COVID-19 Screening Score for Patients without Acute Respiratory Symptoms Undergoing Emergency Medical Procedures in Indonesia.

To rule out coronavirus disease-2019 (COVID-19) in patients scheduled to undergo emergency medical procedures, SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) must be performed. In developing countries, the use of SARS-CoV-2 RT-PCR has been limited by its unavailability and long processing time. Hence, a quick screening score to predict COVID-19 may help healthcare practitioners determine which patients without acute respiratory symptoms can safely undergo an emergency medical procedure. We conducted a cross-sectional study of adult patients without acute respiratory symptoms who were admitted to the emergency department and underwent an emergency medical procedure within 24 hours after admittance. We collected baseline demographic data, COVID-19 screening variables, and SARS-CoV-2 RT-PCR as the gold standard for COVID-19 diagnosis. Bivariate and multivariate analyses were performed, and a scoring system was developed using statistically significant variables from the multivariate analysis. With data from 357 patients, multivariate backward stepwise logistic regression analysis resulted in two significant COVID-19 predictors: the presence of SARS-CoV-2-IgM antibody (adjusted odds ratio [aOR]: 7.02 [95% CI: 1.49-32.96]) and typical chest x-ray (aOR: 23.21 [95% CI: 10.01-53.78]). A scoring system was developed using these predictors with an area under the receiver operating characteristic curve of 0.71 (95% CI: 0.64-0.78). For a cutoff point of ≥ 2, the scoring system showed 42.5% sensitivity and 97.1% specificity but had poor calibration (Hosmer-Lemeshow test P value < 0.001). We believe that the development of this COVID-19 quick screening score may be helpful in a resource-limited clinical setting, but its moderate discrimination and poor calibration hinder its use as a replacement for the SARS-CoV-2 RT-PCR test for COVID-19 screening.

Antibody Responses and Reactogenicity of a Heterologous, Full-Dose Messenger RNA-1273 Booster in Heavily SARS-CoV-2-Exposed CoronaVac-Vaccinated Health-Care Workers in Indonesia: A Real-World Observational Study.

Real-world data on heterologous boosting with messenger RNA (mRNA)-1273 (Moderna) after inactivated COVID-19 vaccination are limited. We report mRNA-1273 boosting in heavily SARS-CoV-2-exposed Indonesian health-care workers who received a two-dose CoronaVac 6 months prior. Between August and November 2021, we measured SARS-CoV-2 spike-specific IgG binding antibody (Bab) titers in all 304 participants, and neutralizing antibody titers in a random subset of 71 participants, on stored paired serum samples taken before and 28 days after a full-dose (100-µg) mRNA-1273 booster. At the time of the mRNA-1273 boost, 107 participants (35.2%) were not previously infected (naive vaccinated), 42 (13.8%) were infected before CoronaVac (infected vaccinated), and 155 (51.0%) were infected after CoronaVac (mostly during the Delta wave; vaccinated infected). At time of the mRNA-1273 boost, neutralizing antibodies could still be detected in 83% of participants (59 of 71) overall, 60% of naive-vaccinated participants (15 of 25), 95.7% of vaccinated-infected participants (22 of 23), and 95.7% of infected vaccinated participants (22 of 23). After the mRNA-1273 boost, 100% of participants (71 of 71) had neutralizing antibody activity, with increases in median Bab and neutralizing antibody serum titers of 9.3- and 27.0-fold overall, 89.1- and 2,803.4-fold in naive-vaccinated participants, 15.9- and 19.9-fold in infected-vaccinated participants, and 2.2- and 18.4-fold in vaccinated-infected participants. In the multivariable analysis, Bab titers after the mRNA-1273 boost were greatest in individuals who had a previous virus breakthrough post-CoronaVac, and when a longer time period (> 4 months) had elapsed since the most recent prior "spike antigen exposure" (either second CoronaVac or virus breakthrough). Overall, adverse reactions were mild and short-lived. In conclusion, a full-dose mRNA-1273 booster after CoronaVac was well tolerated and immunogenic after 28 days, including in those with very low antibody levels.

Molnupiravir and Nirmatrelvir/Ritonavir: The New Available Antiviral Options for COVID-19.

Coronavirus disease 2019 (COVID-19) is a respiratory tract disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the complexity of multimorbidity in Indonesia, it is crucial to find another line of antiviral for COVID-19. This article aims to review two antivirals, molnupiravir and nirmatrelvir/ritonavir, that have been studied extensively in treating COVID-19 with promising results, and their availability in Indonesia. Molnupiravir and nirmatrelvir/ritonavir are two of many repurposed drugs in clinical trials, which have been reported to have a mechanism in quick clearance of SARS-CoV-2, reduction in viral load, and fast symptoms recovery time in phase 1 and 2 clinical trials. Phase 2/3 clinical study in COVID-19 patients without any indication for hospitalization showed that molnupiravir and nirmatrelvir/ritonavir significantly reduced the risk of hospitalization and death.

