Economic Evaluation of COVID-19 Screening Tests and Surveillance Strategies in Low-Income, Middle-Income, and High-Income Countries: A Systematic Review

BACKGROUND Economic evaluation of the testing strategies to control transmission and monitor the severity of COVID-19 after the pandemic is essential. This study aimed to review the economic evaluation of COVID-19 tests and to construct a model with outcomes in terms of cost and test acceptability for surveillance in the post-pandemic period in low-income, middle-income, and high-income countries. MATERIAL AND METHODS We performed the systematic review following PRISMA guidelines through MEDLINE and EMBASE databases. We included the relevant studies that reported the economic evaluation of COVID-19 tests for surveillance. Also, we input current probability, sensitivity, and specificity for COVID-19 surveillance in the post-pandemic period. RESULTS A total of 104 articles met the eligibility criteria, and 8 articles were reviewed and assessed for quality. The specificity and sensitivity of COVID-19 screening tests were reported as 80% to 90% and 40% to 90%, respectively. The target population presented a mortality rate between 0.2% and 19.2% in the post-pandemic period. The implementation model of COVID-19 screening tests for surveillance with a cost mean for molecular and antigen tests was US$ 46.64 (min-max US $0.25-$105.39) and US $6.15 (min-max US $2-$10), respectively. CONCLUSIONS For the allocation budget for the COVID-19 surveillance test, it is essential to consider the incidence and mortality of the post-pandemic period in low-income, middle-income, and high-income countries. A robust method to evaluate outcomes is needed to prevent increasing COVID-19 incidents earlier.

Guillain-Barré Syndrome and multiple lacunar infarcts in a COVID-19 patient

INTRODUCTION

Hyperactivity immune responses to coronavirus disease 2019 (COVID-19) can lead to several manifestations in the human organ. One of the most affected organs is the respiratory system. Not only does it affect the respiratory system, but hyperactivity can also affect the neuromuscular and cerebrovascular systems, though it is scarce for both systems to be affected simultaneously.

CASE PRESENTATION

We presented a mild COVID-19 patient with a history of progressive general weakness and dysphagia on day seventh day after patient was first diagnosed with COVID-19, which continued with diplopia and shortness of breath. The patient experienced respiratory failure type 1 and was admitted to an intensive care unit. A head CT scan showed multiple lacunar infarcts in the nucleus lentiform, while the electromyography (EMG) showed Guillain-Barré syndrome (GBS) with the subtype acute inflammatory demyelinating polyneuropathy (AIDP). The patient was reported to have successful therapy with intravenous immunoglobulin (IVIG) for five days and physical rehabilitation for three months. General weakness disappeared after the therapy, and the patient could do regular daily activities.

CONCLUSIONS

Various neurological symptoms can manifest in COVID-19 patients. Acute progressive muscle weakness should be considered as an autoimmune and cerebrovascular disease induced by COVID-19. Early diagnosis and treatment can provide a better outcome for the patient.

Hemodynamic, Oxygenation and Lymphocyte Parameters Predict COVID-19 Mortality

The mortality of COVID-19 patients has left the world devastated. Many scoring systems have been developed to predict the mortality of COVID-19 patients, but several scoring components cannot be carried out in limited health facilities. Herein, the authors attempted to create a new and easy scoring system involving mean arterial pressure (MAP), PF Ratio, or SF ratio-respiration rate (SF Ratio-R), and lymphocyte absolute, which were abbreviated as MPL or MSLR functioning, as a predictive scoring system for mortality within 30 days for COVID-19 patients. Of 132 patients with COVID-19 hospitalized between March and November 2021, we followed up on 96 patients. We present bivariate and multivariate analyses as well as the area under the curve (AUC) and Kaplan-Meier charts. From 96 patients, we obtained an MPL score of 3 points: MAP < 75 mmHg, PF Ratio < 200, and lymphocyte absolute < 1500/µL, whereas the MSLR score was 6 points: MAP < 75 mmHg, SF Ratio < 200, lymphocyte absolute < 1500/µL, and respiration rate 24/min. The MPL cut-off point is 2, while the MSLR is 4. MPL and MSLR have the same sensitivity (79.1%) and specificity (75.5%). The AUC value of MPL vs. MSLR was 0.802 vs. 0.807. The MPL ≥ 2 and MSLR ≥ 4 revealed similar predictions for survival within 30 days (p < 0.05). Conclusion: MPL and MSLR scores are potential predictors of mortality in COVID-19 patients within 30 days in a resource-limited country.

