Impact of an electronic smart order-set for diagnostic stewardship of Clostridiodes difficile infection (CDI) in a community healthcare system in South Florida.

BACKGROUND: Inappropriate testing for Clostridiodes difficile infection (CDI) increases health care onset cases and contributes to overdiagnosis and overtreatment of patients in a community health care system. METHODS: An electronic smart order set for the testing of CDI was created and implemented to improve the appropriateness of testing. A retrospective review of patients who were tested for CDI, pre and post, was conducted to determine if inappropriate stool testing for CDI decreased post-implementation of the order set. RESULTS: 224 patients were tested for CDI during the study period with the post-implementation period having a higher proportion of patients who met appropriate testing criteria defined by presence of diarrhea (80.5% vs 61.3%; P = .002). The rate of inappropriate CDI stool testing decreased from 31.1% to 11.0% after implementation (P < .001). A higher proportion of CDI patients were readmitted within 30 days of discharge (54.2% vs 33.0%; P = 0.001) during the post-implementation period. CONCLUSIONS: There was a significant reduction in inappropriate CDI testing following the implementation of the order set. There was an observed increase in the proportion of patients who underwent recent gastrointestinal surgery which may have contributed to the increase in 30-day readmission rates during the post-implementation period.

Using machine learning to identify patient characteristics to predict mortality of in-patients with COVID-19 in south Florida.

Introduction: The SARS-CoV-2 (COVID-19) pandemic has created substantial health and economic burdens in the US and worldwide. As new variants continuously emerge, predicting critical clinical events in the context of relevant individual risks is a promising option for reducing the overall burden of COVID-19. This study aims to train an AI-driven decision support system that helps build a model to understand the most important features that predict the "mortality" of patients hospitalized with COVID-19. Methods: We conducted a retrospective analysis of "5,371" patients hospitalized for COVID-19-related symptoms from the South Florida Memorial Health Care System between March 14th, 2020, and January 16th, 2021. A data set comprising patients' sociodemographic characteristics, pre-existing health information, and medication was analyzed. We trained Random Forest classifier to predict "mortality" for patients hospitalized with COVID-19. Results: Based on the interpretability of the model, age emerged as the primary predictor of "mortality", followed by diarrhea, diabetes, hypertension, BMI, early stages of kidney disease, smoking status, sex, pneumonia, and race in descending order of importance. Notably, individuals aged over 65 years (referred to as "older adults"), males, Whites, Hispanics, and current smokers were identified as being at higher risk of death. Additionally, BMI, specifically in the overweight and obese categories, significantly predicted "mortality". These findings indicated that the model effectively learned from various categories, such as patients' sociodemographic characteristics, pre-hospital comorbidities, and medications, with a predominant focus on characterizing pre-hospital comorbidities. Consequently, the model demonstrated the ability to predict "mortality" with transparency and reliability. Conclusion: AI can potentially provide healthcare workers with the ability to stratify patients and streamline optimal care solutions when time is of the essence and resources are limited. This work sets the platform for future work that forecasts patient responses to treatments at various levels of disease severity and assesses health disparities and patient conditions that promote improved health care in a broader context. This study contributed to one of the first predictive analyses applying AI/ML techniques to COVID-19 data using a vast sample from South Florida.

A retrospective study on 198 mpox cases in South Florida: Clinical characteristics and outcomes with focus on human immunodeficiency virus status.

BACKGROUND: Men who have sex with men (MSM) and persons living with human immunodeficiency virus (PLWH) were disproportionately affected by global mpox outbreak in 2022. In this retrospective review, we describe epidemiology and clinical characteristics of mpox infection in South Florida with a focus on human immunodeficiency virus (HIV) status. METHODS: This was a retrospective observational study of 198 adult patients with confirmed diagnosis of mpox between 01 January 2020, and 10 September 2022, in two large health systems in South Florida. A descriptive analysis was performed to summarize demographic, clinical and laboratory characteristics, and outcomes of the patients. RESULTS: Young male patients and PLWH were disproportionately represented among patients with mpox. HIV positive patients were less likely to have adenopathy and myalgia and were more likely to have oral or facial lesions. 22.7% of studied patients were diagnosed with one or more concurrent STI at the time of mpox diagnosis. CONCLUSIONS: We suggest screening for sexually transmitted infections and HIV for patients diagnosed with mpox. We suggest prompt consultation or referral to infectious disease specialist if needed for the patients who are diagnosed with mpox especially in the severely immunocompromised host.

