Streptococcus oralis pulmonic valve endocarditis: a case report and review of the literature.

BACKGROUND: Several factors increase the risk of right-sided endocarditis. The tricuspid valve is usually involved in right-sided endocarditis cases. Infective endocarditis of the pulmonic valve is rare, and few cases of pulmonic valve endocarditis were reported previously. CASE PRESENTATION: Here we describe a case of a 81-year-old Middle Eastern male patient, admitted to our hospital three times in a period of 2 months for fever and cough. He had Streptococcus oralis bacteremia with vegetation that was on the pulmonic valve. We diagnosed him with pulmonic valve endocarditis, and he was treated successfully with intravenous antibiotics. CONCLUSION: It is important to keep high suspicion for isolated pulmonic valve endocarditis in patients with respiratory symptoms. Adequate dental care is important in patients with risk factors for infective endocarditis.

The impact of the Beirut blast on the COVID-19 situation in Lebanon.

AIM: On August 4, 2020, a massive explosion hit Lebanon's capital city, Beirut. The aim of this study was to explore the effect of the Beirut blast on the COVID-19 situation in the country. SUBJECT AND METHODS: Data on COVID-19 were retrieved from the Lebanese Ministry of Public Health (LMOPH), where all the COVID-19 positive cases were reported. The study was divided into two periods, considering the incubation period of the COVID-19 virus: (July 27-August 9, 2020) and (August 10-23, 2020). Information obtained included daily number of cases, tests, deaths, hospitalized patients, intensive care unit (ICU) patients, and mode of acquisition (local vs. expat). Daily positivity rates were reported per 100 tests. An independent sample t-test and a Joinpoint regression analysis were used to determine significance. A p value less than 0.05 was considered significant. RESULTS: A total of 201,010 tests were conducted during our studied period, with 8993 positive cases, constituting a total positivity rate of 4.5 per 100 tests. Case fatality rate over the studied period was 0.8%. The positivity rate of the period prior to August 10, 2020, was 2.7 per 100 tests, significantly less than that of the period following the explosion, which was 6.4 per 100 tests (p < 0.001). During our studied period, daily positivity rates were significantly increasing at a slope of 0.29 (p < 0.001). A significant increase in slope was noted on August 13, 2020 (p < 0.001). The number of hospitalized patients increased from 139 patients on July 27 to 266 on August 23, 2020, and that of ICU patients increased from 36 to 75. CONCLUSION: The port of Beirut explosion resulted in a significant increase in the daily number of positive COVID-19 cases. The aftermath of the explosion, the damage to healthcare facilities, and the overcrowding due to emergency efforts were contributing factors to that increase.

A randomized clinical trial of lipid metabolism modulation with fenofibrate for acute coronavirus disease 2019.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cytotoxicity may involve inhibition of peroxisome proliferator-activated receptor alpha. Fenofibrate activates peroxisome proliferator-activated receptor alpha and inhibits SARS-CoV-2 replication in vitro. Whether fenofibrate can be used to treat coronavirus disease 2019 (COVID-19) infection in humans remains unknown. Here, we randomly assigned inpatients and outpatients with COVID-19 within 14 d of symptom onset to 145 mg of oral fenofibrate nanocrystal formulation versus placebo for 10 d, in a double-blinded fashion. The primary endpoint was a severity score whereby participants were ranked across hierarchical tiers incorporating time to death, mechanical ventilation duration, oxygenation, hospitalization and symptom severity and duration. In total, 701 participants were randomized to fenofibrate (n = 351) or placebo (n = 350). The mean age of participants was 49 ± 16 years, 330 (47%) were female, mean body mass index was 28 ± 6 kg/m2 and 102 (15%) had diabetes. Death occurred in 41 participants. Compared with placebo, fenofibrate had no effect on the primary endpoint. The median (interquartile range) rank in the placebo arm was 347 (172, 453) versus 345 (175, 453) in the fenofibrate arm (P = 0.819). There was no difference in secondary and exploratory endpoints, including all-cause death, across arms. There were 61 (17%) adverse events in the placebo arm compared with 46 (13%) in the fenofibrate arm, with slightly higher incidence of gastrointestinal side effects in the fenofibrate group. Overall, among patients with COVID-19, fenofibrate has no significant effect on various clinically relevant outcomes ( NCT04517396 ).

