Recommendations and guidelines for the diagnosis and management of Coronavirus Disease-19 (COVID-19) associated bacterial and fungal infections in Taiwan.

Coronavirus disease-19 (COVID-19) is an emerging infectious disease caused by SARS-CoV-2 that has rapidly evolved into a pandemic to cause over 600 million infections and more than 6.6 million deaths up to Nov 25, 2022. COVID-19 carries a high mortality rate in severe cases. Co-infections and secondary infections with other micro-organisms, such as bacterial and fungus, further increases the mortality and complicates the diagnosis and management of COVID-19. The current guideline provides guidance to physicians for the management and treatment of patients with COVID-19 associated bacterial and fungal infections, including COVID-19 associated bacterial infections (CABI), pulmonary aspergillosis (CAPA), candidiasis (CAC) and mucormycosis (CAM). Recommendations were drafted by the 7th Guidelines Recommendations for Evidence-based Antimicrobial agents use Taiwan (GREAT) working group after review of the current evidence, using the grading of recommendations assessment, development, and evaluation (GRADE) methodology. A nationwide expert panel reviewed the recommendations in March 2022, and the guideline was endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline includes the epidemiology, diagnostic methods and treatment recommendations for COVID-19 associated infections. The aim of this guideline is to provide guidance to physicians who are involved in the medical care for patients with COVID-19 during the ongoing COVID-19 pandemic.

COVID-19 associated mold infections: Review of COVID-19 associated pulmonary aspergillosis and mucormycosis.

COVID-19-associated mold infection (CAMI) is defined as development of mold infections in COVID-19 patients. Co-pathogenesis of viral and fungal infections include the disruption of tissue barrier following SARS CoV-2 infection with the damage in the alveolar space, respiratory epithelium and endothelium injury and overwhelming inflammation and immune dysregulation during severe COVID-19. Other predisposing risk factors permissive to fungal infections during COVID-19 include the administration of immune modulators such as corticosteroids and IL-6 antagonist. COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated mucormycosis (CAM) is increasingly reported during the COVID-19 pandemic. CAPA usually developed within the first month of COVID infection, and CAM frequently arose 10-15 days post diagnosis of COVID-19. Diagnosis is challenging and often indistinguishable during the cytokine storm in COVID-19, and several diagnostic criteria have been proposed. Development of CAPA and CAM is associated with a high mortality despiteappropriate anti-mold therapy. Both isavuconazole and amphotericin B can be used for treatment of CAPA and CAM; voriconazole is the primary agent for CAPA and posaconazole is an alternative for CAM. Aggressive surgery is recommended for CAM to improve patient survival. A high index of suspicion and timely and appropriate treatment is crucial to improve patient outcome.

Down-regulation of SARS-CoV-2 neutralizing antibodies in vaccinated smokers

Vaccination is an effective approach to help control coronavirus disease 2019 (COVID-19). However, since the vaccines produce a heterogenous immune response, the risk of breakthrough infection is increased in vaccinated individuals who generate low levels of neutralizing antibodies (NAbs). It is therefore paramount in the fight against COVID-19 to identify individuals who have a higher risk of breakthrough infection despite being vaccinated. Here we addressed the effect of cigarette smoking on the production of neutralizing antibodies (NAbs) following COVID-19 vaccination since smoking profoundly suppresses the adaptive immune response to pathogen infection and the association between vaccination and smoking remains unclear. The SARS-CoV-2 Spike antibodies and NAbs (days 0, 14, 42, and 90) were measured in 164 participants received two vaccine doses of an inactivated vaccine (Sinovac-CoronaVac) longitudinally. Anti-Spike antibodies was elevated 14 and 42 days after COVID-19 vaccination compared to baseline (i.e., "Day 0"). Notably, RBD antibodies showed significantly higher expression in the nonsmoking group (n=153) than the smoking (n=11) group on day 42 (p<0.0001, Students t-test). NAbs continually increased after the first and second vaccine dose, peaking on day 42. NAbs titers then significantly decreased until day 90. Compared to nonsmokers, the NAb levels in smokers remained low throughout the period of testing. The median NAb titers in the smoking group was 1.40-, 1.32-, or 3.00-fold lower than that of nonsmoking group on day 14, 42, or 90, respectively. Altogether, our results indicate that smoking is a specific risk factor for COVID-19 breakthrough infection following vaccination.

