A Descriptive Review of Relationship of Urinary Tract Infections with Healthcare-Associated and Community-Onset Bloodstream Infections

Background: Bloodstream Infections (BSIs) that arise secondary to urinary tract infections (UTIs) are frequently encountered in both community and hospital settings and are associated with significant morbidity, mortality, high healthcare costs and prolonged hospital stays Objective: This descriptive review aims to evaluate available information on the relationship of urinary tract infections with healthcare-associated and community-onset bloodstream infections to get a deeper understanding of improved public health interventions and suggest possibilities for future research. Material andMethods: A literature search was conducted using PubMed and Embase. Articles published during the last 10 years (2010 and 2020) were imported into covidence for the initial title and screening. All study s were reviewed by two independent reviewers and were eligible for full-text review if they mentioned urinary tract infection as a source of bloodstream infection. The data obtained were analyzed in Microsoft Excel. Result(s): Out of 65 articles reviewed for full text, 10 studies were selected. In total 6763 BSI cases were reported. We observed 2075 (30.6%) community-acquired (CA) BSIs compared to 1102 (16.2%) healthcare-associated (HCA) BSIs, and 1484 (21.9%) hospital-acquired (HA) BSIs. UTI was a major source of BSIs in community settings followed by HCA BSIs in most studies. Escherichia. coli was the most common pathogen isolated in patients with CA-BSIs. Hospital Acquired and HCA bacterial infections have the most antimicrobial resistance, compared to CA-infections. Conclusion(s): Urinary tract Infections are a major source of developing secondary BSIs. Escherichia. coli is a major pathogen in CA-BSIs. Multidrug-resistant organisms accounted for most of the BSIs, especially in hospital settings and among patients receiving health care.Copyright © 2023, Khyber Medical College. All rights reserved.

Impacts and outcomes of COVID-19 infection in medical oncology patients in a Western Australian tertiary centre

Aim: Assessing impacts of Covid-19 infection in Medical Oncology patients in a highly vaccinated population at a Western Australian hospital post opening of state borders. Method(s): Patients with Covid-19 RAT positivity were prospectively identified between March and May 2022 by treating clinicians. Electronic case notes and pathology records were reviewed for data collection. Outcomes assessed included treatment delays and mortality. Result(s): Thirty-six patientswere identified with solid organ malignancy and RAT positive Covid-19 infection of whom 64% (23) were female. The median age was 57.5 years. 81% (29) had metastatic disease and the most predominant subtype was breast cancer (42%). 81% (29) were on active therapy with 55% on chemotherapy (31% chemotherapy alone). 78% of the patients had received at least two doses of Covid-19 vaccination, with 53% having had at least one booster. 8% were unvaccinated. 78% were community acquired infections versus 22% acquired during a hospital admission. 67% (24) patients were symptomatic at detection, with symptom severity ranging from mild to moderate, with 8% patients needing oxygen for desaturation. 64% were managed as outpatients. A total of 58% received antiviral therapy (14% IV Remdesevir and 86% oral with Molnupiravir (44%) and Paxlovid (50%)) of which 90% completed their course. 90% of those receiving antivirals were on active therapy. Treatment delays were observed in 83% (24/29) of patients with a median delay of 2 weeks. Two deaths were partially attributed to Covid-19 infection in inpatients with disease progression and concurrent bacterial sepsis. Both these patients were double vaccinated and on chemotherapy. No deaths were solely attributed to Covid-19. Conclusion(s): The overall outcomes in this population of WA Oncology patients from Covid-19 infection remained favourable with low mortality despite symptomatic infection requiring antiviral therapy and treatment delays.

