Secondary Infections in Patients with Extremely Severe COVID-19 During ECMO Therapy.

Up to 70% of patients hospitalized for COVID-19 need respiratory support, up to 10% need high-flow oxygen therapy, non-invasive and invasive ventilation. However, standard methods of respiratory support are ineffective in 0.4-0.5% of patients. In case of potentially reversible critical refractory respiratory failure that patients may require ECMO. Management of patients with extremely severe COVID-19 associates with numerous clinical challenges, including critical illness, multiple organ dysfunction, blood coagulation disorders, requiring prolonged ICU stay and care, use of multiple pharmacotherapies including immunosuppressive drugs. Pharmacological suppression of immunity is associated with a significant increase in the risk of secondary bacterial and fungal infections. Currently, data on epidemiology of secondary infections in patients with COVID-19 undergoing ECMO is limited. Aim. To study the prevalence and etiology of secondary infections associated with positive blood cultures in patients with extremely severe COVID-19 requiring ECMO. Materials and methods. A single-center retrospective non-interventional epidemiological study including 125 patients with extremely severe COVID-19 treated with ECMO in April 2020 to December 2021. Results. Out of 700 blood culture tests performed in 125 patients during the study, 250 tests were positive confirming bacteremia/fungemia. Isolated pathogens varied depending on the duration of ECMO: gram-positive bacteria (primarily coagulase-negative staphylococci) dominated from the initiation of ECMO support;increased duration of ECMO associated with an increasing the proportion of pathogens common in ICU (Klebsiella pneumoniae and/or Acinetobacter baumannii with extensively drug resistant and pan-drug resistant phenotypes, and vancomycin-resistant Enterococcus faecium). When ECMO lasted more than 7-14 days, opportunistic pathogens (Candida species, Stenotrophomonas maltophilia, Providencia stuartii, non-diphtheria corynebacteria, Burkholderia species and others) prevailed as etiological agents. Conclusion. Longer duration of ECMO resulted in increasing the rates of infectious complications. In patients undergoing ECMO for more than 14 days, the microbiological landscape becomes extremely diverse, which hampers choosing an empirical antimicrobial therapy. Since potential pathogens causing secondary infections in patients during ECMO are difficult to predict, rapid identification of rare opportunistic pathogens and their sensitivity profile, followed by targeted administration of antimicrobials, seems most beneficial.Copyright © 2023, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved.

Phenotypic Characteristics and Clonal Relationships of Stenotrophomonas maltophilia Isolates in Hospitalized Adults from a Private Center in Lima, Peru.

Stenotrophomonas maltophilia is an opportunistic pathogen, often associated with nosocomial infections. Ten S. maltophilia were isolated from clinical samples during the period January 2021 and June 2022. Eight (80%) patients had cancer as a background disease and 2 patients had coronavirus disease 2019. A fatal outcome was recorded in 4 cases (40% of patients). All the isolates were susceptible to minocycline and levofloxacin. Trimethoprim/sulfamethoxazole and ceftazidime resistance rates were 20% and 40% respectively. Eight different patterns were observed by Pulsed-Field Gel Electrophoresis, only two isolates being clonally identical. The isolation of S. maltophilia in clinical settings requires the implementation of infection prevention measures.

Bacterial and viral upper and lower airways infection in people with cystic fibrosis in stable condition

Background: Bacterial and viral airway infections are adverse factors for prognosis in people with cystic fibrosis (CF). The role of viral infections is unclear. Proper microbiological follow-up is essential, and the correlation between upper (UAW) and lower airway (LAW) microbiology may be important for lung disease management. We aim to evaluate airway microbiology in patients in stable clinical condition. Method(s): Between September 2021 and March 2022 in the Florence CF center, 144 nasal lavage-throat swab paired samples were collected from 72 clinically stable people with CF not chronically colonized by Pseudomonas aeruginosa. The study enrolled 59 children (median age 9, range 2-16) and 13 adults (median age 28, range 18-59). LAW specimens (72)were sampled as throat swab and UAWspecimens (72)were randomly collected by nasal lavage with two methods-Mainz (44) or Ryno-set (28). We performed conventional microbiological analyses on all samples. To screen for respiratory viruses, multiplex polymerase chain reaction (BioFire FilmArray RP 2.1 Plus) was performed. Respiratory symptoms and forced expiratory volume in 1 second (FEV1) valueswere evaluated for all patients. Result(s): Twenty-one (29%) patients tested positive for at least one virus in UAW and LAW specimens. The most frequently identified viruses were human rhinovirus or enterovirus (22%) and respiratory syncytial virus (6%). Two (3%) patients tested positive for SARS-CoV-2. Concordance between sampling methods for viral detection in UAW and LAW specimens was observed in 59 paired samples (82%), including 40 patients with no viral infections and 19 virus positive for both samples. Discordance was described in 13 subjects;10 of 13 did not show viral infection in nasal lavage. Twenty-one percent of positive nasal lavage was performed using Ryno-set and 36% using the Mainz approach. The prevalent bacteriumwas Staphylococcu aureus in UAW (53%) and LAW (69%) cultures, followed by Enterobacteriaceae (UAW 8%, LAW 6%), methicillin-resistant S. aureus (UAW 7%, LAW 6%), P. aeruginosa (UAW 4%, LAW 6%), and other clinically relevant gram-negative bacteria such as Achromobacter xylosoxidans, Stenotrophomonas maltophilia, and Ochrobactrum anthropi (UAW 7%, LAW 13%). Nasal lavage performed with Ryno-set tested positive in 72% of patients, and 64% of Mainz lavage were positive. Mainz nasal lavage showed different S. aureus and P. aeruginosa isolations (48% and 5%, respectively) than the samples collected with Ryno-set technique (61% and 4%, respectively). Concordance between sampling methods for bacterial detection in UAW and LAW was the same with the two methods (53%). Bacterial and viral infections were found in UAWand LAWof stable people with CF, but no clinical correlation was observed. Conclusion(s): The two methods of UAW lavage had slight differences in performance. Virus infection appeared to be less prevalent than bacterial infection in UAWand LAW.We did not find correlations between presence of viruses and respiratory symptoms, but further investigation is needed for a better understanding of the clinical role of viral infection in people with CF.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Value of Biofire Filmarray pneumonia panel in evaluating secondary infection in critically ill patients with Coronavirus disease 2019.

