ICU Level Research Articles

Clinical Characteristics of Hospitalized COVID-19 Patients Who Have Gastrointestinal Bleeds Requiring Intervention: A Case-Control Study.

BackgroundCoronavirus disease 2019 (COVID-19) is widely recognized as a disease that affects the respiratory system, although it can also present with significant extrapulmonary symptoms. Very few studies have suggested an increased risk of gastrointestinal (GI) bleeding. This study aimed to elucidate the incidence, etiology, risk factors, and outcomes of clinically significant GI bleeding requiring endoscopic intervention in patients with COVID-19.MethodsThis is a case-control (1:2) retrospective analysis of all hospitalized adult patients with COVID-19 infection admitted between March 1, 2020, and January 5, 2021, in which we compared patients with upper and lower GI bleeds to those without. Cases are defined as patients hospitalized with COVID-19 who had a GI bleed requiring intervention while controls are defined as patients hospitalized with COVID-19 who did not have a GI bleed. Of 1002 patients admitted to the Albany Medical Center with COVID-19 infection, there were 76 confirmed cases of GI bleeding. These patients were compared to a control group composed of randomly selected patients with COVID-19 infection who were admitted to Albany Medical Center over the same time period. We assessed patients for in-hospital mortality, ventilator-free days on day 28, ICU-free days on day 28, and hospital-free days on day 28. Additional information collected included demographic information, comorbid conditions, COVID-19 treatments received, endoscopy findings, endoscopic treatment received, and if the patients required a packed red blood cell transfusion.ResultsOut of 1007 patients hospitalized with COVID-19, 76 (8%) had a GI bleed requiring endoscopic intervention. Peptic ulcer disease in the stomach or duodenum was the most common finding. The use of steroids, antiplatelet agents, and anticoagulation was not associated with an increased risk of GI bleed in COVID-19 patients. The GI bleed group required ICU care in 37% (28/76) compared with 21% (32/152) in the control group, which was statistically significant (p=0.012; chi-square test). Length of hospital stay was longer in the GI bleed group (median 16 days IQR: 8 to 29 versus 7 days, IQR:4 to 16; p<0.001, Mann Whitney test).ConclusionLength of hospital stay and ICU level of care was higher in the GI bleed group of patients with COVID-19. ICU level of care was noted to be associated with an increased risk of GI bleeding. A GI bleed in COVID-19 patients could be from the virus's direct effect on the gut mucosa or stress-induced bleeding like any other severely sick ICU patient; however, this needs to be explored in future studies.

Assessing The Utility of D-Dimer Driven Anticoagulation Strategies In Severely Obese Patients With COVID-19

Funding AcknowledgementsType of funding sources: None.BackgroundMany studies to date have documented significant inflammatory vascular sequelae in association with COVID-19. Current guidelines suggest an initial strategy of therapeutic-dose anticoagulation to non-critically ill, hospitalized patients requiring low-flow oxygen and a concurrent D-dimer level above the upper limit of normal. However, the utility of D-dimer values in predicting thrombosis in severely obese patients are equivocal to poor, with prior evidence suggesting falsely elevated levels with greater BMI. Given the weight-based dosing of heparin, these patients may also be inadvertently at elevated risk for major bleeds.PurposeTo examine the utility of D-dimer levels in risk stratification and anticoagulation therapy in non-critically ill COVID-19 patients with severe obesity.MethodsIn this single-center, retrospective study, 32 severely obese patients (defined as BMI > 40) hospitalized with COVID-19 and requiring low flow oxygen delivery, without ICU level of care were analyzed. Clinical outcomes were compared between groups receiving therapeutic versus prophylactic doses of anticoagulation. All were treated with low molecular weight heparin (LMWH) per hospital protocol. The following data points were examined: length of hospitalization, mortality, anticoagulation therapy, initial d-dimer levels, thrombotic events, minor/major bleeds, and oxygen modality.ResultsIn total, 78% of patients initially presented with a D-dimer level above the upper limit of normal, with 53% of patients meeting criteria for therapeutic anticoagulation. However, there were no significant differences in incidence of thrombotic events, mean length of hospitalization or overall mortality. Furthermore, despite utilization of appropriate therapeutic anticoagulation, it did not reduce the overall use of oxygen support requirements, including high flow oxygen or non-invasive ventilation, when compared to individuals receiving prophylactic dosing.ConclusionThe clinical utility of D-dimer levels for guiding anticoagulation therapy in severely obese patients with COVID-19 may be limited. Here, we demonstrate that therapeutic dose approaches have nonsignificant differences in clinical outcomes when compared to prophylactic doses in this distinct population.