Inhibitor screening of Spike variants reveals the heterogeneity of neutralizing antibodies to COVID-19 infection and vaccination

Mutations of the coronavirus responsible for coronavirus disease 2019 (COVID-19) could impede drug development and reduce the efficacy of COVID-19 vaccines. Here, we developed a multiplexed Spike-ACE2 Inhibitor Screening (mSAIS) assay that can measure the neutralizing effect of antibodies across numerous variants of the coronaviruss Spike (S) protein simultaneously. By screening purified antibodies and serum from convalescent COVID-19 patients and vaccinees against 72 S variants with the mSAIS assay, we identified new S mutations that are sensitive and resistant to neutralization. Serum from both infected and vaccinated groups with a high titer of neutralizing antibodies (NAbs) displayed a broader capacity to neutralize S variants than serum with low titer NAbs. These data were validated using serum from a large vaccinated cohort (n=104) with a tiled S peptide microarray. In addition, similar results were obtained using a SARS-CoV-2 pseudovirus neutralization assay specific for wild-type S and four prevalent S variants (D614G, B.1.1.7, B.1.351, P.1), thus demonstrating that high antibody diversity is associated with high NAb titers. Our results demonstrate the utility of the mSAIS platform in screening NAbs. Moreover, we show that heterogeneous antibody populations provide a more protective effect against S variants, which may help direct COVID-19 vaccine and drug development. HighlightsO_LIDeveloped a high throughput assay to screen the neutralizing effect of antibodies across multiple SARS-CoV-2 Spike variants simultaneously. C_LIO_LICharacterized the heterogeneity of neutralizing antibodies produced in response to COVID-19 infection and vaccination. C_LIO_LIDemonstrated the capacity of Spike variants neutralization is associated with the diversity of anti-Spike antibodies. C_LI

Clinical features of tuberculosis and Bacillus Calmette-Guérin (BCG) -associated adverse effects in children: A 12-year study.

PURPOSE: To investigate the clinical feature of tuberculosis and BCG adverse effects in children and to examine whether delayed BCG vaccination changes the incidence of BCG osteomyelitis. METHODS: We analyzed patients younger than 18 years with tuberculosis or BCG-associated adverse effects from 2008 to 2019. We compared their clinical features, laboratory tests and outcomes. RESULTS: Totally 137 patients were collected, with 27% of pulmonary tuberculosis (PTB), 31% of extrapulmonary tuberculosis (EPTB) and 42% of BCG-associated adverse effects. The median age was older in PTB than EPTB group (17.1 vs 15.4 years; p = 0.015). More patients in EPTB group had fever than PTB group (55% vs 25%; p = 0.008). Compared with exclusively EPTB, more patients in EPTB plus PTB group had fever (78% vs 38%; p = 0.009), and had more systemic symptoms (67% vs 25%; p = 0.007), lower absolute lymphocyte count (1230 vs 1850/µL; p = 0.033), higher CRP level (5.62 vs 2.21 mg/dL; p = 0.024) and longer hospital stay (20 vs 11 days; p = 0.031). In BCG osteomyelitis group, the median time interval from vaccination to diagnosis was 16.4 months (IQR 15.0-20.2). Age at vaccination, either at birth or 5-8 month-old, did not affect the proportion of BCG osteomyelitis among children with BCG-associated adverse effects. CONCLUSION: Children with EPTB plus PTB had more fever, lower lymphocyte count and higher CRP. The median time interval from vaccination to diagnosis of BCG osteomyelitis was 16.4 months and the proportion of BCG osteomyelitis among children with BCG-associated adverse effects was not affected by delayed vaccination in this study.

