Requiring ICU Admission Research Articles

Risk factors and outcome associated with infection or colonization due to carbapenem-heteroresistant Escherichia coli.

BackgroundUp to 32% of ESBL-producing Enterobacterales strains display a carbapenem-heteroresistant (cHR) phenotype but its clinical relevance is unknown.ObjectivesTo determine risk factors and clinical outcome associated with infection due to cHR ESBL-producing Escherichia coli (ESBL-EC).MethodsA retrospective, case–control study was conducted on patients from whom a pair of clonally related E. coli strains were isolated during separate healthcare encounters with (case) or without (control) development of cHR phenotype in the latter strain. Study groups were compared for host and microbial characteristics and carbapenem exposure. Outcome measures included ICU admission, length of hospitalization, and mortality.ResultsStudy patients (15 cases, 10 controls) were elderly (median age: 74 years) with half admitted from home (52%), most (80%) having ≥3 comorbid conditions and severe functional impairment. Case patients were more likely to have ‘index’ ESBL-EC isolating from blood (27% versus 0%; P = 0.125) and have greater cumulative amount and duration of carbapenem exposure than controls. All control ‘subsequent’ isolates were from urine whereas five cHR case isolates were from blood or respiratory sources. More hospitalized case patients required ICU admission (23% versus 0%; P = 0.257) and prolonged hospital stay (>7 days) than controls (62% versus 38%%; P = 0.387).ConclusionsOur findings deserve confirmation with a larger study population and call attention to the potential for increased morbidity with cHR ESBL-EC infections, which underscores the need to screen for cHR phenotype in patients with repeated growth of ESBL-EC, particularly from systemic sites and patients that have had extensive carbapenem exposure.

Sex differences in susceptibility, severity, and outcomes of coronavirus disease 2019: Cross-sectional analysis from a diverse US metropolitan area.

IntroductionSex is increasingly recognized as an important factor in the epidemiology and outcome of many diseases. This also appears to hold for coronavirus disease 2019 (COVID-19). Evidence from China and Europe has suggested that mortality from COVID-19 infection is higher in men than women, but evidence from US populations is lacking. Utilizing data from a large healthcare provider, we determined if males, as compared to females have a higher likelihood of SARS-CoV-2 susceptibility, and if among the hospitalized COVID-19 patients, male sex is independently associated with COVID-19 severity and poor in-hospital outcomes.Methods and findingsUsing the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, we conducted a cross-sectional analysis of data from a COVID-19 Surveillance and Outcomes Registry (CURATOR). Data were extracted from Electronic Medical Records (EMR). A total of 96,473 individuals tested for SARS-CoV-2 RNA in nasopharyngeal swab specimens via Polymerized Chain Reaction (PCR) tests were included. For hospital-based analyses, all patients admitted during the same time-period were included. Of the 96,473 patients tested, 14,992 (15.6%) tested positive, of whom 4,785 (31.9%) were hospitalized and 452 (9.5%) died. Among all patients tested, men were significantly older. The overall SARS-CoV-2 positivity among all tested individuals was 15.5%, and was higher in males as compared to females 17.0% vs. 14.6% [OR 1.20]. This sex difference held after adjusting for age, race, ethnicity, marital status, insurance type, median income, BMI, smoking and 17 comorbidities included in Charlson Comorbidity Index (CCI) [aOR 1.39]. A higher proportion of males (vs. females) experienced pulmonary (ARDS, hypoxic respiratory failure) and extra-pulmonary (acute renal injury) complications during their hospital course. After adjustment, length of stay (LOS), need for mechanical ventilation, and in-hospital mortality were significantly higher in males as compared to females.ConclusionsIn this analysis of a large US cohort, males were more likely to test positive for COVID-19. In hospitalized patients, males were more likely to have complications, require ICU admission and mechanical ventilation, and had higher mortality than females, independent of age. Sex disparities in COVID-19 vulnerability are present, and emphasize the importance of examining sex-disaggregated data to improve our understanding of the biological processes involved to potentially tailor treatment and risk stratify patients.

