Patients with COVID-19 may have co-infections with other microorganisms. Here we report a case of a patient with an E. coli bacteremia secondary to a urinary tract infection, who experienced fevers while on active antimicrobial therapy. The patient was eventually tested for COVID-19 and found to be positive. This case emphasizes the need to suspect COVID-19 even in patients with documented bacterial infection

Bohn, Brian C, PharmD

Denham, Bryan, MD

Moore, Sarah E, PharmD

Patross, Clayton J, PharmD, BCPS

Ramirez, Julio A

Schulz, Paul

Song, Matthew, PharmD, BCIDP

Wilde, Ashley M, PharmD, BCPS-AQID

English

Patients with COVID-19 may have co-infections with other microorganisms. Here we report a case of a patient with an Escheria coli bacteremia secondary to a urinary tract infection, who experienced fevers while on active antimicrobial therapy. The patient was eventually tested for COVID-19 and found to be positive. This case emphasizes the need to suspect COVID-19 even in patients with documented bacterial infection

University of Louisville

University of Louisville Journal of Respiratory InfectionsCASE REPORTULJRI | https://doi.org/10.18297/jri/vol4/iss1/15 1AbstractPatients with COVID-19 may have co-infections with other microorganisms. Here we report a case of a patient with an E. coli bacteremia secondary to a urinary tract infection, who experi-enced fevers while on active antimicrobial therapy. The patient was eventually tested for COV-ID-19 and found to be positive. This case emphasizes the need to suspect COVID-19 even in patients with documented bacterial infection. IntroductionCurrent CDC guidance encourages health care providers to consider testing for SARS-CoV-2 infection in patients with signs and symptoms consistent with COVID infection. [1] Reports of both viral and bacterial co-infection are now emerging. [2-6] We describe a patient with E. coli bacteremia secondary to a urinary tract infection, who developed persistent high fevers despite receiving appropriate antimicrobial therapy based on sus-ceptibility results. Due to clinical deterioration, the patient was tested for novel corona-virus infection and found to have a positive nasopharyngeal PCR. Our case report serves as a caution against ruling out SARS-CoV-2 when another infectious process may not fully explain a patient’s symptoms.   Case PresentationA 64-year-old white male presented to the emergency department with a chief complaint of burning with urination starting 4 days prior to admission. His past medical history was significant for type 2 diabetes mellitus, hypertension and pancreatitis. The patient also endorsed urinary retention, gait instability, nausea, vomiting and chills. Blood and urine cultures were collected, both of which grew pan-susceptible E. coli. The patient received active antibiotics for his E. coli infection throughout his hospitalization. On hospital day 2, the patient had a urinary catheter placed due to continued urinary retention. He also reported diarrhea and was tested for C. difficile infection, which was negative. Repeat blood cultures were obtained and demonstrated no growth, confirming clearance of the patient’s bacteremia.  On hospital day 4, a CT of the abdomen/pelvis was obtained, which noted an evolving prostate abscess (Figure 1). Of note, the patient also began reporting a dry cough and de-veloped high fevers with a maximum temperature of 103.4o F. That evening, he required BiPAP in order to maintain SaO2 >90%. He was eventually intubated due to respiratory failure. At this point, a nasopharyngeal COVID-19 PCR test was obtained due to rapid clinical deterioration despite adequate management of the patient’s bacterial infection. The patient was also placed into COVID-19 appropriate isolation. The patient went on to develop multi-organ failure, including acute respiratory distress Recommended Citation:Moore, Sarah E; Wilde, Ashley M; Song, Mat-thew; Bohn, Brian C; Patross, Clayton J;  Den-ham, Bryan; Schulz, Paul; Ramirez, Julio A. (2020). “A Patient with Escherichia coli Bacter-emia and COVID-19 Co-Infection: A Case Re-port for the Louisville COVID-19 Epidemiology Study,” The University of Louisville Journal of Respiratory Infections: Vol. 4, Iss. 1, Article 15. Received Date: April 27, 2020Accepted Date: May 20, 2020Published Date: June 4, 2020Copyright: © 2020 