Therapeutic efficacy of macrolides in management of patients with mild COVID-19

Significant differences in usage of antibiotics in three Chinese cities measured by wastewater-based epidemiology

Antibiotic use, particularly inappropriate use by irrational prescribing or over-the-counter purchases, is of great concern for China as it facilitates the spread of antibiotic resistances. In this study, we applied wastewater-based epidemiology (WBE) to monitor the total consumption of eight common antibiotics in three cities in northern, eastern and southern China. Wastewater samples were successively collected from 17 wastewater treatment plants including weekdays and weekends spanning four seasons between 2019 and 2021. The concentration of antibiotics and their corresponding metabolites showed a significant correlation, confirming the measured antibiotics were actually consumed. Different seasonal trends in antibiotic use were found among the cities. It was more prevalent in the winter in the northern city Beijing, with the high antibiotic consumption attributed to peak influenza occurrence in the city. This is clear evidence of irrational prescription of antibiotics since it's known that antibiotics do little to treat influenza. In terms of overall consumption, Foshan is significantly lower, thanks to warmer climate and higher use of herbal tea as a prevention measure. WBE estimates of antibiotic consumption were relatively comparable with other data sources, with azithromycin as the top antibiotic measured here. The studied cities had higher WBE estimated antibiotics consumption than results of previous studies in the literature. Monitoring antibiotic use in different areas and periods through WBE in combination with complementary information, can better inform appropriate antibiotic guideline policies in various regions and nations.

Exploring patterns of antibiotics during and after COVID-19 pandemic in wastewaters of northern Greece: Potential adverse effects on aquatic environment

Antibiotics, recognized as Emerging Contaminants (ECs), have raised concerns due to their pervasive presence in wastewater treatment plants (WWTPs) and subsequent release into aquatic environments, posing potential ecological risks and contributing to the development of antibiotic-resistant genes. The COVID-19 pandemic prompted an unprecedented surge in antibiotic consumption, necessitating a comprehensive assessment of its impact on antibiotic levels in wastewater. In this light, a four-year monitoring study (2020-2023) was conducted in a WWTP located in the Northern Greece (Thessaloniki), employing High-Resolution Mass Spectrometry (HRMS) technology to monitor twenty antibiotics, during distinct phases pre-, during, and post-COVID-19. Our findings revealed that macrolides and fluoroquinolones were among the most often detected categories during the sampling period. Among the compounds detected, azithromycin and clarithromycin showed the most significant increases during the pandemic, doubling their average concentrations. This establishes a clear correlation between the rise in their concentrations and the incidence of COVID-19 cases. A general downward trend after 2021 was attributed to the new restrictions posed in Greece during this year, regarding the liberal prescription of antibiotics. Seasonal variation revealed a minute augmentation of antibiotics' use during the months that infections are increased. Additionally, the study highlights the ecological risks associated with elevated antibiotic presence and emphasizes the need for continued monitoring and regulatory measures to mitigate potential ecological repercussions. These findings contribute to our understanding of the complex interplay between antibiotic consumption, environmental presence, and the COVID-19 pandemic's impact on antibiotic pollution in WWTPs.

Outpatient Intravenous Remdesivir to Prevent Progression to Severe COVID-19: An Observational Study from a Greek Hospital

BACKGROUND

Remdesivir, a viral RNA polymerase inhibitor, has been a powerful weapon in the battle against the SARS-CoV-2 pandemic. Originally approved for use in hospitalized patients, remdesivir improves clinical outcomes in patients with moderate to severe coronavirus disease 2019 (COVID-19). After proving efficacious in hospitalized patients, its use was approved in early disease for symptomatic, non-hospitalized patients that present risk factors for progression to severe disease.

OBJECTIVE

To evaluate whether administration of the antiviral medication remdesivir at an outpatient basis has an effect on hospital admissions of patients presenting with SARSCoV- 2 infection.

METHODS

We conducted an observational clinical trial involving 107 non-hospitalized COVID-19 patients who attended the emergency department of a third-level greek hospital seeking care for symptoms appearing within the previous 5 days and who had at least one risk factor for progression to severe disease. After arterial blood gas evaluation, eligible patients received intravenous remdesivir at a dose of 200 mg on day 1 and 100 mg on days 2 and 3. The efficacy endpoint was set as COVID-19-related hospitalization or death in the next 14 days.

