Corticosteroids in critical COVID-19: Are all corticosteroids equal?

BACKGROUND: The hyperinflammation seen as part of a dysregulated immune response to SARS-CoV-2 in its most severe form leads to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Corticosteroid therapy targets this hyperinflammation, otherwise known as a cytokine storm. It is the only therapeutic agent to date with a mortality benefit, with clear guidelines from national and international health authorities guiding its use.

Bacterial infection, antibiotic use and COVID-19: Lessons from the intensive care unit & nbsp

Background. Empirical broad-spectrum antibiotics are frequently prescribed to patients with severe COVID-19, motivated by concern about bacterial coinfection. There is no evidence of benefit from such a strategy, while the dangers of inappropriate antibiotics are well described. Objectives. To investigate the frequency, profile and related outcomes of infections by bacterial pathogens in patients admitted to an intensive care unit (ICU) with severe COVID-19 pneumonia. Methods. This was a prospective, descriptive study in a dedicated COVID-19 ICU in Cape Town, South Africa, involving all adult patients admitted to the ICU with confirmed COVID-19 pneumonia between 26 March and 31 August 2020. We collected data on patient comorbidities, laboratory results, antibiotic treatment, duration of admission and in-hospital outcome. Results. We included 363 patients, who collectively had 1 199 blood cultures, 308 tracheal aspirates and 317 urine cultures performed. We found positive cultures for pathogens in 20 patients (5.5%) within the first 48 hours of ICU admission, while 73 additional patients (20.1%) had positive cultures later during their stay. The most frequently isolated pathogens at all sites were Acinetobacter baumannii (n=54), Klebsiella species (n=13) and coagulase-negative staphylococci (n=9). Length of ICU stay (p<0.001) and intubation (p<0.001) were associated with positive cultures on multivariate analysis. Disease severity (p=0.5), early antibiotic use (p=0.5), diabetes mellitus (p=0.1) and HIV (p=0.9) were not associated with positive cultures. Positive cultures, particularly for tracheal aspirates (p<0.05), were associated with longer ICU length of stay and mortality. Early empirical antibiotic use was not associated with mortality (odds ratio 2.5;95% confidence interval 0.95 -6.81). Conclusions. Bacterial coinfection was uncommon in patients at the time of admission to the ICU with severe COVID-19. Avoiding early empirical antibiotic therapy is therefore reasonable. Strategies to avoid coinfection and outbreaks in hospital, such as infection prevention and control, as well as the strict use of personal protective equipment, are important to improve outcomes.

COVID-19 infection in high-risk south african pregnancies with and without HIV

Background: Data from Africa reporting the outcomes of COVID-19 infection in pregnancy are limited, particularly for women with high-risk pregnancies (hypertension, diabetes and obesity) and pregnant women living with HIV (PLHIV). We describe the clinical features, maternal and birth outcomes of COVID-19 high-risk pregnancies at a South African tertiary care referral hospital with a 24% antenatal HIV prevalence. Methods: We prospectively collected data from COVID-19 infected pregnant women attending the high-risk obstetric service at Tygerberg Hospital, Cape Town, between 1 May 2020 and 31 July 2020, and documented pregnancy and birth outcomes until 30 October 2020. Laboratory testing for SARS-CoV-2 infection was performed only in symptomatic pregnant women. Descriptive analysis was performed for all COVID-19 infected women with high-risk pregnancies;demographic and outcome variables were compared for PLHIV versus pregnant women without HIV. Results: One hundred pregnant women (72 without HIV and 28 PLHIV) had laboratory-confirmed COVID-19 infection (Table 1). Obesity, hypertensive disorders and gestational diabetes were frequent comorbidities. Among 28 PLHIV, the majority received antiretroviral treatment 27 (96%);median CD4 count was 441 (14-838) cell/mm3 for 21 (75%) and 19 (73%) were virologically suppressed. COVID-19 infection was diagnosed predominantly in the 3rd trimester (81%);50% of women delivered within 2 weeks of infection onset. Forty women developed pneumonia;13 developed adult respiratory distress syndrome (ARDS) and 6 required invasive ventilation. Eight women died, 7 from ARDS and 1 from advanced HIV disease with bacteraemia. Pregnancy outcomes included 91 live births (including 5 sets of twins), 5 stillbirths, 4 miscarriages, 2 mothers who died with the fetus in situ and 1 medical termination of pregnancy. Birth outcomes for 2 women were unknown. Outcome for the 91 liveborn neonates were good except for one who died from complications related to perinatal asphyxia. No significant differences for COVID-19 infection impact and outcome were noted for PLHIV versus those without HIV. Conclusion: In this cohort of high-risk pregnant women with COVID-19 infection, no clinical differences in outcome attributable to HIV-infection were noted, however the majority of PLHIV were virally suppressed. The impact of COVID-19 infection in pregnancy was severe (40% complicated by pneumonia;8% crude mortality rate);neonatal outcomes were favourable.

