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1.
Open Forum Infectious Diseases ; 9(Supplement 2):S814-S815, 2022.
Article in English | EMBASE | ID: covidwho-2189996

ABSTRACT

Background. Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods. We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheterassociated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results. Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (< 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative toWhite patients in both study periods (pre-pandemic, 49% vs 38%;during pandemic, 47% vs 31%;respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30;95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51;95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion. We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. (Figure Presented).

2.
Open Forum Infectious Diseases ; 9(Supplement 2):S813-S814, 2022.
Article in English | EMBASE | ID: covidwho-2189994

ABSTRACT

Background. The COVID-19 pandemic changed accessibility of care and practices within healthcare environments. This period has been associated with healthcare-associated infection outbreaks and shifts in healthcare-associated infectious disease epidemiology. This study's objective is to describe changes in rates and characteristics of antimicrobial-resistant gram negative and Clostridioides difficile (CD) infections during the COVID-19 pandemic in Bernalillo County, New Mexico. Methods. The NM EIP, a collaboration between University of New Mexico and theNMDOH, conducts ongoing laboratory- and population-based surveillance of infectious disease including Clostridium difficile, extended-spectrum beta lactamase (ESBL-E) and carbapenemase-producing gram negative bacteria (CRE). Stata statistical software was used for retrospective analysis of rates and characteristics on NM EIP data from Bernalillo county, NM between 2016 and 2021. Results. Reported C. difficile rates decreased from 76 to 49 cases/month and ESBL-producing Enterobacterales decreased from 145 to 86 cases/month during the pandemic period from March-December 2020 compared with the prior 14 months. Monthly case counts for 2020 are lowest during initial public health orders for the state of New Mexico. Rates of CRE remained constant between 2018-2021. The proportion of CDI cases originating from long-term care facilities decreased significantly from 17.2% to 10.4% (p=0.006) while the proportion attributable to hospital inpatient and community populations remained constant. The proportion of ESBL-E cases from sterile sample sites increased from 3.1% to 4.9% (p=0.05) and the proportion of patients who died within 30 days or prior to discharge increased from 2.2% to 3.2% (p=0.019). Conclusion. Rates and characteristics of CD and ESBL-E infections in Bernalillo countyNMchanged significantly during the COVID-19 pandemic, while rates of CRE remained constant. It is still unclear whether this is related to changes in actual disease rates due to risk factor exposure (healthcare), or if this trend reflects changes in careseeking behavior and/or reporting of cases. (Figure Presented).

3.
Open Forum Infectious Diseases ; 9(Supplement 2):S517-S518, 2022.
Article in English | EMBASE | ID: covidwho-2189818

ABSTRACT

Background. Robust infection control (IC) measures were deployed across healthcare institutions at the start of the COVID-19 pandemic, resulting in increased use of personal protective equipment (PPE), enhanced contact precautions, and emphasis on hand hygiene. The impact of these IC measures on the rates of hospitalacquired infections (HAIs), such as multidrug-resistant organisms (MDROs), device-related infections (DRIs), Clostridium difficile infection (CDI), and respiratory viral infections (RVIs) is not known. Here, we aim to evaluate the effect of the enhanced IC practices on the occurrence of various HAIs in a comprehensive cancer center. Methods. We analyzed the monthly HAIs rates from September 2017 through March 2022, including data 42 months pre-pandemic (September 2016-February 2020) and 24 months during the pandemic (March 2020-August 2021). Reported HAIs were calculated using denominators of patient days for CDI and MDROs, per 1,000 admissions for RVIs, and catheter days for DRIs. The incidence rate ratios (IRR) were calculated for all HAIs. Results. When comparing pre-pandemic to the pandemic period, a significant increase in the overall incidence rate (IR) of MDROs from 0.56 to 0.67 per 1,000 patient days with an IRR of 1.19 (95% CI 1.02-1.39), a decrease in the IR of CLABSIs and a stable IR of CAUTIs and VAEs were observed (Table 1). A significant decrease was observed in the IR of CDI (IRR 0.65 (95% CI 0.55-0.78)). The total IR of hospital-acquired RVIs per 1,000 admissions (5.24 to 1.82;IRR 0.36;95% CI 0.30-0.44) decreased, as did each respiratory virus (Respiratory Syncytial Virus (0.51 to 0.15;IRR 0.30), Influenza (0.50 to 0.24;IRR 0.50), Parainfluenza (1.21- to 0.34;IRR 0.28), Rhinovirus (1.91 to 0.5;IRR 0.26), and Human Metapneumovirus (0.19 to 0.05;IRR 0.24) during their respective respiratory viral seasons (Figure 1). (Table Presented) Conclusion. Implementing strict IC measures during the COVID-19 pandemic in a cancer hospital led to a significant decrease in many HAIs and a reduction in nosocomial RVIs. However, whether these enhanced measures, such as masking at all times as part of patient care, are needed during the upcoming respiratory viral seasons is not known.

