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1.
Japanese Journal of Chemotherapy ; 69(5):361-366, 2021.
Article in Japanese | EMBASE | ID: covidwho-2168769

ABSTRACT

Common cold and influenza are often complicated by pneumococcal pneumonia, but the complication whereas pneumococcal pneumonia complicating COVID-19 is not common. Both influenza and COVID-19 are respiratory viral infections, and their pathogenesis depends on the host immune response. Therefore, clinically, accurate pathogen diagnosis in the early stage of the clinical course for the purpose of formulating an appropriate treatment plan may contribute to improvement of the patient prognosis. Clinical characteristics of COVID-19 in clinical manifestations, epidemiological history, laboratory findings and radiological findings, some of which were different and some of which were similar from influenza or any other common cold. We would like to emphasize the importance of researching the mechanism of pneumonia induced from common cold, influenza, COVID-19 and any other respiratory viral infection. Copyright © 2021 Japan Society of Chemotherapy. All rights reserved.

2.
Cureus ; 14(12):e32686, 2022.
Article in English | PubMed Central | ID: covidwho-2203427

ABSTRACT

In the United States, influenza virus and bacterial pneumonia are known to be the leading causes of hospitalization in the winter season. Although healthcare workers are knowledgeable about the management of these co-infections, with the coronavirus disease 2019 (COVID-19) global pandemic that occurred in 2019, a significant change has occurred. The symptoms and clinical manifestations of COVID-19 are similar to that of influenza virus and bacterial pneumonia which can present a unique challenge for healthcare workers. Many reports are available for influenza virus and bacterial pneumonia but none about influenza, bacterial pneumonia, and COVID-19 co-infection.Here, we present the case of a patient who was admitted with COVID-19, influenza, and bacterial pneumonia co-infection, along with his clinical characteristics, laboratory findings, treatment plan, and outcomes.

4.
Indian Journal of Nephrology ; 32(7 Supplement 1):S119, 2022.
Article in English | EMBASE | ID: covidwho-2201600

ABSTRACT

BACKGROUND: Small percentage of catheter-related bloodstream infection may present atypically with persistent low-grade fever without chills and rigor and in some of these cases blood culture can be negative. These may lead to diagnostic confusion and delay in detection of the common entity of catheter-related blood stream infections. AIM OF THE STUDY: Case discussion with learning points METHODS: We report a case with multiple pictorial images and discuss differential diagnosis with few learning points. RESULT(S): 42-year-old male patient, a known case of end-stage chronic kidney disease on maintenance hemodialysis through a tunneled catheter, presented with a history of intermittent, low-to-moderate fever for 3 weeks. The fever associated with generalized weakness, night sweats but was not associated with chill and rigor. His past medical history included endstage chronic kidney disease due to chronic glomerulonephritis and was on maintenance hemodialysis thrice weekly for last 6 months through tunneled catheter in right IJV. On physical examination, the patient had tachycardia, normotension with a blood pressure of 120/70.mmHg, normal saturation at room air with respiratory rate of 20 /minute. On auscultation, there was reduced breath sounds on left side and normal heart sounds. The catheter site showed no heat, erythema, swelling, tenderness. Chest radiograph revealed left hydropneumothorax with multiple focal pulmonary nodular opacities. CECT chest showed left loculated hydropneumothorax with multiple cavitary nodules with reverse halo sign (Figures 1 and 2). Lab investigations showed significant leukocytosis with neurophilia, random serum glucose of 250.mg/dL, and D-dimer of 3624.ng/mL. Blood cultures from hemodialysis catheter and contralateral peripheral vein were negative for pathogenic bacteria, mycobacteria, and fungal etiology. Urine analysis was sterile and did not have pus cells. On day 4 of admission, patient had left axillary pain. On clinical examination, there was focal tenderness on examination in the left axilla. On ultrasonography, there was a small collection which was aspirated under ultrasound guidance and showed gram-positive bacteria on microscopy. Trans esophageal echocardiography revealed multiple tiny vegetations on right side of interatrial septum on tricuspid valve (Figure 3). Subsequent culture results showed methicillin resistant staphylococcus sensitive to clindamyin, vancomycin, linezolid, ciprofloxacin (Figure 4 and 5). The patient was started on vancomycin and ceftazidine on empirical basis for microscopic findings, and after subsequent culture revealed methicillin-resistant Staphylococcus aureus, he was treated with vancomycin. Permanent catheter was removed. Hemodialysis was continued through temporary right IJV catheter. Blood cultures were cleared from MRSA on hospital day ten. She got discharged home on intravenous Vancomycin for 6-8 weeks and was reported doing well on follow-up. CONCLUSION(S): The learning points are- 1. MRSA infection is common in chronic kidney disease patient on hemodialysis. 2. Clinical presentation of metastatic MRSA infection with infective endocarditis may be indolent with cardiovascular and respiratory stability with absence of fever spikes, chill, and rigor. 3. Common infective causes of cavitary nodules in lung are typical and atypical mycobacterial infection, fungal infection, and pyogenic septic emboli. 4. Uncommon infective causes of reverse halo sign on CT chest need to be remembered and include bacterial pneumonia, septic embolism, mycobacterial infection, invasive aspergillosis, in addition to common infective etiology of reverse halo sign like mucormycosis infection and COVID19 infection.

