Requiring ICU Admission Research Articles

Clinical Features and Predisposing Factors Influencing the Outcome of COVID-19 in First and Second Wave at Nanded, Maharashtra- A Retrospective Study

Introduction: It is crucial to determine possible factors associated with exacerbation of the disease due to the alarming global spread, morbidity and mortality associated with Coronavirus Disease-2019 (COVID-19). It is important to determine the co-morbidities associated with this disease which will help in better treatment of patients in time and to make amendments to management policy. Aim: To compare the clinical features, and predisposing factors (socio-demographic factors and co-morbidities) influencing the outcome in COVID-19 infected patients admitted in a tertiary care centre in the first and second wave of COVID-19 pandemic. Materials and Methods: The retrospective study was conducted at the Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India. The data was collected from the electronic resource which was maintained by the institute Integrated Disease Surveillance Program (IDSP) health record reporting database for the duration of June 2020 to August 2021. This data included patient’s demographic details (age, sex, address, contact number), other details (history of close contacts, international travel) clinical history, different types of symptoms (ICMR patient category), comorbidities, number of patients requiring ICU admission, type of sample, the outcome in terms of death and discharge, cause of death. The analysis was done for the complete data and then for two separate durations of the first and second wave which were compared later with Chi-square test (Bivariate analysis). Results: A total of 8841 patients were involved and the majority of patients in the study were between the age group of 30-75 years, there was a predominance of males in first and second waves with 6514 (73.7%) and 5795 (58.6%) respectively. The paediatric patients had a mortality rate of 100% (n=7) found in the second wave. Fever (39%) and dyspnea (22%) were found as the commonest presentation in both waves. Gastrointestinal manifestations were observed relatively more in the second wave. The serious patients on ventilator were found to have (>91%) the highest mortality. It appeared that the highest attributable risk to severity and mortality (eight to ten times increased) was due to hypertension, diabetes and other co-morbidities. Pregnancy did not predisposed to be as a risk factor. Conclusion: Prompt management and preventive care are needed for patients with co-morbidities to avoid the exacerbation of COVID-19 as well as drug cross interactions.

Thrombotic Events in Covid-19: Incidence and their Association with Lab Parameters, Vaccination Status and Mortality

Background & Objectives: Major arterial or venous thrombotic complications occur frequently with COVID-19. This risk seems to be present despite no known underlying thrombophilia and even adequate anticoagulation does not diminish its risk. Whilst pulmonary embolism may seem to be the most common thrombotic complication, others may also occur. A vaccination link to thrombotic events in COVID-19 has not been studied to the best of our knowledge. Methods: In this retrospective cross-sectional study we determined the incidence of total thrombotic events, individual Venous Thromboembolisms (VTE) and Arterial Thromboembolisms (ATE) that occurred in patients requiring ICU admission for COVID-19 in one of Bahrain’s main COVID ICU facilities for a period of 6 months. We also aim to determine mortality rate in this group of patients, links with specific baseline characteristics, laboratory parameters and patient vaccination status. Results: We studied 1597 patients over 6 months, 6% of patients were found to have VTE or ATE with a cumulative incidence of 6.5% thrombotic events. Elevated D dimer >1 was associated with an increased risk of thrombosis and an increased risk of mortality. There was a higher risk of thrombotic events in unvaccinated individuals. All-cause mortality in COVID-19 patients complicated with thrombosis and mortality solely secondary to thrombotic event were both significantly higher in unvaccinated individuals. Conclusions: Based on the findings of this study, unvaccinated individuals are at significantly higher risk of developing thrombotic events. This will assist in enabling physicians to lower their threshold of diagnosing such events. The urgency of lab parameters the swift management of other risk factors and the importance of vaccination against COVID-19 can be further studied. Keywords: COVID-19, Venous Thromboembolisms, Arterial Thromboembolisms, Mortality, D dimer, Vaccination status

Carcinoembryonic antigen (CEA) and other surrogate inflammatory biomarkers in COVID-19

It has been two years since the global outbreak of the highly contagious and deadly corona virus disease (COVID-19) caused by SARS-CoV-2 first emerged in China. Since then, various diagnostic, prognostic and treatment strategies undertaken to address the pandemic have been dynamically evolving. Predictive and prognostic role of various biomarkers in COVID-19 has been a subject of intense exploration. We aimed to determine the association of Carcinoembryonic antigen (CEA) and various surrogate inflammatory biomarkers with the severity of COVID-19 disease. This retrospective cohort study was carried out on 98 patients admitted in Jaypee Hospital, Noida with COVID-19 disease. Information regarding demographics, laboratory parameters and clinical history was collected from Hospital Information System. Serum levels of CEA and other biomarkers such as Neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), Interleukin-6 (IL-6), Ferritin, and Procalcitonin (PCT) were assessed. Correlation analyses were performed between the parameters and acute respiratory distress syndrome (ARDS) stages. Logistic regression and ROC curve analysis were performed to assess the various parameters for distinguishing COVID-19 patients requiring ICU admission. Mean hospital stay, NLR, CEA, IL-6, CRP, Ferritin (P< 0.0001) and PCT (P =0.01) were significantly higher in ICU patients when compared to general ward patients. NLR, median serum CEA, IL-6, and CRP levels were significantly higher in non-survivor compared to the survivors (P< 0.0001, 0.0341 and 0.0092). CEA correlated well with disease severity based upon ARDS classification and was a better marker to differentiate patient according to ARDS stages (ARDS 0 vs 2 P= 0.0006; 0 vs 3 P< 0.0001; ARDS 1 vs 2 P= 0.0183; 1 vs 3 P=0.0006). The area under the Receiver operating characteristic (ROC) curve for CEA was 0.7467 (95% CI- 0.64885- 0.84459) which revealed the potential of CEA as a biomarker to distinguish COVID-19 patients requiring ICU admission. CEA can be used to predict the severity of COVID-19 associated ARDS as well as patients requiring ICU admission. Along with routine inflammatory biomarkers (NLR, CRP, IL-6, PCT, and ferritin), CEA should be used for early identification of critical COVID-19 positive patients and for assessing prognosis.

