key: cord-1041744-h68ypzef
authors: Allan, PJ; Ambrose, T; Mountford, C; Bond, A; Donnellan, C; Boyle, R; Calvert, C; Cernat, E; Clarke, E; Cooper, SC; Donnelly, S; Evans, B; Glynn, M; Hewett, R; Holohan, AS; Leitch, EF; Louis‐Auguste, J; Mehta, S; Naik, S; Nightingale, J; Rafferty, G; Rodrigues, A; Sharkey, L; Small, M; Teubner, A; Urs, A; Wyer, N; Lal, S
title: COVID‐19 infection in patients with intestinal failure: U.K. experience
date: 2021-02-14
journal: JPEN J Parenter Enteral Nutr
DOI: 10.1002/jpen.2087
sha: 0e0e328421af992dcb027022cbe22d1ae51496e7
doc_id: 1041744
cord_uid: h68ypzef

Background: The direct effect of the COVID‐19 pandemic on patients with intestinal failure (IF) has not been described. Methods: We conducted a nationwide study of U.K. IF centres to evaluate the infection rates, presentations and outcomes in patients with types 2 and 3 IF. Results: A total of 45 patients with IF contracted COVID‐19 between March and August 2020; this included 26 of 2191 (1.2%) Home Parenteral Nutrition (HPN)‐dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community‐acquired COVID‐19 (66.7%) than the proportion in the entire HPN cohort (26.1%; p<0.01). Two HPN‐dependent and 1 hospitalised patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected). Conclusion: This is the first study to describe the outcomes of COVID‐19 in a large cohort of patients of requiring long term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficia. This article is protected by copyright. All rights reserved

Medical care delivery had to rapidly adapt to the COVID-19 pandemic while healthcare systems also tried to reduce morbidity and mortality to patients deemed to be at higher risk of harm from infection. A recent international consensus position paper highlighted the risk to patients with This article is protected by copyright. All rights reserved. chronic intestinal failure (IF) requiring home parenteral nutrition 1 ('HPN', also known as 'type 3 IF 2 ').

As per ESPEN IF was categorised as 2 : Type 1 self-limiting and on PN for <28 days (excluded from this study). Type 2 is severe acute IF, metabolically unstable with enterocutaneous/enteroatmospheric fistulas and/ or hostile abdomen; also labelled here acute IF (AIF). Patients with Type 3 IF are on HPN and may be reversible (e.g. awaiting reconstructive surgery (reversible)) or irreversible condition. A subsequent survey of healthcare professional experience described the pandemic's impact on care provision to these vulnerable patients 3 . Indeed, in the U.K., individuals deemed to be clinically extremely vulnerable from the infection, which included individuals with type 3 IF, were advised to 'shield'; i.e. to stay at home and minimise all face-to-face contact 4 . However, there are no data published on the direct impact of the COVID-19 pandemic on HPN-dependent patients, nor on those hospitalized with acute severe ('type 2' 2 ) IF. We therefore conducted a nationwide study to evaluate the risk and outcomes posed by COVID-19 on patients with types 2 and 3 IF.

U.K. adult and paediatric IF centres were circulated an audit proforma. Data on both Types 2 and 3 were collected from 13.3.2020-1.8.2020. The number of HPN-dependent patients was recorded on 13.3.2020 to give an at risk population at the start of the audit period. All patients with type 2 IF, defined as index hospitalisation with acute severe metabolically unstable IF and who had required PN for more than 28 days were included 2 .

Patients were diagnosed with COVID-19 if either of the following were met: 1) Positive nasopharyngeal polymerase chain reaction (PCR) for SARS-CoV-2 or serum IgG antibody testing.

This article is protected by copyright. All rights reserved.

2) Swab/antibody negative or untested, abnormal chest radiology (chest X-ray or CT scan), with/without compatible symptoms (persistent cough, pyrexia (>37.5C), loss taste/smell) Community acquired infection was defined as a positive diagnosis within 3 days of any hospital admission 5 .

As this study was a retrospective audit, ethical committee approval was not required; however, participating centres were required to register the study with the hospital audit department and submit anonymised data. Data are mean ± 95% confidence interval (CI) unless otherwise stated.

The audit was completed by 20 (of 26 invited (77%)) U.K. adult IF centres (included 2191 HPNdependent patients); 515 (23.5%) were hospitalized for IF/non-IF-related reasons during the audit period. The study also included 298 adults with acute severe (Type 2) IF.