Distinct Clinical Presentations and Outcomes of Hospitalized Adults with the SARS-CoV-2 Infection Occurring during the Omicron Variant Surge.

The COVID-19 Omicron variant has imposed a tremendous burden on healthcare services. We characterized the types of the Omicron variant-associated hospitalizations and their associations with clinical outcomes. Consecutive adults hospitalized with COVID-19 during the Omicron variant surge period of 1-14 January 2022, were classified into one of three groups based on their clinical presentations on admission: Group 1-primary COVID-19; Group 2-extrapulmonary manifestations of COVID-19; and Group 3-incidental COVID-19. Of the 500 patients who were hospitalized, 51.4% fell into Group 1, 16.4% into Group 2, and 32.2% into Group 3. The patients in Groups 1 and 2 were older, with higher proportions of comorbidities than patients in Group 3. The Group 1 patients had the highest mortality rate (15.6%), followed by Group 2 (8.5%), and Group 3 (0.6%), with adjusted odds ratios (OR) of 22.65 (95% confidence interval [CI], 2.75-239.46; p = 0.004) and 10.95 (95% CI, 1.02-117.28; p = 0.048), respectively, compared to Group 3. Those in Group 1 showed a greater utilization of intensive care services (15.9%), followed by Group 2 (10.9%), and Group 3 (2.5%), with adjusted ORs of 7.95 (95% CI, 2.52-25.08; p < 0.001) and 5.07 (95% CI, 1.34-19.15; p = 0.017), respectively, compared to Group 3. The patients in Groups 1 and 2 had longer hospitalization stays than the patients in Group 3 (p < 0.001 and p = 0.002, respectively). Older age (≥65 years) was an independent factor associated with longer hospital stays (OR = 1.72, 95% CI, 1.07-2.77). These findings can help hospitals prioritize patient care and service planning for future SARS-CoV-2 variants.

Bictegravir/emtricitabine/tenofovir alafenamide in a virologically suppressed adult with HIV and end-stage renal disease on chronic peritoneal dialysis: A case report.

Despite increasing rates of renal replacement therapy, data supporting the safe and effective use of HIV treatment guidelines preferred regimens in people on hemodialysis or peritoneal dialysis is limited. Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is a guideline recommended initial regimen for most people with HIV with FDA-approval for use in virologically suppressed people receiving chronic hemodialysis; however, the safety and efficacy of BIC/FTC/TAF remains unknown when used in patients on chronic ambulatory peritoneal dialysis (CAPD). We report the first case of BIC/FTC/TAF use in CAPD.

Mortality and prognostic factors in hospitalized COVID-19 patients with cancer: an analysis from a large healthcare system in the United States.