COVID-19 in Geriatric Patients

Objective: Considering the ongoing pneumonia epidemic associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), aging is a major risk factor alone for serious illness and death. In this study, we aimed to investigate the length of stay, hospital discharge status, and prognostic factors in geriatric patients with COVID-19. Methods: Medical files of 199 patients over the age of 65 years, who were treated as inpatients due to the diagnosis of COVID-19, were reviewed retrospectively. Demographic characteristics, comorbid diseases, laboratory values, the length of stay, and hospital discharge status of eligible patients were evaluated. Results: Of inpatients with COVID-19, the mean age was 75.01±7.86 years and 50.8% were men. In patients, who were transferred to ICU, C-reactive protein (CRP) and ferritin levels were higher compared to patients discharged to home and the monocyte/HDL ratio (MHR) was higher compared to nonsurvivors (p=0.037, p=0.003, p=0.023). Nonsurvivors had significantly higher white blood cell (WBC) counts and erythrocyte sedimentation rates (ESR) compared to patients discharged to home. Nonsurvivors had a significantly shorter length of hospital stay compared to patients, who were transferred to ICU. Conclusion: Geriatric patients are susceptible to adverse clinical outcomes of COVID-19. We think that WBC, ESR, CRP, ferritin, and MHR levels may inform about poor prognosis and the potential discharge status in elderly patients with COVID-19 pneumonia. Gaining insight into poor prognostic factors in elderly patients is essential to control COVID-19 and develop rapid treatment strategies in this age group.

Variability in Intensive Care Utilization for Intracerebral Hemorrhage in the United States: Retrospective Cohort Study

ObjectivesThere are urban-rural geographic health disparities in intracerebral hemorrhage (ICH) outcomes. However, there is limited data regarding the relationship between intensive care (ICU) availability and ICH outcomes. We examined whether ICU availability was a significant contributor to ICH outcomes by US geographic region. Materials and methodsWe used de-identified Medicare inpatient datasets from January 2016 to December 2019 and identified all index ICH admissions, stratifying by ICU care received during the hospitalization. Distributions of teaching hospital status, quartile of ICH volume, hospital urban-rural designation, and ICU availability were obtained using chi-square test. Propensity-score matching was utilized to compare outcomes of more favorable outcome, inpatient mortality, and 30-day all-cause readmissions by ICU availability at each hospital. ResultsOut of a total of 119,891 hospitalizations for ICH, 66,306 (55.3%) received ICU-level care. Of hospitals that treated at least one ICH, 42.6% did not provide ICU level care for any ICH admission during the study period. Teaching hospitals (48.0% vs 7.0%; p<0.0001), hospitals with higher ICH case volumes (p<0.0001) and in larger metropolitan areas (p<0.0001) were more likely to have an ICU available. Propensity score-matched models showed that hospital ICU availability was associated with a lower likelihood of inpatient mortality (29.4% vs 33.7%; p=0.0016) ConclusionsRural-urban disparities in ICH outcomes are likely multifactorial, but ICU availability likely contributes to the disparity. Additional studies are necessary to elucidate other contributing mechanisms.

A Survey of Implementation of ABCDE Protocols.

Spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), delirium assessment/management, early mobility have been termed the ABCDE bundle. The ABCDE bundle has been proven to improve patient outcomes. However, there is often a long gap in dissemination and implementation of evidence-based medicine. To determine the prevalent implementation of and determinants for ABCDE protocol adoption in Pennsylvania. We developed a survey of ABCDE bundle protocols. We surveyed factors around implementation including written protocol presence, standardized assessments to guide protocols, timing of creation of protocols, and estimated adherence to protocols. We also collected data on factors that might be determinants for protocol adoption including ICU staffing models, hospital and ICU level factors. We validated the survey tool using the Michigan Health and Hospital Association Keystone ICU collaborative. We then administered the validated survey to a leader of the medical ICU or mixed medical-surgical ICU of all Pennsylvania Hospitals. Multivariable logistic and ordinal regression were used to determine associations between ICU staffing models and hospital and ICU level factors with the presence of ABCDE bundle protocols. In the study cohort of Pennsylvania ICUs (n = 144), we had 100 respondents (69% response). The median number of hospital beds among the respondents was 185 (IQR 111-355) with a median of 14 ICU beds (IQR 10-20). 86% reported spontaneous awakening trial protocols, 60% reported spontaneous breathing trial protocols, 43% reported delirium assessment/management protocols, and 27% reported early mobility protocols. Being a medical ICU compared to a mixed medical-surgical ICU (OR 3.48, 95% CI 1.19-10.21, P = .02) and presence of multidisciplinary rounds (OR 4.97, 95% CI 2.07-11.94, P < .001) were associated with increasing number of ABCDE bundle protocol components. Variable implementation of ABCDE bundle protocols was present across Pennsylvania. Team communication is important to implementation of these protocols.

#10 Variation in Antibiotic Use and Incidence of Surgical Site Infections in Pediatric Liver Transplant Recipients

