bluuebunny/crossref_metadata_2025_split huggingface dataset:
71. Use of Intravenous Immunoglobulin Therapy Reduces Progression to Mechanical Ventilation in COVID-19 Patients with Moderate to Severe Hypoxia
Authors: Sakoulas George , Geriak Matthew , Kullar Ravina , Greenwood Kris , Habib Mackenzie , Vyas Anuja , Ghafourian Mitra , Dintyala Venkata Naga Kiran , Haddad Fadi 
Published: January 2021

Abstract

Background
The majority of COVID-19 morbidity and mortality occurs in patients who progress to mechanical ventilation. Therefore, therapeutic interventions targeting the mitigation of this complication would markedly improve outcomes and reduce healthcare utilization.

Methods
Patients with COVID-19 from two hospitals in San Diego, California were randomized at a 1:1 ratio to receive standard of care (SOC) plus intravenous immunoglobulin (IVIG) at 0.5 g/kg/day x 3 days with solumedrol 40 mg 30 minutes before infusion (IVIG group) versus SOC alone. The primary composite endpoint was receipt of mechanical ventilation or death before receiving ventilation. Patients were followed until discharge to home or up to 30 days from time of enrollment.

Results
Sixteen patients received IVIG plus SOC and 17 SOC alone. The median age was 54 years for SOC and 57 years for IVIG. Median time from hospital admission to study enrollment was 1 day (range 0–4) for SOC and 2 days (range 0–8) for IVIG. APACHE II scores and Charlson comorbidity indices were similar for IVIG and SOC (median 8 vs 7 and 2 for both, respectively). Seven SOC patients achieved the composite endpoint (6 ventilated, 1 death) versus 2 IVIG patients (2 ventilated), p=0.12, Fisher exact test. Among the subgroup with an estimated A-a gradient of &gt;200 mm Hg at time of enrollment, the IVIG group showed a lower rate of progression to the composite endpoint (2/14 vs 7/12, p=0.04 Fisher exact test), shorter median hospital length (11 vs 24 days, p=0.001 Mann Whitney U), and shorter median intensive care unit (ICU) stay (3 vs 13 days, p=0.005 Mann Whitey U).

Conclusion
This small, prospective, randomized, open-label study showed that when administered to hypoxic non-ventilated COVID-19 patients with an A-a gradient of &gt;200 mm Hg (corresponding to a requirement of 6 liters O2 via nasal cannula to achieve an SpO2 of 92%), IVIG significantly decreased the rates of progression to mechanical ventilation, ICU length of stay, and total hospital length of stay. A Phase 3 prospective, randomized, placebo-controlled, multicenter trial is underway to further validate these findings.

Disclosures
George Sakoulas, MD, Octapharma (Grant/Research Support, Scientific Research Study Investigator)
74. Empiric Antibiotic Therapy and Community-onset Bacterial Co-infection in Patients Hospitalized with COVID-19: A Multi-hospital Cohort Study
Authors: Vaughn Valerie , Gandhi Tejal N , Petty Lindsay A , Patel Payal K , Prescott Hallie , Malani Anurag N , Ratz David , McLaughlin Elizabeth , Chopra Vineet , Flanders Scott A 
Published: January 2021

Abstract

Background
Antibiotic therapy has no known benefit against COVID-19, but is often initiated out of concern for concomitant bacterial infection. We sought to determine how common early empiric antibiotic therapy and community-onset bacterial co-infections are in hospitalized patients with COVID-19.

Methods
In this multi-center cohort study of hospitalized patients with COVID-19 discharged from 32 Michigan hospitals during the COVID-19 Michigan surge, we describe the use of early empiric antibiotic therapy (within the first two days) and prevalence of community-onset bacterial co-infection. Additionally, we assessed patient and hospital predictors of early empiric antibiotic using poison generalized estimating equation models.