Background: To evaluate clinical outcomes in patients with malignancy who are SARS-CoV-2 (COVID-19) positive and investigate if factors such as age, gender, and race contribute to COVID-19 mortality in patients with malignancy. Methods: Retrospective data was gathered from Memorial Healthcare System of COVID-19 patients hospitalized from March 1, 2020 to January 18, 2021. Active malignancy was defined as either receiving antineoplastic therapy or being under surveillance. The primary endpoint was in-hospital mortality. Descriptive statistics were used to summarize the characteristics and outcomes. Univariate and multivariate logistic analysis were performed to define baseline clinical characteristics potentially associated with mortality in cancer patients with COVID-19. Results: A total of 4,870 COVID-19 patients were enrolled in the study, and 265 of those patients had a diagnosis of active malignancy. The study population was diverse which included non-Hispanic whites (NHW) 816 (16.8%), Hispanics 2,271 (46.6%) and Blacks 1,534 (31.5%). Of the cancer patients, 24.1% were NHW, 43% were Hispanic and 28.7% were Black. Amongst the races, 37.5% of in-hospital mortalities were NHW, while 18.4% were Hispanics and 19.7% were Black. The in-hospital mortalities amongst the two malignancy types, solid and hematological, accounted for 24.6% and 23.5% of deaths and they were not found to be statistically significant (P=0.845). After adjustments for age, gender and race were made, cancer was independently associated with an increased in-hospital mortality, with an adjusted odds ratio of 1.48 [95% confidence interval (CI): 1.08-2.01]. Increased age and elevated serum levels of creatinine and C-reactive protein (CRP) were associated with an increased risk of death in cancer patients with COVID-19. Conclusions: COVID-19 in patients with cancer had poorer outcomes in comparison to those who were cancer-free. Both hematological and solid malignancies had similar in-hospital mortality rates. The highest in-hospital mortalities of cancer patients with COVID-19 were non-Hispanic whites in-comparison to Hispanics with the least. Age, elevated levels of creatinine and CRP were independently associated with increased risk of death in cancer patients hospitalized with COVID-19. The findings indicate the need for close surveillance and monitoring of these patients as they are more likely to have higher risk of death from COVID-19.

Reprint of Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Impact of the COVID-19 pandemic on an emergency department-based opt-out HIV screening program in a South Florida hospital: An interrupted time series analysis, July 2018-March 2021.

BACKGROUND: The COVID-19 pandemic has posed a tremendous burden on healthcare services. We evaluated its impact on an emergency department (ED)-based opt-out Human immunodeficiency virus (HIV) testing in a public healthcare system. METHODS: The programmatic data of ED-based HIV testing from July 2018 to March 2021 at the Memorial Regional Hospital, Hollywood, Florida was analyzed by interrupted time series analysis to evaluate the immediate and gradual effects of the COVID-19 pandemic on the number of monthly HIV tests, with an interruption point at March 2020. RESULTS: The average number of monthly HIV tests were significantly lower during the pandemic than the pre-pandemic (791 ± 187 vs 1745 ± 266, P < .001). There was a slight decline trend in the number of monthly HIV tests before the pandemic (estimate -10.29, P = .541). HIV testing dramatically decreased during the initial 7 months of the pandemic, compared to the pre-pandemic period, with the largest decline in the number of HIV tests on March 2020 (estimate -678.48, P = .007). HIV testing slightly increased every month (estimate 4.84, P = .891) during the pandemic period, and the number of HIV tests per month rebounded to the pre-pandemic levels by October 2020. CONCLUSIONS: ED-based HIV testing significantly decreased during the initial 7 months of the pandemic in south Florida. Multiple strategies are necessary to maintain HIV testing during this pandemic era.

Containment of a carbapenem-resistant Acinetobacter baumannii complex outbreak in a COVID-19 intensive care unit.

BACKGROUND: A carbapenem-resistant Acinetobacter baumannii outbreak in the COVID intensive care unit of a community hospital was contained using multidrug resistant organism guidelines. The purpose of this study is to report on an outbreak investigation and containment strategy that was used, and to discuss prevention strategy. METHODS: A multidisciplinary approach contained the spread of infection. Strategies implemented included consultation with experts, screening, and reversal of personal protective equipment conservation. Ensuring infection control best practices are maintained remain important efforts to reduce the spread of multidrug resistant organisms. RESULTS: Five patients with carbapenem-resistant Acinetobacter baumannii were identified from routine clinical cultures within one week and one patient was identified from active surveillance cultures. DISCUSSION: Personal protective equipment conservation, strategies to prevent health care personnel exposure, and patient surge staffing protocols may have increased the likelihood of multidrug resistant organism transmission. Environmental and behavioral infection control regulations with effective administrative guidance, active surveillance cultures, and antimicrobial stewardship are critical to prevent future outbreaks. CONCLUSIONS: After outbreak containment strategies were implemented, no additional patients were identified with carbapenem-resistant Acinetobacter baumannii. Conventional infection prevention and control strategies were re-instituted. A multidisciplinary approach with continued focus on hand hygiene, environmental cleaning, and correct use of personal protective equipment needs to be put in place to successfully contain and prevent the spread of carbapenem resistant infections.

