Introduction: Awake prone positioning (APP) has been widely applied in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure. However, the results from randomised controlled trials (RCTs) are inconsistent. We performed a meta-analysis to assess the efficacy and safety of APP and to identify the subpopulations that may benefit the most from it. Methods: We searched five electronic databases from inception to August 2022 (PROSPERO registration: CRD42022342426). We included only RCTs comparing APP with supine positioning or standard of care with no prone positioning. Our primary outcomes were the risk of intubation and all-cause mortality. Secondary outcomes included the need for escalating respiratory support, length of ICU and hospital stay, ventilation-free days, and adverse events. Results: We included 11 RCTs and showed that APP reduced the risk of requiring intubation in the overall population (RR 0.84, 95% CI: 0.74–0.95; moderate certainty). Following the subgroup analyses, a greater benefit was observed in two patient cohorts: those receiving a higher level of respiratory support (compared with those receiving conventional oxygen therapy) and those in intensive care unit (ICU) settings (compared to patients in non-ICU settings). APP did not decrease the risk of mortality (RR 0.93, 95% CI: 0.77–1.11; moderate certainty) and did not increase the risk of adverse events. Conclusions: In patients with COVID-19-related acute hypoxemic respiratory failure, APP likely reduced the risk of requiring intubation, but failed to demonstrate a reduction in overall mortality risk. The benefits of APP are most noticeable in those requiring a higher level of respiratory support in an ICU environment.

The incidence of Clostridioides difficile infection (CDI) has been increasing compared to pre-COVID-19 pandemic levels. The COVID-19 infection and CDI relationship can be affected by gut dysbiosis and poor antibiotic stewardship. As the COVID-19 pandemic transitions into an endemic stage, it has become increasingly important to further characterize how concurrent infection with both conditions can impact patient outcomes. We performed a retrospective cohort study utilizing the 2020 NIS Healthcare Cost Utilization Project (HCUP) database with a total of 1,659,040 patients, with 10,710 (0.6%) of those patients with concurrent CDI. We found that patients with concurrent COVID-19 and CDI had worse outcomes compared to patients without CDI including higher in-hospital mortality (23% vs. 13.4%, aOR: 1.3, 95% CI: 1.12–1.5, p = 0.01), rates of in-hospital complications such as ileus (2.7% vs. 0.8%, p < 0.001), septic shock (21.0% vs. 7.2%, aOR: 2.3, 95% CI: 2.1–2.6, p < 0.001), length of stay (15.1 days vs. 8 days, p < 0.001) and overall cost of hospitalization (USD 196,012 vs. USD 91,162, p < 0.001). Patients with concurrent COVID-19 and CDI had increased morbidity and mortality, and added significant preventable burden on the healthcare system. Optimizing hand hygiene and antibiotic stewardship during in-hospital admissions can help to reduce worse outcomes in this population, and more efforts should be directly made to reduce CDI in hospitalized patients with COVID-19 infection.

Acute liver failure following COVID-19 infection and/or vaccination is very rare and can be secondary to hemophagocytic lymphohistiocytosis (HLH). Liver injury in such cases appears to be extrinsic and thus treatment hinges on prompt diagnosis and reversal of the primary disease. We describe a patient who developed acute liver failure secondary to HLH after receiving a second dose of the Pfizer COVID-19 vaccine. Persistently elevated liver function tests, fevers, and cytopenia following COVID-19 vaccination should prompt clinicians to calculate an H-score to evaluate for the presence of HLH.