Risk Factors Associated With Hospitalization and Death in COVID-19 Breakthrough Infections

BACKGROUND: Characterizations of coronavirus disease 2019 (COVID-19) vaccine breakthrough infections are limited. We aim to characterize breakthrough infections and identify risk factors associated with outcomes. METHODS: This was a retrospective case series of consecutive fully vaccinated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a multicenter academic center in Southeast Michigan, between December 30, 2020, and September 15, 2021. RESULTS: A total of 982 patients were identified; the mean age was 57.9 years, 565 (59%) were female, 774 (79%) were White, and 255 (26%) were health care workers (HCWs). The median number of comorbidities was 2; 225 (23%) were immunocompromised. BNT162b2 was administered to 737 (75%) individuals. The mean time to SARS-CoV-2 detection was 135 days. The majority were asymptomatic or exhibited mild to moderate disease, 154 (16%) required hospitalization, 127 (13%) had severe-critical illness, and 19 (2%) died. Age (odds ratio [OR], 1.14; 95% CI, 1.04-1.07; P \u3c .001), cardiovascular disease (OR, 3.02; 95% CI, 1.55-5.89; P = .001), and immunocompromised status (OR, 2.57; 95% CI, 1.70-3.90; P \u3c .001) were independent risk factors for hospitalization. Additionally, age (OR, 1.06; 95% CI, 1.02-1.11; P = .006) was significantly associated with mortality. HCWs (OR, 0.15; 95% CI, 0.05-0.50; P = .002) were less likely to be hospitalized, and prior receipt of BNT162b2 was associated with lower odds of hospitalization (OR, 0.436; 95% CI, 0.303-0.626; P \u3c .001) and/or death (OR, 0.360; 95% CI, 0.145-0.898; P = .029). CONCLUSIONS: COVID-19 vaccines remain effective at attenuating disease severity. However, patients with breakthrough infections necessitating hospitalization may benefit from early treatment modalities and COVID-19-mitigating strategies, especially in areas with substantial or high transmission rates

Treatment with Hydroxychloroquine, Azithromycin, And Combination in Patients Hospitalized with COVID-19

Significance: The United States is in an acceleration phase of the COVID-19 pandemic. Currently there is no known effective therapy or vaccine for treatment of SARS-CoV-2, highlighting urgency around identifying effective therapies. Objective: The purpose of this study was to evaluate the role of hydroxychloroquine therapy alone and in combination with azithromycin in hospitalized patients positive for COVID-19. Design: Multi-center retrospective observational study. Setting: The Henry Ford Health System (HFHS) in Southeast Michigan: large six hospital integrated health system; the largest of hospitals is an 802-bed quaternary academic teaching hospital in urban Detroit, Michigan. Participants: Consecutive patients hospitalized with a COVID-related admission in the health system from March 10, 2020 to May 2, 2020 were included. Only the first admission was included for patients with multiple admissions. All patients evaluated were 18 years of age and older and were treated as inpatients for at least 48 h unless expired within 24 h. Exposure: Receipt of hydroxychloroquine alone, hydroxychloroquine in combination with azithromycin, azithromycin alone, or neither. Main outcome: The primary outcome was in-hospital mortality. Results: Of 2,541 patients, with a median total hospitalization time of 6 days (IQR: 4–10 days), median age was 64 years (IQR:53–76 years), 51% male, 56% African American, with median time to follow-up of 28.5 days (IQR:3–53). Overall in-hospital mortality was 18.1% (95% CI:16.6%–19.7%); by treatment: hydroxychloroquine + azithromycin, 157/783 (20.1% [95% CI: 17.3%–23.0%]), hydroxychloroquine alone, 162/1202 (13.5% [95% CI: 11.6%–15.5%]), azithromycin alone, 33/147 (22.4% [95% CI: 16.0%–30.1%]), and neither drug, 108/409 (26.4% [95% CI: 22.2%–31.0%]). Primary cause of mortality was respiratory failure (88%); no patient had documented torsades de pointes. From Cox regression modeling, predictors of mortality were age\u3e65 years (HR:2.6 [95% CI:1.9–3.3]), white race (HR:1.7 [95% CI:1.4–2.1]), CKD (HR:1.7 [95%CI:1.4–2.1]), reduced O2 saturation level on admission (HR:1.5 [95%CI:1.1–2.1]), and ventilator use during admission (HR: 2.2 [95%CI:1.4–3.3]). Hydroxychloroquine provided a 66% hazard ratio reduction, and hydroxychloroquine + azithromycin 71% compared to neither treatment (p \u3c 0.001). Conclusions and relevance: In this multi-hospital assessment, when controlling for COVID-19 risk factors, treatment with hydroxychloroquine alone and in combination with azithromycin was associated with reduction in COVID-19 associated mortality. Prospective trials are needed to examine this impact

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp

Nosocomial Fungal Infections: Epidemiology, Infection Control, and Prevention

Invasive fungal infections are an important cause of morbidity and mortality in hospitalized patients and in the immunocompromised population. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis (IC) and invasive aspergillosis (IA). Included are descriptions of nosocomial infections caused by Candida auris, an emerging pathogen, and IC- and IA-associated with coronavirus disease 2019. The characteristics and availability of newer nonculture-based tests for identification of nosocomial fungal pathogens are discussed. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized

Response to Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?

