Characterization of Coinfections in Patients with COVID-19.

Background: Little is known about coinfections in patients with COVID-19, with antibiotics often initiated empirically. Objectives: To determine the rates and characteristics of early and late coinfections in COVID-19 patients and to characterize the use of anti-infective agents, especially antibiotics. Methods: This retrospective chart review involved patients with COVID-19 who were admitted to Lions Gate Hospital (Vancouver, British Columbia) between January 1 and June 30, 2020. Data were extracted from electronic medical records, and descriptive statistics were used to analyze the data. Results: Of the 48 patients admitted during the study period, 10 (21%) were determined to have coinfections: 3 (6%) had early coinfections and 7 (15%) had late coinfections. Early empiric use of antibiotics was observed in 32 (67%) patients; for 29 (91%) of these 32 patients, the therapy was deemed inappropriate. Patients with coinfections had longer hospital stays and more complications. Conclusions: Despite low rates of early coinfection, empiric antibiotics were started for a majority of the patients. Most late coinfections occurred in patients in the intensive care unit who required mechanical ventilation. Patients with coinfections had poorer outcomes than those without coinfections.

Contexte: On sait peu de choses sur les co-infections chez les patients atteints de COVID-19, les médicaments antibiotiques étant souvent initiés de manière empirique. Objectifs: Déterminer les taux et les caractéristiques des co-infections précoces et tardives chez les patients atteints de COVID-19 et caractériser l'utilisation d'anti-infectieux, en particulier les antibiotiques. Méthodes: Cet examen rétrospectif des dossiers portait sur des patients atteints de COVID-19 qui ont été admis à l'hôpital Lions Gate, à Vancouver (Colombie-Britannique), entre le 1er janvier et le 30 juin 2020. Les données ont été extraites des dossiers médicaux électroniques et des statistiques descriptives ont été utilisées pour analyser les données. Résultats: Sur les 48 patients admis au cours de la période d'étude, 10 patients (21 %) présentaient des co-infections: 3 patients (6 %) avaient des co-infections précoces et 7 (15 %), des co-infections tardives. Une utilisation empirique précoce d'antibiotiques a été observée chez 32 patients (67 %); pour 29 de ces 32 patients (91 %), le traitement a été jugé inapproprié. Les séjours à l'hôpital des patients co-infectés étaient plus longs et ils présentaient davantage de complications. Conclusions: Malgré de faibles taux de co-infection précoce, des antibiotiques empiriques ont été instaurés pour la majorité des patients. La plupart des co-infections tardives sont survenues chez des patients de l'unité de soins intensifs nécessitant une ventilation mécanique. Les résultats des patients avec co-infections étaient moins bons que ceux sans co-infections.

Genetic variation in APOL1 associates with younger age at hemodialysis initiation.

African Americans have a markedly higher incidence of ESRD compared with other racial groups. Two variants in the APOL1 gene, to date observed only among individuals of recent African ancestry, associate with increased risk for renal disease among African Americans. Here, we investigated whether these risk alleles also associate with age at initiation of chronic hemodialysis. We performed a cross-sectional study of 407 nondiabetic African Americans with ESRD who participated in the Accelerated Mortality on Renal Replacement (ArMORR) study, a prospective cohort of incident chronic hemodialysis patients. African Americans carrying two copies of the G1 risk allele initiated chronic hemodialysis at a mean age of 49.0 ± 14.9 years, which was significantly younger than both subjects with one copy of the G1 allele (55.9 ± 16.7 years; P = 0.014) and subjects without either risk allele (61.8 ± 17.1 years; P = 6.2 × 10(-7)). The association between the presence of the G1 allele and age at initiation of hemodialysis remained statistically significant after adjusting for sociodemographic and other potential confounders. We did not detect an association between the G2 risk allele and age at initiation of hemodialysis, but the sample size was limited. In conclusion, genetic variations in APOL1 identify African Americans that initiate chronic hemodialysis at a younger age. Early interventions to prevent progression of kidney disease may benefit this high-risk population.

Comparison of two needle sizes for subcutaneous administration of enoxaparin: effects on size of hematomas and pain on injection.

STUDY OBJECTIVE: To determine whether use of a smaller needle size for subcutaneous injection of enoxaparin would reduce the size of injection-site hematomas and/or decrease the pain of injection. DESIGN: Prospective, randomized trial. SETTING: Community hospital in North Vancouver, British Columbia, Canada. PATIENTS: One hundred twenty-four patients with unstable angina or non-Q-wave myocardial infarction who were administered enoxaparin for anticoagulation. INTERVENTION: Each patient was randomly assigned to one of two groups. One group received enoxaparin injections with a 30-gauge, 5/16-inch insulin syringe, and the other group was injected with a 26-gauge, 3/8-inch tuberculin syringe. MEASUREMENTS AND MAIN RESULTS: Participating nurses used standard measuring tape to determine the largest diameter of each hematoma. Pain was assessed with a 10-unit numeric scale. The two groups did not differ significantly with regard to either the mean size of the largest hematoma/patient (4.2 cm in the insulin-syringe group vs 3.8 cm in the tuberculin-syringe group, p=0.68) or the mean pain score (0.3 in the insulin-syringe group vs 0.5 in the tuberculin-syringe group, p=0.10). CONCLUSIONS: Use of a 30-gauge, 5/16-inch insulin syringe instead of a 26-gauge, 3/8-inch tuberculin syringe does not significantly reduce either hematoma size or pain of injection. A larger study is required to determine whether needle size affects the frequency of hematoma formation.