Abstract Background Surgical site infections (SSIs) are an important source of early complication after liver transplantation (LT). Peri-operative antibiotics to prevent SSI is considered standard of care, yet there are limited data on the frequency of SSI and no consensus on a standardized regimen. A major barrier is the lack of a large cohort of pediatric LT recipients. Leveraging merged data from the Pediatric Health Information System (PHIS) and the United Network for Organ Sharing (UNOS) we assembled a large cohort of pediatric LT patients to describe the frequency of SSI, variation in antibiotic prophylaxis practices and associated factors. Method The source cohort included all patients under 18 years in the UNOS database who received a LT at a PHIS-participating institution between January 1st 2006 to August 6th, 2017. We excluded those undergoing multi-visceral transplantation and/or re-transplantation. Patient data were merged using a probabilistic merge algorithm using the following present in both datasets: transplant center, date of birth, gender and date of transplant. Our primary outcome was any SSI present during the first 30 days of the hospitalization in which the LT was performed. SSI was defined using ICD 9 and ICD-10 diagnosis codes for post-operative surgical site infection, in addition to procedure codes for incision and drainage or return to the operating room. Peri-operative prophylaxis regimens were inclusive of antibiotic(s) received on the day of or day after LT. After all unique antibiotic regimens were identified, we further categorized into 6 levels of clinically relevant antibiotic combinations ranging from narrowest (Level 1 was cefazolin) to broadest spectrum (Level 6 was carbapenems). Patients receiving agents from more than one category defaulted to the broadest spectrum group. Vancomycin/linezolid administration was collected as a distinct covariate. Data collected on baseline factors included age at LT, sex, race, specifics of the LT type, and severity of illness (SOI) defined as receiving ICU level care on at least one day in the week prior to LT. Results Data from PHIS was successfully merged to 3055 (94%) of patients in the UNOS cohort. We excluded 264 multi-visceral transplants and/or re-transplants and 205 LT recipients without a categorizable antibiotic regimen with a final cohort of 2586 patients. This cohort was 50.8% female, 11.6% Black and 65% White with median age of 2 years (IQR of 0,9). 11.6% of patients required at least one ICU level of care day in the week prior to LT and the median hospital stay from day of transplant was 20 days (IQR: 13, 35). An SSI was identified during the hospital stay in 284 (11%) patients. As we discovered that patients less than 1-year of age at transplant were almost twice as likely to experience an SSI compared to patients over 1 year (16.2% versus 8.6%), the distribution of other covariates by antibiotic category was assessed after stratifying &amp;lt;1 year versus &amp;gt;=1 year (Table 1A and Table 1B).Category 5 was the most commonly represented antibiotic group.Significant differences in antibiotic regimen included donor type and type of liver transplanted , receipt of dialysis the week prior, and in those meeting SOI criteria. In older patients, differences in antibiotics administered were additionally noted within race category and if there was concern for donor infection. Conclusion SSI was common and varied by age, with children under one more likely to sustain an SSI. Antibiotic regimens administered varied withing each of these age groups. Factors associated broader-spectrum categories included receipt of a living donor LT, dialysis in the week prior to LT, and needing at least one ICU-level of care day in the week prior to LT. Additional multivariate analyses are warranted and will focus on investigating the degree to which center-specific differences are driving variation and will explore the comparative effectiveness of different antibiotic prophylaxis categories on SSI risk.

Retrospective review of outcomes of patients with multiple myeloma with COVID-19 infection (two-center study).

8048 Background: Coronavirus-2 has profound effects on patients (pts) with Multiple myeloma (MM). At the beginning of the pandemic, COVID-19 infection resulted an overall mortality around 54% (cook et al. BMJ 2020). Here, we report an updated morbidity and fatality for MM. Methods: After obtaining IRB approvals from each participating institute, retrospectively, between January 1, 2021 and August 30, 2021, we identified pts with MM and COVID-19 in two myeloma centers (Levine Cancer Institute (LCI) &amp; the University of Kansas medical center (KUMC). Results: We identified 162 MM pts who had COVID-19 (LCI n=132, UKMC n=30), including 57% males, with median age of 64 years. Current or former smoking reported in 40% of pts. Most pts have associated comorbid conditions: hypertension (45%), hypogammaglobulinemia (32%), CKD (30%), DM (22%), obesity (16.6%), CHF (14%), and CAD (13.5%). Within 3 months prior to infection, treatment included immunomodulatory combinations in 35%, proteasome inhibitors in 28 %, and Daratumumab in 26.5%. Symptoms are summarized in table. 69% had Mild symptoms (no need for hospitalization), 20 % had moderate symptoms (requiring hospitalization), and 9.8% had severe symptoms (ICU level of care). The 18% of pts required oxygen: 6 pts required invasive oxygenation and 3 pts needed vasopressors. The 32% of pts had RRMM, 29.5% on maintenance, and 12% was getting induction. Regarding MM response: &gt;VGPR in 45% and PD in 18%. The 78 pts had ASCT prior to COVID-19 infection: only 3 pts &lt; 1 year and 3 pts &lt; 6 months. MM response or ASCT did not affect hospitalization or mortality.The case fatality rate (CFR) was 6%. In the univariate analysis, CKD, DM, HTN and hepatic dysfunction were associated with an increased risk of hospitalization. However, in multivariate analysis, only CKD, hepatic dysfunction, and Hypogammaglobulinemia significantly increased the risk of admission with only age and lymphopenia were associated with increased COVID-19 related fatatlity. Conclusions: With implementation of center-specific disease control measures and universal screening, pts might have lower case severity and fatality rate than was initially reported. [Table: see text]

Analyzing immunotherapy adverse events in elderly cancer patients.