Of the 2191 HPN-dependent, 1254 (57.2%) self-administered PN; otherwise, PN was administered by a home care nurse (n=572 (26.1%)), family member/carer (n=134 (6.1%)) or combination (n=203 (9.3%)), unknown in 28 (1.3%) cases. other (n=5). The IF mechanism included short bowel syndrome (n=14, 9 with jejunostomy, 3 with ileostomy/ileo-rectal anastomosis, 2 with colon in continuity), fistulas (n=1), motility (n=5) and obstruction (n=6). Notably, GI symptoms associated with COVID-19 infection including vomiting in 4 patients and increased stoma output in 3 patients.

Of the 15 patients with community acquired COVID-19 who were then hospitalized, antibiotics were administered to 8, hydroxychloroquine or dexamethasone to 2. Although only 1 patient required ventilation and recovered, 2 other non-ventilated patients died at admission day 1 and 2 from COVID-19 infection (Table 4) infection. The fatality rate of Type 3 patients in the entire HPN population was 0.09% (2/2191); the case fatality rate was 7.7% (2/26).

19/298 (6.4%) patients with type 2 IF were diagnosed with COVID-19 infection in 12 centres. Tables 1and 2 provide demographics and comorbidities/immunosuppression of those infected with COVID-19. The IF aetiology included adhesions (n=2), cancer (n=3), mesenteric ischaemia (n=3), surgical complications (n=7), trauma (n=1) and other (n=3). The IF mechanism included short bowel syndrome (n=10, to jejunostomy (9) and to ileostomy/ileo-rectal anastomosis(1)), fistulas (n=6), motility or mechanical obstruction (n=2) and mucosal disease (n=1). Method of COVID-19 diagnosis and symptoms are outlined in Table . Notably, GI symptoms associated with COVID-19 infection including increased stoma output in 1 patient.

On contracting COVID-19, 10/19 patients were transferred from the IF ward within the same hospital to a designated COVID-19 general ward and 1 patient was transferred to an Infectious Diseases ward; 8 patients remained on the IF ward. No patient required ventilation. 14/19 received antibiotics, but no patient received dexamethasone or remdesivir. Two of those with type 2 IF died, 1 (1/298=0.3%, the case fatality rate was 5.3% (1/19).) within 7 days of COVID-19 infection and 1 in a hospice with progressive malignancy 21 days after COVID-19 infection, see table 4 for detail. 14 were discharged home, 3 patients remained in hospital at the audit period end.

Four (out of 18 invited (22%)) U.K. paediatric centres completed the audit representing 73 HPNdependent children. 37/73 (50.7%) required hospitalisation during the audit period. Nine children were also included with type 2 IF. Family/carer provided PN administration for 68/73 (93.2%). Only 

This is the first paper to describe occurrence and outcomes of patients with types 2 and 3 IF infected HPN-dependent patients acquired COVID-19 while living in the community despite being asked to 'shield' 4 . Patients may have contracted COVID-19 at home from any close contact, although it is noteworthy that a significantly higher proportion of those who contracted the infection at home required nursing care for HPN administration (66.7% compared to 26.1% in the overall cohort).

Access to appropriate personal protective equipment has been reported by some to have been challenging for those caring for HPN patients 3 . Nosocomial spread of COVID-19 has been noted in hospitalized patients, particularly those with invasive devices (odds ratio reported as 4.28, p=0.007) 9 .

A number of IF services have endeavoured to rapidly train patients or family members during the pandemic to reduce nursing service pressure and minimise contact and this strategy may be useful during the continued pandemic 1 .

As with any retrospective study, data capture may be limited. In addition, we restricted the data collected so as not to overburden busy clinical teams during the pandemic and therefore primarily collected more detailed information on those patients acquiring COVID-19; future, larger studies evaluating the impact of additional risk factors including comorbidities and underlying disease/IF mechanism on COVID-19 infection rates and outcomes compared to the overall HPN population, as well as factors implicated in hospital and community nosocomial spread, would be beneficial.

Nonetheless, we have reported the largest series to-date of occurrence and outcomes in an extremely vulnerable group of patients with severe types 2 and 3 IF. Nosocomial infection whilst at home may be a concern in those requiring nursing care for HPN administration, although larger international datasets with contact testing and tracing are required, not only in the IF population but in other patients living with chronic disease. Loss of sense of smell/taste 0 0 4 

Considerations for the management of home parenteral nutrition during the SARS-CoV-2 pandemic

ESPEN guidelines on chronic intestinal failure in adults

An international survey of clinicians' experience caring for patients on home parenteral nutrition for chronic intestinal failure during the COVID-19 pandemic

The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Nosocomial infection among patients with COVID-19: A retrospective data analysis of 918 cases from a single center in Wuhan