RESULTS

A total of 107 patients (57.0% men) participated in the study, 51 (47.7%) of them fully vaccinated. Most prevalent were age ≥ 60 years old, cardiovascular/cerebrovascular disease, immunosuppression or malignancy, obesity, diabetes mellitus, and chronic lung disease. All patients enrolled completed the 3-day course, with a total of 3 out of 107 patients (2.8%) eventually having a COVID-19-related hospitalization by day 14, while no deaths were reported by day 14.

CONCLUSION

Among non-hospitalized patients with at least one risk factor for progression to severe COVID-19, a 3-day course of intravenous remdesivir yielded favourable results.

Use of a rapid triage assessment tool to discriminate the need for hospitalisation in patients with severe COVID-19 infection presenting to an outpatient clinic: a single-centre, prospective cohort study

OBJECTIVES

The WHO designated individuals with low oxygen saturation, SpO2<94%, as severe SARS-CoV2 infection (COVID-19) and recommendations to seek care in a hospital setting were advised. A rapid, office-based method to select patients with severe COVID-19 who need intensive care was necessary during the peak of the pandemic.

DESIGN, SETTING AND PARTICIPANTS

This is a prospective cohort study of patients with confirmed severe COVID-19 between September 2020 and April 2021.

OUTCOME MEASURES AND ANALYSIS

Oxygen saturation was obtained at rest (SpO2r), following exertion from a 20 m walk test (SpO2e), and the difference was calculated (SpO2Δ). Radiographs and laboratory values were obtained and recorded. Logistic regression models were used to determine variables associated with hospitalisation. A lung injury score was used to quantify pulmonary involvement.

RESULTS

Out of 103 patients enrolled with severe COVID-19 infection, 19 (18.4%) were admitted to the hospital (no deaths). Patients managed as outpatients had a standard treatment protocol. The SpO2Δ and SpO2e were associated with hospitalisation (p<0.005) while SpO2r was no different between non-hospitalised and hospitalised patients (90.7%±2.7% vs 90.8%±2.3%, p=0.87). By contrast, exertional SpO2e was significantly different between non-hospitalised and hospitalised (87.3%±2.6% vs 84.4%±3.4%, p=0.0005). The mean lung injury score was 11.0±3.5 (18-point scale) and did not discriminate against those who would need hospitalisation. Lower lung fields were significantly more involved than the upper (p<0.0001). All patients had elevated biomarkers of inflammation, C reactive protein (CRP) median 82.5 IQR (43-128.6) mg/L and evidence of elevated liver enzymes. A logistic regression model was constructed including SpO2Δ, CRP and alanine aminotransferase to predict hospitalisation. Only SpO2Δ was significant, p=0.012, 95% CI (1.128 to 2.704) and correctly classified 85.71% of patients who could remain at home or would need to receive treatment in the hospital.

CONCLUSION

An office-based, 20 m walk test can help diverge patients with severe COVID-19 who need escalated care. Further, an aggressive standardised treatment protocol can be used to successfully manage patients outside of hospitals despite having severe COVID-19.

Antihistamines as an early treatment for Covid-19

Infection with SARs-COV-2 results in COVID-19 disease. Between March 2020 and August 2021, 468 COVID-19 patients confirmed by PCR or antigen test, in Yepes, Spain, received early treatment with antihistamines, adding azithromycin in selected cases. The primary endpoint is the hospitalization rate of COVID-19 patients, and the secondary endpoints are ICU admission and mortality rates. All endpoints are compared with the official Spanish rates during the time period of the study. There were 20 hospital admissions (hospitalization rate 4,3%), 5 ICU admissions (ICU admission rate 1,1%) and 3 deaths (fatality rate of 0,6%). No patients in the study required follow up treatment, which suggest they did not develop long COVID. Results from this retrospective trail indicate that early treatment of SARS-COV-2 positive patients with antihistamines may reduce the odds of hospitalization (OR: 0.490, CI: 0.313-0.767, p-value: 0.001). Randomized controlled clinical trials are needed to further evaluate the effects of early antihistamine treatment of SARS-CoV-2 patients to prevent hospitalization, ICU admission, mortality and long-covid.