e24009 Background: Immunotherapy (IT) has cemented itself as a mainstay in cancer treatment, especially in those with late stage malignancies. Generally, these agents are well tolerated, but there is a known association with immune-related adverse events (iRAE). Due to an underrepresentation of elderly patients in clinical trial data, it is valuable to understand the tolerance of these agents. The primary objective of our study was to evaluate for an association between older age, defined as age 75 and above, and increased risk for iRAE in a real-world population. Methods: We performed a retrospective study utilizing data from elderly patients (pts) who had first received IT (specifically Pembrolizumab, Nivolumab, Atezolizumab, Avelumab, and Durvalumab) from 01/01/2015 through 12/31/2019. This subset of pts were followed until 12/31/2021. Descriptive analyses were performed to identify iRAE patterns. A chi-square test or a Fisher’s exact test was used to test for associations in bivariate comparisons while a two-sample t-test was used to test for differences in continuous variables between age groups &gt; 75 to 79 years (Group 1) and &gt; 80 years (Group 2). Statistical significance was determined by p &lt; 0.05 unless otherwise noted. Results: 103 pts qualified for assessment over the study period. Group 1 had a total of 48 pts with a median age of 77. Group 2 had a total of 55 pts with a median age of 84. The study had 57 males and 46 females. 96 pts were Stage IV and 7 pts were Stage III. The most prevalent malignancies in the study were lung, skin, and renal cancer. Treatment intent was palliative for 96 pts, adjuvant for 6 pts, and neo-adjuvant for 1 pt. Overall, there were 72 pts with reported iRAE and 31 pts without reported iRAE. Of the pts with iRAE: 7 pts required outpatient observation without intervention, 38 pts required outpatient intervention(s), 19 pts were hospitalized, and 8 pts required ICU level of care. There was one death due to complications from encephalitis associated with hypophysitis and hyperthyroidism. Regarding discontinuation of IT for pts: 42 pts transitioned to hospice, 35 pts had progression of disease, 8 pts finished their treatment regimen, 5 pts developed an alternative diagnosis, and 9 pts discontinued due to iRAE. Nine pts in the study required corticosteroids for their iRAE. There was no statistically significant difference in incidence of any iRAE (regardless of type) between the two age groups 75-79 and over 80 years (p-value = 0.3703). Similarly, there was no difference for sub-categories including stage of cancer, type of cancer, treatment intent, and severity of iRAE. Conclusions: Elderly pts over age 75 that received the aforementioned IT were shown to have relatively tolerable safety profiles regardless of their age group and the majority continued with IT despite iRAE. This study reinforces the notion that IT could be used in geriatric pts without fear of exposing this vulnerable age group to substantial rates of negative outcomes.

Abstract 395: Assessing Current Therapeutic Anticoagulation Strategies In Severely Obese Patients With Covid-19

Objective: To examine the utility of D-dimer levels in risk stratification and anticoagulation therapy in non-critically ill COVID-19 patients with severe obesity Background: Many studies to date have documented significant inflammatory vascular sequelae in association with COVID-19. Current guidelines suggest an initial strategy of therapeutic-dose anticoagulation to non-critically ill, hospitalized patients requiring low-flow oxygen and a concurrent D-dimer level above the upper limit of normal. However, the utility of D-dimer values in predicting thrombosis in severely obese patients are equivocal to poor, with prior evidence suggesting falsely elevated levels with greater BMI. Methods: In this single-center, retrospective study, 32 severely obese patients (defined as BMI &gt; 40) hospitalized with COVID-19 and requiring low flow oxygen without ICU level of care were analyzed. Clinical outcomes were compared between groups receiving therapeutic versus prophylactic doses of anticoagulation. All were treated with low molecular weight heparin (LMWH) per hospital protocol. The following data points were examined: length of hospitalization, mortality, anticoagulation therapy, initial d-dimer levels, thrombotic events, minor/major bleeds, and oxygen modality. Results: In total, 78% of patients initially presented with a D-dimer level above the upper limit of normal, with 53% of patients meeting criteria for therapeutic anticoagulation. However, there were no significant differences in incidence of thrombotic events, mean length of hospitalization or overall mortality. Furthermore, despite utilization of appropriate therapeutic anticoagulation, it did not reduce the overall use of oxygen support requirements, including high flow oxygen or non-invasive ventilation, when compared to individuals receiving prophylactic dosing. Conclusion: The utility of D-dimer levels in guiding anticoagulation therapy in severely obese patients with COVID-19 may be misleading.

The displacement of the SARS-CoV-2 variant Delta with Omicron: An investigation of hospital admissions and upper respiratory viral loads.

SummaryBackgroundThe increase in SARS-CoV-2 infections in December 2021 was driven primarily by the Omicron variant, which largely displaced the Delta over a three-week span. Outcomes from infection with Omicron remain uncertain. We evaluated whether clinical outcomes and viral loads differed between Delta and Omicron infections during the period when both variants were co-circulating.MethodsIn this retrospective observational cohort study, remnant clinical specimens, positive for SARS-CoV-2 after standard of care testing at the Johns Hopkins Microbiology Laboratory, between the last week of November and the end of December 2021, were used for whole viral genome sequencing. Cycle threshold values (Ct) for viral RNA, the presence of infectious virus, and levels of respiratory IgG were measured, and clinical outcomes were obtained. Differences in each measure were compared between variants stratified by vaccination status.FindingsThe Omicron variant displaced Delta during the study period and constituted 95% of the circulating lineages by the end of December 2021. Patients with Omicron infections (N = 1,119) were more likely to be vaccinated compared to patients with Delta (N = 908), but were less likely to be admitted (0.33 CI 0.21–0.52), require ICU level care (0.38 CI 0.17–0.87), or succumb to infection (0.26 CI 0.06–1.02) regardless of vaccination status. There was no statistically significant difference in Ct values based on the lineage regardless of the vaccination status. Recovery of infectious virus in cell culture was reduced in boosted patients compared to fully vaccinated without a booster and unvaccinated when infected with the Delta lineage. However, in patients with Omicron infections, recovery of infectious virus was not affected by vaccination.InterpretationCompared to Delta, Omicron was more likely to cause breakthrough infections of vaccinated individuals, yet admissions were less frequent. Admitted patients might develop severe disease comparable to Delta. Efforts for reducing Omicron transmission are required as, though the admission risk might be lower, the increased numbers of infections cause large numbers of hospitalizations.FundingNIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, Centers for Disease Control and Prevention contract 75D30121C11061, and The Modeling Infectious Diseases in Healthcare Network (MInD) under awards U01CK000589.