ICU-Acquired Pneumonia Is Associated with Poor Health Post-COVID-19 Syndrome.

Background. Some patients previously presenting with COVID-19 have been reported to develop persistent COVID-19 symptoms. While this information has been adequately recognised and extensively published with respect to non-critically ill patients, less is known about the incidence and factors associated with the characteristics of persistent COVID-19. On the other hand, these patients very often have intensive care unit-acquired pneumonia (ICUAP). A second infectious hit after COVID increases the length of ICU stay and mechanical ventilation and could have an influence on poor health post-COVID 19 syndrome in ICU-discharged patients. Methods: This prospective, multicentre, and observational study was carrid out across 40 selected ICUs in Spain. Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated three months after hospital discharge. Results: A total of 1255 ICU patients were scheduled to be followed up at 3 months; however, the final cohort comprised 991 (78.9%) patients. A total of 315 patients developed ICUAP (97% of them had ventilated ICUAP). Patients requiring invasive mechanical ventilation had more persistent post-COVID-19 symptoms than those who did not require mechanical ventilation. Female sex, duration of ICU stay, development of ICUAP, and ARDS were independent factors for persistent poor health post-COVID-19. Conclusions: Persistent post-COVID-19 symptoms occurred in more than two-thirds of patients. Female sex, duration of ICU stay, development of ICUAP, and ARDS all comprised independent factors for persistent poor health post-COVID-19. Prevention of ICUAP could have beneficial effects in poor health post-COVID-19.

P-BN10 Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes in Northern Ireland

Abstract Background Perforated peptic ulcer disease is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in presentation of patients with perforated ulcers. Here we present this study from a Northern Irish perspective on perforated peptic ulcers. Methods A retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with incidence of perforated peptic ulcers. Follow-up data was also collected. Seasons were defined as per UK Met Office. Results Results: A total of 50 patients presented with perforated PUD. Male:female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. 14 patients (28%) were either very frail or had contained perforations and were conservatively managed. 3 deaths were noted (6%). 13 patients (26%) required ICU admission at some stage in their management. Conclusions Slight seasonal variation was noted in presentation of perforated peptic ulcers in our study with more common incidence in winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.

Polymyxin B infusion related respiratory arrest: A case report

A 73 years old male, known hypertensive on medication, with the history of SARS-CoV-2 infection nine months ago, presented to us with mucormycosis, he was treated with Liposomal amphotericin B initially. He developed acute kidney injury with recurrent pulmonary oedema requiring ICU admission and Haemodialysis. He later developed catheter related blood stream infection that grew Carbapenem resistant Klebsiella pneumonia and was started on Polymyxin B. However from day 3 of antibiotics he started to develop recurrent respiratory arrest with no apparent cause. He required a brief period of mechanical ventilation and was successfully weaned. He had recurrent such episodes with no apparent cause. After extensive work up and literature search it was diagnosed as Polymyxin B induced respiratory failure. Polymyxins were stopped, patient was discharged in a stable condition after five days of further observation and is currently on follow up with no such episode of dyspnoea.

EPIDEMIOLOGICAL STUDY OF TRAUMA IN A TERTIARY CARE CENTRE IN NORTHWEST INDIA

Objective: Traumatic injuries are a matter of concern worldwide. However, the rapidly changing socio economical dynamics in a developing country like India deeply influence the epidemiology behind trauma. The aim of this study was to document and analyze the epidemiological parameters and characteristics behind trauma victims admitted to our tertiary care centre. Methods: The observational study was carried out over a period of one year (January 2019 to December 2019) enrolling a total of 300 trauma patients. The age, sex, locality, delay in hospitalization, mechanism of injury, sites of injury and outcomes were documented. Results: Injuries occurred predominantly in the 20-40 age group with males being the chief victims. There was a considerable amount of delay in hospitalization ranging from one hour to more than 24 hours while only 7 patients arrived to the emergency within one hour of trauma. Vehicular trauma (54%) was the most common mechanism of injury. Injuries to the extremities (38.6%) and head (28.6%) were the most common sites. A considerable number of patients (45.3%) required care in the intensive care unit. A total of 172 patients required surgical interventions of various kinds and there was a total mortality rate of 6%. Amongst the polytrauma cases, 54 patients (81.8%) required ICU admission, 42 patients (63.6%) required surgical intervention and 6 patients (9.1%) died after admission. Conclusion: The results of this study highlight some of the problems with our existing infrastructure bringing to light the need for stricter enforcement of traffic safety laws and improvement of infrastructure particularly the roadways in rural areas as well as the referral systems. Vehicular trauma should be seen as a public health problem and appropriate interventions should be implemented. Keywords: Trauma, Road Traffic Accidents, Epidemiology, Head injuries

Characteristics and Outcomes for Low-Risk Hospital Admissions Admitted to the ICU: A Multisite Cohort Study.

