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Jang H, Song J, Kim S, Byun JH, Lee KG, Park KH, Woo E, Lim EK, Jung J, Kang T. ANCA: artificial nucleic acid circuit with argonaute protein for one-step isothermal detection of antibiotic-resistant bacteria. Nat Commun 2023; 14:8033. [PMID: 38052830 DOI: 10.1038/s41467-023-43899-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/23/2023] [Indexed: 12/07/2023] Open
Abstract
Endonucleases have recently widely used in molecular diagnostics. Here, we report a strategy to exploit the properties of Argonaute (Ago) proteins for molecular diagnostics by introducing an artificial nucleic acid circuit with Ago protein (ANCA) method. The ANCA is designed to perform a continuous autocatalytic reaction through cross-catalytic cleavage of the Ago protein, enabling one-step, amplification-free, and isothermal DNA detection. Using the ANCA method, carbapenemase-producing Klebsiella pneumoniae (CPKP) are successfully detected without DNA extraction and amplification steps. In addition, we demonstrate the detection of carbapenem-resistant bacteria in human urine and blood samples using the method. We also demonstrate the direct identification of CPKP swabbed from surfaces using the ANCA method in conjunction with a three-dimensional nanopillar structure. Finally, the ANCA method is applied to detect CPKP in rectal swab specimens from infected patients, achieving sensitivity and specificity of 100% and 100%, respectively. The developed method can contribute to simple, rapid and accurate diagnosis of CPKP, which can help prevent nosocomial infections.
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Affiliation(s)
- Hyowon Jang
- Bionanotechnology Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
| | - Jayeon Song
- Bionanotechnology Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
- Center for Systems Biology, Massachusetts General Hospital Research Institute, 175 Cambridge Street, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sunjoo Kim
- Department of Laboratory Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, 79 Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
| | - Jung-Hyun Byun
- Department of Laboratory Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, 79 Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
| | - Kyoung G Lee
- Division of Nano-Bio Sensors/Chips Development, National NanoFab Center (NNFC), 291 Daehak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
| | - Kwang-Hyun Park
- Disease Target Structure Research Center, KRIBB, 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
| | - Euijeon Woo
- Disease Target Structure Research Center, KRIBB, 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
- Department of Biomolecular Science, KRIBB School of Biotechnology, University of Science and Technology (UST), 217 Gajeong-ro, Yuseong-gu, Daejeon, 34113, Republic of Korea
| | - Eun-Kyung Lim
- Bionanotechnology Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
- Department of Nanobiotechnology, KRIBB School of Biotechnology, UST, 217 Gajeong-ro, Yuseong-gu, Daejeon, 34113, Republic of Korea
- School of Pharmacy, Sungkyunkwan University (SKKU), 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeongi-do, 16419, Republic of Korea
| | - Juyeon Jung
- Bionanotechnology Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea
- School of Pharmacy, Sungkyunkwan University (SKKU), 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeongi-do, 16419, Republic of Korea
| | - Taejoon Kang
- Bionanotechnology Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea.
- School of Pharmacy, Sungkyunkwan University (SKKU), 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeongi-do, 16419, Republic of Korea.