A Protective Fluid Resuscitation Strategy In HF Patients With Sepsis Does Not Significantly Influence Mortality

<h3>Objective</h3> : Administration of at least 30mL/kg of IV crystalloids within the first 3 hours of recognition of sepsis is the current fluid resuscitation goal per the 2018 Surviving Sepsis Campaign update. However, sepsis and concomitant heart failure create a challenging clinical scenario due to fear of volume overload. Our meta-analysis sought to determine if this strategy vs. lower infusion rates influences in-hospital mortality for heart failure patients with sepsis. <h3>Methods</h3> : The terms "heart failure" and "sepsis" or "septic shock" and "fluid bolus" or "fluid administration" were used in Embase and Pubmed. Studies were included if they had: sepsis patients with heart failure, or a subgroup of patients with heart failure, and mortality data on these patients that did or did not meet the 30mL/kg-by-3 hour (30 × 3) goal. Five eligible studies were found. The odds ratio and 95% confidence interval for mortality among HF patients with sepsis who received <30 × 3 vs. at least 30 × 3 were calculated for the five studies using their mortality data. The mortality data from the five studies were totaled to calculate a total odds ratio and 95% CI. <h3>Results</h3> : One study demonstrated a statistically significant increase in the odds ratio for in-hospital mortality when comparing the <30 × 3 vs. the 30 × 3 group (OR 2.96; 95% CI 1.18-7.41) (Table 1 and Figure 1). All other studies demonstrated a non-significant increase in odds of in-hospital mortality. Totaling the data from these studies resulted in 616 patients with HF and sepsis. 78 of the 281 in the <30 × 3 group died and 84 of the 335 in the 30 × 3 group died (OR=1.14; 95% CI 0.84-1.64). <b>Conclusions</b>: Our meta-analysis shows a non-significant increase in odds of in-hospital mortality among hospitalized HF patients with sepsis/septic shock who received a restrictive resuscitation strategy compared to those who met the 30 × 3 goal. This study highlights the need for larger prospective trials to study this interaction further. Limitations include the retrospective nature of the studies. Additional work is needed to account for the influence of systolic vs. diastolic heart failure history, sepsis severity, pressor requirement, ICU vs. non-ICU level of care, and use of invasive hemodynamic monitoring to guide resuscitation.

COVID Infection in Heart Transplant Recipients: Experiences from an Epicenter

PurposeHeart transplant (HT) recipients are at significant risk from Covid-19 infection due to immunosuppression and potential effects on graft function. Currently no standard care management strategy exists for this population. We sought to describe our experiences as a single center caring for HT recipients with Covid-19 infection.MethodsRetrospective chart review of 250 adult HT recipients followed at the University of Southern California identified 46 individuals with PCR-proven Covid-19 infection between March 1st, 2020 and October 1st, 2021. Herein, we report on their baseline clinical characteristics, serial echocardiographic parameters, laboratory values and pharmacologic treatment regimens.Results46 HT patients were identified with Covid-19 infection. Patients were more likely to be male (74%), with a mean age of 52.0 years old, and average BMI of 28.71. The most common indications for HT included NICM (54%) and ICM (22%), and comorbidities included HTN (59%), HLD (59%), DM (39%), and CAD (26%). Over a third of patients (37%) had a history of smoking, and 7 patients (15%) were vaccinated against Covid-19. Patients were on average 6.53 (1.1-9.0) years post-transplant, and on three 3 classes of immunosuppressive medications (89%). The most common presenting symptoms were fever (24%), dyspnea (33%), hypoxic respiratory failure (26%), and GI symptoms (20%). Only 8 patients (17%) had evidence of graft injury with mean donor-derived cell free DNA levels of 0.41 (NL <0.12). Mean EF was 60.7% pre- and 59.0% post-infection. The most common treatment was supportive therapy (39%), followed by monoclonal antibody therapy (28%), steroids (24%; dexamethasone or solumedrol) and antibiotics (24%). Reduction in antimetabolites (33%), calcineurin inhibitors (15%), and prednisone (15%) was common. Half of the patients were admitted to the hospital with 11% requiring ICU level of care, and half were managed as outpatients. Only 4 patients died (1 from non-covid related illness 6 months post-infection) yielding a 91% overall survival rate.ConclusionIn a single-center experience over 18 months, 46 HT patients had proven Covid-19 infection. Overall survival was 91% with mainstays of treatment focusing on supportive care and monoclonal antibody therapy. Further research is needed to clarify optimal treatment strategies in HT patients with Covid-19 infection.

Are Neutrophil-Lymphocyte, Platelet-Lymphocyte, and Monocyte-Lymphocyte Ratios Prognostic Indicators in Patients With Chronic Obstructive Pulmonary Disease in Intensive Care Units?