4.
Open Forum Infectious Diseases ; 9(Supplement 2):S380, 2022.
Article in English | EMBASE | ID: covidwho-2189675

ABSTRACT

Background. Antibiotic stewardship programs (ASP) are relatively new in Mexico. It was until May 2018 that it was established as a public health policy in the country. Few hospitals have acknowledged the mandate and started an ASP despite the efforts. Besides, little has been done to evaluate the efficacy of the program in terms of antibiotic expenditure and the incidence of associated infections. Therefore, the main objective was to evaluate antibiotic expenditure before and after the ASP in a third-level hospital in Mexico. As a secondary analysis, the relationship with Clostridioides difficile infections was explored. Methods. This is a retrospective and descriptive study from January 2017 to February 2020 (pre-COVID-19 pandemic). First, the mean antibiotic expenditure (adjusting for DDD/patient days-costs in USD) was evaluated before and after (June 2018 as the first month of implementation) the ASP. Statistical difference of the means was evaluated. It was also performed an exploratory analysis between the prescription of Clindamycin and Levofloxacin with the number of cases and deaths related to C. difficile infection. Results. The average antibiotic expenditure before ASP was US$13,468 +/- 3,267, and US$8,193 +/- 2,574 (p< 0.001) after. Graph 1 presents the changes in trend. Specifically, caspofungin, ciprofloxacin, clindamycin, fluconazole, levofloxacin, linezolid, piperacillin/tazobactam, and tigecycline showed statistically significant reduction after June 2018. Graph 2 displays the descriptive relationship between the prescription of levofloxacin and clindamycin, the cases of C. difficile infection, and the elimination of all associated mortality. Graph 1. Antibiotic expenditure. Before and after AMS Graph 2. Relationship between monthly consumption of clindamycin and levofloxacin and the number of cases/deaths secondary to Clostridioides difficile infections, before and after ASP. Conclusion. The ASP has significantly reduced the antibiotic expenditure in the hospital. Besides reducing the prescription of associated antibiotics, a possible reduction in C. difficile infections and associated deaths were observed.

5.
Open Forum Infectious Diseases ; 9(Supplement 2):S246-S247, 2022.
Article in English | EMBASE | ID: covidwho-2189646

ABSTRACT

Background. Timely diagnosis and use of contact precautions for Clostridioides difficile infection (CDI) is key to prevent spread in hospital settings. Empowering nursing staff to order stool tests and proactively implement precautions has been shown to reduce hospital acquired CDI. Our institution established a nurse driven CDI order set in 2019, however only 1% of tests were ordered by nurses in the past year. The goal of this quality improvement project was to understand current use of the nurse-driven CDI order set using a novel humble inquiry approach. Methods. We used humble inquiry, an interview approach that poses questions while building relationships with participants through humility, curiosity, and active listening skills to explore barriers to utilization of a nurse driven CDI order set. Two nursing students at a 182-bed Veterans Health Administration (VA) hospital were trained to use humble inquiry and a three-item interview guide. A convenience sample of nurses and nursing assistants were interviewed about a) what they know about the nurse driven CDI order set, b) where there is documentation about the order set and c) barriers to use of the order set (if any). Interviews were conducted from January to April 2022. Demographics were analyzed descriptively. Interview data and the experience of conducting humble inquiry were analyzed using manifest content analysis. Results. Interviews (n=19) with nurses (n=16) and nursing assistants (n=3) revealed the majority (13/19 = 68%) were not aware of the nurse driven CDI order set. Of those aware, most were able to identify the location of information on their unit and where to document in the electronic medical record. The two most common barriers included lack of awareness of the order set and patient reluctance to disclose their bowel habits. Delay in providers reading notes (3/19=16%) and lack of PPE during COVID (1/19= 5%) were also identified as barriers. The nursing students reported the humble inquiry approach allowed participants to be the "experts" and "teachers". Conclusion. The humble inquiry method was valuable in understanding viewpoints and identifying barriers to utilization of a nurse drive CDI order set. Lack of awareness of the order set and patient modesty were identified as barriers and may be targeted for future interventions.