The Efficacy and Safety of Monoclonal Antibody Treatments Against COVID-19: A Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

The use of monoclonal antibody as the proposed treatment of COVID-19 showed different results in various prior studies, and Efficacy remains open in literature. This study aimed to comprehensively determine the effect of monoclonal antibodies on clinical, laboratory, and safety outcomes in COVID-19 patients.

METHODS

Sixteen RCTs were analyzed in this meta-analysis using RevMan 5.4 to measure the pooled estimates of risk ratios (RRs) and standardized mean differences (SMDs) with 95% CIs.

RESULTS

The pooled effect of Monoclonal antibodies demonstrated efficacy on mortality risk reduction (RR=0,89 (95%CI 0.82-0.96), I2=13%, fixed-effect), Tocilizumab also show efficacy on mortality risk reduction for severe-critical disease (RR=0.90 (95%CI 0.83-0.97), I2=12%, fixed-effect)), need for mechanical ventilation (RR=0.76 (95%CI 0.62-0.94), I2=42%, random-effects), and hospital discharge (RR=1.07 (95%CI 1.00-1.14), I2=60%, random-effects). Bamlanivimab monotherapy did not reduce viral load (SMD=-0.07 (95%CI -0.21-0.07), I2=44%, fixed-effect). Monoclonal antibodies did not differ from placebo/standard therapy for hospital discharge at day 28-30 (RR=1.05 (95%CI 0.99-1.12), I2=71%, random-effects) and safety (RR=1.04 (95%CI 0.76-1.43), I2=54%, random-effects).

CONCLUSION

Tocilizumab should be used for severe to critical COVID-19 because it is not harmful and can improve mortality risk, mechanical ventilation, and hospital discharge. Bamlanivimab-Etesevimab and REGN-COV2 reduced viral load in mild-moderate outpatients.

EVALUATION OF COVID-19 VACCINE EFFECTIVENESS AMONG HEALTHCARE WORKERS USING CASCADE ANALYSIS

Background: Healthcare workers in Indonesia have been prioritized for vaccination. Nevertheless, fully vaccinated healthcare workers are still at risk of being infected with COVID-19, but will be less likely to develop severe symptoms, be hospitalized or be at risk for death as compared to those who have not been vaccinated. Objectives: This study aims to analyze the incidence of COVID-19 in fully vaccinated healthcare workers. Methods: This cross-sectional study was conducted in 2021. All healthcare workers who have been fully vaccinated, have recovered from COVID-19 (2-4 weeks after vaccination) and able to complete a questionnaire were the participants. The collected data was then analyzed using the cascade method. Results: Based on the 529 collected questionnaires, by using the cascade analysis conclude that the percentage of healthcare workers who have been fully vaccinated was 99%, healthcare workers who have been fully vaccinated and then infected with COVID-19 was 14%, healthcare workers who have been fully vaccinated, infected with COVID-19 and hospitalized was 4%, healthcare workers who have been fully vaccinated, exposed to COVID-19, hospitalized and experienced the long-haul effect of COVID-19 was 0%. Discussion: Health workers are still at risk of being confirmed by COVID-19, because have high risk of being exposed in the workplace. The risk of being confirmed and severity are also influenced by age, gender and comorbidities. Conclusions: Complete vaccinations of healthcare workers did not reduce their risk of being infected with COVID-19, however, it can reduce the severity and the risk of the long-haul effects.

