bluuebunny/crossref_metadata_2025_split huggingface dataset:
296. Description of Super-infections in Hospitalized Patients with COVID-19
Authors: Kludjian Geena , Spivack Stephanie , Gallucci Stefania , Kilpatrick Laurie , Mishkin Aaron D , Sajjan Umadevi , Tam Vincent , Gallagher Jason C , Gallagher Jason C 
Published: December 2021

Abstract

Background
The rate of bacterial and fungal super-infections (SI) in inpatients with COVID-19 is unknown. In this study, we aimed to identify and describe patients that developed secondary infections while hospitalized with COVID-19.

Methods
We performed a retrospective chart review on patients admitted to our health system between March and May 2020 with confirmed COVID-19 by nasopharyngeal PCR. We reviewed patients with positive cultures from urine, blood, sputum, and sterile sites. Patients with positive cultures had cases reviewed to determine if they represented a true infection, defined by CDC criteria. SIs were defined as infections that occurred at least 48 hours or longer after the initial positive SARS-CoV-2 test. Additional data was collected on patient demographics, COVID-related therapies, types of infections, and outcomes.

Results
902 patients were admitted with COVID-19 during our study period. Of these, 52 patients (5.8%) developed a total of 82 SIs. Tables 1 and 2 describe patient and infection characteristics. Patients identified as having a SI were admitted for a median of 30 days; 56% had mortality, and 39% of remaining patients were readmitted within 90 days.
Table 1. Patient Characteristics

Table 2. Super-infections

Conclusion
Overall, the rate of SIs in patients admitted with COVID-19 is low. These patients had a long length of stay, which may be either a cause of SI or an effect. Further analysis with matched COVID-positive control patients who do not develop SIs is needed to evaluate the risk of development of SIs in relation to presenting respiratory status, COVID-related therapies, and other patient-specific factors.

Disclosures
Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Consultant, Speaker’s Bureau)Merck (Consultant, Grant/Research Support, Speaker’s Bureau)Qpex (Consultant)scPharmaceuticals (Consultant)Shionogi (Consultant) Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Individual(s) Involved: Self): Speakers’ bureau; Merck (Individual(s) Involved: Self): Consultant, Grant/Research Support; Nabriva: Consultant; Qpex (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant
315. A Multi-center Study to Describe Obese Pediatric Patients with COVID-19 Across the United States
Authors: Hammoud Roukaya Al , Murphy James , Del Bianco Gabriela P , Heresi Gloria , Chang Michael L 
Published: December 2021

Abstract

Background
Obesity is linked to increased risk of complications and is reported to be the most common underlying condition for severely ill SARS-CoV-2 infected individuals. Therefore, we aim further to explore the clinical outcomes of obese children with COVID-19.

Methods
Data were from the Pediatric COVID-19 Case Registry, which includes any patient &lt; 21 years of age diagnosed with COVID-19 at 170 instructions across the United States. A total of 778 COVID-19 positive non-immunocompromised hospitalized patients aged 24 months or older were included. Patients were assigned as obese or non-obese based on BMI as reported from medical records referenced to CDC BMI by gender and age classification (https://www.cdc.gov/growthcharts/clinical_charts.htm).

Results
Patients meeting inclusion criteria included 56% not obese and 44% obese. Compared to matched US population, obese children and adolescents appeared in this database at a rate of 2.3 times their frequency in the population. Obese patients were more likely to be Hispanic and older, symptomatic, have abnormal radiological findings, and require oxygen and ICU admission. Mortality, in this analysis, was similar across the groups.
Demographic and clinical characteristics. NS: Not significant *within seven days of COVID diagnosis ***mild: no need for supplemental oxygen; moderate: need for supplemental oxygen and severe: need for mechanical ventilation.

Conclusion
The incidence of obesity in hospitalized COVID children is higher than that of the general population (34% vs. 19%), highlighting obesity as an important risk factor for hospitalization associated with SARS-CoV-2 infected. Therefore, obese children and adolescents with COVID should be prioritized for COVID immunization and managed aggressively, given their significant COVID morbidity.

Disclosures
All Authors: No reported disclosures
342. Secondary Infections following Tocilizumab for Treatment of COVID-19 Pneumonia
Authors: Warner Adam , Abbas Mujahed , Avner Benjamin S , Flynn Thomas E , Walroth Todd A , Jagger Brett W 
Published: December 2021

Abstract

Background
Guidelines recommend use of tocilizumab (TCZ), an inhibitor of pro-inflammatory IL-6 signaling, for hospitalized patients with progressive severe or critical Coronavirus disease 2019 (COVID-19). The incidence of infectious complications following the use of TCZ for COVID-19 has not been well-described.

