Jonna Lorenz

COVID-19 patients often need to be placed on ventilators. The notion has become so common during the pandemic that it’s sometimes easy to forget that the experience can be traumatic. The gruesome details can be found easily enough online, including this 

 by the hospital system Atrium Health, with a headline that reads like a warning label: “The Shocking Truth of What Happens to COVID-19 Patients in the ICU on Life Support.”

Jennifer Cline PT, MS, director of therapy at Atrium, says that “from a physical therapy standpoint, once you have a tube down your throat, you can’t eat anymore. You can’t go to the bathroom. You can’t bathe yourself. And every single day that you lie in bed, the weakness that you feel keeps increasing.”

When the lucky survivors of COVID-19 are finally taken off ventilators, Cline says that they often can’t hold their heads up, grip of squeeze things, and it even takes many of them a while to be able to stand again.

 offers some hope that that experience can be avoided. Investigators in Columbia found that high-flow oxygen therapy reduced the need for mechanical ventilation and shortened the time to clinical recovery among patients with severe COVID-19.

The randomized, open-label, multicenter clinical trial, included 199 patients hospitalized with severe COVID-19 at 3 hospitals in Colombia between August 13, 2020, and January 12, 2021. Patients were randomized into 2 groups, receiving either high-flow oxygen therapy through a nasal cannula or conventional oxygen therapy.

“Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy,” the study authors, led by Gustavo A. Ospina-Tascón, MD, PhD, Department of Intensive Care, Fundación Valle del Lili, wrote.

Intubation occurred in 34.3% of 99 patients in the high-flow oxygen group compared with 51% of 100 who received conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). Median time to clinical recovery within 28 days also was shorter among patients who received high-flow oxygen therapy at s 11 days (interquartile range, 9-14) compared with 14 days (IQR, 11-19) among those in the conventional therapy group (HR, 1.39; 95% CI, 1.00-1.92; P = .047). Clinical recovery occurred in 77.8% of patients in the high-flow oxygen therapy group compared with 71% of those in the conventional therapy group.

Arterial hypoxemia is a primary feature of severe COVID-19, the study authors noted. Oxygen supplementation is used to manage hypoxemic respiratory failure. The study didn’t use an oxygen escalation strategy but rather provided high-flow oxygen therapy in the early stages of respiratory failure, within 30 minutes after randomization.

“Avoiding systematic intubation in COVID-19 could prevent complications related to invasive mechanical ventilation, sedation, delirium and neuromuscular paralysis,” the study authors wrote. “In addition, successful prevention of intubation could optimize resources during pandemic conditions.”

Patients enrolled in the study were adults aged 18 or older admitted to the emergency department, a general ward, or intensive care unit with suspected or confirmed SARS-CoV-2 infection, acute respiratory failure and clinical signs of respiratory distress. The media age of participants was 60 and 32.7% were women.

Those in the high-flow oxygen therapy group were treated with heated and humidified gas at an initial flow of 60 L/min and an F102 of 1.0 continuously applied until intubation or improvement in clinical signs and respiratory distress.

Secondary outcomes included median ventilator-free days within the first 28 days after randomization, which was 28 in the high-flow oxygen therapy group compared with 24 in the conventional therapy group (adjusted odds ratio, 0.77; 95% CI, 0.33-1.68; P = .01). Need for kidney transplant therapy, in-hospital and intensive care unit length of stay, and proportion of adverse events were not significantly different between the two groups.

Strengths of the study include consistently maintained randomization and well-defined protocol. Results are consistent with studies of acute hypoxemic respiratory failure due to other etiologies.

Limitations include that the study wasn’t blinded, that it was a relatively small sample size from only 3 hospitals, it wasn’t powered to demonstrate differences in mortality, and it evaluated only clinical outcomes without measurements of transpulmonary pressures, minute volume and nonhomogeneous distribution of tidal ventilation.

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High-flow oxygen therapy reduced the need for mechanical ventilation and shortened the time to clinical recovery among patients with severe COVID-19, says the study.

Breathing Easier: Technique Might Keep COVID Patients Off of Ventilators

When it comes to what circumstances help breed 

 infection (CDI), there are some that could be called the usual suspects. They include increased age, hospitalization, use of proton pump inhibitors, and use of antibiotics, according to a recent study out of Pakistan. That study, published in 

 looked at data from 200 patients diagnosed with


–associated diarrhea (CDAD) at a tertiary care hospital in Pakistan between June 2020 and March 2021, along with 200 patients without CDAD in a control group.

“Identifying and addressing the risk factors associated with CDI will help [reduce] the incidence of infection and associated complications,” the authors, led by Aarzoo Gupta of Vardhman Mahavir Medical College and Safdarjung Hospital in Faridabad, India, wrote.

The study included detailed histories of patients’ use of treatments (antibiotics, proton pump inhibitors, and histamine 2 receptor antagonists), previous CDI diagnoses, and hospitalization in the past 30 days. Investigators also noted patients’ body mass index (BMI) and comorbidities including diabetes, chronic kidney disease (CKD), hypertension, and malignancy.

