Indonesian Geriatrics Society Consensus on COVID-19 Management in Older Adults.

More than 80% of death cases and 95% of severe COVID-19 occur in patients aged over 60 years. Atypical clinical manifestations with high morbidity and mortality further emphasize the importance of COVID-19 management in older adults. Some older patients may appear asymptomatic while other may present with acute respiratory distress syndrome and multi organ failure. Fever, higher respiratory rate and crackles may present. The most common chest x-ray finding is ground glass opacity. Other imaging modalities that are often used are pulmonary computed tomography scan and lung ultrasonography. COVID-19 management in older adults should be comprehensive, starting from oxygen, fluid, nutritional, physical rehabilitation, pharmacology and psychosocial therapy. In this consensus, we also discuss about management of older adults with special condition such as diabetes mellitus, kidney disease, malignancy, frailty, delirium, immobilization and dementia. In post COVID-19 phase, we believe that physical rehabilitation is important as it is done to improve fitness.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital.

BACKGROUND: There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital. METHODS: We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time. RESULTS: Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016-1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96). CONCLUSIONS: In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.

Diagnostic Model of COVID-19 Infection Based on the Combination of Clinical Symptoms, Chest Radiography and Laboratory Test.

BACKGROUND: COVID-19 is an infection caused by SARS-COV 2.For screening the patient, Rapid antigen for COVID-19 is used with a high diagnostic value. However, there are still some cases of false-negative even with clinical symptoms suggesting COVID-19. Undetected COVID-19 patients certainly will increase  transmission. A simple and practical diagnostic model, using determining factors, is required to guide physicians through a quicker decision making process, especially when deciding the need for the isolation rooms for patients with COVID-like symptoms. METHODS: This study is a cross-sectional study. The study was conducted at CiptoMangunkusumo Hospital, Jakarta.History of contact with COVID-19, clinical symptoms, laboratory examination, and chest radiograph data were taken from medical records. Bivariate and multivariate analyses were conducted to assess the effect sizes of patient factors on the diagnostic results.ROCcurve and Hosmer-Lemeshow calibration was used to make the scoring. RESULTS: There were 187 patients with the majority of subjects in the age group < 60 years old. The selected variables in this scoring systemwere contact history,fever/history of fever, dyspnea with respiratory rate >20 breaths/minute, leucocyte ≤ 10.000 cells/mLand typical chest radiography. The area under the curve for this model was 0,777 (CI95% (0,706-0,847), P<0,001). The probability was 82% with a cut-off point ≥ 4. CONCLUSION: Determinant models based on the combination of contact history, presence or history of fever, dyspnea, leucocyte count ≤ 10.000 cells/mL and typical chest radiography provides good accuracy to aid physicians in managing isolation room needs for patients with suspected COVID-19.

Convalescent Plasma in Older Adults with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Among all patients infected with coronavirus disease 2019 (COVID-19), the older adult population was the most affected, with 80%-90% of fatalities occurring in this group. The effectiveness of convalescent plasma (CP) in older adults is considerably more restricted than that in adults, resulting in a demand for data on the efficacy of therapeutic CP in older adults. This meta-analysis of updated literature examined the effect of CP in older adults with COVID-19. METHODS: Relevant literature was identified from studies indexed in the Cochrane, PubMed, and Google Scholar databases between December 2019 and April 2022. The primary outcome was all-cause mortality. Risk estimates were pooled using a random-effects model. The risk of bias was assessed by regression-based Egger test using the relative risk (RR) and upper and lower confidence intervals (CIs) of the three included studies. RESULTS: Among 377 studies identified, three full-text studies that included 1,038 patients met the inclusion criteria. The results of our meta-analysis showed that CP administration lowered the mortality risk in older adults with COVID-19 (RR=0.47; 95% CI, 0.26-0.86; p=0.01; I2=0%, p<0.81). CP therapy was more useful if delivered early in the course of the disease (within 72 hours of onset) and in less severe stages of the disease. Mortality tended to be lower in the high-titer group. CONCLUSIONS: CP treatment was significantly associated with a lower risk of mortality in older adults with COVID-19 than in patients not administered CP. The timing of CP administration is critical since earlier treatment after disease onset was associated with a better prognosis.