Objective To explore the application value of Biofire Filmarry pneumonia panel (PN) in detection of secondary and concomitant pathogen among critically ill patients with coronavirus disease 2019(COVID-19). Methods We consecutively included and analyzed the clinical data of critically ill patients with COVID-19 transferred to the ICU from February to April 2020 in the Sino-French Campus of Wuhan Tongji Hospital. Samples of Bronchoalveolar lavage fluid obtained by bedside bronchoscopy were sent for Biofire Filmarray PN and standard culture concomitantly. We compared the results of two methods and evaluated their concordance. Results In total, 21 critically ill patients with COVID-19 were included and 54 samples were tested, including 33 (61.1%) Biofire Filmarray PN tests (21 patients) and 21 (38.9%) standard cultures (14 patients), in which 19 pairs (38 samples) underwent both tests simultaneously. In Biofire Filmarray PN group, the turnaround time was about 1 hour. There were 74 positive results in 32 samples (97.0%) from 20 patients, including 29 cases(39.2%) of Acinetobacter baumannii complex, 21 cases (28.4%) of Pseudomonas aeruginosa, 16 cases (21.6%)of Klebsiella pneumoniae, 5 cases (6.8%) of Escherichia coli, 1 case (1.4%)each of Enterobacter cloacae, Haemophilus influenzae, and respiratory syncytial virus. In the standard culture group, the turnaround time was about 3 days. 19 positive results returned in 16 (76.2%) samples from 11 patients, including 8 cases (42.1%) of Pseudomonas aeruginosa, 6 cases (31.6%) of Acinetobacter baumannii, 4 cases (21.1%) of Stenotrophomonas malt and 1 case (5.3%) of Myxobacterium. Among the 19 pairs of "back-to-back" specimens, 15 pairs were concordant, and the agreement ratio was 78.9%. Conclusions Acinetobacter baumannii and Pseudomonas aeruginosa may be the common pathogens of secondary or concomitant infection in critically ill patients with COVID-19. Biofire Filmarray PN is a rapid diagnostic test and has application value in such patients;its sensitivity and accuracy require further investigation with larger sample sizes.Copyright © 2021, Peking Union Medical College Hospital. All rights reserved.

Clinical Features and Risk Factors for Mortality in Patients with Stenotrophomonas maltophilia Infection

Introduction: It is important to know the risk factors for death in reducing mortality in patients with Stenotrophomonas maltophilia infections. The purpose of this study was to examine the risk factors associated with mortality in hospitalized patients with S. maltophilia infections. Material(s) and Method(s): Patients with S. maltophilia infections aged 18 years and older who were hospitalized in Haseki Research and Training between January 1, 2017, and April 30, 2022, were included in the study. The patients were divided into two groups, non-survivors and survivors, and the clinical features and laboratory parameters of the groups were compared. Mortality risk factors were analyzed by logistic and Cox regression analyses. Result(s): A total of 75 patients with S. maltophilia infections were included. The mortality rate was 38.6% (n= 29). Advanced age (OR= 1.05, 95% CI= 1.012-1.085, p= 0.009), COVID-19 pneumonia (OR= 9.52, 95% CI= 1.255-72.223, p= 0.029), and presence of central venous catheter (CVC) (OR= 18.25, 95% CI= 2.187-152.323, p= 0.007) were risk factors for death. Conclusion(s): Physicians should be aware of the potential risk of S. maltophilia infections for mortality, particularly in patients with predefined risk factors such as advanced age, the presence of CVC, and COVID-19. Performing CVC care in accordance with infection prevention and control measures and timely removal of CVC may be beneficial in reducing deaths due to S. maltophilia infection.Copyright © 2023 Bilimsel Tip Yayinevi. All rights reserved.