Risk factors for mortality and progression to severe COVID-19 disease in the Southeast region in the United States: A report from the SEUS Study Group

Identify risk factors that could increase progression to severe disease and mortality in hospitalized SARS-CoV-2 patients in the Southeast region of the United States. Multicenter, retrospective cohort including 502 adults hospitalized with laboratory-confirmed COVID-19 between March 1, 2020, and May 8, 2020 within 1 of 15 participating hospitals in 5 health systems across 5 states in the Southeast United States. The study objectives were to identify risk factors that could increase progression to hospital mortality and severe disease (defined as a composite of intensive care unit admission or requirement of mechanical ventilation) in hospitalized SARS-CoV-2 patients in the Southeast United States. In total, 502 patients were included, and 476 of 502 (95%) had clinically evaluable outcomes. The hospital mortality rate was 16% (76 of 476); 35% (177 of 502) required ICU admission and 18% (91 of 502) required mechanical ventilation. By both univariate and adjusted multivariate analyses, hospital mortality was independently associated with age (adjusted odds ratio [aOR], 2.03 for each decade increase; 95% confidence interval [CI], 1.56--2.69), male sex (aOR, 2.44; 95% CI, 1.34-4.59), and cardiovascular disease (aOR, 2.16; 95% CI, 1.15-4.09). As with mortality, risk of severe disease was independently associated with age (aOR, 1.17 for each decade increase; 95% CI, 1.00-1.37), male sex (aOR, 2.34; 95% CI, 1.54-3.60), and cardiovascular disease (aOR, 1.77; 95% CI, 1.09-2.85). In an adjusted multivariate analysis, advanced age, male sex, and cardiovascular disease increased risk of severe disease and mortality in patients with COVID-19 in the Southeast United States. In-hospital mortality risk doubled with each subsequent decade of life.

Secondary Causes of Hypertriglyceridemia are Prevalent Among Patients Presenting With Hypertriglyceridemia Induced Acute Pancreatitis

BackgroundHypertriglyceridemia induced acute pancreatitis (HIAP) is the third common cause of acute pancreatitis. HIAP can result in recurrent attacks of severe AP with significant morbidity and mortality. Hypertriglyceridemia (HTG) could be primary or secondary. Although genetic causes of HTG are well studied, the prevalence of secondary causes of HTG in patients presenting with HIAP is not well characterized. This study aimed to identify the prevalence of risk factors for secondary hypertriglyceridemia among patients presenting with HIAP in a tertiary referral center in a large metropolitan area. MethodsThis is a retrospective analysis of all patients admitted with AP from August 2012–2017. A subgroup of patients with triglycerides >880 mg/dl were included for analysis. Secondary causes of HTG were identified. Secondary analysis evaluating the severity of pancreatitis was performed. ResultsThere were 3,746 patients admitted for AP of which 57 patients had AP and HTG. Of these 57 patients, 70.2% had history of diabetes mellitus, 26.3% had history of heavy alcohol use, 22.8% had chronic kidney disease, 47.3% with obesity, and 21.1% with metabolic syndrome. Two patients were classified as unexplained HTG. Secondary analysis showed a total of 45.6% of patients requiring ICU admission. 26.3% of patients with severe inflammatory pancreatitis and 17.5% of patients with severe necrotizing pancreatitis. ConclusionsIn our cohort of HIAP, 55 out of 57 patients had secondary causes for HTG. Identifying secondary causes of HTG during acute hospitalization is important to tailor outpatient treatment in order to prevent future admissions with HIAP.

Clinical course and outcomes of COVID-19 in rheumatic disease patients: a case cohort study with a diverse population.

ObjectiveTo determine clinical course and outcomes in rheumatic disease patients with coronavirus disease 2019 (COVID-19) and compare results to uninfected patients.MethodsWe conducted a case cohort study of autoimmune disease patients with COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR) from February 1, 2020, to July 31, 2020, and compared them in a 1:3 ratio with uninfected patients who were matched based on race, age, sex, and comorbidity index. Patient demographics, clinical course, and outcomes were compared among these patient groups.ResultsA total of 70 rheumatic disease patients with COVID-19 (mean age, 56.6 years; 64% African American) were identified. The 34 (49%) patients who were hospitalized used oral glucocorticoids more frequently than those treated as outpatients (p < 0.01). All 10 patients using anti-TNFα medications were treated as outpatients (p < 0.01). Those hospitalized with COVID-19 more often required ICU admission (17 (50%) vs 27 (26%), p = 0.01) and intubation (10 (29%) vs 6 (6%), p < 0.01) than uninfected patients and had higher mortality rates (6 (18%) vs 3 (3%), p < 0.01). Of the six COVID-19 patients who died, only one was of African ancestry (p = 0.03).ConclusionRheumatic disease patients infected with COVID-19 were more likely to require ICU admission, ventilation, and died more frequently versus uninfected patients with autoimmune disease. Patients on anti-TNFα medications were hospitalized less frequently, while those on chronic glucocorticoids were hospitalized more frequently. These findings have important implications for medication choice in rheumatic disease patients during the ongoing spread of COVID-19.Key Points• We show that hospitalized rheumatic disease patients with COVID-19 have poorer outcomes including ICU admission, ventilation, and death compared to hospitalized rheumatic disease patients not infected with COVID-19.• This study adds further support regarding protective effects of anti-TNFα medications in COVID-19 disease course, with 0 of 10 of these patients required hospitalization.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10067-021-05578-x.