In the case group, 31 patients were older than 65 (15.5%), compared with 16 (8%) in the control group (OR [odds ratio], 2.10 [1.11-3.99]; 

 = .02). “This age group is not only termed as a risk factor for CDI but such patients also demonstrate poor prognosis, leading to increased clinical severity and death rates,” the authors wrote.

Patients with CDI also had significantly higher hospitalization (25.5% vs 6%; OR, 5.36 [2.75-10.42]; 

 < .0001), use of proton pump inhibitors in past 30 days (23.0% vs 10.5%; OR, 2.54 [1.45-4.45]; 

 = .001), and use of antibiotics in the past 30 days (36.0% vs 10.5%; OR, 4.76 [2.80-8.19]; 

“Studies have suggested that almost every antibiotic results in an increased chance of developing CDI,” the authors wrote. “This also includes the drugs that are used to treat CDI, namely metronidazole and vancomycin.”

Other risk factors included a BMI above 25 kg/m2 (31% vs 21%; OR, 1.69 [1.07-2.65]; 

 = .02), diabetes (27% vs 16%; OR, 1.94 [1.18-2.17]; 

= .008), CKD (19% vs 9.5%; OR, 2.23 [1.23-4.03]; 

= .007), and malignancy (6% vs 2%; OR, 3.12 [0.99-9.86]; 

“Given the findings [above], our study suggests that the use of acid-suppressive agents should be carefully considered, and the over-the-counter availability of these agents should be discouraged,” the authors wrote. “This would help the doctors to keep a check in order to avoid overdose. Moreover, hygiene practices, such as hand washing practices, sterilizing used [equipment] at the hospital, using clean medical devices, etc, should be adopted to avoid infection risk. Maximum management of antibiotic intake should also be taken into consideration.”

CDI is the leading cause of health care–associated infections, causing about a half million infections and $1 billion in health care costs each year. Although CDI is often associated with health care settings, a recent study by investigators at the University of Houston found that the bacterium is prevalent in a variety of settings, including on 45% of shoe soles.

 Healthy people can carry CDI without illness or symptoms.

Gupta A, Savanti F, Singh B, et al. Risk factors associated with Clostridium difficile-associated diarrhea. 

. 2021;13(9):e18115. doi:10.7759/cureus.18115

Alonso CD, Kelly CP, Garey KW, et al. Ultrasensitive and quantitative toxin measurement correlates with baseline severity, severe outcomes, and recurrence among hospitalized patients with Clostridioides difficile infection. 

Lorenz, J. Risk factors associated with C diff infection. 

. October 31, 2021. Accessed November 1, 2021. https://www.contagionlive.com/view/risk-factors-associated-with-c-diff-infection

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The use of almost every antibiotic increases the chances of Clostridioides difficile infection, and that includes the drugs that are used to treat C diff, a study states.

C Diff Infection? Take Note of the Risk Factors

Football is a numbers game. The same could be said for the deadly COVID-19. Counties that hosted professional and college football games with limited in-person attendance during the COVID-19 pandemic didn’t see a substantial increase in COVID-19 cases, according to investigators with Massachusetts General Hospital.

, analyzed US counties that hosted NFL and NCAA football games to estimate the association between games with limited in-person attendance and spread of COVID-19.

A total of 528 games (101 NFL and 427 NCAA) were included in the study, which also included a matched control group with 361 counties similar in size and COVID-19 restrictions that did not host a game on the corresponding day. For NFL games, attendance ranged from 6,000 to 13,797, with a median of 9,949. NCAA attendance wasn’t available.

“We surmise that the NFL and NCAA policies regarding limited in-person attendance, mask use, and social and physical distancing measures in stadiums was not associated with substantially higher community spread of COVID-19,” the authors, led by Asmae Toumi, BS, of Massachusetts General Hospital, wrote. “Additionally, an important number of NFL and NCAA football stadiums are outdoors or have a retractable roof, which could have had an impact on mitigating spread.”

On game day, the median daily new COVID-19 cases in counties that hosted football games was 26.14 cases per 100,000 residents compared with 24.11 cases per 100,000 residents for counties in the control group. The change in number of cases within 14 days after game day ranged from -5.17 to 4.72 cases per 100,000 residents, with a mean of 1.21.

“Our study provides evidence suggesting that in-person attendance of football games with social distancing and mask use could be resumed in the 2021 to 2022 season,” the authors wrote. “However, it is worth noting that newly emerging variants of SARS-CoV-2 have less predictable implications at this point and might lead to more disruptive interruptions in the future.”

Limitations of the study included that attendance was considered as a binary variable since in-person attendance wasn’t available for NCAA games. The study also didn’t control for other large events or the possibility of spillover to adjacent counties.

“Studies such as that by Toumi et al, which add to our understanding of the virus and its transmission, are essential for providing decision-makers with the information needed to design and enact policies that align with evidence and protect people in the community,” Michael A. Rubin, MD, PhD, MS, of the Salt Lake City Health Care System and the University of Utah School of Medicine, said in an 

. “More like it are needed as the United States and other countries confront the mounting political and societal pressure of regaining a sense of normalcy that comes with returning our large and beloved sports arenas to full—and full-throated—capacity.”