Identification of Inappropriate Antibiotic Orders During Implementation of a Multidisciplinary Antimicrobial Stewardship Program Within the Primary Care Setting.

OBJECTIVE: The aim of the study was to describe implementation of an outpatient antibiotic stewardship program at primary care practices in South Florida and the proportion of appropriate and inappropriate orders and reasons for inappropriateness during the intervention. METHODS: An antibiotic stewardship committee at a large hospital system implemented aspects of The Core Elements of Outpatient Antibiotic Stewardship at outpatient facilities in 2018. Interventions included an education/awareness campaign directed at prescribers (audit and feedback, routine education at prescribers' meetings, availability of updated guidelines in a shared drive and antibiogram via intranet) and patients (posters, tear-off sheets on symptom relief for viral illness). Orders were evaluated using clinical documentation, current antibiogram, and Infectious Diseases Society of America guidelines. An appropriate order was defined as a correct antibiotic and dose/frequency and duration of therapy. An inappropriate antibiotic order was defined as not meeting 1 or more of the abovementioned conditions. Descriptive statistics assessed the data. RESULTS: In this retrospective review of 2934 oral antibiotic orders from January 1 to December 31, 2018, 2565 (87.4%) were necessary while 369 (12.6%) were unnecessary. Of 2565 necessary orders, 1448 (56.5%) were appropriate while 1117 (43.5%) were inappropriate. Of 1117 inappropriate orders, 24.9% had all 3 conditions; 41.5% of inappropriate orders were solely due to wrong duration of therapy. CONCLUSIONS: Although our institution demonstrated commitment to optimizing antibiotic prescribing by providing resources to clinicians and patients about evidence-based antibiotic prescribing, inappropriate antibiotic prescribing was persistent. The interventions used must continue to evolve and include point-of-care access to guidelines and clinical decision support tools.

Characteristics, Vaccination Status and Outcomes Among Healthy Younger Adults in a Large Public Healthcare System in the South Florida Region.

Nationally, the 18-49 years old age group are less likely to be vaccinated compared to those 50 years and older. Data describing the risk of COVID-19 severe illness that requires hospitalization among younger healthy adults is limited. In an effort to underscore the importance of vaccination and provide data that may influence COVID-19 risk perception, COVID-19 data of a sample of hospitalized non-elderly age group who clinically may not be considered as high risk for severe COVID-19 illness are presented. Specifically, this retrospective chart review (spanning the period of March 2020 to September 2021) provides a descriptive analysis examining the characteristics, vaccination status and outcomes of adults who were hospitalized at Memorial Healthcare System with laboratory-confirmed COVID-19. The study's data focuses on non-pregnant adults, aged 18-49 years old, without underlying conditions and with no reported history of smoking. As a sub-analysis, data on young and otherwise healthy pregnant females who were hospitalized with COVID-19, as well as data stratified by the pre-Delta and Delta variant dominant period are also presented. There was a total of 482 young and otherwise healthy non-pregnant adults who were hospitalized with COVID-19. Overall, more than 13% of our study population had severe COVID-19 disease. Further, a higher proportion of unvaccinated patients had severe COVID-19 compared to those who received at least one dose of the vaccine. All ventilator or ECMO placements, 30-day readmissions and deaths occurred among unvaccinated patients.

Cytomegalovirus reactivation in critically-ill Coronavirus Disease 2019 patients: A case series of 11 patients.

The mortality associated with Coronavirus Disease 2019 is greatly influenced by known risk factors such as elderly age, cardiovascular disease, hypertension, diabetes, and immunosuppression. As cytomegalovirus reactivation in critically ill patients has been linked with higher morbidity and mortality in intensive care settings, it has been suggested that cytomegalovirus reactivation might lead to worse clinical outcomes of patients with Coronavirus Disease 2019. Here we describe the clinical course of 11 patients with Coronavirus Disease 2019 and concomitant cytomegalovirus viremia. We conclude that further research is necessary to formulate guidelines on diagnosis and treatment of cytomegalovirus reactivation in Coronavirus Disease 2019 patients.

Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Emergency Room "Opt-Out" HIV Testing Pre- and During COVID-19 Pandemic in a Large Community Health System.

BACKGROUND: South Florida has the highest HIV rates across the country. Emergency Rooms (ERs) are optimal clinical sites for the identification of people living with HIV. We aimed to evaluate the feasibility and yield of opt-out HIV testing among ER patients in a large community healthcare system in South Florida, and determine the impact of the COVID-19 pandemic on HIV testing. METHODS: This was a retrospective study conducted in the Memorial Healthcare System, Hollywood, Florida. HIV test was offered on an "opt-out" basis to patients aged 16 years or older presenting to the ER of the Memorial Regional Hospital between July 2018 and August 2020. Number of ER visits, HIV testing offered, acceptance of HIV testing, tested positive for HIV infection and linkage to care were reviewed and analyzed. RESULTS: A total of 105,264 (53.7%) patients of 196,110 ER visits were eligible for HIV testing and 39,261 (37.3%) completed HIV testing. Of those tested, 206 (0.5%) patients tested positive, with 54 (26.2%) new infected patients and 152 (73.8%) known infected patients who had not disclosed their status. 45 (60%) of 75 patients with known HIV infections who were not engaged in HIV care were successfully relinked into care after testing, and engagement in care increased from 50.7% pre-testing to 80.3% post-testing (p = 0.001). 45 (83.3%) of 54 newly diagnosed patients were successfully linked into care. During the COVID-19 pandemic, there was a significant reduction in both the ER visits and HIV tests as compared with the pre-pandemic period (p = 0.007 and p < 0.001, respectively). CONCLUSION: An "Opt-out" HIV testing program was successfully implemented in a community hospital ERs. The use of this strategy successfully identified patients with undiagnosed HIV infection and improved their engagement in HIV care. Given the impact of COVID-19 pandemic on the testing program, new strategies should develop to reduce service disruption and maintain the progress of "Opt-out" HIV testing.

Iatrogenic Cushing syndrome following lumbar medial branch block in a patient with HIV on ritonavir and darunavir.

We present a case report of a 62-year old female with HIV and chronic facetogenic back pain who underwent bilateral L3-L4 and L4-L5 medial branch nerve blocks using triamcinolone acetonide 80 mg. 2 weeks later she presented to the emergency department with acute anxiety/depression and was discharged with psychiatric follow-up. 2 weeks after this she presented to the outpatient HIV clinic with persistent uncontrolled depression alongside classic cushingoid features (e.g., buffalo hump, moon facies). She was diagnosed with iatrogenic Cushing syndrome caused by a drug-drug interaction between triamcinolone and ritonavir, a protease inhibitor and a CYP3A4 enzyme inhibitor. While the literature describes the interaction of ritonavir with intra-articular/intranasal/epidural triamcinolone, this is the first documented occurrence following a nerve block procedure. Symptoms resolved within 6 months alongside discontinuation of protease inhibitor therapy.

Lay abstract We report a 62-year old woman with history of HIV and depression who developed Cushing syndrome, which is a state of steroid excess in the body, after a nerve block procedure for treatment of back pain. Her first symptoms were worsening anxiety and depression, causing her to go to the emergency department. Unfortunately, the relationship to the steroids was not identified at the time. Later, she developed increased fat deposition in her face and upper neck, which is characteristic of Cushing syndrome. The HIV medications responsible for this adverse event were determined to be ritonavir and darunavir, which are classified as protease inhibitors. Her symptoms improved within 6 months in association with discontinuation of ritonavir and darunavir. This is the first known case of Cushing syndrome following a nerve block procedure for back pain, although previous cases have documented this occurrence following other forms of steroid treatments.

COVID-19 Coinfection with Mycobacterium abscessus in a Patient with Multiple Myeloma.