6.
Open Forum Infectious Diseases ; 9(Supplement 2):S237-S238, 2022.
Article in English | EMBASE | ID: covidwho-2189644

ABSTRACT

Background. Clostridioides difficile infection (CDI) is the leading cause of nosocomial diarrhea and a costly burden on the healthcare system. The COVID-19 pandemic brought enhanced infection control measures that could hypothetically decrease CDI transmission. Nonetheless, diarrhea secondary to COVID-19 and increased usage of broad-spectrum antibiotics could potentially increase testing for or frequency of CDI. We aimed to assess variations in CDI testing and frequency during the first surge of the COVID-19 pandemic in a tertiary community medical center in the Southern United States. Methods. Records from adult patients were retrospectively reviewed at Princeton Baptist Medical Center, Birmingham, AL. Three groups spanning equal time periods were created based on the CDC COVID-19 rate curves for Alabama: PPG (pre-pandemic, 03/01/2020 to 05/31/2020), PG (pandemic, 06/01/2020 to 08/ 31/2020), and SCG (seasonal control, 06/01/2019 to 08/31/2019). We included patients >= 18 years old and excluded readmissions and follow-up visits. We determined the frequency, testing rates, and positivity rates for CDI in each group to assess their differences. Also, we measured the rate of coinfection between C. difficile and SARS-CoV-2. CDI cases were defined as positive toxin enzyme-linked immunosorbent assay (EIA) and glutamate dehydrogenase (GDH), or positivity of either in addition to positive nucleic acid amplification test (NAAT). Differences in frequencies and rates across groups were compared with Fisher exact test. Results. Overall, 7,252 hospitalized patients and 29,671 outpatients were included (Figure 1). No outpatient CDI cases were detected. Outpatient testing rates were: PPG 3 (0.05%), PG 4 (0.05%), and SCG 9 (0.06%). Among inpatients, 3,912 (53.9%) were female with a mean +/- SD age of 61.2 +/- 17.5 years. Overall, CDI frequency, testing rates, and positivity rates did not vary significantly among all groups (Table 1). Among those tested, the only case of C.difficile/SARS-CoV-2 coinfection corresponded to PPG. Conclusion. There were no statistically significant differences in CDI frequency, or positivity rate between the pre-pandemic, pandemic, and seasonal control groups for inpatients. No CDI cases were detected in outpatients. This is likely due to a low testing rate in our population.

7.
Open Forum Infectious Diseases ; 9(Supplement 2):S185-S186, 2022.
Article in English | EMBASE | ID: covidwho-2189593

ABSTRACT

Background. Despite multiple studies indicating a low prevalence of bacterial coinfection in coronavirus disease 2019 (COVID-19) patients, the majority of hospitalized COVID-19 patients receive one or more antibiotics. Patients with coinfection usually have multiple risk factors and poor clinical outcomes. Methods. A retrospective case control study was conducted comparing clinical characteristics and antimicrobial use in hospitalized adult COVID-19 patients with bacterial co-infections vs. randomly selected patients without co-infections (matched on month of admission). The study was conducted at three hospitals within the Montefiore Medical Center, Bronx, NY between March 1, 2020 and October 31, 2020. A multivariable logistic regression model was developed to assess the relationship of each predictor variable with coinfection status. Secondary outcomes included hospital mortality, antibiotic days of therapy (DOT), and C. difficile infection. Results. A total of 150 patients with coinfection and 150 patients without coinfection were included in the analysis. Table 1 summarized baseline characteristics and risk factors. The multivariable logistic regression model indicated that presence of a central line (OR=5.4, 95% CI: 2.7-11.1), prior antibiotic exposure within 30 days (OR=5.3, 95% CI: 2.8-10.0), prior ICU admission (OR=3.6, 95% CI: 1.7-7.6), steroid use (OR=2.7, 95% CI: 1.4-4.9), and any comorbid condition (OR=2.7, 95% CI: 1.4-5.2) were significantly associated with the development of coinfection (table 2). Mortality was higher in patients with coinfection (56% vs. 11%, p < 0.0001) (table 3). Average antibiotic DOT was 10.5 in coinfected patients compared to 4 in noncoinfected patients, (p < 0.0001). Forty-one percent of coinfected patients had a multidrug resistant organism isolated. C. difficile rate was higher in coinfected patients (4% vs. 0%, p=0.03). Conclusion. As the healthcare community contends with a 3rd year of COVID-19 pandemic, understanding risk factors most predictive of bacterial coinfection can guide empiric antimicrobial therapy and targeted stewardship interventions. Ideally, co-infection risk scores are developed which may be useful for future inpatient surges.