Methods
We conducted a retrospective, observational matched cohort study of severely ill, hospitalized adult patients with confirmed COVID-19 who were treated with TCZ between 2/24/2021 and 6/1/2021. The intervention group, comprised of patients who received a single dose of TCZ, was matched based on c-reactive protein (CRP) and fraction of inspired oxygen (FiO2) with a control group who did not receive TCZ, and were hospitalized between 10/12/2020 and 3/6/2021. The primary outcome of the study was diagnosis of a bacterial or fungal infection after day 3 of the index hospitalization. Secondary outcomes included all-cause mortality during the study period and length of stay.

Results
75 patients who received TCZ were identified during the study period, and matched 1:1 with 75 control patients. Baseline CRP and FiO2 were similar between groups, while the median age in the TCZ group was younger (61 versus 71 years), reflecting the epidemiology of the outbreak during the TCZ and control study periods. 15 bacterial and fungal infections were identified in the TCZ group (20.0%) and 4 (5.3%) infections in the control group (p = 0.012). The majority of infections in both groups were bacterial, with a disproportionate number of bloodstream infections in the TCZ group [7 (9.3%) vs 2(2.6%); p = 0.166]. 28 patients (37.3%) died in the TCZ group compared to 39 (52.0%) in the matched control (p = 0.068). Median time to discharge was similar between TCZ and control patients (11 versus 12 days; 95% CI -2,2).

Conclusion
Secondary infections in adult patients with severe and critical COVID-19 were more common in patients who had received TCZ. Prospective studies are needed to confirm and further describe this association.

Disclosures
All Authors: No reported disclosures
353. New-Onset Diabetes as an Acute Complication of COVID-19: A National Population Cohort Analysis
Authors: Hong Kwan , Kim Jeehyun , Yum Sujin , Gómez Raquel Elizabeth Gómez , Chun Byung Chul 
Published: December 2021

Abstract

Background
Diabetes is emerging as one of the complications of coronavirus disease 2019 (COVID-19), but this is hard to be revealed with cross-sectional studies since it is also known as the major predisposing factor for high-risk COVID-19. Therefore, this study aimed to estimate the risk of new-onset diabetes after COVID-19 through a population follow-up study.

Methods
All COVID-19 confirmed cases in Korea from January 20 to June 4, 2020, were matched with national health insurance data and their health screening data, both provided by the National Health Insurance Service of Korea. Controls were selected as the people who received the PCR test for COVID-19 and showed negative results in the same period and followed up until July 19, 2020. We selected the outcome as the diagnosis of diabetes according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10, E10 – E14). People who were diagnosed with diabetes in the past five years were excluded from both groups. After performing a log-rank test between groups, adjusted incidence rate and hazard ratio were estimated using Cox proportional hazard modeling. Demographic characteristics (age, sex, region, family histories of hypertension/diabetes, and income) and underlying health conditions such as hypertension, dyslipidemia, heart disease, alcohol consumption, cigarette smoking, and BMI were adjusted. Proportional assumptions were tested by the zph test and the sensitivity analysis by excluding each factor in turn and comparing results.

Results
A total of 6,247 COVID-19 patients and 143,594 controls without diabetes in the past were included for the analysis. The number of new-onset diabetes were 759 (12.15%) in COVID-19 patients and 3,465 (2.41%) in controls (P &lt; 0.01). The adjusted incidence of diabetes was 15.34 (95% confidence interval, CI: 14.10 – 16.66) and 11.18 (95% CI: 10.67 – 11.72) per 100 person-year, respectively, with the mean follow-up time as 46.31 (standard deviation: 16.37) days. The adjusted hazard ratio of diabetes in COVID-19 cases was 2.97 (95% CI: 2.44 – 3.63).

Conclusion
Since COVID-19 patients showed a higher incidence of new-onset diabetes in a short-time follow-up, we should consider diabetes as one of the possible complications of COVID-19.

Disclosures
All Authors: No reported disclosures
365. Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic
Authors: Subramanian Praveen , Stun Lucy , Bahr Nathan , Satterwhite Lewis , Bhakta Maharshi , Atrouni Wissam El , Plapp Fred , Newman Jessica 
Published: December 2021

Abstract

Background
Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of studies that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infections.

Methods
An anonymous 10-question survey was distributed to 125 physicians (Infectious Diseases, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group.

Results
Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3-10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation.