Impact of COVID 19 on bacterial respiratory isolates (2018-2021) from a UK tertiary cardio-thoracic ICU

Aim: To study the impact of COVID-19 admissions during 1st and 2nd surges on bacteriology of ICU respiratory isolates. Method(s): Retrospective time trend analysis of bacterial respiratory isolates from a single centre, tertiary cardiothoracic ICU (CT-ICU) from patients admitted from Jan 2018- June 2021. We compared pre-COVID-19 (January 2018- March 2020) and COVID-19 periods (April 2020- June 2021) and surge periods (surge 1: March 2020- June 2020, surge 2: January- March 2021) to similar time frames in previous years. Chi-square test used to compare proportions. Result(s): 4974 respiratory isolates (Sputum-4230, BAL-563, ET secretions-181) included. During surge 2, culture positivity and gram-negative rates tripled from baseline (20% to 75%;p<0.05). Comparing the pre- pandemic to pandemic period, rates of Klebsiella sp, Acinetobacter sp and Stenotrophomonas sp increased from 12% to 21.3%, 2.4% to 6.2% and 10.5% to 14.3% respectively, while Pseudomonas sp dropped from 30.7% to 23.1% (all p<0.05). MDR Pseudomonas increased significantly from 38.9% to 47.9% (p<0.05), with a non-significant increase in MRSA (5.2% to 9.3%;p=0.34) and MDR enterobacterales (22.6% to 23%;p=0.48). Conclusion(s): This is the first report from a UK CTICU showing a marked epidemiological shift in the bacteriology of respiratory isolates in terms of organism profile, increase in culture positivity and MDR Pseudomonas rates during the pandemic. Analyzing trends on longevity of the findings will help guide changes to infection control and antibiotic policies. This emphasizes the importance of unit specific ecology in choosing appropriate timely antimicrobial therapy and therefore improving patient outcome.

Upraising Stenotrophomonas maltophilia in Critically Ill Patients: A New Enemy?

Stenotrophomonas maltophilia (S. maltophilia), an important pathogen in immuno-compromised patients, has recently gained attention in patients admitted in intensive care units (ICU). We sought to investigate clinical features of infections caused by S. maltophilia in ICU patients and identify risk factors for mortality. We conducted a retrospective study in two multivalent non-COVID-19 ICUs of tertiary-teaching hospitals in Greece and Spain, including patients with isolated S. maltophilia from at least one clinical specimen along with clinical signs of infection. A total of 103 patients (66% male) were analyzed. Median age was 65.5 (54-73.3) years and mean APACHE II and SOFA scores upon ICU admission were 18.36 (±7.22) and 18.17 (±6.95), respectively. Pneumonia was the predominant clinical syndrome (72.8%), while 22% of cases were among hemato/oncology patients. Crude 28-day mortality rate was 54.8%, even though, 14-day clinical and microbiological response was 96%. Age, APACHE II on ICU admission, hemato-oncologic disease, and multi-organ failure were initially identified as potential predictors of mortality. In the multivariable analysis, only increasing age and hemato-oncologic disease were shown to be independent risk factors for 28-day mortality. High all-cause mortality was observed in critically ill patients with predominantly respiratory infections by S. maltophilia, despite initial clinical and laboratory response after targeted treatment. The study elucidates a potentially worrisome emerging pathogen in the ICU.

Efficacy in Galleria mellonella Larvae and Application Potential Assessment of a New Bacteriophage BUCT700 Extensively Lyse Stenotrophomonas maltophilia.

In recent years, Stenotrophomonas maltophilia (S. maltophilia) has become an important pathogen of clinically acquired infections accompanied by high pathogenicity and high mortality. Moreover, infections caused by multidrug-resistant S. maltophilia have emerged as a serious challenge in clinical practice. Bacteriophages are considered a promising alternative for the treatment of S. maltophilia infections due to their unique antibacterial mechanism and superior bactericidal ability compared with traditional antibiotic agents. Here, we reported a new phage BUCT700 that has a double-stranded DNA genome of 43,214 bp with 70% GC content. A total of 55 ORFs and no virulence or antimicrobial resistance genes were annotated in the genome of phage BUCT700. Phage BUCT700 has a broad host range (28/43) and can lyse multiple ST types of clinical S. maltophilia (21/33). Furthermore, bacteriophage BUCT700 used the Type IV fimbrial biogenesis protein PilX as an adsorption receptor. In the stability test, phage BUCT700 showed excellent thermal stability (4 to 60°C) and pH tolerance (pH = 4 to 12). Moreover, phage BUCT700 was able to maintain a high titer during long-term storage. The adsorption curve and one-step growth curve showed that phage BUCT700 could rapidly adsorb to the surface of S. maltophilia and produce a significant number of phage virions. In vivo, BUCT700 significantly increased the survival rate of S. maltophilia-infected Galleria mellonella (G. mellonella) larvae from 0% to 100% within 72 h, especially in the prophylactic model. In conclusion, these findings indicate that phage BUCT700 has promising potential for clinical application either as a prophylactic or therapeutic agent. IMPORTANCE The risk of Stenotrophomonas maltophilia infections mediated by the medical devices is exacerbated with an increase in the number of ICU patients during the Corona Virus Disease 2019 (COVID-19) epidemic. Complications caused by S. maltophilia infections could complicate the state of an illness, greatly extending the length of hospitalization and increasing the financial burden. Phage therapy might be a potential and promising alternative for clinical treatment of multidrug-resistant bacterial infections. Here, we investigated the protective effects of phage BUCT700 as prophylactic and therapeutic agents in Galleria mellonella models of infection, respectively. This study demonstrates that phage therapy can provide protection in targeting S. maltophilia-related infection, especially as prophylaxis.