A CASE OF SARS-COV-2 ASSOCIATED WITH QUADRUPLE BACTERIAL COINFECTION

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: SARS-CoV-2 has been associated with co-infecting pathogens, such as bacteria, viruses, and fungi. Little has been reported about community acquired atypical bacterial co-infections with SARS-CoV-2. We present a case of a patient with recent COVID-19 pneumonia and diagnosis of Legionella and Mycoplasma pneumonia, in addition of E. coli and C. perfringens bacteremia, that emphasizes SARS-CoV-2 impact in human immunity and the need to consider community acquired infections. CASE PRESENTATION: A 64-year-old male with history of hypertension, alcohol use disorder, iron deficiency anemia, and recent COVID-19 pneumonia presented to the ED with shortness of breath, dark urine, and increased confusion. The patient was admitted to the hospital a week prior with COVID-19 pneumonia and acute kidney injury. He received dexamethasone, remdesivir, and IV fluids. After 8 days, he was discharged home. Upon evaluation, he was afebrile and normotensive, but tachycardic, 129/min, on 4 L of nasal cannula sating 100%. On exam, the patient was oriented only to person and had decreased breath sounds bilaterally. Labs revealed an elevated WBC, 15.3 K/mcL, with left shift, low Hgb, 7.8 g/dL, with low MCV, 61 fL, increased BUN/Cr, 56 mg/dL and 2.8 mg/dL, and an abnormal hepatic panel, AST 121 U/L, ALT 45 U/L, alkaline phosphatase 153 U/L. Ammonia, GGT, CPK and lactic acid were within normal range;but the D-dimer and procalcitonin were elevated, 4618 ng/mL and 25.12 ng/mL, respectively. A urinalysis showed gross pyuria, positive leukocyte esterase and mild proteinuria. CT head showed no acute abnormalities, but the chest X-Ray revealed a hazy opacity in the left mid and lower lung, followed by a CT chest that demonstrated peripheral and lower lobe ground glass opacities and a CT abdomen that showed right sided perinephric and periureteral stranding. Given increased risk for thromboembolism, a VQ scan was done being negative for pulmonary embolism. The patient was admitted with acute metabolic encephalopathy, acute kidney injury, transaminitis, pyelonephritis and concern for hospital acquired pneumonia. Vancomycin, cefepime and metronidazole were ordered. HIV screen was negative. COVID-19 PCR, Legionella urine antigen and Mycoplasma IgG and IgM serologies were positive. Blood cultures grew E. coli and C. perfringens. Infectious Disease and Gastroenterology were consulted. The patient was started on azithromycin and a colonoscopy was done showing only diverticulosis. After an extended hospital course, the patient was cleared for discharge, without oxygen needs, to a nursing home with appropriate follow up. DISCUSSION: Co-infection with bacteria causing atypical pneumonia and bacteremia should be considered in patients with recent or current SARS-CoV-2. CONCLUSIONS: Prompt identification of co-existing pathogens can promote a safe and evidence-based approach to the treatment of patients with SARS-CoV-2. Reference #1: Alhuofie S. (2021). An Elderly COVID-19 Patient with Community-Acquired Legionella and Mycoplasma Coinfections: A Rare Case Report. Healthcare (Basel, Switzerland), 9(11), 1598. https://doi.org/10.3390/healthcare9111598 Reference #2: Hoque, M. N., Akter, S., Mishu, I. D., Islam, M. R., Rahman, M. S., Akhter, M., Islam, I., Hasan, M. M., Rahaman, M. M., Sultana, M., Islam, T., & Hossain, M. A. (2021). Microbial co-infections in COVID-19: Associated microbiota and underlying mechanisms of pathogenesis. Microbial pathogenesis, 156, 104941. https://doi.org/10.1016/j.micpath.2021.104941 Reference #3: Zhu, X., Ge, Y., Wu, T., Zhao, K., Chen, Y., Wu, B., Zhu, F., Zhu, B., & Cui, L. (2020). Co-infection with respiratory pathogens among COVID-2019 cases. Virus research, 285, 198005. https://doi.org/10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Albert Chang No relevant relationships by Eric Chang No relevant relationships by KOMAL KAUR No relevant relationships by Katiria Pintor Jime ez

Trends in intravenous antibiotic prescriptions pre- and postintroduction of Kaftrio® in a large UK adult cystic fibrosis centre