Pneumolysin as a target for new therapies against pneumococcal infections: A systematic review

BACKGROUND

This systematic review evaluates pneumolysin (PLY) as a target for new treatments against pneumococcal infections. Pneumolysin is one of the main virulence factors produced by all types of pneumococci. This toxin (53 kDa) is a highly conserved protein that binds to cholesterol in eukaryotic cells, forming pores that lead to cell destruction.

METHODS

The databases consulted were MEDLINE, Web of Science, and Scopus. Articles were independently screened by title, abstract, and full text by two researchers, and using consensus to resolve any disagreements that occurred. Articles in other languages different from English, patents, cases report, notes, chapter books and reviews were excluded. Searches were restricted to the years 2000 to 2021. Methodological quality was evaluated using OHAT framework.

RESULTS

Forty-one articles describing the effects of different molecules that inhibit PLY were reviewed. Briefly, the inhibitory molecules found were classified into three main groups: those exerting a direct effect by binding and/or blocking PLY, those acting indirectly by preventing its effects on host cells, and those whose mechanisms are unknown. Although many molecules are proposed as toxin blockers, only some of them, such as antibiotics, peptides, sterols, and statins, have the probability of being implemented as clinical treatment. In contrast, for other molecules, there are limited studies that demonstrate efficacy in animal models with sufficient reliability.

DISCUSSION

Most of the studies reviewed has a good level of confidence. However, one of the limitations of this systematic review is the lack of homogeneity of the studies, what prevented to carry out a statistical comparison of the results or meta-analysis.

CONCLUSION

A panel of molecules blocking PLY activity are associated with the improvement of the inflammatory process triggered by the pneumococcal infection. Some molecules have already been used in humans for other purposes, so they could be safe for use in patients with pneumococcal infections. These patients might benefit from a second line treatment during the initial stages of the infection preventing acute respiratory distress syndrome and invasive pneumococcal diseases. Additional research using the presented set of compounds might further improve the clinical management of these patients.

Antibiotics Use in COVID-19 Patients: A Systematic Literature Review

The issue of bacterial infections in COVID-19 patients has received increasing attention among scientists. Antibiotics were widely prescribed during the early phase of the pandemic. We performed a literature review to assess the reasons, evidence and practices on the use of antibiotics in COVID-19 in- and outpatients. Published articles providing data on antibiotics use in COVID-19 patients were identified through computerized literature searches on the MEDLINE and SCOPUS databases. Searching the MEDLINE database, the following search terms were adopted: ((antibiotic) AND (COVID-19)). Searching the SCOPUS database, the following search terms were used: ((antibiotic treatment) AND (COVID-19)). The risk of bias in the included studies was not assessed. Both quantitative and qualitative information were summarized by means of textual descriptions. Five-hundred-ninety-three studies were identified, published from January 2020 to 30 October 2022. Thirty-six studies were included in this systematic review. Of the 36 included studies, 32 studies were on the use of antibiotics in COVID-19 inpatients and 4 on antibiotic use in COVID-19 outpatients. Apart from the studies identified and included in the review, the main recommendations on antibiotic treatment from 5 guidelines for the clinical management of COVID-19 were also summarized in a separate paragraph. Antibiotics should not be prescribed during COVID-19 unless there is a strong clinical suspicion of bacterial coinfection or superinfection.

Consumption trends of pharmaceuticals and psychoactive drugs in Latvia determined by the analysis of wastewater

Wastewater-based epidemiology (WBE) was applied to evaluate seasonal variations of the consumption of pharmaceuticals (i.e. antibiotics, NSAIDs, antiepileptics, antihypertensives and others), caffeine, alcohol and nicotine in Latvia throughout 2021. In addition, weekly variation of caffeine, nicotine and alcohol consumption was investigated. Pronounced seasonality was observed in the consumption of antibiotics and decongestants, as well as caffeine, nicotine and alcohol. Correlation with COVID-19 statistics was observed in the case of macrolide antibiotics and antiasthmatic salbutamol. Comparison of the estimated consumption values obtained using the WBE approach and the statistics revealed that the majority of compounds data are in good agreement except angiotensin II receptor blocker group antihypertensives where the most overestimated consumption values were observed.