5.
Neurology ; 93(23 Supplement 2):S37-S38, 2022.
Article in English | EMBASE | ID: covidwho-2196695

ABSTRACT

Objective To evaluate the safety and efficacy of efgartigimod in patients with generalized myasthenia gravis (MG) enrolled in the ADAPT+ longterm extension study. Background Treatment with efgartigimod, a human IgG1 antibody Fc-fragment that blocks neonatal Fc receptor, resulted in clinically meaningful improvement (CMI) in MG-specific outcome measures in the ADAPT phase 3 clinical trial. All patients who completed ADAPT were eligible to enroll in its ongoing open-label, 3-year extension study, ADAPT+. Design/Methods Efgartigimod (10 mg/kg IV) was administered in cycles of once-weekly infusions for 4 weeks, with subsequent cycles initiated based on clinical evaluation. Efficacy was assessed during each cycle utilizing Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scales. Results Ninety-one percent of ADAPT patients (151/167) entered ADAPT+. As of February 2021, 106 AChR-Ab+ and 33 AChR-Ab- patients had received at least 1 dose of open-label efgartigimod (including 66 ADAPT placebo [PBO] patients). The mean (SD) study duration was 363 (114) days, resulting in 138 patient-years of observation. Similar incidence rates per patient year (IR/PY) of serious adverse events were seen in ADAPT (efgartigimod: 0.11;placebo: 0.29) compared to ADAPT+ (0.25). Five deaths (acute myocardial infarction, COVID-19 pneumonia/septic shock, bacterial pneumonia/MG crisis, malignant lung neoplasm, and unknown [multiple cardiovascular risk factors identified on autopsy]) occurred;none were considered related to efgartigimod by the investigator. AEs were predominantly mild or moderate. CMI was observed in AChR-Ab+ patients during each cycle (up to 10 cycles) at magnitudes comparable to improvements observed at week 3 of cycle 1 (mean[SE] improvements: MG-ADL, -5.1[0.34];QMG, -4.7[0.41]). Clinical improvements mirrored maximal reductions in total IgG and AChR-Abs across all cycles. Conclusions This analysis suggests the efficacy of long-term treatment with efgartigimod was consistent across multiple cycles. No new safety signals were identified, despite being conducted before vaccine availability during the COVID-19 pandemic.

6.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2194362

ABSTRACT

Case Description: 54-year-old man presented to the Emergency Department (ED) three weeks after Covid-19 infection for progressively worsening dyspnea and hypoxemia. Dexamethasone and prophylactic apixaban (2.5mg twice a day) were initiated and he was discharged 48 hours later. A week after discharge he re-presented to the ED requiring 6L of oxygen (O ) despite uninterrupted dexamethasone and apixaban therapy. His past medical history was significant for quiescent IgG4 disease on Rituximab and Type 1 Diabetes. He was afebrile, tachycardic and tachypneic with decreased right lower lobe breath sounds. He had an elevated erythrocyte sedimentation rate and C-reactive protein, no leukocytosis and no pulmonary embolism of CT. He was admitted and vancomycin and cefepime antibiotic therapy for a superimposed bacterial pneumonia was begun. On day 12 of the hospital stay, he experienced new onset chest pain. Evaluation showed an elevated troponin and submillimeter ST segment elevation concerning for an evolving STEMI. Coronary angiography demonstrated an 90% diffuse mid LAD stenosis and two large coronary aneurysms of the left circumflex artery (LCx). The mid-LAD was stented using a 3.0 x 38 mm and 2.75 x 26 mm Onyx drug eluting stents with resolution of his chest pain. IgG4 serum level was normal and imaging did not demonstrate active IgG4 disease. He was discharged on aspirin and clopidogrel. Due to concern for a hypercoagulable state in the setting of Covid 19 infection, IgG4 disease and the large coronary aneurysms for thrombus formation, warfarin anticoagulation was also initiated. On review of his coronary imaging, the largest LCx aneurysm was 9mm on admission and 12mm three weeks later with evidence of diffuse coronary inflammation. CT Fractional Flow Reserve (abnormal <= 0.80) demonstrated decreased flow at the distal aneurysm with no focal stenosis to account for flow reduction. Conclusion(s): 54-year-old man with IgG4 disease presenting with prolonged Covid-19 infection and acute NSTEMI. He was found to have large, flow limiting coronary aneurysms and inflamed coronary arteries all consistent with his IgG4 disease. Management of these aneurysms will be discussed.

