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Background: Sepsis is a life-threatening condition that needs immediate diagnosis and treatment to maximize the chances of survival. Bacterial superinfection is a severe and frequent complication among COVID-19 patients and its diagnosis is challenging. Previous reports suggested that Pancreatic Stone Protein (PSP) may be a predictive biomarker for sepsis in critically ill patients. We report a case series of three COVID- 19 patients admitted to our intensive care unit (ICU) with risk of sepsis. Method(s): We daily monitored PSP, procalcitonin (PCT), and C-reactive protein (CRP) levels in three COVID- 19 patients admitted to our ICU. Microbiological sampling and antibiotic treatment were performed according to the ward organization and in case of clinical suspects for infection. Positive cultures and antibiotic treatment were retrieved from clinical charts and patients were followed from ICU admission up to a maximum of 20 days. Result(s): Patient 1 (male, 55 years-old, overweight, no other comorbidity) was admitted to the ICU in treatment with Ceftriaxone then interrupted on day 7. On day 2 he was intubated and piperacillin/tazobactam was started on day 12 for suspected hospital acquired pneumonia. PSP levels markedly increased on day 10 with no significant changes in CRP and PCT levels. On day 13 a positive bronchospirate for Klebsiella pneumoniae was found. Similarly, patient 2 (male, 70 years-old, mild emphysema and diabetes) was admitted to ICU without antibiotic and with a PSP level of 287 ng/ml. His conditions rapidly worsened in severe septic shock requiring intubation. CRP markedly raised 48-72 hours after PSP with only mild increase of PCT. Patient 3 (male, 78 years-old, no comorbidities) was admitted to ICU with high levels of PSP and piperacillin/tazobactam therapy was started. After 48-72 hours CRP levels increased with no significant changes of PCT. A positive bronchospirate for Ps. aeruginosa was collected on day 3. Conclusion(s): Our findings suggest a potential role of PSP as early biomarker of sepsis in critically ill COVID-19 patients. Daily PSP monitoring may anticipate an appropriate treatment of COVID-19 patients with a septic complication in comparison with the actual laboratory markers. Further studies are needed to confirm our hypothesis.
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Lymphangitis carcinomatosa refers to pulmonary interstitial involvement by cancer and is a dreaded clinical finding in oncology because it is a late manifestation indicative of metastatic malignancy, from either a lung or a nonlung primary cancer, and is associated with poor prognosis. Its presentation is nonspecific, often with subacute dyspnoea and a nonproductive cough in a person with a known history of malignancy, but in some cases is the first manifestation of cancer. CT imaging can be suggestive, typically demonstrating thickening of the peribronchovascular interstitium, interlobular septa and fissures. However, a biopsy may be required to confirm the pathological diagnosis as these changes can also be due to concurrent disease such as heart failure, ILD, infection, radiation pneumonitis and drug reactions. Diagnosis allows symptomatic treatment, with personalised treatment directed towards the primary cancer most likely to provide a meaningful benefit. Future research should focus on prospective clinical trials to identify new interventions to improve both diagnosis and treatment of lymphangitis carcinomatosa.Copyright © ERS 2021.
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PURPOSE: We aimed to determine whether interferon gamma-1b prevents hospital-acquired pneumonia in mechanically ventilated patients. METHODS: In a multicenter, placebo-controlled, randomized trial conducted in 11 European hospitals, we randomly assigned critically ill adults, with one or more acute organ failures, under mechanical ventilation to receive interferon gamma-1b (100 µg every 48 h from day 1 to 9) or placebo (following the same regimen). The primary outcome was a composite of hospital-acquired pneumonia or all-cause mortality on day 28. The planned sample size was 200 with interim safety analyses after enrolling 50 and 100 patients. RESULTS: The study was discontinued after the second safety analysis for potential harm with interferon gamma-1b, and the follow-up was completed in June 2022. Among 109 randomized patients (median age, 57 (41-66) years; 37 (33.9%) women; all included in France), 108 (99%) completed the trial. Twenty-eight days after inclusion, 26 of 55 participants (47.3%) in the interferon-gamma group and 16 of 53 (30.2%) in the placebo group had hospital-acquired pneumonia or died (adjusted hazard ratio (HR) 1.76, 95% confidence interval (CI) 0.94-3.29; P = 0.08). Serious adverse events were reported in 24 of 55 participants (43.6%) in the interferon-gamma group and 17 of 54 (31.5%) in the placebo group (P = 0.19). In an exploratory analysis, we found that hospital-acquired pneumonia developed in a subgroup of patients with decreased CCL17 response to interferon-gamma treatment. CONCLUSIONS: Among mechanically ventilated patients with acute organ failure, treatment with interferon gamma-1b compared with placebo did not significantly reduce the incidence of hospital-acquired pneumonia or death on day 28. Furthermore, the trial was discontinued early due to safety concerns about interferon gamma-1b treatment.
