Multi-donor Fecal Microbial Transplantation for Critically Ill Patients: Rationale and Standard Operating Procedure

Patients in intensive care unit often lose a considerable fraction of their gut microbiome due to exposure of broad-spectrum antibiotics and other reasons. Dysbiosis often results in prolonged diarrhea and increase occurrence of multi-drug resistant pathogens in the colon with clinical consequences not yet well understood. Restoring the microbioma by faecal microbial transplantation (FMT) is a plausible therapeutic possibility, so far only documented in case reports and case series using very heterogeneous methodologies. Before FMT in critically ill can be tested in randomised controlled trials, there is a burning need to describe a standardized operating procedure (SOP) of the whole process, respecting the specifics of critically ill population, such as the risk of disrubted intestinal barrier and time critical nature of the procedure. We describe the SOP that has been developed for experimental use in critically ill patients by a multidisciplinary team of intensivists, gastroenterologist and microbiologist based on feedback from regulatory authority (State Institue of Drug Control of the Czech Republic). The hallmarks of these SOPs are multi-donor freshly frozen transplantate quaranteeded for 3 months consisting of 7 aliqutes from 7 unrelated healthy donors, and administered by rectal tube. In this paper we discuss the rationale for this SOP and the process of its development in details and release the full proposed SOP is in the form of online appendix.

208. Comparison of Bloodstream Infections in Hospitalized Patients Before and During the COVID-19 Surge in a Community Hospital in the South Bronx: An Observational Study

Background There is a paucity of data of bloodstream infections (BSI) before and during the COVID-19 pandemic. The aim of our study was to compare the incidence and characteristics of blood stream infections (BSI) in hospitalized patients before and during the surge of COVID-19 pandemic in a community hospital in South Bronx. Methods This is a retrospective observational comparative study of adult hospitalized patients with BSI admitted before (Jan 1-Feb 28, 2020) and during COVID-19 surge (Mar 1- May 1,2020). The incidence of BSI, patient demographics, clinical and microbiological characteristics of infections including treatment and outcomes were compared. Results Of the 155 patients with BSI, 64 were before COVID and 91 were during the COVID surge (Table 1). Incidence of BSI was 5.84 before COVID and 6.57 during surge (p = 0.004). Majority of patients during COVID period had ARDS (39.6%), required mechanical ventilation (57%), inotropic support (46.2%), therapeutic anticoagulation (24.2%), proning (22%), rectal tube (28.6%), Tocilizumab (9.9%), and steroids (30.8%) in comparison to pre-COVID (Table 2). Days of antibiotic therapy prior to BSI was 5 days before COVID and 7 during COVID. Mortality was higher among patients with BSI admitted during COVID surge (41.8% vs. 14.1% p < 0.0001). Of 185 BSI events, 71 were Pre-COVID and 114 during surge. Primary BSI were predominant (72%) before COVID contrary to secondary BSI (46%) (CLABSI) during COVID. Time from admission to positive culture was 2.5 days during COVID compared to 0.9 pre-COVID. Majority of BSI during COVID period were monomicrobial (93%) and hospital acquired (50%) (p=0.001). Enterococcus (20.2%), E.coli (13.2%), and MSSA (12.3%) were predominant microbes causing BSI during COVID vs. MRSA (15.5%), Streptococci (15.5%), and S. pneumoniae (14.1%) before COVID (Figure 1). In multivariate logistic regression, Enterococcal coinfection was associated with COVID positivity (OR 2.685, p = 0.038), mechanical ventilation (OR 8.739, p = 0.002), and presence of COPD/Asthma (OR 2.823, p = 0.035). Comparison of Microorganisms Isolated in the BSI X-axis represents the total number of BSI events whereas the number at the end of each bar represents the percentage Conclusion Higher incidence of secondary BSI (CLABSI) due to Enterococcus spp. was observed during the surge of COVID-19 infection in the South Bronx. Breakdown of infection control measures during the COVID-19 pandemic could have been contributory. Disclosures All Authors: No reported disclosures

201. Comparison of Bloodstream Infections Between Hospitalized Patients with and without COVID-19 Infection During the First Wave of the COVID-19 Pandemic in a Community Hospital in South Bronx: An Observational Study

Background Comparative data on bloodstream infections (BSI) in hospitalized patients with and without SARS-CoV2 positive test is lacking. Methods A retrospective observational study comparing (BSI) with and without COVID-19 infection was performed was performed from Jan1- May 1, 2020. Patient demographics, clinical microbiological characteristics of infections, therapeutic interventions and outcomes was compared between the two groups. Results Of 155 patients with BSI, 104 were SARS-CoV2 PCR negative (N) while 51 were positive (Table 1). Majority of SARS-CoV2 positives (P) had ARDS (58.8%), required mechanical ventilation (73%), inotropic support (55%), therapeutic anticoagulation (28%), proning (35%), Rectal tube (43%), Tocilizumab (18%), and steroids (43%) (Table 2). BSI was higher in N with HIV (16.3% vs 3.9% p=0.027). Duration of antibiotic therapy (DOT) prior to BSI was significantly longer in P (15 days vs. 5 days, p < 0.0001) (table 2). In-hospital mortality was significantly higher among P with BSI (49% vs. 21% p < 0.0001). 185 BSI events were observed during the study period with 117 in N patients and 68 in P. Primary BSI was predominant (76%) in N while secondary BSI (65%) was common in P of which 50% were CLABSI. Median time from admission to positive culture was 0.86 days in N compared to 12.4 in P (p = 0.001). Majority of BSI in P were monomicrobial (88%) and hospital acquired (71%) when compared to N (p< 0.001). Enterococcus spp (28%), Candida spp(12%), MRSA (10%) and E.coli (10%) were predominant microbes in P compared to Streptococcus grp (16%), MSSA (14%), MRSA (13%) and E.coli (12%) in N (figure 1). Mortality from BSI was associated with COVID-19 infection (OR 2.403, p = 0.038), DM (OR 2.335, p = 0.032), Charlson comorbidity index >3 (OR 1.236, p = 0.004), and mechanical ventilation (OR 11.398, p < 0.001) on multivariate analysis. Comparison of Microorganisms isolated in the BSI X-axis represents the number of BSI events whereas the number at the end of each bar represents the percentage Conclusion Increased events of hospital acquired, secondary BSI (CLABSI) due to Enterococcus was observed in adult P compared to N. These patients were critically ill, developed BSI in the second week of hospitalization, had longer DOT prior to positive cultures and worse outcomes. Breakdown of infection control measures and inappropriate antimicrobial use during the surge could be contributory. Disclosures All Authors: No reported disclosures