8.
Open Forum Infectious Diseases ; 9(Supplement 2):S32, 2022.
Article in English | EMBASE | ID: covidwho-2189508

ABSTRACT

Background. Bacterial co-infection has been reported with COVID-19, but risk factors for bacterial co-infection remain unclear due to limited large scale studies. We seek to identify predictive factors associated with risk of co-infection with multidrug-resistant organisms for patients hospitalized at Veterans Affairs (VA) hospitals with COVID-19. Methods. This retrospective cohort study included Veterans admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a confirmed positive COVID-19 test within the previous 14 days and up to 2 days after admission. Outcomes of interest were hospital-onset co-infection (HOI, > 2 calendar days after admission) and community-onset co-infection (COI, within 2 calendar days of admission). Potential risk factors included both patient- (e.g. vital sign, medication use) and facility-level covariates (e.g. bed size, antibiotic use rate). We compared the covariate distributions for patients with and without HOI and COI. Our analytical approaches included variance inflation factors to detect the presence of multicollinearity among these factors, and Least Absolute Shrinkage and Selection Operator to identify the subset of factors associated with HOI and COI. We conducted a two-stage analysis, first performing feature selection among the individual-level risk factors followed by identification of facility-level risk factors. Optimal models were identified using 10-fold cross validation. Results. By July 2021, 33,383 patients were admitted to VA with positive COVID-19 test. We found that medications for ventilator induction (OR with 95% CI: 2.9 (2.2, 3.9)), norepinephrine (OR with 95% CI: 1.6 (1.2, 2.2)) and antimicrobial therapies for gram-positive infections (OR with 95% CI: 4.5 (3.6, 5.6)) [Table 1] were associated with the increased risk of HOI and patients in facilities with high C difficile infection rates were more likely to have COI detected (OR with 95% CI: 1.14 (1.11, 1.18)) [Table 2]. Homeless Veterans had higher risk of developing an HOI (OR with 95% CI: 1.5 (1.1, 2.0)), but not a COI. Conclusion. Risk factors for HOI and COI in COVID-19 were distinct, with specific classes of medications and antibiotics as well as patient factors resulting in increased risk for HOI. Further work is needed to better understand the risk factors for COI. (Table Presented).

9.
Journal of the Formosan Medical Association ; 121(12):2371-2375, 2022.
Article in English | EMBASE | ID: covidwho-2150065
10.
Life (Basel) ; 12(10)2022 Oct 05.
Article in English | MEDLINE | ID: covidwho-2066224

ABSTRACT

INTRODUCTION: This study primarily sought to evaluate the risk factors for toxic megacolon development and treatment outcomes in Clostridium difficile-positive COVID-19 patients, secondarily to determining predictors of survival. METHODS: During the second COVID-19 wave (May 2020 to May 2021), we identified 645 patients with confirmed COVID-19 infection, including 160 patients with a severe course in the intensive care unit. We selected patients with Clostridium difficile infection (CDI) (31 patients) and patients with toxic megacolon (9 patients) and analyzed possible risk factors. RESULTS: Patients who developed toxic megacolon had a higher incidence (without statistical significance, due to small sample size) of cancer and chronic obstructive pulmonary disease, a higher proportion of them required antibiotic treatment using cephalosporins or penicillins, and there was a higher rate of extracorporeal circulation usage. C-reactive protein (CRP) and interleukin-6 values showed significant differences between the groups (CRP [median 126 mg/L in the non-toxic megacolon cohort and 237 mg/L in the toxic megacolon cohort; p = 0.037] and interleukin-6 [median 252 ng/L in the group without toxic megacolon and 1127 ng/L in those with toxic megacolon; p = 0.016]). As possible predictors of survival, age, presence of chronic venous insufficiency, cardiac disease, mechanical ventilation, and infection with Candida species were significant for increasing the risk of death, while corticosteroid and cephalosporin treatment and current Klebsiella infection decreased this risk. CONCLUSIONS: More than ever, the COVID-19 pandemic required strong up-to-date treatment recommendations to decrease the rate of serious in-hospital complications. Further studies are required to evaluate the interplay between COVID-19 and CDI/toxic megacolon.

