Incidence and risk factors for clinically confirmed secondary bacterial infections in patients hospitalized for coronavirus disease 2019 (COVID-19).

OBJECTIVE: The true incidence and risk factors for secondary bacterial infections in coronavirus disease 2019 (COVID-19) remains poorly understood. Knowledge of risk factors for secondary infections in hospitalized patients with COVID-19 is necessary to optimally guide selective use of empiric antimicrobial therapy. DESIGN: Single-center retrospective cohort study of symptomatic inpatients admitted for COVID-19 from April 15, 2020, through June 30, 2021. SETTING: Academic quaternary-care referral center in Portland, Oregon. PATIENTS: The study included patients who were 18 years or older with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) PCR test up to 10 days prior to admission. METHODS: Secondary infections were identified based on clinical, radiographic, and microbiologic data. Logistic regression was used to identify risk factors for secondary infection. We also assessed mortality, length of stay, and empiric antibiotics among those with and without secondary infections. RESULTS: We identified 118 patients for inclusion; 31 (26.3%) had either culture-proven or possible secondary infections among hospitalized patients with COVID-19. Mortality was higher among patients with secondary infections (35.5%) compared to those without secondary infection (4.6%). Empiric antibiotic use on admission was high in both the secondary and no secondary infection groups at 71.0% and 48.3%, respectively. CONCLUSIONS: The incidence of secondary bacterial infection was moderate among hospitalized patients with COVID-19. However, a higher proportion of patients received empiric antibiotics regardless of an identifiable secondary infection. Transfer from an outside hospital, baseline immunosuppressant use, and corticosteroid treatment were independent risk factors for secondary infection. Additional studies are needed to validate risk factors and best guide antimicrobial stewardship efforts.

The Need for Antiviral Drugs for Pandemic Coronaviruses From a Global Health Perspective.

Respiratory failure due to SARS-CoV-2 has caused widespread mortality, creating an urgent need for effective treatments and a long-term need for antivirals for future emergent coronaviruses. Pharmacotherapy for respiratory viruses has largely been unsuccessful with the exception of early treatment of influenza viruses, which shortens symptom duration and prevents infection in close contacts. Under the rapidly evolving circumstances of the COVID-19 pandemic, most clinical trials of experimental treatments in the United States have focused on later stages of the disease process. Worldwide, the clinical studies of the most impactful drugs, remdesivir and dexamethasone in ACTT-1, RECOVERY, and Solidarity, have studied hospitalized patients. Less than half of clinical trials in the U.S. have investigated oral agents, and the majority have taken place in hospitals at a disease stage where the viral load is already decreasing. The limited success of treatments for respiratory viruses and the viral dynamics of COVID-19 suggest that an antiviral therapy with the greatest impact against pandemic coronaviruses would be orally administered, well-tolerated, target a highly conserved viral protein or host-coronavirus interaction and could be used effectively throughout the world, including resource-poor settings. We examine the treatment of respiratory viral infections and current clinical trials for COVID-19 to provide a framework for effective antiviral therapy and prevention of future emergent coronaviruses and call attention to the need for continued preclinical drug discovery.

Understanding viral shedding of severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Review of current literature.

OBJECTIVE: Transmission of SARS-CoV-2 has significant implications for hospital infection prevention and control, discharge management, and public health. We reviewed available literature to reach an evidenced-based consensus on the expected duration of viral shedding. DESIGN: We queried 4 scholarly repositories and search engines for studies reporting SARS-CoV-2 viral shedding dynamics by PCR and/or culture available through September 8, 2020. We calculated the pooled median duration of viral RNA shedding from respiratory and fecal sources. RESULTS: The review included 77 studies on SARS-CoV-2. All studies reported PCR-based testing and 12 also included viral culture data. Among 28 studies, the overall pooled median duration of RNA shedding from respiratory sources was 18.4 days (95% CI, 15.5-21.3; I2 = 98.87%; P < .01). When stratified by disease severity, the pooled median duration of viral RNA shedding from respiratory sources was 19.8 days (95% CI, 16.2-23.5; I2 = 96.42%; P < .01) among severely ill patients and 17.2 days (95% CI, 14.0-20.5; I2 = 95.64%; P < .01) in mild-to-moderate illness. Viral RNA was detected up to 92 days after symptom onset. Viable virus was isolated by culture from -6 to 20 days relative to symptom onset. CONCLUSIONS: SARS-COV-2 RNA shedding can be prolonged, yet high heterogeneity exists. Detection of viral RNA may not correlate with infectivity since available viral culture data suggests shorter durations of shedding of viable virus. Additional data are needed to determine the duration of shedding of viable virus and the implications for risk of transmission.

Infectious Diseases Simulation for Medical Students: Experiential Instruction on Personal Protective Equipment.

Introduction: The emergence of COVID-19 highlighted the critical importance of appropriate use of personal protective equipment (PPE) for the safety of patients and health care personnel. However, previously published survey data indicated that formal instruction on the correct utilization of PPE is uncommon in medical school curricula, and there is no published guidance about optimal instruction methods. The infectious disease (ID) simulation lab at Oregon Health & Science University filled this need. Methods: Second- through fourth-year medical students participated in the infection intersession, a 2-week didactic session that students were required to enroll in once during their clinical rotations. As part of the course, students completed the ID simulation lab, during which they were presented with common ID syndromes (suspected tuberculosis, C. difficile colitis, and neutropenic fever) and asked to select the proper PPE prior to interacting with standardized patients. ID physicians acted as the patients and then conducted feedback sessions, which focused on PPE choice, donning and doffing techniques, and ID diagnosis and management principles. Results: More than 500 medical students participated between 2016 and 2020, demonstrating the feasibility of the experience. The average exam scores were above 80%, and the average student evaluation score of the session was 8.9 out of 10, demonstrating acceptability. Discussion: The ID simulation lab allowed students to reinforce didactic teaching about PPE, dispel common misconceptions, and receive real-time feedback from ID clinicians. Availability of the lab and facilitators were limiting factors. Future work will focus on better understanding the efficacy of the sessions.