Immunogenicity and Effectiveness of Primary and Booster Vaccine Combination Strategies during Periods of SARS-CoV-2 Delta and Omicron Variants.

In this study involving a cohort of employees of the National Airline company in Lebanon, we assessed humoral immunity levels and the effectiveness of two COVID-19 vaccines, Gam-COVID-Vac versus BNT162b2, after two doses and after a homologous and heterologous BNT162b2 booster, in addition to the impact of hybrid immunity. Vaccine effectiveness (VE) was retrospectively determined against laboratory-confirmed SARS-CoV-2 infection during the periods of Delta and Omicron variants' predominance, separately, and was calculated based on a case-control study design. The humoral immune response, measured by a SARS-CoV-2 anti-spike receptor-binding domain (RBD) IgG titer, was prospectively assessed after the aforementioned vaccination schemes at different time points. This study showed higher effectiveness of BNT162b2 after two doses (81%) compared to two doses of Gam-COVID-Vac (41.8%) against the Delta variant of SARS-CoV-2, which correlated with anti-spike antibody levels. Regarding the Omicron variant, protection against infection and antibody levels were severely compromised and the correlation between an anti-spike IgG titer and effectiveness was lost, unlike the situation during the Delta wave. Considering the booster vaccination schemes, a homologous BNT162b2 booster after a BNT162b2 primary vaccination induced a higher humoral immune response when compared to that induced by a heterologous BNT162b2 booster after a Gam-COVID-Vac primary vaccination. However, the VE of both booster regimens against the Omicron variant was almost equal (64% in the homologous regimen and 57% in heterologous regimen). Hybrid immunity evidenced a better humoral response and a greater and longer protection against Delta and Omicron infections compared to vaccination-induced immunity in COVID-19-naïve individuals. Finally, the findings show that VE waned with time during the same wave, highlighting the importance of reinforcing primary and booster COVID-19 vaccination mainly at the beginning of each wave during the surge of a new variant of concern.

Revisiting the potential role of BCG and MMR vaccines in COVID-19.

Despite the development and deployment of effective COVID-19 vaccines, many regions remain poorly covered. Seeking alternative tools for achieving immunity against COVID-19 remains to be of high importance. "Trained immunity" is the nonspecific immune response usually established through administering live attenuated vaccines and is a potential preventive tool against unrelated infections. Evidence regarding a possible protective role for certain live attenuated vaccines against COVID-19 has emerged mainly for those administered as part of childhood vaccination protocols. This review summarizes the relevant literature about the potential impact of Bacille Calmette-Guérin (BCG) and measles, mumps and rubella (MMR) vaccines on COVID-19. Existing available data suggest a potential role for BCG and MMR in reducing COVID-19 casualties and burden. However, more investigation and comparative studies are required for a better understanding of their impact on COVID-19 outcomes.

Efficacy of tocilizumab in COVID-19: A review of the current evidence.

