Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO: A retrospective single-center experience

Objectives: Data about COVID-19 patients treated with veno-arterial-ECMO (VA-ECMO) is limited. Reported survival rates range from 27.9% to 77.8%, depending on VA-ECMO indication. A subgroup of patients suffers from circulatory failure due to a COVID-19 associated hyperinflammatory state (CovHI). In these patients, differentiation between inflammation and sepsis is difficult but important. In this retrospective case series, differential diagnoses of COVID-19 associated refractory circulatory failure and survival rates in different indications for VA-ECMO are investigated. Method(s): Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO at the University Hospital Regensburg between March 2020 and May 2022. Specific treatment for COVID-19 was in accordance with respective guidelines. Mycotic infections were either invasive or met current definitions of COVID19-associated-pulmonary aspergillosis. Result(s): At VA-ECMO initiation, median age was 57.3 years (IQR: 51.4 - 61.8), SOFA score 16 (IQR: 13 - 17) and norepinephrine dosing 0.53mug/kg/min (IQR: 0.32 - 0.78). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Survival to hospital discharge was 39%. 17 patients were primarily supported with VA-ECMO only (survival 42%), 3 patients were switched from VV to VA-ECMO (survival 0%), and 8 patients were converted from VA to VAV or VV-ECMO (survival 50%). Indications for VA-ECMO support were pulmonary embolism (PE) (n=5, survival 80%), right heart failure due to secondary pulmonary hypertension (n=5, survival 20%), cardiac arrest (n=4, survival 25%), acute left heart failure (ALHF) (n=11, survival 36%) and refractory vasoplegia (n=3, survival 0%). Inflammatory markers at VA-ECMO initiation were higher in patients with ALHF or vasoplegia;in these patients a higher rate of invasive fungal infections (10/14, 71% vs. 4/14, 29%;p=0.023) compared to the other patients was found. Conclusion(s): Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decisions making. Circulatory failure due to vasoplegia should be considered very carefully as indication for VA-ECMO. A high rate of mycotic infections mandates an intense microbiological workup of these patients and must be considered as an important differential diagnosis to CovHI.

Nanosponges: As a Dynamic Drug Delivery Approach for Targeted Delivery

Recent advancements in nanotechnology have resulted in improved medicine delivery to the target site. Nanosponges are three-dimensional drug delivery systems that are nanoscale in size and created by cross-linking polymers. The introduction of Nanosponges has been a significant step toward overcoming issues such as drug toxicity, low bioavailability, and predictable medication release. Using a new way of nanotechnology, nanosponges, which are porous with small sponges (below one microm) flowing throughout the body, have demonstrated excellent results in delivering drugs. As a result, they reach the target place, attach to the skin's surface, and slowly release the medicine. Nanosponges can be used to encapsulate a wide range of medicines, including both hydrophilic and lipophilic pharmaceuticals. The medication delivery method using nanosponges is one of the most promising fields in pharmacy. It can be used as a biocatalyst carrier for vaccines, antibodies, enzymes, and proteins to be released. The existing study enlightens on the preparation method, evaluation, and prospective application in a medication delivery system and also focuses on patents filed in the field of nanosponges.Copyright © 2023 The Authors.

Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Background: Mucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%. Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19. Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates. Result(s): This study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001. Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%). Conclusion(s): Mucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.Copyright © 2023, The Author(s).

Use of novel oxygenated right ventricular assist device hybrid ECLS for adolescents with refractory hypoxemic respiratory dailure due to Covid-19 pneumonia

Objectives: To describe institutional experience using Oxygenated Right Ventricular Assist Device (OxyRVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU), including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular (RV) dysfunction or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to Cardiohelp systems with built in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult critical care colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia. (Figure Presented).