We thank the authors Maria Mendoza et al. (1) for their comments related to our publication on the clinical characteristics and outcomes of COVID-19 in solid organ transplant (SOT) recipients (2). Our study included a cohort of 47 consecutive SOT recipients with COVID-19. As noted in our study the 12 patients with mild to moderate COVID-19 that were treated as outpatients were excluded from the analysis to avoid potential selection bias. The study therefore compares 35 hospitalized SOT and 100 hospitalized non-transplant patients with COVID-19

Outcomes of COVID-19 in a Large Cohort of Lung Transplant Recipients: A Retrospective Study

Background: Early reports of COVID-19 in lung transplant recipients (LTRs) showed high hospitalization and mortality rates. However, the outcomes of COVID-19 in LTRs since the advent of newer therapies and vaccines have been poorly defined. Methods: We evaluated the risks for SARS-CoV-2-related hospitalization and mortality in a cohort of LTRs at the Henry Ford Lung Transplant Program in Detroit, Michigan during the study period March 2020–March 2022. Univariate logistic regression, followed by multivariable modeling were performed to estimate the odds ratio (OR) with 95% confident intervals (CI). Results: Sixty-four laboratory-confirmed SARS-CoV-2 infections were identified in 59 patients. For the primary analysis of the hospitalization and mortality risks, we included these 59 patients with symptomatic COVID-19. SARS-CoV-2 infections were confirmed with real-time polymerase chain reaction (RT-PCR) from a nasopharynx swab. The mean age (±STD) was 61 (±12), 63% were males, 27% were African Americans, and the time from lung transplant to COVID-19 was 5.5 (±4.8) years. Thirty-four (57.6%) patients were hospitalized, and the inpatient mortality rate was 24% (8/34). A multivariable analysis showed that patients with a higher baseline forced expiratory volume (FEV1) were less likely to be hospitalized (OR = 0.91 and 95% CI 0.87–0.98, p = 0.02). Seventy-five percent (75%; 6/8) of patients on invasive mechanical ventilation died, compared with only 8% mortality rate in those without mechanical ventilation (OR = 36.0 and 95% CI 4.2–310.4, p p = 0.17) and Delta (p = 0.22) waves, no significant risk was detected after adjusting for other covariates. Five LTRs were diagnosed with COVID-19 twice. Thirty of the sixty-four COVID-19 cases (46.8%) occurred in LTRs that had received at least two doses of any of the available mRNA vaccines at a median of 123 days (IQR 98–164 days) after vaccination. Twelve of the thirty (40%) were hospitalized, and four patients (33%) died during their hospitalizations. Conclusions: In our LTR population, the hospitalization and mortality rates associated with COVID-19 were high despite the increased use of new therapies. Vaccine-breakthrough infections were common and were associated with poor outcomes. Studies are needed to determine optimal prevention and therapeutic strategies to improve COVID-19 outcomes in LTRs

Impact and limitations of the 2015 National Health and Safety Network case definition on catheter-associated urinary tract infection rates

Application of the new 2015 NHSN definition of catheter-associated urinary tract infection (CAUTI) in intensive care units reduced CAUTI rates by ~50%, primarily due to exclusion of candiduria. This significant reduction in CAUTI rates resulting from the changes in the definition must be considered when evaluating effectiveness of CAUTI prevention programs. Infect Control Hosp Epidemiol 2017;38:239-241

Impact of T2 Candida Panel on Species Specific Anti-fungal De-escalation

Background: Candidemia is associated with a 30-day mortality of 20-40%, with likelihood of death increasing by 50% for each day therapy is delayed. T2 Candida is approved by the FDA for the diagnosis of candidemia with a sensitivity of 90% and specificity of 98%. The mean time to Candida detection is estimated to be 4.4 hours. Standard blood culture turnaround time is 3 days. Prompt diagnosis is essential to effectively treat candida infection. Methods: Retrospective analyses were conducted on 70 T2MR positive patients. The primary endpoint is time to de-escalation fromechinocandin to fluconazole based on T2 species identified. Secondary endpoints are time to T2 positivity and identification of risk factors for mortality and clinical outcomes of invasive candidiasis (IC).Univariate logistic regression was used to determine association between individual risk factors and primary outcomes. Multivariate Logistic regression models were created using forward selection to model the odds of IC and mortality. Time to de-escalation of echinocandins were modeled using Kaplan-Meier estimators. Results: Univariate analysis showed statistically significant associations between mortality and sepsis diagnosis, hypotension, abnormal WBC count, and tachycardia (P\u3c0.05). Odds of mortality were reduced in patients receiving TPN (OR 0.292, 95% CI 0.097-0.874). Tachycardia, age, and presence of prosthetic devices were the best predictors of mortality (P\u3c0.05). The best predictors of IC were LOS, hypotension, and abnormal WBC count (P \u3c0.05).T2 Testing reduced the turnaround time of test results compared to standard blood cultures from 3 days to \u3c10 hours. In CA/CT positive T2, 50% of patients were de-escalated to Fluconazole therapy in 4 days. CG/CK positive T2 had 50% de-escalation in 20 days. Conclusion: Patient with sepsis, hypotension, abnormal WBC count and tachycardia should raise possibility of IC. T2 testing lowers the turnaround time and allows for timely treatment and de-escalation, compared to standard blood cultures.https://scholarlycommons.henryford.com/merf2019clinres/1004/thumbnail.jp