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BackgroundPatients with ESKD on maintenance dialysis receive dialysis in common spaces with other patients and have a higher risk of severe SARS-CoV-2 infections. They may have persistently or intermittently positive SARS-CoV-2 RT-PCR tests after infection. We describe the clinical course of SARS-CoV-2 infection and the serologic response in a convenience sample of patients with ESKD to understand the duration of infectivity.MethodsFrom August to November 2020, we enrolled patients on maintenance dialysis with SARS-CoV-2 infections from outpatient dialysis facilities in Atlanta, Georgia. We followed participants for approximately 42 days. We assessed COVID-19 symptoms and collected specimens. Oropharyngeal (OP), anterior nasal (AN), and saliva (SA) specimens were tested for the presence of SARS-CoV-2 RNA, using RT-PCR, and sent for viral culture. Serology, including neutralizing antibodies, was measured in blood specimens.ResultsFifteen participants, with a median age of 58 (range, 37‒77) years, were enrolled. Median duration of RT-PCR positivity from diagnosis was 18 days (interquartile range [IQR], 8‒24 days). Ten participants had at least one, for a total of 41, positive RT-PCR specimens ≥10 days after symptoms onset. Of these 41 specimens, 21 underwent viral culture; one (5%) was positive 14 days after symptom onset. Thirteen participants developed SARS-CoV-2–specific antibodies, 11 of which included neutralizing antibodies. RT-PCRs remained positive after seroconversion in eight participants and after detection of neutralizing antibodies in four participants; however, all of these samples were culture negative.ConclusionsPatients with ESKD on maintenance dialysis remained persistently and intermittently SARS-CoV-2–RT-PCR positive. However, of the 15 participants, only one had infectious virus, on day 14 after symptom onset. Most participants mounted an antibody response, including neutralizing antibodies. Participants continued having RT-PCR–positive results in the presence of SARS-CoV-2–specific antibodies, but without replication-competent virus detected.

Background To describe post-COVID-19 vaccination [fully vaccinated (FV) and first booster] immune response and occurrence of reinfection ( >90 days from prior infection) in nursing home residents (NHr) with/without evidence of prior SARS-CoV-2 infection. Methods In a longitudinal prospective cohort of 36 NHr from 3 NHs, interviews, chart abstractions, and specimens [blood and anterior nasal swabs (ANs)] were collected at baseline and monthly visits. ANs underwent molecular and BinaxNOW™ antigen testing. Quantitative Meso Scale Discovery platform tested blood specimens for anti-spike (S) protein and anti-nucleocapsid (N) antibodies. In addition, in a subset (n=13), S-specific memory B cells (MBCs) were tested with ELISpot assays. Results The cohort's median age was 72 years; 46% male, 64% White Non-Hispanic, 80% had ≥3 comorbidities, and 29 (81%) had prior SARS-CoV-2 infection. Of 36, 76% received Pfizer-BioNTech and 24% Moderna homologous vaccine. The median distribution of anti-S IgG concentrations among those with prior infection increased 15‒30 days post-FV, remained stable for 90 days, and declined by 120 days. The anti-S IgG remained above the estimated vaccine effectiveness (VE) thresholds published [Pfizer-BioNTech (95% VE: 530 BAU/ml), Moderna (90% VE: 298 BAU/ml)]. Among those without previous infection, anti-S IgG declined after 60 days and stayed near the VE thresholds until a recent infection/booster. Age, sex, and comorbidities had no appreciable impact on anti-S IgG. From enrollment to November 2021, 1of 29 had reinfection. From December 2021 to January 2022, 2 of 7 had a new infection, and 4 of 29 had reinfection, as shown by anti-N IgG rise. Persistently low numbers of total and anti-S MBC were seen across the evaluation, even with post-booster anti-S MBC rise. There was an immediate rise in anti-S IgG concentrations in all participants post-booster, irrespective of recent infection. Conclusion These findings from a NH convenience cohort suggest that prior SARS-CoV-2 infection has a pronounced immunomodulatory enhancing effect on the magnitude and duration of FV immune response. The decline of anti-S antibodies post-FV and rise after booster supported the booster recommendation in this cohort. The low MBC counts indicate immunosenescence in this high-risk population. Disclosures Hollis Houston, BA, Fidelity: Stocks/Bonds.