Mortality and other outcomes of patients with coronavirus disease pneumonia admitted to the emergency department: A prospective observational Brazilian study.

The first cases of coronavirus disease (COVID-19) in Brazil were diagnosed in February 2020. Our Emergency Department (ED) was designated as a COVID-19 exclusive service. We report our first 500 confirmed COVID-19 pneumonia patients. From 14 March to 16 May 2020, we enrolled all patients admitted to our ED that had a diagnosis of COVID-19 pneumonia. Infection was confirmed via nasopharyngeal swabs or tracheal aspirate PCR. The outcomes included hospital discharge, invasive mechanical ventilation, and in-hospital death, among others. From 2219 patients received in the ED, we included 506 with confirmed COVID-19 pneumonia. We found that 333 patients were discharged home (65.9%), 153 died (30.2%), and 20 (3.9%) remained in the hospital. A total of 300 patients (59.3%) required ICU admission, and 227 (44.9%) needed invasive ventilation. The multivariate analysis found age, number of comorbidities, extension of ground glass opacities on chest CT and troponin with a direct relationship with all-cause mortality, whereas dysgeusia, use of angiotensin converting enzyme inhibitor or angiotensin-ii receptor blocker and number of lymphocytes with an inverse relationship with all-cause mortality. This was a sample of severe patients with COVID-19, with 59.2% admitted to the ICU and 41.5% requiring mechanical ventilator support. We were able to ascertain the outcome in majority (96%) of patients. While the overall mortality was 30.2%, mortality for intubated patients was 55.9%. Multivariate analysis agreed with data found in other studies although the use of angiotensin converting enzyme inhibitor or angiotensin-ii receptor blocker as a protective factor could be promising but would need further studies. The study was registered in the Brazilian registry of clinical trials: RBR-5d4dj5.

P134 SARS-CoV-2 infection in cystic fibrosis during the first pandemic wave in Italy: a multi-centre prospective study with a control group

Background: Patients with cystic fibrosis (CF) are at high risk of developing severe forms of viral respiratory infections. This study aimed at comparing symptoms and clinical course of SARS-CoV2 infection with other respiratory infections in patients with CF. Methods: We carried out a prospective multicentre cohort study within the Italian CF Society involving 32 CF centres following 6,597 patients. CF centres were contacted to collect baseline and follow-up data of all patients who had reported symptoms suggestive of COVID-19 or who had had contact with a positive/suspected case between the end of February and July 2020. Symptoms and clinical course of the infection were compared between patients who tested positive by molecular testing (cases) and those who tested negative (controls). Results: Thirty patients were reported from the centres, 16 of whom tested positive and 14 negative. Fever, cough, asthenia and dyspnea were the most frequently reported symptoms and their frequency were not significant different between groups. Eight cases (50%) were hospitalised but none required ICU admission. Two adults with a history of lung transplant required non-invasive ventilation;none required ICU admission. All patients fully recovered without short-term sequelae. Changes in FEV1 (percent of predicted) after recovery were not significantly different between groups (median, interquartile range: 3.0%, –1.5, 5.5 among cases and –3.0%, –8.5, 6.3 among controls, P = 0.48). Conclusions: Symptoms and clinical course of SARS-CoV-2 infection in our patients was not significantly different from other respiratory infections. The clinical course of COVID-19 was relatively favourable, however CF patients with severely impaired respiratory function and organ transplant may develop complications and a negative outcome. The study is ongoing, and we are recruiting patients during the second wave of the pandemic.

Characteristics and Outcomes of COVID-19 Infection from an Urban Ambulatory COVID-19 Clinic-Guidance for Outpatient Clinicians in Triaging Patients.