Appropriate Timing and Type of Physical Training in Patients with COVID-19 for Muscle Health and Quality of Life: A Systematic Review.

Physical activity is beneficial to modulate immune system function and has inverse relationship to ARDS linked with SARS-CoV-2. Physical activity consists of daily activity and physical training. Studies regarding effect of physical training on patients with COVID-19 are controversial. This systematic review aims to investigate physical training on muscle health and QOL in patients with COVID-19. The literature review was carried out using keywords: (Exercise) AND (COVID) AND (Muscle) AND (Observational Study) in several databases of PubMed and Cochrane Central Register of Controlled Trials (CENTRAL). All references were reviewed using critical appraisal Newcastle Ottawa Scale (NOS) and Centre for Evidence-Based Medicine (CEBM) checklist. The studies were subsequently screened for reporting exercise, muscle, and COVID-19. The descriptions of the extracted data are guided by Preferred Reporting Items for Systematic Reviews (PRISMA) statement with GRADE approach. This study is registered in PROSPERO: ID CRD42021295188. Six studies pooled and entered review synthesis. Studies were reviewed using critical appraisal by NOS and CEBM. Two clinical trial studies and four observational designs were selected. Our result showed physical training improved patients' outcomes in the acute phase, critical phase, and post-COVID-19 phase. Multiple types of physical trainings were suggested by those studies, and most of them showed beneficial effects to patients with COVID-19 in different phases. The level of evidence by GRADE was downgraded, and further investigations are needed to establish guidelines and strong recommendation for a specific stage of COVID-19.

Thrombocytopenia as a prognostic marker in COVID-19 patients: diagnostic test accuracy meta-analysis.

This systematic review and meta-analysis aimed to evaluate thrombocytopenia as a prognostic biomarker in patients with coronavirus disease 2019 (COVID-19). We performed a systematic literature search using PubMed, Embase and EuropePMC. The main outcome was composite poor outcome, a composite of mortality, severity, need for intensive care unit care and invasive mechanical ventilation. There were 8963 patients from 23 studies. Thrombocytopenia occurred in 18% of the patients. Male gender (P = 0.037) significantly reduce the incidence. Thrombocytopenia was associated with composite poor outcome (RR 1.90 (1.43-2.52), P < 0.001; I2: 92.3%). Subgroup analysis showed that thrombocytopenia was associated with mortality (RR 2.34 (1.23-4.45), P < 0.001; I2: 96.8%) and severity (RR 1.61 (1.33-1.96), P < 0.001; I2: 62.4%). Subgroup analysis for cut-off <100 × 109/l showed RR of 1.93 (1.37-2.72), P < 0.001; I2: 83.2%). Thrombocytopenia had a sensitivity of 0.26 (0.18-0.36), specificity of 0.89 (0.84-0.92), positive likelihood ratio of 2.3 (1.6-3.2), negative likelihood ratio of 0.83 (0.75-0.93), diagnostic odds ratio of 3 (2, 4) and area under curve of 0.70 (0.66-0.74) for composite poor outcome. Meta-regression analysis showed that the association between thrombocytopenia and poor outcome did not vary significantly with age, male, lymphocyte, d-dimer, hypertension, diabetes and CKD. Fagan's nomogram showed that the posterior probability of poor outcome was 50% in patients with thrombocytopenia, and 26% in those without thrombocytopenia. The Deek's funnel plot was relatively symmetrical and the quantitative asymmetry test was non-significant (P = 0.14). This study indicates that thrombocytopenia was associated with poor outcome in patients with COVID-19.PROSPERO ID: CRD42020213974.

Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis.