Disseminated Mucormycosis in a patient on long term immunosuppression: Severe fungal infections as multi-system disorders

Introduction: Mucormycosis is a rare, severe fungal infection with an incidence of 0.005 to 0.17 per million.1 but incidence has risen recently, particularly in the Asian subcontinent, due to use of immunosuppression for Covid19.2 Presentations can vary and are classified into: rhino-orbito-cerebral, pulmonary, cutaneous, disseminated, renal and gastrointestinal. Risk factors include diabetes, immunosuppression, iron overload, malnutrition, and prematurity.1,3 Although mucormycosis has an extremely high mortality rate and disseminated infection is usually fatal, treatment options exist if diagnosed early and surgical debridement may be curative. Objective(s): We present a case of mucormycois in a female patient in her 40s who was immunosuppressed with methotrexate for rheumatoid disease. This case is discussed to increase awareness of critical illness caused by opportunistic invasive fungal infections in immunosuppressed patients and promote timely identification and management. Method(s): We detail the clinical context and management of a patient with mucormycosis and discuss relevant literature. Result(s): A female patient in her 40s who had been experiencing upper respiratory tract symptoms for several weeks, including cough and brown sputum, was admitted with a presumptive diagnosis of methotrexate toxicity after a full blood count performed by the general practitioner demonstrated pancytopenia. Initially, National Early Warning System 2 score (NEWS2) was 2 but became intensely hypertensive during blood transfusion and then profoundly shocked with an escalating NEWS2. Broad-spectrum antibiotics and fluconazole were commenced for neutropenic sepsis and the patient was referred to critical care in multiple organ failure. Computerised tomography (CT) scan of the chest, abdomen and pelvis showed "left upper lobe consolidation, which with neutropenia might represent an angioinvasive aspergillosis". She had multiple areas of skin discolouration and desquamation. Haematology and Infectious Diseases opinions were sought, and a bone marrow biopsy was performed which showed severe toxic effects consistent with sepsis/life threatening infection. Progressive proptosis was noted, and CT scan of her head was requested. Sadly, she was never stable enough for CT transfer. Beta D Glucan and aspergillus antigen serology was negative. Broncho-alveolar lavage demonstrated Candida albicans and then, later, Rhizopus arrhizus was isolated and anti-fungal treatment changed to voriconazole and then amphotericin B. Upon reviewing the notes in light of the positive culture for Rhizopus, the patient had likely been exhibiting symptomatic Mucormycosis sinus infection for some time prior to this admission with disseminated infection. The patient's condition continued to deteriorate and she sadly died. Conclusion(s): * The Early Warning Score significantly underestimated how unwell the patient was upon arrival in ED, a systems-based assessment would have demonstrated that the patient had multiple system dysfunction and significant potential to deteriorate suddenly despite having stable observations * The methotrexate level has no clinical value in diagnosing or refuting a diagnosis of methotrexate toxicity * A full examination of the immunosuppressed patient including ENT is a necessity when searching for a source of infection * Invasive fungal infections can cause multi-system symptoms and atypical presentations * As a greater proportion of patients have received systemic immunosuppression for Covid-19, vigilance for more unusual pathogens, including Mucormycosis by clinicians is advised.

Fungal Infections (FI) Associated with Covid-19

The aim of this study was to conduct a survey of the fungal species associated with COVID-19 viral infection in 150 patients who were admitted to the intensive care unit (ICU) in Al-Diwaniyah Teaching Hospital in Al-Diwaniyah City, Iraq, for a five-month period from October 2021 to February 2022. The results indicated the dominance of Candida spp. over the rest of the isolated fungal species, with 97 isolates (64.66%). Aspergillus spp., with 15 isolates (10%), came in second. Rhizopus sp. with 2 isolates (1.33%). Then with 1 isolate (0.66%) for each of Penicillium sp., Coccidiodes sp., and Rhodotorula sp., Also, results show that the male has a higher percentage than the female (54.9%) and co-infections with fungi were more common in the 60-69 age group then in the 70-79 age group (34% versus 24%, respectively). Taking a deeper look at the patients' medical histories, it was shown that fungal co-infection was more prevalent in those with chronic sickness than in those without chronic disease (55.66% versus 43.14%, respectively).Copyright © RJPT All right reserved.

Use of Novel Oxygenated Right Ventricular Assist Device Hybrid ECLS for Adolescents with Refractory Hypoxemic Respiratory Failure due to Covid-19 Pneumonia

Objective: To describe institutional experience using Oxygenated Right Ventricular Assist Device Oxy-RVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU) including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular dysfunction (RV) or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to CardiohelpTM systems with built-in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients were cannulated directly to Oxy-RVAD ECLS support. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult-focused colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia.

