Characteristics of patients positive for COVID-19 and multidrug-resistant organisms in Tennessee, 2020–2021

Background: Multidrug-resistant organisms (MDROs) are a global threat. To track and contain the spread, the Tennessee Department of Health (TDH) performs targeted surveillance of carbapenemase-producing and pan-nonsusceptible organisms. When these MDROs are identified, TDH conducts a containment response and collects epidemiological data, which includes risk factors such as indwelling devices and previous hospitalizations. The impact of the COVID-19 pandemic on these MDROs is not well understood. Therefore, we have described the characteristics of cases positive for both COVID-19 and select MDROs. Methods: MDRO investigation data from January 1, 2020–September 30, 2021 were matched with all COVID-19 case data from the TDH statewide surveillance system, National Electronic Disease Surveillance System Base System. MDRO-positive date was defined as the specimen collection date;COVID-19 case date was first defined as the date of symptom onset and if missing, then diagnosis date, and investigation creation date, respectively. Descriptive statistics and Fisher exact tests were calculated using SAS version 9.4 software. Results: Among 336 MDRO cases, 50 had a reported SARS-CoV-2–positive result. MDRO types were Enterobacterales (CRE) (n = 31), Acinetobacter spp (CRA) (n = 18), and Pseudomonas aeruginosa (n = 1). Of these 50 cases, 20 were MDRO-positive before and 30 days after the COVID-19 case date, respectively. Of the 18 CRA cases, 16 (89%), were positive after the COVID-19 case date, compared to 13 (42%) among 31 CRE cases (P < .01). Also, 35 patients (70%) had a record of hospitalization, and 22 (63%) had their MDRO specimen collected after the COVID-19 case date (P = .37). Of these 22 patients, 4 had their MDRO specimen collected during their COVID-19 hospitalization, with an average duration from admission to MDRO collection date of 17 days (range, 4–36). Among the 50 coinfected cases, 8 died, 7 (88%) of whom were MDRO-positive after their COVID-19 case date. Data on indwelling devices at time of MDRO positivity were completed for 17 cases;14 had an indwelling device and, among these, 13 (93%) were MDRO-positive after their COVID-19 case date. Conclusions: MDRO cases with specimen collections after COVID-19 comprised the majority of hospitalized patients, patients who died, and patients with indwelling devices compared to those with MDROs collected before their COVID-19 case date. These results show a stark difference with CRA as the most common MDRO among post–COVID-19 cases. Our data were limited by reporting gaps. We recognize that patients can remain colonized with MDROs for lengthy durations, which could have result in undetected MDRO cases prior to the COVID-19 case date. More data and analyses are needed to make targeted public health recommendations. However, these findings highlight the burden of MDROs among COVID-19 cases. including adverse health outcomes.Funding: NoneDisclosures: None

Determining the effect of COVID-19 on antibiotic use in long-term care facilities across Tennessee

Background: Nationally, a decrease in total antibiotic use in nursing homes during the COVID-19 pandemic was observed with an increase in select agents used for respiratory infections. Currently there is minimal data on antibiotic use in long-term care facilities (LTCFs) in Tennessee. To address this issue, the Tennessee Department of Health (TDH) developed a monthly point-prevalence survey of antibiotic use. Utilizing this tool, we sought to determine the effect the pandemic had on antibiotic use in Tennessee LTCFs. Method: We developed a REDCap questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. Antibiotic use percentage was determined by dividing the number of residents who received an antibiotic on the day of survey by facilities' average censuses. Data were divided into a prepandemic period (January 2019–February 2020) and a period during the pandemic (March 2020–December 2021). Antibiotic prescriptions were grouped into 4 classes according to their most common uses: Clostridium difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs), and respiratory infections. Average percentage of residents on antibiotics were compared between study periods. Results: In total, 37 facilities participated in the survey during the prepandemic period and 32 facilities participated during the pandemic period;14 participated during both periods. The average percentage of residents on antimicrobials before the pandemic was 16.3%, which decreased to 11.5% during the pandemic period (P = .04). During the prepandemic period, 40.2% of antibiotics prescribed were in the common for SSTI category and 38.3% were in the common for respiratory infections category (P = .01);during the pandemic period, 64.3% of antibiotics prescribed were in the common for SSTI category and 45.8% were in the common for respiratory infections category (P = .01). The 3 most prescribed antibiotics in the prepandemic period were amoxicillin (148 prescriptions), doxycycline (140 prescriptions), and levofloxacin (135 prescriptions). The 3 most prescribed antibiotics during the pandemic were doxycycline (141 prescriptions), levofloxacin (125 prescriptions), and trimethoprim–sulfamethoxazole (115 prescriptions). Conclusions: Survey results revealed that antibiotic prescriptions commonly used for respiratory infections increased 7.5% during the pandemic study period. Additionally, the average percentage of residents on antimicrobials fell 4.8% during this period. Both statistics reflect what has been seen nationally with a decrease in antibiotic use with an increase in respiratory antibiotics. This could be due to multiple factors including decreased reporting, a change in healthcare delivery during the pandemic, and facilities seeing an increase of respiratory tract infections. These data will be used to guide future TDH antibiotic stewardship efforts in the long-term care setting.Funding: NoneDisclosures: None