Interleukin-6 (IL-6) expression of lung tissue in COVID-19 patient severity through core biopsy post mortem

Introduction

In COVID-19 patients, Interleukin-6 (IL-6) will increase, and the production of antigens will be excessive, which will cause excessive inflammation of the tissues, especially the respiratory tract, which causes fibrosis in the lungs and can lead to death.

Objective

To analyze IL-6 expression of lung tissue in COVID-19 patient severity.

Methods

The study is an observational analytic design from July to December 2020. COVID-19 patient severity who died was examined for IL-6 expression on lung tissue. The lung tissue sampling uses the core biopsy method.

Results

The total number of samples obtained was 38 samples. Characteristics of patients with a mean age of patients were 48 years, male, the most common chief complaint was shortness of breath, mean symptom onset was 5 days, patient length of stay was 10 days, the most common cause of death was a combination of septic shock and ARDS and the most common comorbid diabetes mellitus. There is an increased WBC, neutrophils, platelets, procalcitonin, CRP, BUN, creatinine serum, AST, ALT, and D-dimer. In this study, the average tissue IL-6 expression was 72.63, with the highest frequency of strong positive 47.4%.

Conclusion

An increase in IL-6 expression on lung tissue showed the severity of COVID-19 infection.

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IL-6 levels increased in severity of COVID-19.

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IL-6 is elevated in comorbid COVID-19 patients.

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IL-6 increases inflammatory indicators in COVID-19.

Neutrophil Elastase in the Pathogenesis of Chronic Obstructive Pulmonary Disease: A Review

Abstract:

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality globally. It is associated with a low quality of life and socio-economic burden. Airway destruction in COPD pathogenesis is primarily due to the three mechanisms: protease-antiprotease imbalance, chronic airway inflammation, and oxidative stress, which is triggered by exposure to harmful particles, such as cigarette smoking. Neutrophil elastase (NE), a serine protease stored in azurophilic granules of neutrophils, actively participates in airway remodeling and microbiocidal activity. It hydrolyzes elastin, collagen, and other vital extracellular matrix proteins (EMP) in the respiratory tissue. In addition, neutrophil elastase activates other principal proteinases such as matrix metalloprotease (MMP)-2, MMP-9, Cathepsin B, Meprin α protease, and Calpain that amplify EMP degradation. Macrophage, the primary leukocyte, responsible for lung parenchymal inflammation in COPD, is also activated by NE. However, neutrophil elastase level is positively correlated with the degree of airway inflammation and disease severity. Neutrophil elastase activates reactive oxygengenerating systems such as nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and myeloperoxidase and it also generates mitochondrial-derived-reactive oxygen species formation by inducing the secretion of Interleukin (IL)-1 andTumour necrosis factor (TNF)- α. In addition, neutrophil elastase stimulates respiratory cell apoptosis by direct (e.g., activating the caspase-3 pathway) and indirect mechanisms (e.g., by secretion of Neutrophil Extracellular Traps). Surprisingly, neutrophil elastase may have small anti-inflammatory properties. In conclusion, neutrophil elastase is one of the main culprits responsible for COPD pathogenesis by mediating the activation of Triad COPD pathogenesis.

