Epidemiology, clinical features and outcomes of hospitalized patients with COVID-19 by vaccination status: a multicenter historical cohort study.

INTRODUCTION: COVID-19 disease resulted in over six million deaths worldwide. Although vaccines against SARS-CoV-2 demonstrated efficacy, breakthrough infections became increasingly common. There is still a lack of data regarding the severity and outcomes of COVID-19 among vaccinated compared to unvaccinated individuals. METHODS: This was a historical cohort study of adult COVID-19 patients hospitalized in five Ascension hospitals in southeast Michigan. Electronic medical records were reviewed. Vaccine information was collected from the Michigan Care Improvement Registry. Data were analyzed using Student's t-test, analysis of variance, the chi-squared test, the Mann-Whitney and Kruskal-Wallis tests, and multivariable logistic regression. RESULTS: Of 341 patients, the mean age was 57.9 ± 18.3 years, 54.8% (187/341) were female, and 48.7% (166/341) were black/African American. Most patients were unvaccinated, 65.7%, 8.5%, and 25.8% receiving one dose or at least two doses, respectively. Unvaccinated patients were younger than fully vaccinated (p = 0.001) and were more likely to be black/African American (p = 0.002). Fully vaccinated patients were 5.3 times less likely to have severe/critical disease (WHO classification) than unvaccinated patients (p < 0.001) after controlling for age, BMI, race, home steroid use, and serum albumin levels on admission. The case fatality rate in fully vaccinated patients was 3.4% compared to 17.9% in unvaccinated patients (p = 0.003). Unvaccinated patients also had higher rates of complications. CONCLUSIONS: Patients who were unvaccinated or partially vaccinated had more in-hospital complications, severe disease, and death as compared to fully vaccinated patients. Factors associated with severe COVID-19 disease included advanced age, obesity, low serum albumin, and home steroid use.

Risk Factors for In-hospital Mortality from Coronavirus Disease 2019 Infection Among Black Patients-An Urban Center Experience.

BACKGROUND: Racial disparities are central in the national conversation about coronavirus disease 2019 (COVID-19) , with Black/African Americans being disproportionately affected. We assessed risk factors for death from COVID-19 among Black inpatients at an urban hospital in Detroit, Michigan. METHODS: This was a retrospective, single-center cohort study. We reviewed the electronic medical records of patients positive for severe acute respiratory syndrome coronavirus 2 (the COVID-19 virus) on qualitative polymerase chain reaction assay who were admitted between 8 March 2020 and 6 May 2020. The primary outcome was in-hospital mortality. RESULTS: The case fatality rate was 29.1% (122/419). The mean duration of symptoms prior to hospitalization was 5.3 (3.9) days. The incidence of altered mental status on presentation was higher among patients who died than those who survived, 43% vs 20.0%, respectively (P < .0001). From multivariable analysis, the odds of death increased with age (≥60 years), admission from a nursing facility, Charlson score, altered mental status, higher C-reactive protein on admission, need for mechanical ventilation, presence of shock, and acute respiratory distress syndrome. CONCLUSIONS: These demographic, clinical, and laboratory factors may help healthcare providers identify Black patients at highest risk for severe COVID-19-associated outcomes. Early and aggressive interventions among this at-risk population may help mitigate adverse outcomes.

Clinical Features and Risk Factors for In-Hospital Mortality From COVID-19 Infection at a Tertiary Care Medical Center, at the Onset of the US COVID-19 Pandemic.