BackgroundCoronavirus infection (COVID) presents with flu-like symptoms and can cause serious complications. Here, we discuss the presentation and outcomes of COVID in an ambulatory setting along with distribution of positive cases amongst healthcare workers (HCWs).MethodPatients who visited the COVID clinic between 03/11/2020 and 06/14/2020 were tested based on the CDC guidelines at the time using PCR-detection methods. Medical records were reviewed and captured on a RedCap database. Statistical analysis was performed using both univariate and bivariate analysis using Fischer’s exact test with 2-sided P values.ResultsOf the 2471 evaluated patients, 846 (34.2%) tested positive for COVID. Mean age of positivity was 43.4 years (SD ± 15.4), 60.1% were female and 49% were Black. 58.7% of people tested had a known exposure, and amongst those with exposure, 57.3% tested positive. Ninety-four patients were hospitalized (11.1%), of which 22 patients (23.4%) required ICU admission and 10 patients died. The overall death rate of patients presenting to clinic was 0.4%, or 1.2% amongst positive patients. Median length of hospital stay was 6 days (range 1-51). Symptoms significantly associated with COVID included: anosmia, fever, change in taste, anorexia, myalgias, cough, chills, and fatigue. Increased risk of COVID occurred with diabetes, whereas individuals with lung disease or malignancy were not associated with increased risk of COVID. Amongst COVID positive HCWs, the majority were registered nurses (23.4%), most working in general medicine (39.8%) followed by critical care units (14.3%).Discussion/ConclusionBlacks and females had the highest infection rates. There was a broad range in presentation from those who are very ill and require hospitalization and those who remain ambulatory. The above data could assist health care professionals perform a targeted review of systems and co-morbidities, allowing for appropriate patient triage.

Factors Associated with Hospital and Intensive Care Admission in Paediatric SARS-CoV-2 Infection: A Prospective Nationwide Observational Cohort Study

Background: 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 laboratory-confirmed 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.Methods: Data were collected through the Swiss Paediatric Surveillance Unit from children Findings: In total, 678 children were included. The median age was 12.2 (IQR 5.0 – 14.6) years, 316 (47%) were female and 106 (16%) 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 Interpretation: 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.Funding: The study is supported by the Swiss Federal Office of Public Health and has received grants from the Swiss Society of Paediatrics and the Paediatric Infectious Disease Group of Switzerland.Declaration of Interest: None to declare.Ethical Approval: The study has received ethical approval by the Ethikkommission Nordwest- undZentralschweiz (EKNZ 2020-01130).

Sequential Organ Failure Assessment (SOFA) Score Is Superior to Classical Prognostic Indices in Prediction of Severity, Intensive Care Unit Admissions and Mortality in Acute Pancreatitis

Introduction: Acute Pancreatitis (AP) is common and severe AP is potentially lethal. Many prognostic indices (APACHE-II, BISAP, Glasgow's, HAPS, Ranson's, SOFA) are used to predict severity. We evaluate utility of these indices in predicting severity, need for ICU admission, and mortality. Methodology: A retrospective audit of 653 patients with AP from July 2009 to September 2016 is done. The demographic and clinical profile and patient outcomes were collected. Severe acute pancreatitis (SAP) was defined as per revised Atlanta classification. Results: The mean age was 58.7±17.5 years with 58.7% males. Commonly identified etiologies of AP was gallstones(n=404, 61.9%), alcohol(n=38, 5.8%) and hypertriglyceridemia(n=19, 2.9%). 81(12.4%) patients developed SAP, 20(3.1%) required ICU admission and 12(1.8%) deaths were attributed to SAP. All-cause in-hospital mortality was 36(5.5%); 7(1.1%) cardiovascular causes, and 5(0.8%) pneumonia. Ranson's and APACHE-II demonstrated highest sensitivity in predicting SAP(92.6%, 80.2% respectively), ICU admission(100%) and mortality(100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP(13.6%, 24.7% respectively), ICU admission(40.0%, 25.0% respectively) and mortality(50.0%, 25.5% respectively). SOFA demonstrated highest specificity in predicting SAP(99.7%), ICU admission(99.2%) and mortality(98.9%). SOFA demonstrated highest positive predictive value, positive likelihood ratio, diagnostic odds ratio and overall accuracy in predicting SAP, ICU admission and mortality. The highest Area under Receiver-operator Curves(AUROC) was demonstrated by SOFA and Ranson's cumulative(Ranson score at 48 hours) in predicting SAP(0.966, 0.857 respectively), ICU admission(0.943, 0.946 respectively) and mortality(0.968, 0.917 respectively). Conclusion: SOFA score and Ranson's cumulative are accurate in severity stratification, prediction of ICU admission and mortality in acute pancreatitis.