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Shmoury AH, Zakhour J, Sawma T, Haddad SF, Zahreddine N, Tannous J, Bou Fakhreddine H, Rizk N, Kanj SS. Bacterial respiratory infections in patients with COVID-19: A retrospective study from a tertiary care center in Lebanon. J Infect Public Health 2023; 16 Suppl 1:19-25. [PMID: 37923680 DOI: 10.1016/j.jiph.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Despite multiple reports of increased incidence of bacterial respiratory tract infections following COVID-19 globally, the microbiology is not yet fully elucidated. In this study, we describe the microbiology of bacterial infections and the prevalence of multidrug resistant organisms (MDROs) in hospitalized COVID-19 patients with community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP) which includes both non-ventilated hospital acquired pneumonia (NVHAP) and ventilator-associated pneumonia (VAP). To our knowledge, this is the first study that compares the microbiology of VAP and NVHAP in COVID-19 patients. METHODS This is a longitudinal retrospective cohort study conducted at the American University of Beirut Medical Center (AUBMC), a tertiary-care centre in Lebanon. Adult patients with confirmed COVID-19 and concurrent bacterial respiratory infections with an identifiable causative organism who were hospitalized between March 2020 and September 2021 were included. Bacterial isolates identified in hospital-acquired pneumonia (HAP) were divided into 3 groups based on the time of acquisition of pneumonia after admission: hospital day 3-14, 15-28 and 29-42. RESULTS Out of 1674 patients admitted with COVID-19, 159 (9.5%) developed one or more respiratory infections with an identifiable causative organism. Overall, Gram-negative bacteria were predominant (84%) and Stenotrophomonas maltophilia was the most common pathogen, particularly in HAP. Among 231 obtained isolates, 59 (26%) were MDROs, seen in higher proportion in HAP, especially among patients with prolonged hospital stay (> 4 weeks). Non-fermenter Gram-negative bacilli (NFGNB) (OR = 3.52, p-value<0.001), particularly S. maltophilia (OR = 3.24, p-value = 0.02), were significantly more implicated in VAP compared to NVHAP. CONCLUSIONS NFGNB particularly S. maltophilia were significantly associated with COVID-19 VAP. A high rate of bacterial resistance (25%), especially among Gram-negative bacteria, was found which may compromise patients' outcomes and has important implications in guiding therapeutic decisions in COVID-19 patients who acquire bacterial respiratory infections.
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Affiliation(s)
- Abdel Hadi Shmoury
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johnny Zakhour
- Department of Internal Medicine, Division of Infectious Diseases, Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tedy Sawma
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sara F Haddad
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nada Zahreddine
- Infection Control and Prevention Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Tannous
- Infection Control and Prevention Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hisham Bou Fakhreddine
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nesrine Rizk
- Department of Internal Medicine, Division of Infectious Diseases, Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Souha S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon.
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Ceccarelli G, Alessandri F, Migliara G, Baccolini V, Giordano G, Galardo G, Marzuillo C, De Vito C, Russo A, Ciccozzi M, Villari P, Venditti M, Mastroianni CM, Pugliese F, d’Ettorre G. Reduced Reliability of Procalcitonin (PCT) as a Biomarker of Bacterial Superinfection: Concerns about PCT-Driven Antibiotic Stewardship in Critically Ill COVID-19 Patients-Results from a Retrospective Observational Study in Intensive Care Units. J Clin Med 2023; 12:6171. [PMID: 37834815 PMCID: PMC10573961 DOI: 10.3390/jcm12196171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The aim of this study was to assess whether procalcitonin levels is a diagnostic tool capable of accurately identifying sepsis and ventilator-associated pneumonia (VAP) even in critically ill COVID-19 patients. METHODS In this retrospective, observational study, all critically ill COVID-19 patients who survived for ≥2 days in a single university hospital and had at least one serum procalcitonin (PCT) value and associated blood culture and/or culture from a lower respiratory tract specimen available were eligible for the study. RESULTS Over the research period, 184 patients were recruited; 67 VAP/BSI occurred, with an incidence rate of 21.82 episodes of VAP/BSI (95% CI: 17.18-27.73) per 1000 patient-days among patients who were included. At the time of a positive microbiological culture, an average PCT level of 1.25-3.2 ng/mL was found. Moreover, also in subjects without positive cultures, PCT was altered in 21.7% of determinations, with an average value of 1.04-5.5 ng/mL. Both PCT and PCT-72 h were not linked to a diagnosis of VAP/BSI in COVID-19 patients, according to the multivariable GEE models (aOR 1.13, 95% CI 0.51-2.52 for PCT; aOR 1.32, 95% CI 0.66-2.64 for PCT-72 h). CONCLUSION Elevated PCT levels might not always indicate bacterial superinfections or coinfections in a severe COVID-19 setting.