BACKGROUND: Mortality from COVID-19 has been associated with older age, black race, and comorbidities including obesity, Understanding the clinical risk factors and laboratory biomarkers associated with severe and fatal COVID-19 will allow early interventions to help mitigate adverse outcomes. Our study identified risk factors for in-hospital mortality among patients with COVID-19 infection at a tertiary care center, in Detroit, Michigan. METHODS: We conducted a single-center, retrospective cohort study at a 776-bed tertiary care urban academic medical center. Adult inpatients with confirmed COVID-19 (nasopharyngeal swab testing positive by real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay) from March 8, 2020, to June 14, 2020, were included. Clinical information including the presence of comorbid conditions (according to the Charlson Weighted Index of Comorbidity (CWIC)), initial vital signs, admission laboratory markers and management data were collected. The primary outcome was in-hospital mortality. RESULTS: Among 565 hospitalized patients, 172 patients died for a case fatality rate of 30.4%. The mean (SD) age of the cohort was 64.4 (16.2) years, and 294 (52.0%) were male. The patients who died were significantly older (mean [SD] age, 70.4 [14.1] years vs 61.7 [16.1] years; P < 0.0001), more likely to have congestive heart failure (35 [20.3%] vs 47 [12.0%]; P = 0.009), dementia (47 [27.3%] vs 48 [12.2%]; P < 0.0001), hemiplegia (18 [10.5%] vs 18 [4.8%]; P = 0.01) and a diagnosis of malignancy (16 [9.3%] vs 18 [4.6%]; P = 0.03).From multivariable analysis, factors associated with an increased odds of death were age greater than 60 years (OR = 2.2, P = 0.003), CWIC score (OR = 1.1, P = 0.023), qSOFA (OR = 1.7, P < 0.0001), WBC counts (OR = 1.1, P = 0.002), lymphocytopenia (OR = 2.0, P = 0.003), thrombocytopenia (OR = 1.9, P = 0.019), albumin (OR = 0.6, P = 0.014), and AST levels (OR = 2.0, P = 0.004) on admission. CONCLUSIONS: This study identified risk factor for in-hospital mortality among patients admitted with COVID-19 in a tertiary care hospital at the onset of U.S. Covid-19 pandemic. After adjusting for age, CWIC score, and laboratory data, qSOFA remained an independent predictor of mortality. Knowing these risk factors may help identify patients who would benefit from close observations and early interventions.

Tocilizumab: A retrospective multi-center cohort study of critically ill patients with COVID-19.

BACKGROUND: Coronavirus disease 19 (COVID-19) can have a severe presentation characterized by a dysregulated immune response requiring admission to the intensive care unit (ICU). Immunomodulatory treatments like tocilizumab were found to improve inflammatory markers and lung injury over time. We aim to evaluate the effectiveness of tocilizumab treatment on critically ill patients with severe COVID-19. MATERIALS AND METHODS: We conducted a multi-center retrospective cohort study of 154 adult patients admitted to the ICU for severe COVID-19 pneumonia between March 15 and May 8, 2020. Data were obtained by electronic medical record (EMR) review. The primary outcome of interest was mortality. RESULTS: Of 154 patients, 34 (21.4%) received tocilizumab. Compared to the non-treated group, the treated group was significantly younger, had fewer comorbidities, lower creatinine and procalcitonin levels, and higher alanine aminotransferase levels on admission. The treated group was more likely to receive supportive measures in the context of critical illness. The overall case fatality rate was 71.4%, and it was significantly lower in the treated than the non-treated (52.9 vs. 76.7%, p = 0.007). In multivariable survival analysis, tocilizumab treatment was associated with a 2.1 times lower hazard of mortality when compared to those who were not treated (hazard ratio: 0.47; 95% CI: 0.27, 0.83; p = 0.009). The prevalence of secondary infection was higher in the treated group compared to the non-treated without significant difference (p = 0.17). CONCLUSION: Tocilizumab treatment for critically ill patients with COVID-19 resulted in a lower likelihood of mortality.

Unusual case of necrotizing pneumonia caused by Fusobacterium nucleatum complicating influenza a virus infection.

We report a rare case of Fusobacterium nucleatum necrotizing pneumonia following an influenza viral infection. This rare bacterial lung infection can have severe complications such as respiratory failure and septic shock, so early recognition and treatment are necessary.

Predictors for Severe COVID-19 Infection.

BACKGROUND: COVID-19 is a pandemic disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Predictors for severe COVID-19 infection have not been well defined. Determination of risk factors for severe infection would enable identifying patients who may benefit from aggressive supportive care and early intervention. METHODS: We conducted a retrospective observational study of 197 patients with confirmed COVID-19 admitted to a tertiary academic medical center. RESULTS: Of 197 hospitalized patients, the mean (SD) age of the cohort was 60.6 (16.2) years, 103 (52.3%) were male, and 156 (82.1%) were black. Severe COVID-19 infection was noted in 74 (37.6%) patients, requiring intubation. Patients aged above 60 were significantly more likely to have severe infection. Patients with severe infection were significantly more likely to have diabetes, renal disease, and chronic pulmonary disease and had significantly higher white blood cell counts, lower lymphocyte counts, and increased C-reactive protein (CRP) than patients with nonsevere infection. In multivariable logistic regression analysis, risk factors for severe infection included pre-existing renal disease (odds ratio [OR], 7.4; 95% CI, 2.5-22.0), oxygen requirement at hospitalization (OR, 2.9; 95% CI, 1.3-6.7), acute renal injury (OR, 2.7; 95% CI, 1.3-5.6), and CRP on admission (OR, 1.006; 95% CI, 1.001-1.01). Race, age, and socioeconomic status were not independent predictors. CONCLUSIONS: Acute or pre-existing renal disease, supplemental oxygen upon hospitalization, and admission CRP were independent predictors for the development of severe COVID-19. Every 1-unit increase in CRP increased the risk of severe disease by 0.06%.

