Clinical and laboratory characteristic of patients with COVID-19 and meningococcal co-infection.

Objective. To analyze clinical and laboratory characteristics of patients with COVID-19 and meningococcal co-infection. Patients and methods. We analyzed cases of mixed infection caused by SARS-CoV-2 and meningococci in 8 patients treated in Moscow Multidisciplinary Clinical Center 'Kommunarka.' We used mass spectrometry for microbiological examination followed by culturing in accordance with the results of examination. All patients were tested positive for COVID-19 by PCR and meningococcal infection by bacteriological method. Results. Patients were admitted to hospital on average 5.88 +/- 4.2 days after COVID-19 onset. Two patients had moderate disease, whereas 6 patients had severe disease and were admitted to the intensive care unit. Study participants presented with different forms of meningococcal infection, including nasopharyngitis (n = 1), meningitis (n = 1), pneumonia (n = 2), menin-gococcemia (n = 3), and mixed form meningitis and meningococcemia (n = 1). Fatal outcome was observed in 37.5% of cases. Conclusion. The problem of meningococcal infection remains highly relevant during the COVID-19 pandemic. So-infection is characterized by an increase in the proportion of rare forms (pneumonia), which requires special attention of clinicians. The implementation of mass spectrometry will allow early detection of meningococcal infection in patients with rare forms and timely initiation of adequate and optimal therapy. Copyright © 2022.

Cerebral Vasculopathy-Associated Ischemic Stroke in the Setting of Bacterial Meningitis

INTRODUCTION: Bacterial Meningitis is known to have high morbidity and mortality rates. A less recognized complication from this disease includes acute ischemic stroke, which conveys a worse prognosis. DESCRIPTION: A 37-year-old previously healthy woman presented to the hospital with progressive encephalopathy associated with ataxia and dysarthria. Her immediate past travel history revealed a trip to Europe where she endured a COVID19 infection three weeks before her admission. Nevertheless, she recovered without any complications. However, she developed fatigue and headaches, prompting a diagnosis of post-COVID19 syndrome by her primary care physician. Over the course of several days, her ability to carry out her normal daily activities and perform work-related duties deteriorated as she developed severe fatigue accompanied by a painless diffuse skin rash. She presented to the ED once she started having symptoms of dysarthria, abasia, and truncal ataxia. An emergently obtained CSF sample was consistent with bacterial meningitis. Standard empiric antibiotics and steroids were administered. The patient's condition acutely decompensated soon after antibiotics administration. A follow-up head CT showed global cerebral edema and hydrocephalus, triggering an EVD placement for ICP monitoring. An MRI brain showed multiple bilateral acute ischemic strokes in the brainstem and basal ganglia. A head CT angiography showed diffuse narrowing of the cerebral arteries. The patient ultimately completed a course of antibiotics (Neisseria PCR was positive). We used TCD-guided blood pressure augmentation to prevent the progression of cerebral ischemia. The patient was discharged on long-term steroid therapy for presumed post-infectious vasculopathy. A follow-up MRI brain did not reveal a progression of cerebral ischemia. DISCUSSION: Bacterial Meningitis is a severe disease with significant complications. One such complication is ischemic stroke. However, the exact pathophysiology is unknown. Understanding the risks of developing cerebral ischemia and the related pathophysiology could help improve patient outcomes with better treatment modalities. The interplay between COVID19 infection and conventional infectious pathogens is an ongoing area of interest.

Disseminated Strongyloiodes Infection after Corticosteroid Use

INTRODUCTION: While there are endemic foci of Strongyloides in the southeastern United States, strongyloidiasis in the US is most commonly found in immigrants and military veterans who have lived in endemic regions. We report a case of reactivated disseminated strongyloidiasis in a critically ill COVID-19 patient. DESCRIPTION: A 46 year old undomiciled man with a medical history of hypertension was found down by a friend and brought to the hospital for evaluation of altered mental status. The patient immigrated from Mexico in 1991 and lived in Florida for several years working as a gardener. On presentation he complained of headaches, with tremors and tongue fasciculations noted on physical exam. He underwent treatment for alcohol withdrawal. His hospital course was complicated by COVID-19 pneumonia requiring intubation, and a subarachnoid hemorrhage that did not require acute neurosurgical intervention. Several days after completion of remdesivir and dexamethasone treatment for COVID-19, the patient's absolute eosinophil count increased from 20/ uL on admission to 340/uL with a peak at 1500/uL. The patient was found to have Strongyloides and ESBL Klebsiella in a bronchoalveolar lavage after a bedside bronchoscopy. Ivermectin 200ug/kg/day and meropenem 2g every 8 hours were started. The patient remained persistently comatose despite being off sedation and a relatively benign brain MRI that demonstrated resolving subarachnoid hemorrhages. Strongyloides were confirmed in the CSF nine days after initial discovery in the BAL. Albendazole 400mg BID was added to the regimen and meropenem was continued for possible culture negative bacterial meningitis in the setting of disseminated strongyloidiasis. HIV and HTLV-1 serology was negative. The patient remained in the ICU with poor neurological status and ongoing goals of care discussions with the family. DISCUSSION: Strongyloides hyperinfection is an uncommon complication with a high mortality rate, with meningeal involvement often described post-mortem. Prophylactic anti-parasitic agents can be considered for patients identified as high risk for chronic strongyloidiasis who are about to undergo corticosteroid treatments, including COVID-19 associated regimens.