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COVID-19 , Healthcare-Associated Pneumonia , Adult , Humans , Female , Middle Aged , Male , Interferon-gamma , SARS-CoV-2 , Critical Illness , Double-Blind MethodABSTRACT
Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Description of case: We report a case of Tropheryma whipplei endocarditis, a rare cause of bloodculture-negative infective endocarditis (BCNIE). Due to its rarity and lack of availability of diagnostic tests in district hospitals, the diagnosis remains challenging. The objective of this case report is to increase physician awareness of this pathogen. A 61-year-old man presented to the Emergency Department with central chest pain at rest. A 12-lead ECG demonstrated ST- segment depression in V4-V6 leads, and his serial troponin levels were raised. He was commenced on treatment for acute coronary syndrome and transferred to the Coronary Care Unit. An echocardiogram showed a 15mm x 15mm vegetation in the aortic valve with mild aortic regurgitation. His initial microbiology workup, which included two sets of blood cultures (pre-antibiotics), MRSA screen & COVID-19 PCR, was negative. He was transferred to a cardiothoracic centre four days later. Pre-operative CT coronary angiogram showed severe three vessel coronary artery disease. He underwent triple coronary artery by-pass grafts and tissue aortic valve replacement. During early post-op recovery, he had fever episodes and an elevated C-reactive protein of 280 mg/L but normal white cell counts. He was treated with intravenous Tazocin for hospital-acquired pneumonia and discharged on doxycycline. Two weeks post-discharge, he had a positive 16S/18S PCR for Tropheryma whipplei on molecular analysis of the aortic valve. He was treated for Whipples endocarditis with a 4-week course of IV Ceftriaxone, followed by a 12-month course of oral Cotrimoxazole. The patient has reported doing well since the surgery. Discussion(s): Molecular assay with PCR of the heart valve is the mainstay of diagnosing Whipple's endocarditis. There have been 5 previously reported cases of Whipple's endocarditis in the United Kingdom in our knowledge. It is likely under-reported because of a reliance on tissue diagnosis. Preceding intestinal manifestations and arthralgia should raise its clinical suspicion for timely workup. Physician awareness of Whipple's Endocarditis is paramount in investigating for this pathogen.
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Case Report: Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus, with C. neoformans and C. gattii being the most common species to cause human disease. Immunocompromised individuals are predisposed to infections with C. neoformans, which has known predilection to CNS and pulmonary lymph nodes. We present a unique case of disseminated cryptococcosis in the setting of end-stage renal disease (ESRD), cirrhosis, tumor necrosis factor inhibitor use and steroid use for COVID19. Method(s): A single-patient case report was conducted after IRB approval. Case Presentation: A 55-year-old woman with uncontrolled diabetes, lupus, rheumatoid arthritis on adalimumab, hepatitis C status post boceprevir, cirrhosis, former IV drug use, and ESRD on hemodialysis via bovine arterial-venous fistula graft presented with worsening dyspnea, cough, and altered mental status. Three months prior, patient was admitted to an outside hospital for COVID19, complicated by pulmonary embolism status post anticoagulation therapy. Patient was treated with an unknown steroid regimen, which was continued by a second outside facility when symptoms failed to improve. Patient then presented to our facility 24 hours after discharge due to continued symptoms. On admission, patient was noted to have altered mentation and hypoxia with pulmonary edema on chest x-ray and was urgently hemodialyzed. Further work-up was obtained due to non-resolving symptoms, including blood and sputum cultures, cocci serology and QuantiFERON gold. CT chest revealed bilateral consolidations. Patient was started on antibiotics for presumed hospital-acquired pneumonia. During the hospital stay, preliminarily blood cultures grew yeast and patient was started on Micafungin. However, Micafungin was changed to Liposomal Amphotericin B as ovoid structures seen on gram stain could not confirm nor rule out cryptococcus. Subsequent bronchial wash and bronchoalveolar lavage cultures, as well as final blood cultures resulted Cryptococcus neoformans. Serum cryptococcus antigen returned reactive, titer 1:512. Antibiotics were discontinued and Isavuconazonium was started with Liposomal Amphotericin B. Due to recurrent headaches, lumbar puncture was obtained and revealed lymphocytic pleocytosis without cryptococcal antigenicity. Patient completed 14 days of Liposomal Amphotericin B and Isavuconazole with continuation of Isavuconazole upon discharge. Conclusion(s): Disseminated cryptococcosis in non-HIV patients is rare in the modern HIV era. Clinicians should be aware and include it in their differential of any patient with multiple risk factors for opportunistic infection. In patients with cirrhosis and ESRD, treatment is limited given altered pharmacokinetics. Studies have shown improved survival with the addition of Isavuconazole in patients with disseminated cryptococcosis with CNS involvement in the setting of chronic liver disease and ESRD.