Biologic-Induced Infections in Inflammatory Bowel Disease: The TNF-α Antagonists.

OBJECTIVE: To review the mechanism and association of infectious risk among the tumor-necrosis factor α (TNF-α) antagonists used in inflammatory bowel disease. DATA SOURCES: A PubMed literature search was performed using the following search terms: infliximab, adalimumab, certolizumab, golimumab, inflammatory bowel disease, crohn's, ulcerative colitis, adverse effects, adverse events, safety, and infection. STUDY SELECTION AND DATA EXTRACTION: Meta-analyses and cohort studies with outcomes pertaining to quantitative infectious risk were reviewed. Case reports and case series describing association between TNF-α inhibitors and infection were also reviewed. DATA SYNTHESIS: A total of 7 recent meta-analyses of randomized trials demonstrate inconclusive association of infection with TNF-α antagonists. Registry data suggest that medications carry an independent risk of opportunistic infections. Risk factors for infection include older age, malnutrition, diabetes, and possibly combination therapy. Reported infections vary widely but include intracellular and granulomatous bacteria, viruses, and fungi. CONCLUSION: TNF-α antagonists are associated with an increased risk of opportunistic infection, although this risk has not been demonstrated conclusively in randomized controlled trials. Knowledge of concomitant risk factors, mechanism of infectious risk, and available treatment options can improve patient care in the clinical setting.

Daptomycin-associated eosinophilic pneumonia with rechallenge: a case report
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PURPOSE: A case of daptomycin-associated acute eosinophilic pneumonia (AEP) with positive rechallenge is reported. SUMMARY: AEP associated with daptomycin is reported in the literature, and the product labeling contains a warning and precaution statement. Criteria for diagnosing daptomycin-induced AEP varies and generally includes bronchoalveolar lavage (BAL) eosinophils ≥ 25%. We report a case of a 70-year-old woman with cough, shortness of breath, and altered mental status who presented ~ 9 days after starting therapy with daptomycin to treat methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis. Daptomycin was utilized because of a presumed vancomycin allergy. Aspiration pneumonia was suspected and IV ampicillin and sulbactam was initiated. Clinical status improved initially but ~ 1 week later, her respiratory status declined. During work-up, peripheral eosinophils were abnormal at 11.6%, so daptomycin therapy was discontinued. BAL revealed 5% eosinophils with negative infectious work-up. Respiratory status rapidly improved after discontinuation of daptomycin. Linezolid therapy was initiated. Due to an uncertain association with daptomycin and concerns associated with long-term linezolid therapy, the patient agreed to rechallenge with daptomycin. Within 24 hours, respiratory symptoms returned and daptomycin was permanently discontinued. The patient rapidly recovered without the need for systemic corticosteroid treatment. CONCLUSIONS: Our case supports a broadened definition of pulmonary eosinophilia associated with daptomycin administration. It is important for clinicians to consider daptomycin as an etiology of pneumonia with abnormal eosinophils when other causes have been excluded. Clinicians could also consider peripheral eosinophilia as a possible indication of AEP when BAL is not available or cannot be obtained.
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Septic Arthritis Caused by Pasteurella multocida: A Source Control Issue.

Pasteurella multocida is known to be the most commonly isolated pathogen of soft tissue infections caused by cat or dog-inflicted wounds. We present a case of a 66-year-old female who was bitten by a cat, prescribed antibiotic therapy outpatient, and developed a septic metacarpophalangeal joint despite appropriate antibiotics. A failure to improve with appropriate antibiotic therapy should raise suspicion of a source control problem and prompt surgical intervention, a principle that is highlighted in this case. Pasteurella multocida septic arthritis of the fingers manifests in less than 4% of cases, making this case a rare presentation of a septic joint, which necessitated surgical management.

Predictors of prolonged length of stay in adult patients with respiratory syncytial virus infections - a multi-center historical cohort study.