Antibiotics for the treatment of COVID-19

BACKGROUND

The effect of antibiotics with potential antiviral and anti-inflammatory properties are being investigated in clinical trials as treatment for COVID-19. The use of antibiotics follows the intention-to-treat the viral disease and not primarily to treat bacterial co-infections of individuals with COVID-19. A thorough understanding of the current evidence regarding effectiveness and safety of antibiotics as anti-viral treatments for COVID-19 based on randomised controlled trials (RCTs) is required.

OBJECTIVES

To assess the efficacy and safety of antibiotics compared to each other, no treatment, standard of care alone, placebo, or any other active intervention with proven efficacy for treatment of COVID-19 outpatients and inpatients.  SEARCH METHODS: We searched the Cochrane COVID-19 Study Register (including MEDLINE, Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies to 14 June 2021.

SELECTION CRITERIA

RCTs were included that compared antibiotics with each other, no treatment, standard of care alone, placebo, or another proven intervention, for treatment of people with confirmed COVID-19, irrespective of disease severity, treated in the in- or outpatient settings. Co-interventions had to be the same in both study arms. We excluded studies comparing antibiotics to other pharmacological interventions with unproven efficacy.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias of primary outcomes using the Cochrane risk of bias tool (ROB 2) for RCTs. We used GRADE to rate the certainty of evidence for the following primary outcomes: 1. to treat inpatients with moderate to severe COVID-19: mortality, clinical worsening defined as new need for intubation or death, clinical improvement defined as being discharged alive, quality of life, adverse and serious adverse events, and cardiac arrhythmias; 2. to treat outpatients with asymptomatic or mild COVID-19: mortality, clinical worsening defined as hospital admission or death, clinical improvement defined as symptom resolution, quality of life, adverse and serious adverse events, and cardiac arrhythmias.

MAIN RESULTS

We included 11 studies with 11,281 participants with an average age of 54 years investigating antibiotics compared to placebo, standard of care alone or another antibiotic. No study was found comparing antibiotics to an intervention with proven efficacy. All studies investigated azithromycin, two studies investigated other antibiotics compared to azithromycin. Seven studies investigated inpatients with moderate to severe COVID-19 and four investigated mild COVID-19 cases in outpatient settings. Eight studies had an open-label design, two were blinded with a placebo control, and one did not report on blinding. We identified 19 ongoing and 15 studies awaiting classification pending publication of results or clarification of inconsistencies. Of the 30 study results contributing to primary outcomes by included studies, 17 were assessed as overall low risk and 13 as some concerns of bias. Only studies investigating azithromycin reported data eligible for the prioritised primary outcomes. Azithromycin doses and treatment duration varied among included studies.  Azithromycin for the treatment of COVID-19 compared to placebo or standard of care alone in inpatients We are very certain that azithromycin has little or no effect on all-cause mortality at day 28 compared to standard of care alone (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.90 to 1.06; 8600 participants; 4 studies; high-certainty evidence). Azithromycin probably has little or no effect on clinical worsening or death at day 28 (RR 0.95; 95% CI 0.87 to 1.03; 7311 participants; 1 study; moderate-certainty evidence), on clinical improvement at day 28 (RR 0.96; 95% CI 0.84 to 1.11; 8172 participants; 3 studies; moderate-certainty evidence), on serious adverse events during the study period (RR 1.11; 95% CI 0.89 to 1.40; 794 participants; 4 studies; moderate-certainty evidence), and cardiac arrhythmias during the study period (RR 0.92; 95% CI 0.73 to 1.15; 7865 participants; 4 studies; moderate-certainty evidence) compared to placebo or standard of care alone. Azithromycin may increase any adverse events slightly during the study period (RR 1.20; 95% CI 0.92 to 1.57; 355 participants; 3 studies; low-certainty evidence) compared to standard of care alone. No study reported quality of life up to 28 days. Azithromycin for the treatment of COVID-19 compared to placebo or standard of care alone in outpatients Azithromycin may have little or no effect compared to placebo or standard of care alone on all-cause mortality at day 28 (RR 1.00 ; 95% CI 0.06 to 15.69; 876 participants; 3 studies; low-certainty evidence), on admission to hospital or death within 28 days (RR 0.94 ; 95% CI 0.57 to 1.56; 876 participants; 3 studies; low-certainty evidence), and on symptom resolution at day 14 (RR 1.03; 95% CI 0.95 to 1.12; 138 participants; 1 study; low-certainty evidence). We are uncertain whether azithromycin increases or reduces serious adverse events compared to placebo or standard of care alone (0 participants experienced serious adverse events; 454 participants; 2 studies; very low-certainty evidence). No study reported on adverse events, cardiac arrhythmias during the study period or quality of life up to 28 days. Azithromycin for the treatment of COVID-19 compared to any other antibiotics in inpatients and outpatients One study compared azithromycin to lincomycin in inpatients, but did not report any primary outcome. Another study compared azithromycin to clarithromycin in outpatients, but did not report any relevant outcome for this review.