High HIV prevalence in an early cohort of hospital admissions with COVID-19 in Cape Town, South Africa

Background. South Africa (SA) has a high prevalence of HIV and tuberculosis. Cape Town was the SA metropole most affected in the early stages of the COVID-19 pandemic. Early observational data from Africa may provide valuable insight into what can be expected as the pandemic expands across the continent.Objectives. To describe the prevalence, clinical features, comorbidities and outcome of an early cohort of HIV-positive and HIV-negative patients admitted with COVID-19.Methods. This was a descriptive observational study of an early cohort of adults with COVID-19 pneumonia admitted from 25 March to 11 May 2020.Results. Of 116 patients (mean age 48 years, 61% female) admitted, 24 were HIV-positive (21%). The most common symptoms reported were cough (n=88;73%), shortness of breath (n=78;69%), fever (n=67;59%), myalgia (n=29;25%) and chest pain (n=22;20%). The most common comorbidities were hypertension (n=46;41%), diabetes mellitus (n=43;38%), obesity (n=32;28%) and HIV (n=24;21%). Mortality was associated with older age (mean (standard deviation) 55 (12) years v. 46 (14) years;p&lt;0.01);the presence of hypertension or hypertension along with diabetes and/or obesity;lower partial pressure of arterial oxygen to fraction of inspired oxygen ratio;and higher urea level, white cell count, neutrophil count, and C-reactive protein, lactate dehydrogenase and ferritin levels, and high neutrophil to lymphocyte ratio. The overall survival rate for all hospital admissions was 86/116 (73%). In this early cohort, survival was similar in patients with HIV (n=18;75%) compared with those without HIV (n=67;75%) (p=1). Of the 74 patients admitted to the wards, 63 (85%) survived, whereas 22 of 42 (52%) admitted to the intensive care unit survived.Conclusions. Patients with HIV infection represented a large proportion of all COVID-19 admissions. The presentation and outcome of patients with HIV did not differ significantly from those of patients without HIV.

Diabetes mellitus and COVID-19: A review and management guidance for South Africa

This article reviews the association between diabetes mellitus (DM) and COVID-19. We report on the convergence of infectious diseases such as coronavirus infections and non-communicable diseases including DM. The mechanisms for the interaction between COVID-19 and DM are explored, and suggestions for the management of DM in patients with COVID-19 in South Africa are offered.

HIV and SARS-CoV-2 co-infection: The diagnostic challenges of dual pandemics.

The first critically ill patient admitted to our hospital in Cape Town, South Africa, during the COVID-19 pandemic was co-infected with HIV and SARS-CoV-2. Pneumocystis jirovecii pneumonia (PCP) and other respiratory opportunistic infections share many clinical features with severe COVID-19. Our understanding of the nuances of co-management of HIV and COVID-19 is evolving. We describe the diagnostic and therapeutic challenges presented by this case.

Leadership and early strategic response to the SARS-CoV-2 pandemic at a COVID-19 designated hospital in South Africa.

While many countries are preparing to face the COVID-19 pandemic, the reported cases in Africa remain low. With a high burden of both communicable and non-communicable disease and a resource-constrained public healthcare system, sub-Saharan Africa is preparing for the coming crisis as best it can. We describe our early response as a designated COVID-19 provincial hospital in Cape Town, South Africa (SA).While the first cases reported were related to international travel, at the time of writing there was evidence of early community spread. The SAgovernment announced a countrywide lockdown from midnight 26 March 2020 to midnight 30 April 2020 to stem the pandemic and save lives. However, many questions remain on how the COVID-19 threat will unfold in SA, given the significant informal sector overcrowding and poverty in our communities. There is no doubt that leadership and teamwork at all levels is critical in influencing outcomes.