Objectives: Several studies have reported risk factors for severe disease and mortality in hospitalized adults with RSV infections. There is limited information available regarding the factors that affect the duration of a patient's hospital length of stay (LOS). Methods: This was a multicenter historical cohort study of adult patients hospitalized for laboratory-confirmed RSV in Southeast Michigan between January 2017 and December 2021. Hospitalized patients were identified using the International Classification of Diseases, Tenth Revision 10 codes for RSV infection. Mean LOS was computed; prolonged LOS was defined as greater than the mean. Results: We included 360 patients with a mean age (SD) of 69.9 ± 14.7 years, 63.6% (229) were female and 63.3% (228) of white race. The mean hospital LOS was 7.1 ± 5.4 days. Factors associated with prolonged LOS in univariable analysis were old age, body mass index (BMI), smoking status, Charlson Weighted Index of Comorbidity (CWIC), home oxygen, abnormal chest x-ray (CXR), presence of sepsis, use of oxygen, and antibiotics at the time of presentation. Predictors for prolonged LOS on admission in multivariable analysis were age on admission (p < 0.001), smoking status (p = 0.001), CWIC (p = 0.038) and abnormal CXR (p = 0.043). Interpretation: Our study found that age on admission, smoking history, higher CWIC and abnormal CXR on admission were significantly associated with prolonged LOS among adult patients hospitalized with RSV infection. These findings highlight the significance of promptly recognizing and implementing early interventions to mitigate the duration of hospitalization for adult patients suffering from RSV infection.

Epidemiology and risk factors for isolation of Escherichia coli producing CTX-M-type extended-spectrum ß-lactamase in a large U.S. Medical Center.

A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum ß-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.

Facial nerve palsy: An early sign of COVID-19.

Introduction: Bell's palsy is a peripheral lower motor neuron (LMN) facial nerve palsy, characterized by the acute onset (72 hours or less) of unilateral peripheral facial paresis without other neurologic signs. Bell's palsy has been described at three clinical junctures of COVID-19 infection: as the unique initial signal of COVID-19, as an accompanying feature during the acute phase of COVID-19 when respiratory and systemic symptoms predominate, or during the recuperative phase beginning 2-3 weeks after resolution of respiratory and systemic covid symptoms. Case report: We present a unique case of a COVID-19-related facial nerve palsy that occurred 3 weeks prior to the onset of pneumonia caused by COVID-19. Conclusions: This case report suggests an association between early COVID-19 presenting as facial nerve palsy and alerts physicians about the ways in which COVID-19 may cause this phenomenon.

Gallbladder Empyema and Epidural Abscess Due to Salmonella Enteritidis After Treatment of Primary Infection: Case Report and Review of the Literature.

Nontyphoidal Salmonella can cause gallbladder empyema and disseminated disease in patients with suppressed immune systems. We are reporting a unique case of concomitant gallbladder empyema and epidural abscess due to Salmonella enterica subsp enterica serovar Enteritidis in a patient who was appropriately treated for the primary Salmonella infection complicated by bacteremia. A high degree of suspicion is needed in high-risk patients as timely intervention can avoid life-threatening complications.

Small Fiber Neuropathy After SARS-CoV-2 Infection and Vaccination: A Case-Based Comparison.

COVID-19-associated neuropathies, whether post-infection or post-vaccination, have not been fully described. A variety of theories exist to explain these phenomena, many of them centering on immune dysregulation. We aim to contribute to the discussion on the similarities and differences behind the two conditions and to bolster the call for further research to be done in this area. We will discuss two different case presentations, one patient experiencing a post-COVID-19 infection neuropathy and the other experiencing a post-COVID-19 vaccination neuropathy.

A rare presentation of infectious mononucleosis: cholestatic hepatitis with hyperbilirubinemia.

Introduction: Epstein-Barr virus infection with mononucleosis is the most common presentation in young adults. Most infections are self-limited, although in a few cases complications can include serious conditions such as lymphoproliferative disorders or in less severe cases, mild hepatitis. Case report: We present an unusual case of a young male with no liver disease, who presented with markedly elevated cholestatic pattern hyperbilirubinemia, as well as hepatitis. The patient responded well to symptomatic treatments, with spontaneous improvement of the hyperbilirubinemia and transaminitis. Conclusions: Epstein-Barr virus mononucleosis can frequently present with mild elevation of transaminases, but very rarely can have marked elevation of bilirubin, which may make clinicians doubt that the infection is the sole culprit of the process.