11.
Chest ; 162(4):A1780, 2022.
Article in English | EMBASE | ID: covidwho-2060861

ABSTRACT

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Lung toxicity due to antineoplastic therapy is reported with both cytotoxic and molecularly targeted agents [1]. We present one such case of lung injury induced by capecitabine. CASE PRESENTATION: A 79-year-old female with history of triple negative infiltrating duct carcinoma of the right breast (status post mastectomy and adjuvant chemotherapy with docetaxel and cyclophosphamide 3 years prior) presented to the hospital with dyspnea on exertion following her fourth cycle of capecitabine therapy for breast cancer recurrence. Patient developed nausea, vomiting, and malaise with cycles 1, 2, and 3 of capecitabine therapy with onset of severe dyspnea on exertion, cough, and hypoxia following cycle 4. Computed tomography (CT) scan of the chest on admission showed consolidative opacities in the right upper, right middle, and anterior right lower lobe along with smaller opacities in the left lung apex and small subcentimeter nodules;no pulmonary embolism. Antibiotics were given for a short duration for suspected pneumonia without improvement. Capecitabine was held on discharge. She presented again to the emergency room with worsening shortness of breath, diarrhea, fatigue, and dizziness. COVID test was negative. Chest x-ray redemonstrated patchy airspace disease involving the right apical, lateral, mid lower lung field. Oral steroids were recommended for suspected organizing pneumonia, but the patient refused due to concerns about side effects. Her hospital course was complicated by Clostridium difficile infection (treated with oral vancomycin) and left lower extremity deep venous thrombosis (treated with anticoagulation). Subsequently she followed up with pulmonology outpatient. Repeat imaging showed evolving infiltrates in the same areas with elevated aspergillus IgG level (18.0 mcg/ml) and IgE (178 kU/L) but negative galactomannan and sputum bacterial/fungal/acid fast cultures. Oral steroids were initiated with clinical and symptomatic improvement. DISCUSSION: Capecitabine is a prodrug of fluorouracil (antimetabolite). It is used as a chemotherapy agent in multiple types of cancer including breast cancer. Respiratory side effects include cough (<7%) and bronchitis (<5%). Lung injury/pneumonitis is a rare complication with only a few cases reported to date [2,3]. The timing of symptoms with chemotherapy administration and the negative infectious work-up supports capecitabine as the inciting etiology of lung injury. Withholding chemotherapy and starting systemic steroids were effective treatments in this case of chemotherapy induced lung toxicity. CONCLUSIONS: Capecitabine induced lung injury is a rare but important entity and should always be kept in mind while evaluating dyspnea in cancer patients. Reference #1: Capri G, Chang J, et al. An open-label expanded access study of lapatinib and capecitabine in patients with HER2-overexpressing locally advanced or metastatic breast cancer. Ann Oncol. 2010;21(3):474. Epub 2009 Oct 8. DOI: 10.1093/annonc/mdp373 Reference #2: C. J. Benthin, G. Allada. Capecitabine-Induced Lung Injury. American Journal of Respiratory and Critical Care Medicine 2016;193:A1653. Reference #3: Andrew K Chan, Bok A Choo, John Glaholm. Pulmonary toxicity with oxaliplatin and capecitabine/5-Fluorouracil chemotherapy: a case report and review of the literature. Onkologie. 2011;34(8-9):443-6. doi: 10.1159/000331133. Epub 2011 Aug 19. DISCLOSURES: No relevant relationships by William Karkowsky No relevant relationships by Chahat Puri No relevant relationships by Sahib Singh

12.
Swiss Medical Weekly ; 152:9S-10S, 2022.
Article in English | EMBASE | ID: covidwho-2040977

ABSTRACT

Robust infection control (IC) measures were deployed across healthcare institutions at the start of the COVID-19 pandemic, resulting in increased use of personal protective equipment (PPE), enhanced contact precautions, and emphasis on hand hygiene. The impact of these IC measures on the rates of hospital-acquired infections (HAIs), such as multidrug-resistant organisms (MDROs), device- related infections (DRIs), Clostridium difficile infection (CDI), and respiratory viral infections (RVIs) is not known. Here, we evaluated the effect of the enhanced IC practices on the occurrence of HAIs in a comprehensive cancer center. We analyzed the monthly HAIs rates from September 2017 through March 2022, including data 42 months pre-pandemic and 24 months during the pandemic. The incidence rate ratios (IRR) were calculated for all HAIs. When comparing pre-pandemic to the pandemic period, a significant increase in the overall incidence rate (IR) of MDROs from 0.56 to 0.67 per 1,000 patient days with an IRR of 1.19 (95% CI 1.02- 1.39), a decrease in the IR of CLABSIs and a stable IR of CAUTIs and VAEs were observed. A significant decrease was observed in the IR of CDI (IRR 0.65 (95% CI 0.55-0.78)). The total IR of hospitalacquired RVIs per 1,000 admissions (5.24 to 1.82;IRR 0.36;95% CI 0.30-0.44) decreased. Implementing strict IC measures during the COVID-19 pandemic in a cancer hospital led to a significant decrease in many HAIs and a reduction in nosocomial RVIs. However, whether these enhanced measures are needed during the upcoming respiratory viral seasons is not known.

13.
Journal of the Canadian Association of Gastroenterology ; 4, 2021.
Article in English | EMBASE | ID: covidwho-2032052