Conclusion
Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

Disclosures
All Authors: No reported disclosures
414. Observed Time Burden with Nursing Practices in an Emergency Room COVID-19 Isolation Zone at a University Affiliated Hospital in Korea
Authors: Choi Imyoung , Kang JaHyun 
Published: December 2021

Abstract

Background
The coronavirus disease 2019 (COVID-19) has caused great burdens on emergency room (ER) and front-line ER healthcare personnel faced with great challenges, including threats to their safety. This study aimed to provide a basis for additional workload of ER nurses who are charged with providing care for COVID-19 confirmed or suspicious cases.
Table 1. Summary of Frequency and Time Burden with Nursing Practices in an Emergency Room COVID-19 Isolation Zone. Note. IV, intravenous; IM, intramuscular; ID, intradermal; SC, subcutaneous; PPE, personal protective equipment; CPR, cardiopulmonary resuscitation

Methods
With institutional review board approval, we recruited ER nurses who were assigned to COVID-19 isolation zone with more than 6 months’ ER work experience. After their demographic information were collected through a questionnaire, their nursing practices and practice time during their 1 shift (day or evening) were recorded by one researcher using a stopwatch and an observation form. For each observation shift, unit-related information was collected, including the numbers of hospitalized patients, admission, discharge, and transfer of patients. For each nursing practice, frequency and total time spent were analyzed using descriptive statistics with SPSS 26.0 program.

Results
From January 4 to February 22, 2021, a total 18 nurses (27.4 years old on average with 25.2 months of ER experience) were observed from 20 different shifts. During the observation period, the average number of nurses’ working hours was 8.27 ± 0.39 hours. A total of 6,567 tasks were monitored with 337,703 seconds (93.81 hours) of the total time spent. Infection control practices were most frequent (33.88%) followed by nursing management (27.80%), assessment and observation (11.07%), medication (10.35%), pre and post examination care(4.86%), education (4.37%), communication (4.10%), safety care (1.10%), and others (0.03; Table 1). Nursing management (e.g., nursing recording) was most time-consuming (49.29%) followed by assessment and observation (15.03%), medication (12.94%), patient education (6.10%), infection control (5.30%), and safety care (1.64%).

Conclusion
This study showed that infection control practices were most frequent while time spent was relatively insignificant among ER nurses in charge of COVID-19 isolation zones. Further studies for more observations or with different study designs at other ER settings are necessary to understand nurse’s burdens with COVID-19 emergency care.

Disclosures
All Authors: No reported disclosures
415. A Whole Genome Sequencing Analysis of a Multi-unit Long-term Care Facility COVID-19 Outbreak
Authors: Kong Ling Yuan , Parkes Leighanne , Longtin Yves , Greenaway Christina , Zaharatos Jerry , Loo Vivian , Savard Noémie , Dion Réjean , Éric Fournier , Roger Michel , Moreira Sandrine 
Published: December 2021

Abstract

Background
The coronavirus disease (COVID-19) pandemic has affected residents in long-term care facilities (LTCF) significantly. Understanding transmission dynamics in this setting is crucial to control the spread of COVID-19 in this population. Using whole genome sequencing (WGS) of SARS-CoV-2, we aimed to delineate the points of introduction and transmission pathways in a large LTCF in Quebec, Canada.

Methods
Between 2020-10-28 and 2021-01-09, COVID-19 cases occurred in 102 residents and 111 HCW at a 387-bed LTCF; cases were distributed in 11 units on 6 floors. As part of outbreak analysis, SARS-CoV-2 isolates underwent WGS using the Oxford Nanopore Minion and the Artic V3 protocol. Lineage attribution and sequence types (ST, within 3 mutations) were assigned based on Pangolin classification and variant analysis. Epidemiologic data including date of positive PCR test, resident room number and HCW work location were collected. Self-reported high-risk exposures were collected by HCW questionnaire via phone interview after consent. Cases and their ST, geo-temporal relations and HCW-reported exposures were examined via network plots and geography-based epidemic curves to infer points of introduction and paths of transmission.

Results
Of 170 isolates available from 100/102 residents and 70/111 HCW, 130 (76.4%) were successfully sequenced. Phylogenetic analysis revealed 7 separate introductions to the LTCF. Grouping of ST by units was observed, with temporal appearance of ST supporting HCW introduction in 7/11 units. Proportion of phone interview completion was low at 35% (26/70). Few HCW recalled specific high-risk exposures. Recalled exposures supported by genetic linkage revealed potential between-unit introductions from HCW-to-HCW transmission at work and outside the workplace (e.g. carpooling). On one unit, a wandering resident was identified as a likely source of transmission to other residents (Figure 1).

Network plot of cases clustered by geographic unit, colour-coded by sequence type. Circles represent residents; addition signs represent healthcare workers. Blue lines represent identified high-risk exposures. Node labels represent floor and unit identifiers; 2 units per floor.

Conclusion
We demonstrate the complex genomic epidemiology of a multi-unit LTCF outbreak, putting into evidence the importance of a multi-faceted approach to limit transmission. This analysis highlights the utility of using WGS to uncover unsuspected transmission routes, such as HCW contact outside work, which can prompt new infection control measures.