Effect of the COVID-19 pandemic on Tennessee hospital antibiotic use

Background: On March 5, 2020, the Tennessee Department of Health (TDH) announced the first case of COVID-19 in the state. Since then, hospitals have been overwhelmed by the spike in respiratory infections. Several studies have attempted to describe the impact of the pandemic on antibiotic prescriptions. The NHSN Antimicrobial Use Option offers a platform for hospitals to report their antibiotic usage. The TDH has established access to hospital antibiotic usage data statewide through an existing NHSN user group. We compared the change in the volume of inpatient antibiotic prescriptions before and during the pandemic. Methods: An ecological study was conducted from January 2019 to December 2021. Aggregated facility-level data from the NHSN Antimicrobial Use Option were used to describe antibacterial use among Tennessee hospitals. Data from facilities that had reported at least 1 month of data during the study period were included in this study. The antimicrobial use rate was calculated by dividing the antimicrobial days of therapy (DOT) by the number of 1,000 days present. Overall antimicrobial use rates as well as specific antimicrobial use rates for azithromycin, ceftriaxone, and piperacillin–tazobactam were compared across years. Results: In total, 55 hospitals reported at least 1 month of data into the NHSN Antimicrobial Use Option during the study period. These hospitals had a median bed size of 140 (range, 12–689). Conclusions: We observed a modest increase in overall antibiotic use during the COVID-19 pandemic in Tennessee facilities. This trend appeared to be primarily attributed to agents used for community-acquired respiratory infections, such as azithromycin and ceftriaxone, earlier in the pandemic. However, both of these agents have fallen to prepandemic use levels during 2021. The fact that overall use increased in 2021 suggests that other agents not analyzed may have contributed to this effect. Further analysis may help determine which agents are responsible for this increase in 2021.Funding: NoneDisclosures: None

Obstructive sleep apnea and white matter hyperintensities: correlation or causation?

Obstructive sleep apnea (apnea) is thought to cause small vessel ischemic episodes in the brain from hypoxic events, postulated as white matter hyperintensities (hyperintensities) identified on MRI which are implicated in cognitive decline. This study sought to evaluate these correlations. A retrospective evaluation of adults who underwent polysomnography (4/1/2016 to 4/30/2017) and a brain MRI prior to apnea diagnosis or within a year post-diagnosis was completed. MRI visual evaluation of hyperintensities using Fazekas scores were collected blind to clinical data. Collated clinical/MRI data were stratified and analyzed using chi-square, fishers t-tests, ANOVA/ANCOVA and linear regression. Stratification by apnea category revealed no significant differences in any variables including hyperintensity measures (Fazekas p=0.1584; periventricular p=0.3238; deep p=0.4618; deep total p=0.1770). Stratification by Fazekas category, periventricular and deep hyperintensities revealed increasing prevalence with age (p=0.0001); however, apnea categories were not significantly associated (Fazekas p=0.1479; periventricular p=0.3188; deep p=0.4503), nor were any individual apnea indicators. Continuous apnea measurements werre not associated with any hyperintensity factor; total deep hyperintensities were not associated with any apnea factors. Continuous BMI was not found to be associated with any apnea or hyperintensity factors. Only hypertension was noted to be associated with Fazekas (p=0.0045), deep (p=0.0010) and total deep (p=0.0021) hyperintensities; however, hypertension was not associated with apnea category (p=0.3038) or any associated factors. These data suggest apneas alone from OSA are insufficient to cause WMH, but other factors appear to contribute to the complex development of small vessel ischemic injury associated with age and cognitive decline.

Types, management and complications in paediatric distal radial fractures sustained during COVID-19 lockdown.

