406. Incidence of Community and Hospital Acquired Infections in Critically Ill COVID-19 Patients in the Dominican Republic

Abstract Background The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. COVID-19 causes lower respiratory tract infection (LRTI) and hypoxia. There is a paucity of data on bacterial and fungal coinfection rates in patients with COVID-19 at low and middle income countries (LMICs). Our objective is to describe the clinical characteristics of critically ill patients with COVID-19 in the Dominican Republic (DR) Methods We performed a retrospective review of patients admitted to the ICU with COVID-19 from March 14th to December 31st 2020, at a 296-bed tertiary care level and teaching Hospital in the Dominican Republic. Demographic and clinical information was collected and tabulated. Laboratory confirmed bacterial and fungal infections were defined as community acquired infections (CAI) if diagnosed within 48 hours of admission and hospital acquired infections (HAI) when beyond 48 hours. Microbiologic data was tabulated by source and attribution. Results Our cohort had 382 COVID-19 patients. Median age was 64 and most were male (64.3%) and 119 (31.1%) were mechanically ventilated and 200 (52%) had central venous catheters. A total of 28 (7%) laboratory confirmed community acquired infections and 55 (14%) HAIs occurred. Community acquired infections included 13 (46%) bloodstream infections (BSIs), 11 (39%) urinary tract infections (UTI) and 6 (21%) LRTIs. HAIs included 39 (70%) BSIs, 11 (20%) UTIs and 6 (11%) ventilator associated pneumonias (VAP). Causal organisms of community and hospital acquired BSI and UTI are in Figure 1 and Figure 2 respecively. All-cause mortality was 35.3% (135/382) in our cohort, and 100% mortality (76) in those with coinfections. Figure 1. Community acquired and hospital acquired bloodstream infections in COVID-19 patients admitted to the ICU Figure 2. Community acquired and hospital acquired urinary tract infections in COVID-19 patients admitted to the ICU Conclusion Community and hospital acquired infections were common and in the ICU and likely contributed to patient outcomes. More than two thirds of HAIs in the ICU were BSIs. Central venous catheter device utlization and maintenance may play a role in BSIs, along with immunosuppression from COVID-19 therapeutics and translocation from mucosal barrier injury. Mortality in patients with coinfections was higher than those without. Infection prevention strategies to reduce device utilization during COIVD-19 in LMICs may have an impact on HAIs. Disclosures All Authors: No reported disclosures

Conclusion. COVID-19 vaccination programs take several months to implement. Besides fully vaccination of the population, it is important to check if people became really safe from the virus. The COVID-19 Normality Rate is a double check multivariate score that can be used as a criteria for optimal time to return to in-person learning safely.
Disclosures. All Authors: No reported disclosures Background. Enterprise Risk Management (ERM) in healthcare is a method used to identify, assess and reduce risk to patients and the hospital organization. The objective of this study is to identify clinical and organizational challenges and risks in healthcare management caused by COVID-19, and its impact on patients and healthcare workers, in a low-resource obstetric setting.