A Study to Evaluate Post COVID-19 Manifestations at Tertiary Care Center of Central India- an Observational Study

Background: Emerging and re-emerging infectious diseases have plagued mankind and have been potential killers since historic times. Objective: To evaluate the remnant and new manifestations in discharged patient after acute COVID 19 up to 6 months. Material and Methods: This observational cross sectional study was conducted in at Tertiary Care Hospital in Central India in wards and OPDs. Patients who were diagnosed, treated and discharged for COVID -19 infection and now presented with either signs or symptoms consistent with COVID- 19 infection or those not explained by any alternative means. Duration of study was conducted from Nov 2020 to Dec 2022. Results: There are less number of patients with NL ratio more than 8, likely because of higher mortality associated with high NL ratio. Among the dreadful post covid manifestation diabetes seen in (8.4%), CNS involvement seen in (8.04%), Mucor mycosis (5.9%), pulmonary thromboembolism (1.7%). Other symptoms which were also seen were dyspnea (49.5%), anosmia (42.8%), hairfall (23.5%), sinusitis (19.3%), headache (17.6%), chest pain (15.1%), depression (13.4%) etc. Mucor mycosis is observed in patients who were previously diabetic or develops diabetes during acute covid infection. Conclusion: It is clear that care for patients with COVID-19 does not conclude at the time of hospital discharge, and interdisciplinary cooperation is needed for comprehensive care of these patients in the outpatient setting. As such, it is crucial for healthcare systems and hospitals to recognize the need to establish dedicated COVID- 19 clinics, where specialists from multiple disciplines are able to provide integrated care. [ FROM AUTHOR] Copyright of Journal of Cardiovascular Disease Research (Journal of Cardiovascular Disease Research) is the property of Journal of Cardiovascular Disease Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Infections in Patients With Cirrhosis Have a Changing Profile Over Time and Are Linked to a Higher Risk of Death Compared to Patients Without Cirrhosis

Introduction: Intensive care outcomes in patients with cirrhosis are relatively poor. The comparison between outcomes, especially related to infections, remains unclear in those with and without cirrhosis. With the emergence of resistant and fungal organisms, the changes in infection profiles over time are important to analyze. The aim of this study is to determine the impact of cirrhosis and infections on inpatient death over time in a qSOFA-matched cohort of patients with and without cirrhosis. Method(s): Inpatients admitted to ICUs throughout 2015-2021 were analyzed. Patients with cirrhosis were matched 1:1 by age, gender, and admission qSOFA to patients without;COVID-positive patients were excluded. Admission demographics, labs, the reasons for ICU transfer, infections, and inpatient death or hospice referral were obtained for each patient. Comparisons were made between patients with and without cirrhosis and those who died/referred to hospice versus not. Logistic regression for death/hospice was performed. In patients with cirrhosis, the culture results were compared over the years. Result(s): 1669 patients;833 cirrhosis and 836 non-cirrhosis patients were included. Patients with cirrhosis had higher rates of infection, positive culture, abdominal infection, and bacteremia. They also had higher gram-positive and fungal infections with a higher rate of VRE. They showed a greater organ failure load, death, and hospice referral compared to patients without cirrhosis. Logistic regression showed that cirrhosis (OR 4.0, p< 0.0001), admission qSOFA (1.60, p< 0.0001), WBC (1.02, p=0.003), reasons for ICU (altered mental status 1.69, hypotension 1.79, renal support 2.77, respiratory failure 1.79, CVA 1.96, all p< 0.0001) with Infection (1.77, p< 0.0001, >1 microbe isolated 1.86, p=0.05) were risk factors for death/hospice. The infection trend in the cirrhosis group showed a significant decrease in positive cultures and gram-negative infections and an increase in fungal and gram-positive infections over time. Conclusion(s): Despite matching for demographics and qSOFA, patients with cirrhosis had higher risks of death and organ failures. They were more likely to develop gram-positive and fungal infections with multiple organisms and VRE. Time trends in cirrhosis showed lower rates of positive cultures and gram-negative infections and an increase in fungal and gram-positive infections over time, which should encourage re-evaluation of diagnostic and prophylactic strategies in cirrhosis-related infections. (Figure Presented).

Fungal osteomyelitis of the skull in patients after COVID-19 associated pneumonia.

