Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19: A Nonrandomized Controlled Trial

IMPORTANCE

Awake prone positioning may improve hypoxemia among patients with COVID-19, but whether it is associated with improved clinical outcomes remains unknown.

OBJECTIVE

To determine whether the recommendation of awake prone positioning is associated with improved outcomes among patients with COVID-19-related hypoxemia who have not received mechanical ventilation.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic nonrandomized controlled trial was conducted at 2 academic medical centers (Vanderbilt University Medical Center and NorthShore University HealthSystem) during the COVID-19 pandemic. A total of 501 adult patients with COVID-19-associated hypoxemia who had not received mechanical ventilation were enrolled from May 13 to December 11, 2020.

INTERVENTIONS

Patients were assigned 1:1 to receive either the practitioner-recommended awake prone positioning intervention (intervention group) or usual care (usual care group).

MAIN OUTCOMES AND MEASURES

Primary outcome analyses were performed using a bayesian proportional odds model with covariate adjustment for clinical severity ranking based on the World Health Organization ordinal outcome scale, which was modified to highlight the worst level of hypoxemia on study day 5.

RESULTS

A total of 501 patients (mean [SD] age, 61.0 [15.3] years; 284 [56.7%] were male; and most [417 (83.2%)] were self-reported non-Hispanic or non-Latinx) were included. Baseline severity was comparable between the intervention vs usual care groups, with 170 patients (65.9%) vs 162 patients (66.7%) receiving oxygen via standard low-flow nasal cannula, 71 patients (27.5%) vs 62 patients (25.5%) receiving oxygen via high-flow nasal cannula, and 16 patients (6.2%) vs 19 patients (7.8%) receiving noninvasive positive-pressure ventilation. Nursing observations estimated that patients in the intervention group spent a median of 4.2 hours (IQR, 1.8-6.7 hours) in the prone position per day compared with 0 hours (IQR, 0-0.7 hours) per day in the usual care group. On study day 5, the bayesian posterior probability of the intervention group having worse outcomes than the usual care group on the modified World Health Organization ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16-2.31). However, on study days 14 and 28, the posterior probabilities of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84-1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67-1.86), respectively. Exploratory outcomes (progression to mechanical ventilation, length of stay, and 28-day mortality) did not differ between groups.

CONCLUSIONS AND RELEVANCE

In this nonrandomized controlled trial, prone positioning offered no observed clinical benefit among patients with COVID-19-associated hypoxemia who had not received mechanical ventilation. Moreover, there was substantial evidence of worsened clinical outcomes at study day 5 among patients recommended to receive the awake prone positioning intervention, suggesting potential harm.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04359797.

Postpackage pasteurization of ready-to-eat deli meats by submersion heating for reduction of Listeria monocytogenes

A mixed cocktail of four strains of Listeria monocytogenes was resuspended in product purge and added to a variety of ready-to-eat (RTE) meat products, including turkey, ham, and roast beef. All products were vacuum sealed in shrink-wrap packaging bags, massaged to ensure inoculum distribution, and processed by submersion heating in a precision-controlled steam-injected water bath. Products were run in pairs at various time-temperature combinations in either duplicate or triplicate replications. On various L. monocytogenes-inoculated RTE deli meats, we were able to achieve 2- to 4-log cycle reductions when processed at 195 degrees F (90.6 degrees C), 200 degrees F (93.3 degrees C), or 205 degrees F (96.1 degrees C) when heated from 2 to 10 min. High-level inoculation with L. monocytogenes (approximately 10(7) CFU/ml) ensured that cells infiltrated the least processed surface areas, such as surface cuts, folds, grooves, and skin. D- and z-value determinations were made for the Listeria cocktail resuspended in product purge of each of the three meat categories. However, reduction of L. monocytogenes in product challenge studies showed much less reduction than was observed during the decimal reduction assays and was attributed to a combination of surface phenomena, including surface imperfections, that may shield bacteria from the heat and the migration of chilled purge to the product surface. The current data indicate that minimal heating regimens of 2 min at 195 to 205 degrees F can readily provide 2-log reductions in most RTE deli meats we processed and suggest that this process may be an effective microbial intervention against L. monocytogenes on RTE deli-style meats.