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The last both authors contributed equally Purpose To design clinical and public health policies, including immunization, during the COVID-19 pandemic, it is critical to monitor not only infections due to SARS-CoV-2 but other pathogens as well. We evaluated interim results from the first year of a multi-site study of community-acquired pneumonia (CAP) and early onset hospital-acquired pneumonia (HAP) in Germany to assess the contribution of different pathogens over time. Methods This multicenter trial is being conducted from January 2021 to December 2023 at three hospitals in Thuringia: Jena University Hospital (1396 beds), SRH Hospitals Gera (951 beds) and Suhl (653 beds). Adult hospitalized patients with CAP/early onset HAP are identified by a screening algorithm which includes assessment by a study physician. Study procedures included: health data collection, urine specimens (using S. pneumoniae serotype-specific urinary antigen detection assays (UAD-1/2) and BinaxNOW), and nasopharyngeal swabs (analyzed by multiplex microbiological analysis), disease severity assessments, mortality (follow-up to day 90), pathogen spectrum, and quality of life (follow-up to day 180). Results Within the first year (2021), 760 patients (58 % male, 70 % >= 60 years) were enrolled. ICU admission occurred in 16.1 % of cases, and 9.2 % required mechanical ventilation. Pathogens were identified for 553 cases. SARS-CoV-2 was identified in 78.4 % in the first half of the year while S. pneumoniae was detected in 6 cases (2.1 %;2/6 as a co-infection (0.7 %)). Other respiratory viruses were detected in 18 of 338 cases, of which 15 (4.2 %) were coinfections with SARS-CoV-2. In the second half of 2021, SARS-CoV-2 was identified in 58.3 % of cases, however, other pathogens occurred more frequently including S. pneumoniae 10.2 % (n/N = 34/333;13/34 as a co-infection with SARS-CoV-2 (3.9 %)) and other respiratory viruses 11.4 % (n/N = 41/360;11/41 as a co-infection with SARS-CoV-2 (3.0 %)). Influenza was not detected. Conclusion While SARS-CoV-2 remained the most common pathogen among patients with CAP/early onset HAP during the study year, other pathogens reemerged during the second half of 2021. Correspondingly, co-infections with SARS-CoV-2 increased, with pneumococci as the leading pathogen.
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Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.