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service

ABSTRACT BACKGROUND: This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region METHODS: All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed RESULTS: Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths CONCLUSION: The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region Keywords: multiple trauma, general surgery, paediatrics

DELAYED DEBRIDEMENT FOR NECROTIZING SOFT TISSUE INFECTIONS: EXPERIENCE WITH IMMUNOCOMPROMISED PEDIATRIC CANCER PATIENTS.

Background: Standard management of necrotizing soft tissue infections (NSTI) includes combination of antimicrobial chemotherapy, supportive care and surgical debridement. Debridement is often done very early in the course of illness to remove dead tissue. Fatality rates from this condition are very high. Objective: To evaluate the strategy of delayed rather than early debridement in the management of NSTI in immunocompromised hematologic malignancy patients. Patients and Methods: Twenty patients included in the study. All were immunocompromised pediatric patients on cancer treatment who present with necrotizing soft tissue infection. Debridement was deferred on initial presentation. After stabilization of the general condition of the patients and improvement of the local conditions by developing line of demarcation between the necrotic area and the inflamed area, the patients underwent delayed debridement in the O.R with excision of the overtly dead tissue only. Results: There were 13 males and 7 females with age ranging from 9 months to 16 years. After initial treatment with antibiotics, in 7 out of 20 patients the antibiotics alone succeeded to halt the progress of infection. In the remaining 13, the process proceeded to SIRS and MODS. They required ICU admission for a range of monitoring and organ support. Only one patient died. The remaining 12 required significant debridement and later grafting of the bare area after development of the healthy granulation tissue. Good functional outcome of the affected part was achieved with the aid of variable physiotherapy courses. Conclusion: NSTI in immunocompromised patients with cancer is a pathology known of high fatality rate. Delayed rather than early debridement was associated with low mortality rates and limb preservation with good functional outcome.

Hypocoagulable Coagulation Profile and Endogenous Heparinoids Are Associated with Invasive Ventilation and Mortality in COVID-19

Background & Aims: A procoagulant state with pulmonary micro-thrombosis has been described in COVID-19, which contributes to pathophysiology of respiratory failure along with diffuse alveolar damage. Cytokine storm and systemic inflammation in COVID-19 generates endogenous heparinoids from the endothelium which leads to secondary organ failures. We prospectively studied the dynamic association of the coagulation abnormalities with respiratory failure and mortality in patients with COVID-19.Methods: We did a prospective observational study in adults aged between 18-80 years with COVID 19 pneumonia requiring intensive care (ICU) admissions in a tertiary care hospital in North India. All patients received standard medical therapy based on best available evidence. Patients were categorized based on the oxygen support therapy into low flow, high flow and invasive ventilation groups. In patients considered to be at risk of thromboembolic or bleeding phenomena, paired coagulation tests were performed at days 1 and 3 with, Sonoclot ® (glass beaded and heparinase-treated). All patients were consecutively followed for inflammatory markers, ventilator requirements and survival. Activated clotting time (ACT) 75 units were used as the cut-off for hypercoagulable state. The heparin like effect (HLE) was considered by a correction of ≥ 40 s in hACT (heparinized treated ACT). The trial is registered with ClinicalTrials.gov (NCT04668404).Results: A total of 2324 patients with COVID-19 were screened from August 2020 to November 2020. Two hundred and fifteen patients requiring ICU admission were assessed and 74 patients with a median age of 54(42-67) years were enrolled. A procoagulant profile was seen in 45.5%, 32.4% and 20.7% in low-flow, high-flow, and invasive ventilation. Paired Sonoclot ® assays in 33 patients demonstrated HLE in 17 (51.5%) and 20 (62.5%) at days 1 and 3 respectively. In multivariate analysis, the presence of HLE (HR 1.02; CI 1.08-1.6; p 131 s, clot rate 96.7 mg/l at admission predicted mortality.Conclusions: HLE contributes to hypocoagulable effect, need for invasive ventilation and mortality in patients with COVID-19.Trial Registration: The trial is registered with ClinicalTrials.gov (NCT04668404).Funding Statement: NoneDeclaration of Interests: NoneEthics Approval Statement: Ethical clearance was obtained from the Institutional Review Board (PGI/IEC/2020/000997 dated 24 August 2020)

Innovative mid-trimester termination of pregnancy in a COVID-19 critically Ill patient