Background: Since the introduction of Kaftrio® in 2020, people with CF (pwCF) have reported significant health improvements. Real-world experiences over the last 2 years suggest that pwCF are using fewer antibiotics. Evidence has confirmed this is the case with nebulised antibiotics, however it is unclear what the impact has been on intravenous antibiotics (IVABx). Objective: To investigate IVABx use in pwCF, in our centre, pre and post Kaftrio® commencement. Method: Retrospective data was collected from our internal pharmacy database on number of IVABx dose units issued pre and post the widespread use of Kaftrio®. Results: Since Jan 2020, 282 pwCF, 81% of our cohort, have commenced on Kaftrio®;initially via clinical trials and compassionate use programmes, then more widely from August 2020 following its UK licence. (Table Presented) Pharmacy data shows overall IVABx prescriptions have reduced consistently since 2019 with a trend towards less inpatient therapy. Conclusion: Data suggests that the use of IVABx has reduced in our centre since the introduction of Kaftrio®. Other factors which may have influenced IVABx usage during this period include the COVID-19 pandemic, which led to pwCF “shielding” for several months during 2020, providing protection from community acquired infections and potentially increasing anxiety levels around seeking in-patient healthcare. CFHealthHub has also been vital during this time, supporting pwCF to increase their adherence to longterm nebulised treatments. Further work is needed to investigate the trends of antibiotic usage (nebulised and IV) beyond the pandemic and the effect on the long-term health outcomes of pwCF.

Impact of COVID-19 on the disease course in cystic fibrosis? A Registry-based study

Objectives: The COVID-19 pandemic led to global precautionary actions. This may have positively affected disease course in CF in 2020 compared to previous years. Methods: This retrospective cross-sectional study uses Belgian CF Registry data. Disease course outcomes were defined by FEV1, BMI, need for antibiotics (AB), number of visits to CF centre and respiratory cultures. Nonlung transplanted patients, followed since 2018, were eligible. Cumulative difference was tested byWilcoxon Rank Sum Test while paired differences by T-test or Signed Rank Test. Bonferroni correction was applied for multiple testing. Outcomes were compared between 2018 and 2019, 2018– 2020, 2019–2020. Results: 1,260 patients were enrolled (56.5% adults). Change in weight zscore improved significantly: [mean(SD;p-value)] 2018–2020: 0.12 (0.54;p = 0.0002);2019–2020: 0.11 (0.46;p < 0.0001). Change in BMI improved overall: 2018–2020: 0.42 (1.58;p < 0.0001);2019–2020: 0.28 (1.22;p < 0.0001);2018–2019: 0.13 (1.25;p = 0.0036). No difference in FEV1 was found. Lower proportion of IV AB in hospital was seen: 2018–2020: 34.9%(n = 400) vs. 27.7%(n = 324) p = 0.0002;2019–2020: 33.0%(n = 289) vs. 27.7%(n = 324) p = 0.0052. Fewer days of IVABwere found: 2018–2020: 10.5 (18.5) [mean(SD)] vs. 8.5 (16.5) p = 0.0008;2019–2020: 11.2 (27.8) vs. 8.5 (16.5) p = 0.0066. In 2020 fewer patients had ≥4 sputum samples: 2018– 2020: 81.9% (n = 911) vs. 73.5% (n = 840) p < 0.0001;2019–2020: 84.6% (n = 957) vs. 73.5% (n = 840) p < 0.0001. No difference in hospital visits was seen. H.Influenzae isolation was statistically reduced: 2018–2020: 23.8% (n = 272) vs.16.1% (n = 188) p < 0.0001;2019–2020: 23.7% (n = 279) vs.16.1% (n = 188) p < 0.0001. Conclusion: Fewer infections were reported in 2020 compared to previous years with less need for IVAB and fewer hospitalisation days. A decrease in H influenzae suggests less community acquired infections. Improvement in BMI and weight may be due to fewer infections. Reduced amount of sputum samples may reflect local hospital hygiene measures