Impact of cefepime therapy on mortality among patients with bloodstream infections caused by extended-spectrum-ß-lactamase-producing Klebsiella pneumoniae and Escherichia coli.

Extended-spectrum-ß-lactamase (ESBL)-producing pathogens are associated with extensive morbidity and mortality and rising health care costs. Scant data exist on the impact of antimicrobial therapy on clinical outcomes in patients with ESBL bloodstream infections (BSI), and no large studies have examined the impact of cefepime therapy. A retrospective 3-year study was performed at the Detroit Medical Center on adult patients with BSI due to ESBL-producing Klebsiella pneumoniae or Escherichia coli. Data were collected from the medical records of study patients at five hospitals between January 2005 and December 2007. Multivariate analysis was performed using logistic regression. One hundred forty-five patients with BSI due to ESBL-producing pathogens, including K. pneumoniae (83%) and E. coli (16.5%), were studied. The mean age of the patients was 66 years. Fifty-one percent of the patients were female, and 79.3% were African-American. Fifty-three patients (37%) died in the hospital, and 92 survived to discharge. In bivariate analysis, the variables associated with mortality (P < 0.05) were presence of a rapidly fatal condition at the time of admission, use of gentamicin as a consolidative therapeutic agent, and presence of one or more of the following prior to culture date: mechanical ventilation, stay in the intensive care unit (ICU), and presence of a central venous catheter. In multivariate analysis, the predictors of in-hospital mortality included stay in the intensive care unit (odds ratio [OR], 2.17; 95% confidence interval [CI], 0.98 to 4.78), presence of a central-line catheter prior to positive culture (OR, 2.33; 95% CI, 0.77 to 7.03), presence of a rapidly fatal condition at the time of admission (OR, 5.13; 95% CI, 2.13 to 12.39), and recent prior hospitalization (OR, 1.92; 95% CI, 0.83 to 4.09). When carbapenems were added as empirical therapy to the predictor model, there was a trend between empirical carbapenem therapy and decreased mortality (OR, 0.61; 95% CI, 0.26 to 1.50). When added to the model, receipt of empirical cefepime alone (n = 43) was associated with increased mortality, although this association did not reach statistical significance (OR, 1.66; 95% CI, 0.71 to 3.87). The median length of hospital stay was shorter for patients receiving empirical cefepime than for those receiving empirical or consolidated carbapenem therapy. In multivariate analysis, empirical therapy with cefepime for BSI due to an ESBL-producing pathogen was associated with a trend toward an increased mortality risk and empirical carbapenem therapy was associated with a trend toward decreased mortality risk.

COVID-19 Rebound After Paxlovid Treatment: A Case Series and Review of Literature.

Since the declaration of COVID-19 as a pandemic in 2020, several therapies have been developed to reduce symptoms of COVID-19 infection and prevent progression. Paxlovid is an antiviral that was authorized for emergency use in December 2021 for non-hospitalized symptomatic patients with COVID-19 to prevent progression to severe disease. Relapse of symptoms following a period of improvement after treatment with Paxlovid has been described recently. Data are limited, but the disease course in available case reports is usually mild and requires no additional antiviral treatment. We present the cases of COVID-19 relapse (COVID-19 rebound) in two patients following treatment with Paxlovid.

Unusual Case of Non-HIV Patient With Multifocal Pyomyositis: Developed on Appropriate Antibiotic Therapy.

Pyomyositis is a clinical condition classically associated with tropical climates, but there are an increasing number of reports in temperate climates. We present a diabetic patient, who presented with gastrointestinal symptoms and right foot ulcer. He was found to have methicillin-resistant Staphylococcus aureus (MRSA). Initial computed tomography (CT) scan of abdomen and pelvis was negative for any abscesses, but after persistent bacteremia developed pyomyositis being on appropriate antibiotic therapy. This case may make physicians aware that initial negative test results do not always preclude the presence of pyomyositis in the presence of risk factors.

A comparison of coronavirus disease 2019 (COVID-19) versus influenza during the pandemic: Can we distinguish COVID-19 from flu?

We conducted a retrospective chart review examining the demographics, clinical history, physical findings, and comorbidities of patients with influenza and patients with coronavirus disease 2019 (COVID-19). Older patients, male patients, patients reporting fever, and patients with higher body mass indexes (BMIs) were more likely to have COVID-19 than influenza.