The author(s). This origi-nal article is brought to you for free and open access by ThinkIR: The University of Louis-ville’s Institutional Repository. For more infor-mation, please contact thinkir@louisville.edu. This article is distributed under the terms of the Creative Commons Attribution 4.0 Internation-al License (CC BY 4.0), which permits unre-stricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Funding Source: The author(s) received no specific funding for this work.Conflict of Interest: All authors declared no conflict of interest in relation to the main objec-tive of this work.A Patient with Escherichia coli Bacteremia and COVID-19 Co-Infection: A Case Report for the Louisville COVID-19 Epidemiology StudySarah E Moore1*, Pharm.D; Ashley M Wilde1, Pharm.D BCPS-AQ ID; Matthew Song1, Pharm.D BCIDP; Brian C Bohn1, Pharm.D; Clayton J Patross1, Pharm.D BCPS; Bryan Denham2, MD; Paul Schulz3, MD; Julio A Ramirez4, MD1Norton Pharmacy Services, Norton Healthcare, Louisville, KY, USA, 2Norton Audubon Hospital, Norton Healthcare, Louisville, KY, USA, 3Norton Infectious Diseases Specialists, Norton Healthcare, Louisville, KY, USA , 4Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, USA*sarah.moore@nortonhealthcare.orgULJRI | https://doi.org/10.18297/jri/vol4/iss1/15 2ULJRI A Patient with Escherichia coli Bacteremia and COVID-19 Co-infection: A Case Report for the Louisville COVID-19 Epidemiology Studysyndrome (Figure 2), and required continuous renal replacement therapy and multiple vasopressors to maintain MAP >65 mmHg. On hospital day 9, the COVID-19 PCR test resulted positive, confirming COVID-19 coinfection. At this time, the patient was non-responsive off sedation and was compassionately extubated shortly thereafter. DiscussionSARS-CoV-2 can present with a constellation of non-specific symptoms. In our patient, nausea and diarrhea were pos-sibly the first COVID-19 related symptoms to present. This was followed by a non-productive cough, fevers, and even-tual respiratory decompensation. [7,8] Initially, the patient’s fevers while on antibiotics were thought to be attributable to his undrained prostate abscess. However, given that this patient was initially afebrile and then developed high fe-vers while receiving antibiotics, this raised suspicion for a second infectious process. The median incubation period of SARS-CoV-2 appears to be about 5 days. Lauer et al reported that in their cohort, <2.5% of patients displayed any symptoms within 2.2 days. [9-11] Based on this information, it seems most likely that our patient acquired COVID-19 prior to presenting to the hospital. Guidelines from the Surviving Sepsis Campaign suggest that based on current evidence, the presence of another respi-ratory pathogen does not necessarily rule out the possibility of COVID-19. [12] In this case, there was delay in clinical suspicion and COVID-19 testing. During the first four days of hospitalization, the patient was not in isolation resulting in numerous healthcare worker exposures. This highlights the importance of the aforementioned recommendation. Universal patient screening upon admission may have identified this patient as a COVID-19 case earlier.Figure 1. CT abdomen/pelvis obtained on hospital day 2. Findings significant for enlarged prostate (1), seminal vesicles and thick-walled urinary bladder (not visualized here). New focal 2 x 1.3 cm region of decreased attenuation at the right lateral periphery of the prostate (2). It is unclear if this represents phlegmon/early abscess in the setting of prostatitis.21ULJRI | https://doi.org/10.18297/jri/vol4/iss1/15 3ULJRI A Patient with Escherichia coli Bacteremia and COVID-19 Co-infection: A Case Report for the Louisville COVID-19 Epidemiology StudyFigure 2. CT chest obtained on hospital day 5. Findings include extensive bilateral dense consolidation involving the upper and lower lobes. There is a small left pleural effusion. Overall appearance is consistent with widespread pneumonia and acute respiratory distress syndrome (ARDS).  Clinical outcomes in patients with COVID-19 and bacterial coinfections have not been well-described. Fan and col-leagues describe a case of a patient with COVID-19 and M. pneumoniae infection. [3] These authors suggest that failing to treat other causes of infection in COVID-19 patients is likely to increase morbidity and mortality. Worse outcomes were observed in patients with bacterial coinfection and H1N1 influenza.  