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Introduction: COVID-19 is a disease caused by the SARS-CoV-2 virus. Healthcare-associated infections (HCAI) are infections acquired during a stay in a hospital or other healthcare setting that were not incubating at the time of admission. Objective(s): To describe the impact of HCAI in hospitalised patients with COVID-19. Method(s): A retrospective and descriptive study of hospitalised patients with COVID-19 in a Portuguese hospital in 2020 was conducted. Result(s): The sample consisted of 1110 patients of whom 229 acquired HCAI. The main comorbidities were hypertension 62.45% (n=143), obesity 24.01% (n=55), arrhythmias 20.52% (n=47), ischaemic heart 11.35% (n=26) and heart failure 16.16%. Infectious agents were isolated in 27.95% (n=64), with Escherichia coli and Klebsiella pneumoniae being the most frequent. HCAI's classification were: 5.68% (n=13) nosocomial bacteraemia 31.89% (n=73);urinary tract infection 54.15% (n=124);hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia 8.28% (n=19). Ventilatory support required: 14.85% (n=34) didn't require, 49.34% (n=113) conventional oxygen therapy (COT);2.62% (n=6) high flow therapy, 3.06% (n=7) non-invasive ventilation, 16.16% (n=37) HelmetCPAP, 12.66% (n=29) invasive mechanical ventilation (IMV) and 1.31% (n=3) ECMO. The mean number of days of admission was 14.84 (+/-13.67). The probability of death HCAI's patients was OR 1.63, 95% CI 1.154-2.304. Conclusion(s): The sample shows a high incidence of nosocomial infections. The most frequent HCAI were HAP mainly with clinical diagnosis. Clinical stabilisation of comorbidities and COT were effective for most patients but IMV and Helmet-CPAP for the most severe. HCAI are a high risk factor for mortality.
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Background. In October 2019 updated community acquired pneumonia (CAP) guidelines were published, highlighting indications for empiric anti-MRSA and antipseudomonal antibiotics and use of MRSA nares screens. During a review of patients receiving vancomycin and piperacillin-tazobactam at our institution in 2020 we noted frequent use of anti-MRSA and antipseudomonal antibiotics and infrequent use of MRSA nares screens for CAP. In May 2020 we initiated a multifaceted intervention, including prospective audit and feedback, an updated pneumonia order set, and system-wide education. In this study we sought to describe gaps in the care of patients with CAP at our institution and to evaluate the impact of a multifaceted intervention on those gaps in care. Methods. We performed a retrospective cohort study on a random sample of unique adult patients admitted with pneumonia from January 1, 2020 through June 30, 2021. Exclusion criteria included COVID infection within 4 weeks of admission, no antibiotics for pneumonia given during admission, immunocompromised condition, and diagnosis of hospital-acquired or ventilator-associated pneumonia. The primary objective was to describe the percentage of patients receiving appropriate anti-MRSA and antipseudomonal therapy and MRSA nares testing during the study period. The secondary objective was to compare appropriateness of these outcomes before and after the intervention. Study groups Results. For the 126 patients reviewed, 68.3% received the appropriate empiric spectrum of activity for MRSA and Pseudomonas aeruginosa, improving from 60% to 80% before and after the intervention respectively. The percentage of patients screened for MRSA increased from 6 to 34%;however, the percentage of appropriate MRSA screens decreased from 71 to 54% because screens were often collected despite absence of MRSA risk factors. Results Conclusion. The percentage of patients receiving appropriate anti-MRSA and antipseudomonal therapy for CAP improved after a multifaceted stewardship intervention. The percentage of patients for whom appropriate MRSA nares screens was performed worsened, mainly due to use of MRSA nares screens when not needed. (Figure Presented).
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Background. Limiting antibiotic prescribing to the shortest effective duration reduces antibiotic-associated adverse events and resistance. Up to two-thirds of patients receive excessive durations of therapy for pneumonia. This study evaluated the effect of a stewardship intervention to reduce excess antibiotic duration for inpatients with pneumonia. Methods. A dashboard was developed to generate real-time alerts when inpatients at an academic medical center received antibiotics with an indication of community- or hospital-acquired pneumonia for more than 5 or 7 days, respectively. From November 2019 through April 2021, alerts were regularly reviewed by the antibiotic stewardship (AS) team and intervened upon when patients exceeded the guideline recommended duration of therapy for pneumonia without additional indications for continuing antibiotics. We compared inappropriate duration of therapy pre- and post-implementation of the dashboard by calculating the mean number of excess days of antibiotics beyond the recommended duration. Patients with SARS-CoV-2 infection and patients on hospital services that care for patients with cysticfibrosis, bronchiectasis, or immunocompromising conditions were excluded. Four other hospitals within the same health system that did not utilize the dashboard generated alerts served as a comparison group. Results. During the intervention period, the AS team reviewed 834 patients with dashboard alerts and documented 115 interventions. For alerts reviewed without intervention, reasons for lack of intervention included active Infectious Diseases consult, additional infection diagnosis requiring a longer duration, and delayed clinical improvement. In the post-implementation period there was a mean of 1.28 excess days of antibiotics for pneumonia compared to the pre-implementation mean of 1.36 excess days. In comparison, aggregating data from the hospitals not utilizing the dashboard, there was a mean of 0.67 excess days post-intervention, compared to a mean 0.62 days pre-intervention. Conclusion. The pneumonia dashboard is a potentially valuable stewardship tool which may reduce excess days of antibiotics for pneumonia. The dashboard's impact may be improved by daily review and excluding patients with additional infection diagnoses.