Results
Between 3/10/2020 and 5/10/2020, data were collected on 951 COVID-19 PCR positive patients. Patient characteristics are described in Table 1. Nearly two thirds (62.4%, 593/951) of COVID-19 positive patients were prescribed early empiric antibiotic therapy, most of which (66.2%, 393/593) was directed at community-acquired pathogens. Across hospitals, the proportion of COVID-19 patients prescribed early empiric antibiotics varied from 40% to 90% (Figure 1). On multivariable analysis, patients were more likely to receive early empiric antibiotic therapy if they were older (adjusted rate ratio [ARR]: 1.01 [1.00–1.01] per year), required respiratory support (e.g., low flow oxygen, ARR: 1.16 [1.04–1.29]), had signs of a bacterial infection (e.g., lobar infiltrate, ARR: 1.17 [1.02–1.34]), or were admitted to a for-profit hospital (ARR: 1.27 [1.11–1.45]); patients admitted later were less likely to receive empiric antibiotics (April vs. March, ARR: 0.72 [0.62–0.84], Table 2). Community-onset bacterial co-infections were identified in 4.5% (43/951) of COVID-19 positive patients (2.4% [23/951] positive blood culture; 1.9% [18/951] positive respiratory culture).

Conclusion
Despite low prevalence of community-onset bacterial co-infections, patients hospitalized with COVID-19 often received early empiric antibiotic therapy. Given the potential harms from unnecessary antibiotic use, including additional personal protective equipment to administer antibiotics, judicious antibiotic use is key in hospitalized patients with COVID-19.

Disclosures
Tejal N. Gandhi, MD, Blue Cross Blue Shield of Michigan (Grant/Research Support) Scott A. Flanders, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Blue Cross Blue Shield of Michigan (Research Grant or Support)
75. Systemic Anticoagulation Use Is Independently Associated with Lower Mortality in Hospitalized COVID-19 Patients with D-dimer Level Higher Than 5 Mcg/ml
Authors: Sung Joowhan , Bachour Rima 
Published: January 2021

Abstract

Background
Elevated D-dimer level is frequently seen in patients with COVID-19 and is associated with worse clinical outcomes. The potential benefit of systemic anticoagulation in COVID-19 has been suggested, but data lack on when to initiate anticoagulation. We aimed to identify a cut-off value of D-dimer at which anticoagulation may provide mortality benefit in COVID-19.

Methods
A retrospective review was conducted for a cohort of patients hospitalized with COVID-19 at a 262-bed community hospital in a Washington D.C. suburb. Patients hospitalized between April 1, 2020, and April 30, 2020, with laboratory-confirmed COVID-19 were included if d-dimer levels were checked during hospitalization. Demographics, laboratory results, and hospital courses were reviewed. Logistic regression was used to examine the association between anticoagulation and in-hospital mortality, controlling for the d-dimer value. The association was examined in subgroups with different d-dimer cut-offs. Multivariable logistic regression models were developed to assess if the association between anticoagulation and mortality remains after adjusting for other mortality risk factors.

Results
101 patients were included in the study and 32 (31.7%) died during hospitalization. The average age was 61.2 ± 14.8 years old and 50.5% were males. Older age, male sex, hypertension, and peak d-dimer level were associated with mortality in univariable analysis (p&lt; 0.05). For patients with peak d-dimer level &gt;3mcg/mL, anticoagulation use was associated with lower mortality after controlling for the d-dimer level (OR 0.25, 95% CI 0.06–0.97 p=0.045). This association weakened after adjusting for age, sex, and hypertension. (OR 0.33, 95% CI 0.07–1.46, p=0.143). For patients with peak d-dimer level &gt;5 mcg/mL, anticoagulation use was associated with lower mortality after controlling for the d-dimer level (OR 0.11, 95% CI 0.02–0.68, p=0.017) and this association remained significant after adjusting for age, sex, and hypertension (OR 0.11, 95% CI 0.01–0.86, p=0.035).

Conclusion
In hospitalized COVID-19 patients with a d-dimer level higher than 5 mcg/mL, anticoagulation use was independently associated with lower mortality.

Disclosures
All Authors: No reported disclosures
76. Effect of Early Administration of Systemic Corticosteroids on Outcomes in Patients with COVID-19 Pneumonia
Authors: Papamanoli Aikaterini , Kalogeropoulos Andreas , Fung Jenny , Nakamura Jacquelyn , Yoo Jeanwoo , Grewal Prabhjot , Karkala Nikitha , Abata Joshua , Tsui Stella T , Coritsidis Alexandra , Mojahedi Azad , Jacob Robin , Hotelling Jessica , Dhaliwal Simrat , Rawal Sahil , Marcos Luis 
Published: January 2021

Abstract

Background
Systemic corticosteroids (steroids) have been empirically used in acute respiratory distress syndrome, an entity also present in coronavirus disease 19 (COVID-19). Early steroids administration could accelerate resolution of symptoms and reduce intensive care unit (ICU) stay in these patients, but practice varies widely as evidence is scant.