7.
Pediatric Critical Care Medicine Conference: 11th Congress of the World Federation of Pediatric Intensive and Critical Care Societies, WFPICCS ; 23(11 Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2190814

ABSTRACT

BACKGROUND AND AIM: Flu is generally benign, although it can sometimes cause serious complications. The goal of the study was to describe the frequency, clinical evolution and complications of influenza in a PICU during five epidemic seasons. METHOD(S): Retrospective observational study of patients with influenza diagnosis admitted to PICU between 2015 and 2022. Demographic variables, morbidity, virus serotype, treatments, mortality and length of the PICU stay, were collected. RESULT(S): Twenty-five patients were admitted into the PICU for influenza, with a median age of 2 (IQR 2 - 6.5) years;52% were male and 40% had associated morbidity. Influenza A accounted for 80%, influenza B 12% and co-infection influenza A+B 8%. Bacterial co-infection was present in 20%, with the most common organisms being streptococcus pneumoniae and streptococcus pyogenes. We observed complications in 80% (sepsis/septic shock, bacterial pneumonia, pleural effusion, myocarditis, supraventricular tachycardia and seizures);64% received antibiotic therapy and 40% Oseltamivir. Non-invasive respiratory support was required in 48%, mechanical ventilation in 28% and inotropicvasopressor drugs in 20%. During the COVID-19 pandemic, there were no admissions for Influenza in the 2020-2021 season, and the first admission occurred in March 2022. Twenty-four months free of influenza were observed. During the study period, median PICU stay was 2 days [IQR 2 - 6.5]. Three children died (12%). CONCLUSION(S): We observed a high rate of complications and mortality, especially during the last SARS-COV-2 prepandemic season, since then we have only had 1 mild case admitted. Preventive measures against SARS-CoV-2 have probably contributed to reducing Influenza transmission.

8.
Critical Care Medicine ; 51(1 Supplement):435, 2023.
Article in English | EMBASE | ID: covidwho-2190613

ABSTRACT

INTRODUCTION: Cryptogenic organizing pneumonia (COP) accounts for 5% of all ILD cases. Due to a low incidence rate of 1 case per 100,000 persons per annum, it is often misdiagnosed as bacterial pneumonia, but when timely managed, it has an excellent prognosis. We discuss Methamphetamine, a commonly abused stimulant that has unfortunately not yet garnered enough notoriety as a respiratory toxidrome for causing inhalation injury, potentially leading to fulminant COP. DESCRIPTION: A 44-year-old male presented to ED with fevers, cough, and dyspnea gradually worsening over the past two weeks. Of note, he smoked ten cigarettes/day and relapsed to methamphetamines inhalation, the latest use being two weeks prior. On physical exam, oxygen saturation was 70% on RA and had significant bilateral inspiratory crackles. The respiratory Viral Panel, including COVID-19, was negative. Drug screens were negative. Chest X-Ray and CTA showed bilateral ground glass opacities concerning multifocal pneumonia but no pulmonary embolism. Broadspectrum antibiotics were started. For worsening Acute Hypoxemic Respiratory failure (AHRF) on Day 3, he underwent intubation and mechanical ventilation. Further workup for infectious etiologies like S. pneumoniae and Legionella, HIV-1, and sputum and blood cultures were all negative. Initial autoimmune and connective tissue disease workup was within normal limits. Bronchoalveolar lavage (BAL) analysis did not yield an infectious, inflammatory, or neoplastic source. On day 7, he underwent an open lung biopsy which confirmed COP, with histological features of toxic injury. IV glucocorticoids were started, with gradual improvement noticed in AHRF. DISCUSSION: Respiratory failure within 30 days of hospitalization is the most common cause of mortality in fulminant COP.If a patient's history suggests exposure to inhaled amphetamine and have no response to antibiotics for supposed pneumonia, physicians should consider COP to make a timely diagnosis and initiate glucocorticoid treatment to warrant rapid clinical improvement, often seen as early as 72 hours, and prevent future relapses.With Substance use continuing to be a major healthcare problem, now more than ever, healthcare providers must be familiar with respiratory toxidrome to provide timely diagnosis and treatment.

9.
Critical Care Medicine ; 51(1 Supplement):229, 2023.
Article in English | EMBASE | ID: covidwho-2190562

ABSTRACT

INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is a rare but severe complication associated with COVID-19 infection in which diffuse inflammation involving multiple organ systems ensues. This condition is commonly described as a sequela in patients with moderate to severe COVID-19 pneumonia. Herein, we describe the case of a 74-year-old female patient who was previously fully vaccinated and developed MIS-A after hospitalization for COVID-19 pneumonia. DESCRIPTION: The patient is a 74-year-old female who presented with fever, chills, and shortness of breath. Of note, the patient was discharged four weeks prior, after hospitalization for COVID-19 pneumonia, and treated with dexamethasone and Remdesivir. During that hospitalization, the patient was noted to be hypoxic on 2 liters via nasal cannula. However, the patient's oxygenation status improved during the hospitalization, and she was discharged home two weeks prior on oral dexamethasone. On arrival at ED, the patient was notably hypotensive, tachycardic, tachypneic, febrile, and hypoxic to 88% on room air. Labs showed CRP at 49, IL-6 at 9.51, creatinine level 2.27, and troponin at 1.83. Computed tomography (CT) chest with contrast showed moderate right and multiple basal left pulmonary embolism. The patient was subsequently admitted to medical floors with a diagnosis of post covid inflammatory pneumonitis, pulmonary embolism, and possible myocarditis. The patient's condition worsened during the hospital stay;she was diagnosed with super-added bacterial pneumonia and subsequent sepsis and passed away in the ICU after the family decided to focus on comfort measures. DISCUSSION: The CDC guidelines for diagnosing MIS-A require fever, multi-organ involvement, and elevated inflammatory markers after a recent COVID-19 infection. There have been multiple reported cases, and they have all been in patients with severe COVID-19 pneumonia. After completing her vaccination series, our patient developed COVID-19 infection and subsequent MIS-A. To our knowledge, this is the first reported case of MIS-A in a fully vaccinated patient, adding to the literature that vaccinations, though they prevent severe COVID-19 infection, may not completely prevent the development of rare long-term complications.