In response to the coronavirus pandemic the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines advised treating distal radial fractures non-operatively where possible. A cohort was studied retrospectively to assess whether the COVID pandemic lockdown within the UK altered types, the management and complications of paediatric distal radial fractures. The cohort studied comprised of 194 paediatric distal radial fractures in the pre-COVID cohort and 101 fractures in the COVID cohort. There was no significant differences in the type of fractures in the two cohorts. Significantly more high energy injuries were sustained among the COVID cohort than the pre-COVID (p < 0.001). The COVID cohort had significantly more patients managed in cast (p < 0.001) and significantly more managed with K-wire fixation (p = 0.049). The COVID cohort had significantly more complications (p = 0.016) at minimum 10-month follow-up. The results suggest that treatment of paediatric distal radial fractures during lockdown was too conservative and subsequent complications may put additional strain on orthopaedic services.Level of evidence: IV.

Home Information and Communication Technology Use and Student Academic Performance: Encouraging Results for Uncertain Times.

This study set out to examine the associations of certain information communication technology (ICT) factors in the home environment with academic performance. We employed existing data sets collated by Pearson Clinical Assessment in 2016 which included the WIAT-III A&NZ (Wechsler Individual Achievement Test - Australian and New Zealand Standardised, Third Edition) completed by 714 students aged between 4 and 18 years old, and the home environment questionnaire (HEQ) completed by the parents of those children. Sequential multiple regression models were used to analyze the complex interactions between home ICT factors and measures of student reading, writing, mathematical, and oral ability. The findings of this study indicate that after accounting for the known powerful predictors of household income and parental education: (a) a student's access to an ICT rich home environment, (b) their aptitude in using home ICT, and (c) their recreational use of home ICT, are largely unrelated to academic performance. We observed some small positive correlations between academic performance and child ICT affinity, but also comparably sized negative associations with use of social media and educational TV viewing. Encouragingly, we propose that these findings suggest that increasing levels of ICT use and access in the home are unlikely to be detrimental to academic progress. These results provide important information for parents and educators given the impact of the Coronavirus global pandemic and the near world-wide adoption of ICT for home-schooling.

A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland.

INTRODUCTION: In order to minimise the risk of breast cancer patients for COVID-19 infection related morbidity and mortality prioritisation of care has utmost importance since the onset of the pandemic. However, COVID-19 related risk in patients undergoing breast cancer surgery has not been studied yet. We evaluated the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland region. METHODS: A prospective cohort study of patients having breast cancer surgery was carried out in a geographical region during the first eight weeks of the hospital lockdown and outcomes were compared to the regional cancer registry data of pre-COVID-19 patients of the same units (n = 1415). RESULTS: 188 operations were carried out in 179 patients. Tumour size was significantly larger in patients undergoing surgery during hospital lockdown than before (cT3-4: 16.8% vs. 7.4%; p < 0.001; pT2 - pT4: 45.5% vs. 35.6%; p = 0.002). ER negative and HER-2 positive rate was significantly higher during lockdown (ER negative: 41.3% vs. 17%, p < 0.001; HER-2 positive: 23.4% vs. 14.8%; p = 0.004). While breast conservation rate was lower during lockdown (58.6% vs. 65%; p < 0.001), level II oncoplastic conservation was significantly higher in order to reduce mastectomy rate (22.8% vs. 5.6%; p < 0.001). No immediate reconstruction was offered during lockdown. 51.2% had co-morbidity, and 7.8% developed postoperative complications in lockdown. There was no peri-operative COVID-19 infection related morbidity or mortality. CONCLUSION: breast cancer can be safely provided during COVID-19 pandemic in selected patients.

COVID-19 and orthopaedic surgery: evolving strategies and early experience.

AIMS: COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the 'hotspots' in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19. METHODS: Adapting to the crisis locally involved five operational elements: 1) triaging and workflow of orthopaedic patients; 2) operation theatre feasibility and functioning; 3) conservation of human resources and management of workforce in the department; 4) speciality training and progression; and 5) developing an exit strategy to resume elective work. Two hospitals under our trust were redesignated based on the treatment of COVID-19 patients. Registrar/consultant led telehealth reviews were carried out for early postoperative patients. Workflows for the management of outpatient care and inpatient care were created. We looked into the development of a dedicated operating space to perform the emergency orthopaedic surgeries without symptoms of COVID-19. Between March 23 and April 23, 2020, we have surgically treated 133 patients across both our hospitals in our trust. This mainly included hip fractures and fractures/infection affecting the hand. CONCLUSION: The COVID-19 pandemic is not the first disease outbreak affecting the UK, nor will it be the last. The current crisis has necessitated rapid development of new hospital guidelines and early adaptive strategies in our services. Protocols and directives need to be formalized keeping in mind that COVID-19 will have a long and protracted course until a definitive cure is discovered.