Prognostication following ICU admission can often be determined based on known risk factors, including demographics and illness severity; however, little is known about outcomes of patients deemed to be "low-risk" at the time of hospital admission who subsequently are admitted to the ICU. The objectives of this study were to determine the characteristics, outcomes, and costs for patients requiring ICU admission despite having lower predicted mortality when they were admitted to the hospital. In this historical cohort study, we used a prospectively maintained ICU registry that included all ICU admissions to The Ottawa Hospital for patients 18 years or older from January 2011 to December 2016. We classified patients as low-risk using the Hospital-patient 1-year Mortality Risk at admission score, a hospital admission score validated to predict 1-year mortality. The primary outcome was inhospital mortality. Secondary outcomes included adverse events, resource utilization, and costs. Of the 17,173 total ICU patients, 3,445 (20.1%) were classified as low-risk at hospital admission. Low-risk patients were younger (48.7 vs 67.5 yr; p < 0.001) and had a lower Multiple Organ Dysfunction Score (2.37 vs 4.14; p < 0.001). Mortality for low-risk patients was significantly lower than for non-low-risk patients (4.1% vs 25.4%; p < 0.001). For low-risk patients, multivariable logistic regression showed mortality was independently associated with older age (odds ratio, 1.02 per 1 yr; 95% CI, 1.00-1.03 per 1 yr), Multiple Organ Dysfunction Score (odds ratio, 1.42 per 1 point; 95% CI, 1.31-1.54 per 1 point), fluid management adverse events (odds ratio, 2.84; 95% CI, 1.29-6.25), hospital-acquired infections (odds ratio, 1.60; 95% CI, 1.02-2.51), and mechanical ventilation (odds ratio, 1.98; 95% CI, 1.20-3.26). Despite their robust premorbid status, low-risk patients admitted to the ICU had significant inhospital mortality. Fluid management adverse events, hospital-associated infections, multiple organ dysfunction, and mechanical ventilation are important prognostic factors for low-risk patients.

COVID-19 outcomes of patients with gynecologic cancer in New York City: An updated analysis from the initial surge of the pandemic

BackgroundDespite significant increase in COVID-19 publications, characterization of COVID-19 infection in patients with gynecologic cancer remains limited. Here we present an update of COVID-19 outcomes among people with gynecologic cancer in New York City (NYC) during the initial surge of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]). MethodsData were abstracted from gynecologic oncology patients with COVID-19 infection among 8 NYC area hospital systems between March and June 2020. Multivariable logistic regression was utilized to estimate associations between factors and COVID-19 related hospitalization and mortality. ResultsOf 193 patients with gynecologic cancer and COVID-19, the median age at diagnosis was 65.0 years (interquartile range (IQR), 53.0–73.0 years). One hundred six of the 193 patients (54.9%) required hospitalization; among the hospitalized patients, 13 (12.3%) required invasive mechanical ventilation, 39 (36.8%) required ICU admission. Half of the cohort (49.2%) had not received anti-cancer treatment prior to COVID-19 diagnosis. No patients requiring mechanical ventilation survived. Thirty-four of 193 (17.6%) patients died of COVID-19 complications. In multivariable analysis, hospitalization was associated with an age ≥ 65 years (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.11, 4.07), Black race (OR 2.53, CI 1.24, 5.32), performance status ≥2 (OR 3.67, CI 1.25, 13.55) and ≥ 3 comorbidities (OR 2.00, CI 1.05, 3.84). Only former or current history of smoking (OR 2.75, CI 1.21, 6.22) was associated with death due to COVID-19 in multivariable analysis. Administration of cytotoxic chemotherapy within 90 days of COVID-19 diagnosis was not predictive of COVID-19 hospitalization (OR 0.83, CI 0.41, 1.68) or mortality (OR 1.56, CI 0.67, 3.53). ConclusionsThe case fatality rate among patients with gynecologic malignancy with COVID-19 infection was 17.6%. Cancer-directed therapy was not associated with an increased risk of mortality related to COVID-19 infection.