Efficacy and Safety of Anticoagulants for COVID-19 Patients in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Purpose: This study aims to analyze the efficacy and safety of anticoagulants for COVID-19 patients in the intensive care unit. Methods: A comprehensive search was conducted using databases such as MEDLINE, PubMed, EuropePMC, Science Direct, Google Scholar, Clinicaltrial.gov, The Cochrane Central Register of Controlled Trial (CENTRAL, Cochrane Library) and several other published articles from the systematic review up to March 31, 2021. The Newcastle-Ottawa Scale (NOS) was used for the studies’ qualitative assessment. The primary outcome examined was mortality rate, while the secondary included the length of stay (LOS) in thei care unit; hospital length of stay (HOS), coagulation markers including D-dimer, Platelet count, aPTT, PT and fibrinogen; markers of inflammation specifically C-reactive protein; and other adverse events ranging from hemorrhage to thrombosis. Additionally, the quantitative synthesis was conducted using fixed and random effects model in “The Revman 5.4”, while heterogeneity was tested using the I-squared (I2) measure. Results: A total of 1,062 articles were found during the initial search step and eventually 12 were chosen to be analyzed quantitatively in a meta-analysis. Comparison of the results related to anticoagulant group with no anticoagulant or standard care treatment showed that anticoagulant group significantly reduced mortality rate with RR= 0.53; 95 % CI, 0.30-0.95; P= 0.03, with I2 = 88% and venous thromboembolism (VTE) RR = 0.53; 95% CI, 0.37-0.76; P = .0007 with I2 = 35%. Conclusions: Based on the results, anticoagulants can mitigate mortality rate and VTE in COVID-19 patients.

Predictive Value of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Acute Physiology and Chronic Health Evaluation (APACHE II), and New Early Warning Signs (NEWS-2) Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit (ICU)

Introduction

Various mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients.

Materials and methods

We conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality.

Result

qSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%).

Conclusion

All scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate.

How to cite this article

Asmarawati TP, Suryantoro SD, Rosyid AN, Marfiani E, Windradi C, Mahdi BA, et al. Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit. Indian J Crit Care Med 2022;26(4):464–471.

Predictive accuracy of blood inflammatory markers on COVID-19 mortality

Background: The impact of COVID-19 may be more severe in developing countries. Our study aims to analyze the accuracy of several inflammatory biomarkers in predicting COVID-19 mortality, providing information about the most suitable markers for developing countries. Methods: A retrospective cohort study was conducted at Dr. Soetomo General Hospital, Indonesia, from March to June 2020. White Blood Cells (WBC) count, Neutrophil-Lymphocyte Ratio (NLR), Procalcitonin (PCT), D-Dimer, and C-Reactive Protein (CRP) have been collected from the electronic medical records. We performed survival analysis to provide the hazard ratio and Receiver Operating Characteristic (ROC) curve analysis to test for accuracy for each parameter. Results: A total of 423 patients who met the criteria for participating had a median age of 54 (IQR 45-61) years. Patients in the death group are characterized by older age and shorter length of hospitalization. The WBC, NLR, PCT, D-Dimer, and CRP are found significantly higher in the death group (P=0.000). The WBC, NLR, PCT, D-Dimer, and CRP have an Area Under the Curve (AUC) of 0.709, 0.773, 0.738, 0.721, and 0.769, respectively moderate accuracy in predicting COVID-19 patient mortality. We found that NLR is significantly more accurate than the age parameter (Z=3.527; P=0.000) but has equal accuracy with other laboratory parameters.  Conclusions: Since NLR obtained the highest accuracy, we still recommend routine complete blood count tests as prognostic biomarkers with the highest feasibility to be performed in developing countries.

The spectrum of Cefditoren for Lower Respiratory Tract Infections (LRTIs) in Surabaya

Background:

Empirical antibiotics among outpatients with Lower Respiratory Tract Infections (LRTIs) are scarcely allocated in Indonesia. The study aims to evaluate the pathogens causing LRTIs, drug sensitivity test and the minimum inhibitory concentrations of 90% (MIC90) of Cefditoren, Azithromycin, Amoxicillin-Clavulanic Acid, and Cefixime

Methods:

The study was performed in adult outpatients with LRTI that can be expectorated. Patients with diabetes mellitus, HIV, lung tuberculosis, renal or hepatic failure, and hemoptysis were excluded. We performed bacterial culture, antibiotic sensitivity, and MIC measurement of four antibiotics.