Severe Mycoplasma pneumoniae pneumonia requiring intensive care in children, 2010-2019.

BACKGROUND/PURPOSE: Despite the high prevalence of Mycoplasma pneumoniae infections, reports on severe life-threatening M. pneumoniae pneumonia (MPP) in children are limited. METHODS: We retrospectively enrolled pediatric patients with PCR-positive MPP requiring ICU admission in a children's hospital in Taipei, Taiwan from Jun 2010 to October 2019. Clinical manifestations and laboratory data of severe MPP were analyzed. Macrolide susceptibility was determined by genotyping, and its relationship with clinical manifestations was also analyzed. RESULTS: Approximately 5% (34/658) children hospitalized for MPP required ICU admission. Compared with non-ICU cases (n = 291), ICU cases (n = 34) were associated with more underlying conditions, more pleural effusion, longer fever duration, longer hospital stay, the requirement of second-line antibiotic treatment, and delayed effective and second-line antibiotic treatment. Macrolide resistance was similar in ICU and non-ICU groups (53% vs 53%; p = 0.986). In severe MPP, patients requiring endotracheal intubation were associated with more septic shock, empyema, ARDS, prolonged fever after effective antibiotic treatment, delayed second-line and effective antibiotic treatment. In 18 of the 22 patients with pleural fluid analysis, the pleural effusion was alkaline (pH > 7.7) and lymphocyte-predominant. CONCLUSION: M. pneumoniae infection can cause severe life-threatening pneumonia in children. Delayed effective and second-line antibiotic treatments are associated with severe life-threatening MPP.

Clinical features and risk factors associated with bacteremia of nontyphoidal salmonellosis in pediatric patients, 2010-2018.

BACKGROUND/PURPOSE(S): This study aimed to investigate clinical features and antimicrobial susceptibility of inpatient children with nontyphoidal salmonellosis from 2010 to 2018. METHODS: We retrospectively collected pediatric patients with nontyphoidal Salmonella infection confirmed by positive cultures in a tertiary medical center in Taiwan from 2010 to 2018. Patients' characteristics, clinical manifestations, and laboratory data were collected. Serogroup category and antimicrobial susceptibility were also analyzed. RESULTS: Of total 569 isolates, ampicillin resistant rate was 53% in average, third-generation cephalosporin resistant rate was 6.7%, ciprofloxacin resistant rate was 9% and trimethoprim-sulfamethoxazole resistant rate was 30%. Compared to the resistant rates in 2010, the resistance rate of third generation cephalosporin was significantly higher (3.4% vs. 11%, p = 0.003) but that of ciprofloxacin was significantly lower (20% vs. 11%, p < 0.001) in 2018. Among 297 inpatients with nontyphoidal salmonellosis, Group D (38%) was the most common in the bacteremia patients whereas Group B (48%) was the most common in the non-bacteremia patients. Among 244 immunocompetent inpatients with community-acquired salmonellosis, the bacteremia patients had significantly longer fever duration and diarrhea duration before hospitalization (p < 0.001), and significant higher rate of anemia (p = 0.028) due to either thalassemia trait or prolonged disease course than the non-bacteremia patients. CONCLUSION: Third-generation cephalosporin was still the drug of choice for nontyphoidal Salmonella infection in children though the resistant rate increased progressively. Significant risk factors associated with bacteremia were longer fever and diarrhea duration and anemia due to either thalassemia trait or prolonged disease course in immunocompetent children.