Secondary Infections among COVID-19 Hospitalised Patients and their Antimicrobial Susceptibility Pattern: A Cross-sectional Study in a Tertiary Care Hospital

Introduction: The novel coronavirus (2019-nCoV) is a contagious virus that causes respiratory infection and has shown evidence of human-to-human transmission. In this infection the immunity of the patient is decreased;making them susceptible to various secondary infections. This leads to increased morbidity and mortality in these patients. Aim: To estimate the profile of secondary infections in hospitalised Coronavirus Disease-2019 (COVID-19) patients and analyse their antimicrobial susceptibility pattern. Materials and Methods: A cross-sectional study was conducted for a period of five months from June to October 2021, which included COVID-19 positive patients with secondary infection admitted in the dedicated COVID hospital, Maharaja Krishna Chandra Gajapati Medical College and Hospital (MKCG MCH), Berhampur, Odisha, India. Clinical samples like blood, urine, sputum, tissue biopsy and Bronchoalveolar Lavage (BAL) were collected aseptically from patients with COVID-19 and were processed in microbiology laboratory as per standard operating procedures. All the necessary information like demographic features (age, gender), associated co-morbidities and oxygen saturation levels of COVID-19 positive patients at the time of admission were collected and entered in a Microsoft Excel sheet for further analysis. Results of continuous variables were described by mean and range while categorical variables were described by frequency. All the generated data was analysed by Statistical Package for the Social Sciences (SPSS) 16.0. Results: A total of 438 patients suspected of COVID-19 were admitted during the study period, out of which 138 patients were positive for COVID-19 by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Out of 138 COVID-19 positive patients, 105 patients were willing to give samples and their samples were processed for bacterial and fungal culture and sensitivity. Total 18/105 (17.1%) samples were positive for bacterial and fungal growth. Blood Stream Infection (BSI) were seen in 14/18 (77.8%) and was predominantly associated with Staphylococcus aureus 5/14 (35.7%), followed by Enterococcus spp. 3/14 (21.4%). Out of total culture positive cases, 2/18 (11.1%) showed Urinary Tract Infection (UTI). Of the UTI cases Escherichia coli was isolated from 1/2 (50%) of cases. Out of total culture positive cases, 2/18 (11.1%) were identified having mucormycosis. All gram positive bacteria had shown maximum resistant to ampicillin and gram negative bacteria were resistant to ampicillin-sulbactam, levofloxacin, cotrimoxazole. Conclusion: In COVID-19 positive patients with secondary infection, early diagnosis and prompt treatment will lead to improved patient care and better outcome.

COVID-19 HYPERINFLAMMATION CAN BE PREDICTED USING ROUTINE CLINICAL LABORATORY MARKERS

Background/Aims Since early in the COVID-19 pandemic, there has been interest in the concept that some morbidity and mortality may be due to excessive inflammation. Several definitions of COVID-19 hyperinflammation COV-HI) have been proposed, including Manson criteria (C-reactive protein, CRP ≥150mg/L or doubling above 50mg/L in 24 hours and/or ferritin 1500ug/L);and Webb criteria (includes CRP ≥150mg/L or ferritin ≥750ug/L). A consistent finding has been worse outcomes. Little is known regarding the underlying pathologies separating these patients from others. Aim To investigate whether machine learning using standard laboratory features can identify a distinguishing 'COV-HI signature'. Methods A database of daily clinical and laboratory features was collected from 611 patients admitted to hospital with confirmed COVID-19 during the first wave of community-acquired infection at University College London Hospitals, Sheffield Teaching Hospitals, Newcastle upon Tyne Hospitals and Royal Wolverhampton. All data prior to mechanical ventilation were interrogated. Patients were categorised as COV-HI based on Webb thresholds (CRP >150 mg/L or ferritin ≥750ug/L). Laboratory features (peak or nadir depending on recognised predictors of illness severity) included: minimum lymphocyte count 10

Bacterial and Fungal Co-Infections and Superinfections in a Cohort of COVID-19 Patients: Real-Life Data from an Italian Third Level Hospital.