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Affiliation(s)
- Giancarlo Ceccarelli
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Francesco Alessandri
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
- Intensive Care Unit, Department of General, Specialistic Surgery, University of Rome Sapienza, 00185 Rome, Italy
| | - Giuseppe Migliara
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Valentina Baccolini
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Giovanni Giordano
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
- Intensive Care Unit, Department of General, Specialistic Surgery, University of Rome Sapienza, 00185 Rome, Italy
| | - Gioacchino Galardo
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
| | - Carolina Marzuillo
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, ‘Magna Graecia’ University of Catanzaro, 88100 Catanzaro, Italy;
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy;
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Mario Venditti
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Claudio M. Mastroianni
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
| | - Francesco Pugliese
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
- Intensive Care Unit, Department of General, Specialistic Surgery, University of Rome Sapienza, 00185 Rome, Italy
| | - Gabriella d’Ettorre
- Hospital Policlinico Umberto I, 00161 Rome, Italy; (G.C.); (G.G.); (G.M.); (V.B.); (G.G.); (M.V.); (C.M.M.); (F.P.); (G.d.)
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, 00185 Rome, Italy; (C.M.); (P.V.)
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Bavaro DF, Papagni R, Belati A, Diella L, De Luca A, Brindicci G, De Gennaro N, Di Gennaro F, Romanelli F, Stolfa S, Ronga L, Mosca A, Pomarico F, Dell'Aera M, Stufano M, Dalfino L, Grasso S, Saracino A. Cefiderocol Versus Colistin for the Treatment of Carbapenem-Resistant Acinetobacter baumannii Complex Bloodstream Infections: A Retrospective, Propensity-Score Adjusted, Monocentric Cohort Study. Infect Dis Ther 2023; 12:2147-2163. [PMID: 37653122 PMCID: PMC10505116 DOI: 10.1007/s40121-023-00854-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/01/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Bloodstream infections (BSI) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) are associated with high mortality with limited treatment. The aim of this study is to compare effectiveness and safety of colistin-based versus cefiderocol-based therapies for CRAB-BSI. METHODS This is a retrospective observational study enrolling patients with monomicrobial CRAB-BSIs treated with colistin or cefiderocol from 1 January 2020, to 31 December 2022. The 30-day all-cause mortality rate was the primary outcome. A Cox regression analysis was performed to identify factors independently associated with mortality. A propensity score analysis using inverse probability of treatment weighting (IPTW) was also performed. RESULTS Overall 118 patients were enrolled, 75 (63%) and 43 (37%) treated with colistin- and cefiderocol-based regimens. The median (q1-q3) age was 70 (62-79) years; 70 (59%) patients were men. The 30-day all-cause mortality was 52%, significantly lower in the cefiderocol group (40% vs 59%, p = 0.045). By performing a Cox regression model, age (aHR = 1.03, 95% CI 1.00-1.05), septic shock (aHR = 1.93, 95% CI 1.05-3.53), and delayed targeted therapy (aHR = 2.42, 95% CI 1.11-5.25) were independent predictors of mortality, while cefiderocol-based therapy was protective (aHR = 0.49, 95% CI 0.25-0.93). The IPTW-adjusted Cox analysis confirmed the protective effect of cefiderocol (aHR = 0.53, 95% CI 0.27-0.98). CONCLUSIONS Cefiderocol may be a valuable treatment option for CRAB-BSI, especially in the current context of limited treatment options.
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Affiliation(s)
- Davide Fiore Bavaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy.
| | - Roberta Papagni
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Alessandra Belati
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Lucia Diella
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Antonio De Luca
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Gaetano Brindicci
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Nicolò De Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Federica Romanelli
- Section of Microbiology and Virology, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Stefania Stolfa
- Section of Microbiology and Virology, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Luigi Ronga
- Section of Microbiology and Virology, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Adriana Mosca
- Section of Microbiology and Virology, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Francesco Pomarico
- Hospital Pharmacy Department, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Maria Dell'Aera
- Hospital Pharmacy Department, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Monica Stufano
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Salvatore Grasso
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University Hospital Polyclinic, University of Bari, Piazza Giulio Cesare n. 11, 70124, Bari, Italy
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Mangioni D, Chatenoud L, Colombo J, Palomba E, Guerrero FA, Bolis M, Bottino N, Breda G, Chiaruttini MV, Fior G, Marotta M, Massobrio G, Matinato C, Muscatello A, Previtali P, Santambrogio S, Tardini F, Zuglian G, Grasselli G, Fumagalli R, Gori A, Stocchetti N, Monti G, Bandera A. Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients 1. Emerg Infect Dis 2023; 29:1598-1607. [PMID: 37486196 PMCID: PMC10370845 DOI: 10.3201/eid2908.230115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.