Characterizing and developing strategies for the treatment of community-acquired pneumonia at a community hospital.

BACKGROUND: Patients admitted to Lions Gate Hospital, North Vancouver, British Columbia, with a primary diagnosis of community-acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared with 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential savings of 406 bed days and warranted an investigation into the management of CAP. OBJECTIVE: To characterize and provide recommendations for the management of CAP. METHODS: A retrospective chart review of patients admitted with a primary diagnosis of CAP between May 1, 2000 and August 31, 2000. RESULTS: Fifty-one patients were included in the study, with a mean LOS of 9.9 days and a median LOS of five days. Based on pneumonia severity index scores calculated for each patient, eight patients (16%) were admitted inappropriately. Initial empirical antibiotic choices were consistent with the Canadian CAP guidelines in 27 patients (53%), with inconsistencies arising mainly because cephalosporin or azithromycin monotherapy regimens were prescribed. Step-down from intravenous to oral antibiotics occurred in approximately 20 patients (39%). An additional 12 patients (24%) could have undergone step-down, and step-down was not applicable in 19 patients (37%). The potential annual cost avoidance from implementing admission criteria based on a pneumonia severity index score, applying step-down criteria and promoting early discharge criteria was estimated to be $220,000. CONCLUSIONS: Considerable variability exists in the treatment of CAP. A CAP preprinted order sheet was developed to address the issues identified in the present study and provide consistency in the management of CAP at Lions Gate Hospital.

Time to effective antibiotic administration in adult patients with septic shock: a descriptive analysis.

OBJECTIVE: To determine the median time to antibiotic administration following the onset of septic shock at our institution as well as the appropriateness of empiric therapy, sources of delay in antibiotic administration and the effect of delays on survival. RESEARCH METHODOLOGY: Retrospective health record review of 55 patients with septic shock admitted to the intensive care unit (ICU) between July 1, 2008 and December 31, 2009. SETTING: Nine-bed adult medical-surgical ICU within a 300-bed community acute care hospital. MAIN OUTCOME MEASURES: Median time to antibiotic administration, appropriateness of empiric therapy, sources of delay in antibiotic administration. RESULTS: The median (min,max) time to the initiation of antibiotics was determined to be 1.7 (0,31) hours. Only 34% (19/55) of patients received antibiotics within the recommended one hour. Empiric antibiotic therapy was determined to be appropriate in 91% (50/55) of patients. The median (min,max) time to administration of effective antibiotic therapy tended to be faster in the emergency room [1.1 (0,16) hours] compared to the ICU [2.3 (0,13)]. CONCLUSION: The median time to antibiotic administration at our institution following the onset of septic shock was longer than the evidence-based guideline recommendations of within one hour.

Evaluation of an electrolyte replacement protocol in an adult intensive care unit: a retrospective before and after analysis.

BACKGROUND: Electrolyte imbalances are frequently encountered in the Intensive Care Unit (ICU) and protocol-driven interventions may facilitate more timely and uniform care. OBJECTIVE: To compare the effectiveness and timeliness of electrolyte replacement in an adult ICU before and after implementation of an Electrolyte Replacement Protocol (ERP) and to assess nurse and physician satisfaction with the ERP. METHODS: Health records of adult patients who experienced hypokalaemia, hypomagnesaemia, or hypophosphataemia in the ICU during the study periods were retrospectively reviewed. Effectiveness of the ERP was assessed by the number of replacement doses indicated but not given and the number of doses and total dose required to normalise the low electrolyte level. Timeliness was evaluated by the time between the laboratory reporting the low electrolyte level and administration of the replacement dose. Nurse and physician satisfaction with the ERP was assessed through a written survey. RESULTS: After implementation of the ERP, the number of replacement doses indicated but not given was reduced for magnesium from 60% to 35% (p=0.18) and for phosphate from 100% to 64% (p=0.04). The time to replacement was reduced for potassium from 79 to 60 min (p=0.066) and for magnesium from 307 to 151 min (p=0.15). Nurses and physicians were satisfied with the ERP. CONCLUSIONS: Implementation of an ERP resulted in improvements in the effectiveness and timeliness of electrolyte replacement and nurses and physicians were satisfied with the ERP.