Purpose. To demonstrate possibilities of multispiral computed tomography in the detection of fungal osteomyelitis in two patients with second type of diabetes mellitus two and six months after COVID-19 associated pneumonia. Material and methods. We present two clinical observations of patients with second type of diabetes mellitus who complained about pain in the upper jaw, nasal purulent discharge, difficulty in nasal breathing which appeared two and six months after COVID-19 associated pneumonia. To identify pathological changes, patients were directed to the department of radiology for the purpose of performing MSCT of the skull. Results. In the presented clinical cases, using MSCT, the features of the radiological semiotics of skull bone changes were studied in patients with fungal infection on the background of type 2 diabetes mellitus, the use of corticosteroids and after the viral COVID-19 associated pneumonia. The diagnosis was verified by histological and cytological studies of biopsy (surgical) material. Discussion. Recently, there has been an increase in the number of cases of fungal osteomyelitis of the jaws and paranasal sinuses in patients after viral pneumonia caused by SARS-CoV-2. The most common fungal infection is mucormycosis, caused by fungi belonging to the order Mucorales. The rhinocerebral form of mucormycosis is common in patients with diabetes mellitus after treatment with corticosteroids with the background of immunosuppression. This form of mucormycosis contributes to the appearance of extensive bone-destructive changes in the middle and upper zones of the maxillofacial region, requiring further surgical treatment. Conclusion. The 2019 coronavirus infection (COVID-19) caused by SARS-CoV-2 and type 2 diabetes remain urgent healthcare problems worldwide. This combination in a patient after treatment of COVID-19 associated pneumonia with corticosteroids leads to immunosuppression and the development of concomitant infections, including fungal ones. Fungal osteomyelitis in such patients, as a rule, affects the skull and is characterized by an aggressive course and requires surgical treatment. The use of modern and high-tech methods of radiation imaging, such as MSCT, allows to obtain complete diagnostic information about the localization and prevalence of the lesion, which, in the future, determines the management tactics and surgical treatment of patients of this category.Copyright © 2022 Chinese Journal of Pediatric Surgery. All rights reserved.

Evaluation of risk factors associated with mortality in patients with ventilator-associated pneumonia caused by Pseudomonas aeruginosa with difficult-to-treat resistance

Introduction: Evaluation of prognostic factors in patients with ventilator- associated pneumonia (VAP) due to P. aeruginosa. The effectiveness of novel antipseudomonal antibiotics was reviewed. Method(s): Retrospective, single-center cohort analysis between April 2018 and June 2022. Data were obtained from the ENVIN-HELICS and electronic medical records. Demographic variables, underlying diseases and diagnosis to admission were registered. We considered each treatment appropriate according to Tamma PD et al. [1] criteria. We registered ventilator-associated tracheobronchitis (VAT) and pneumonia (VAP) episodes together with the recurrency of the infection. Result(s): From 61 patients included, 77% were admitted for ARDS due to COVID-19. The mean APACHE-II was 14.3 +/- 6.6. 7 patients required ECMO and 4 required RRT. The median length of stay in the ICU was 52 (ICR 36-84) days. 91 respiratory infections were recorded: 60 VAP and 31 VAT. On the first episode, carbapenem-resistance to meropenem was 40%;rising up to 58% on the second one. 6 patients developed a third episode (VAT) with a 100% of carbapenem- resistance. 13 (14%) respiratory infections showed resistance to the novel beta-lactamase inhibitor cephalosporins (8 to ceftalozanetazobactam and 5 to ceftazidime-avibactam). No resistance to cefiderocol was detected. During ICU stay, 21 patients (34%) developed secondary bacteremia from other foci and 7 (11%) invasive mycoses. Overall mortality was 49.2%. On the univariate analysis we found statistical significant relationships between mortality and COVID-19 admission, SOFA >= 7 points on the first VAP or the development of secondary bacteremia (Table 1). Conclusion(s): COVID-19 admission, SOFA >= 7 points on the first VAP or other secondary bacteremia were associated with mortality. The 14.3% of respiratory infections were resistant to the new beta-lactamase inhibitor cephalosporins. No resistance to cefiderocol was detected.