BACKGROUND: Coronavirus disease (COVID-19) is a worldwide pandemic causing multiple fatalities and morbidities worldwide. We report a case of severe pneumonia causing acute respiratory distress syndrome due to a coinfection with SARS-CoV-2 and Mycobacterium abscessus in an elderly patient with multiple myeloma in Florida, USA. Case Presentation. An 84-year-old male with a medical history significant for multiple myeloma not in remission was sent to the emergency department to rule out COVID-19 infection prior to continuing his chemotherapy sessions. At presentation, he had nonspecific mild symptoms and an unremarkable physical examination. He had significant blood test findings including serum lactate dehydrogenase 373 U/L, high sensitive C-reactive protein 17.40 mg/l, and ferritin 415 ng/ml. Xpert-SARS-CoV-2 was positive. Chest radiograph revealed patchy areas of interstitial infiltrates in mid to lower lung zones. During his hospitalization course, his oxygenation deteriorated, requiring mechanical intubation. Repeat chest radiograph showed worsening bilateral infiltrates. He was started on broad-spectrum antibiotics and eventually weaned off mechanical intubation and extubated. On the 11th day of admission, he was found to be bradycardic and in shock, and he was reintubated. His labs showed worsening inflammatory markers along with kidney dysfunction to the point of requiring renal replacement therapy. He received both convalescent plasma and remdesivir for treatment of COVID-19 pneumonia. Eventually, repeat blood cultures came back positive for the growth of acid-fast beaded bacilli. While awaiting final culture and sensitivity reports, his antibiotics were upgraded to cover possible nocardia infection. Repeat blood and sputum cultures resulted in growth of AFB bacilli Mycobacterium abscessus 1 week after. CONCLUSIONS: This case report highlights the importance of keeping a broad differential and considering multiple coinfections, including atypical ones during this COVID-19 pandemic, such as the one that was discussed above, Mycobacterium abscessus, in order to provide goal-directed therapy.

The Epidemiology and Predictors of Outcomes Among Confirmed COVID-19 Cases in a Large Community Healthcare System in South Florida.

The novel coronavirus disease 2019 (COVID-19) continues to be a major public health concern. The aim of this study was to describe the presenting characteristics, epidemiology and predictors of outcomes among confirmed COVID-19 cases seen at a large community healthcare system which serves the epicenter and diverse region of Florida. We conducted a retrospective analysis of individuals with lab-confirmed SARS-CoV-2 infection who were seen, from March 2, 2020 to May 31, 2020, at Memorial Healthcare System in South Florida. Data was extracted from a COVID-19 registry of patients with lab-confirmed SARS-CoV-2 infection. Univariate and backward stepwise multivariate logistic regression models were used to determine predictors of key study outcomes. There were a total of 1692 confirmed COVID-19 patients included in this study. Increasing age was found to be a significant predictor of hospitalization, 30-day readmission and death. Having a temperature of 38 °C or more and increasing comorbidity score were also associated with an increased risk of hospitalization. Significant predictors of ICU admission included having a saturated oxygen level less than 90%, hypertension, dementia, rheumatologic disease, having a respiratory rate greater than 24 breaths per minute. Being of Hispanic ethnicity and immunosuppressant utilization greatly increased the risk of 30-day readmission. Having an oxygen saturation less than 90% and an underlying neurological disorder were associated with an increased likelihood of death. Results show that a patient's demographic, underlying condition and vitals at triage may increase or reduce their risk of hospitalization, ICU admission, 30-day readmission or death.

COVID-19 infection among first responders in Broward County, Florida, March-April 2020.

