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Kim DY, Lin MY, Jennings C, Li H, Jung JH, Moore NM, Ghinai I, Black SR, Zaccaro DJ, Brofman J, Hayden MK. Duration of Replication-Competent Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Shedding Among Patients With Severe or Critical Coronavirus Disease 2019 (COVID-19). Clin Infect Dis 2022; 76:e416-e425. [PMID: 35607802 PMCID: PMC9213867 DOI: 10.1093/cid/ciac405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/05/2022] [Accepted: 05/18/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patterns of shedding replication-competent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in severe or critical COVID-19 are not well characterized. We investigated the duration of replication-competent SARS-CoV-2 shedding in upper and lower airway specimens from patients with severe or critical coronavirus disease 2019 (COVID-19). METHODS We enrolled patients with active or recent severe or critical COVID-19 who were admitted to a tertiary care hospital intensive care unit (ICU) or long-term acute care hospital (LTACH) because of COVID-19. Respiratory specimens were collected at predefined intervals and tested for SARS-CoV-2 using viral culture and reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Clinical and epidemiologic metadata were reviewed. RESULTS We collected 529 respiratory specimens from 78 patients. Replication-competent virus was detected in 4 of 11 (36.3%) immunocompromised patients up to 45 days after symptom onset and in 1 of 67 (1.5%) immunocompetent patients 10 days after symptom onset (P = .001). All culture-positive patients were in the ICU cohort and had persistent or recurrent symptoms of COVID-19. Median time from symptom onset to first specimen collection was 15 days (range, 6-45) for ICU patients and 58.5 days (range, 34-139) for LTACH patients. SARS-CoV-2 RNA was detected in 40 of 50 (80%) ICU patients and 7 of 28 (25%) LTACH patients. CONCLUSIONS Immunocompromise and persistent or recurrent symptoms were associated with shedding of replication-competent SARS-CoV-2, supporting the need for improving respiratory symptoms in addition to time as criteria for discontinuation of transmission-based precautions. Our results suggest that the period of potential infectiousness among immunocompetent patients with severe or critical COVID-19 may be similar to that reported for patients with milder disease.
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Affiliation(s)
- Do Young Kim
- Correspondence: M. Hayden, Rush University Medical Center, 1653 W. Congress Pkwy, Chicago, IL 60612 ()
| | - Michael Y Lin
- Department of Internal Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Cheryl Jennings
- Rush Research Cores, Rush University Medical Center, Chicago, Illinois, USA
| | - Haiying Li
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - Jae Hyung Jung
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Nicholas M Moore
- Department of Internal Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA,Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA,Department of Medical Laboratory Science, Rush University Medical Center, Chicago, Illinois, USA
| | - Isaac Ghinai
- Chicago Department of Public Health, Chicago, Illinois, USA
| | | | - Daniel J Zaccaro
- Social & Scientific Systems, Inc, a DLH Holdings Corporation, Durham, North Carolina, USA
| | | | - Mary K Hayden
- Department of Internal Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
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Klompas M. New Insights into the Prevention of Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia Caused by Viruses. Semin Respir Crit Care Med 2022; 43:295-303. [PMID: 35042261 DOI: 10.1055/s-0041-1740582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A fifth or more of hospital-acquired pneumonias may be attributable to respiratory viruses. The SARS-CoV-2 pandemic has clearly demonstrated the potential morbidity and mortality of respiratory viruses and the constant threat of nosocomial transmission and hospital-based clusters. Data from before the pandemic suggest the same can be true of influenza, respiratory syncytial virus, and other respiratory viruses. The pandemic has also helped clarify the primary mechanisms and risk factors for viral transmission. Respiratory viruses are primarily transmitted by respiratory aerosols that are routinely emitted when people exhale, talk, and cough. Labored breathing and coughing increase aerosol generation to a much greater extent than intubation, extubation, positive pressure ventilation, and other so-called aerosol-generating procedures. Transmission risk is proportional to the amount of viral exposure. Most transmissions take place over short distances because respiratory emissions are densest immediately adjacent to the source but then rapidly dilute and diffuse with distance leading to less viral exposure. The primary risk factors for transmission then are high viral loads, proximity, sustained exposure, and poor ventilation as these all increase net viral exposure. Poor ventilation increases the risk of long-distance transmission by allowing aerosol-borne viruses to accumulate over time leading to higher levels of exposure throughout an enclosed space. Surgical and procedural masks reduce viral exposure but do not eradicate it and thus lower but do not eliminate transmission risk. Most hospital-based clusters have been attributed to delayed diagnoses, transmission between roommates, and staff-to-patient infections. Strategies to prevent nosocomial respiratory viral infections include testing all patients upon admission, preventing healthcare providers from working while sick, assuring adequate ventilation, universal masking, and vaccinating both patients and healthcare workers.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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