Analysis of biofilm formation in nosocomial Stenotrophomonas maltophilia isolates collected in Bulgaria: An 11-year study (2011-2022).

The present study aimed to explore the genotypic and phenotypic characteristics of biofilm formation in Bulgarian nosocomial Stenotrophomonas maltophilia isolates (n = 221) during the period 2011-2022, by screening for the presence of biofilm-associated genes (BAG) (spgM, rmlA and rpfF), their mutational variability, and assessment of the adherent growth on a polystyrene surface. The methodology included: PCR amplification, whole-genome sequencing (WGS) and crystal violet microtiter plate assay for biofilm quantification. The overall incidence of BAG was: spgM 98.6%, rmlA 86%, and rpfF 66.5%. The most prevalent genotype was spgM+/rmlA+/rpfF+ (56.1%), followed by spgM+/rmlA+/rpfF- (28.5%), and spgM+/rmlA-/rpfF+ (9.5%), with their significant predominance in lower respiratory tract isolates compared to those with other origin (P < 0.001). All strains examined were characterized as strong biofilm producers (OD550 from 0.224 ± 0.049 to 2.065 ± 0.023) with a single exception that showed a weak biofilm-forming ability (0.177 ± 0.024). No significant differences were observed in the biofilm formation according to the isolation source, as well as among COVID-19 and non-COVID-19 isolates (1.256 ± 0.028 vs. 1.348 ± 0.128, respectively). Also, no correlation was found between the biofilm amounts and the corresponding genotypes. WGS showed that the rmlA accumulated a larger number of variants (0.0086 per base) compared to the other BAG, suggesting no critical role of its product to the biofilm formation. Additionally, two of the isolates were found to harbour class 1 integrons (7-kb and 2.6-kb sized, respectively) containing sul1 in their 3' conservative ends, which confers sulfonamide resistance. To the best of our knowledge, this is the first study on S. maltophilia biofilm formation in Bulgaria, which also identifies novel sequence types (ST819, ST820 and ST826). It demonstrates the complex nature of this adaptive mechanism in the multifactorial pathogenesis of biofilm-associated infections.

Stenotrophomonas maltophilia Epidemiology, Resistance Characteristics, and Clinical Outcomes: Understanding of the Recent Three Years' Trends.

BACKGROUND: Stenotrophomonas maltophilia is an emerging pathogen classified as a public health concern, that infects critically ill patients and has expressed resistance against antimicrobial therapy. The aim of this study was to examine the epidemiological pattern, resistance characteristics and clinical outcomes of S. maltophilia infections in hospitalized patients. METHODS: The study included 393 S. maltophilia isolates from different clinical specimens as well as the clinical data of 209 Intensive Care Unit (ICU) patients. The patients' data were obtained from medical and laboratory files. Descriptive statistics and a univariate analysis were used to report and compare the demographics, clinical data, and outcomes. RESULTS: The S. maltophilia was mostly isolated from the respiratory specimens of ICU patients. The adult patients were more likely to develop serious infections and worse outcomes than were pediatric patients. The most common co-infecting pathogens were SARS-CoV2 and Pseudomonas aeruginosa. The death rate was 44.5% and increased to 47.1% in the case of a respiratory infection. Septic shock was the most significant predictor of mortality. Older age and mechanical ventilation were independent and significant risk factors that worsened the outcomes in patients with respiratory infections. CONCLUSIONS: The identification of S. maltophilia as a threat highlights the importance of surveillance studies in this region.

CEFIDEROCOL FOR TREATMENT OF PATIENTS WITH GRAM-NEGATIVE RESPIRATORY INFECTIONS: US HOSPITAL EXPERIENCE FROM JANUARY 2020 TO JUNE 2021