BACKGROUND: First responders (FRs) may have a significant risk of coronavirus 19 (COVID-19) infection than the general population due to job-related exposures. We aimed to determine the prevalence and exposure patterns of COVID-19 among FRs. METHODS: Between March and April 2020, FRs in Broward County, Florida, were screened for COVID-19 infection by real-time reverse transcription polymerase chain reaction assay using nasopharyngeal swabs. Demographics and COVID-19 positive rate of the FRs were summarized. RESULTS: A total of 3375 FRs were screened for COVID-19 infection. The median age of FRs tested was 42 years (IQR 33-52 years), and 1464 (43.4%) were men. A total of 2902 (85.9%) were asymptomatic, and 473 (14.1%) reported symptoms associated with COVID-19. Overall, 289 (8.6%) were positive, with the highest rates among the age between 25 and 49 years. Of those testing positive, 235 (81.3%) were asymptomatic. Fourteen days after their first positive test, 81 (69.8%) of the 116 asymptomatically infected FRs were negative, and 35 (30.2%) remained positive and asymptomatic. CONCLUSIONS: The FRs in Broward County, FL, had an overall infection rate of 8.6% at the time of COVID-19 testing, and asymptomatic FRs accounted for 81.3% of infection. Active surveillance should be focused on the asymptomatic FRs with COVID-19.

Treatment of chronic hepatitis C virus infection with crushed ledipasvir/sofosbuvir administered through a percutaneous endoscopic gastrostomy tube in a patient with HIV coinfection.

PURPOSE: Ledipasvir/sofosbuvir is an oral combination therapy containing fixed doses of direct-acting antiviral agents indicated for the treatment of hepatitis C virus (HCV) infection. Currently there are limited data on the clinical efficacy of crushed ledipasvir/sofosbuvir administered via feeding tube. SUMMARY: This case report discusses the successful treatment of chronic HCV genotype 1b infection with crushed ledipasvir/sofosbuvir administered through a percutaneous endoscopic gastrostomy (PEG) tube in a patient with human immunodeficiency virus (HIV) coinfection and high-grade sarcoma who had severe swallowing difficulties. The patient received crushed ledipasvir/sofosbuvir daily for a total of 12 weeks. At 12 weeks the patient had achieved a sustained virologic response. CONCLUSION: Currently, ledipasvir/sofosbuvir is available only as a tablet, with limited pharmacokinetic data available to guide clinicians on use of the fixed-dose combination medication in crushed form. This case report highlights our experience treating a patient with HCV/HIV coinfection through administration of crushed ledipasvir/sofosbuvir via PEG tube, which we found to be a safe and effective therapeutic option.

HIV Neuropathy-Associated Foot Drop, a Presenting Sign of HIV Infection, Resolving After Initiation of Antiretroviral Therapy: A Clinical Vignette.

ABSTRACT: Peripheral neuropathy is one of the most frequent complaints in patients with HIV. Many complex syndromes exist, with the etiology being secondary to the disease process itself, antiretroviral medication, or immune reconstitution. However, isolated mononeuropathy is rare. In this case, we present a previously healthy man who complained of several months of worsening right foot drop that did not improve with physical therapy or lifestyle interventions. He had begun to use an solid ankle-foot orthotic on this right lower limb to minimize tripping and prevent falls. He had no other neuromuscular involvement or constitutional complaints. Nerve conduction study of the right lower limb showed decreased peak amplitude, prolonged distal latency, and decreased conduction velocity of the deep peroneal nerve. Electromyography revealed abnormal insertional activity and absent motor unit action potentials in both the right tibialis anterior and right extensor digitorum brevis muscles. Magnetic resonance imaging of the right lower limb was suggestive of acute/subacute denervation of the right tibialis anterior muscle. An extensive laboratory workup revealed active HIV infection with a significant viral load. Once the diagnosis was made, the patient was started on antiretroviral treatment. Six months later, his foot drop had entirely resolved, in association with significant improvements in viral load and CD4 count. He has since been ambulating without assistive devices and his HIV/AIDS disease process remains well controlled. This clinical vignette is the first, to our knowledge, to illustrate that an acute focal mononeuropathy causing foot drop and gait dysfunction in an otherwise healthy-appearing individual can be a heralding sign of HIV/AIDS. Furthermore, it also suggests that this functional deficit can be reversed with timely initiation of antiretroviral treatment. Early recognition, diagnosis, and treatment in this patient have not only led to an uncomplicated AIDS disease course but also restored his ability to ambulate with complete independence and improved his quality of life.