250. An Assessment of the Penicillin Allergy Label in Patients Undergoing Orthopedic Procedures at a VA Medical Center

BackgroundApproximately 10% of the population is labeled as penicillin (PCN) allergic, while only 1% of these individuals have a true IgE mediated allergy. This label influences the prescription of the most appropriate antibiotic and ultimately leads to antimicrobial resistance, hospital readmission, increased length of hospital stays, use of critical care beds, and greater healthcare costs. Post-surgical complications in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) are also increased when patients receive an alternative antibiotic due to PCN allergy. MethodsA retrospective chart review identified patients who underwent a TKA or THA during the 2018-2020 calendar years at the Washington DC VA Medical Center. Multiple operations at different times on the same patient were regarded as separate events. The primary outcome was patients who were evaluable for penicillin allergy de-labeling and the secondary outcome was perioperative antibiotic choice.ResultsPatients in both groups were predominantly male, Black, and over the age of 60. Of a total of 317 procedures performed, we identified 28 procedures in which patients carried a PCN allergy label (PAL) and received a β-lactam alternative antibiotic for surgical prophylaxis. No patients in the PAL group received cefazolin for prophylaxis, compared to 87% of the non-PAL group who were appropriately given cefazolin. In the group carrying the PAL, 62% of patients received vancomycin and 29% of patients received clindamycin for pre-operative prophylaxis. Only one of these patients had a formal allergy consult note, but the PCN allergy was not addressed during that visit. Fewer patients (4%) required ICU admission during their hospitalization in the non-PAL group versus 10% of patients in the PAL group. Table 1. Patient Demographics and Procedure Detail ConclusionThe use of alternative antibiotics in pre-procedural prophylaxis can contribute to adverse events associated with high-risk broader spectrum antimicrobials as well as increased costs associated with antimicrobials such as vancomycin. Our facility began implementation of a penicillin de-labeling program in 2018 via skin testing and direct oral challenge in collaboration with colleagues from Allergy and Immunology. Removal of PAL in this population can increase rates of appropriate prophylaxis. Disclosures All Authors: No reported disclosures

1160. Predictive Factors to Guide Empiric Antimicrobial Therapy of Acute Hematogenous Osteomyelitis in Children

Abstract Background Acute hematogenous osteomyelitis (AHO) is a serious infection in children. ESPID guidelines recommend empiric therapy with antistaphylococcal β-lactams in regions with a low methicillin-resistant S. aureus (MRSA) prevalence. In areas with a moderate-high prevalence of MRSA, selection of empiric therapy can be more challenging. We sought to examine factors present at the time of admission which may predict etiology and guide treatment in pediatric AHO in a region with endemic MRSA. Methods We reviewed admissions with ICD9/10 codes for AHO from 2011-2020 in otherwise healthy children. Patients with chronic infection, open or penetrating trauma, orthopedic hardware in situ, or disease secondary to a contiguous focus were excluded. Medical records were reviewed for clinical and laboratory parameters present on the day of admission. Results 586 cases were included. An etiology was identified in 76.8% of cases and S. aureus was most commonly identified (66.2%, 19% MRSA, Figure 1). Infection due to Kingella kingae (0.7%) occurred in younger children (p=0.01). Significant differences in presenting features were noted across pathogens, although S. aureus dominated in all sub-groups (Figure 2). Among children with respiratory symptoms at presentation, Group A Streptococcus (GAS, 10.7%), and S. pneumoniae (2.6%, p=0.01) were identified twice as frequently. Among children with reptiles exposure, Salmonella was identified in 10.8% (p=0.04). Multifocal infections and those requiring ICU admission were due to S. aureus in 88% and 97% of cases, respectively; these cases were disproportionately MRSA (36.4%, p=0.01 and 54%, p&amp;lt; 0.001). Both ESR and CRP were higher among MRSA compared to any other pathogen (Figure 3, p&amp;lt; 0.01). A CRP at presentation &amp;gt; 7 mg/dl had a 79.6% sensitivity for MRSA infection with a negative predictive value of 91.5%. Among those with either an ESR &amp;gt; 50 mm/hr or a CRP &amp;gt; 7 mg/dl, an organism was identified in 83.2% Depiction of the relative frequency of major pathogens among a cohort of 586 cases of acute hematogenous osteomyelitis in children Depiction of the relative frequency of different organisms in children with AHO with various history, exam and laboratory findings Scatterplot depicting ESR and CRP levels across major hematogenous osteomyelitis pathogens Conclusion Subtle differences in symptoms, history and laboratory parameters can provide clues to etiology in pediatric AHO. A CRP &amp;gt; 7 mg/dl at time of presentation is suggestive of MRSA AHO, and this should be considered when planning empiric therapy. Likewise, the absence of extreme elevation of CRP may serve an antibiotic stewardship role in MRSA endemic regions. Disclosures Sheldon L. Kaplan, MD, Pfizer (Research Grant or Support) Jonathon C. McNeil, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Allergan (Grant/Research Support)Nabriva (Grant/Research Support, Other Financial or Material Support, Site PI for a multicenter trial)

788. Enterobacter cloacae Infection Characteristics and Outcomes in Military Personnel who Sustained Trauma in Iraq and Afghanistan

Background Enterobacter cloacae is a Gram-negative rod with chromosomally-induced Amp-C β-lactamase with multidrug-resistant potential. Joint Trauma System guidelines for treating combat wounds include prophylaxis with cefazolin and ertapenem, potent inducers of Amp-C. We evaluated clinical characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections. MethodsAll initial solitary (those with single isolates) and serial E. cloacae isolates (≥24 hours from initial isolate from any site) were collected from the Trauma Infectious Disease Outcomes Study (6/2009-12/2014). Inclusion required E. cloacae isolation from a clinical infection. Amp-C-inducing β-lactams were classified based on induction potential and lability to the Amp-C β-lactamase as Amp-C induction levels. ResultsOf 653 E. cloacae isolates, 253 met inclusion criteria – 64 patients had only initial isolates, 54 patients had serial isolates. Patients were largely male (99%), median age 23 years (IQR 21-27), with injury severity score of 34 (IQR 24-45). Initial isolates were wound (70%), respiratory (22%), blood (7%), urine (1%), and other (1%). Patients commonly had blast injuries (89%), required ICU admission (95%), and had a median hospital stay of 57 days (IQR 39-82). Patients with serial isolates showed a trend towards earlier clinical infection (5 vs 8 days, P = 0.07). They were also less likely to receive carbapenems prior to E. cloacae isolation compared to those with only initial isolates (4% vs 38%) and more likely to receive 1st generation cephalosporins (79% vs 58%, P = 0.01). The serial isolate group received more days of 1st generation cephalosporins (median 6 days vs 2.5 days, P = 0.01). Cumulative antimicrobial therapy trended towards significance and was greater with the serial isolates (median 100 days vs 74 days, P = 0.08). There was no difference in number of surgical interventions between those with and without serial isolates (P = 0.54). Overall, 6 patients died. Conclusion E. cloacae infections after battlefield trauma were frequently encountered and associated with exposure to 1st generation cephalosporins. Serial infections did not correlate to worse patient outcomes but displayed a trend towards an overall greater duration of antibiotic use.Disclosures William N. Bennett, V, MD, Abbvie (Shareholder)Amgen (Shareholder)Nabriva (Shareholder)