10.
Critical Care Medicine ; 51(1 Supplement):213, 2023.
Article in English | EMBASE | ID: covidwho-2190547

ABSTRACT

INTRODUCTION: Secondary bacterial pneumonia in patients with COVID-19 is a severe complication. It has been noted that the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) positive respiratory cultures in patients with COVID-19 is approximately 6%. However, the true prevalence of bacterial co-infection in these patients is unknown. However, we do not know if infection with the SARS-COV-2 virus or the development of COVID-19 impacts the performance of the MRSA nasal swab screening test. Thus, we conducted a retrospective cohort study evaluating the predictive value of MRSA screening swabs in patients with COVID-19 and secondary bacterial pneumonia. METHOD(S): This was an IRB-approved, retrospective cohort study of patients who had nasopharyngeal specimens positive for SARS-COV-2 virus, screening MRSA nasal swabs performed, and bacterial cultures collected. Patients were diagnosed with pneumonia based on a standardized definition. The primary objective of this study was to determine the sensitivity, specificity, positive predictive value, and negative predictive value of a positive MRSA nasal swab and MRSA pneumonia in patients who are also positive for the SARS-COV-2 virus. Secondary outcomes included hospital length of stay, in-hospital mortality, and antibiotic therapies. RESULT(S): A total of 293 patients were included in the final analysis and 662 microbiological samples were evaluated in this study. The specificity (91.8% [95% CI 88.6% to 95%]) and negative predictive values (NPV 97.4% [95% CI 95.4% - 99.3%]) of MRSA nasal swabs were high. However, the sensitivity (46.2%;95% CI 19.1% to 73.3%) and positive predictive value (PPV 20.7%;95% CI 59.5 - 35.4%) were low. Those patients with a negative MRSA nasal swab had a median length of stay of 14 days (IQR 6 days to 26 days) and those with a positive nasal swab had a median length of stay of 20 days (IQR 12 days to 28 days) (p=0.096). There was no difference in in-hospital mortality. CONCLUSION(S): In general, screening MRSA swabs in patients with COIVD-19 had a high NPV and low positive PPV. Thus, the performance of screening MRSA swabs in patients with COIVD-19 and secondary bacterial pneumonia was similar to those patients without COVID-19.

11.
Critical Care Medicine ; 51(1 Supplement):194, 2023.
Article in English | EMBASE | ID: covidwho-2190535

ABSTRACT

INTRODUCTION: Tocilizumab has been used for treatment of COVID-19 in hospitalized patients who require supplementation oxygen. Various concerns regarding its use in pregnant patients have been presented, however very limited data exists regarding the use of tocilizumab in this population. METHOD(S): Between July 2021 and November 2021, 7 pregnant patients unvaccinated against COVID-19 were admitted to the medical intensive care unit with acute hypoxemic respiratory failure secondary to COVID-19 infection. The average age of patients was 29 with average gestational term of 27 weeks and average BMI of 38kg/m2. All patients had received dexamethasone and remdesivir per standard hospital protocols and antibiotics for superimposed bacterial pneumonia in patients with infiltrates concerning for concomitant bacterial picture. However, these patients still had high oxygen requirements prompting administration of tocilizumab. Each patient received 800mg of tocilizumab as a single dose. RESULT(S): After administration of tocilizumab, oxygen requirements decreased in 6 out of 7 patients, resulting in an avoidance of mechanical ventilation. Typical serum markers used to measure inflammatory response in COVID-19, including C-reactive protein and D-dimer, showed improvement after administration of tocilizumab in 6 out of 7 patients. All pregnancies progressed to successful live birth with no notable fetal deformities or malformations. Out of the 7 patients, there were 5 preterm deliveries, defined as gestational age of 37-38 weeks. 2 of the 7 patients underwent caesarean delivery for maternal hypoxia, both in the setting of severe COVID-19 infection. All infants had a birth weight within normal limits for their gestational age. No complications were noted during vaginal birth of caesarean delivery. CONCLUSION(S): Based on this review, it appears that the use of tocilizumab provided benefit in 85.7% of patients, preventing progression to mechanical ventilation. Based on this case series, tocilizumab seems to be a safe option for pregnant woman and subsequently their babies, with no severe complications or deformities noted during birth. However, 71.4% of patients did undergo preterm labor, prompting future research into whether these is any correlation between tocilizumab and preterm labor.