The use of immune suppressive drugs combined with the natural immune suppression caused by SARS-CoV-2 can lead to a surge of secondary bacterial and fungal infections. The aim of this study was to estimate the incidence of superinfections in hospitalized subjects with COVID-19. We carried out an observational retrospective single center cohort study. We enrolled patients admitted at the "Garibaldi" hospital for ≥72 h, with a confirmed diagnosis of COVID-19. All patients were routinely investigated for bacterial, viral, and fungal pathogens. A total of 589 adults with COVID-19 were included. A total of 88 infections were documented in different sites among 74 patients (12.6%). As for the etiology, 84 isolates were bacterial (95.5%), while only 4 were fungal (4.5%). A total of 51 episodes of hospital-acquired infections (HAI) were found in 43 patients, with a bacterial etiology in 47 cases (92.2%). Community-acquired infections (CAIs) are more frequently caused by Streptococcus pneumoniae, while HAIs are mostly associated with Pseudomonas aeruginosa. A high rate of CAIs and HAIs due to the use of high-dose corticosteroids and long hospital stays can be suspected. COVID-19 patients should be routinely evaluated for infection and colonization. More data about antimicrobial resistance and its correlation with antibiotic misuse in COVID-19 patients are required.

Incidence of Community and Hospital Acquired Infections in Critically Ill COVID-19 Patients in the Dominican Republic

Background. The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. COVID-19 causes lower respiratory tract infection (LRTI) and hypoxia. There is a paucity of data on bacterial and fungal coinfection rates in patients with COVID-19 at low and middle income countries (LMICs). Our objective is to describe the clinical characteristics of critically ill patients with COVID-19 in the Dominican Republic (DR) Methods. We performed a retrospective review of patients admitted to the ICU with COVID-19 from March 14th to December 31st 2020, at a 296-bed tertiary care level and teaching Hospital in the Dominican Republic. Demographic and clinical information was collected and tabulated. Laboratory confirmed bacterial and fungal infections were defined as community acquired infections (CAI) if diagnosed within 48 hours of admission and hospital acquired infections (HAI) when beyond 48 hours. Microbiologic data was tabulated by source and attribution. Results. Our cohort had 382 COVID-19 patients. Median age was 64 and most were male (64.3%) and 119 (31.1%) were mechanically ventilated and 200 (52%) had central venous catheters. A total of 28 (7%) laboratory confirmed community acquired infections and 55 (14%) HAIs occurred. Community acquired infections included 13 (46%) bloodstream infections (BSIs), 11 (39%) urinary tract infections (UTI) and 6 (21%) LRTIs. HAIs included 39 (70%) BSIs, 11 (20%) UTIs and 6 (11%) ventilator associated pneumonias (VAP). Causal organisms of community and hospital acquired BSI and UTI are in Figure 1 and Figure 2 respecively. All-cause mortality was 35.3% (135/382) in our cohort, and 100% mortality (76) in those with coinfections. Conclusion. Community and hospital acquired infections were common and in the ICU and likely contributed to patient outcomes. More than two thirds of HAIs in the ICU were BSIs. Central venous catheter device utlization and maintenance may play a role in BSIs, along with immunosuppression from COVID-19 therapeutics and translocation from mucosal barrier injury. Mortality in patients with coinfections was higher than those without. Infection prevention strategies to reduce device utilization during COIVD-19 in LMICs may have an impact on HAIs.

Treatment and prevention of community-acquired bacterial meningitis

Bacterial meningitis is a serious infection that requires immediate treatment. Recommended empiric antimicrobial therapy is based upon the most likely pathogen, according to a patient’s age and immune status. Antimicrobial therapy should be modified after identification of the causative microorganism and results of susceptibility tests. Preventive measures include the use of vaccines that target Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae, as well as the use of chemoprophylaxis in selected situations. Pharmacists are in a key position to recommend appropriate antimicrobial therapy for the treatment and prophylaxis of bacterial meningitis and to ensure that patients are receiving recommended vaccinations.