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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Epiglottitis is an inflammation of the epiglottis which can be life-threatening in the absence of prompt intervention. Although primarily a pediatric condition, streptococcus pneumonia has been identified as a common pathogen in adults. SARS-CoV 2 has been known to affect a multitude of systems including the upper respiratory tract, but rarely the epiglottis. CASE PRESENTATION: A 66-year-old female with a past history of hypertension, and hypothyroidism presented with acute onset pharyngodynia and dysphagia with a feeling of throat closing up due to swelling and difficulty speaking. She had a recent COVID-19 diagnosis and was doing well except for mild fatigue. Upon presentation, she was hemodynamically stable. Physical exam revealed posterior pharyngeal edema without any exudate, mildly edematous uvula, and no stridor. Laboratory data was pristine except for elevated inflammatory markers. Rapid streptococcal test and MRSA swab were negative. Sputum culture showed usual respiratory flora and blood cultures were negative. A neck CT showed diffuse edema without any evidence of abscess. Laryngoscopy performed by the ENT surgeon revealed diffuse edema including epiglottitis. Emergent intubation revealed supra and epiglottis edema sparing the vocal cords. The patient was given Decadron and Benadryl to help with the edema along with clindamycin and subsequently transferred to ICU for further care. She was treated with Ceftriaxone for 7 days due to a chest X-ray finding of pneumonia. As for COVID 19 treatment, she received a course of Remdesivir and Decadron. Decadron was given at an increased interval to reduce edema around the epiglottis. Her ICU course was complicated with hypotension requiring intermittent vasopressor support, and acute kidney injury from ischemic acute tubular necrosis which slowly improved. Repeat CT chest showed bibasilar consolidations with peripheral ground-glass opacities. In view of hospital-acquired pneumonia, she was started on Ertapenem. Her clinical condition improved and she was successfully extubated. She was shifted to the floors from where she was discharged without any further complications. DISCUSSION: There are only two other reported cases of COVID 19 epiglottitis. The patient's advanced age and obesity were non-modifiable risk factors, but the COVID-19 infection played a role. The virus can lead to excessive upregulation of the host inflammatory response through repeat epithelial and endothelial damage leading to a cytokine storm, which may be responsible for this presentation. A great level of attention is to be maintained while attending to these patients given the multitude of systems that can be affected. CONCLUSIONS: COVID-19 is a potential cause of life-threatening acute epiglottitis. Early suspicion and direct visualization of the epiglottis is the key to success for early management. Reference #1: Emberey J, Velala SS, Marshall B, et al. Acute Epiglottitis Due to COVID-19 Infection. Eur J Case Rep Intern Med. 2021;8(3):002280. Published 2021 Mar 3. doi:10.12890/2021_002280 Reference #2: Smith C, Mobarakai O, Sahra S, Twito J, Mobarakai N. Case report: Epiglottitis in the setting of COVID-19. IDCases. 2021;24:e01116. doi: 10.1016/j.idcr.2021.e01116. Epub 2021 Apr 7. PMID: 33842206;PMCID: PMC8025537. DISCLOSURES: No relevant relationships by Arunava Saha
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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
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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
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SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: COVID-19 patients requiring admission to an ICU have a higher risk of invasive pulmonary aspergillosis (IPA) with a reported incidence of 19.6%-33.3%. CASE PRESENTATION: A 63-year-old male presented with progressively worsening dyspnea for one week. He has a past medical history of atrial fibrillation, hypertension, and obesity. He was tested positive for COVID about two weeks prior. He did receive a single dose of Moderna vaccine. Initial chest x-ray(CXR) showed diffuse ground-glass opacities. He was initiated on Remdesivir and decadron, and later received a dose of tocilizumab. He was intubated on hospital day 3 for worsened hypoxemia. Repeat CXR suggested some improvement but a new left lower lobe airspace haziness. He also had new-onset leukocytosis with elevated procalcitonin level. He was started on cefepime for concern of superimposed hospital-acquired pneumonia. A second dose of tocilizumab was administered. No