12.
Open Forum Infectious Diseases ; 9(Supplement 2):S478-S479, 2022.
Article in English | EMBASE | ID: covidwho-2189775

ABSTRACT

Background. Antibiotic stewardship has been a central challenge of the COVID-19 pandemic. Empiric antibiotic therapy is offered in 56.6%-74.6% of inpatients with COVID-19, with microbiologically confirmed bacterial pneumonia reported in only 3.5%-16% of cases. Procalcitonin (PCT) as a biomarker for bacterial infection is of interest in improving antibiotic use. PCT-guided antibiotic stewardship initiatives have demonstrated reduction in the use of antibiotics in the COVID-19 pandemic. An Infectious Diseases (ID) consultation was obtained on most patients at our institution throughout the COVID-19 pandemic. We report a significant reduction in antibiotic use among COVID-19 patients in the setting of near-universal ID consultation in COVID-19 patients. Methods. We evaluated the records of 1346 patients with COVID-19 from March 2020 - May 2021 at four hospitals with ID consultant availability. We assessed the inclusion of an ID consultant, antibiotic indication, initiation and discontinuation, PCT levels, radiologic images, and changes to therapy decisions. A chi-square test of independence and simple logistic regression were conducted to determine whether an association exists between the PCT level and the decision to discontinue antibiotics. Results. Of 1346 patients with a confirmed COVID-19 diagnosis, 64.6% (870/ 1346) received antibiotics on admission. The most common diagnosis associated with initial antibiotic administration was bacterial pneumonia (692/870, 79.5%). An ID consultation was obtained on 97.8% (677/692) of the patients that received antibiotics for suspected bacterial pneumonia. In 48.1% (326/677) of these patients, antibiotics were discontinued within the first 48 hours of the ID consultation. A statistically significant difference was noted between the PCT level and continuation of antibiotics (X2= 67.02, p < .01). The odds of discontinuing antibiotics for the upper (PCT > 0.51) and middle (PCT = 0.26-0.50) groups were 0.22 and 0.37, respectively, when compared to the lower (PCT <= 0.25) group. Conclusion. Early consultation of an ID specialist and evaluation of PCT levels leads to significant reductions in inappropriate antibiotic use. PCT may be a useful adjunct in assisting with the decision to discontinue antibiotics.

13.
Open Forum Infectious Diseases ; 9(Supplement 2):S474, 2022.
Article in English | EMBASE | ID: covidwho-2189767

ABSTRACT

Background. Baricitinib is a treatment authorized by the FDA for the treatment of moderate to severe COVID-19, despite this there are few approved drugs;polymerized type I collagen (PTIC) is a drug that has been used in Mexico with great potential for treating moderate to severe cases of COVID-19. Methods. Comparative, descriptive and retrospective analysis of two populations of adult patients affected by COVID-19 confirmed by antigen test or RT-PCR as well as CO-RADS 6 CT, who consented to be treated between 2020 and 2021, a population using oral baricitinib at a dose of 4mg/day/14 days and another using polymerized type I collagen intramuscularly at a dose of 1.5ml every 12 hours for 3 days, followed by 1.5ml every 24 hours for 4 days;The most affected age and gender, comorbidities and laboratory abnormalities are analyzed, as well as improvement in inflammatory and oxygenation indices measured by pulse oximetry and SAFI (SpO2/FiO2), finally the outcome of the patients and the presence of adverse events. Results. 80 patients for each group, the most affected gender was male;the average age in the PTIC group was 51 years and in the baricitinib group it was 56 years;the main comorbidities were obesity, diabetes and hypertension in both groups;the decrease in acute phase reactants such as CRP, D-dimer and ferritin was greater in the PTIC group compared to the baricitinib group, the latter drug requiring a regimen of more days to achieve the objectives of the first drug (PTIC 7 days and baricitinib 14 days);Similarly, in oxygenation measured, the PTIC group reached goals in less time compared to the baricitinib group, which required twice as many days of treatment to achieve adequate oxygenation;Regarding the outcomes, there was a higher mortality in the baricitinib group compared to the PTIC group (6.25% vs 3.75%). Regarding adverse events reported for the PTIC group, they were minor and related to the intramuscular administration of the drug in 7 patients, while in the baricitinib group, 5 patients were reported with added bacterial pneumonia. Conclusion. Polymerized type I collagen has anti-inflammatory and immunomodulatory potential similar to baricitinib in cases of moderate to severe COVID-19, even reaching treatment goals in less time both in inflammatory indices and in oxygenation indices.