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Bavaro DF, Diella L, Belati A, Metrangolo G, De Santis L, Spada V, Camporeale M, Dargenio A, Brindicci G, Balena F, Fiordelisi D, Signorile F, Loseto G, Pasciolla C, Minoia C, Attolico I, Perrone T, Simone S, Rendina M, Giovine N, Di Gennaro F, Musto P, Guarini A, Di Leo A, Gesualdo L, Dell'Aera M, Saracino A. Efficacy of Remdesivir and Neutralizing Monoclonal Antibodies in Monotherapy or Combination Therapy in Reducing the Risk of Disease Progression in Elderly or Immunocompromised Hosts Hospitalized for COVID-19: A Single Center Retrospective Study. Viruses 2023; 15:v15051199. [PMID: 37243285 DOI: 10.3390/v15051199] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Remdesivir (REM) and monoclonal antibodies (mAbs) could alleviate severe COVID-19 in at-risk outpatients. However, data on their use in hospitalized patients, particularly in elderly or immunocompromised hosts, are lacking. METHODS All consecutive patients hospitalized with COVID-19 at our unit from 1 July 2021 to 15 March 2022 were retrospectively enrolled. The primary outcome was the progression to severe COVID-19 (P/F < 200). Descriptive statistics, a Cox univariate-multivariate model, and an inverse probability treatment-weighted (IPTW) analysis were performed. RESULTS Overall, 331 subjects were included; their median (q1-q3) age was 71 (51-80) years, and they were males in 52% of the cases. Of them, 78 (23%) developed severe COVID-19. All-cause in-hospital mortality was 14%; it was higher in those with disease progression (36% vs. 7%, p < 0.001). REM and mAbs resulted in a 7% (95%CI = 3-11%) and 14% (95%CI = 3-25%) reduction in the risk of severe COVID-19, respectively, after adjusting the analysis with the IPTW. In addition, by evaluating only immunocompromised hosts, the combination of REM and mAbs was associated with a significantly lower incidence of severe COVID-19 (aHR = 0.06, 95%CI = 0.02-0.77) when compared with monotherapy. CONCLUSIONS REM and mAbs may reduce the risk of COVID-19 progression in hospitalized patients. Importantly, in immunocompromised hosts, the combination of mAbs and REM may be beneficial.
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Affiliation(s)
- Davide Fiore Bavaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Lucia Diella
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Alessandra Belati
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Giuliana Metrangolo
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Laura De Santis
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Vito Spada
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Michele Camporeale
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Angelo Dargenio
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Gaetano Brindicci
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Flavia Balena
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Deborah Fiordelisi
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Fabio Signorile
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Giacomo Loseto
- Hematology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Crescenza Pasciolla
- Hematology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Carla Minoia
- Hematology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Immacolata Attolico
- Unit of Hematology and Stem Cell Transplantation, AOUC Policlinic, 70124 Bari, Italy
| | - Tommasina Perrone
- Unit of Hematology and Stem Cell Transplantation, AOUC Policlinic, 70124 Bari, Italy
| | - Simona Simone
- Nephrology Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy
| | - Maria Rendina
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy
| | - Nicoletta Giovine
- Hospital Pharmacy Department, University Hospital of Bari, 70124 Bari, Italy
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, AOUC Policlinic, 70124 Bari, Italy
- Department of Precision and Regenerative Medicine and Ionian Area University of Bari and Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, 70124 Bari, Italy
| | - Attilio Guarini
- Hematology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy
| | - Maria Dell'Aera
- Hospital Pharmacy Department, University Hospital of Bari, 70124 Bari, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy
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7