The current COVID-19 pandemic has introduced many challenges on the presentation of the disease, effects of the disease on co-morbidities of the patient and the management of these. This has necessitated innovative ways of managing these patients. This is particularly so in pregnant women with COVID-19. We present a case of a pregnant woman in her mid-trimester who presented with severe COVID-19 disease requiring ICU admission who required termination of pregnancy due to worsening condition while on ventilator. She presented with high fever, cough and difficulty in breathing. These rapidly deteriorated requiring ECMO. Her liver function, kidney function and inflammatory markers equally deteriorated very fast despite various treatments including using convalescence plasma. We decided to terminate the pregnancy to help in managing her condition. The baby died just when we were considering the termination of the pregnancy thus requiring Mid-trimester termination of the non-viable pregnancy. We initially tried to use vaginal misoprostol for the termination but failed thus we had to find a way of using mifepristone pre-treatment for the termination. An innovative used of mifepristone through the nasogastric tube was devised and we successfully terminated the pregnancy with mifepristone pre-treatment followed by a single dose of misoprostol with minimal blood loss. The patient’s condition improved rapidly after the termination of pregnancy and she recovered fully. We feel her pregnant status might have contributed to her severe symptoms and the disease may have contributed to the demised of the baby. We recommend the use of mifepristone through the nasogastric tube in the process of termination of pregnancy in a sick ventilated patient.

ICU admission of COVID-19 patients: Identification of risk factors

ABSTRACT Background The WHO has declared COVID-19 as a global pandemic with a rapidly increasing number of patients at a rate exceeding the limits of health-care resources. Some people seem to be at higher risk of worse prognosis and increased mortality. Identifying these vulnerable groups is a necessity. Aim of study To identify the risk factors associated with ICU admission in COVID-19 patients. Methodology We present a retrospective study where the clinical data of patients with laboratory-confirmed COVID-19 infection were collected from Ain-Shams University Isolation-Hospital records on admission from 10 April 2020 to 30 July 2020 to identify risk factors in patients requiring ICU admission during hospital stay. Results Of 323 subjects diagnosed by the RT-PCR as positive COVID-19, 62 (19.2%) of which were admitted at the ICU. The mean age of the subjects was 46.6 ± 16 years. Significant morbidities were associated with higher age groups (p value 0.000), smokers (p value 0.004), Cairo-residents (p value 0.009), being a health-care provider (p value 0.001) and hypertensive patients (p value 0.000). Conclusions Elderly, smokers, diabetic and hypertensive need further attention during disease course. Our results call for further investigations of risk factors for COVID-19 severity; preferably on large prospective cohorts, to increase their validity.

CT chest interpretation of novel coronavirus disease (COVID-19)

Introduction: In December 2019, the outbreak of a novel corona virus infection occurred in Wuhan City, China. Early discussions suggested that computed tomography (CT) should be the preferred modality for the diagnosis of COVID-19. However, the use of CT for COVID-19 diagnosis is controversial. Also, the detailed CT features of COVID-19 have been reported in only a small number of articles in the literature. Objective: To evaluate lung abnormalities on thin-section CT scans in patients with COVID-19. Materials and Methods: This study included the first 60 clinically suspected patients for COVID-19 infection. The patients have further investigated for COVID-19 infection by reverse transcription-polymerase chain reaction (RT-PCR) test and CT chest. We identified CT patterns suggestive of COVID-19 infection and calculated the total CT severity score. The imaging reports of the CT chest study were compared with the RT-PCR test results. Results: In our study, we had 37 male patients and 23 female patients. COVID-19 pneumonia was diagnosed in 55 of the 60 patients, but five patients did not show any commonly described findings of COVID-19 pneumonia. Of the 55 patients, the majority of them had ground-glass opacities. The bilateral lower lobes were involved in the majority of the cases. RT-PCR results show that, of the 60 patients, 37 were positive for COVID-19 and 23 were negative for COVID-19. The mean total lung severity score for the 60 patients was 11.5 (range, 0–25). Mediastinal lymphadenopathy was notably absent in all 60 patients and only five patients had traces of bilateral pleural effusion and only one patient had air trapping. In terms of the distribution of disease in the axial plane, peripheral distribution was found in most of the cases. The patients with higher CT scores required ICU admission and ventilator support, and had a poor prognosis. Conclusion: We found that chest CT may be useful as a standard method for the rapid diagnosis of COVID-19 to optimize the management of patients in hospital settings where nucleic acid testing kits are not available or available in limited quantities. Chest CT plays a crucial role in the early detection of COVID-19, particularly for those patients with a negative RT-PCR.