As cases of coronavirus 2019 (COVID-19) keep rising, reported deaths are increasing. Public health measures have been implemented with mixed efficacy. As vaccines are becoming more widely available and accessible globally, treating critically ill COVID-19 patients remains an issue with only dexamethasone found to be therapeutically effective to date. However, trials studying the efficacy of IL-6 inhibitors, namely tocilizumab have been underway with promising results. This paper is a narrative review that aims to review the current evidence provided by randomized clinical trials (RCT) for the use of tocilizumab in COVID-19. Electronic database searches were carried out in Medline, PubMed, Embase, Google Scholar, and ongoing clinical trial registries with the period set from January 1, 2020 to February 20, 2021. Prepublication manuscripts were found using the pre-print repository medRxiv. Keywords included "COVID-19,""coronavirus,""SARS-CoV-2,""sepsis,""pneumonia,""cytokine storm,""cytokine release syndrome,""IL-6 inhibitors," and "tocilizumab," as exact phrases, and a combination of subject headings according to databases syntax. Only trials with a clear and well-defined methodology, at least 100 patients recruited, and which have had results published either after peer review or in pre-print were included. In hospitalized patients with severe COVID-19, who are hypoxic and have a CRP ≥ 75 mg/L, the current evidence favors the use of a combination of tocilizumab and corticosteroids to reduce mortality, among other clinical benefits. There is also overwhelming evidence of the good safety profile of tocilizumab with only few cases of neutropenia reported with a decrease in infection rates. Tocilizumab is currently thought to work through the inhibition of IL-6 receptors (IL-6R), preventing downstream activation of pro-inflammatory reactions and cytokine release syndrome.

COVID-19 and Candida duobushaemulonii superinfection: A case report.

INTRODUCTION: Critically ill COVID-19 patients are at high risk for nosocomial bacterial and fungal infections due to several predisposing factors such as intensive care unit stay, mechanical ventilation, and broad-spectrum antibiotics. Data regarding multidrug resistant (MDR) Candida species in COVID-19 patients is scarce, and nonexistent regarding Candida duobushaemulonii superinfections. CASE DESCRIPTION: A 34-year-old male presented to our institution with acute respiratory distress syndrome (ARDS) due to COVID-19 infection and developed Candida duobushaemulonii fungemia after multiple courses of antibiotics and prolonged mechanical ventilation. He died after recurrent pneumothorax led to respiratory failure and cardiac arrest. DISCUSSION: Bacterial and fungal infections are common complications of viral pneumonia in critically ill patients. Data regarding these infections in COVID-19 patients has been poorly studied with only a few cases reporting secondary infection, mostly without identifying specific pathogens. Prolonged hospital stays, invasive interventions (central venous catheter, mechanical ventilation), and the use of broad-spectrum antibiotics in COVID-19 infections could carry a high risk of bacterial and/or fungal superinfections. CONCLUSION: Strategies to improve outcome in COVID-19 ICU patients should include early recognition of candidemia and appropriate antifungal therapy.

Impact of COVID-19 pandemic on the utilization of routine immunization services in Lebanon.

INTRODUCTION: The global abrupt progression of the COVID-19 pandemic may disrupt critical life-saving services such as routine immunization (RI), thus increasing the susceptibility of countries to outbreaks of vaccine-preventable diseases (VPDs). Being endemic to several infectious diseases, Lebanon might be at increased risk of outbreaks as the utilization of RI services might have deteriorated due to the pandemic and the country's political unrest following the October 2019 uprising. The aim of this study was to assess the changes in the utilization of RI services in both the public and private sectors following the COVID-19 pandemic. METHODS: A self-administered cross-sectional survey was completed electronically, in April 2020, by 345 private pediatricians who are registered in professional associations of physicians in Lebanon and provide immunization services at their clinics. Means of the reported percentages of decrease in the utilization of vaccination services by pediatricians were calculated. As for the public sector, an examination of the monthly differences in the number of administered vaccine doses in addition to their respective percentages of change was performed. Adjustment for the distribution of RI services between the sectors was performed to calculate the national decrease rate. RESULTS: The utilization of vaccination services at the national level decreased by 31%. In the private sector, immunization services provision diminished by 46.9% mainly between February and April 2020. The highest decrease rates were observed for oral poliovirus vaccine (OPV) and hepatitis A, followed by measles and pneumococcal conjugate vaccines. The number of vaccine doses administered in the public sector decreased by 20%. The most prominent reductions were detected for the OPV and measles vaccines, and during October 2019 and March 2020. CONCLUSION: The substantial decrease in the utilization of RI as a result of the COVID-19 pandemic requires public health interventions to prevent future outbreaks of VPDs.