Neonatal Infection Due to SARS-CoV-2: An Epidemiological Study in Spain.

Objective: Coronavirus disease 2019 (COVID-19) cases caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to increase worldwide. Although some data from pediatric series are available, more evidence is required, especially in neonates, a group with specific characteristics that deserve special attention. This study aimed to describe general and clinical characteristics, management, and treatment of postnatal-acquired (community and nosocomial/hospital-acquired) COVID-19 neonatal cases in Spain. Methods: This was a national prospective epidemiological study that included cases from a National Registry supported by the Spanish Society of Neonatology. Neonates with postnatal SARS-CoV-2 infection were included in this study. General data and infection-related information (mode and source of transmission, age at diagnosis, clinical manifestations, need for hospitalization, admission unit, treatment administered, and complementary studies performed, hospital stay associated with the infection) were collected. Results: A total of 40 cases, 26 community-acquired and 14 nosocomial were registered. Ten were preterm newborns (2 community-acquired and 8 nosocomial COVID-19 cases). Mothers (in both groups) and healthcare workers (in nosocomial cases) were the main source of infection. Hospital admission was required in 22 community-acquired cases [18 admitted to the neonatal intermediate care unit (NIMCU) and 4 to the neonatal intensive care unit (NICU)]. Among nosocomial COVID-19 cases (n = 14), previously admitted for other reasons, 4 were admitted to the NIMCU and 10 to the NICU. Ten asymptomatic patients were registered (5 in each group). In the remaining cases, clinical manifestations were generally mild in both groups, including upper respiratory airways infection, febrile syndrome or acute gastroenteritis with good overall health. In both groups, most severe cases occurred in preterm neonates or neonates with concomitant pathologies. Most of the cases did not require respiratory support. Hydroxychloroquine was administered to 4 patients in the community-acquired group and to 2 patients in the nosocomial group. Follow-up after hospital discharge was performed in most patients. Conclusions: This is the largest series of COVID-19 neonatal cases in Spain published to date. Although clinical manifestations were generally mild, prevention, treatment, and management in this group are essential.

Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople).

BACKGROUND: Hospital admissions for non-coronavirus disease 2019 (COVID-19) pathology have decreased significantly. It is believed that this may be due to public anxiety about acquiring COVID-19 infection in hospital and the subsequent risk of mortality. AIM: To identify patients who acquire COVID-19 in hospital (nosocomial COVID-19 infection (NC)) and their risk of mortality compared to those with community-acquired COVID-19 (CAC) infection. METHODS: The COPE-Nosocomial Study was an observational cohort study. The primary outcome was the time to all-cause mortality (estimated with an adjusted hazard ratio (aHR)), and secondary outcomes were day 7 mortality and the time-to-discharge. A mixed-effects multivariable Cox's proportional hazards model was used, adjusted for demographics and comorbidities. FINDINGS: The study included 1564 patients from 10 hospital sites throughout the UK, and one in Italy, and collected outcomes on patients admitted up to April 28th, 2020. In all, 12.5% of COVID-19 infections were acquired in hospital; 425 (27.2%) patients with COVID died. The median survival time in NC patients was 14 days compared with 10 days in CAC patients. In the primary analysis, NC infection was associated with lower mortality rate (aHR: 0.71; 95% confidence interval (CI): 0.51-0.98). Secondary outcomes found no difference in day 7 mortality (adjusted odds ratio: 0.79; 95% CI: 0.47-1.31), but NC patients required longer time in hospital during convalescence (aHR: 0.49, 95% CI: 0.37-0.66). CONCLUSION: The minority of COVID-19 cases were the result of NC transmission. No COVID-19 infection comes without risk, but patients with NC had a lower risk of mortality compared to CAC infection; however, caution should be taken when interpreting this finding.