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.

The Adjunctive Effects of Acupuncture for Hospitalized COVID-19 Patients: a Single-Blinded Randomized Clinical Study.

Background: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a coronavirus (SARS-CoV-2) that can induce cytokine storm. To this point, no specific drug has been effective for curing COVID-19. Objectives: The aim of this study was to determine the effects of a combination of acupuncture intervention and pharmacologic treatment in hospitalized COVID-19 patients with mild-moderate symptoms. Methods: A single-blinded randomized controlled clinical trial of hospitalized COVID-19 patients confirmed by RT-PCR examination with mild-moderate symptoms was conducted from August to September 2020. Participants were assigned to the treatment group (receiving pharmacologic treatment and manual acupuncture intervention) or the control group (receiving only pharmacologic treatment). Laboratory outcomes, including complete blood count, C-reactive protein (CRP) and ferritin levels, and erythrocyte sedimentation rate (ESR), were measured before and after the intervention. For clinical outcomes, we evaluated the duration of the cough symptom. Results: We found that participants in the treatment group had a shorter duration of the cough symptom compared to the control group, and the difference was statistically significant. In the treatment group, we found an increase in the percentage of lymphocyte count and ESR, while in the control group, both parameters were decreased; however, the differences were not statistically significant. There was a decrease in the mean of CRP and ferritin levels in both groups, and the differences were not statistically significant. Conclusion: Our study has shown promising results for the effects of combined treatment of acupuncture and pharmacologic treatment on the duration of the cough symptom in hospitalized COVID-19 patients with mild-moderate symptoms. Further large-scale studies with rigorous design are needed to examine these preliminary results.

COVID-19 Pandemic-to-Endemic Transition in Indonesia: What Does the Future Hold?

Since first reported in December 2019, SARS-2 Coronavirus (SARS-CoV-2) infection has become a world-class pandemic, overwhelming every aspect of the global system. Globally, 526 billion confirmed cases with 6,3 billion death cases were reported by World Health Organization (WHO) by 31 May 2022. In that period, Indonesia has reported 6 billion confirmed cases with a case fatality rate reaching 2.58%. The number of new weekly cases and new weekly death have continued the declining trend observed since its peak in January 2022, i.e. 3% decrease of new weekly cases and 11% decrease of new weekly death as compared to the previous week. In response to the current epidemiology improvement, countries including Indonesia have relaxed some regulations on COVID-19 as the preparation for pandemic-to-endemic transition.Endemic is not equal to harmless. Commonly, endemic is falsely interpreted as the end of COVID-19, bringing to a false complacency. Endemic "label" on an infectious disease, such as malaria, HIV infection, tuberculosis in certain regions of the world, means the overall rates of infection are static - neither rising nor falling. Endemic "label" defines nothing about time duration to reach disease end or how many populations will still be susceptible to the disease. Therefore, transition for pandemic-to-endemic of COVID-19 could not simply translated into the end of either public and health service awareness, or research on COVID-19. It then should add new emerging perspective on COVID-19 research as was mandated by WHO. One example of which is evidence-based strategies for infection prevention control and personal protective equipment for infection control de-escalation in relation to COVID-19 pandemic scaling back.In the spirit of nurturing research and publication in this transition for pandemic-to-endemic era, the Indonesian Journal of Internal Medicine published various COVID-19 associated-original articles, systematic review, and case series across various COVID-19 condition. Atici, et. al. and Tunjungputri, et. al. report articles on factors and treatment that is associated with higher COVID-19 survival. Corticosteroids, Interleukin-6 inhibitors and anticoagulant administered to the proper subset of COVID-19 population are several beneficial treatments among limited evidence-based proven treatment available today. These supportive treatments, whenever indicated at the proper time, should be considered in managing every COVID-19 patient. In addition, high antibiotic use in COVID-19 patients despite low secondary bacterial infection has been widely reported. Chen, et. al. report a similar situation in Indonesia and should raise the awareness of antimicrobial resistance thread now and in the future. Together with proper diagnostic stewardship, the simple predictors of secondary bacterial infection that have been concluded could potentially be used to reduce liberal antibiotic use while optimizing the use in indicated patients. Prabowo, et al. enriched our understanding on usage of telemedicine to monitor post COVID-19 condition in Indonesian populations.High quality research has, and will again, save the livelihoods of people across the world. While future pandemics could not be completely prevented, the research infrastructures that have built during last 2 years could be used as a strong modality to be better prepared and coordinated in future outbreak/ pandemic response by detecting and preventing the emerging diseases at their very early stage. Waste in COVID-19 research and multiple COVID-19 associated research article retractions should caution researchers -as evidence-producer- and clinicians -as evidence-user- in prioritizing the scientific inquiry and questioning individual conflict of interest. Insightful articles addressing the multitude aspects of the COVID-19 pandemic-to-endemic transition related topics are still needed in the future.