INTRODUCTION: National Institute for Health and Care Excellence (NICE) endorsed clinical frailty scale (CFS) to help with decision-making. However, this recommendation lacks an evidence basis and is controversial. This meta-analysis aims to quantify the dose-response relationship between CFS and mortality in COVID-19 patients, with a goal of supplementing the evidence of its use. METHODS: We performed a systematic literature search from several electronic databases up until 8 September 2020. We searched for studies investigating COVID-19 patients and reported both (1) CFS and its distribution (2) CFS and its association with mortality. The outcome of interest was mortality, defined as clinically validated death or non-survivor. The odds ratio (ORs) will be reported per 1% increase in CFS. The potential for a non-linear relationship based on ORs of each quantitative CFS was examined using restricted cubic splines with a three-knots model. RESULTS: There were a total of 3817 patients from seven studies. Mean age was 80.3 (SD 8.2), and 53% (48-58%) were males. The pooled prevalence for CFS 1-3 was 34% (32-36%), CFS 4-6 was 42% (40-45%), and CFS 7-9 was 23% (21-25%). Each 1-point increase in CFS was associated with 12% increase in mortality (OR 1.12 (1.04, 1.20), p = 0.003; I2: 77.3%). The dose-response relationship was linear (Pnon-linearity=0.116). The funnel-plot analysis was asymmetrical; Trim-and-fill analysis by the imputation of two studies on the left side resulted in OR of 1.10 [1.03, 1.19]. CONCLUSION: This meta-analysis showed that increase in CFS was associated with increase in mortality in a linear fashion.

Elevated interleukin levels are associated with higher severity and mortality in COVID 19 - A systematic review, meta-analysis, and meta-regression.

BACKGROUND AND AIMS: COVID 19 pneumonia commonly leads to ARDS. The occurrence of ARDS in COVID 19 patients is thought to occur secondary to an exaggerated immunologic response. In this meta-analysis, we aim to comprehensively study the various levels of immunological parameters in patients with COVID 19. MATERIALS AND METHODS: We performed a systematic literature search from PubMed, EuropePMC, SCOPUS, Cochrane Central Database, and medRxiv with the search terms, "COVID-19" and "Interleukin". The outcome of interest was prognosis in COVID 19 patients. RESULTS: We performed meta analysis of 16 studies. Higher counts of CD4 and CD8 with Lower Levels of TNF-a, IL2R, IL6, IL8 were observed on patients with good prognosis compared to patients with poor prognosis; -0.57 (pg/mL) (-1.10, -0.04, p = 0.04), (I2 91%, p < 0.001); -579.84 (U/mL) (-930.11, -229.57, p < 0.001), (I2 96%, p < 0.001); -1.49 (pg/mL) (-1.97, -1.01, p < 0.001), (I2 94%, p < 0.001); -0.80 (pg/mL) (-1.21, -0.40, p < 0.001), (I2 79%, p < 0.001); -2.51 (pg/mL) (-3.64, -1.38, p < 0.00001), (I2 98%, p < 0.001) respectively. Meta-regression showed age and hypertension (coefficient: 1.99, and -1.57, p = 0.005, and 0.006) significantly influenced association between IL-6 and poor outcome. CONCLUSION: Elevated immune response to coronavirus occurs in COVID 19 patients. Higher counts of CD4 and CD8 were seen in patients with good prognosis compared to patients with poor prognosis, with Lower levels of TNF-a, IL2R, IL6, IL8, were observed in patients with good prognosis compared to patients with poor prognosis.

Risk factors and laboratory test results associated with severe illness and mortality in COVID-19 patients: A systematic review.