Results:

There were 126 patients with LRTIs, and 61 patients were eligible for the study. We identified 69 bacteria. We found Klebsiella pneumonia (n=16; 26.23%), Staphylococcus aureus (n=11; 18%), Pseudomonas aeruginosa (n=8; 13.11%), Acinetobacter baumanii complex (n= 4; 6.55%), Streptococcus pneumonia (n=3; 4.9%) and others bacteria as causa of LRTI. Testing MIC90 of Cefditoren and three empiric antibiotics on LRTI found that Cefditoren has a lower MIC of 90 for K. pneumonia (0.97(2.04) µg.mL-1) and S. pneumonia (0.06(0.00)µg.mL-1) than other antibiotics, but almost the same as Cefixime ((0.05(0.16)µg.mL-1) and (0.38(0.17)µg.mL-1). MIC90 Cefditoren for S.aureus (3.18(3.54)µg.mL-1) and P.aeruginosa (9.2(3.53)µg.mL-1) is lower than Cefixime but higher than Azithromycin and Amoxicillin-Clavulanic acid. Reference data MIC90 of Cefditoren for LRTI bacteria is lower than the other three oral empirical antibiotics.

Conclusions:

In vitro studies of an outpatient LRTI in Surabaya found gram-negative bacteria dominant. Cefditoren can inhibit K.pneumonia and S.pneumonia has lower MIC90 compared to other antibiotics. Cefditoren can inhibit gram-negative and positive bacteria causing LRTI.

Inflammatory Mechanism and Clinical Implication of Asthma in COVID-19

Asthma is a chronic inflammatory disease of the respiratory tract that has become a public health problem in various countries. Referring to the Global Initiative for Asthma, the prevalence of asthma continues to increase especially in children. Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that has declared a pandemic by the world health organization on March 2020. For many years, it has been known that people with asthma have a worse impact on respiratory viral infections. Asthma has been listed by the centers for disease control and prevention as one of the risk factors for COVID-19, although several studies have different results. SARS-CoV-2 utilizes angiotensin-converting enzyme 2 (ACE2) as its cellular receptor, and it has been known that the expression of the ACE2 receptor is reduced in asthma patients. This reduced expression could also be accounted from the therapy of asthma. This paper aims to discuss the pathophysiology of asthma and COVID-19 and the susceptibility of asthma patients in contracting COVID-19.

Community knowledge and attitude in recognizing asthma symptoms and using medication for asthma attacks: a cross-sectional study

OBJECTIVES

Uncontrolled asthma may be life-threatening. Poor understanding of disease process and appropriate medication use appears to influence community attitude in facing asthmatic patients in an emergency, thereby contributing to increasing the risk of mortality. This study aimed to analyze community-level knowledge about asthma and attitude towards asthma management.

METHODS

This observational, cross-sectional study was conducted among the community in Gresik, Indonesia, from March to July 2019. Participants included in this study were adults, who could read, write, and communicate well. Data were collected through questionnaires to evaluate the level of knowledge and attitude towards asthma.

RESULTS

In total, 100 respondents were selected with 91% of women, with a mean age of 49.11 ± 14.42 years and with various levels of education. The respondents had good knowledge by getting a score of 76%. Knowledge regarding recognition of asthma symptoms was scored the highest (83%). However, knowledge about medication use for asthma was lacking, especially in identifying the medicine choice (21%) and inhaler use (48%). The respondents also showed a 'positive' attitude with a score of 89%. Most respondents (72%) agreed that when inhaled drugs were unable to relieve the asthma attack, they need to bring the patient to a hospital.

CONCLUSIONS

The level of respondent's knowledge in recognizing asthma symptoms was good, but there were misconceptions about asthma medication, especially in inhaler use. Overall, the respondents had a positive attitude towards asthma perception and management.

The clinical impact of bacterial co-infection among moderate, severe and critically ill COVID-19 patients in the second referral hospital in Surabaya

Background: Data on the prevalence of bacterial co-infections among COVID-19 patients are limited, especially in our country, Indonesia. We aimed to assess the rate of bacterial co-infections in hospitalized COVID-19 patients and report the most common microorganisms involved and the antibiotic use in these patients.