Infections and nervous system dysfunctions

Spread of pathogens to the nervous system is a serious complication of infections. In addition to infections with well-known microbes and viruses in the Western world, and the World Health Organization priorities of HIV/AIDS, malaria, and tuberculosis, several neglected tropical infectious diseases target the nervous system and have high mortality rates. Infections can cause cognitive and behavioral disturbances as well as late-onset epilepsy in survivors. The specialized environment in the brain dampens immune responses to avoid harmful effects on the nonrenewable nervous tissue. Some pathogens can therefore evade efficient elimination, persist, and be involved in interactions with nervous tissue that create balances, which, if lost by the host, can result in long-term functional disturbances. Viruses also can be useful tools to study the structure and function of the nervous system. Neuroscience can disclose mechanisms of neurodegeneration and brain dysfunctions from studies of the interplay among pathogens, nervous tissues, and immune responses that could lead to better management of brain disorders. © 2023 Elsevier Inc. All rights reserved.

Neonatal Fever in the COVID-19 Era:Odds of a Serious Bacterial Infection

Background: Pre-COVID literature suggests that viral infections account for about 90% of cases of fever in infants ≤56 days of age. Given the reduction in non-SARS-CoV-2 viral infections observed during the COVID-19 pandemic, we sought to determine if SBI accounted for a higher than usual proportion of fever cases in this age group during this period. Methods: We performed a multi-center, retrospective chart review of infants age ≤56 days presenting with fever to emergency departments (EDs) of six community hospitals affiliated with the same academic children's hospital. We compared the incidence of SBIs, viral meningitis, and viral bronchiolitis during March 2020 - February 2021 (pandemic year) with the same calendar months in the two preceding years (pre-pandemic years). Results: From March 2018 to February 2021, 543 febrile infants presented to the EDs, 95 during the pandemic year (Mar 2020-Feb 2021) compared to 231 and 217 in the pre-pandemic years (Mar 2018- Feb 2019 and Mar 2019-Feb 2020, respectively). The incidence of SBI was 28.4% (27/95) during the pandemic year compared to 11.6% (27/231) and 6.9% (15/217) in the pre-pandemic years (p<0.001);bacteremia 13.7% (13/95) during the pandemic year compared to 2.2% (5/231) and 1.4% (3/217) in the pre-pandemic years;and UTI 19% (18/95) during the pandemic compared to 11.3% (26/231) and 6.5% (14/217) in the pre-pandemic years (TABLE 1). Five patients were diagnosed with bacterial meningitis over the three-year period, four of them during the pandemic year, a rate of 4.2% (4/95). Rate of positivity for viral CSF PCR during the pandemic year was 6.4% (3/47) compared to 20.8% (25/120) and 20.4% (23/113) in the pre-pandemic years (Mar 2018-Feb 2019 and Mar 2019-Feb 2020 respectively;p=0.070). 2.1% (2/95) febrile young infants were admitted with a co-morbid diagnosis of bronchiolitis during the pandemic year compared to 4.3% (10/231) and 6.0% (13/217) in the pre-pandemic years (Mar 2018-Feb 2019 and Mar 2019-Feb 2020 respectively;p=0.310). The risk ratio for SBI (FIGURE 1) for pre-pandemic year 1 (referent;Mar 2018-Feb 2019) compared to the pandemic year (Mar 2020-Feb 2021) was 2.43 (95% CI 1.51-3.92;Bonferroni adjusted p=0.001);and the risk ratio for pre-pandemic year 2 (referent;Mar 2019-Feb 2020) compared to the pandemic year was 4.11 (95%CI 2.29-7.37;Bonferroni adjusted p<0.001). Conclusion: The COVID-19 pandemic led to an increase in the proportion of SBIs among febrile infants ≤56 days of age. This is likely a result of reduction in non-SARS-CoV-2 viral infections. Greater vigilance is thus warranted in the evaluation of febrile infants during the COVID-19 pandemic. (Table Presented).

