Respiratory Bacterial and Fungal Superinfections During the Third Surge of the COVID-19 Pandemic in Iran.

Objective: We characterized bacterial and fungal superinfection and evaluated the antimicrobial resistance profile against the most common superinfection-causing pathogens (Klebsiella pneumoniae, Acinetobacter baumannii, and Staphylococcus aureus). Methods: In a cross-sectional study, 192 respiratory samples were collected from patients with and without SARS-COV-2 admitted to a teaching hospital in Tehran. Superinfection proportions and the antibiotic resistance profile were assessed and compared with demographic, comorbidities, and other clinical factors. Results: Superinfection rate was 60% among COVID-19 patients (p = 0.629). Intensive care unit admission (p = 0.017), mortality rate (p ≤ 0.001), and antiviral and corticosteroid therapy (p ≤ 0.001) were significantly more common among patients with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The most common superinfections were caused by K. pneumoniae (42.7%, 82/192), A. baumannii (14.6%, 28/192), and S. aureus (13%, 25/192). A. baumannii isolates exhibited greater antibiotic resistance. Forty-four percent (11/25) of S. aureus isolates were cefoxitin resistant and also confirmed as methicillin-resistant S. aureus by PCR. Conclusion: The rise of difficult-to-treat infections with a high burden of antibiotic resistance, coupled with an increase in mortality rate of SARS-COV-2 superinfected individuals, illustrates the impact of the COVID-19 pandemic on antimicrobial resistance. Post-pandemic antimicrobial resistance crisis management requires precise microbiological diagnosis, drug susceptibility testing, and prescription of antimicrobials appropriate for the patient's condition.

High-dose Intravenous Vitamin C in Early Stages of Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Double-blind, Randomized, Controlled Clinical Trial.

Objective: Based on previous studies in the sepsis population, Vitamin C could prevent injuries when administered in high doses and before the damage is established. This study aimed to evaluate the protective potentials of high-dose Vitamin C in the progression of coronavirus disease 2019 (COVID-19). Methods: A double-blind, placebo-controlled clinical trial was conducted. Patients with moderate-to-severe disease severity based on the World Health Organization definition were enrolled and received 12 g/d Vitamin C (high-dose intravenous Vitamin C [HDIVC]) or placebo for 4 days. Sequential Organ Failure Assessment (SOFA) score as a primary outcome, National Early Warning Score, Ordinal Scale of Clinical Improvement, and cytokine storm biomarkers were recorded on days 0, 3, and 5. Survival was also assessed on day 28 after enrollment. Findings: Seventy-four patients (37 patients in each group) were enrolled from April 5, 2020, to November 19, 2020, and all patients completed follow-up. A lower increase in SOFA score during the first 3 days of treatment (+0.026 vs. +0.204) and a higher decrease in this parameter in the last 2 days (-0.462 vs. -0.036) were observed in the treatment group. However, these differences did not reach a significance level (P = 0.57 and 0.12, respectively). Other indices of clinical and biological improvement, length of hospitalization, and intensive care unit admission days were the same between the two groups. Treatment did not affect the 28-day mortality. Conclusion: Among patients with moderate-to-severe disease of COVID-19, the use of HDIVC plus standard care resulted in no significant difference in SOFA score or 28-day mortality compared to the standard care alone.

Rapid implementation of telepharmacy service to improve patient-centric care and multidisciplinary collaboration across hospitals in a COVID era: A cross-sectional qualitative study.

Background and Aim: The COVID-19 pandemic forced healthcare systems to apply new technology-based solutions. The main objective of our study was to describe the conceptual model for rapid implementation of telepharmacy service and the main steps that should be considered. Method: In response to a limited number of on-site clinical pharmacy specialists and a lack of technology infrastructure, a cross-sectional telepharmacy program was established to support major teaching hospitals. A store and forward model of teleconsultation was employed using WhatsApp messenger to cover various aspects of multidisciplinary collaboration in COVID-19 management. All identifiable personal information was removed from all exchanged messages of collaborative consultations. The thematic analysis of consultations was performed to extract the main themes and subthemes that should be considered for designing future telepharmacy systems. Results: Through telepharmacy service, 600 intensive care unit teleconsultations for COVID-19 cases were conducted in the residence center and nonresidence centers. In total, 1200 messages were exchanged between specialists in 3 months. The average time taken to respond to a message was 1.30 h. Thematic analysis revealed four main concepts and 15 subconcepts that should be considered in telepharmacy consultations for COVID-19 management. Based on the extracted themes, a conceptual model for developing a telepharmacy program was devised. Conclusion: The results showed that by utilizing telehealth, clinical pharmacists could cover critically ill patients who need pharmacotherapy counseling through interdisciplinary collaboration. Moreover, the main features of our service that are represented through this survey can be employed by other researchers for developing telepharmacy services.

Case series of nebulizing r-tPA for COVID-19 induced acute respiratory distress syndrome.

Fibrin deposition in the alveolar spaces during pulmonary involvement of COVID-19 impairs the O2/CO2 exchange and leads to respiratory symptoms. In this report, Recombinant Tissue Plasminogen Activator (r-tPA) has been nebulized to 3 critically ill COVID-19 patients in order to resolve the deposited fibrin while avoiding the risk of bleeding. Based on these observations, nebulization of r-tPA may be a potential therapeutic approach and new area of research for future studies.

Case series of nebulizing r‐tPA for COVID‐19 induced acute respiratory distress syndrome

Fibrin deposition in the alveolar spaces during pulmonary involvement of COVID‐19 impairs the O2/CO2 exchange and leads to respiratory symptoms. In this report, Recombinant Tissue Plasminogen Activator (r‐tPA) has been nebulized to 3 critically ill COVID‐19 patients in order to resolve the deposited fibrin while avoiding the risk of bleeding. Based on these observations, nebulization of r‐tPA may be a potential therapeutic approach and new area of research for future studies. Fibrin cast depositions play an important role in COVID‐19‐induced ARDS. Systemic administration of fibrinolytic may accompany with risk of bleeding. Nebulization of r‐tPA (Recombinant Tissue Plasminogen Activator) can temporally associated with transient improvements in oxygenation in COVID‐19‐induced ARDS. Fibrinolytic nebulization would minimize bleeding risk‐associated systemic administration.

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS.

BACKGROUND: In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease. MAIN BODY: SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS. CONCLUSIONS: Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.