Background Acute kidney injury (AKI) is a complication that has been described among severely ill patients with COVID-19 and may be more common in those with underlying chronic kidney disease (CKD). Some patients with AKI require renal replacement therapy (RRT), including continuous RRT (CRRT). During the COVID-19 pandemic, some US areas experienced CRRT supply shortages. We sought to describe the percent of hospitalized COVID-19 patients who developed AKI or needed RRT to inform patient care and resource planning. Methods We searched for studies in the literature and public health investigations that described CKD, AKI, and/or RRT in COVID-19 patients from January 2020 onward. Studies were excluded if no CKD, AKI, or RRT information was provided. We abstracted counts of hospitalized COVID-19 patients, including those admitted to intensive care units (ICU) who developed AKI, underwent RRT, and/or had CKD. Data were pooled across cohorts by geographic region with available data (US, China, or United Kingdom [UK]). We compared proportions using Chi-square tests. Results A total of 311 studies were identified; 23 studies (US n=11; China n=11; UK n=1) that described kidney disease and/or kidney-related outcomes in hospitalized COVID-19 patients were included. Underlying CKD prevalence was higher in US cohorts (10.3%) compared with China (2.5%) or UK (1.5%) (p< 0.0001). AKI was markedly higher among hospitalized (31.3% vs. 6.4%; p < 0 .001) and ICU patients (55.4% vs. 18.2%; p< 0.0001) in the US compared to China. The percent of ICU patients requiring RRT in the US (16.8%) was significantly different from that reported in China (12.5%) and the UK (23.9%) (p< 0.0001). Limitations include differences in CKD and RRT definitions across studies. Conclusion AKI is a frequent outcome among US COVID-19 patients, affecting almost one third of hospitalized and more than half of ICU patients. AKI was reported more frequently in the US than China. The percent of ICU patients who received RRT was higher in the US and UK than in China. Understanding the occurrence of kidney-related outcomes among patients with COVID-19 including the impact of underlying CKD and regional practice variations is essential for healthcare systems to successfully plan for RRT needs during the pandemic. Disclosures All Authors: No reported disclosures

Background Staphylococcus aureus treatment guidelines are being revised to include proposed quality measures for evaluation of patients with S. aureus bacteremia (SAB) (e.g., infectious disease [ID] consultation, echocardiogram, and documenting clearance of bacteremia). We describe current management practices of SAB to identify opportunities for quality improvement.MethodsWe conducted a pilot assessment of SAB cases reported to CDC’s Emerging Infections Program active, laboratory- and population-based surveillance from 24 hospitals in four states during 1–2 months in 2017 or 2018. An SAB case was the isolation of S. aureus from a blood culture among adults (≥18 years) in the catchment area. We collected clinical and demographic information and performed a descriptive analysis of management of SAB cases.ResultsAmong 109 SAB cases identified, 50 (46%) were methicillin-resistant S. aureus (MRSA). While hospitalized, 87 (80%) patients were evaluated by ID consultation, 90 (83%) underwent an echocardiogram (26 were transesophageal), and 92 (84%) had documented clearance of bacteremia. During the hospitalization, 15 (14%) died and 12 (11%) left against medical advice (AMA). Of those who survived and did not leave AMA, median duration of hospitalization after initial culture was 10.5 days (interquartile range 7–18). In total, 10 survivors (9% of cases) completed at least 2 weeks of antibiotics while hospitalized, and 65 (60% of cases) were discharged on antibiotic therapy. Among the 25 MRSA patients discharged on antibiotics, common treatments were vancomycin (64%), daptomycin (8%), ceftaroline (8%), and linezolid (4%). Among the 40 methicillin-susceptible SAB patients discharged on antibiotics, cefazolin (56%), ceftriaxone (13%), cefepime (5%), linezolid (5%), nafcillin (3%), and vancomycin (3%) were most common. The remainder of outpatient treatments included oral β-lactams, clindamycin, doxycycline, levofloxacin, and erythromycin.ConclusionOverall, the majority of patients with SAB underwent evaluation according to the proposed quality measures and received therapy with targeted anti-staphylococcal agents, although opportunities to optimize treatment remain. Hospitalized patients who leave AMA represent a particular challenge for effective SAB therapy.Disclosures All authors: No reported disclosures.