SESSION TITLE: Late Breaking Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Cefiderocol is a siderophore cephalosporin that has broad activity against Gram-negative (GN) pathogens including carbapenem resistant isolates through its unique mode of cell entry. This study describes the usage of cefiderocol in US hospitals, in patients with microbiology confirmed respiratory infections, during its first 1.5 years following commercial availability. METHODS: This was a retrospective study of patients with microbiology confirmed GN respiratory infections in US hospitals, treated with cefiderocol consecutively for ≥3 days between January 2020 to June 2021, as captured by the Premier Healthcare database. This study describes the clinical characteristics, microbiology profile, and 14-day and 28-day in-hospital all-cause mortality (IH-ACM) amongst patients treated with cefiderocol. Index culture was defined as the last culture sample(s) obtained before cefiderocol initiation, or the first culture obtained after cefiderocol initiation if no microbiology evaluation was performed prior to cefiderocol use. Index pathogen(s) were the pathogen(s) identified from the index culture(s). RESULTS: Among 113 hospitalized patients who received ≥3 days cefiderocol and had ≥1 positive respiratory culture for GN pathogens, median age was 61 years with interquartile range (IQR) of 48-72 years, 57% were male, and 93% were admitted via emergency room or urgent care. The most common comorbidities were renal disease (37%), diabetes (36%), congestive heart failure (35%), and chronic pulmonary disease (33%). Seventy-seven percent of patients received mechanical ventilation and 89% were treated in an intensive care unit. The most frequent index pathogens were Pseudomonas aeruginosa (56%), Stenotrophomonas maltophilia (24%), Klebsiella pneumoniae (13%), and Acinetobacter baumannii (11%). Also 28% of patients had more than one pathogen from index cultures and over 10% also had positive GN index cultures from other sites such as blood, urine or wound. Among 96 pathogens tested for carbapenems, 87% were resistant. Median time from hospital admission to cefiderocol initiation was 14 days (IQR: 5-25). Median cefiderocol duration was 8 days (IQR: 6-14). Before initiating cefiderocol, 88% of patients received other GN antibiotics. Median length of hospital stay was 28 days (IQR: 16-45). Crude 14-day and 28-day IH-ACM were 21.2% (95%CI: 13.7%-28.8%) and 27.4% (95%CI: 19.2-35.7%), respectively. IH-ACM was higher in COVID patients than non-COVID patient (53.1% vs. 8.6% for 14-day ACM and 65.6% vs. 12.3% for 28-day ACM, respectively). CONCLUSIONS: During the initial phase of availability, the most frequent use of cefiderocol was to treat critically ill patients with non-fermenter pathogen infections.IH-ACM appears to be affected by infection characteristics, especially COVID-19 status. CLINICAL IMPLICATIONS: Real-world data supports that Cefiderocol is effective in treating GN respiratory infections as shown in IH-ACM DISCLOSURES: Employee relationship with Shionogi Inc Please note: 2015 - present Added 06/02/2022 by Bin Cai, value=Salary No relevant relationships by Andrew Cooper Employee relationship with Shionogi, Inc Please note: 3 years Added 06/03/2022 by Stephen Marcella, value=Salary No relevant relationships by Yun Zhou

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel

EFFECT OF HIGH- VS LOW-DOSE OF DEXAMETHASONE ON INCIDENCE OF HOSPITAL-ACQUIRED INFECTIONS IN ACUTE HYPOXEMIC RESPIRATORY FAILURE IN SARS COV-2 PNEUMONIA

SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: To compare the incidence of hospital acquired infections (HAI) in patients treated with systemic corticosteroids (dexamethasone or equivalent alternative corticosteroid) with high (> 10 mg/day) vs low (6 mg/day) dose for COVID-19 related acute hypoxemic failure METHODS: Observational cohort study of COVID-19 patients from July 25 and Oct 1, 2021 at a tertiary care hospital. 227 hospitalized patients were positive for COVID-19. 168 patients were included in the analysis. Corticosteroid type and dose was analyzed. Comparison of high vs low dose cohorts was done. Primary outcome measure was incidence of HAI in each group. Bloodstream Infections (BSI), Hospital Acquired Pneumonia (HAP) and Urinary Tract Infections (UTI) were included. Secondary measures were number of patients requiring intubation, length of ICU stay and inpatient mortality. Descriptive statistics were used to compare variables between cohorts including body mass index (BMI), severity of illness (SOFA and modified SOFA scores) and glucose control RESULTS: Of 168 patients: 68 (40%) received high dose (> 10 mg dexamethasone) & 100 patients (60%) received low dose (6 mg dexamethasone) corticosteroids. High vs Low dose: Demographics: Age (57 vs. 64 years;p 0.21), sex (51% vs. 57% female;p 0.77) & chronic comorbidities including BMI (29.2 vs 33.1;p 0.45). Severity of illness scores at day of corticosteroid use were similar (SOFA 4.7 vs 4.1;p 0.71 & mSOFA 2.6 vs 2.3;p 0.07) despite difference in rates of patients that required intubation (56% vs 18%;p<0.001). 45% of intubated died in high dose compared to 18% in low dose group. Overall mortality was 29.4% vs 11%;p 0.011. Glucose control (insulin > 50 u/day) was worse in high dose group (35% vs 14%;p<0.01). Baricitinib or tocilizumab used in 60% vs 44% of intubated;p0.62). HAI data: BSI- High dose 18/68 (26.5 %) vs low dose group 13/10 (13%);p 0.07. UTI-High dose 4/68 (6%) vs low dose group 5/100 (5%);p 1.00. HAP-High dose 27/68 (39.7%) vs low dose group 11/100 (11%);p <0.001. High dose group HAP > 1 organism: 15/27 (MSSA 44%, Aspergillus 18%, MRSA 18%, Streptococcus 26%, Pseudomonas 18%, rest were Enterobacter, H Influenzae, Acinetobacter, Serratia, E coli, Klebsiella, Providencia and Citrobacter species at 3% each). Low dose group HAP > 1 organism: 2/11 (Streptococcus 36%, MSSA 27%, H Influenzae 18%, rest were pseudomonas, E coli, stenotrophomonas and acinetobacter species) CONCLUSIONS: In hospitalized COVID-19 patients with acute respiratory failure, high dose dexamethasone use was associated with significantly higher HAP rates compared to low dose dexamethasone. Moreover the high dose group had higher BSI, worse glucose control, higher intubations and deaths in the intubated cohort despite similar severity of illness in either group CLINICAL IMPLICATIONS: High dose dexamethasone may increase susceptibility to HAIs and negatively impact outcomes in COVID-19 associated hypoxemic failure DISCLOSURES: No relevant relationships by Beenish Bhutta No relevant relationships by Rosalyn Chi No relevant relationships by Jason Graf No relevant relationships by mohsin iqbal No relevant relationships by Rajat Kapoor No relevant relationships by Rachel Kruer No relevant relationships by Connor Parker No relevant relationships by Omar Rahman No relevant relationships by James Skinner