clinical improvement was seen, and additional workups were obtained. Serial CXRs revealed increasing diffuse airspace opacities concerning for ARDS. Tracheal aspirate culture grew coagulase-negative staphylococcus and Aspergillosis Fumigatus. Cefepime was changed to vancomycin, and voriconazole and caspofungin were added. Unfortunately, the patient's respiratory status worsened with increasing ventilation requirement. He also developed septic shock and acute renal failure requiring CVVH. He became even more hypotensive after CVVH initiation, and multiple vasopressors were required to maintain his hemodynamics. Unfortunately, he continued to deteriorate and he also developed profound respiratory acidosis. He died shortly afterwards after family decided to withdraw care. DISCUSSION: In this case, in addition to superimposed bacterial pneumonia, pulmonary aspergillosis likely also contributed to his clinical deterioration. The mechanism by which fungal infections develop in COVID-19 infection is not well-understood. Severe COVID-related immune dysregulation, ARDS, and high-dose steroids use are potential culprits for the increased risk of IPA. Tocilizumab, an IL-6 receptor monoclonal antibody used in patients with severe COVID-19 infection, may also predispose the patient to IPA according to post-marketing data. The mortality rate from current case reports is as high as 64.7%. Diagnosis and treatment in such a scenario remain a challenge. Sputum culture, serum Beta-galactomannan, Beta-D glucan, and aspergillosis PCR have low sensitivity. Tissue biopsy and CT scan in critically ill patients are often not feasible. Voriconazole is usually considered the first-line treatment in IPA. CYP3A4-mediated drug interactions between azoles and antiviral agents require further investigation. CONCLUSIONS: Clinicians should be aware that severe COVID-19 patients are at higher risk of IPA. The prognosis is poor. Early detection and treatment in clinically deteriorated patients are warranted. Reference #1: Borman, A.M., Palmer, M.D., Fraser, M., Patterson, Z., Mann, C., Oliver, D., Linton, C.J., Gough, M., Brown, P., Dzietczyk, A. and Hedley, M., 2020. COVID-19-associated invasive aspergillosis: data from the UK National Mycology Reference Laboratory. Journal of clinical microbiology, 59(1), pp.e02136-20. Reference #2: Lai CC, Yu WL. COVID-19 associated with pulmonary aspergillosis: A literature review. J Microbiol Immunol Infect. 2021;54(1):46-53. doi:10.1016/j.jmii.2020.09.004 Reference #3: Thompson Iii GR, Cornely OA, Pappas PG, et al. Invasive Aspergillosis as an Under-recognized Superinfection in COVID-19. Open Forum Infect Dis. 2020;7(7):ofaa242. Published 2020 Jun 19. doi:10.1093/ofid/ofaa242 DISCLOSURES: No relevant relationships by Jason Chang No relevant relationships by Jason Chang No relevant relationships by kaiqing Lin No relevant relationships by Guangchen Zou
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SESSION TITLE: Imaging Across the Care Spectrum SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to approximately 474 million cases and a devastating 6 million deaths worldwide, to date. Despite a relatively low incidence of secondary bacterial infections in COVID-19 patients, the frequency of empiric treatment with antibiotics is as high as 60 to 100%, highlighting a lack of stringent antibiotic stewardship. This promotes the development of multidrug resistant microorganisms. The purpose of this study was to evaluate the utility of the procalcitonin (PCT) biomarker in identifying the development of hospital acquired pneumonia (HAP) in COVID-19 patients. METHODS: We conducted a single center retrospective study of COVID-19 patients admitted between March 2020 to March 2021. COVID-19 patients who developed HAP during their index hospitalization were compared to those who did not develop HAP. Included in the study were COVID-19 positive patients who received empiric antibiotics for < 48 hours and had at least one PCT value ≥ 48 hours since admission. Exclusion criteria included patients with conditions that could affect PCT values including chronic kidney disease stage 5 and above, malignancy and elevated bilirubin levels. Patients with positive microbiology data < 48 hours of admission and those receiving antibiotic therapy prior to admission were excluded as well. All data was analyzed via SPSS. RESULTS: The median age of the cohort was 65 years. There was no difference in demographics in those who had HAP compared to those who did not. Median Charlson comorbidity index (CCI) (3,2;p=0.6) PCT (0.16, 0.13;p=0.91), ferritin (707, 659.5;p=0.48), and C-reactive protein (CRP) (10.56, 6.78;p=0.19) within 48 hours of admission did not