ABSTRACT

Background: Leflunomide is an oral disease-modifying antirheumatic drug (DMARD), with anti-inflammatory and immunomodulatory properties that has been in use since 1998. Common leflunomide side-effects include gastrointestinal symptoms (nausea, abdominal pain and diarrhea), occurring in 10-20% of patients treated with leflunomide. Scarce evidence exists that leflunomide can cause colitis. Aims: We present the case of a 61-year-old female, with Lupus Erythematosus who presented with colitis induced by long-term leflunomide treatment. Methods: Case report and review of literature Results: A 61-year-old female was seen by the gastroenterology team with complaints of diarrhea ongoing for 6 weeks associated with 10 lb weight loss. The patient had a complex medical history, including lupus, hypothyroidism, asthma, atrial fibrillation, recurrent C. difficile infection, Bell's palsy and avascular necrosis secondary to long-term corticosteroid therapy. Previous immunosuppressive therapies included prednisone, mycophenolic acid (Myfortic), hydroxychloroquine, azathioprine, mycophenolate (CellCept) but due to multiple intolerances, she was initiated on leflunomide in 2014 and has been maintained on it since. Stool analysis ruled out infectious causes. COVID-19 testing was also negative. A CT of the abdomen revealed pancolitis. This was confirmed on colonoscopy, which revealed mild, Mayo 1 pancolitis and normal terminal ileum. She was initiated on Mezavant as a treatment for possible ulcerative colitis. However, during the hospitalization her symptoms, worsened and bloody diarrhea was noted. She underwent a subsequent endoscopic evaluation which revealed more severe disease, Mayo 2-3 colitis, with mucosal hyperemia and ulcerations, as well as effacement of the vasculature. Initial pathology results revealed mild colitis, but repeat pathology results revealed moderate active colitis, with cryptitis, crypt abscesses and significant apoptosis consistent with drug-induced colitis. Given these findings, the diagnosis of leflunomide-induced colitis was made. Leflunomide was therefore discontinued, the patient was initiated on a higher dose of corticosteroids and cholestyramine was initiated. Following these measures, her diarrhea resolved. Conclusions: Leflunomide may cause diarrhea in up to 33% of patients. Challenges related to the diagnosis of leflunomide-induced colitis exist, including the rarity of the diagnosis, a not completely understood mechanism for acute leflunomide-induced diarrhea, as well as variable endoscopic and histologic findings associated with the diagnosis. This report illustrates a case of leflunomide-induced colitis which should be considered in patients on leflunomide, who present with symptoms of abdominal pain and diarrhea, even years after medication initiation.

14.
Journal of the Formosan Medical Association ; 121(9):1617-1621, 2022.
Article in English | Scopus | ID: covidwho-2015654
15.
Indian Journal of Critical Care Medicine ; 26:S76-S77, 2022.
Article in English | EMBASE | ID: covidwho-2006365

ABSTRACT

Introduction: COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has resulted in 119.2 million infections and 2.64 million deaths by 14 March 2021, globally. As of March 14, 2021, India has seen 11.35 million infections and 0.15 million deaths. Critically ill COVID-19 patients need hospitalization, which increases their risk of acquiring secondary bacterial and fungal infections and would lead to a significant increase in morbidity and mortality. The prevalence of secondary infections in ICU patients infected with COVID-19 is not well understood. Objectives: The aim of our study was to know the prevalence and impact of secondary infections on patients with COVID-19 infection admitted to ICU. Materials and methods: This was an observational prospective study conducted in Apollo hospital, for a period of 6 months (December 2020 to June 2021). We considered patients who develop secondary infections (bacterial/ fungal) developed 48 hours after ICU admission until death or discharge. Results: Among 50 patients, males were 68% and females were 32%. The mean age at presentation was 55 years. Secondary infections were detected in 29 patients (58%) with a median of 9 days after intensive care unit (ICU) admission (Fig. 1). Among which 79.3% was bacterial and 20.7% was fungal infections. Most of which were isolated from blood-16/29 patients (55.2%), respiratory-9/29 patients (31.03%), and urine-4/29 patients (13.8%). Gram-negative organisms were predominant [Klebsiella (39.1%), Acinetobacter (26.1%), E. coli (17.4%), Pseudomonas (13.0%)] over grampositive organisms-enterococci (4.4%). Among fungal infections, Aspergillosis in 3/6 patients (50%), Mucor in 1/6 patients (16.7%), and Candida in 2/6 patients (33.3%) were noted. The average length of ICU stay in patients with secondary infections was significantly high when compared to patients without secondary infections. Out of 50 patients, 10 patients were on high oxygen support, 24 required BIPAP support, 16 were ventilated. Patients who developed secondary infections received a high dose of steroids (mean dose of steroids received was 1996 mg). Patients receiving invasive mechanical ventilation or longer ICU (>9 days) stay had a higher rate of secondary infections (p < 0.001). Similarly, a 28-day mortality rate was also more in patients with secondary infections (17/29 patients;58.62%) when compared to patients without infections (5/21 patients;23.8%). Conclusion: For critically ill COVID patients, the secondary infection rates were found to be high. Although antibiotics likely provide minimal benefit as empirical treatment in COVID-19 patients and may be associated with unintended consequences including adverse events, toxicity, resistance, and C. difficile infections, it is always prudent for clinicians to prescribe them judiciously to ICU patients to reduce the length of ICU stay and mortality. We must have a high suspicion for fungal infections in patients who have long ICU stays and not improving with empirical antibiotics, as early detection and timely treatment may reduce mortality (Figs 2-4).

