A Multicenter Retrospective Cohort Study to Characterize Patients Hospitalized With Multisystem Inflammatory Syndrome in Adults and Coronavirus Disease 2019 in the United States, 2020-2021

BACKGROUND

The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated multisystem inflammatory syndrome in adults (MIS-A) requires distinguishing it from acute coronavirus disease 2019 (COVID-19) and may affect clinical management.

METHODS

In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention case definition to identify adults hospitalized with MIS-A at 6 academic medical centers from 1 March 2020 to 31 December 2021. Patients MIS-A were matched by age group, sex, site, and admission date at a 1:2 ratio to patients hospitalized with acute symptomatic COVID-19. Conditional logistic regression was used to compare demographic characteristics, presenting symptoms, laboratory and imaging results, treatments administered, and outcomes between cohorts.

RESULTS

Through medical record review of 10 223 patients hospitalized with SARS-CoV-2-associated illness, we identified 53 MIS-A cases. Compared with 106 matched patients with COVID-19, those with MIS-A were more likely to be non-Hispanic black and less likely to be non-Hispanic white. They more likely had laboratory-confirmed COVID-19 ≥14 days before hospitalization, more likely had positive in-hospital SARS-CoV-2 serologic testing, and more often presented with gastrointestinal symptoms and chest pain. They were less likely to have underlying medical conditions and to present with cough and dyspnea. On admission, patients with MIS-A had higher neutrophil-to-lymphocyte ratio and higher levels of C-reactive protein, ferritin, procalcitonin, and D-dimer than patients with COVID-19. They also had longer hospitalization and more likely required intensive care admission, invasive mechanical ventilation, and vasopressors. The mortality rate was 6% in both cohorts.

CONCLUSIONS

Compared with patients with acute symptomatic COVID-19, adults with MIS-A more often manifest certain symptoms and laboratory findings early during hospitalization. These features may facilitate diagnosis and management.

989. Role of Bone Biopsy and Deep Tissue Culture for Antibiotic Stewardship in Diabetic Foot Infections

Background

Bone biopsy is the gold standard for identifying the etiology of infectious osteomyelitis (OM) but is not always done in the setting of diabetic foot infections (DFIs), even in settings where resistant organisms are common. This study aimed to describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with DFIs.

Methods

We retrospectively reviewed all patients admitted with a DFI between 2018 and 2020 and selected for patients diagnosed with infectious OM of the lower extremity for whom bone biopsy or deep tissue culture was obtained. Statistics were performed in R version 4.2.0.

Results

Of 305 patients with DFI, 47 patients received 41 deep tissue cultures and 29 bone biopsies for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had gram positive organisms and 24 (34%) had gram negative organisms. Multidrug resistant organisms were isolated in 7 (14.9%) patients, including 5 cases of MRSA (10.2%) and 2 cases of ESBL-producing organisms (4.3%). Pseudomonas aeruginosa was isolated in 3 (6.4%) patients. Culture data resulted in antibiotic changes in 41 (87.2%) patients. Therapy was narrowed in 29 (61.7%) patients and broadened due to inadequate empiric coverage in 4 patients (8.5%). Culture-directed therapy was started in 4 (8.5%) patients in which it had initially been withheld. Culture data from 18 (40%) patients showed sensitivity to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (80% vs 75%, p=0.857). There was a trend towards utilization of less MRSA coverage (38.2% vs 50.5%, p=0.16) and Pseudomonas coverage (34.0% vs 41.9%, p=0.36) in patients undergoing bone biopsy or deep tissue culture, but this did not reach statistical significance. Table 1:Bacteria isolated from deep tissue culture or bone biopsy and effect on antibiotic therapyFigure 1:Empiric antibiotics in hospital vs culture directed antibiotics on discharge

Conclusion

In patients with DFIs, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. While culture data usually allowed for narrowing of antibiotics, it revealed inadequate empiric coverage in a subset of patients.

Disclosures

Janna L. Williams, MD, Abbvie: COVID19 Infection Prevention Consultant Shannon Galvin, MD, Gilead: Grant/Research Support.

Role of bone biopsy and deep tissue culture for antibiotic stewardship in diabetic foot osteomyelitis

OBJECTIVES

To describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with diabetic foot osteomyelitis (DFO).

METHODS

We retrospectively reviewed patients admitted with a diabetic foot ulcer (DFU) between 3 March 2018 and 31 December 2019 and selected for patients diagnosed with infectious osteomyelitis (OM) of the lower extremity. We stratified patients by whether a bone biopsy or deep tissue culture was obtained and compared rates of antibiotic utilization with chi-squared and Fisher's exact tests.

RESULTS

Of 305 patients with a DFU, 152 (50%) were clinically diagnosed with DFO. Forty-seven patients received 41 deep tissue cultures and 29 bone biopsy cultures for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had Gram-positive organisms and 19 (42%) had Gram-negative organisms. MDR organisms were isolated in 7 (15%) patients. Culture data resulted in antibiotic changes in 41 (87%) patients. Therapy was narrowed in 29 (62%) patients and broadened due to inadequate empirical coverage in 4 (9%) patients. Culture data from 18 (40%) patients showed susceptibility to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (77% versus 75%, P = 0.86), although less MRSA coverage was used (34% versus 50%, P = 0.047).

CONCLUSIONS

In patients with DFO, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. Culture data usually allowed for narrowing of antibiotics but revealed inadequate empirical coverage in a subset of patients.

Paired-like homeobox gene (PHOX2B) nonpolyalanine repeat expansion mutations (NPARMs): genotype-phenotype correlation in congenital central hypoventilation syndrome (CCHS)

PURPOSE

CCHS is an extremely rare congenital disorder requiring artificial ventilation as life support. Typically caused by heterozygous polyalanine repeat expansion mutations (PARMs) in the PHOX2B gene, identification of a relationship between PARM length and phenotype severity has enabled anticipatory management. However, for patients with non-PARMs in PHOX2B (NPARMs, ~10% of CCHS patients), a genotype-phenotype correlation has not been established. This comprehensive report of PHOX2B NPARMs and associated phenotypes, aims at elucidating potential genotype-phenotype correlations that will guide anticipatory management.

METHODS

An international collaboration (clinical, commercial, and research laboratories) was established to collect/share information on novel and previously published PHOX2B NPARM cases. Variants were categorized by type and gene location. Categorical data were analyzed with chi-square and Fisher's exact test; further pairwise comparisons were made on significant results.

RESULTS

Three hundred two individuals with PHOX2B NPARMs were identified, including 139 previously unreported cases. Findings demonstrate significant associations between key phenotypic manifestations of CCHS and variant type, location, and predicted effect on protein function.

CONCLUSION

This study presents the largest cohort of PHOX2B NPARMs and associated phenotype data to date, enabling genotype-phenotype studies that will advance personalized, anticipatory management and help elucidate pathological mechanisms. Further characterization of PHOX2B NPARMs demands longitudinal clinical follow-up through international registries.