Fungal infections in the ICU during the COVID-19 era

Aim of this study is to evaluate the incidence of fungal infections in COVID-19 intensive care unit (ICU) patients, to identify potential risk factors and to investigate whether differences in patients' outcomes are depicted. Material-Methods: This prospective observational study included critically ill patients diagnosed with COVID-19 that were admitted from 1/9/2020 to 1/11/2021 in ICU of the 1st Respiratory Department of Sotiria Chest Diseases Hospital. Epidemiologic characteristics, severity of disease, medication, outcome and complications were recorded. Result(s): Out of 300 patients included (213 men, 60,4+/-13,23 (mean+/-SD) years-old), 22 (7,3%) developed fungal infections (16 COVID-19 Associated Pulmonary Aspergillosis, 5 COVID-19 Associated Candidemia and 1 both). They were 6 female & 16 male, 55,73+/-13,28 years-old. Most patients had co-infections with multi-drug resistant bacteria. Patients with fungal infections were statistifically more on high dose of corticosteroids, invasive mechanical ventilation and renal replacement treatment (p<0.05). They had statistically more positive blood and bronchial secretion cultures, as well as more incidents of septic shock, venous thromboembolism and varotrauma (p<0.05). Their PaO2/FiO2 ratio on admission was statistically lower (p<0.05). Finally, after adjustment for confounfing factors and ICU days, they were at higher risk of dying (50% mortality). Conclusion(s): Fungal infections are a significant co-infection in critically ill COVID-19 patients. Those patients seem to have more severe respiratory failure on admission, be on higher doses of corticosteroids and in need of organ failure support. They also seem to develop more complications of COVID-19 and be at a higher risk of dying.

Secondary bacterial infections in patients with covid-19

Coronavirus Disease 2019 (COVID-19) has been classified as a global threat, affecting millions of people and killing thousands. It is caused by the SARS-CoV-2 virus, which emerged at the end of 2019 in Wuhan, China, quickly spreading worldwide. Patients’ clinical features vary, and secondary infections represent a constant risk of increased mortality among those who need hospitalization. Damaged respiratory epithelium and dysregulation of the immune response are the main pathophysiological mechanisms of increased microbial adhesion to the airway epithelial cells and the development of secondary infections. However, the exact incidence of secondary infections in COVID-19 patients is not thoroughly known (3.2%–80%) due to limited and heterogeneous studies that lead to conflicting or non-comparable results. Infection-risk stratification in critically ill patients includes early ICU admission (within 48 hours from hospitalization), age, comorbidity, immunosuppressive drugs administration, and disease severity indexes (oxygenation, inflammation, and cytolysis score). In treating secondary infections, the local epidemiology (which usually includes multidrug-resistant strains) and the modification of any antibiotic regimen according to the cultures’ results are critical. Prompt and appropriate antimicrobial agents represent the cornerstone in secondary infection treatment for COVID-19 hospitalized patients. © 2021 Lachana A. et al.

Ιncidence, pathogenesis and management of thromboembolic complications in severe COVID-19

Arterial and venous thromboembolic events are frequent complications of severe COVID 19 with an estimated incidence approximately 30%. High levels of D-dimers and fibrinogen, prothrombin time (PT) prolongation and mild thrombocytopenia compose the hypercoagulable profile of COVID 19 patients, while positive antiphospholipid antibodies have also been reported. The hyperinflammatory state in combination with the endothelial damage by the virus and the diffuse microvascular thrombosis contribute to the pathogenesis. Vigilance should be maintained for the early diagnosis of thrombotic complications. Low molecular weight heparin (LMWH) has been shown to reduce mortality in high risk patients, while the administration of higher dose of anticoagulants (intermediate, therapeutic) in order to prevent thromboembolic disease is further investigated. Pneumon 2020, 33(4):1-5.

The role of diabetes mellitus and obesity in COVID 19 patients

Several risk factors (old age, hypertension, cardiovascular disease, immunodeficiency) have been related with coronavirus disease 2019 (COVID 19). Among them, Diabetes Mellitus (DM) and obesity are recognized to increase the susceptibility and severity of the infection. A higher inflammatory response observed in these patients, the immune system dysfunction and increased expression of angiotensin converting enzyme 2 (ACE2) which is a the target for SARS-CoV-2, contribute to the worse outcome of diabetic and obese patients. Adequate blood glucose control improves the prognosis, while critically ill COVID 19 patients with high metabolic risk should be monitored for new onset DM.