16.
Value in Health ; 25(7):S345, 2022.
Article in English | EMBASE | ID: covidwho-1926720

ABSTRACT

Objectives: Since the COVID-19 pandemic, the potential for vaccines to reduce pressure on health care systems has received much attention. However, evaluation of how vaccination may impact health system pressure is hindered by lack of a formal definition and measurement framework. We developed an approach for defining health system pressure and measuring its impact in healthcare settings and applied this approach to respiratory syncytial virus (RSV) and Clostridioides difficile (C. difficile) infections. Methods: We conducted a targeted literature review and assessed hospital guidelines for prevention and control of RSV and C. difficile infections in hospital settings in Germany, Italy, and the UK. The definition and framework were tested via semi-structured interviews among healthcare professionals. Results: Health system pressure can be generally defined as resource utilisation given a pre-set usable capacity. Its impact can be measured as the opportunity cost of actions taken to prevent or mitigate pressure. Actions to prevent or mitigate pressure due to RSV or C difficile can be classified by their impact on staff (labour resources), stuff (non-labour resources and materials), and structure capacity. Increased staffing needs drive RSV pressure during the RSV respiratory season and are considered to be extremely likely and extremely costly by 75% of the interviewees. C. difficile pressure is driven by the activation of outbreak-induced infection control protocols, which are likely to affect every capacity dimensions according to over 60% of the interviewees, and lead to large costs of infrastructure needed to isolate patients. In general, actions to mitigate pressure are associated with higher costs than actions used to prevent pressure before it occurs. Conclusions: This research describes a novel definition and framework for health system pressure. Further development and application of this framework may enable HTA bodies to describe and measure the potential impact of vaccination on health care systems.

17.
American Family Physician ; 105(3):262-270, 2022.
Article in English | EMBASE | ID: covidwho-1848427

ABSTRACT

Health care–associated infections (HAIs) are a significant cause of morbidity and mortality in the United States. Common examples include catheter-associated urinary tract infections, central line–associated bloodstream infections, ventilator-associated pneumonia, surgical site infections, and Clostridioides difficile infections. Standardized infection control processes and precautions have been shown to reduce the rate of HAIs, and targeted practices for HAIs have shown further reductions. Patient safety tools have been developed for various HAIs to help guide administrators and are free for public use through the Centers for Disease Control and Prevention STRIVE (States Targeting Reduction in Infections via Engagement) initiative. The Choosing Wisely initiative makes best practice recommendations for physicians to improve quality of care and reduce costs;targeted recommendations were developed to reduce the risk of HAIs. For example, using invasive devices only when indicated and for the shortest time possible reduces the risk of device-related HAIs. The goal of antibiotic stewardship is to reduce C. difficile infections and further development of multidrug-resistant organisms such as vancomycin-resistant Enterococcus and carbapenem-resistant Enterobacteriaceae. Antibiotic stewardship targets physician behaviors such as reviewing antibiotic therapy choices every 48 to 72 hours, reviewing culture results as soon as available, de-escalating antibiotic therapy when appropriate, and documenting the indications for initiating and continuing antibiotic therapy.

18.
Open Forum Infectious Diseases ; 8(SUPPL 1):S103-S104, 2021.
Article in English | EMBASE | ID: covidwho-1746766

ABSTRACT

Background. The COVID-19 pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. Our objective was to evaluate the impact of COVID-19 pandemic on incidence and trends of healthcare-associated infections (HAIs) in a network of hospitals. Methods. This was a retrospective review of central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), C. difficile infections (CDI), and ventilator-associated events (VAE) in 51 hospitals from 2018 to 2021. Descriptive statistics were reported as mean hospital-level monthly incidence rates (IR) and compared using Poisson regression GEE models with period as the only covariate. Segmented regression (SR) analysis was performed to estimate changes in monthly IR of CAUTIs, CLABSIs and CDI in the baseline period (01/2018 - 02/2020) and the Pandemic period (03/2020 -03/2021). SR model was not appropriate for VAE based on the plot. All models were constructed using SAS v.9.4 (SAS Institute, Cary NC). Results. Compared to the baseline period, CLABSIs increased significantly by 50% from 0.6 to 0.9/ 1000 catheter days (P< 0. 001). In contrast, no significant changes were identified for CAUTI (P=0.87). Similar trends were seen in SR models for CLABSI and CAUTI (Figures 1, 2 and Table 1). While overall CDIs decreased significantly from 3.5 to 2.5/10,000 patient days in the pandemic period (P< 0.001), SR model showed increasing pandemic trend change (Figure 3). VAEs increased > 700% from 6.9 to 59.7/1000 ventilator days (P=0.15), but displayed considerable variation during the pandemic period (Figure 4). Compared to baseline period, there was a significant increase in central line days (647 vs 677, P=0.02), ventilator days (156 vs 215, P< 0.001), but no change in urinary catheter days (675 vs 686, P=0.32) during the pandemic period. Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs and VAEs, no change in CAUTIs, and an increasing trend in CDI incidence. These variations in trends of different HAIs are likely due, in part, to unique characteristics of the underlying infection, resource shortages, staffing concerns, increased device use, changes in testing practices, and the limitations of surveillance definitions.