Effect of Anchang Decoction on Inflammation and Immunity in Rats with Ulcerative Colitis Based on miRNA-146a/JAK/STAT/SOCS-3 Signal Pathway / 中国实验方剂学杂志

Objective:To study the anti-inflammatory effects of low， middle， and high doses of Anchang decoction on ulcerative colitis in SD rats， and also explore the possible mechanism of Anchang decoction in the prevention and treatment of ulcerative colitis through the effect of different doses on miRNA-146a/non-receptor tyrosine protein kinase（JAK）/signal transduction and activator of transcription 3（STAT3）/cytokine signaling protein-3（SOCS-3） signal pathway and its downstream proteins. Method:The experimental rats were divided into control group ， model group ， mesalazine group（1 g·kg^-1） and Anchang decoction low（6 g·kg^-1）， middle（12 g·kg^-1）and high dose groups（24 g·kg^-1）， with 10 rats in each group. Except for the control group， 2，4，6-trinitrobenzenesulfonic acid （TNBS）/ethanol enema was used in all the other groups to establish a rat model of ulcerative colitis for 14 days respectively. The general changes of the mental state， stool traits， hair and other general conditions of the rats were observed， and score was graded with reference to the disease activity index （DAI） table. The pathological changes of colon tissue of rats in each group were observed by hematoxylin-eosin （HE） staining. The levels of serum tumor necrosis factor-<italic>α</italic>（TNF-<italic>α</italic>）， interleukin-10（IL-10）， interleukin-17（IL-17）， interleukin-1<italic>β</italic>（IL-1<italic>β</italic>）and interleukin-6（IL-6）were detected by enzyme linked immunosorbent assay （ELISA）. The expression levels of JAK2， phosphorylation STAT3 （p-STAT3）， STAT3 and inhibitor of SOCS-3 in colon tissue were detected by Western blot. Real-time fluorescence quantitative polymerase chain reaction （Real-time PCR） was used to detect the expression of JAK2， p-STAT3， STAT3， SOCS-3 mRNA in rat colon and miRNA-146a in rat plasma. Result:Compared with the normal group， the expression of JAK2， p-STAT3， STAT3 protein and the expression of JAK2， p-STAT3 and STAT3 mRNA in the model group increased （<italic>P</italic><0.05）， and the relative expression of miRNA-146a， SOCS-3 mRNA and SOCS-3 protein decreased in the model group （<italic>P</italic><0.05）. Compared with the model group， the mental state， food intake， coat color， etc. of rats in the administration groups were significantly improved， the DAI score was significantly reduced （<italic>P</italic><0.05）， the colonic ulcer tissues of rats in the administration groups were improved significantly， the expression levels of JAK2， p-STAT3， STAT3 protein and the expression of JAK2， p-STAT3 and STAT3 mRNA in the colon tissue of the administration groups were decreased （<italic>P</italic><0.05）， and the relative expression levels of miRNA-146a， SOCS-3 mRNA and SOCS-3 protein were increased in the administration groups （<italic>P</italic><0.05）. Conclusion:Anchang decoction can alleviate ulcerative colitis and reduce the activation of inflammatory factors by affecting the expression of genes and proteins related to miRNA-146a/JAK/STAT/SOCS-3 signal transduction pathway.

Proteome-wide analysis of differentially-expressed SARS-CoV-2 antibodies in early COVID-19 infection

Rapid and accurate tests that detect IgM and IgG antibodies to SARS-CoV-2 proteins are essential in slowing the spread of COVID-19 by identifying patients who are infected with COVID-19. Using a SARS-CoV-2 proteome microarray developed in our lab, we comprehensively profiled both IgM and IgG antibodies in forty patients with early-stage COVID-19, influenza, or non-influenza who had similar symptoms. The results revealed that the SARS-CoV-2 N protein is not an ideal biomarker for COVID-19 diagnosis because of its low immunogenicity, thus tests that rely on this marker alone will have a high false negative rate. Our data further suggest that the S protein subunit 1 receptor binding domain (S1-RBD) might be the optimal antigen for IgM antibody detection, while the S protein extracellular domain (S1+S2ECD) would be the optimal antigen for both IgM and IgG antibody detection. Notably, the combination of all IgM and IgG biomarkers can identify 87% and 73.3% COVID-19 patients, respectively. Finally, the COVID-19-specific antibodies are significantly correlated with the clinical indices of viral infection and acute myocardial injury (p[≤]0.05). Our data may help understand the function of anti-SARS-CoV-2 antibodies and improve serology tests for rapid COVID-19 screening.