Fungal pneumonia in COVID-19 patients: Risk factors and early prediction

Objective To determine the risk factors for developing secondary fungal pneumonia in moderate to severe coronavirus disease 2019 (COVID-19) cases. Using predictors of fungal infection helps to guide the diagnosis and treatment in these cases and save their lives. Patients and methods A total of 257 patients with moderate to severe COVID-19 pneumonia were examined in this retrospective study at Al Qassimi Hospital of EHS. An assessment of clinical, laboratory, and radiologic findings was performed upon admission. The data were collected and analyzed. Results Overall, 32% of critically ill COVID cases had fungal infection;47% of them were candida, whereas aspergillosis and yeast were positive in 26.5% each. At the time of hospitalization, computed tomography chest findings had a strong correlation with fungal culture results in COVID-19 cases. Fungal infection in COVID-19 cases correlated strongly with metabolic acidosis, high erythrocyte sedimentation rate, high blood sugar, need for mechanical ventilation at admission, vasopressor use, renal replacement, long duration of steroid treatment, long stay in ICU, and long duration on mechanical ventilation. The longer the duration of PCR positivity, the higher the incidence of positive sputum fungal culture result. Conclusion COVID-19-infected patients with other risk factors for fungal infections should always be considered to have fungal infections if pathogenic organisms are isolated from respiratory secretions or other microbiological or immunological markers appear positive. Computed tomography chest finding in COVID-19 cases is an important predictor for fungal infection.Copyright © 2023 The Egyptian Journal of Chest Diseases and Tuberculosis.

Characterization of secondary bacterial and fungal infections in ICU hospitalized patients with COVID-19: retrospective observational study

Introduction: We aimed to describe the incidence, risk factors, and clinical outcomes of bacterial and fungal co-infections and superinfections in intensive care patients with COVID-19 in a retrospective observational study. Method(s): A retrospective cohort of intensive care patients with confirmed SARS-CoV-2 by PCR was analysed from January to March 2021. This was contrasted to a control group of influenza-positive patients admitted during 2012-2022. Patient demographics, microbiology and clinical outcomes were analysed. Result(s): A total of 70 patients with confirmed SARS-CoV-2 were included;6 (8.6%) of 70 had early bacterial isolates identified rising to 42 (60%) of 70 throughout admission. Blood cultures, respiratory samples, and urinary samples were obtained from 66 (94.3%), 18 (25.7%) and 61 (87.1%) COVID-19 patients. Positive blood culture was identified in 13 patients (18.6%). Bacteraemia resulting from respiratory infection was confirmed in 3 cases (all ventilator-associated). Line-related bacteraemia was identified in 9 patients (6 Acinetobacter baumannii, 4 Enterococcus spp. and 1 Pseudomonas aeruginosa and 1 Micrococcus lylae). No concomitant pneumococcal, Legionella or influenza co-infection was detected. Invasive fungal infections with Aspergillus spp. were identified in 2 cases. Pneumococcal coinfections (7/68;10.3%) were identified in the control group of confirmed influenza infection;clinically relevant bacteraemias (6/68;8.8%), positive respiratory cultures (15/68;22.1%). The rate of hospital- acquired infections was 51.4% for COVID-19 and 27.9% for influenza. Longer intensive care stay, type 2 diabetes, obesity and hematologic diseases were independent risk factors for superinfections in the COVID-19 cohort. Conclusion(s): Respiratory coinfections occurred in influenza but not in COVID-19 patients. The rate of hospital-acquired infections (51.4% for COVID-19;27.9% for influenza) was unexpectedly high in both groups.

Lung cavitation as a rare complication of severe COVID-19: report of 3 cases

Introduction: Lung cavitation is a rare radiological finding of COVID- 19 pneumonia associated with unfavorable outcome. Its pathogenesis is unclear and it is characterized by diffuse alveolar damage, intra-alveolar hemorrhage and necrosis of parenchymal cells. Method(s): We retrospectively reviewed the radiological findings of COVID-19 patients admitted to our ICU during the pandemic in order to identify the development of lung cavitary lesions. Result(s): From 11/2020 until 10/2022 1000 patients were admitted to our COVID-19 ICU (92% on invasive mechanical ventilation). According to our data there were three cases of lung cavity formation. The first case was a 78 years male with history of hypertension. Chest CT (Day26) showed a 11.6 cm cavity in the right middle lobe (Fig. 1). The second case was a 52 year old female with history of diabetes mellitus, obesity, hypertension and rheumatoid arthritis. Follow up chest CT (D29) revealed progressive development of multiple bilateral cavitary lesions. The third case was a 61 year old male with no medical history, who developed (D17) multiple cavitary lesions in both lower lobes, concomitant with left-sided pulmonary embolism. The presence of other well defined etiologies of cavitary lesions such as mycobacterial and fungal infections as well as neoplasmatic or autoimmune diseases had been widely excluded. However, since pulmonary cavitation is a late complication of severe COVID disease, we cannot overlook the fact that all patients suffered from superinfections by XDR Acinetobacter baumanii and/or Klebsiella pneumonia, as most of our patients with prolonged length of stay. Moreover, two of the three patients developed pneumothorax. All patients finally died. Conclusion(s): Although bacterial co-infection does not allow absolute association between cavitary formation and coronavirus disease, it seems that destructive triggers, such as bacteria or mechanical ventilation, may aggravate COVID underlying lung lesions leading to cavitation.