AUTHORS' CONCLUSIONS

We are certain that risk of death in hospitalised COVID-19 patients is not reduced by treatment with azithromycin after 28 days. Further, based on moderate-certainty evidence, patients in the inpatient setting with moderate and severe disease probably do not benefit from azithromycin used as potential antiviral and anti-inflammatory treatment for COVID-19 regarding clinical worsening or improvement. For the outpatient setting, there is currently low-certainty evidence that azithromycin may have no beneficial effect for COVID-19 individuals. There is no evidence from RCTs available for other antibiotics as antiviral and anti-inflammatory treatment of COVID-19. With accordance to the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. However, in relation to the evidence for azithromycin and in the context of antimicrobial resistance, antibiotics should not be used for treatment of COVID-19 outside well-designed RCTs.

Efficacy of COVID-19 Treatments: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background: We provided a comprehensive evaluation of efficacy of available treatments for coronavirus disease 2019 (COVID-19).

Methods: We searched for candidate COVID-19 studies in WHO COVID-19 Global Research Database up to August 19, 2021. Randomized controlled trials for suspected or confirmed COVID-19 patients published on peer-reviewed journals were included, regardless of demographic characteristics. Outcome measures included mortality, mechanical ventilation, hospital discharge and viral clearance. Bayesian network meta-analysis with fixed effects was conducted to estimate the effect sizes using posterior means and 95% equal-tailed credible intervals (CrIs). Odds ratio (OR) was used as the summary measure for treatment effect. Bayesian hierarchical models were used to estimate effect sizes of treatments grouped by the treatment classifications.

Results: We identified 222 eligible studies with a total of 102,950 patients. Compared with the standard of care, imatinib, intravenous immunoglobulin and tocilizumab led to lower risk of death; baricitinib plus remdesivir, colchicine, dexamethasone, recombinant human granulocyte colony stimulating factor and tocilizumab indicated lower occurrence of mechanical ventilation; tofacitinib, sarilumab, remdesivir, tocilizumab and baricitinib plus remdesivir increased the hospital discharge rate; convalescent plasma, ivermectin, ivermectin plus doxycycline, hydroxychloroquine, nitazoxanide and proxalutamide resulted in better viral clearance. From the treatment class level, we found that the use of antineoplastic agents was associated with fewer mortality cases, immunostimulants could reduce the risk of mechanical ventilation and immunosuppressants led to higher discharge rates.

Conclusions: This network meta-analysis identified superiority of several COVID-19 treatments over the standard of care in terms of mortality, mechanical ventilation, hospital discharge and viral clearance. Tocilizumab showed its superiority compared with SOC on preventing severe outcomes such as death and mechanical ventilation as well as increasing the discharge rate, which might be an appropriate treatment for patients with severe or mild/moderate illness. We also found the clinical efficacy of antineoplastic agents, immunostimulants and immunosuppressants with respect to the endpoints of mortality, mechanical ventilation and discharge, which provides valuable information for the discovery of potential COVID-19 treatments.