differ significantly between the groups either. Notably, PCT (0.09,0.47;p=0.01) and CRP (3.37, 6.59, p=0.01) 48 hours after admission were significantly higher in COVID-19 patients who developed HAP. However, when PCT and CRP were included in multivariate logistic regression, neither remained a significant predictor of HAP. The odds ratios of PCT and CRP 48 hours after admission were 1.25 (95% CI:0.85-1.8;p=0.27) and 1.08 (95% CI:0.95-1.23;p=0.22), respectively. CONCLUSIONS: Our study did not show a significant difference in the median CCI, PCT, CRP and ferritin obtained within 48 hours of admission in patients who developed HAP versus those who did not. However, PCT and CRP obtained 48 hours after admission, were higher in patients who developed HAP. CLINICAL IMPLICATIONS: The data support the use of PCT and CRP as potential tools to predict the development of concomitant HAP in COVID-19 patients and as guides for antibiotic stewardship in this patient population. DISCLOSURES: No relevant relationships by Mythri Anil Kumar No relevant relationships by Tara McLaughlin No relevant relationships by Raj Parikh No relevant relationships by Meher Singha
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INTRODUCTION: High-grade gliomas account for <5% of all pediatric brain tumors with a 20% 5-year overall survival even with maximal safe resection followed by concurrent radiotherapy and chemotherapy. Patients in low-and middle-income countries already face delays and barriers to the treatment they require. The current COVID pandemic has added unique challenges to the delivery of complex, multidisciplinary health services to these patients. METHODOLOGY AND RESULTS: We retrospectively reviewed the records of four patients, ages 2-18 years old, with histologically confirmed high-grade glioma managed in a tertiary government institution from 2020-2021. Three of the patients had a supratentorial tumor and one patient had multiple tumors located in both supra-and infratentorial compartments. Neurosurgical procedures performed were: gross total excision (1), subtotal excision (2), and biopsy (1). The tissue diagnoses obtained were glioblastoma (3) and high-grade astrocytoma (1). Two patients survived and are currently undergoing adjuvant radiotherapy and chemotherapy. The remaining two patients expired: one from hospital-acquired pneumonia and the other from COVID-19 infection. DISCUSSION: Decreased mobility due to lockdowns, the burden of requiring negative COVID-19 results before admission for surgery, reduced hospital capacity to comply with physical distancing measures, the postponement of elective surgery to minimize COVID-19 transmission, physician and nursing shortages due to infection or mandatory isolation of staff, cancellation of face-to-face outpatient clinics, and hesitation among patients and their families to go to the hospital for fear of exposure were found to be common causes of delays in treatment. Also, the redirection of health resources and other government and hospital policies to handle the COVID-19 pandemic resulted in an overall delay in the delivery of health services. In particular, the management of pediatric patients with cancers, especially high-grade gliomas, was significantly disrupted.
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Introduction: Viral pathogens have been reported increasingly in pneumonia patients. There are few studies in Turkey on viral and atypical bacterial etiology in adult patients with community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). In this study, it was aimed to determine atypical and viral pathogens in patients with pneumonia requiring ICU and to research clinical progression. Materials and Methods: Adult patients admitted to adult ICUs between November 2016-October 2017 with either CAP or HAP diagnosis were included prospectively. Viral pathogens and also atypical bacterial pathogens were investigated with the in-house multiplex polymerase chain reaction method. Results: Two hundred patients were enrolled to the study, of whom 63 had CAP (31.5%) and 137 had HAP (68.5%). Viral agents were identified in 31 (15.5%) patients in total, 11 (17.5%) in CAP and 20 (14.6%) in HAP. The most identified viral etiologic agents were rhinovirus, influenza A, and coronavirus HKU. Eight patients (4%) had Mycoplasma pneumoniae. All patients were negative for Legionella pneumoniae and Chlamydophila pneumoniae. Mortality rates were 16.7% for cases with a viral etiology only, 29.2% for cases with bacterial pathogens only, and 23.5% for cases with mixed agents identified. Conclusion: Viral pathogens and M. pneumoniae should be remembered in the etiology of severe pneumonia patients.