328. Bacteremia in Patients Hospitalized with Covid-19 Disease, Risk Factors, Impact of immunomodulator Therapy, Role of Inflammatory Markers, Antibiotic Use, and Outcomes: A Single Center Retrospective Study

BackgroundNovel coronavirus 2019 (Covid19) caused by SARS-CoV2 can lead to significant morbidity and mortality. There is unclear association between Covid19 and bacteremia. Patient characteristics and outcomes are not well defined. This retrospective cohort study assessed this in patients with Covid19 and bacteremia.MethodsPatients with Covid-19 admitted to a tertiary care suburban academic medical center (UH) were assessed retrospectively by EMR chart review for co-morbidities, pre and in hospital factors, and outcomes as defined below. Bacteremias grouped into gram-negative or gram-positive with collation of each unique bacterial species (Table 1). ResultsTotal 1398 patients with Covid19 hospitalized at UH during local peak of pandemic of whom 238 (17.02%) developed 264 bacteremias with gram-positive (244, 92.4%) and gram-negative organisms (20, 7.57%). Relevant characteristics (Table 2) 53% with immunomodulator therapy (steroids/Tocilizumab), mean length of stay 21.04days (SEM ± 1.67) with day SARS-CoV2 PCR positivity -1.15days from hospitalization (SEM ± 0.49) and day initial bacteremia 6.38 (SEM ± 0.77), 55.4% required ICU admission, with 89% ICU admissions requiring mechanical ventilation. Most common co-morbidity (Figure 1 full list) Hypertension 56.3% followed by Obesity (BMI >30) 45.8% and CAD/CHF 40.3%. Laboratory parameters (Table 3)significant for average difference (date bacteremia- date admission) for Procalcitonin 4.15ng/mL (SEM ± 0.97, p-value 0.02), CRP -0.934mg/dL (SEM ± 0.95, p-value 0.32), WBC 7.027 K/uL (SEM ± 0.65, p-value < 0.005). These analyses excluded difference of 0 from hospital day 1 bacteremia. Average antibiotic number (1+ dose per antibiotic) 3.24 (SEM ± 0.16) and total C difficile cases 3 (1.26%). Mortality rate34.45%. Table 2.Patient Hospitalization CharacteristicsRelevant hospitalization characteristics, Covid19 and bacteremia co-infections Relevant laboratory parameters for patients with Covid19 and bacteremia co-infectionConclusionPatients with Covid19 and bacteremia had high mortality (Figure 2), 53% received immunomodulator therapy, possibly contributing to bacteremia development. With bacteremia increase in WBC and Procalcitonin, not CRP, noted. Most organisms CoNS, likely contaminants, gram positive bacteremias likely from indwelling lines. Only 3 C difficile infections identified. Trends noted in Procalcitonin rise, immunomodulator therapy, and low C difficile infection rates warrant further studies. Post-hospitalization OutcomesDisclosures All Authors: No reported disclosures

288. Clinical Variables Associated with COVID-19 Mortality and ICU Admission in a Public Safety-net Hospital in Chicago

BackgroundThe COVID-19 pandemic has disproportionately impacted minorities in the United States. John H. Stroger Jr. Hospital (JSH) is a tertiary care hospital within the safety-net system for Cook County in Chicago, Illinois. In this study we report demographics, clinical characteristics and outcomes of patients admitted with COVID-19 in our hospital during the spring surge of 2020. MethodsA retrospective study was done including patients > 18 years of age admitted to JSH with positive PCR for SARS-CoV2 from March 18 to May 30th, 2020. Outcomes, clinical and demographic characteristics were extracted from the electronic medical record. Moderate and severe disease were defined as radiographic evidence of pulmonary infiltrates and SpO2 > 94% on room air or SpO2< 94% on room air, respectively. Bivariate analysis and logistic regression were performed to assess for risk factors for admission to the intensive care unit and mortality. Results625 patients were included, 424 (68%) were male. Median age was 44 years (44,63). 364 (58%) were Hispanic and 222 (36%) non-Hispanic Blacks. 113 (18%) of patients presented with mild disease, 204 (33%) with moderate disease, 298 (48%) with severe disease. 73 patients (12%) died. 153 (24%) required ICU admission, 84 (13%) required intubation [Table 1]. In bivariate analysis, increasing age and diabetes (DM) were associated with increased mortality and ICU admission (p=0.001, Tables 2 and 3). Race/ethnicity was not associated with increased mortality or ICU admission. In the multivariate analysis, elevated glucose on admission regardless of DM and CKD were associated with mortality (p < 0.001). ConclusionJSH is a safety net hospital that provides care for the most vulnerable population of Chicago. The proportion of Hispanic patients increased in the later weeks of the pandemic until they represented most of the inpatient population and presented with more severe disease (Figure 1). Although race was not associated with mortality or ICU admission, the high prevalence of chronic diseases such as hypertension and DM in our population may explain the higher rate of admissions. Strengthening of preventive medicine and social engagement with minorities must be a crucial effort to decrease the burden of COVID-19 in this population. Graph showing disease severity on admission by Race/Ethnicity (upper). Notice the predominance of severe disease (orange) in Hispanic patients. Graph showing Race/Ethnicity Distribution by Week (lower). Notice the gradual increase and predominance of Hispanic patients (orange) in the later weeks of the study period compared to Black (blue) and White (green) patients.Disclosures All Authors: No reported disclosures

