hyperinflammation. The IL-6 receptor-targeted monoclonal antibody tocilizumab (TCZ)has been repurposed to treat COVID-19-related hyperinflammation, but prospective data are lacking. Given TCZ'srisks of secondary infection and potential blunting of the adaptive immune response and its finite supply, study of theefficacy, safety, and dose response of TCZ for the treatment of COVID-19-related hyperinflammation is needed. Methods: We conducted an adaptive phase 2 study of low-dose (LD) TCZ in hospitalized, non-mechanicallyventilated adult patients with COVID-19 pneumonitis and evidence of hyperinflammatory syndrome, with C-reactiveprotein (CRP) ≥ 40 micrograms per milliliter. Dose cohorts were determined by a trial Operations Committee, withthe initial doses of 80 or 200 milligrams, depending on the magnitude of CRP elevation and epidemiologic riskfactors. Doses were decreased to 40 mg and 120 mg after interim assessment. The primary objective was to assessthe relationship of dose to clinical improvement in temperature and oxygen requirement and biochemical responseby CRP. Results: 32 patients received LD TCZ. 25 of 32 (78%) patients receiving LD TCZ at any dose achieved feverresolution. In terms of dose-response, fever resolution in 24 hours was observed in 6 of 8 (75%) who received 200milligrams, 3 of 4 (75%) who received 120 milligrams, 11 of 15 (73%) who received 80 milligrams, and 5 of 5 (100%)who received 40 milligrams (p = 0.80 for response rate difference). Biochemical response consistent withinterleukin-6 pathway inhibition, corresponding to a ≥ 25% CRP decline, after a single dose of LD TCZ wasobserved in 5 of 8 (63%) who received 200 milligrams, 4 of 4 (100%) who received 120 milligrams, 10 of 15 (67%)who received 80 milligrams, and 5 of 5 (100%) who received 40 milligrams (p = 0.34 for response rate difference).100% of patients achieved CRP response within two doses of LD TCZ. Within the 28-day follow-up period, 5 (16%)patients died. For patients who recovered, median time to clinical recovery was 4 days (interquartile range, 2-5).Clinically presumed and/or cultured bacterial superinfections were reported in 4 (12.5%) patients. Correlativebiologic studies examining anti-SARS-CoV-2 antibody production across a range of TCZ doses are presentedseparately (abstract A-22514927). Conclusions: LD TCZ, in addition to standard of care, was associated with improvement of clinicalhyperinflammation parameters in hospitalized adult patients with COVID-19 pneumonitis. No relationship betweenTCZ dose and clinical or biochemical response relationship was identified. Results of the COVIDOSE trial provide arationale for a randomized, controlled trial of LD TCZ versus standard of care in those patients with COVID-19pneumonitis who have evidence of hyperinflammation. (COVIDOSE, ClinicalTrials.gov number, NCT04331795 .).