14.
Open Forum Infectious Diseases ; 9(Supplement 2):S356, 2022.
Article in English | EMBASE | ID: covidwho-2189669

ABSTRACT

Background. Acinetobacter baumannii typically causes infections in debilitated, hospitalized patients and is difficult to treat due to multiple virulence factors and the presence of intrinsic and acquired antibiotic resistance mechanisms leading to frequent isolation of multi-drug resistant (MDR) phenotypes. Due to problematic pharmacokinetics and/or dose-limiting toxicities of salvage agents, combination therapy with aminoglycosides, ampicillin/sulbactam, polymyxins, minocycline, or tigecycline, is often used. Eravacycline has demonstrated greater in-vitro potency against A. baumannii compared to other tetracycline derivatives making it potentially the more appealing option. However, its utility is hindered by a lack of data supporting pharmacodynamic targets and adequate dosing strategies for CRAB. The goal of this case series was to describe our experience with the use of combination eravacycline therapy for the treatment of CRAB pneumonia. Methods. This case series included all patients >= 18 years of age, diagnosed with SARS-CoV-2, >= 1 sputum culture positive for CRAB and a clinical diagnosis of new bacterial pneumonia, who received at least one dose of eravacycline between April 1st and October 1st, 2020. The primary outcome was clinical resolution of CRAB pneumonia. Secondary outcomes evaluated microbiological resolution, need for extended durations of therapy, and frequency of re-starting CRAB therapy within 48 hours of completion. Results. In total, 25 patients were included in this case series. The median duration of combination therapy was 10 days. Most patients (96%) received eravacycline + ampicillin/sulbactam, with 7 of those patients also receiving inhaled colistin (Table 2). In total, 17 (68%) patients achieved clinical resolution of CRAB pneumonia. Post-treatment sputum cultures were collected in 18 patients, of which 13 (72%) achieved microbiological resolution. One patient received > 14 days of therapy and no patients re-initiated therapy within 48 hours of eravacycline completion. Table 1: Baseline Characteristics Table 2: Study Outcomes Conclusion. In this small case series, eravacycline showed favorable clinical outcomes in patients with CRAB pneumonia. In light of limited treatment options, this agent can be considered for CRAB pneumonia salvage therapy.

15.
Open Forum Infectious Diseases ; 9(Supplement 2):S184-S185, 2022.
Article in English | EMBASE | ID: covidwho-2189591

ABSTRACT

Background. Procalcitonin (PCT) is often measured in patients with signs of bacterial infection. PCT is often elevated in bacterial pneumonia and septic shock and usually low in viral infections. Recent studies have found a correlation between PCT and disease severity in COVID-19, and most patients receive antibiotics despite bacterial co-infection being rare. We sought to characterize PCT trends in COVID-19, assess its relation to bacterial pneumonia, and assess its relation to clinical decision making around antimicrobial use. Methods. We included patients >=18 hospitalized at Michigan Medicine (3/1/20- 10/31/21), positive for COVID-19, with >= 1 PCT measurement. Structured query was used to retrospectively extract data. Patients started on an antibiotic underwent retrospective chart review by 2 reviewers for presence of bacterial pneumonia (bPNA), and were classified as having proven, probable, possible, or no bPNA (Figure 1). Multivariable models controlling for time from start of the pandemic, demographics, and comorbidities were used to determine associations of PCT and bPNA with antimicrobial use. Figure 1: Flow diagram of patients included in analyses Results. 793 patients met inclusion criteria, with 224 (28.2%) initiated on antibiotics. Of these 224, 33 (14.7%) had proven/probable bPNA, 125 (55.8%) had possible bPNA, and 66 (29.5%) had no bPNA. On average, patients had 2.6 +/-3.7 (mean +/-SD) PCT measurements, with 4.1 +/-5.2 if on antibiotics vs. 2.0 +/-2.6 if not. Initial PCT was higher in those on antibiotics and highest in those with proven/probable bPNA (Table 1). After adjustment for confounders, initial PCT was associated with antibiotic initiation (OR 1.68, 95% CI 1.47-1.91, p < 0.0001) (Table 2). Initial PCT (RR 1.11, 95% CI 1.03-1.20, p=0.008), change in PCT over time (RR 1.03, 95% CI 1.01-1.05, p=0.007), and bPNA category (RR 1.51, 95% CI 1.23-1.84, p < 0.0001) were associated with antibiotic duration (Table 3). Conclusion. PCT was elevated in patients with COVID-19, but more pronounced with bPNA. Antibiotics were started in > 25% of patients, regardless of bPNA. PCT trends associate with the decision to initiate antibiotics and treatment duration, independent of bPNA and comorbidities. Future prospective studies should determine if PCT can be used to safely make decisions around antibiotic treatment for bacterial infection during COVID-19.