502. Early COVID-19 Treatment with SARS-CoV-2 Neutralizing Antibody Sotrovimab

BackgroundCOVID-19 disproportionately results in hospitalization and death in older patients and those with underlying comorbidities. Sotrovimab is a pan-sarbecovirus monoclonal antibody that binds a highly conserved epitope of the SARS-CoV-2 receptor binding domain and has an Fc modification that increases half-life. Sotrovimab retains activity against UK, S. Africa, Brazil, India, New York and California variants in vitro.ObjectivesTo evaluate the efficacy and safety of treatment with sotrovimab in high-risk, non-hospitalized patients with mild/moderate COVID-19, as part of the COMET-ICE clinical trial.MethodsMulticenter, double-blind, phase 3 trial in non-hospitalized patients with symptomatic COVID-19 and ≥1 risk factor for disease progression were randomized 1:1 to an IV infusion of sotrovimab 500 mg or placebo. The primary efficacy endpoint was the proportion of patients with COVID-19 progression, defined as hospitalization > 24 hours or death, due to any cause, ≤29 days of randomization.ResultsThe study met the pre-defined primary efficacy endpoint in a preplanned interim analysis: the risk of COVID-19 progression was significantly reduced by 85% (97.24% CI, 44% to 96%; P = 0.002) in 583 patients. In the final intention-to-treat analysis (N = 1057), the adjusted relative risk reduction was 79% (95% CI, 50% to 91%; p< 0.001) through Day 29 in recipients of sotrovimab (n=528) vs. placebo (n=529). Treatment with sotrovimab (ITT) resulted in a numerical reduction in the need for ER visits for illness management, hospitalization for acute illness management (any duration) or death (any cause) compared to placebo. No participants on sotrovimab required ICU admission, compared to 9 participants on placebo, of whom 4 participants required mechanical ventilation. No participants who received sotrovimab died, compared to 4 participants on placebo. The incidence of adverse events was similar between treatment arms and SAEs were numerically more common in the placebo arm.ConclusionTreatment with sotrovimab 500 mg IV resulted in a clinically and statistically significant reduction in progression of COVID-19 to hospitalization or death in patients with mild/moderate disease and was well-tolerated.Study fundingGSK & VIR; NCT04545060Disclosures Jaynier Moya, MD, VIR Biotechnology (Other Financial or Material Support, Jaynier Moya received non-financial support for serving as a clinical trial investigator for Vir Biotechnology) Diego Rodrigues Falci, MD, MSc, PhD, Gilead Sciences (Grant/Research Support, Scientific Research Study Investigator, Speaker's Bureau)GSK (Grant/Research Support, Scientific Research Study Investigator, Advisor or Review Panel member)MSD (Speaker's Bureau)Pfizer (Speaker's Bureau)United Medical (Speaker's Bureau, Other Financial or Material Support) Joel Solis, MD, VIR Biotechnology (Other Financial or Material Support, Joel Solis received non-financial support for serving as a clinical trial investigator for Vir Biotechnology) Hanzhe Zheng, PhD, VIR Biotechnology (Employee) Nicola Scott, MSc, GlaxoSmithKline (Employee, Shareholder) Andrea L. Cathcart, PhD, Gilead (Shareholder)VIR (Employee, Shareholder) Christy Hebner, PhD, Vir Biotechnology (Employee, Shareholder) Jennifer Sager, PhD, GSK (Other Financial or Material Support)Vir Biotechnology (Employee, Shareholder) Erik Mogalian, PharmD, PhD, Vir Biotechnology (Employee, Shareholder) Daren Austin, PhD, GlaxoSmithKline (Employee, Shareholder) Amanda Peppercorn, MD, GlaxoSmithKline (Employee) Elizabeth L. Alexander, MD, MSc, GlaxoSmithKline (Grant/Research Support, Other Financial or Material Support)VIR Biotechnology (Employee, Shareholder, GSK pharmaceuticals) Wendy W. Yeh, MD, Vir Biotechnology (Employee) Almena Free, MD, Amgen (Scientific Research Study Investigator)Astra Zeneca (Scientific Research Study Investigator)Cardurian (Scientific Research Study Investigator)Coherus (Scientific Research Study Investigator)Freenome (Scientific Research Study Investigator)GlaxoSmithKline/Vir (Scientific Research Study Investigator)Ionis (Scientific Research Study Investigator)Kowa (Scientific Research Study Investigator)New Amsterdam (Scientific Research Study Investigator)Regenacy (Scientific Research Study Investigator)Romark (Scientific Research Study Investigator)Scynexis (Scientific Research Study Investigator) Cynthia Brinson, MD, Abbvie (Scientific Research Study Investigator)BI (Scientific Research Study Investigator)Gilead Sciences Inc. (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker's Bureau, Personal fees)GSK (Scientific Research Study Investigator)Novo Nordisk (Scientific Research Study Investigator)ViiV Healthcare (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker's Bureau) Melissa Aldinger, PharmD, VIR Biotechnology (Employee) Adrienne Shapiro, MD, PhD, Vir Biotechnology (Scientific Research Study Investigator)