Characteristics and outcome determinants in patients with pulmonary tuberculosis in ICU

Background Severe tuberculosis requiring intensive care unit care is rare but commonly known to be of bad prognosis. The acute respiratory failure due to pulmonary infections is a common cause for ICU admission. However, despite their high mortality rate, the TB-related critical conditions are rarely reported. Most studies on critical care TB cases were not conducted in high TB burden areas and were retrospective in nature. Objective To identify potential prognostic factors and determinants of patient outcome in cases with pulmonary TB admitted to ICU. Subjects and methods This was a prospective observational study conducted on 51 patients with active pulmonary TB who required ICU admission for at least 24 h in ICU unit of Abbassia Chest Hospital during the period from January 1, 2018 till December 31, 2018. All patients were subjected to history and clinical examination, radiological and laboratory workup, and APACHI II score. Patients were diagnosed and managed according to National TB Control Guidelines in Egypt. Hospital course, complications and ICU stay period were monitored and were correlated to the outcome. Results Mean age of all studied patients was 42.9±16.4 years, 35 male (68.6%) and 16 females. There was Statistically significant correlation between patient outcome, and APACHE II score, arterial blood gases, duration of mechanical ventilation and the total ICU stay in days respectively. ICU complications occurred in 72.5% of patients and they were significantly correlated with patient outcome. Conclusion Pulmonary TB requiring ICU is rare but markedly of bad prognosis. Patients commonly admitted to ICU due to respiratory failure, sepsis, multi organ failure, ARDS and massive hemoptysis. Bad prognosis was related to respiratory failure, high APACHE II score, need for mechanical ventilation and its duration, ICU stay and related complications. Mechanical ventilation and APACHE II score were found to be predictors of mortality.

1576. Re-Evaluation of cefepime or piperacillin-tazobactam to Decrease Use of Carbapenems in ESBL-Producing Enterobacterales BloodStream Infections (REDUCE-BSI)

BackgroundThe ideal therapy for treatment of bloodstream infections (BSI) due to ESBL-producing organisms is widely debated. Although prior studies have demonstrated efficacy of non-carbapenems (CBPNs) for ESBL infections, results from the MERINO study group found increased mortality associated with piperacillin/tazobactam (PT) when compared with meropenem for treatment of ESBL BSI. The goal of this study was to investigate patient outcomes associated with the use of CBPN-sparing therapies (PT and cefepime (CEF)) for ESBL BSI. The primary outcome was in-hospital mortality between non-CBPN (PT and CEF) and CBPN groups. Secondary outcomes included clinical cure, microbiologic cure, infection recurrence, and development of resistance.MethodsThis was a retrospective observational study of patients admitted to the hospital from May 2016 - May 2019 with a positive blood culture for an ESBL-producing organism. Patients receiving meropenem, ertapenem, PT, or CEF were included. Patients were excluded if < 18 years old, receiving antibiotics for < 24 hours, treated for a polymicrobial BSI, or receiving concomitant antibiotic therapy for another gram-negative (non-ESBL) infection.ResultsOne hundred and fourteen patients were analyzed; 74 (65%) patients received CBPN therapy compared with 40 (35%) patients that received a non-CBPN (CEF N=30, PT N=10). There were no statistically significant differences in baseline characteristics between groups. The overall in-hospital mortality rate was 6% (N=7). Eight percent of patients (N=6) in the CBPN arm died compared to 3% (N=1) of patients in the non-CBPN arm, P = 0.42. No difference in mortality was detected between groups when evaluating subgroups with Pitt bacteremia score ≥4 (N=25), requiring ICU admission (N=50), non-genitourinary source (N=50), or by causative organism (N=76 E. coli; N=38 Klebsiella spp.). There was no difference between groups for secondary outcomes.ConclusionCEF and PT are reasonable options for the treatment of ESBL BSI and did not result in increased mortality or decreased clinical efficacy when compared to CBPNs in this cohort.Disclosures All Authors: No reported disclosures