Disclosures
All Authors: No reported disclosures
422. Sustainability of Improvements to Hand Hygiene Performance Throughout the COVID-19 Pandemic
Authors: Williams Victoria R , Muller Matthew , Powis Jeff , Ricciuto Daniel R , Mertz Dominik , Katz Kevin , Castellani Lucas , Hota Susy S , Hota Susy S , Payne Michael , Johnstone Jennie , Leis Jerome A 
Published: December 2021

Abstract

Background
Hand hygiene (HH) is a standard infection prevention and control precaution to be applied in healthcare settings to prevent transmission of COVID-19. Many healthcare institutions observed significant improvements in HH performance during wave one of the COVID-19 pandemic but the sustainability of this change is unknown. Our aim was to evaluate long-term HH performance throughout subsequent waves of the pandemic across acute care hospitals in Ontario, Canada.

Methods
HH adherence was measured using a previously validated group electronic monitoring system which was installed on all alcohol handrub and sink soap dispensers inside and outside each patient room across 56 inpatient units (35 wards and 21 critical care units) spanning 13 acute care hospitals (6 university and 7 community teaching hospitals) from 1 November 2019 to 31 May 2021. Daily HH adherence was compared with daily COVID-19 case count across Ontario. During this period, weekly performance continued to be reported to units but unit-based quality improvement discussions were inconsistent due to the COVID-19 response.

Results
Figure 1 depicts daily aggregate HH adherence plotted against the new daily COVID-19 case count across Ontario. An elevation in HH adherence was seen prior to the start of the first wave, rising almost to 80% and then remained above 70% for the peak of wave one. During waves two and three, peak COVID-19 case counts were associated with a maximum HH adherence of 51%, only marginally above the pre-pandemic baseline. After the end of wave one (from 1 July 2020 to 31 May 2021) the median HH performance was only 49% (interquartile range 47%-50%).
Figure 1. Hand hygiene adherence across 13 acute care hospitals in comparison to overall new daily COVID-19 cases in Ontario

Conclusion
Initial improvements in HH adherence preceding the start of the COVID-19 pandemic were not sustained, possibly due to increasing comfort and reduced anxiety associated with providing care to COVID-19 patients leading to a perception of reduced COVID-19 transmission risk. These findings highlight the need for HH monitoring to be tied to longitudinal unit-led quality improvement in order to achieve durable changes in practice.

Disclosures
Susy S. Hota, MSc MD FRCPC, Finch Therapeutics (Research Grant or Support) Susy S. Hota, MSc MD FRCPC, Finch Therapeutics (Individual(s) Involved: Self): Grant/Research Support
444. County-level COVID-19 Case Fatality Rate in Medicaid Expansion States Compared to Non-Expansion States
Authors: El-Nahal Walid , Berry Stephen , Psoter Kevin , Gebo Kelly 
Published: December 2021

Abstract

Background
Medicaid expansion has been adopted by 38 states and the District of Columbia,1,2 contributing to lower rates of uninsured individuals in the US.3 During the COVID-19 pandemic, Medicaid enrollment offset employer-based insurance losses precipitated by the recession.4 The aim of this study was to evaluate whether Medicaid expansion may have impacted COVID-19 mortality.

Methods
We conducted an ecologic study that included all US counties in the 50 states and District of Columbia. County-specific Medicaid expansion status was based on whether expansion was adopted within the state. COVID-19 cases and deaths for each county were obtained from the Centers of Disease Control (CDC). Unadjusted and multivariable negative binomial regression with robust standard errors to account for clustering of counties within each state were used to evaluate the association of COVID-19 case fatality rate and Medicaid expansion status. Adjusted models included the addition of four sets of county-level covariates thought to influence the association of Medicaid status and COVID-19 fatality rate: demographics, comorbidities, economic indicators, and physician density. These analyses were then performed in subgroups of counties defined by urbanicity (metro, suburban or rural) and quartiles of poverty rates. Incidence Rate Ratios (IRR) and 95% confidence intervals (CI) are reported.

Results
A total of 1,814 Medicaid expansion and 1,328 non-expansion counties were included in the analysis. Crude case fatality rates were 2.1% (non-expansion) and 1.8% (expansion). Medicaid expansion was not associated with a significantly lower COVID-19 case fatality rate in either the unadjusted (IRR: 0.86; 95% CI: 0.74, 1.01) or fully adjusted (IRR: 1.02; 95% CI: 0.90, 1.16) models. In adjusted models, Medicaid expansion status was also not associated with differences in COVID-19 case fatality rate when counties were stratified by either urbanicity or percent of individuals living below the poverty line.

Conclusion
In this county-level analysis, Medicaid expansion status was not associated with a significant difference in county-level COVID-19-related case fatality rates among people of all ages. Future individual-level studies are needed to better characterize the effect of Medicaid on COVID-19 mortality.

Disclosures
All Authors: No reported disclosures