Background and objectiveChronic obstructive pulmonary disease (COPD) is a condition in which the expiratory airflow is restricted and is characterized by inflammation. Recently, inflammation-related biomarkers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) have been used to predict the prognosis in COPD. The aim of this study was to evaluate the role of biomarkers such as NLR, PLR, and MLR in COPD patients in intensive care and to examine the ability of these markers to predict the prognosis [length of stay in hospital (LOSH), duration of mechanical ventilation (MV), length of stay in ICU (LOS ICU), and mortality].MethodsA total of 562 patients who were treated in the ICU between 2018 and 2019 were retrospectively reviewed. Among them, 369 were patients with COPD. We evaluated clinical data including patient demographics, Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, LOS ICU, LOSH, duration of MV, as well as NLR, PLR, and MLR values. Data on patient deaths (30-day mortality) was obtained from the Death Notification System.ResultsAge, LOSH, CCI, and SOFA were found to predict mortality in COPD patients. In cases with mortality, age, inotropic use, MV duration, LOS ICU, APACHE II, CCI, SOFA, lymphocyte count, neutrophil count, platelet count, monocyte count, NLR, PLR, and MLR levels were statistically significantly higher than those in cases without mortality. There was a positive and low statistically significant relationship of NLR, PLR, and MLR with prognostic factors like MV duration, APACHE II scores, and SOFA scores.ConclusionThe NLR, PLR, and MLR values may be used as prognostic indicators in COPD patients in intensive care. Although there are many studies endorsing the use of biomarkers such as NLR, PLR, and MLR as prognostic indicators, further comparative studies on this subject are still required to gain deeper insights into the topic.

604 From admission to discharge: a total friction burn review from a single institution

IntroductionMost friction burns are adequately managed in an outpatient setting. However, many require hospital admission, operative excision, and extended care especially those that present at trauma or burn centers. There is a wide variance in friction burn management. Our goal is to review the etiology, management, and outcomes of such burns warranting hospitalization.MethodsWe conducted a retrospective review of all friction burns admitted to a single, American Burn Association verified burn center from January 1, 2016 to December 31, 2020. Individual chart analysis was performed using data from the hospital’s burn registry. Statistical analysis was performed using Chi-square and Wilcoxon rank-sum test with p< 0.05 being significant.ResultsEighty-two patients met the inclusion criteria. Mean age was 35.4 years (95% CI 31.6-39.2). The overall mean Total Body Surface Area (TBSA) was 9.0 % (95% CI 7.5-10.6), and mean TBSA of 3rd degree burns was 1.1 % (95% CI 0.6-1.7). The most common mechanism of injury was motorcycle collision (45, 55%), followed by pedestrian struck by automobile (13, 16%). Fifty-four individuals (65%) had a concomitant injury. The most common topical agent used was silver sulfadiazine (52%), followed by bacitracin (21%). Sixteen patients (20%) required ICU level of care. Twenty-eight (34%) patients required surgery for their friction burns and 15 (18%) ultimately required a split-thickness skin graft. The mean number of operations was 2.4 (95% CI 1.6-3.1).Overall, the operative group was younger (29.9 vs 38.3 years, p=0.026), more likely to have a concomitant traumatic brain injury (25% vs 7%, p=0.027) and had a longer hospital length of stay (17.5 vs 3.9 days, p< 0.001). Both groups had a similar overall TBSA (8.5% vs 10.0%, p=0.35), but the operative group had larger surface area comprised of 3rd degree burns (3.05% vs 0.2%, p< 0.001). Eighty-one patients survived with the sole death due to massive hemoptysis.ConclusionsFriction burns resulting in hospital admission are associated with high-energy traumatic mechanisms and concomitant injuries. Patients who need operative intervention of their burns typically require multiple procedures often culminating in a split-thickness skin graft.

The Third Wave: Comparing Seasonal Trends in COVID-19 Patient Data at a Large Hospital System in New York City

IMPORTANCE:The third wave of COVID-19 is unique in that vaccines have been widely available; however, the highly transmissible Delta variant has been the predominant strain. Temporal changes of hospitalized patient characteristics should continue to be analyzed as COVID-19 progresses.OBJECTIVES:Compare the demographics and outcomes of hospitalized patients during New York City’s third wave of COVID-19 to the first two waves.DESIGN, SETTING, AND PARTICIPANTS:Retrospective cohort study across five hospitals within Mount Sinai Health System, a quaternary academic medical system in New York City. Participants were adult inpatients admitted with COVID-19 identified by positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction at admission or clinical documentation of infection during the three waves of COVID-19.MAIN OUTCOMES AND MEASURES:Patient demographics, comorbidities, vaccination status, and outcomes of COVID-19 patients hospitalized at Mount Sinai Health System were examined. Patients admitted during the third wave were notably younger than the first two, were mostly unvaccinated against COVID-19, and there was a higher rate of patients who self-report as Black or African American as compared with the first two waves. The rate of patients requiring ICU level of care remained consistent throughout all three periods; however, the rate of patients requiring invasive mechanical ventilation decreased and inhospital mortality has trended down. Unvaccinated patients in the third wave are significantly younger with lower comorbidity burden than fully vaccinated patients.RESULTS:A total of 13,036 patients were included between the 3 waves. In the 3rd wave patients were notably younger, with a lower intubation rate and lower inhospital death rate. In the 3rd wave, 400 (62.9%) were unvaccinated, 236 (37.1%) were fully vaccinated, and 34 (4.8%) were partially vaccinated. Unvaccinated patients had similar rates of intubation and invasive mechanical ventilation compared with vaccinated patients, though inhospital mortality was lower in unvaccinated patients compared with vaccinated patients which may be expected given their lower age and burden of comorbidities.CONCLUSIONS AND RELEVANCE:We continue to see improved outcomes in hospitalized COVID-19 patients. Patients that are unvaccinated against COVID-19 are younger and have less reported comorbidities.