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Reyes LF, Rodriguez A, Fuentes YV, Duque S, García-Gallo E, Bastidas A, Serrano-Mayorga CC, Ibáñez-Prada ED, Moreno G, Ramirez-Valbuena PC, Ospina-Tascon G, Hernandez G, Silva E, Díaz AM, Jibaja M, Vera-Alarcon M, Díaz E, Bodí M, Solé-Violán J, Ferrer R, Albaya-Moreno A, Socias L, Figueroa W, Lozano-Villanueva JL, Varón-Vega F, Estella Á, Loza-Vazquez A, Jorge-García R, Sancho I, Shankar-Hari M, Martin-Loeches I. Risk factors for developing ventilator-associated lower respiratory tract infection in patients with severe COVID-19: a multinational, multicentre study, prospective, observational study. Sci Rep 2023; 13:6553. [PMID: 37085552 PMCID: PMC10119842 DOI: 10.1038/s41598-023-32265-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 03/24/2023] [Indexed: 04/23/2023] Open
Abstract
Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 patients, VA-LRTI was diagnosed in 28.8% [948/3287]. The cumulative incidence of ventilator-associated pneumonia (VAP) was 18.6% [610/3287], followed by ventilator-associated tracheobronchitis (VAT) 10.3% [338/3287]. A total of 1252 bacteria species were isolated. The most frequently isolated pathogens were Pseudomonas aeruginosa (21.2% [266/1252]), followed by Klebsiella pneumoniae (19.1% [239/1252]) and Staphylococcus aureus (15.5% [194/1,252]). The factors independently associated with the development of VA-LRTI were prolonged stay under invasive mechanical ventilation, AKI during ICU stay, and the number of comorbidities. Regarding the clinical impact of VA-LRTI, patients with VAP had an increased risk of hospital mortality (OR [95% CI] of 1.81 [1.40-2.34]), while VAT was not associated with increased hospital mortality (OR [95% CI] of 1.34 [0.98-1.83]). VA-LRTI, often with difficult-to-treat bacteria, is frequent in patients admitted to the ICU due to severe COVID-19 and is associated with worse clinical outcomes, including higher mortality. Identifying risk factors for VA-LRTI might allow the early patient diagnosis to improve clinical outcomes.Trial registration: This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.
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Affiliation(s)
- Luis Felipe Reyes
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia.
- Clinica Universidad de La Sabana, Chía, Colombia.
- Pandemic Sciences Institute, University of Oxford, Oxford, UK.
| | - Alejandro Rodriguez
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Yuli V Fuentes
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Clinica Universidad de La Sabana, Chía, Colombia
| | - Sara Duque
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Esteban García-Gallo
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Alirio Bastidas
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Cristian C Serrano-Mayorga
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Clinica Universidad de La Sabana, Chía, Colombia
| | - Elsa D Ibáñez-Prada
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Gerard Moreno
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | | | - Glenn Hernandez
- Critical Care Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Ana Maria Díaz
- Eugenio Espejo Hospital of Specialties, Quito, Pichincha, Ecuador
| | - Manuel Jibaja
- Eugenio Espejo Hospital of Specialties, Quito, Pichincha, Ecuador
| | | | - Emili Díaz
- Critical Care Department, Hospital Universitari Parc Taulí, Universitat Autonoma Barcelona, Sabadell, Spain
| | - María Bodí
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Jordi Solé-Violán
- Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
- Universidad Fernando Pessoa, Canarias, Spain
| | - Ricard Ferrer
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | | | - Lorenzo Socias
- Son Llatzer University Hospital, Palma de Mallorca, Spain
| | - William Figueroa
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | | | | | - Ángel Estella
- Jerez University Hospital, Jerez de la Frontera, Spain
| | - Ana Loza-Vazquez
- Critical Care Department, Hospital Universitario Virgen del Valme, Sevilla, Spain
| | | | - Isabel Sancho
- Critical Care Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Manu Shankar-Hari
- Intensive Care Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, UK
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8