BackgroundWe aimed to systematically review all relevant studies related to the risk factors and laboratory test results associated with severe illness and mortality in COVID-19 patients.MethodsWe utilised PubMed, Scopus, ProQuest, Wiley Online Library, ScienceDirect and MedRxiv to search for studies, with additional hand-searched journals. We included systematic reviews/meta-analyses, cohort and case control studies of suspected and/or confirmed COVID-19 cases with severe illness and/or mortality as outcomes. We included laboratory test results and risk factors. We assessed risk of bias using ROBIS-I and Newcastle-Ottawa Scale assessment tool. Type of study, risk of bias, and precision of results determined evidence sufficiency.ResultsOf 26 records included, sufficient evidence suggested the association between age >60 years, hypertension, coronary heart disease, DM, serum LDH 250-500 U/L, LDH >500 U/L, and lymphopenia (lymphocyte count ≤1.0 x 109 /L) and severe illness of COVID-19. CD3+CD8+ cell count ≤ 75 cell/µl, D-dimer > 1 mg/L, AKI stage 2 and 3, proteinuria ≥1+, hematuria ≥1+, and peak serum creatinine > 13.26 µmol/L are associated with mortality.ConclusionAge >60 years, hypertension, DM, and coronary heart disease are the risk factors for severe illness of COVID-19. Laboratory test results associated with severe illness are serum LDH 250-500 U/L, LDH >500 U/L, and lymphopenia, whereas test results associated with mortality are CD3+CD8+ cell count ≤ 75 cell/µl, AKI stage 2 and 3, proteinuria ≥1+, hematuria ≥1+, D-dimer > 1 mg/L, peak serum creatinine > 13.26 µmol/L.

Dilemma of Prioritising Health and the Economy During COVID-19 Pandemic in Indonesia.

Since the detection of the first confirmed case of coronavirus disease 2019 (COVID-19) in early March 2020, 248,852 cases have been detected in Indonesia by 21 September 2020. At least 100 doctors have died from COVID-19 nationwide. Full large-scale social restriction was a temporary measure, followed by an early transition to the new normal era during the never-ending first wave in the country. Workers in industrial, retail, transport, and tourism fields suffered a significant decrease in work. Many countries are, however, in dilemma of protecting the health of the citizens and prioritising economy. Health should be prioritised because it is an important aspect of our lives for our economy. Poor health is estimated to reduce global gross domestic product (GDP) by 15% annually through premature deaths and potential loss of productivity of the working-age citizens. Pandemics also depress economy through decrease in both supply and demand. Data from flu pandemic a century ago suggested the importance of aggressiveness and speed of intervention. Taiwan's early action led to beneficial effects on SARS-CoV-2 infection rate and economy recovery. The target of enhancement of containment measures, provision of personal protective equipments, and testing and isolation facilities should be achieved earlier and be more than the projected demand.

Clinical Profile of Elderly Patients with COVID-19 hospitalised in Indonesia's National General Hospital.

Latar BelakangSebanyak 38.6% kasus kematian pasien COVID-19 di Indonesia terjadi di populasi lansia. Data mengenai profil klinis pasien rawat inap lansia dengan COVID-19 masih tidak ada. Padahal kelompok pasien ini adalah pasien risiko tinggi selama pandemi ini yang memerlukan perhatian lebih.MetodeStudi deskriptif ini menggunakan data lengkap pasien lansia dengan COVID-19 yang dirawat inap di Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo (RSUPN Cipto Mangunkusumo) dari April hingga akhir Agustus 2020. Data termasuk karakteristik klinis, gejala, komorbiditas, multimorbiditas dan luaran mortalitas pasien.HasilDi populasi pasien lansia (n=44), mayoritas berusia di antara 60-69 tahun (68%), berjenis kelamin laki-laki (66%), dan tidak memiliki riwayat kontak erat dengan pasien COVID-19 sebelumnya (86%). Gejala tersering ialah demam, batuk, dan sesak yang merupakan gejala khas COVID-19, sedangkan penyakit kronis tersering adalah diabetes melitus, hipertensi, dan keganasan. Multimorbiditas ditemukan hanya di 14% pasien lansia, dan para pasien tersebut bertahan hidup pasca infeksi virus SARS-CoV-2. Angka kematian pasien lansia rawat inap dengan COVID-19 di studi ini adalah 23%, dan 90% dari kasus kematian berjenis kelamin laki-laki.KesimpulanPasien laki-laki mendominasi kasus terkonfirmasi dan kasus kematian lansia dengan COVID-19. Gejala khas COVID-19 hanya ditemukan di sekitar setengah pasien penelitian. Pasien yang meninggal dunia memiliki persentase gejala khas lebih tinggi. Gejala tidak khas pun mungkin ditemukan di pasien lansia. Immunosenescence dan fungsi imunoregulasi jenis kelamin tertentu dihipotesiskan memiliki peran penting dalam menyebabkan kematian lansia di studi ini.Kata Kunci: Profil Klinis, Lansia, Pasien Geriatri, COVID-19, Indonesia  ABSTRACTBackgroundOlder people contributed to 38.6% of death cases related to COVID-19 in Indonesia. Data regarding clinical profile of hospitalised elderly with COVID-19 in Indonesia were still lacking. Older people are at-risk population in the pandemic, whom we should pay attention to.MethodsThis single centre descriptive study utilised complete data of elderly inpatients with COVID-19 in Indonesia's national general hospital from April to late August 2020. The data consisted of clinical characteristics, symptoms, comorbidities, multimorbidity, and mortality outcome.ResultsAmong elderly patients (n=44), a majority of patients were aged 60-69 years (68%), were male (66%), and had no history of close contact with COVID-19 patient (86%). The most common symptoms were fever, cough and shortness of breath (classic symptoms of COVID-19), whereas the most common chronic diseases were diabetes mellitus, hypertension, and malignancy. Multimorbidity was only found in 14% of patients, all of whom remained alive following SARS-CoV-2 infection. The death rate among elderly inpatients with COVID-19 in this study was 23%, and male older adults contributed to 90% of death cases.ConclusionMale patients dominated both confirmed cases and death cases among elderly with COVID-19. Classic symptoms of COVID-19 were only found in about half of the study patients. Non-survivors had higher percentage of the classic symptoms of COVID-19 than survivors. Atypical COVID-19 presentations are possible in older adults. We postulated that immunosenescence and sex-specific immunoregulatory function play an important role in causing death in this study cohort. Keywords: Clinical Profile, Elderly, Geriatric Patient, COVID-19, Indonesia.