Observational Study on Secondary Bacterial Infection and the Use of Antibiotics in COVID-19 Patients Treated in a Tertiary Referral Hospital.

BACKGROUND: Data on secondary bacterial infection in patients with COVID-19 in Indonesia are still limited, while the use of empirical antibiotics continues to increase. This study aims to determine the secondary bacterial infection rate in hospitalized COVID-19 patients and factors related to secondary bacterial infection. METHODS: This is a retrospective cohort study on hospitalized COVID-19 patients undergoing treatment at Cipto Mangunkusumo Hospital from March 2020 to September 2020. Secondary bacterial infection is defined as the identification of a bacterial pathogen from a microbiological examination. RESULTS: From a total of 255 subjects, secondary infection was identified in 14.5%. Predictors of secondary infection were early symptoms of shortness of breath (OR 5.31, 95% CI 1.3 - 21.5), decreased consciousness (OR 4.81, 95% CI 1.77 - 13.0), length of stay > 12 days (OR 8.2, 95% CI 2.9 - 23.3), and central venous catheter placement (OR 3.0, 95% CI 1.1 - 8.0) The most common pathogen of secondary bacterial infection is Acinetobacter sp. (n=9; 28%). Empirical antibiotics were administered to 82.4% of subjects with predominant use of macrolides (n=141; 32.4%). CONCLUSION: The secondary bacterial infection rate in COVID-19 was 14.5% and is associated with dyspnea, decreased consciousness, length of stay >12 days, and central venous catheter placement. The use of antibiotics in COVID-19 reaches 82.4% and requires special attention to prevent the occurrence of antibiotic resistance.

Peran penting pengendalian resistensi antibiotik pada pandemi COVID-19

Infeksi oleh SARS-2 Coronavirus telah menjadi fokus perhatian bukan hanya pada layanan kesehatan bahkan layanan publik di seluruh dunia sepanjang tahun 2020. Hingga 30 Desember 2020 World Health Organization mencatat 80.773.033 kasus COVID-19 terkonfirmasi dengan mortalitas mencapai 1.783.619 (22%) di seluruh dunia. Indonesia melaporkan sebanyak 727.122 kasus terkonfirmasi dengan mortalitas sebesar 29,8%.

Impact of diabetes mellitus on COVID-19 clinical symptoms and mortality: Jakarta's COVID-19 epidemiological registry.

BACKGROUND AND AIMS: While the higher prevalence of diabetes mellitus (DM) at younger age in Indonesia might contribute to the relatively higher COVID-19 mortality rate in Indonesia, there were currently no available evidence nor specific policy in terms of COVID-19 prevention and management among DM patients. We aimed to find out the association between diagnosed diabetes mellitus (DM) with COVID-19 mortality in Indonesia. METHODS: We performed a retrospective cohort study using Jakarta Province's COVID-19 epidemiological registry within the first 6 months of the pandemic. All COVID-19 confirmed patients, aged >15 years with known DM status were included. Patients were assessed for their clinical symptoms and mortality outcome based on their DM status. A multivariate Cox-regression test was performed to obtain the relative risk (RR) of COVID-19 mortality in the diagnosed DM group. RESULTS: Of 20,481 patients with COVID-19, 705 (3.4%) had DM. COVID-19 mortality rate in DM group was 21.28%, significantly higher compared to 2.77% mortality in the non-DM group [adjusted RR 1.98 (CI 95% 1.57-2.51), p < 0.001]. In addition, COVID-19 patients with DM generally developed more symptoms. CONCLUSIONS: DM is associated not only with development of more COVID-19 clinical symptoms, but also with a higher risk of COVID-19 mortality. This finding may provide a basis for future policy regarding COVID-19 prevention and management among diabetes patients in Indonesia.

Coagulation profile and correlation between D-dimer, inflammatory markers, and COVID-19 severity in an Indonesian national referral hospital.