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Iacovelli A, Oliva A, Siccardi G, Tramontano A, Pellegrino D, Mastroianni CM, Venditti M, Palange P. Risk factors and effect on mortality of superinfections in a newly established COVID-19 respiratory sub-intensive care unit at University Hospital in Rome. BMC Pulm Med 2023; 23:30. [PMID: 36670381 PMCID: PMC9854038 DOI: 10.1186/s12890-023-02315-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Little is known on the burden of co-infections and superinfections in a specific setting such as the respiratory COVID-19 sub-intensive care unit. This study aims to (i) assess the prevalence of concurrent and superinfections in a respiratory sub-intensive care unit, (ii) evaluate the risk factors for superinfections development and (iii) assess the impact of superinfections on in-hospital mortality. METHODS Single-center retrospective analysis of prospectively collected data including COVID-19 patients hospitalized in a newly established respiratory sub-intensive care unit managed by pneumologists which has been set up from September 2020 at a large (1200 beds) University Hospital in Rome. Inclusion criteria were: (i) COVID-19 respiratory failure and/or ARDS; (ii) hospitalization in respiratory sub-intensive care unit and (iii) age > 18 years. Survival was analyzed by Kaplan-Meier curves and the statistical significance of the differences between the two groups was assessed using the log-rank test. Multivariable logistic regression and Cox regression model were performed to tease out the independent predictors for superinfections' development and for mortality, respectively. RESULTS A total of 201 patients were included. The majority (106, 52%) presented severe COVID-19. Co-infections were 4 (1.9%), whereas 46 patients (22%) developed superinfections, mostly primary bloodstream infections and pneumonia. In 40.6% of cases, multi-drug resistant pathogens were detected, with carbapenem-resistant Acinetobacter baumannii (CR-Ab) isolated in 47%. Overall mortality rate was 30%. Prior (30-d) infection and exposure to antibiotic therapy were independent risk factors for superinfection development whereas the development of superinfections was an independent risk factors for in-hospital mortality. CR-Ab resulted independently associated with 14-d mortality. CONCLUSION In a COVID-19 respiratory sub-intensive care unit, superinfections were common and represented an independent predictor of mortality. CR-Ab infections occurred in almost half of patients and were associated with high mortality. Infection control rules and antimicrobial stewardship are crucial in this specific setting to limit the spread of multi-drug resistant organisms.
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Affiliation(s)
- Alessandra Iacovelli
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Alessandra Oliva
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Infective Diseases Unit, Policlinico Umberto I Hospital Rome, 00185 Rome, Lazio Italy
| | - Guido Siccardi
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Infective Diseases Unit, Policlinico Umberto I Hospital Rome, 00185 Rome, Lazio Italy
| | - Angela Tramontano
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Daniela Pellegrino
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Claudio Maria Mastroianni
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Infective Diseases Unit, Policlinico Umberto I Hospital Rome, 00185 Rome, Lazio Italy
| | - Mario Venditti
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Infective Diseases Unit, Policlinico Umberto I Hospital Rome, 00185 Rome, Lazio Italy
| | - Paolo Palange
- grid.7841.aDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy ,grid.417007.5Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
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9
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Prompt and Appropriate Antimicrobial Therapy Improves Outcomes of NDM-Producing and KPC-Producing Klebsiella pneumoniae Bloodstream Infections in Patients Hospitalized for COVID-19: A Comparative Retrospective Case-Series. Antibiotics (Basel) 2022; 11:antibiotics11111519. [DOI: 10.3390/antibiotics11111519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Secondary bloodstream infections (BSIs) caused by KPC- and NDM-producing Klebsiella pneumoniae (K.p.) during the course of COVID-19 infections lead to significant mortality. Herein, a comparative retrospective case series of KPC- or NDM-K.p. BSIs occurring in COVID-19 subjects treated with Ceftazidime/Avibactam (CAZ/AVI) for KPC-K.p., or CAZ/AVI+ Aztreonam (ATM) for NDM-K.p is reported. All patients hospitalized for COVID-19 in two Italian hospitals with a BSI between March and September 2021 were included. The main outcome was 14-day mortality. Overall, 44 patients were included: 