Gastrointestinal Presentation in COVID-19 in Indonesia: A Case Report.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently causing a widespread infection in the world. During the pandemic, physicians may need to raise the index of suspicion earlier in at-risk patients presenting with gastrointestinal symptoms, which are uncommon findings in coronavirus disease 2019 (COVID-19) patients. We report a patient in Indonesia with chest pain and gastrointestinal symptoms who was later confirmed to have SARS-CoV-2 infection after spending days of hospitalisation in the standard ward.

COVID-19 and Indonesia.

Coronavirus disease 2019 (COVID-19) pandemic is an ongoing problem in more than 200 countries in the world. Indonesia has been greatly affected by COVID-19 with case fatality rate (CFR) being 8.9% in the end of March 2020. We have some room for improvement related to the unreadingess of healthcare facility and the major steps taken by the government. It is suggested that the country should have stricter Stay-at-Home notice, suppress the spread by imposing lockdown on a large scale, improve healthcare service, and increase the availability of personal protective equipments (PPE). It is important to avoid an epidemic peak that potentially overwhelms healthcare service by quarantining the case contacts. Lockdown may prolong the epidemic doubling time significantly. Demand of health system is likely to grow since the number of COVID-19 case is likely to rise. Effective procedures for protecting medical staff from infection are essential. Scientific research in Indonesia is also crucial to provide suggestion and recommendation pertinent to COVID-19.

The Importance of Chest CT Scan in COVID-19.

The coronavirus disease 2019 (COVID-19) is a highly transmissible acute respiratory disease that is caused by the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2), a beta coronavirus first discovered in Wuhan, China, in late 2019. COVID-19 has been spreading swiftly globally, and as of March 2020, has been officially declared a pandemic by the World Health Organization (WHO). One of the challenges in managing COVID-19 is the identification of a swift, accessible, and reliable diagnostic modality that could serve as an alternative to a reverse-transcriptase polymerase chain reaction (RT-PCR). As of the writing of this paper, RT-PCR is still the recommended tool in diagnosing COVID-19, but the notion of a more prompt and accurate diagnostic tool is a possibility worth looking into. The objective of this case study is to investigate the importance and utility of chest computed tomography (CT) in the diagnosis of COVID-19, as increasing pieces of evidence suggest that chest CT could prove useful in the clinical pathway in diagnosing COVID-19.