310. Cryptococcal Infection Following COVID-19 infection in Solid Organ Transplant Recipients: A Case Series

BackgroundFungal infections have been identified with or following SARS-CoV-2 infection, most commonly COVID associated pulmonary aspergillosis. Cryptococcus species are ubiquitous in the environment and the third most common invasive fungal infection following Solid Organ Transplant (SOT). We describe four cases of concurrent or subsequent cryptococcal infection within 90 days following COVID-19 infection.MethodsWe conducted a retrospective study of patients presenting with proven cryptococcosis either concurrently or within 90 days following COVID-19 diagnosis. Cases were identified March 2020 through May 2021. All were seen at the University of Alabama in Birmingham, a regional referral and comprehensive transplant center. Exemption for this review was approved by our IRB.ResultsFour cases were identified, all were SOT recipients. Case details are provided in Table 1. No patients required ICU level care at any point. COVID-19 treatment included 10 days of increased steroids for 3 patients, remdesivir for 2, and 1 received no treatment for COVID-19. In contrast to the typical time-course for cryptococcal infection post-SOT (median time approx. 500 days post-transplant), three patients were greater than 2 years post-transplant and were without rejection or recent changes in immunosuppression. Patient 1 was less than 6 months post liver-kidney transplant and was diagnosed at time of admission with concurrent COVID-19 and cryptococcal pneumonia. Infection was disseminated in the other 3 cases including positive blood cultures in 2 patients and cryptococcal meningitis (CM) in 2 patients. CM cases presented later following COVID-19 and had the longest delay between symptom onset (headache, neurologic symptoms) and CM diagnosis. One patient had CM 8 years prior, but had done extremely well off fluconazole for over 6 years prior to this recurrence. All patients are doing well at most recent follow-up evaluations.Table 1. Summary of Cases ConclusionWe describe the first case series with a temporal association between SARS-CoV-2 infection and cryptococcosis. All cases were immunocompromised due to SOT. Some symptoms were attributed to post-COVID syndrome leading to significant delays in diagnosis for those patietns, highlighting the importance of considering this association for at-risk patients.Disclosures Todd P. McCarty, MD, Cidara (Grant/Research Support)GenMark (Grant/Research Support, Other Financial or Material Support, Honoraria for Research Presentation)T2 Biosystems (Consultant)

1215. A Mixed Methods Study on Severe Bacterial Infections in People Who Inject Drugs

BackgroundSevere bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This mixed methods study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.MethodsWe conducted 34 quantitative and 15 qualitative interviews between August 2020 and June 2021 at Bellevue Hospital in New York City. Eligible participants were (1) >/= 18 year of age, (2) admitted with a SBI, and (3) reported injection drug use within the 90 days prior to admission. Quantitative and qualitative data was obtained using a quantitative survey and in-depth, semi structured interviews of participants respectively. Analysis was performed to examine trends and explore common themes potentially contributing factors to SBI.ResultsOf the 34 participants included, the median age was 37.5, 85% were male, 53% white, and 65% reported being homeless within the past 3 months. Endocarditis was the most common primary diagnosis (65%). Median length of hospital stay was 24 days and 35% required ICU level care during admission. A causative microorganism was identified in 85% of participants and 50% had Staphylococcus aureus as the sole organism. Discharges against medical advice occurred in 35%. Daily injection drug use in prior 30 days was 95% with a median of 10 injections per day. In the 30 days prior to admission, 50% reported an increase in injection frequency, 80% reported reusing needles and/or syringes, 75% reused cookers, 65% reused cottons. Analysis of qualitative interview data revealed high risk injection behaviors. Participants were not practicing and unaware of strategies to reduce their risk of drug injection-related SBI. Prior hospitalizations for SBI did not impact on this knowledge deficit on what constitutes bacterial infection risk and how to prevent it. ConclusionStudy findings highlight the complexity of the injection drug use process and the potential social and physiological pathways leading to SBI. Multiple domains at the structural, network, and individual level that impact drug injection practices and provide context by which these factors predispose and lead to physiological tissue damage and the development of SBI among PWID. Disclosures Benjamin Eckhardt, MD, MS, Gilead Sciences (Grant/Research Support)