16.
Open Forum Infectious Diseases ; 9(Supplement 2):S177, 2022.
Article in English | EMBASE | ID: covidwho-2189574

ABSTRACT

Background. Coinfection in patients with SARS-CoV-2 has been associated with greater complications. We describe the clinical characteristics and outcomes of 126 pediatric patients with COVID-19 and viral, bacterial, or fungal coinfection. Methods. We retrospectively reviewed and analyzed electronic data of all pediatric patients who tested positive for SARS-CoV-2 from April 16, 2020, to April 15, 2022, in our center. Confirmation of COVID-19 was based on positive RT-PCR. Viral coinfections (VC) were identified using a multiplex RT-PCR respiratory viral panel, bacterial coinfection (BC) was determined by positive bacterial culture (blood, bronchoalveolar lavage, sputum, urine) or clinical/radiological manifestations and antimicrobial assessment by a pediatric Infectious Diseases expert and fungal coinfection (FC) diagnosis based on Consensus definitions of invasive fungal disease. Results. During the study period, among 400 pediatric patients with COVID-19, 126 children had coinfection. Children >10 years were the most affected age group. Underlying disease was present in 69%, hematological malignancies were the most common (17.5%). BC was detected in 76.9% (n=97), bacterial pneumonia (54.6%) was the main diagnosis, followed by oncologic patients with initial febrile neutropenia and posterior SARS-CoV-2 detection (14,4%). Unusual BC as congenital syphilis w detected;acute appendicitis was the initial presentation of COVID-19 in 8 patients. VC was identified in 15.87% (n=20), prevailing rhinovirus (9.5%) and adenovirus (3.96%), One FC presented as proven pulmonary aspergillosis (0.8%). B-V and B-F coinfection were detected in 2 patients. Fever and cough were the most common symptoms, higher fever >40degreeC was mostly observed in the BC group (3%). Twenty-seven patients with BC (27.8%) were admitted to intensive care, with the OR 0.7 IR 95% (0.611-1.008), 4.1% died. One ICU admission was observed in the VC group (5%) and all VC cases resolved without complications. Conclusion. Pediatric patients with COVID-19 coinfection, especially BC were common in our center representing nearly one-third of the infected children, including unusual coinfections. BC was identified as a risk factor for ICU admission OR 0.7 IR 95% (0.611-1.008). Favorable outcomes were observed in most cases.

17.
Open Forum Infectious Diseases ; 9(Supplement 2):S168-S169, 2022.
Article in English | EMBASE | ID: covidwho-2189557

ABSTRACT

Background. Antibiotic overuse has been well described among hospitalized adults with COVID-19 but similar evaluations in children are lacking. We sought to quantify bacterial infection rates and antibiotic utilization among critically ill children hospitalized with COVID-19 to identify opportunities to optimize care. Methods. We performed a single center retrospective cohort study of all children hospitalized with symptomatic COVID-19 in a pediatric intensive care unit between May 16, 2020 and February 11, 2022 at a tertiary care children's hospital in the Southeastern U.S. We performed medical record review to demographic and clinical characteristics. This study was approved by the institutional IRB with a waiver of consent. Results. During the study period there were 92 subjects hospitalized in the intensive care unit with COVID-19. Demographic and clinical characteristics of the cohort are summarized in the Table. Median age was 12.4 years, median length of stay was 6 days, 32% of subjects required mechanical ventilation and 5% died. The vast majority of children had one or more comorbidities and only 1 subject was fully vaccinated against SARS-CoV-2. Thirteen (14%) subjects had bacterial growth from any clinical specimen. Eight subjects had respiratory cultures that may have represented airway colonization;when these were excluded, 5 (5%) subjects had either urinary tract or bloodstream infections. Two of the bloodstream infections were caused by drug-resistant organisms and were hospital-acquired. Despite the low number of subjects with bacterial infections, 45% received antibiotics for >3 days. The antibiotic days of therapy per subject varied widely and ranged from 0 to 61 days. Conclusion. In this cohort of nearly 100 critically ill children with COVID-19, the rate of culture-confirmed bacterial infection ranged from 5-14% yet nearly half of patients received antibiotics. Limitations include the single center and retrospective study design and the fact that bacterial pneumonia may not be cultureconfirmed. Despite these limitations, this work suggests that children with COVID-19 rarely have bacterial co-infections and are often prescribed unnecessary antibiotics.