CLINICAL IMPACT OF COMMUNITY ACQUIRED RESPIRATORY VIRUSES IN PATIENTS WITH SOLID ORGAN TRANSPLANTS

SESSION TITLE: Not the Normal Host: Infections Still Matter SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Community Acquired Respiratory Viruses (CARVs) are associated with poor outcome in Solid Organ Transplant (SOT) recipients. We reviewed some of these outcomes such as respiratory support, length of stay (LOS), ICU admission, steroid use & 30-day all-cause mortality. METHODS: Multihospital, single center, retrospective review of electronic health records from 01/01/2014-12/31/2019. RESULTS: 23 SOT recipients (M=20, F=3) who tested positive for CARVs were identified. SOT distribution was heart=2, kidney=4, liver=3, lung=11, heart-lung=1, lung-kidney=1 & heart-kidney=1. Mean age at admission was 60 years, average LOS was 8 days with 2 pts needing >2 weeks. 6 pts required intensive care unit;8 pts required supplemental oxygen support. 16 pts had infiltrates on chest imaging. 15 pts had a 90-day readmission with respiratory complaints. 8 pts had bronchoscopy & 20 had positive nasal swab. 3 pts had a negative nasal swab but positive Bronchoalveolar lavage (BAL) for CARV while 2 pts had negative BAL but positive nasal swab. CARV distribution was Rhinovirus 48%, Parainfluenza 29%, Metapneumovirus 12%, Respiratory syncytial virus 0.03%, Adenovirus 0.03% & Non-novel Coronavirus 0.06%. 5 pts had bacterial coinfection (Pseudomonas aeruginosa, Corynebacterium striatum & Stenotrophomonas maltophilia). All pts were immunosuppressed, intravenous immunoglobulins (IVIG) were used in 3 pts, antivirals in 7 pts (ribavirin in 6 & oseltamivir in 1) & steroids in 10 pts. 12 pts had transplant organ biopsy with 5 showing acute cellular rejection. 11 pts had underlying Coronary artery disease and 17 pts had hematologic disorders (Post-transplant lymphoproliferative disorder, leukemia, Myelodysplastic syndrome, & multiple myeloma). 35% pts died within 1 year (2 during same admit). Cause of death was refractory septic shock (1), respiratory failure (3), cardiac arrest (3) & chronic lung allograft dysfunction (CLAD) (1). CONCLUSIONS: In this cohort, we assessed the SOT recipients positive for CARVs who required admission & evaluated the impact on their clinical course. This analysis noted a significant rate of acute & chronic rejections, bronchiolitis obliterans and CLAD in these patients. Newer tests like multiplex NAT & (semi) quantitative NAT (QNAT) can diagnose CARVs in addition to Human Influenza Virus. Patients can present with wheezing, croup, bronchiolitis, pneumonitis & pneumonia. Impact of CARVs seems to vary by the type of organ transplant, level of neutropenia/lymphopenia, upper versus lower respiratory infection and intrinsic pathogenicity of virus. Various preventive & therapeutic measures were employed in an attempt to improve outcomes in these patients. CLINICAL IMPLICATIONS: Transplant receipients are at a high risk of infections especially CARVs which may increase morbidity and mortality. This analysis emphasizes the value of timely diagnosis and treatment in this specific patient population who are immunocompromised. DISCLOSURES: No relevant relationships by Supriya Singh

ANTIBIOTIC RESISTANCE PATTERNS IN INFECTIONS ASSOCIATED WITH HEALTH CARE IN A THIRD LEVEL CENTER WITH HOSPITAL RECONVERSION IN THE COVID-19 PANDEMIC