SARS-CoV-2 proteome microarray for mapping COVID-19 antibody interactions at amino acid resolution

COVID-19 has quickly become a worldwide pandemic, which has significantly impacted the economy, education, and social interactions. Understanding the humoral antibody response to SARS-CoV-2 proteins may help identify biomarkers that can be used to detect and treat COVID-19 infection. However, no immuno-proteomics platform exists that can perform such proteome-wide analysis. To address this need, we created a SARS-CoV-2 proteome microarray to analyze antibody interactions at amino acid resolution by spotting peptides 15 amino acids long with 5-amino acid offsets representing full-length SARS-CoV-2 proteins. Moreover, the array processing time is short (1.5 hours), the dynamic range is ~2 orders of magnitude, and the lowest limit of detection is 94 pg/mL. Here, the SARS-CoV-2 proteome array reveals that antibodies commercially available for SARS-CoV-1 proteins can also target SARS-CoV-2 proteins. These readily available reagents could be used immediately in COVID-19 research. Second, IgM and IgG immunogenic epitopes of SARS-CoV-2 proteins were profiled in the serum of ten COVID-19 patients. Such epitope biomarkers provide insight into the immune response to COVID-19 and are potential targets for COVID-19 diagnosis and vaccine development. Finally, serological antibodies that may neutralize viral entry into host cells via the ACE2 receptor were identified. Further investigation into whether these antibodies can inhibit the propagation of SARS-CoV-2 is warranted. Antibody and epitope profiling in response to COVID-19 is possible with our peptide-based SARS-COV-2 proteome microarray. The data gleaned from the array could provide invaluable information to the scientific community to understand, detect, and treat COVID-19.

Reactions of amides with organoaluminum compounds: factors affecting the coordination mode of aluminum amidates.

Factors affecting the coordination mode of an amidato group on aluminum will be presented. The reaction of N-tert-butylalkylacetamide ((t)BuNHCR([double bond]O)) with 1.1 molar equiv of Me(3)Al in refluxing hexane affords a pentacoordinated, dimeric compound [Me(2)Al[eta(2)-(t)BuNC(R)(mu(2)-O)]](2) (3, R = p-(t)Bu-C(6)H(4); 4, R = 2,6-F,F-C(6)H(3); 5, R = Me; 6, R = CF(3); 7, R = p-F(3)C-C(6)H(4)). However, in the presence of 2.2 molar equiv of Me(3)Al, N-tert-butyl-4-tert-butylbenzamide ((t)BuNHC(p-(t)Bu-C(6)H(4))([double bond]O in refluxing hexane gives [Me(2)Al[eta(2)-(t)BuNC(p-(t)Bu-C(6)H(4))(mu(2)-O)]AlMe(3)], 8. In contrast, the reaction of R'NHCR' '([double bond]O) with 1 molar equiv of R(3)Al at room temperature produces tetracoordinated, dimeric, eight-membered ring aluminum compounds [R(2)Al[mu,eta(2)-R'NC(R' ')O]](2) (9, R = Me, R' = 2,6-(i)Pr, (i)()Pr-C(6)H(3), R' ' = Ph; 10, R = Me, R' = (i)Bu, R' ' = Ph; 11, R = Et, R' = Bn, R' ' = Ph; 12, R = Me, R' = Ph, R' ' = CF(3); 13, R = Me, R' = Bn, R' ' = CF(3)). On the other hand, 4'-chlorobenzanilide ((p-Cl-C(6)H(4))NHCPh([double bond]O)) reacts with R(3)Al to produce trimeric, twelve-membered ring aluminum compounds [R(2)Al[mu, eta(2)-(p-Cl-C(6)H(4))NC(Ph)O]](3) (14, R = Me; 15, R = Et). Furthermore, the reaction of 2'-methoxybenzanilide with 1 molar equiv of Me(3)Al in hexane yields a dinuclear aluminum complex [Me(2)Al(o-OMe-Ph)NC(Ph)(O)AlMe(3)], 16.