A Qualitative Study Based on a Case Series of Obstetric COVID-19 Patients to Determine Risks in Management Associated with Severity in a Government Hospital in the Philippines
Methods. From a census of patients from 1 April 2020 to 30 July 2020, four cases of COVID-19 in pregnancy representing different severity levels were selected. A patient tracer activity was done for each patient, documenting events that the patient and healthcare team experienced from admission to discharge. A case series on these patients was written. A focus group consisting of an OB-GYN resident, OB-GYN consultant, OB-GYN nurse, OB-GYN infectious disease consultant, and internal medicine resident and consultant, was formed. Each case was presented to the focus group to establish the context of risk assessment. Risks were identified using the framework of Enterprise Risk Management. Each risk was classified according to their risk domain and severity. Root cause analysis via the fishbone method was used to identify the causes of the risks.
Results. Operational risks identified were delayed swab results, false negative swab results, and delayed patient transport. Clinical/Patient risks identified were COVID-19 exposure of healthcare workers and other non-COVID patients, inadvertent community exposure, risk for severe clinical manifestations of COVID-19, and lack of specific treatment for COVID-19. Risk to human capital identified were COVID-19 infection of hospital staff and decreased quantity of workforce due to quarantine. Most risks were assessed to be moderate risk or high risk in terms of severity. Root cause analysis showed that common causes of risks were due to exposure to asymptomatic patients and delayed and false-negative swab results.
Conclusion. The results of this study may be used towards the final steps of ERM: risk evaluation, treatment and management, in a low resource setting.
Disclosures Background. The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. COVID-19 causes lower respiratory tract infection (LRTI) and hypoxia. There is a paucity of data on bacterial and fungal coinfection rates in patients with COVID-19 at low and middle income countries (LMICs). Our objective is to describe the clinical characteristics of critically ill patients with COVID-19 in the Dominican Republic (DR) Methods. We performed a retrospective review of patients admitted to the ICU with COVID-19 from March 14th to December 31st 2020, at a 296-bed tertiary care level and teaching Hospital in the Dominican Republic. Demographic and clinical information was collected and tabulated. Laboratory confirmed bacterial and fungal infections were defined as community acquired infections (CAI) if diagnosed within 48 hours of admission and hospital acquired infections (HAI) when beyond 48 hours. Microbiologic data was tabulated by source and attribution.

Conclusion.
Community and hospital acquired infections were common and in the ICU and likely contributed to patient outcomes. More than two thirds of HAIs in the ICU were BSIs. Central venous catheter device utlization and maintenance may play a role in BSIs, along with immunosuppression from COVID-19 therapeutics and translocation from mucosal barrier injury. Mortality in patients with coinfections was higher than those without. Infection prevention strategies to reduce device utilization during COIVD-19 in LMICs may have an impact on HAIs.
Disclosures. Background. Currently, only dexamethasone, tocilizumab and sarilumab have conclusively been shown to reduce mortality of COVID-19. No drug for prevention or treatment in earlier stages of COVID-19 are yet found, with previously promising drugs such as hydroxychloroquine and remdesivir have been shown to be ineffective. Several new candidates are now being studied in clinical trials. Safe and effective treatments will need to be both affordable and widely available. We therefore revised our original 2020 analysis to reflect recent developments. In this update we analysed the cost of production, current national list prices, and API availability for oral and IV dexamethasone, ivermectin, colchicine, dutasteride, budesonide, baricitinib and monoclonal antibodies tocilizumab and sarilumab.
Methods. Costs of production for new and potential COVID-19 drugs (dexamethasone, ivermectin, dutasteride, budesonide, baricitinib, tocilizumab, sarilumab and colchicine) were estimated using an established and published methodology based on costs of active pharmaceutical ingredients (API), extracted from the global shipping records database Panjiva. This was compared with national pricing data from low, medium, and high-income countries. Annual API export volumes from India were used to estimate the current availability of each drug.
Results. Repurposed therapies can be generically manufactured at very low percourse costs: ranging from $2.58 for IV dexamethasone (or $0.19 orally) to $0.12 for ivermectin. No export price data was available for baricitinib, tocilizumab or sarilumab. When compared against international list prices, we found wide variations between countries. Drug API availability was generally good, with colchicine being the most available with sufficient annual API exported for 59.8 million treatment courses. A summary is shown in Table 1. Table 1. Summary of list prices, estimated production costs, and current availability of potential COVID-19 drugs selected for analysis. OD = Once daily, BD = twice per day, EUA = Emergency Use Authorisation (only to be given with remdesivir) *In most recent 12-month period.

Conclusion.
Successful management of COVID-19 will require equitable access to treatment for all, not just those able to pay. Repurposed drugs can be manufactured at very low costs if shown to be clinically effective, and offers an affordable, widely available option for patients at all stages of the disease from pre-exposure prophylaxis to asymptotic and mild infections, through to critical care until vaccination coverage is expanded.
Disclosures. All Authors: No reported disclosures