COVID-19 associated Aspergillosis

Invasive pulmonary aspergillosis (IPA) may complicate severe COVID-19 patients. The incidence, although is not well confirmed, varies (20-35%) and the already recognized host factors for IPA in immunosuppressed patients are not identified in non-immunocompromised patients with COVID-19 associated pulmonary aspergillosis (CAPA). Additionally, clinical characteristics and radiological findings are not specific. Given the probable high burden of the co-infection, a screening diagnostic work-up, including serum and BAL galactomannan measurement, fungal cultures of upper and lower respiratory tract samples are considered mandatory in all mechanically ventilated patients with COVID-19.

Demographic and clinical features of critically ill patients with COVID-19 in Greece: The burden of diabetes and obesity.

AIMS: The aim of the study was to investigate the association between type-2 diabetes mellitus, other underlying diseases and obesity with the outcomes of critically ill Covid-19 patients in Greece. METHODS: In this retrospective observational multi-centre study, data and outcomes of 90 RNA 2109-nCoV confirmed critically ill patients from 8 hospitals throughout Greece, were analysed. All reported information stand through April 13th 2020. RESULTS: The median age of the patients was 65.5 (IQR 56-73), majority were male (80%) and obesity was present in 34.4% of patients most prevalent to younger than 55 years. Hypertension was the prevailing comorbidity (50%), followed by cardiovascular diseases (21.1%) and type-2 diabetes (18.9%). At admission, common symptoms duration had a median of 8 (IQR 5-11) days. A 13.3% of the patients were discharged, 53.4% were still in the ICUs and 28.9% deceased who were hospitalised for fewer days than the survivors [6 (IQR 3-9) vs. 9 (IQR 7-14.5) respectively]. Aging was not a risk factor but diabetes deteriorates the outcomes. Obesity poses a suggestive burden as it was more notable in deceased versus survivors. CONCLUSIONS: Type 2 diabetes and obesity may have contributed to disease severity and mortality in COVID-19 critically ill patients in Greece.

Serum Hydrogen Sulfide and Outcome Association in Pneumonia by the SARS-CoV-2 Coronavirus

BACKGROUND: The pneumonia of COVID-19 illness has often a subtle initial presentation making mandatory the use of biomarkers for evaluation of severity and prediction of final patient disposition. We evaluated the use of hydrogen sulfide (H2S) for the outcome of COVID-19 pneumonia. PATIENTS AND METHODS: We studied 74 patients with COVID-19. Clinical data were collected, and survival predictors were calculated. Blood was collected within 24 h after admission (day 1) and on day 7. H2S was measured in sera by monobromobimane derivation followed by high-performance liquid chromatography and correlated to other markers like procalcitonin and C-reactive protein (CRP). Tumor necrosis factor alpha and interleukin (IL)-6 were also measured in serum. RESULTS: Survivors had significantly higher H2S levels on days 1 and 7 after admission. A cut-off point of 150.44 muM could discriminate survivors from non-survivors with 80% sensitivity, 73.4% specificity, and negative predictive value 95.9%. Mortality after 28 days was 32% with admission levels lower than or equal to 150.44 muM and 4.1% with levels above 150.44 muM (P: 0.0008). Mortality was significantly greater among patients with a decrease of H2S levels from day 1 to day 7 greater than or equal to 36% (p: 0.0005). Serum H2S on day 1 was negatively correlated with IL-6 and CRP and positively correlated with the absolute lymphocyte count in peripheral blood. CONCLUSION: It is concluded that H2S is a potential marker for severity and final outcome of pneumonia by the SARS-CoV-2 coronavirus. Its correlation with IL-6 suggests anti-inflammatory properties.

Covid-19 associated aspergillosis

Invasive pulmonary aspergillosis (IPA) may complicate severe COVID-19 patients. The incidence, although is not well confirmed, varies (20-35%) and the already recognized host factors for IPA in immunosuppressed patients are not identified in non-immunocom-promised patients with COVID-19 associated pulmonary aspergil-losis (CAPA). Additionally, clinical characteristics and radiological findings are not specific. Given the probable high burden of the co-infection, a screening diagnostic work-up, including serum and BAL galactomannan measurement, fungal cultures of upper and lower respiratory tract samples are considered mandatory in all mechanically ventilated patients with COVID-19. Pneumon 2020, 33(2):1-4. © 2020, Technogramma. All rights reserved.