The US Food and Drug Administration’s full approval of the Pfizer-BioNTech COVID-19 vaccine granted on August 23 also could boost events. Former FDA Commissioner Mark McClellan, MD, PhD, said that he expects more vaccine requirements at venues such as indoor dining, sports and entertainment venues. McClellan is the Robert J. Margolis Professor of Business, Medicine, and Policy, and founding Director of the 

Sports venues have been areas of concern during the pandemic, with some worrying games could become super spreader events. A study from West Virginia University 

 found that US cities saw influenza mortality rates increase between 5% and 24% during the professional football, basketball, hockey, and baseball seasons.

Touchdown! Attendance at professional and college football games may resume with COVID-19 mitigation measures, according to a study. But will the delta variant move the goalpost?

Sparsely Attended Football Games Do Not Spread COVID-19

, might also become the nexus of an examination into health care disparities that the coronavirus uncovered. Nursing homes with Black residents had a greater number of COVID-19 infections and deaths during the pandemic than those without Black residents, a new study from Columbia University School of Nursing found.

Journal of American Medical Directors Association

, included data from 11,587 nursing homes in the United States that reported data to the US Centers for Disease Control and Prevention during the pandemic.

“COVID created a crisis in nursing homes, that’s for sure. I think everybody has heard that over the past year, and it’s worse for minorities,” Pat Stone, PhD, director of the Center for Health Policy at Columbia University School of Nursing told Contagion. “It exacerbated health disparities. That’s the biggest takeaway.”

Among nursing homes included in the study, 3639 (31.4%) had no Black residents, under 20% of residents were Black in 1020 (8.8%), Black residents accounted for 20% to 49.9% of residents in 1586 (13.7%), 50% or more residents were Black in 681 (5.9%) nursing homes, and race was not reported for 4661 (40.2%) nursing homes.

COVID-19 infections were 13.6 percentage points higher in nursing homes with 50% or more Black residents, and deaths were 3.5 percentage points higher.

Stone attributed the disparities to structural racism, saying that nursing homes that have a high percentage of Black residents have fewer resources, poor staffing, worse infection control processes and a higher dependence on Medicaid with fewer patients on Medicare.

“We need to fight for these vulnerable people that are living in nursing homes and provide the best care,” Stone said. “We need advocacy because we need to have some changes in policies.”

The study found that disparities were greatest in rural settings and that nursing homes with the highest proportion of Black residents were more likely to be for-profit organizations, report staffing shortages, have the highest percentage (about 75%) of residents on Medicaid, have lower RN and aide hours per resident.

Other factors included that nursing homes with a large proportion of Black residents were located in communities with a scarcity of resources such as transportation and health services and with low socioeconomic indicators such as education and income along with mistrust in the healthcare system.

The study authors call for investments in infrastructure, social services, health care, education and housing in Black communities and an increase in Medicaid reimbursement to nursing homes. But even before the reinforcements arrive, nursing home care can be improved for a relatively small investment, as 

 on how one long-term care facility managed to hold off COVID-19.

Stone said she will continue to research infection prevention and control measures, such as having a certified infection preventionist on staff in nursing homes, which has been associated with improved resident outcomes. Ann Marie Pettis, RN, BSN, CIC, FAPIC, the president of the Association for Professionals in Infection Control and Epidemiology, 

 last June that states should mandate that a fulltime infection preventionist be assigned to every long-term care facility, something that states don’t currently mandate. In addition, the sad fact is that, despite billions more allocated for nursing homes, the facilities are 

For her part, Stone plans to continue her research on the impact of health disparities on infection prevention and control measures.

“This is really changing the landscape of infection prevention and control, which needed to be done. But we don’t know how that’s going to look a year from now and we don’t know how that will look for nursing homes that serve minorities,” Stone said. “Will they be able to make these changes as well as other nursing homes? So, that’s where my research is going next.”

Racial disparities in COVID-19 infection and mortality rates have been a topic of ongoing research during the pandemic. A 

 found that social and environmental factors have a greater impact on disparities than biological or genetic differences.

 that evaluated COVID-19 health disparities underscored the long history of inequities throughout history and around the globe.

Jonna Lorenz is a freelance journalist with more than 20 years of experience. Her background is in business and health care news, including reporting, editing and research for newspapers and websites.

Investigators with Columbia University School of Nursing found that COVID-19 infections were 13.6 percentage points higher in nursing homes with 50% or more Black residents, and deaths were 3.5 percentage points higher, compared with nursing homes with no Black residents.

Jonna Lorenz

Articles

Breathing Easier: Technique Might Keep COVID Patients Off of Ventilators

C Diff Infection? Take Note of the Risk Factors

Sparsely Attended Football Games Do Not Spread COVID-19

Health Care Disparities Uncovered in Nursing Homes