Methods
We reviewed the records of 498 adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with COVID-19 requiring high-ﬂow O2 (non-rebreather mask, Venturi mask with FiO2 &gt;50%, or high-ﬂow nasal cannula). We excluded those (N=29) who received mechanical ventilation (MV) or died within 24h of admission. We followed patients until death or discharge. We compared outcomes between patients who received early steroids (i.e. prior to MV) and those who did not. We used adjusted Cox models to evaluate the composite of death or need for MV. We also evaluated healthcare resources utilization.

Results
Of 469 patients, 175 (37.3%) received steroids while on high flow O2. Table 1 summarizes the baseline characteristics. Patients who received steroids were more likely to have asthma, had slightly longer duration of symptoms, lower O2 saturation, higher NT-proBNP and lower IL-6 levels at baseline. In total, 228 patients (48.6%) reached the composite endpoint (123 died and 105 received MV). By 7 days, 32.5% of patients who received steroids died or were intubated vs. 44.8% of those who did not (log-rank P=0.008), Figure 1. In models adjusted for race, age, sex, comorbidities, baseline O2 saturation and procalcitonin, steroids reduced risk for death or MV by 44% (hazard ratio [HR] 0.56; 95%CI 0.42–0.76; P&lt; 0.001). The effect was time-dependent with initial HR 0.34 (95%CI 0.21–0.56; P&lt; 0.001) and daily attenuation by 10.2% (95%CI 1.7%–19.4%; P=0.017). Mortality at 7 and 14 days did not differ between groups (8.1% vs. 8.3% and 19.1% vs. 21.0%, respectively, log-rank P=0.75). Among discharged patients, length of hospital stay was longer, but ICU stay was shorter with steroids, Table 2.
Patient Characteristics According to Use of Early Steroids

Healthcare Resources Utilization According to Use of Early Steroids Among Discharged Patients

Conclusion
Early administration of steroids reduced primarily the need for MV in our high-risk COVID-19 patients, with shorter ICU utilization, at the expense of longer hospital stay. Further studies are needed to optimize the use of steroids in these patients.

Disclosures
All Authors: No reported disclosures
77. Long Term Care Facility Residents Hospitalized with COVID-19 Infection Present with Atypical Symptoms
Authors: Pop-Vicas Aurora E , Haleem Ambar , Osman Fauzia , Shirley Daniel , Striker Robert , Safdar Nasia 
Published: January 2021

Abstract

Background
Fever and cough are frequently reported in COVID-19 infections, although little is known about the subgroup of symptomatic patients who do not manifest these classic symptoms. We aimed to compare clinical manifestations and outcomes for hospitalized COVID-19 patients with typical vs. atypical presentations and identify risk factors for atypical COVID-19 presentations.

Methods
We conducted a retrospective cohort of all patients hospitalized with laboratory-confirmed COVID-19 infections during 3/13- 5/13/2020 at UW Health, a network of 3 acute-care hospitals in Midwest. We defined atypical cases as patients hospitalized for COVID-19 related reasons presenting without fever and cough and compared them in univariate analysis with patients manifesting both symptoms (controls). We identified independent risk factors for atypical COVID-19 presentations by logistic regression.

Results
Among the 163 patients hospitalized during the 60-day study frame, 39 (24%) had atypical presentations. Table 1 shows demographic, clinical manifestations, and outcomes of atypical vs. typical cases. On univariate analysis, atypical cases were more likely to be older, reside in a long-term-care facility (LTCF), have underlying diabetes mellitus, stroke, cardiac disease, and deny myalgias or dyspnea, despite having no significant difference in the prevalence of hypoxia or radiological lung infiltrates. Atypical cases also had a significantly higher Beta-Natriuretic-Peptide and lower C-Reactive-Protein, although other inflammatory markers were not significantly different. They were less likely to be admitted to the ICU, and more likely to die within 30 days, as older patients with respiratory failure and multiple comorbidities opted for comfort measures and less aggressive care. On multivariate analysis, LTCF residence was the only independent predictor for atypical status (Table 2).