1309. Incidence and Epidemiology of Invasive Pneumococcal Disease due to Serotype 3 in South-Central Ontario

BackgroundIn our population, the most common serotype (ST) of S. pneumoniae causing invasive pneumococcal disease (IPD) is now ST 3. We undertook an analysis of population based surveillance for IPD to examine the incidence and epidemiology of ST 3 disease over the last 25 years.MethodsThe Toronto Invasive Bacterial Diseases Network has performed population-based surveillance for IPD in Toronto/Peel region (pop’n 4.5M) since 1995. All sterile site isolates of S. pneumoniae are reported to a central study laboratory, isolates are serotyped, and clinical and vaccination data are collected via patient and physician interview and chart review. Population data are obtained from Statistics Canada.ResultsFrom 1995-2020, 11032 episodes of IPD occurred; 10015 had STs available, and 10484 clinical data. Overall, ST 3 comprised 9.2% of cases (N=931). Compared to other patients with IPD, those with ST 3 IPD were older (median age 65 vs. 58.5, P< .001), more likely to have underlying lung (22.7% v 16.0%, P< .0001) and cardiac (21.7 v 18.4, P=.02) disease and less likely to be immunocompromised (IC) (23.1% v 29.0% P< .0001). ST3 episodes were more likely to be pneumonia (81% v 65%), less likely to be bacteremia without focus (7.6% v 18.9%), and more likely to require ICU admission (42.3% v 25.1%) and to die (27.1% v 16.6%). In multivariable analysis, patients with ST 3 disease remained more likely to die (OR 1.65; 95%CI1.3-2.0). Over time, the proportion of patients with ST 3 IPD who were nursing home (NH) residents (18/171 in 1995-2000 vs. 4/215 in 2016-2020, P=.0002), and who were IC (46/169 in 1995-2000 vs 39/204 in 2016-2020, P=.007) decreased significantly; in IPD due to other STs, the proportion who were NH residents declined, but the proportion IC increased significantly. The case fatality rate (CFR) declined significantly in IPD due to ST3 but not other STs (Figure 1). Changes in incidence are shown in Figure 2.Figure 2: Incidence of serotype 3 IPD over time, Toronto/Peel, 1995-2020 The incidence of ST3 IPD in children and adults under 65 did not change significantly from 1995/96 to 2019/20. In older adults, the annual incidence of disease declined from 4.98 per 100,000 per year in 1995-2000 to 3.53 per 100,000 per year in 2001-2010 (IRR 0.71, 95%CI 0.56-0.90), then to 2.23 per 100,000 per year in 2011-2020 (IRR compared to 2001-2010 0.63, 95%CI 0.50-0.79)FIgure 2: Case fatality rate of IPD due to serotype 3 and other serotypes over time, 1995-2020, Toronto-Peel The case fatality rate of IPD due to ST3 declined from 37.6% (56/149) in 1995-2000 to 50/235 (21.3%) in 2015-2020 (P<.0001). The CFR in other serotypes did not change.ConclusionThe epidemiology of IPD due to ST3 has changed significantly over time and the CFR has declined. The incidence of ST3 disease in children and younger adults has not changed significantly, although the power to detect change is low in children. In older adults the incidence of ST3 disease declined significantly after PPV23 introduction in 1995/6 and again after PCV13 introduction for children.Disclosures All Authors: No reported disclosures

Factors associated with hospital and intensive care admission in paediatric SARS-CoV-2 infection: a prospective nationwide observational cohort study