Investigation of the Etiological Causes of Central Nervous System Infection in Children with Multiplex PCR

Objective The aim of this study is to investigate the causative agents of central nervous system (CNS) infection in hospitalized pediatric patients by multiplex polymerase chain reaction. Methods We retrospectively reviewed the medical records of children who underwent lumbar puncture with suspected CNS infection between September 2019 and September 2021. The cerebrospinal fluid (CSF) samples were evaluated by the BioFire FilmArray Meningitis/Encephalitis (ME) Panel. Results The etiology of the infection was established in 13,02% (n = 25) cases. Human herpesvirus (HHV) type 6 was the most commonly identified pathogen 60% (n = 15), followed by enterovirus 20% (n = 5), Streptococcus pneumoniae 8% (n = 2), Streptococcus agalactiae 4% (n = 1), HHV type 1 4% (n = 1), and Listeria monocytogenes 4% (n = 1). The statistical analysis showed that the age of the group with enterovirus was younger than the age of the group with other causative microorganisms and the group with HHV-6 (respectively p: 0.032;p: 0.011). The hospitalization periods of the group with enterovirus and HHV-6 were shorter than the hospitalization periods of the other causative microorganisms (respectively p: 0.016;p: 0.000) and the absolute neutrophil count values of the group with HHV-6 were lower than the group of other causative microorganisms (p: 0.015). Conclusion Our study identified HHV-6 as the main cause of CNS infection in Istanbul during coronavirus disease 2019 pandemic when isolation measures were taken. The duration of hospital stay was found to be shorter in CNS infection caused by viral agents. Revealing the causative agent in the CSF is a fast and effective method that prevents unnecessary antibiotic treatment and shortens the hospitalization period of patients.

Special Issue: Microbiologists making waves around the South Pacific. (Special Issue: Microbiologists making waves around the South Pacific.)

This special issue includes 11 articles focusing on development of container laboratories in response to COVID-19;COVID-19 in Fiji;Pacific Regional Infectious Disease Association (PRIDA) - capacity-building for microbiology and infectious disease across the Pacific;meningococcal surveillance in Southeast Asia and the Pacific;tropical fever in remote tropics;movement of arboviruses between Indonesia and Western Australia;Rotavirus surveillance informs diarrhoea disease burden in the WHO Western-Pacific region;surveillance for One Health and high consequence veterinary pathogens (Brucellosis, Coxiellosis and Foot and Mouth Disease) in Southeast Asia - Lao PDR and Cambodia in focus and the importance of international partnerships;Avian influenza H5N1.

Meningococcal disease. Seasons 2018-2019, 2019-2020

Invasive meningococcal disease (IMD) is a disease caused by Neisseria meningitidis. IMD has been notifiable since 1901 and must be reported to the National Epidemiological Surveillance Network (RENAVE). This study shows the results obtained during the 2018-2019 and 2019-2020 seasons. During the 2018-2019 season, the incidence of invasive meningococcal disease continued the increasing trend observed during the previous five seasons. Mainly due to the increase of cases of serogroup W and Y. The incidence of cases reported during the 2019/2020 season decreased by 31,3% compared to the previous 2018/2019 season. Incidence decreased in all serogroups and in all age groups. This decrease could be due to the addition of several factors. First, this season coincided, in part, with the onset of the COVID pandemic, and measures to contain the spread of SARS-CoV-2 affected its transmission. Second, the tetravalent conjugate vaccine (Men ACWY) was introduced into the vaccination schedule in adolescents (12 years old) and finally, other limitations of surveillance during this year could affect the decrease.

Treatment and prevention of community-acquired bacterial meningitis

Bacterial meningitis is a serious infection that requires immediate treatment. Recommended empiric antimicrobial therapy is based upon the most likely pathogen, according to a patient’s age and immune status. Antimicrobial therapy should be modified after identification of the causative microorganism and results of susceptibility tests. Preventive measures include the use of vaccines that target Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae, as well as the use of chemoprophylaxis in selected situations. Pharmacists are in a key position to recommend appropriate antimicrobial therapy for the treatment and prophylaxis of bacterial meningitis and to ensure that patients are receiving recommended vaccinations.

What's New in Neuraxial Labor Analgesia.

PURPOSE OF REVIEW: This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. RECENT FINDINGS: There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. SUMMARY: Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70-75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.

3' Tth Endonuclease Cleavage Polymerase Chain Reaction (3TEC-PCR) Technology for Single-Base-Specific Multiplex Pathogen Detection using a Two-Oligonucleotide System.

Polymerase chain reaction (PCR) is the standard in nucleic acid amplification technology for infectious disease pathogen detection and has been the primary diagnostic tool employed during the global COVID-19 pandemic. Various PCR technology adaptations, typically using two-oligonucleotide dye-binding methods or three-oligonucleotide hydrolysis probe systems, enable real-time multiplex target detection or single-base specificity for the identification of single-nucleotide polymorphisms (SNPs). A small number of two-oligonucleotide PCR systems facilitating both multiplex detection and SNP identification have been reported; however, these methods often have limitations in terms of target specificity, production of variable or false-positive results, and the requirement for extensive optimisation or post-amplification analysis. This study introduces 3' Tth endonuclease cleavage PCR (3TEC-PCR), a two-oligonucleotide PCR system incorporating a modified primer/probe and a thermostable cleavage enzyme, Tth endonuclease IV, for real-time multiplex detection and SNP identification. Complete analytical specificity, low limits of detection, single-base specificity, and simultaneous multiple target detection have been demonstrated in this study using 3TEC-PCR to identify bacterial meningitis associated pathogens. This is the first report of a two-oligonucleotide, real-time multiplex PCR technology with single-base specificity using Tth endonuclease IV.