Methods: This study is a retrospective cohort study,among COVID-19 adult patients admitted to Universitas Airlangga Hospital Surabaya from 14 March-30 September 2020. The bacterial infection is defined based on clinical assessment, laboratory parameters, and microbiology results.

Results: A total of 218 patients with moderate to critical illness and confirmed COVID-19 were included in this study. Bacterial infection was confirmed in 43 patients (19.7%). COVID-19 patients with bacterial infections had longer hospital length of stay (17.6 6.62 vs 13.317.12), a higher proportion of respiratory failure, intensive care treatment, and ventilator use. COVID-19 patients with bacterial infection had a worse prognosis than those without bacterial infection (p<0.04). The empirical antibiotic was given to 75.2% of the patients. Gram-negative bacteria were commonly found as causative agents in this study (n = 39; 70.37%).

Conclusion: COVID-19 patients with bacterial infection have a longer length of stay and worse outcomes. Healthcare-associated infections during intensive care treatment for COVID-19 patients must be carefully prevented.

The clinical impact of bacterial co-infection among moderate, severe and critically ill COVID-19 patients in the second referral hospital in Surabaya

Background: Data on the prevalence of bacterial co-infections among COVID-19 patients are limited, especially in our country, Indonesia. We aimed to assess the rate of bacterial co-infections in hospitalized COVID-19 patients and report the most common microorganisms involved and the antibiotic use in these patients. Methods: This study is a retrospective cohort study, among COVID-19 adult patients admitted to Universitas Airlangga Hospital Surabaya from 14 March-30 September 2020. The bacterial infection is defined based on clinical assessment, laboratory parameters, and microbiology results. Results: A total of 218 patients with moderate to critical illness and confirmed COVID-19 were included in this study. Bacterial infection was confirmed in 43 patients (19.7%). COVID-19 patients with bacterial infections had longer hospital length of stay (17.6 ± 6.62 vs 13.31±7.12), a higher proportion of respiratory failure, intensive care treatment, and ventilator use. COVID-19 patients with bacterial infection had a worse prognosis than those without bacterial infection (p<0.04). The empirical antibiotic was given to 75.2% of the patients. Gram-negative bacteria were commonly found as causative agents in this study (n = 39; 70.37%). Conclusion: COVID-19 patients with bacterial infection have a longer length of stay and worse outcomes. Healthcare-associated infections during intensive care treatment for COVID-19 patients must be carefully prevented.

Age, neutrophil lymphocyte ratio, and radiographic assessment of the quantity of lung edema (RALE) score to predict in-hospital mortality in COVID-19 patients: a retrospective study

Background: Available data suggest that case fatality rate of COVID-19 patients in Surabaya is higher than global cases. Thus, it is important to identify risk factors to prevent the mortality. This study aimed to assess the factors associated with hospital mortality of COVID-19 patients, and develop a prediction score based on these findings.

Methods: We analyzed 111 patients, who were diagnosed with COVID-19 based on reverse-transcriptase polymerase chain reaction. The following patient characteristics were obtained from records: age, gender, type of symptoms, onset of symptoms, neutrophil lymphocyte ratio (NLR), absolute lymphocyte count, chest x-ray abnormalities, lung involvement, type of lesion, radiographic assessment of the quantity of lung edema (RALE) score, and mortality. Data were analyzed using SPSS 25.0.

Results Multivariate analysis showed that age >50 years ( p=0.043), NLR score >5.8 ( p=0.016) and RALE score >2 ( p=0.002) can predict the mortality of COVID-19 patients in the hospital. ROC curve analysis of the score ability to predict mortality showed an area under the curve of 0.794. The cut-off point is 4.5, with a sensitivity of 96.7% and specificity of 49.4% to predict the mortality of COVID-19 patient in the hospital.