18.
Open Forum Infectious Diseases ; 9(Supplement 2):S129-S130, 2022.
Article in English | EMBASE | ID: covidwho-2189547

ABSTRACT

Background. Hospitalized COVID-19 patients with severe pneumonia are commonly treated for secondary bacterial pneumonia. The Biofire pneumonia panel, a rapid molecular diagnostic tool with 18 bacterial, 8 viral and 7 resistance gene targets, was made available to critical care and infectious disease clinicians in May 2020 at our institution. We sought to describe its utilization and influence on antibiotic use in patients hospitalized with COVID-19 lower respiratory tract infection (LRTI). Methods. Eligible patients with COVID-19 LRTI (positive PCR test and abnormal chest imaging) had sputum or bronchoalveolar lavage pneumonia panel (PNP) paired with a respiratory tract culture between May 4 and Dec. 8, 2020, were included. Demographics, comorbidities, clinical data including microbiologic testing, PNP indication( s), and antibiotic use after testing were ed through chart review. Descriptive statistics were utilized. Results. Characteristics of 133 patients are provided in Table 1. Median age was 61 years, 93 (70%)weremale, 93 (70%)weremechanically ventilated, and 68 (51%) died within 30 days on PNP testing. PNP results, including culture results are listed in Table 2. No target was identified in 63 (47%) patients. Staphylococcus aureus was the most common bacterial isolate identified (MSSA in 32 [24%], MRSA in 8 [6%]) with culture growth in 21 specimens. More than 1 target was identified in 29 patients (22%). Empiric antibiotics and subsequent modifications within 24h hours of pneumonia panel are provided in Table 3. Vancomycin and cefepime were most frequently prescribed. Antibioticmodifications were made in 71/133 patients. Cessation of the anti-MRSA agent occurred in 39/72 (54%) of eligible patients and the anti-Pseudomonal agent in 21/78 (27%). Conclusion. The PNP is a useful tool to evaluate secondary bacterial pneumonia in critically ill COVID-19 patients and may assist clinicians and antimicrobial stewardship programs in expedited antibiotic discontinuation or de-escalation particularly where rates of secondary bacterial infection are low, such as COVID-19 LRTI. (Table Presented).

19.
Value in Health ; 25(12 Supplement):S131, 2022.
Article in English | EMBASE | ID: covidwho-2181122

ABSTRACT

Objectives: Antimicrobial resistance is a critical public health issue in Greece, which has worsened during COVID-19 pandemic due to antibiotic overuse. The present study assesses the cost-effectiveness of ceftolozane/tazobactam(C/T) in ICU-admitted ventilated hospital-acquired bacterial pneumonia (vHABP) and ventilator-associated bacterial pneumonia (VABP) due to Multiple Drug Resistant Pseudomonas Aeruginosa in Greece. Method(s): The model is based on data from ASPECT-NP Phase-3 study and PACTS surveillance data from Italy. The model consists of two parts: a decision-tree, depicting the period from vHABP/VABP diagnosis to hospital discharge and a Markov model, projecting long-term outcomes following hospital discharge. The model calculates costs and outcomes within a 40 years' time-horizon. Costs and QALYs are discounted at an annual rate of 3.0%. Outcomes included Incremental Cost Effectiveness Ratio(ICER), Quality Adjusted Life Years (QALY's) and Life Years (LY's) for each comparator as well as hospital resource use and mortality (for each comparator).The comparator used in the base case analysis was Meropenem. A deterministic sensitivity analysis (DSA) was performed to test the parameters with the greatest impact on the ICER and a Probabilistic Sensitivity Analysis (PSA) was run to test the robustness of the results. Result(s): Patients who received C/T spent 1.97 days less (17.99 days) with mechanical ventilator support compared to Meropenem 19.97 days with mechanical ventilator support. Patients in the treatment arm with Meropenem are expected to have 8.66 LY's and 7.11 QALY's with a cost of 33,896. Whereas patients in the C/T arm are expected to have 10.18 LY's and 8.34 QALY's at a cost of 35,135. The ICER for C/T was 994 per QALY compared to Meropenem. C/T showed a 99.94% probability of being cost effective at a threshold of 52,770 per QALY (3x Greek- GDP per capita). Conclusion(s): The present study suggests that Ceftolozane/Tazobactam is a cost-effective treatment for Greek vHABP/VABP patients. Copyright © 2022

20.
European Geriatric Medicine ; 13(Supplement 1):S190, 2022.
Article in English | EMBASE | ID: covidwho-2175447

ABSTRACT

Introduction: 50% of older patients with COVID-19 have high malnutrition (M) risk, which is related to loss of taste and smell, loss of appetite, severe weakness, and complications. Moreover, M is related to a high mortality rate. We aimed to investigate the nutritional status of geriatric in-patients with COVID-19 and to determine the relationship between the two. Method(s): A retrospective study of the electronic medical record was performed, in which 313 patients (202 women) were treated for COVID-19 in the Geriatric department of LSMU Kaunas Hospital. Demographic data and blood test results were collected, and complications and outcomes of the disease were registered. Data was analysed using the Pearson correlation coefficient and Student's t-test. Result(s): The mean age of the subjects was 82.0 +/- 7.2 years. The following qualitative indicators of malnutrition were identified: Lymphopenia - 95.8%, hypoalbuminaemia - 84.9%, anaemia - 35.5%, vitamin D deficiency - 79.3%. Mild level of disease was detected in 10.5%, moderate in 8%, and severe in 81.5% of patients. The majority of subjects developed bacterial pneumonia (70%). Complications of the disease were identified: Respiratory failure (RF) (82.7%), hypovolemia (H) (70.3%), renal impairment (IR) (22.4%), Cl. difficile-induced enterocolitis (15%), pulmonary embolism (PE) (7.7%), and sepsis (5.4%). PE, sepsis, RI, and RF were associated with a higher mortality rate. Mortality was associated with older age. Significant relationships were found between lymphopenia, hypoalbuminemia and severe COVID-19. Key conclusions: Patients with severe COVID-19 were more likely to have lymphopenia and hypoalbuminemia, with the lowest mean of nutritional status and the highest prognostic illness mean.

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