23 with KPC-K.p. and 21 with NDM-K.p. BSIs. The median (q1–q3) age was 67 (57–75) years, and 32 (72%) were males. The two groups were similar in terms of baseline comorbidity, or severity of COVID-19. Notably, 14-day mortality of KPC-K.p. BSIs and NDM-K.p. BSIs (26% vs. 38%, p = 0.521) and 28-day mortality (35% vs. 48%, p = 0.541) were similar. A Cox regression model of delayed initiation of an appropriate antibiotic therapy after the onset of symptoms independently predicted mortality: initiation between 24 and 72 h (aHR = 12.03; 95% CI = 1.10–130, p = 0.041); and initiation after 72h (aHR = 36.9, 95% CI = 3.22–424, p = 0.004). Moreover, a trend towards an increased risk of mortality was observed for polymicrobial infections (aHR = 3.73, 95% CI = 0.87–15.8, p = 0.074), while a protective effect was observed for a beta-lactam loading dose at the start of treatment (aHR = 0.16, 95% CI = 0.02–1.10, p = 0.064). The high mortality of KPC and NDM-K.p. BSIs in COVID-19 patients may be reduced by an early and appropriate antibiotic therapy. Further efforts should be made to develop antimicrobial stewardship and infection control programs in COVID-19 wards.
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10
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Tiseo G, Galfo V, Occhineri S, Forniti A, Caroselli C, Falcone M, Menichetti F. Risk factors and outcomes of fungal superinfections in patients with severe COVID-19: an observational study from Pisa academic hospital. LE INFEZIONI IN MEDICINA 2022; 31:55-61. [PMID: 36908395 PMCID: PMC9994824 DOI: 10.53854/liim-3101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/22/2023] [Indexed: 03/06/2023]
Abstract
Background Superinfections acquired during the hospital course represent common complications in COVID-19 patients. Several studies reported an increasing incidence of COVID-19 associated pulmonary aspergillosis (CAPA) and candidaemia. The aim of this study is to describe fungal superinfections in a large cohort of hospitalized patients with COVID-19 and identify factors independently associated with the risk of fungal superinfections. Methods Observational study including patients with COVID-19 admitted to the tertiary-care, University Hospital of Pisa, Italy from April 2020 to May 2021. Patients with pneumonia and laboratory confirmed SARS-CoV-2 infection with a RT-PCR test on a nasopharyngeal swab, were eligible for the study. Patients who died within 24 hours from admission and those with missing data were excluded. Data about fungal superinfections were collected. To identify factors independently associated with the development of fungal superinfections, a multivariate regression analysis was performed. Results Among 983 patients with COVID-19, 52 (5.3%) fungal superinfections were detected. Fungal superinfections included: 24/52 (46%) CAPA, 27/52 (51.9%) episodes of candidaemia and 1 case of pulmonary pneumocystosis in a haematological patient. All patients with CAPA were cared for in intensive care unit (ICU). The majority of patients received liposomal amphotericin B as antifungal treatment (83.3%). In-hospital mortality was 41.7%. Among 27 episodes of candidaemia, 16 (59.3%) occurred in ICU while 11 (40.7%) in medical wards. In-hospital mortality was 14.8%. Overall, patients with fungal superinfections had a median age of 73 (IQRs 59-77) years and a median length of ICU stay of 40 (17-50) days. In-hospital mortality among all patients with superinfections was 28.8%. On multivariable analysis, ICU stay (OR 17.63, 95% CI 8.3-37.41, p<0.001), high-dose steroids (OR 13.48, 95% CI 6.68-27.26, p<0.001), and diabetes mellitus (OR 2.14, 95% CI 1.09-4.17, p=0.026) were factors independently associated with the risk of developing a fungal superinfection. Conclusions Fungal superinfections may complicate the hospital course of COVID-19 patients, especially of those admitted to ICU. Surveillance with detection of galactomannan on bronchoalveolar lavage in patients with clinical deterioration should be performed. A rational use of steroids is essential to avoid the risk of developing a fungal superinfection.
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Affiliation(s)
- Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Sara Occhineri
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Arianna Forniti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Claudio Caroselli
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
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