82. Multisystem Inflammatory Syndrome in Children and non-sars-cov-2 Infections: A Retrospective Cross-sectional Study

BackgroundMultisystem inflammatory syndrome in children (MIS-C) has been described in areas with high Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) burden. Clinical features included in the MIS-C case definition (e.g fever, elevated inflammatory markers) overlap with features of other childhood infections. The prevalence of non-SARS-CoV-2 infection in patients evaluated for MIS-C has not been described.Patients evaluated for MIS-C, and therapies administered. MethodsRetrospective cohort study of patients < 21 years of age admitted to a freestanding children’s hospital in Boston, MA from May 14-June 6, 2020 who were evaluated for MIS-C. We identified patients undergoing Rheumatology consultation and echocardiogram (per the hospital’s protocol for evaluating children with suspicion for MIS-C). We tabulated patients evaluated for MIS-C found to have non-SARS-CoV-2 infection detected on standard microbiologic testing.Results39 patients met inclusion criteria. Median age was 5 years (IQR 2–12 years). Of evaluated patients, 19/39 (49%) were diagnosed with MIS-C according to the Massachusetts Department of Public Health case definition; 10/39 (26%) required ICU admission. Non-SARS-CoV-2 infections were identified in 7/39 (18%), of whom 5/7 (71%) had bacterial infections, 1/7 (14%) had viral infection, and 1/7 (14%) had viral and bacterial co-infections; no fungal or parasitic infections were identified. Of patients diagnosed with MIS-C, 2/19 (11%) were found to have non-SARS-CoV-2 infection. Additionally, 5/19 (26%) had a positive polymerase chain reaction test for SARS-CoV-2 at time of MIS-C diagnosis, of whom 4/5 (80%) received remdesivir. Of patients evaluated for MIS-C, 17/39 (44%) received intravenous immune globulin, 14/39 (36%) aspirin, 4/39 (10%) anakinra, and 14/39 (36%) methylprednisolone. Additionally, 21/39 (54%) received antibacterial and 5/39 (13%) antiviral therapy (Table).ConclusionIn this study, non-SARS-CoV-2 infections were diagnosed in 18% of children evaluated for MIS-C. Clinicians should consider alternative or concomitant infectious diagnoses in patients undergoing MIS-C evaluation. Research is needed to identify clinical and laboratory features that may distinguish patients with MIS-C from those with non-SARS-CoV-2 infection.Disclosures All Authors: No reported disclosures

532. COVID-19 Pneumonia in Patients with Hematologic Malignancies – A Report from the US Epicenter

BackgroundLimited data are available for risk assessment and outcome of COVID-19 in patients with hematologic malignancies (HM). We present a single center study of COVID-19 pneumonia in a cohort of 31 patients with HM.MethodsData were abstracted from electronic medical records for patients admitted to NYPH between 3/5/20 and 4/17/20 and entered into a REDCap database.ResultsTwenty (64.5%) were male; median age was 71 years. There were 8 patients with Multiple Myeloma (MM), 8 with Chronic Lymphocytic Leukemia (CLL), 6 (19.4%) had AML, 5 (16.1%) NHL, 2 (3.2%) ALL; CML, MDS and Polycythemia Vera occurred in 1 patient each. Twenty-four (77.4%) had active HM; 6 (19.4%) were in remission; and 1 relapsed. Nineteen patients (61.3%) received recent chemotherapy and 11 (35.5%) immunosuppressive therapies. There were 7 (22.6%) hematopoietic stem cell transplant (HSCT) recipients (4 allogeneic and 3 autologous). Comorbidities were evenly distributed among all malignancies: 18 (58.1%) had hypertension, 9 (38.7%) obesity, 7 (22.6%) diabetes mellitus, and 11 (35.5%) were former smokers. The most common symptoms included cough (90.3%), fever (83.9%) and dyspnea (61.3%); 7 (22.6%) had nausea and vomiting; 7 (22.6%) had diarrhea. On presentation, hypoxia (O2 sat ≤94% on room air) occurred in 64.5%; median ALC was 330/ml; 23 (74.2%) had ALC< 1000/ml; median CRP was 15.9 mg/dl (2.5–40.4), ferritin 1162 ng/ml (264 - > 16500), and D-dimers 456 ng/ml (< 150–2418). Thirteen patients (41.9%) required ICU admission and were intubated; among those 9 (69.2%) had either MM or CLL. Co-infections were uncommon; two patients developed HSV1 pneumonitis and one of these also had CMV pneumonitis. Twenty-eight (90.3%) were treated with hydroxychloroquine, 5 (16.1%) remdesivir, 2 (6.5%) tocilizumab, 1 (3.2%) sarilumab, and 4 (12.9%) with methylprednisolone 0.5mg/kg Q12h. Seventeen patients (54.8%) recovered and were discharged, 12 (38.7%) died; 2 (6.5%) were still hospitalized but left the ICU.ConclusionIn our cohort, there were predominantly more patients with MM and CLL and 56% of these were intubated; larger cohort studies will further define the risk and outcome for COVID-19 in patients with HM.Disclosures Michael J. Satlin, MD, MS, Achaogen (Consultant)Allergan (Grant/Research Support)Merck (Grant/Research Support)Shionogi Inc. (Consultant)