Co-infections and antimicrobial use in hospitalized patients with moderate-severe COVID-19

Introduction/Aim: Coinfection in COVID-19 has been reported internationally, however, data on prevalence and outcomes in Australia is lacking. This study aimed to determine the prevalence and microbiology of coinfections, associated antimicrobial use, and outcomes in hospitalised patients with moderate-severe COVID-19 admitted to the Sunshine Coast University Hospital (SCUH). Method(s): A retrospective observational cohort study of adult patients admitted to the SCUH from February to July 2022 with moderate-severe COVID-19 was conducted. Demographics, comorbidities, laboratory, microbiological and radiological results, antimicrobial use, and hospital length of stay were collected. All-cause 30-day mortality and ICU admission were also collected, and incidence rate ratios (IRR) were calculated. Result(s): Sixty-six patients (57% male;median age 78.3) were captured. 13 coinfections occurred in 11 (16.7%) patients. Microbiological testing was performed in 94% of patients;respiratory viral PCR in 78.8%, blood cultures in 69.7%, sputum cultures in 25.8%, urinary antigens in 13.6% and atypical serology in 12.1%. Bacterial pathogens were most prevalent (53.8% of coinfections), whilst viral and fungal infections accounted for 30.8% and 15.4%, respectively. The most common pathogens were Streptococcus pneumoniae, Pseudomonas aeruginosa and influenza A. Most patients (74.2%) received empirical antibiotic therapy (mean = 5.5 days), with similar rates of use between those with coinfection (66.7%) and those without (75.9%). Overall patient mortality was 10.6%, with coinfections demonstrating a higher 30-day mortality (IRR = 2.0). Coinfected patients were seven times more likely to experience ICU admission (IRR = 7.5) compared to patients without coinfections. Conclusion(s): The prevalence of confirmed coinfection in hospitalised patients with moderate-severe COVID 19 was low;however, antimicrobial use was high. Importantly, patients with coinfections were twice as likely to die, and seven times more likely to be admitted to ICU. This study indicates the importance of developing improved diagnostic tools to identify coinfection and to help guide appropriate antimicrobial use.

Immediate and Contributory Causes of Death in Patients Hospitalized with Covid-19

Background: Accurate determination of the immediate and contributory causes of death in patients with COVID-19 is important for optimal care and instituting mitigation strategies. Method(s): All deaths in Qatar between March 1, 2020 and August 31, 2022 flagged for likely relationship to COVID-19 by were evaluated by two independent reviewers trained to determine and assign the most likely immediate underlying cause of death. Each decedent's electronic medical records was comprehensively reviewed, and the cause of death was assigned based on the most plausible underlying event that triggered the event(s) that led to death based on clinical documentation and a review of laboratory, microbiology, pathology, and radiology data. After cause assignment, each case was categorized into major diagnostic groups by organ system, syndrome, or disease classification. Result(s): Among 749 deaths flagged for likely association with COVID-19, the most common admitting diagnoses were respiratory tract infection (91%) and major adverse cardiac event (MACE, 2.3%). The most common immediate cause of death was COVID pneumonia (66.2%), followed by MACE (7.1%), hospital associated pneumonia (HAP, 6.8%), bacteremia (6.3%), disseminated fungal infection (DFI, 5.2%), and thromboembolism (4.5%). The median length of hospital stay was 23 days (IQR 14,38). COVID pneumonia remained the predominant cause irrespective of the time from admission, though the proportion dropped with increasing length of stay in the hospital. Other than COVID pneumonia, MACE was the predominant cause of death in first two weeks but declined thereafter. No death occurred due to bacteremia, HAP, or DFI in the first week after hospitalization, but became increasing common with increased length of stay in the hospital accounting for 9%, 12%, and 10% of all deaths after 4 weeks in the hospital respectively. The majority of deaths (86%) occurred in the intensive care unit setting. COVID pneumonia accounted for approximately two-thirds of deaths in each setting. MACE and HAP were approximately equally represented in both settings while bacteremia and disseminated fungal infection were more common in the intensive care unit setting. Conclusion(s): Nearly one-third of patients with COVID infection die of non- COVID causes, some of which are preventable. Mitigation strategies should be instituted to reduce the risk of such deaths. (Figure Presented).