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Hospital-acquired pneumonia (HAP) is a substantial public health issue that is associated with high mortality rates and is complicated by an arsenal of microbial etiologies, expressing multidrug-resistant phenotypes, rendering relatively limited therapeutic options. BioFire FilmArray Pneumonia Panel plus (BFPP) is a simple multiplexed PCR system that integrates sample preparation, nucleic acid extraction, amplification, and analysis of microbial etiology, with a turnaround time of about one hour. In comparison to standard culture methods, BFPP is simpler, easier to perform, and can simultaneously detect the most common pathogens involved in lower respiratory tract infections (34 targets). Accordingly, we evaluated the diagnostic performance of the multiplexed BFPP for the rapid detection of 27 clinically relevant respiratory pathogens and 7 genetic markers among 50 HAP cases admitted to the intensive care unit (ICU), who submitted mini-bronchoalveolar (mBAL) specimens. In comparison to standard culture methods, BFPP showed an overall sensitivity of 100% [95% CI; 90-100] and overall specificity of 90% [95% CI; 87.4-92.5] among all the tested bacterial targets. BFPP identified 11 viral targets (22%) among the tested specimens. The BFPP semi-quantitative analysis showed a concordance rate of 47.4% among positive culture specimens. For the investigation of the antibiotic resistance genes, BFPP showed a positive percent agreement (PPA), a negative percent agreement (NPA), and an overall percent agreement (OPA), reaching 97% [95% CI; 90-100], 95% [95% CI; 91.5-97], and 95% [95% CI; 93-97], respectively, with standard antibiotic sensitivity testing. In conclusion, BFPP has the potential to enhance the rapid microbiological diagnosis of HAP cases, and could aid in tailoring appropriate antibiotic therapies.
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Introduction: The coronavirus disease 2019 (COVID-19) lockdown strategies were associated with a significant decrease in the common respiratory viral diseases and decreased the need for hospitalization among children in the COVID-19 outbreak. However, the trend of non-COVID-19 pneumonia in adult people remains uncertain. Our aim is to assess the impact of the COVID-19 pandemic on the incidence of the non-COVID-19 pneumonia in adult people and understand whether the substantial decrease in pneumonia cases is the same as the decline in the incidence of respiratory viral disease activity. Methods: We conducted a retrospective analysis of adult patients presenting with pneumonia from January 2019 to December 2020. Details on all the demographics of the patient of pneumonia, hospital course details, prior admission history within 3 months, respiratory culture, and antibiotics sensitivity test were also obtained. Results: The number of adult patients with community-acquired pneumonia in 2020 was lower than that in 2019, which decreased by 74 patients in 2020. The decreasing number of patients with community-acquired pneumonia between 2019 and 2020 was from -13.9% in January to March 2020 to -39.7% in October to December 2020. The decreasing number of patients with community-acquired pneumonia between 2019 and 2020 was from -14.8% in the youngest cohort to -28.7% in those aged ≥85 years. The number of reduced patients with community-acquired pneumonia is greater in late seasons and older age, respectively. The number of adult patients with hospital-acquired pneumonia in 2020 was lower than that in 2019, which decreased by 23 patients in 2020. The decreasing number of patients with hospital-acquired pneumonia between 2019 and 2020 was from -20.0% in January to March 2020 to -52.4% in October to December 2020. The decreasing number of patients with hospital-acquired pneumonia between 2019 and 2020 was from 0% in the youngest cohort to -45.6% in those aged ≥ 85 years. The number of reduced patients with hospital-acquired pneumonia is greater in late seasons and older age, respectively. Conclusion: Interventions applied to control the COVID-19 pandemic were effective not only in substantial changes in the seasonal influenza activity, but also in decreasing adult pneumonia cases.