Impact of diabetes mellitus and co-morbidities on mortality in patients with COVID-19: A single-center retrospective study.

OBJECTIVES: To describe the effect of diabetes mellitus (DM) on clinical outcomes of patients admitted with COVID-19 infection. METHODS: We carried out a single center, observational, retrospective study. We included adult patients with laboratory-confirmed diagnosis of COVID-19 admitted to a tertiary hospital in Jeddah, Saudi Arabia, from April 2020 to December 2020. Electronic medical records were reviewed for demographics, clinical status, hospital course, and outcome; and they were compared between the patients with or without DM. RESULTS: Out of 198 patients included in the study, 86 (43.4%) were diabetic and 112 (56.5%) were non-diabetic. Majority of the patients were males 139 (70.2%) with a mean age of 54.14±14.89 years. In-hospital mortality rate was higher in diabetic patients than in non-diabetic patients (40 vs. 32; p=0.011). The most common comorbidity was hypertension (n=95, 48%) followed by ischemic heart disease (n=35, 17.7%), chronic kidney disease (n=17, 9.6%), and bronchial asthma (n=10, 5.1%). CONCLUSION: The risk of SARS-CoV-2 infection is higher among diabetic patients; particularly, those with preexisting co-morbidities or geriatric patients. Diabetic patients are prone to a severe clinical course of COVID-19 and a significantly higher mortality rate.

Effectiveness of Antimicrobial Stewardship Program in Long-Term Care: A Five-Year Prospective Single-Center Study.

Objective: To report the effectiveness of the antimicrobial stewardship program (ASP) in a long-term care (LTC) facility, by analyzing the change in antimicrobial consumption and cost and multidrug resistance (MDR) rates over a 5-year period. Method: A prospective interventional study was conducted at a 106-bed facility (nursing home: 100 beds and an intensive care unit (ICU): 6 beds). The ASP was designed and led by a multidisciplinary team including an infectious disease consultant, two clinical pharmacists, a clinical microbiologist, and an infection control preventionist. Five key performance indicators were monitored: (1) intravenous (IV)-to-oral switch rate, (2) consumption of restricted IV antimicrobials (raw consumption and defined daily doses (DDD) index), (3) cost of restricted IV antimicrobials, (4) antimicrobial sensitivity profiles, and (5) MDR rate among hospital-acquired infections (MDR-HAI). Result: A ∼5.5-fold enhancement of the IV-to-oral switch and a 40% reduction in the overall consumption of restricted IV antimicrobials were observed. Regarding the cost, the cumulative cost saving was estimated as 5.64 million SAR (US$1.50 million). Microbiologically, no significant change in antimicrobial sensitivity profiles was observed; however, a large-size reduction in the MDR-HAI rate was observed, notably in ICU where it declined from 3.22 per 1,000 patient days, in 2015, to 1.14 per 1,000 patient days in 2020. Interestingly, the yearly overall MDR rate was strongly correlated with the level of antimicrobial consumption. Conclusion: The implementation of a multidisciplinary ASP in LTC facilities should be further encouraged, with emphasis on physicians' education and active involvement to enhance the success of the strategy.

In-vitro activity of ceftolozane/tazobactam against recent clinical bacterial isolates from two Saudi Arabian hospitals.

BACKGROUND: Antimicrobial resistance is continuously increasing. Adding tazobactam to ceftolozane improves the latter's activity spectrum against resistant strains. We aimed to determine the susceptibility of recently collected bacterial isolates to ceftolozane/tazobactam (C/T) and other antibiotics. METHODS: This was a prospective cohort study conducted between March 2017 and March 2018. The in-vitro activities of C/T and 14 other antibiotics were assessed against 192 gram-negative bacterial (GNB) isolates (P. aeruginosa, K. pneumonia, E. coli, and other Enterobacterales) prospectively collected from two hospitals in Saudi arabia; in the laboratories of the International Health Management Associates Inc. Samples were obtained from intensive care units (ICUs) and non-ICU locations. The minimum inhibitory concentrations (MICs) of the antibiotics were determined by broth microdilution. Isolates were obtained from different infection sites [urine (31.8%), urinary bladder samples (15.1%), abscess/pus (20.3%), endotracheal aspirates (18.8%)]. RESULTS: Our sample showed substantial drug resistance; 66.1% of the collected isolates showed either multiple or extensive drug resistance. Susceptibility rates of P. aeruginosa (n = 50), E.coli (n = 40), K. pneumoniae (n = 64) and other Enterobacterales (n = 38) to C/T were 74%, 87.5%, 48.4% and 71.1%, respectively. According to MIC50 values (1 µg/mL for both P. aeruginosa and other Enterobacterales, 0.5 µg/mL for E.coli, and 4 µg/mL for K. pneumoniae), C/T was among the most potent antibiotics against these isolates. CONCLUSIONS: C/T displayed high potency against all examined bacterial isolates. It was mainly active against E.coli followed by P.aeruginosa and other Enterobacterales and its lowest susceptibility rate was reported against K. pneumoniae.

Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic.

The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.

Awake Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019 Patients Without Invasive Mechanical Ventilation.

OBJECTIVES/BACKGROUND: Extracorporeal membrane oxygenation is used as rescue therapy for patients with acute respiratory distress syndrome in whom conventional therapy has failed prior to an Extra Corporeal Membrane Oxygenator to rescue Lung Injury in Severe Acute Respiratory Distress Syndrome trial. Since then, extracorporeal membrane oxygenation has been incorporated as part of the standard treatment algorithm in many centers for patients with severe acute respiratory distress syndrome. Since the emergence of coronavirus disease 2019 in early 2020, extracorporeal membrane oxygenation has been used effectively as rescue therapy and as a bridge to recovery in some patients with refractory respiratory failure. DESIGN SUBJECT AND INTERVENTION: We present a 38-year-old male healthcare worker diagnosed with coronavirus disease 2019 and progressed to critical condition with severe surgical emphysema on a high-flow nasal cannula with Fio2 100%, a flow of 40 L/min, and a maximum oxygen saturation of 88%. He was successfully treated by applying awake extracorporeal membrane oxygenation, without a need for invasive mechanical ventilation, to avoid worsening barotrauma and hemodynamic compromise potentially induced by positive pressure ventilation. MAIN RESULTS AND CONCLUSIONS: To our knowledge, this is one of the first cases to be reported in the literature on the use of awake extracorporeal membrane oxygenation as a "treatment" for barotrauma due to severe acute respiratory distress syndrome in a coronavirus disease 2019 patient, without the need for invasive mechanical ventilation. In selected patients with severe respiratory failure, awake extracorporeal membrane oxygenation can be used as a salvage treatment and obviate the need for invasive mechanical ventilation.