Objetive: Description of the different isolated microorganisms and their prevalence in infections associated with health care, in addition to determining their patterns of resistance to antibiotics in patients admitted with a confirmed or suspected diagnosis of COVID-19 in the Intensive Care Unit, during a third-level medical center with hospital reconversion. Method: Patient demographic data was obtained from the clinical record, with defined criteria. Antibiotic resistance patterns were evaluated as well as the identification of isolated bacteria in cultures of expectoration, pleural fluid, catheter tips. For bacterial identification and resistance mechanisms, automated equipment and phenotypic tests were used, following the CLSI (Clinical & Laboratory Standards Institute) criteria. Results: A total of 100 patients with bacterial infection added to the main COVID-19 picture were obtained, representing pneumonia, urinary tract infection, catheter infections and bacteremia. A total of 100 strains were isolated, of which 84 are Extremely Drug Resistant, 12 Multidrug Resistant and only 4 variable sensitivity. The bacteria with the highest prevalence is Staphylococcus aureus with, followed by Pseudonomas aeruginosa and Stenotrophomonas maltophilia. 100% of the patients admitted to the ICU (Intensive Care Unit) had death. Conclusion: The increase in resistance to antibiotics in the COVID-19 pandemic has set off alarms due to the complication that this brings, and the improper use of drugs as prophylaxis or attempted treatment only generates selective pressure that leads to an increase in resistance as observed in the isolated strains in this study, where the vast majority present enzymes as well as other resistance mechanisms that confer them to be XDR (Extremely Drug Resistant).

Epidemiologic and clinical characteristics of human bocavirus infection in children hospitalized for acute respiratory tract infection in Qingdao, China.

Persistent infection and prolonged shedding of human bocavirus 1 (HBoV1) in children have been reported, and the role of HBoV1 as a sole causative pathogen in acute respiratory infection (ARI) is yet to be established. While the reported prevalence of HBoV infection varies due to different detection methods and sampling criteria, determining the viral and bacterial etiology of HBoV infection using multiplex real-time PCR is yet to be reported. Herein, we aimed to further explore the pathogenicity of HBoV in patients with ARI by screening the viral and bacterial infections in children with ARI in Qingdao and comparing the epidemiological, clinical characteristics, and etiological results. Human bocavirus was identified in 28.1% of the samples, and further sequencing analysis of the detected HBoV confirmed 96.4% as HBoV1. The rate of HBoV as a single viral infection was 75%, and the rate of coinfection with bacteria was 66.1%, suggesting the need for continued monitoring of HBoV in children with ARIs. Clinical characterization suggested that HBoV infection may affect the function of organs, such as the liver, kidney, and heart, and the blood acid-base balance. Additionally, it is essential to promote awareness about the importance of disinfection and sterilization of the hospital environment and standardizing operations. The interactions between HBoV and other pathogens remain to be investigated in further detail in the future.

Characteristics and influencing factors for Stenotrophomonas maltophilia infection in a tertiary general hospital of Sanya city and drug resistance from 2016 to 2020

OBJECTIVE: To investigate the characteristics and influencing factors for Stenotrophomonas maltophilia (SMA) infection in Sanya and analyze the drug resistance so as to provide guidance for prevention and control of infection in medical institutions. METHODS: The hospitalization data were collected from the patients with SMA infection who were hospitalized in three tertiary general hospitals of Sanya from 2016 to 2020. The characteristics of SMA infection and influencing factors for respiratory tract and non-respiratory tract SMA infection were retrospectively analyzed, and the result of drug susceptibility testing was observed. RESULTS: A total of 753 case times of patients had SMA infection, including 606 (80.48%) case times of respiratory tract infection and 147 (19.52%) case times of non-respiratory tract infection. The isolation rate was the highest in respiratory medicine department (16.73%), followed by critical care medicine department (15.67%) and neurosurgery department (12.35%). The percentages of the patients with advanced age, complications with hypertension and pulmonary diseases, tracheotomy were the higher in the respiratory tract infection group than in the non-respiratory tract infection group (P < 0.05);while the percentages of the patients with malignant tumors, bacteremia, surgery, urinary tract intubation, low immunity and use of antibiotics and immunosuppressants were the higher in the non-respiratory tract infection group than in the respiratory tract infection group (P < 0.05). The result of drug susceptibility testing showed that the drug resistance rate of the SMA strains to sulfamethoxazole-trimethoprim was only 2.39%, while the drug resistance rate to ceftazidime was as high as 74.50%. CONCLUSION: The major influencing factors for the respiratory tract SMA infection include pulmonary diseases, hypertension, advanced age and tracheotomy;the influencing factors for the non-respiratory tract SMA infection include malignant tumors, low immunity, long-term excessive use of immunosuppressants and broad-spectrum antibiotics, bacteremia, surgery and urinary tract intubation. The SMA strains isolated from the city are highly sensitive to sulfamethoxazole-trimethoprim but are highly resistant to ceftazidime and chloramphenicol. It is necessary for the hospital to reasonably use antibiotics based on the result of drug susceptibility testing.

