305. Cholecystitis as a Possible Immunologic Consequence of COVID-19; Case Series from a Large Healthcare System

Abstract Background Gastrointestinal manifestations are commonly seen in COVID-19 disease with up to 50% of patients reporting nausea or diarrhea. Cholecystitis has been described in rare cases related to COVID-19, possibly in consequence of immune activation, but biliary disease from SARS-CoV-2 infection is not well described. We examined a case series of patients with both COVID-19 and cholecystitis at our institution. Methods We performed a retrospective chart review of all patients with a diagnosis of cholecystitis within 3 months of SARS-CoV-2 infection; looking at clinical, laboratory, and radiographic characteristics of this population. Results 30 individuals were identified with a diagnosis of cholecystitis within 3 months of diagnosis of SARS-CoV-2 infection. Most patients presenting with cholecystitis were female and obese (see Table 1). 14 individuals were diagnosed with SARS-CoV-2 infection during the same presentation as their cholecystitis diagnosis, usually as part of pre-operative screening. Of 16 individuals diagnosed with SARS-CoV-2 prior to their cholecystitis presentation, a mean of 24 and 17 days elapsed between SARS-CoV-2 infection and cholecystitis symptom onset and radiographic diagnosis, respectively (see Figure 1). Most of these patients had mild respiratory disease, with only 9 developing an oxygen requirement, and only 3 requiring mechanical ventilation. While 17 patients were treated surgically for their cholecystitis, this did not appear to impact symptom resolution. Table 1. Patient Characteristics Figure 1. Time between COVID-19 and Cholecystitis Conclusion Cholecystitis may be an uncommon complication of COVID-19 disease. Cholecystitis may manifest most often 2-4 weeks following SARS-CoV-2 infection. This timing is similar to that in Multisystem Inflammatory Syndrome following SARS-CoV-2 infection and given similarities in timing to we hypothesize that cholecystitis in our patients could be driven by immune activation. Disclosures Christopher Polk, MD, Atea (Research Grant or Support)Gilead (Advisor or Review Panel member, Research Grant or Support)Humanigen (Research Grant or Support)Regeneron (Research Grant or Support) Mindy Sampson, MD, Regeneron (Grant/Research Support) Catherine Passaretti, MD, Nothing to disclose

Background. The incidence of bacterial or fungal coinfections in COVID-19 patients is low. The incidence of nosocomial superinfections is higher, especially related to ICU admission. Treating COVID-19 with steroids plus tocilizumab (TCZ) has been associated with superinfections. Therefore, the use of antibiotic prophylaxis prior to infusion of TCZ could be considered to reduce the risk of life-threatening superinfections in critically ill patients.
Methods. Retrospective, single center cohort study. COVID-19 patients older than 14 years, admitted to Hospital Central de la Defensa (Madrid, Spain) from Mar 5th to Nov 24th, 2020 with a diagnosis of COVID-19 were included. Local protocols suggested antimicrobial prophylaxis before the infusion of TCZ. Medical records, treatments received, and microbiological data of all patients who received TCZ were reviewed. Microbiological isolates were considered in the 14 days following the administration of TCZ. Two ID specialists independently reviewed the medical record and decided to qualify the isolate as superinfection or colonization.
Results. 2,069 patient records were analyzed. 70 patients received TCZ; all of them were admitted to ID wards and under steroid treatment. 45 (64,5%) patients received antibiotic prophylaxis. The preferred antibiotics were ceftriaxone (N = 18) and ceftobiprole (N = 14). No significant differences were found in age, Charlson index or COVID-19 SEIMC-Score. 24 isolates were detected in 14 patients (18 bacterial, 6 fungal). 17 isolates were considered superinfections; the most frequent isolates were C. albicans (N=5), E. faecalis (N=3) and S. epidermidis (N=2). There were no statistically significant differences between the different prophylaxis strategies in terms of in-hospital mortality or ICU admission. However, patients who received ceftobiprole tended to have fewer isolates and fewer superinfections than those receiving ceftriaxone (ceftobiprole group: 2 isolates in 1 patient, 1 (7,1%) patient with superinfection; ceftriaxone 11 isolates in 5 patients, 4 (22,2%) patients with superinfection) (p= 0,35, Fisher exact test).   Background. Gastrointestinal manifestations are commonly seen in COVID-19 disease with up to 50% of patients reporting nausea or diarrhea. Cholecystitis has been described in rare cases related to COVID-19, possibly in consequence of immune activation, but biliary disease from SARS-CoV-2 infection is not well described. We examined a case series of patients with both COVID-19 and cholecystitis at our institution.
Methods. We performed a retrospective chart review of all patients with a diagnosis of cholecystitis within 3 months of SARS-CoV-2 infection; looking at clinical, laboratory, and radiographic characteristics of this population.
Results. 30 individuals were identified with a diagnosis of cholecystitis within 3 months of diagnosis of SARS-CoV-2 infection. Most patients presenting with cholecystitis were female and obese (see Table 1). 14 individuals were diagnosed with SARS-CoV-2 infection during the same presentation as their cholecystitis diagnosis, usually as part of pre-operative screening. Of 16 individuals diagnosed with SARS-CoV-2 prior to their cholecystitis presentation, a mean of 24 and 17 days elapsed between SARS-CoV-2 infection and cholecystitis symptom onset and radiographic diagnosis, respectively (see Figure 1). Most of these patients had mild respiratory disease, with only 9 developing an oxygen requirement, and only 3 requiring mechanical ventilation. While 17 patients were treated surgically for their cholecystitis, this did not appear to impact symptom resolution.  Background. There is increasing evidence that patients hospitalized with COVID-19 receive unnecessary antibiotics. The consequences of antibiotic overuse as it relates to antimicrobial resistance and development of secondary infections remains uncertain. The objective of this study is to compare antibiotic prescription patterns in patients with a history of COVID-19 to those without a history of COVID-19 and determine if there are differences in the frequency of secondary infections from Clostridioides difficile (C. difficile), multidrug-resistant (MDR) bacteria, and candida infections.
Methods. This study is a single-center, retrospective cohort study of 18,757 adults hospitalized during the COVID-19 pandemic from March 1, 2020 to March 31, 2021. Patients were stratified as COVID-19 positive, throughout all hospitalizations subsequent to the date of initial positivity, or COVID-19 negative. Differences in antibiotic practice patterns between the two groups were quantified using days of therapy per 1000 patient days (DOT/1000 PD). The frequency of C. difficile infection, MDRbacteria, and candida infections were assessed among the two groups.
Results. During the 12-month study period, on average, the COVID-19 positive group received 21.81% more antibiotics than COVID-19 negative patients, with up to 56.15% increase seen in the first month of the pandemic (Table 1, Figure 1) The COVID-19 positive group had an increased frequency of Candidemia (0.73% versus 0.18%, p< .00001) and decreased isolation of ESBL organisms (1.17% versus 1.87%, p< 0.01416) compared to the COVID-19 negative group. There were no significant differences in frequency of C. difficile infection, isolation of other MDR-organisms, or Candida auris between the two groups. (Table 2) Table 1. Antibiotic days of therapy in COVID-19 positive and COVID-19 negative patients.

Conclusion.
Patients with a history of COVID-19 infection received an average of 21.81% more antibiotics, have higher rates of candidemia, but lower rates of ESBL infection than those without a history of COVID-19 infection. The potential increase in antibiotic exposure could account for the increase in candidemia in patients with a history of COVID-19. Future studies include investigating the decrease in ESBL infections seen, perhaps due to receipt of broad antibiotics in COVID-19 patients that target ESBL bacteria.
Disclosures. Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)