Coronavirus disease 2019 (COVID-19) is usually less severe in children compared to adults. This study describes detailed clinical characteristics, treatment and outcomes of children with COVID-19 in a non-hospitalised and hospitalised setting and quantifies factors associated with admission to hospital and intensive care unit in children with SARS-CoV-2 infection on a nationwide level. Data were collected through the Swiss Paediatric Surveillance Unit from children < 18 years with confirmed SARS-CoV-2 infection. All 33 paediatric hospitals in Switzerland reported non-hospitalised and hospitalised cases from March 1 to October 31, 2020 during both pandemic peaks. In total, 678 children were included. The median age was 12.2 years (IQR 5.0–14.6), 316 (46.6%) were female and 106 (15.6%) had comorbidities. Overall, 126 (18.6%) children were hospitalised of whom 16 (12.7%) required ICU admission. Comorbidities were the only factor associated with hospital admission in a multivariable regression analysis (odds ratio 3.23, 95%CI 1.89 to 5.50; p-value < 0.01). Children with preexisting comorbidities did not require ICU admission more often. Hospitalised children more often presented with fever (96 [76.2%] vs 209 [38.1%], p-value < 0.01) and rash (16 [12.8%] vs 6 [1.1%], p-value < 0.01). Anosmia/dysgeusia was more prevalent in non-hospitalised children (73 [13.3%] vs 3 [2.4%], p-value < 0.01). In hospitalised children, oxygen treatment was required in 34 (27.0%), inotropes in nine (7.3%) and mechanical ventilation in eight (6.3%) cases. Complications were reported in 28 (4.1%) children with cardiovascular complications being most frequent (12 [1.8%]). Three deaths were recorded.Conclusion: This study confirms that COVID-19 is mostly a mild disease in children. Fever, rash and comorbidities are associated with higher admission rates. Continuous observation is necessary to further understand paediatric COVID-19, guide therapy and evaluate the necessity for vaccination in children.What is Known:• Clinical manifestations of SARS-CoV-2 infection in children vary from asymptomatic to critical disease requiring intensive care unit admission.• Most studies are based on hospitalised children only; currently, there is limited data on non-hospitalised children.What is New:• The clinical spectrum and severity of COVID-19 is influenced by age: in children less than 2 years, fever, cough and rhinorrhoea are the most common symptoms and in adolescents, fever, cough and headache are more common.• Hospitalised children more often presented with fever and rash, while anosmia/dysgeusia is more prevalent in non-hospitalised children.• Children with pre-existing comorbidities are more frequently hospitalised but do not require ICU admission more often.

Modified Brixia chest X-ray severity scoring system and correlation with intubation, non-invasive ventilation and death in a hospitalised COVID-19 cohort.

There are few existing severity scoring systems in the literature, and no formally widely accepted chest X-ray template for reporting COVID-19 infection. We aimed to modify the chest X-ray COVID-19 severity scoring system from the Brixia scoring system with placement of more emphasis on consolidation and to assess if the scoring tool could help predict intubation. A severity chest X-ray scoring system was modified from the Brixia scoring system. PCR positive COVID-19 positive patient's chest X-rays admitted to our hospital over 3 months were reviewed and correlated with; non-invasive ventilation, intubation and death. An analysis was performed using a receiver operating curve to predict intubation from all admission chest X-rays. The median score of all 325 admission chest X-rays was 3 (Interquartile range (IQR) 0-6.5). The median score of admission chest X-rays of those who did not require ICU admission and survived was 1.5 (IQR 0-5); and 9 (IQR 4.75-12) was median admission score of those requiring intubation. The median scores of the pre-intubation ICU chest X-rays was 11.5 (IQR 9-14.125), this increased from a median admission chest X-ray score for this group of 9 (P-value < 0.01). A cut-off score of 6 had a sensitivity of 77% and specificity of 73% in predicting the need for intubation. Higher chest X-ray severity scores are associated with intubation, need for non-invasive ventilation and death. This tool may also be helpful in predicting intubation.

Early Antibiotic Administration is Independently Associated with Improved Survival in Traumatic Brain Injury

Central and systemic immune dysfunction after traumatic brain injury (TBI) can lead to infectious-related complications, which may result in delayed mortality. The role of early empiric antibiotics after TBI has not been characterized to date, but is recommended in select cases to decrease complications. We aimed to determine the relationship between early antibiotic use and in-hospital mortality in TBI patients. A retrospective review was conducted of TBI patients requiring ICU admission at an urban, academic, Level I trauma center from 01/2014 to 08/2016. Data collection included demographics, injury characteristics, details regarding antibiotic use, and outcomes. Early antibiotic administration was defined as any antibiotic given within 48 hs from admission. Patients given early antibiotics (EARLY) were compared to those who received their first dose later or did not receive any antibiotics (non-EARLY). Of the 488 TBI patients meeting inclusion criteria, 189 (38.7%) received early antibiotics. EARLY patients were younger (EARLY 54.2 versus non-EARLY 61.5 ys, P <0.01) and more likely to be male (71.4% versus 60.9%, P=0.02). Injury severity scores (23.6 versus 17.2, P <0.01) and regional head abbreviated injury scale scores (3.9 versus 3.7, P <0.01) were significantly higher in patients who received early antibiotics. Unadjusted in-hospital mortality rates were similar, however EARLY was associated with a lower mortality rate (AOR 0.17, 95% CI: 0.07 - 0.43, adjusted P <0.01) after adjusting for confounders. Despite presenting with a higher injury burden, TBI patients who received early antibiotics had a lower associated mortality rate compared to their counterparts. Future investigations are necessary to understand the underlying mechanisms that result in this potential survival benefit.

Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes.

BackgroundPerforated peptic ulcer disease (PUD) is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in the presentation of patients with perforated ulcers. Here we present this study from our experience in a Northern Irish acute district hospital.MethodsA retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with the incidence of perforated peptic ulcers. Follow-up data were also collected. Seasons were defined as per UK Met Office.ResultsA total of 50 patients presented with perforated PUD. Male to female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. Fourteen patients (28%) were either very frail or had contained perforations and were conservatively managed. Three deaths were noted (6%). Thirteen patients (26%) required ICU admission at some stage in their management.ConclusionSlight seasonal variation was noted in the presentation of perforated peptic ulcers in our study with a higher incidence in the winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.