Conclusions Age, NLR score and RALE score were associated with mortality of COVID-19 patients in the hospital and might be used as a predictor for mortality of COVID-19 patients in health care centre where radiologists are available. The prediction score may be useful for frontline physicians to effectively manage patients with a higher score to prevent mortality.

Optimal use of tocilizumab for severe and critical COVID-19: a systematic review and meta-analysis

Background: Several studies have revealed the potential use of tocilizumab in treating COVID-19 since no therapy has yet been approved for COVID-19 pneumonia. Tocilizumab may provide clinical benefits for cytokine release syndrome in COVID-19 patients. Methods: We searched for relevant studies in PubMed, Embase, Medline, and Cochrane published from March to October 2020 to evaluate optimal use and baseline criteria for administration of tocilizumab in severe and critically ill COVID-19 patients. Research involving patients with confirmed SARS-CoV-2 infection, treated with tocilizumab and compared with the standard of care (SOC) was included in this study. We conducted a systematic review to find data about the risks and benefits of tocilizumab and outcomes from different baseline criteria for administration of tocilizumab as a treatment for severe and critically ill COVID-19 patients. Results: A total of 26 studies, consisting of 23 retrospective studies, one prospective study, and two randomised controlled trials with 2112 patients enrolled in the tocilizumab group and 6160 patients in the SOC group, were included in this meta-analysis. Compared to the SOC, tocilizumab showed benefits for all-cause mortality events and a shorter time until death after first intervention but showed no difference in hospital length of stay. Upon subgroup analysis, tocilizumab showed fewer all-cause mortality events when CRP level ≥100 mg/L, P/F ratio 200-300 mmHg, and P/F ratio <200 mmHg. However, tocilizumab showed a longer length of stay when CRP <100 mg/L than the SOC. Conclusion: This meta-analysis demonstrated that tocilizumab has a positive effect on all-cause mortality. It should be cautiously administrated for optimal results and tailored to the patient's eligibility criteria.

Multidrug-Resistant Infections Among Hospitalized Adults With Community-Acquired Pneumonia In An Indonesian Tertiary Referral Hospital

Objectives

To evaluate the clinical and microbiological appearance among hospitalized pneumonia patients focusing on resistance and risk factors for mortality in a referral hospital.

Patients and methods

The study was an observational retrospective study on patients with CAP from 2014 to 2016 at Dr Soetomo referral hospital of Surabaya, Indonesia. All positive cultures with antimicrobial susceptibility results from blood and respiratory specimens were included. Patients infected with drug-susceptible pathogens and MDR organisms were also assessed in terms of clinical characteristics, day-3 clinical improvement, and 14-day mortality.

Results

Of 202 isolates, 181 possessed antimicrobial susceptibility data. S. pneumoniae was the most prevalent pathogen causing CAP (18.3%). Most patients were empirically treated with ceftriaxone (n=75; 41.4%). Among beta-lactam antibiotics, the susceptibility to the third-generation cephalosporins remained relatively high, between 67.4% and 82.3%, compared with the other beta-lactams such as amoxicillin/clavulanate and ampicillin/sulbactam (a sensitivity rate of 36.5% and 47.5, respectively). For carbapenem antibiotics, imipenem and meropenem susceptibility was 69.6% and 82.3% respectively. Approximately 22% of isolates were identified as MDR that showed significant differences in clinical outcomes of 14-day mortality rates (p<0.001). Notably, patients with day-3 improvement had a lower risk of mortality (OR= 0.06; 95% CI= 0.02–0.19).

Conclusion

One-fifth of causative agents among hospitalized CAP cases were identified as MDR organisms. The pathogens of MDR and non-MDR CAP remain susceptible to the third-generation cephalosporins. Together with additional consideration of culture findings and Pneumonia Severity Index (PSI) assessment, a 3-day clinical assessment is essential to predict the prognosis of 14-day mortality.

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