Conclusion
LTCF residents are more likely to experience COVID-19 respiratory illness (hypoxia, pneumonia) without classic symptoms (fever, cough, myalgias, dyspnea). Given the excessive pandemic burden in the LTCF setting, timely recognition and diagnosis of these atypical, more subtle presentations is critical.

Disclosures
All Authors: No reported disclosures
80. COVID-19 Testing, Characteristics, and Outcomes Among People Living with HIV in an Integrated Health System
Authors: Chang Jennifer J , Bruxvoort Katia , Chen Lie Hong , Rodriguez Janelle , Akhavan Bobak , Hechter Rulin C 
Published: January 2021

Abstract

Background
Understanding attributes of COVID-19 clinical severity among people living with HIV/AIDS (PLWH) is critical for risk stratification and treatment strategies, but data among this population are limited.

Methods
We conducted a retrospective study among health plan members at Kaiser Permanente Southern California. We identified PLWH aged ≥ 18 years with a positive SARS-CoV-2 molecular diagnostic test or COVID-19 diagnosis and compared COVID-19 outcomes to HIV-negative cases. Chart review was conducted to examine HIV viral suppression, most recent CD4+ counts, and antiretroviral regimens in the year prior to COVID-19 diagnosis, as well as COVID-19 clinical presentation and outcomes.

Results
Between 3/1/20 and 5/31/20, 590 PLWH were tested for SARS-CoV-2, of which 47 (8.0%) were positive. An additional 14 patients had a clinical COVID-19 diagnosis, for a total of 61 cases identified among the population of 10,702 PLWH. Of these, 10 (16.4%) were hospitalized, 4 (6.6%) were admitted to ICU, 3 (6.4%) required invasive mechanical ventilation, and 1 (1.6%) died from COVID-19. In comparison, of the 12,921 HIV-negative individuals with COVID-19, 1975 (15.3%) were hospitalized, 494 (3.8%) were admitted to ICU, 444 (3.4%) required invasive mechanical ventilation, and 300 (2.3%) died from COVID-19. For 42 PLWH for whom chart review was complete (cases through 5/7/20), 52% were aged ≥ 50 years, and 98% were male. In the year prior to COVID-19 diagnosis, 98% were virally suppressed (HIV RNA &lt; 40 copies/mL). Most recent mean CD4+ count was 600 cells/mm3, and 4.8% had CD4+ ≤ 200 cells/mm3. Median CD4 count was similar between hospitalized and non-hospitalized patients. Antiretroviral regimens included NRTIs (98% of patients), NNRTIs (31%), PIs (26%), INSTIs (57%), and CCR5 inhibitors (2.3%). The most common presenting symptoms were cough (76% of patients), fever (71%), and shortness of breath (48%).
Table 1. SARS-CoV-2 testing, characteristics, and COVID-19 outcomes of HIV-infected and HIV-uninfected individuals at Kaiser Permanente Southern California, 3/1/20 to 5/31/20

Conclusion
In this population of patients with well-controlled HIV, risks of severe COVID-19 outcomes were similar to HIV-negative individuals, although sample sizes of PLWH with COVID-19 were small. Analyses adjusted for demographics and comorbidities are needed to assess risk of severe COVID-19 among PLWH and to determine clinical predictors in this population.

Disclosures
Katia Bruxvoort, PhD, MPH, GlaxoSmithKlein (Research Grant or Support) Lie Hong Chen, DrPH, Merk (Research Grant or Support)
82. Multisystem Inflammatory Syndrome in Children and non-sars-cov-2 Infections: A Retrospective Cross-sectional Study
Authors: Campbell Jeffrey , Roberts Jordan E , Dubois Melanie , Li Caitlin , Sandora Thomas , Lamb Gabriella S 
Published: January 2021

Abstract

Background
Multisystem 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.

Methods
Retrospective cohort study of patients &lt; 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.

Results
39 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).