TP9.2.30Sigmoid Volvulus: Is a More Aggressive Approach Justified? Results of a Retrospective Cohort Study

Aims Sigmoid volvulus is a common cause of emergency surgical admission. It often affects older males who are institutionalised and are less suitable surgical candidates. Definitive treatment is surgical but first line treatment is via endoscopic devolution with or without placement of a rectal tube. After non-operative management recurrence is likely and carries a high mortality, therefore an early surgical approach may be considered in patients who are fit for surgery. We have retrospectively analysed a cohort of patients with sigmoid volvulus in order to clarify if and when a more aggressive management is indicated. Methods We have reviewed data on admitted patients diagnosed with sigmoid volvulus over a 2-year period. Demographic, clinical data, morbidity and mortality were recorded in a database. Analysis was carried out with statistical programs. The primary endpoint was patient survival. Secondary endpoint was the estimation of the factors that condition surgical choice. Results We analysed 78 cases. 74.4% had multiple admissions and recurrences. 39.7% of patients underwent surgical resection. The average survival was 54.9±8.8 months from the first hospitalisation, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low “social score”, a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival. Conclusions In conclusion, we believe that early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.

Prognostic Factors in the Decision-Making Process for Sigmoid Volvulus. Results of a Single-Centre Retrospective Cohort Study.

BACKGROUND: Sigmoid volvulus is a common cause of emergency surgical admission. It often affects older males who are institutionalized and are less suitable surgical candidates. Definitive treatment is surgical, but first line treatment is via endoscopic devolution with or without placement of a rectal tube. After non-operative management recurrence is likely and carries a high mortality, therefore an early surgical approach may be considered in patients who are fit for surgery. We have retrospectively analyzed a cohort of patients with sigmoid volvulus in order to clarify if and when a more aggressive management is indicated.METHODS: We have reviewed data on admitted patients diagnosed with sigmoid volvulus over a 2-year period. Demographic, clinical data, morbidity and mortality were recorded in a database. The primary endpoint was patient survival. Secondary endpoint was the estimation of the factors that condition surgical choice.RESULTS: We analysed 332 admission of 78 patients. 39.7% of patients underwent surgical resection. The average survival was 54.9±8.8 months from the first hospitalization, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low "social score", a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival.CONCLUSION: Early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.

A case report of Hirschsprung’s disease presenting as sigmoid volvulus and literature review, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to reach a diagnosis and avoid morbidity and mortality. Sigmoid volvulus is a rare complication of Hirschsprung’s disease, which has been reported in neonates, children, and adults. Here we report a case of sigmoid volvulus accompanied by undiagnosed Hirschsprung's disease. Case presentation A 9 years old boy who presented with sudden onset of colicky abdominal pain of 4 h duration associated with gross abdominal distension and 2 episodes of non-bilious vomiting. A plain abdominal radiographs showed single hugely dilated bowel loops in the left lower quadrant with single air fluid level. Sigmoid volvulus was considered and rectal tube deflation was done and it was successful. Full thickness rectal biopsy was done and it was consistent with aganglionic megacolon. A primary trans-anal Soave endo-rectal pull through was done 3 weeks later, after biopsy result arrived, which yielded loss of symptoms and regular bowel movement. Conclusions Sigmoid volvulus should be considered in the differential for children presenting with acute onset of abdominal obstruction. It should be known that when its’s diagnosed in children, it is often associated with Hirschsprung's disease. Therefore, a proper diagnostic and treatment algorithm should be followed in order not to miss associated HD and to give optimum care to such patients.

A Novel Approach to the Symptomatic Management of Chronic Megacolon

Background. Chronic megacolon is a rare condition which primarily occurs in patients with autonomic dysfunction of a variety of causes. Its management is often challenging and people with chronic megacolon often suffer from abdominal distension, pain, and malabsorption. Given the struggles clinicians experience in managing these patients long term, this case study provides an example of an alternate strategy for the symptomatic management of chronic megacolon. Case Description. An 80-year-old male with early Parkinson’s disease developed megacolon following a basal ganglia stroke. He had a protracted hospital stay over 6 months due to malabsorption requiring total parenteral nutrition and electrolyte disturbances. A trial of subcutaneous neostigmine was unsuccessful, so patient underwent a trial of intermittent rectal tube decompression which improved his symptoms and malabsorption. This technique was then taught to the patient’s wife until she was confident performing this herself. With continuation of decompression approximately every three days, the patient was able to return to oral nutrition and no longer required ongoing electrolyte replacement. He was able to be discharged into the community with significant improvement in his quality of life. Conclusion. This is the first report to suggest the benefit of intermittent rectal tube decompression in the community for the long-term management of chronic megacolon. Further prospective studies should evaluate the potential for this strategy to be implemented in a wider cohort of patients who are not responsive to existing treatments for chronic megacolon.