These patients were more likely to require mechanical ventilation and longer ICU stays than patients without coinfection. [13] Additionally, pa-tients with bacterial coinfection had an inpatient mortality rate of 31%, versus 21% in patients with influenza alone (p=0.002). [13] It is possible that similar outcomes may be observed in the SARS-CoV-2 pandemic, but further data is needed before any conclusions may be drawn. In conclusion, this case highlights the importance of considering COVID-19 infection even in the setting of a confirmed alternate infectious diagnosis. Clinicians should consider isolation and testing for coinfection if clinically appropriate. References1. Centers for Disease Control and Prevention. Evaluating and testing persons for coronavirus disease 2019 (COVID-19). National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. 2020 Apr. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html 2. Touzard-Romo F, Tapé C, Lonks JR. Co-infection with SARS-CoV-2 and human metapneumovirus. R I Med J (2013). 2020 Mar;103(2):75–6. Available from: https://www.ncbi.nlm.nih.gov/nlmcatalog/101605827 PMID:32192233 3. Fan BE, Lim KG, Chong VC, Chan SS, Ong KH, Kuperan P. COVID-19 and mycoplasma pneumoniae coinfection. Am J Hematol. 2020 Mar 15. https://onlinelibrary.wiley.com/doi/epdf/10.1002/ajh.25785 ULJRI | https://doi.org/10.18297/jri/vol4/iss1/15 4ULJRI A Patient with Escherichia coli Bacteremia and COVID-19 Co-infection: A Case Report for the Louisville COVID-19 Epidemiology Study4. Khodamoradi Z, Moghadami M and Lotfi M. Co-infection of coronavirus disease 2019 and influenza A: a report from Iran. Arch Iran Med. 2020;23(4):239-243.5. Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. JAMA. 2020 Apr;323(20):2085. https://doi.org/10.1001/jama.2020.6266 PMID:32293646 6. Sun Y, Koh V, Marimuthu K, Ng OT, Young B, Vasoo S, et al. Epidemiologic and clinical predictors of COVID-19. Clin Infect Dis. 2020;ciaa322.; [Epub ahead of print]. https://doi.org/10.1093/cid/ciaa322. 7. Sun Y, Koh V, Marimuthu K, Ng OT, Young B, Vasoo S, Chan M, Lee VJ, De PP, Barkham T, Lin RT. Epidemiological and clinical predictors of COVID-19. Clin Infect Dis. 2020 Mar 25.8. D’Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L. Diarrhea during COVID-19 infection: pathogenesis, epi-demiology, prevention and management. Clin Gastroenterol Hepatol. 2020 Apr 8. https://www.ncbi.nlm.nih.gov/pubmed/32278065 9. Linton NM, Kobayashi T, Yang Y, Hayashi K, Akhmetzhanov AR, Jung SM, et al. Incubation period and other ep-idemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data. J Clin Med. 2020 Feb;9(2):1–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7074197/pdf/jcm-09-00538.pdf  https://doi.org/10.3390/jcm9020538 PMID:32079150 10. Linton NM, Kobayashi T, Yang Y et al. Incubation period and other epidemiological characteristics of 2019 nov-el coronavirus infections with right truncation: a statistical analysis of publicly available case data. J Clin Med 2020;9(2):1-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7074197/pdf/jcm-09-00538.pdf11. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KS, Lau EH, Wong JY, Xing X. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020 Mar;382(13):1199–207. https://www.nejm.org/doi/10.1056/NEJMoa2001316?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov 12. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020 Mar 28:1-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/pdf/134_2020_Article_6022.pdf 13. Rice TW, Rubinson L, Uyeki TM, Vaughn FL, John BB, Miller RR 3rd, et al.; NHLBI ARDS Network. Critical ill-ness from 2009 pandemic influenza A virus and bacterial coinfection in the United States. Crit Care Med. 2012 May;40(5):1487–98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653183/pdf/nihms463168.pdf , https://doi.org/10.1097/CCM.0b013e3182416f23 PMID:22511131

A Patient with Escherichia coli Bacteremia and COVID-19 Co-Infection: A Case Report for the Louisville COVID-19 Epidemiology Study

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A Patient with Escherichia coli Bacteremia and COVID-19 Co-Infection: A Case Report for the Louisville COVID-19 Epidemiology Study

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