Conclusion
In 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
83. A Descriptive Analysis of a Multi-disciplinary Approach to Opioid Use Disorder Treatment Within an Infectious Diseases Clinic
Authors: Blevins Sarah R , Stivers Tiffany , Sabitus Kathryn , Weeks Ryan , Porterfield J Zachary , Thornton Alice 
Published: January 2021

Abstract

Background
Opioid overdose is the leading cause of injury-related death in the US. Kentucky ranks in the top 5 states for opioid overdose deaths. The rate of injection drug use-associated infections (IDU-AI) has risen; the University of Kentucky Infectious Diseases division (UKID) treated 401 endocarditis cases in 2018, of which 73% were IDU-AI. To curb overdose deaths, ease financial burden on healthcare, and improve patient outcomes, patients need tools for recovery from opioid use disorder (OUD). Access to OUD treatment in Kentucky and much of the US is limited. Poverty, unemployment, and legal issues are barriers.

Methods
UKID implemented a multi-disciplinary approach to expand access to medication assisted treatment (MAT). This is an ongoing study. Any patient ≥18 years old with IDU-AI and OUD is eligible for enrollment unless pregnant or incarcerated. At enrollment and at three additional time points, patients complete both a study specific and Government Performance and Results Act (GPRA) survey. Patients may start MAT and mental health counseling with UKID or be referred elsewhere and are eligible for transportation assistance and medical case management.

Results
To date, there have been 127 referrals. Of these, 87 (69%) were eligible and 54 enrolled (62% of eligible). Primary IVDU-AI includes HIV (n=4; 7%), HCV (n=5; 9%), HIV/HCV (n=3; 6%), endocarditis (n=32; 59%), and other (n=10; 19%). Patients are 48% male (n=26) and 91% white (n=91) with a median age of 34 years (IQR: 16); 35% are receiving MAT (n=19) with 14.8% (n=8) managed by UKID. Other service data are available for 51 patients. Naloxone was dispensed to 45 (88%) patients, 24 (47%) received relapse prevention services, 13 (25%) engaged in peer support, 9 (18%) participated in self-help groups, and 10 (20%) received transportation aid.

Conclusion
Increasing engagement in MAT and wrap-around services is an important touchpoint for OUD. We present a comprehensive program to achieve this for patients who would otherwise be discharged without follow-up for OUD. This program shows proof of concept that patients can be engaged in MAT by ID providers. Ongoing analysis will include longitudinal review of patient progress and outcomes, including hospital readmission, and a study to determine patients’ perceived impact on their quality of life.

Disclosures
All Authors: No reported disclosures
89. Construction of an Electronic Algorithm to Efficiently Target Antimicrobial Stewardship Efforts for Adults Hospitalized with Community-acquired Pneumonia
Authors: Lautenbach Ebbing , Hamilton Keith W , Grundmeier Robert , Neuhauser Melinda M , Hicks Lauri , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline , Frager Nicole , Menon Muida , Kratz Ellen , Gerber Jeffrey 
Published: January 2021

Abstract

Background
Although antibiotic stewardship programs (ASPs) have had success in curtailing inappropriate antibiotic use, they remain time- and labor-intensive. To expand the reach of ASPs, approaches to more efficiently target ASP efforts are urgently needed. We developed and validated an electronic algorithm to identify inappropriate antibiotic use in patients hospitalized with community-acquired pneumonia (CAP).

Methods
Within the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC), we used ICD-10 diagnostic codes to identify inpatient patient encounters for pneumonia between 3/15/17 – 3/14/18 for which patients received a systemic antibiotic in the first 48 hours of hospitalization. Exclusion criteria included transfer from another facility, intensive care unit admission or death in first 48 hours, immunocompromising condition, or specific comorbidities. We randomly selected 300 subjects (150-HUP, 150-PPMC). Inappropriateness of antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration of therapy were based on established hospital and IDSA guidelines.

Results
Of 300 subjects, median age was 60, 53% were female, and median hospital stay was 4.25 days. Of the 300 subjects, 237 (79%) were admitted to general medicine, hospitalist, family medicine, or geriatrics services. On chart review, 295 (98%) subjects were correctly diagnosed with CAP. Of these subjects, the choice of initial antibiotic(s) was appropriate in 263 (89%). Of these 263 subjects, 222 (84%) had an appropriate duration of therapy. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion
An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate for patients hospitalized for CAP. This algorithm could be used to efficiently target ASP initiatives. The impact of interventions based on this algorithm should be tested in future studies.
Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures
All Authors: No reported disclosures