BACKGROUND: Coagulopathy and inflammation are associated with coronavirus disease 2019 (COVID-19) severity. This study assessed D-dimer concentration and its correlation with inflammatory markers and COVID-19 severity. METHODS: This was a retrospective cross-sectional study involving 194 COVID-19 cases, with the severity of infection graded in accordance with the World Health Organization (WHO) guidelines. We measured D-dimer, C-reactive protein (CRP), and ferritin on admission and determined the cutoff values for D-dimer and CRP and evaluated the correlation between D-dimer and CRP and ferritin. RESULTS: Median D-dimer, CRP, and ferritin concentrations were 2240 µg/L, 73.2 mg/L, and 1173.8 µg/mL, respectively. The highest median D-dimer value was seen in mild and moderate acute respiratory distress syndrome (ARDS). The highest ferritin concentration was seen in severe ARDS. There was a significant correlation between D-dimer value and CRP (r = 0.327), but no significant correlation between D-dimer and ferritin (r = 0.101). The area under the receiver operating characteristic curve (AUC) for the combination of CRP ≥72.65 mg/L and D-dimer ≥1250 µg/L as a marker of COVID-19 severity was 0.722 (95% confidence interval (CI): 0.615-0.781). CONCLUSION: The combination of CRP ≥72.65 mg/L and D-dimer ≥1250 µg/L can be used as marker of COVID-19 severity, with moderate accuracy.

Hematologic Profiles and Correlation Between Absolute Lymphocyte Count and Neutrophil/Lymphocyte Ratio with Markers of Inflammation of COVID-19 in an Indonesian National Referral Hospital.

INTRODUCTION: COVID-19 is a pandemic with significant mortality and it is important to differentiate severe and non-severe cases. We conducted a study to evaluate hematologic profiles with inflammation markers in COVID-19 patients and to determine the correlation of neutrophil-lymphocyte ratio (NLR) with disease severity. METHODS: A cross-sectional study involving hospitalized COVID-19 patients confirmed with a positive SARS-CoV-2 PCR test in Dr. Cipto Mangunkusumo Hospital. Lymphocyte count, NLR, C-reactive protein (CRP) and ferritin were evaluated in severe and non-severe COVID-19 cases at hospital admission. Data was analyzed using Spearman correlation. RESULTS: There were 41 patients aged 20 to 79 years with COVID-19; 33 (80.5%) were non-severe, and 8 (19.5%) were severe cases. There is a statistically significant difference in WBC, relative neutrophils and lymphocytes, NLR, and CRP between non-severe and severe cases. There is a strong correlation between NLR and CRP (r = 0.738; p < 0.001). Our findings show that NLR and absolute lymphocyte count, but not ferritin, play a role in differentiating between non-severe and severe COVID-19 cases. CONCLUSION: In COVID-19 cases, a strong correlation between NLR and CRP might suggest the use of NLR to differentiate between non-severe and severe cases, especially in a remote healthcare facility.

COVID-19 patient condition at early pandemic in Jakarta

COVID-19 is a disease caused by severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) that has become a pandemic. It became apparent that COVID-19 transmitting from person to person. The clinical manifestations and characteristics of COVID-19 encompassing from asymptomatic infection until severe pneumonia and death. This study aimed to describe and compare the characteristics between COVID-19 suspected patients and confirmed patients at an early pandemic in Jakarta Indonesia. Methods: a cross-sectional design was used in this study. Data were collected from march to April 2020 using the electronic health record reporting database initial laboratory tests and rt-PCR for SARS-CoV-2 results. There were 58 subjects: 43 COVID-19 confirmed patients and 15 COVID-19 suspected patients. Results: male was found predominantly in COVID-19 confirmed patients than female. The mean age of confirmed patients was 496 years old. Nearly half of the confirmed patients had comorbidities namely hypertension and diabetes mellitus. Fever and cough were the most common presenting symptoms and they were also found in suspected patients. Confirmed patients tended to have lymphopenia and neutrophilia. Pulmonary infiltrate was the most common feature in both confirmed and suspected patients. Conclusion: there were no significant differences found between COVID-19 confirmed and suspected cases regarding demographic characteristics comorbidities presenting symptoms physical examination results laboratory tests and chest x-ray results. Covid-19 confirmed patients had a history of exposure to COVID-19 confirmed patients.

Coronavirus Disease 2019: Tinjauan Literatur Terkini

Pada awal 2020, dunia dikejutkan dengan mewabahnya pneumonia baru yang bermula dari Wuhan, Provinsi Hubei yang kemudian menyebar dengan cepat ke lebih dari 190 negara dan teritori. Wabah ini diberi nama coronavirus disease 2019 (COVID-19) yang disebabkan oleh Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Penyebaran penyakit ini telah memberikan dampak luas secara sosial dan ekonomi. Masih banyak kontroversi seputar penyakit ini, termasuk dalam aspek penegakkan diagnosis, tata laksana, hingga pencegahan. Oleh karena itu, kami melakukan telaah terhadap studi-studi terkait COVID-19 yang telah banyak dipublikasikan sejak awal 2020 lalu sampai dengan akhir Maret 2020. Kata Kunci: COVID-19, pandemi, SARS-CoV-2, Wuhan Coronavirus Disease 2019: Review of Current Literatures