COVID-19 patients are at greater risk of developing fungal infections with prolonged course of steroids and invasive ventilation in intensive care unit (ICU)

Introduction: COVID-19 pandemic infection has affected over 650 million people with over 6 million deaths. Critically unwell patients are at increased risk of developing invasive fungal infections [1]. The aim of this study was to identify the number of patients admitted to ICU with COVID-19 who developed fungal infections and to compare these patients (fungal group) with those without fungal infections (non-fungal group) to investigate which factors may have contributed to increased risk of infection. Method(s): Retrospective study undertaken in a tertiary teaching hospital ICU. 174 patients admitted with severe COVID-19 infection during March 2020 until May 2021 were included. Result(s): 81(47%) patients developed fungal infections of which 94% had Candida and 6% had Aspergillus infection. Age and smoking history did not appear to be a contributing factor. The nonfungal group had significantly higher body mass index (33 +/- 8 vs 31 +/- 7, p = 0.01). ICU length of stay [23(1-116) vs 8(1-60), p < 0.001], hospital length of stay [30(3-183) vs 15(1-174) +/- 7, p < 0.001], steroid days [10(1-116) vs 4(0-28), p = 0.02] and ventilation days [18(0-120) vs 2(0-55), p < 0.001] were significantly higher in the fungal group. The mortality rate in both groups were similar (51% vs 51.6%). Conclusion(s): Fungal infections are extremely common in COVID- 19 patients admitted to ICU, seen in almost half of patients in this cohort (47%). Longer treatment with corticosteroids appears to increase the risk of developing fungal infections. Increased length of ICU stay, and a greater length of mechanical ventilation significantly increase the risk of fungal infections in COVID-19 patients in intensive care. Fungal infection, however was not associated with increase in mortality.

Evaluating Photopheresis Regimens for Advanced CTCL: The Role of the SARS-CoV-2 Pandemic-A Single-Center Retrospective Study

Extracorporeal photopheresis (ECP) is an established, safe, and effective treatment for cutaneous T-cell lymphoma (CTCL). There is no published literature reviewing the clinical efficacy of ECP at varying frequencies or the ideal duration of therapy. The SARS-CoV-2 pandemic necessitated a reduced frequency of ECP for patients with CTCL at our center. We performed a retrospective chart review of patients with CTCL receiving ECP at the Penn Dermatology Photopheresis Service (PDPS) on March 1, 2020, and followed up their course until January 31, 2021. Our retrospective cohort study suggests that one day of ECP with extending duration between treatments can be considered an alternative maintenance regimen in appropriate patients with stable disease on concomitant multimodality immunomodulatory therapy.

Regional spread of Candida auris.

The geographical routes and time schedule of spread of C. auris - the fungus first identified in 2009 are discussed. Data on the increasing frequency of C. auris infections and rapid dissemination of the fungus from the regions of origin - southern Asia, eastern Asia, southern Africa and southern America - towards different regions of all continents except Antarctica, especially after 2016, are presented. Three different clades are encountered in Great Britain, all four clades - in the USA. South Asian clade is currently present in Russia: the introduction was associated with labor migration from Middle Asia. The necessity of C. auris surveillance, essential for the establishment of sources and routes of transmission and dissemination of different clades is emphasized. A window of possibilities is still present to prevent further spread of the fungus with the ability to cause outbreaks of hospital infections including intensive care departments. Rapid implementation of preventive measures during the pandemic of COVID-19 are needed taking into account introduction of fungus in new countries and clinics, as well as increased frequency of C. auris infections in some hospitals for patients infected with SARS-CoV-2 virus.Copyright © 2021, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.