First Candida auris Outbreak during a COVID-19 Pandemic in a Tertiary-Care Center in Lebanon.

Candida auris is an emerging fungal pathogen considered as a global health threat. Recently there has been growing concern regarding drug resistance, difficulty in identification, as well as problems with eradication. Although outbreaks have been reported throughout the globe including from several Arab countries, there were no previous reports from Lebanon. We herein report the first cases of C. auris infection from the American University of Beirut Medical Center, a tertiary care center in Lebanon describing the clinical features of the affected patients in addition to the infection control investigation and applied interventions to control the outbreak. Fourteen patients with C. auris infection/colonization identified using MALDI-TOF and VITEK 2- Compact system were reported over a period of 13 weeks. Patients were admitted to four separate critical care units. All of them came through the emergency room and had comorbid conditions. Half of the patients were infected with COVID-19 prior to isolation of the C. auris. C. auris was isolated from blood (two isolates), urine (three isolates), respiratory tract (10 isolates) and skin (one isolate). All the patients had received broad spectrum antibiotics prior to isolation of C. auris. Six patients received antifungal treatment, while the remaining eight patients were considered colonized. Environmental cultures were taken from all four units and failed to isolate the organism from any cultured surfaces. A series of interventions were initiated by the Infection Prevention and Control team to contain the outbreak. Rapid detection and reporting of cases are essential to prevent further hospital transmission. A national standardized infection control registry needs to be established to identify widespread colonization.

COVID-19: Second Wave or Multiple Peaks, Natural Herd Immunity or Vaccine - We Should be Prepared.

Between December 31, 2019, and August 30, 2020 (date of this article), the novel coronavirus and its corresponding infection, coronavirus disease (COVID-19), increased to more than 25 million cases, and 843 158 deaths have been registered. Countries around the world have been affected, albeit in different levels and intensities.Despite implementations of preventive public health measures, most countries are seriously preparing for 1 or more waves. The threat of this surge is likely to persist until herd immunity is acquired either by natural infection or through vaccination. However, given the time frame needed for herd immunity to occur and the low probability that a vaccine will be available on a global scale by the coming fall and winter seasons, contingency preparedness plans should be established and put in place for the coming days or months. These plans should help mitigate new peaks of the pandemic while relaxing the social isolation rules, patient, public health, and hospital levels.In this article, we discuss recommendations that practicing physicians and public health agencies should provide to individuals, especially those at risk of infection, to take and implement pre-emptive measures in anticipation of the potential next peak of the pandemic.

COVID-19 Pandemic: An Insult Over Injury for Lebanon.

The outbreak of the novel coronavirus disease in 2019 (COVID-19) caused a plethora of challenges worldwide and tested healthcare systems across the six continents. Lebanon had recently faced harsh political and economic crises. We aim to describe the effect of COVID-19 on an already crisis-stricken country. A descriptive analysis of the burden of COVID-19 pandemic on Lebanon was performed. Relevant data on COVID-19 was retrieved from the Lebanese Ministry of Public Health from February 21 till June 13th, 2020. Results obtained were analyzed and a literature review was performed. 1422 confirmed COVID-19 cases were identified and reported in Lebanon by June 13th, 2020, comprising an incidence rate of 208/million persons. There has been a total of 31 deaths thus far, with a reported death rate of 5/million persons. The age group with the highest number of cases was 20-29 years. Beirut was the district with the highest number of cases (18%). The COVID-19 crisis has impacted the country on a multifactorial level. COVID-19 could not have come at a worse time for Lebanon. The country is on brink of bankruptcy, the healthcare system is struggling for survival and the government is striving to regain the trust of the population.