Challenges Faced by an ECMO Patient

Aim and objective: To elaborate the challenges faced by an ECMO patient and the issues to be overcome and how to address them and combat with the help of a multidisciplinary team. This is a case of a 34-year-old male patient without any comorbidities who tested positive for COVID on 08/07/21 who was on home quarantine for 8 days and reported to hospital on 16/07 in view of breathlessness, was started on oxygen, bipap and tried on remdesivir, steroids, and tocilizumab and baricitinib. The patient was not maintaining saturations and was intubated on 26/07 and as there was refractory hypoxaemia was initiated on ECMO on the next day. The patient was started on ceftazidime and levoflox along with voriconazole as serum galactomannan was positive and ET cultures showed Stenotrophomonas maltophilia. The patient was tracheostomized on 01/08 and was keeping well till 12/08 when there were episodes of desaturation and tachypnoea and blood culture showed Candida auris and BAL culture showed Chryseobacterium and MDR Klebsiella with NDM, OXA-48 AND VIM+. The patient developed septic shock and required dual vasopressors. BAL galactomannan had titres of 4.5 and the patient was initiated on a mixture of ceftazidime, avibactum, voriconazole, and anidulafungin. The patient started having hemoglobinuria subsequently and acute kidney injury secondary to this and required 3 sessions of dialysis and the whole ECMO circuit was changed. Improvement in the parameters followed with normalization of blood pressure and urine output too. When there was a sigh of relief as things were getting normal patient started having heavy bouts of tracheal bleeding and bronchoscopy was done again with endobronchial biopsy showing CMV endobronchitis with focal ulceration and was started on ganciclovir. There were maleana episodes too which normalized after initiation of antivirals and CMV enterocolitis was suspected to be the cause. Now the patient is on trial off mode with decannulation being planned.

Rare Form of Congenital Cystic Bronchiectasis in a Filipino Adult

Background: Tuberculosis remains to be the most common lung infection in the Philippines. Compliance to medication leads to significant improvement. A portion of the population however remains untreated leading to complication such as bronchiectasis. In the approach to treatment, etiologies such as a possible genetic abnormality must be considered aside from a post inciting event. Case: This is a case of D.A. 20 year old, female who came in due to difficulty of breathing. She grew up having recurrent upper and lower respiratory tract infection. She was previously treated with pulmonary tuberculosis for 6 months last 2011. She was initially admitted at the COVID wards during the surge because any patient with pulmonary complains with bilateral infiltrates will be tagged as COVID suspect until a negative RT PCR result becomes available. She was admitted with complains of difficulty of breathing with desaturation. Her body mass index is 12.8 which is underweight. Pertinent physical examination shows bilateral coarse crackles with clubbing which suggest a chronic disease. Complete work up was done. Echocardiography which revealed an ejection fraction of 74%, severe pulmonary hypertension with dilated right atrium and right ventricle. Chest radiography revealed bronchiectatic changes with infiltrates while a confirmatory chest computed tomography scan revealed post infection pulmonary fibrosis with cystic bronchiectasis both lung fields. Spirometry revealed a severe obstructive ventilatory defect with no response to bronchodilator and a probable restrictive ventilatory defect which explains why the patient had higher frequency of admissions. Paranasal sinus xray to rule out Kartagener's syndrome was done which revealed normal results. Microbiologic studies such as sputum TB culture and sputum gene xpert was negative. The sputum culture revealed Stenotrophomonas maltophilia which was treated with intravenous antibiotics. To rule out other possible differentials for the cystic bronchiectasis, karyotyping was facilitated which revealed a normal female karyotype (46 XX). She was managed as a case of cor pulmonale, post tuberculous bronchiectasis, bacterial pneumonia, with considerations of mucociliary defects such as cystic fibrosis. It was unfortunate that a sweat chloride test was not done as it was not available in the country. Conclusion: In a country with endemic infectious pulmonary diseases such as tuberculosis, there is an anticipated sequelae of post infection bronchiectasis and fibrosis. Even if resources are scare and diagnostic tests are limited, repeated lung infection in a young patient warrants further investigation as congenital causes of structural lung diseases may initially present as an infectious process. (Figure Presented).

Palatal Infection by Multidrug Resistant Non Fermenting Gram Negative Bacilli in a COVID-19 Positive Patient Mimicking Black Fungus Infection- A Case Report

As the second wave of Coronavirus Disease 2019 (COVID-19) swept through India, many patients developed serious bacterial secondary infections such as pneumonia, sepsis and fungal infections such as mucormycosis. Among the bacterial infections, the most common organisms associated with secondary bacterial infections were Pseudomonas aeruginosa, Acinetobacter baumannil and Stenotrophomonas maltophilia. Here, authors present a rare case of 31-year-old COVID-19 positive male patient with sepsis who developed palatal necrosis due to infection caused by a non fermenting Gram negative bacillus resembling the lesions seen in mucormycosis. The necrotic tissue, bronchoalveolar lavage fluid and blood samples were sent for culture. Blood cultures yielded Elizabethkingella meningosepticum and necrotic tissue yielded Stenotrophomonas maltophilia.