989. Isavuconazonium Sulfate Treatment of Blastomycosis: A Case Series

Abstract Background Blastomyces fungi, endemic to the Ohio and Mississippi River Valleys, cause pneumonia and disseminated disease in both immunocompetent and immunocompromised patients. Prolonged antifungal therapy is commonly complicated by hepatic toxicity, QT prolongation, and drug interactions. Isavuconazonium sulfate is dosed once daily, does not prolong the QT interval, and has fewer drug interactions, but there is a paucity of data for its use in blastomycosis. Methods This case series of blastomycosis treated with isavuconazonium sulfate at the University of Wisconsin Hospital and Clinics from 2015 to December 2019 focuses on long term outcomes. Inclusion criteria were adults, that received at least one day of isavuconazole. Exclusion criteria was no blastomycosis diagnosis. Results Of 14 cases, median age was 53 years, 6/14 were female, 11/14 White, 2/14 Black, 1/14 Hmong, 6/14 had a solid organ transplant (4 renal, 1 heart, 1 bilateral lung), 1/14 on a TNF-alpha inhibitor (infliximab). Most cases, 9/14 had moderate severity illness requiring inpatient care, 2/14 required ICU level care, and 3/14 were outpatient. Most cases, 11/14, were initially treated with Liposomal Amphotericin B (LAMB) for a median duration of 14 days, 9/14 cases received itraconazole, 8/14 voriconazole, 1/14 posaconazole. Isavuconazonium sulfate was started after adverse drug effects with other azoles in 10/14 cases, prolonged QT interval in 3/14, drug interactions in 2/14, subtherapeutic azole levels in 2/14. Isavuconazonium sulfate was well tolerated and used for median duration of 255 (average 68% total treatment course). 3/14 cases had adverse reactions to isavuconazonium sulfate: nausea, rash, elevated liver enzymes. There was only one death during therapy from a fatal hemorrhagic stroke, and 2/14 cases were still on therapy at end of data collection. 11/14 were cured after treatment course. Conclusion This is the largest case series treating Blastomycosis with isavuconazonium sulfate, and it adds to the evidence that isavuconazonium sulfate can be safely used to treat pulmonary and disseminated blastomycosis. Prospective data is needed to compare isavuconazonium sulfate to other antifungals for the treatment of Blastomycosis. Disclosures All Authors: No reported disclosures

Abstract 13068: Use of Cardiac Implantable Electronic Devices in Carcinoid Heart Disease

Introduction: Carcinoid heart disease (CHD) is a rare sequelae of hormonally active neuroendocrine tumors that often requires cardiac surgical intervention. Little is reported on cardiac implantable electronic device (CIED) implantation in the CHD patient population. Hypothesis: We sought to establish the safety and efficacy of CIED implantation in patients with CHD. Methods: We retrospectively reviewed patients with a diagnosis of CHD who underwent CIED implantation at our institution (Mayo Clinic) and evaluated indications for implant, perioperative complications, and mortality. Results: A total of 27 patients with a cumulative follow up of 75 patient-years were identified during the study period. The most common indication for device implant was high grade atrioventricular block (n=18, 66.7%). 14 (51.8%) had baseline conduction disease and 26 (96.2%) underwent cardiac surgery prior to CIED implant. The majority of devices implanted were dual chamber permanent pacemakers (PPM) (n=17, 63.0%), while other devices included single chamber PPM, epicardial PPM, chronic resynchronization devices, and intracardiac defibrillators. Peri-operative complication occurred in 6 patients (22.2%), with 2 patients requiring ICU level care. No patient suffered carcinoid crisis during implantation and there was no peri-implant mortality. Long term, 3 patients required device extraction: 1 for infection, 1 for lead related pain, and 1 for generator migration. The median time to death from implant was 2.5 years, with one-year mortality at 15%. Conclusions: In this unique cohort of patients with CHD, CIED can be performed safely. CIED most often occurred in the post cardiac surgical period and carcinoid crisis was uncommon.

Nasal high flow therapy use in wards in patients with chronic obstructive pulmonary disease may spare ICU resources.

Nasal high flow therapy has been previously studied for the management of acute hypoxic respiratory failure in patients with chronic obstructive pulmonary disease but the data regarding its use outside of the intensive care unit are sparse. We aimed to evaluate safety and efficacy of nasal high flow therapy outside of the intensive care unit in patients with acute hypoxic respiratory failure and known chronic obstructive pulmonary disease. We conducted a retrospective matched historic cohort study of adult patients with diagnosed chronic obstructive pulmonary disease presenting with acute hypoxic respiratory failure between December 2017 to June 2019, after the initiation of a new protocol, which allowed patients to be managed with nasal high flow therapy on the medical/surgical wards instead of transferring them to the ICU per prior standard of care. Nasal high flow therapy was initiated either in the emergency department or on the medical/surgical wards. Patients were matched with historical cohorts who were managed with prior standard of care based on age, body mass index, comorbidities, and home oxygen use. Primary outcome of interest was difference in rates of mechanical ventilation. Secondary outcomes included hospital length of stay, total number of days spent in the intensive care unit, and in‐hospital mortality. A total of 90 patients met study inclusion criteria and were matched to 90 historical control patients. Among the study group, 8% required mechanical ventilation versus 9% in the control group (p = 0.79). Hospital length of stay was 7 days in study group versus 6 days in control group (p = 0.02), and in‐hospital mortality was the same in both study and control groups at 12% (p = 0.99). Nineteen percent of study group patients required ICU level of care at any time during the admission compared with 49% of control group (p < 0.001). Nasal high flow therapy use in patients with acute hypoxic respiratory failure and underlying chronic obstructive pulmonary disease outside of the intensive care unit may spare ICU resources and cost without delay in definitive care such as mechanical ventilation.