19.
Open Forum Infectious Diseases ; 8(SUPPL 1):S259, 2021.
Article in English | EMBASE | ID: covidwho-1746687

ABSTRACT

Background. There is increasing evidence that patients hospitalized with COVID-19 receive unnecessary antibiotics. The consequences of antibiotic overuse as it relates to antimicrobial resistance and development of secondary infections remains uncertain. The objective of this study is to compare antibiotic prescription patterns in patients with a history of COVID-19 to those without a history of COVID-19 and determine if there are differences in the frequency of secondary infections from Clostridioides difficile (C. difficile), multidrug-resistant (MDR) bacteria, and candida infections. Methods. This study is a single-center, retrospective cohort study of 18,757 adults hospitalized during the COVID-19 pandemic from March 1, 2020 to March 31, 2021. Patients were stratified as COVID-19 positive, throughout all hospitalizations subsequent to the date of initial positivity, or COVID-19 negative. Differences in antibiotic practice patterns between the two groups were quantified using days of therapy per 1000 patient days (DOT/1000 PD). The frequency of C. difficile infection, MDRbacteria, and candida infections were assessed among the two groups. Results. During the 12-month study period, on average, the COVID-19 positive group received 21.81% more antibiotics than COVID-19 negative patients, with up to 56.15% increase seen in the first month of the pandemic (Table 1, Figure 1) The COVID-19 positive group had an increased frequency of Candidemia (0.73% versus 0.18%, p< .00001) and decreased isolation of ESBL organisms (1.17% versus 1.87%, p< 0.01416) compared to the COVID-19 negative group. There were no significant differences in frequency of C. difficile infection, isolation of other MDR-organisms, or Candida auris between the two groups. (Table 2) Conclusion. Patients with a history of COVID-19 infection received an average of 21.81% more antibiotics, have higher rates of candidemia, but lower rates of ESBL infection than those without a history of COVID-19 infection. The potential increase in antibiotic exposure could account for the increase in candidemia in patients with a history of COVID-19. Future studies include investigating the decrease in ESBL infections seen, perhaps due to receipt of broad antibiotics in COVID-19 patients that target ESBL bacteria.

20.
Open Forum Infectious Diseases ; 8(SUPPL 1):S296, 2021.
Article in English | EMBASE | ID: covidwho-1746606

ABSTRACT

Background. Patients with severe SARS-CoV-2 infection are at high risk of complications due to the intensive care unit stay. Hospital-acquired infections (HAI) are one of the most common complication and cause of death in this group of patients, it is important to know the epidemiology and microbiology of this hospital-acquired infections in order to begin to the patients a proper empirical treatment. We describe the epidemiologic and microbiologic characteristics of HAI in patients with COVID-19 hospitalized at intensive care unit (ICU) in a tertiary level private hospital in Mexico City. Methods. From April to December 2020, data from all HAIs in patients with severe pneumonia due to SARS-CoV-2 infection with mechanical ventilation at ICU were obtained. The type of infection, microorganisms and antimicrobial susceptibility patterns were determined. Results. A total of 61 episodes of HAIs were obtained, the most common was ventilator associated pneumonia (VAP) in 52.4% (n=32) followed by urinary tract infection (UTI) 34.4%(n=21) and bloodstream infection (BSI) 9.84% (n=6). Only two episodes corresponded to C. difficile associated diarrhea. We identified 82 different microorganisms, the most frequent cause of VAP was P. aeruginosa 22% (10/45) followed by K. pneumoniae 20% (9/45);for UTI, E. coli 28.5% (6/21), and S. marcescens 19% (4/21);for BSI the most frequent microorganism was S. aureus 28.5 (2/7). Regarding the antimicrobial susceptibility patters the most common were Extended Spectrum Beta-Lactamase (ESBL) Gram-negative rods followed by Methicillinresistant Staphylococcus aureus. Conclusion. In patients with severe COVID-19 hospitalized in the ICU the most frequent HAIs were VAP and UTI caused by P. aeruginosa and E. coli respectively. ESBL enterobacteriaceae was the most common resistant pattern identifed in the bacterial isolations in our series.

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