ESCMID COVID-19 living guidelines: drug treatment and clinical management

SCOPE

In January 2021, the ESCMID Executive Committee decided to launch a new initiative to develop ESCMID guidelines on several COVID-19-related issues, including treatment of COVID-19.

METHODS

An ESCMID COVID-19 guidelines task force was established by the ESCMID Executive Committee. A small group was established, half appointed by the chair, and the remaining selected with an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the PICO (population, intervention, comparison, outcome) format was developed at the beginning of the process. For each PICO, two panel members performed a literature search with a third panellist involved in case of inconsistent results. Voting was based on the GRADE approach.

QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS

A synthesis of the available evidence and recommendations is provided for each of the 15 PICOs, which cover use of hydroxychloroquine, bamlanivimab alone or in combination with etesevimab, casirivimab combined with imdevimab, ivermectin, azithromycin and empirical antibiotics, colchicine, corticosteroids, convalescent plasma, favipiravir, remdesivir, tocilizumab and interferon β-1a, as well as the utility of antifungal prophylaxis and enoxaparin. In general, the panel recommended against the use of hydroxychloroquine, ivermectin, azithromycin, colchicine and interferon β-1a. Conditional recommendations were given for the use of monoclonal antibodies in high-risk outpatients with mild-moderate COVID-19, and remdesivir. There was insufficient evidence to make a recommendation for use of favipiravir and antifungal prophylaxis, and it was recommended that antibiotics should not be routinely prescribed in patients with COVID-19 unless bacterial coinfection or secondary infection is suspected or confirmed. Tocilizumab and corticosteroids were recommended for treatment of severe COVID-19 but not in outpatients with non-severe COVID-19.

SCOPE

The aim of the present guidance is to provide evidence-based recommendations for management of adults with coronavirus disease 2019 (COVID-19). More specifically, the goal is to aid clinicians managing patients with COVID-19 at various levels of severity including outpatients, hospitalized patients, and those admitted to intensive care unit. Considering the composition of the panel, mostly clinical microbiologists or infectious disease specialists with no pulmonology or intensive care background, we focus only on pharmacological treatment and do not give recommendations on oxygen supplement/support. Similarly, as no paediatricians were included in the panel; the recommendations are only for adult patients with COVID-19. Considering the current literature, no guidance was given for special populations such as the immunocompromised.

Ceftazidime - Avibactam susceptibility among carbapenem-resistant Enterobacterales in a pilot study in Turkey

This study aimed to detect carbapenemase genes and to determine the in vitro susceptibility of Ceftazidime-Avibactam (CZA) in Enterobacterales isolates. Carbapenemase genes were detected by polymerase chain reaction. CZA sensitivity of isolates was evaluated with broth microdilution (BMD) and disk diffusion methods. A total of 318 carbapenem-resistant Enterobacterales isolates were included. Most of the isolates (n = 290, 91.2%) were identified as Klebsiella pneumoniae. The most common carbapenemase type was OXA-48 (n = 82, 27.6%). CZA susceptibility was evaluated in 84 isolates with OXA-48 and KPC carbapenemase activity. Both BMD and disk diffusion methods revealed that 95.2% of the isolates were sensitive to CZA; whereas, 4 (4.76%) isolates were resistant to CZA. Among colistin resistant isolates, 96.5% (n = 80) of them were susceptible to CZA. Our study demonstrated high in vitro efficacy of CZA in Enterobacterales isolates producing OXA-48 carbapenemase. High susceptibility rates against colistin resistant isolates which generally are also pan drug resistant, makes CZA a promising therapeutic choice for difficult-to-treat infections. Due to its high correlation with the BMD, disk diffusion method is a suitable and more practical method in detecting CZA in vitro activity.

Prevalence of cutaneous bacterial infections and nasal carriage of Staphylococcus aureus in recipients of renal transplants

BACKGROUND

Renal transplant recipients (RTRs) often develop bacterial infections as a result of their long-term immunosuppressive treatment. However, there is no published case-control study of cutaneous bacterial infections in this population, and the prevalence of nasal Staphyloccus aureus carriage and its role in cutaneous bacterial infections in RTRs are not known.

AIMS

To determine whether the prevalence of cutaneous bacterial infections and nasal S. aureus carriage are increased in RTRs and to investigate the association between nasal S. aureus carriage and cutaneous staphylococcal infections.

METHODS

In total, 66 outpatient RTRs and 67 controls were investigated for the presence of cutaneous bacterial infections. Bacterial cultures were taken from clinically suspicious cutaneous lesions, and three nasal swabs were collected to detect nasal S. aureus colonization.

RESULTS

Cutaneous bacterial infection was suspected in 42.4% of RTRs, and in 14.2% of controls. However, of the lesions that could be cultured, microbiologically proven cutaneous bacterial [methicillin-sensitive S. aureus (MSSA)] infections were confirmed in only two RTRs and one control subject. Nasal S. aureus carriage was found in 10.6% of RTRs and 29.9% of controls (P < 0.05). Both RTRs with MSSA infection were nasal carriers, whereas nasal S. aureus carriage was not detected in the only control subject with MSSA infection. All S. aureus isolates were oxacillin-sensitive.

CONCLUSION

Screening for nasal S. aureus carriage does not seem to assist in preventing staphylococcal bacterial infections in outpatient RTRs.

[Biofilm production and antifungal susceptibility patterns of Candida species isolated from hospitalized patients]

Biofilm producing Candida species are known to be more resistant to immune response and antimicrobial agents which leads to treatment failure. The aim of this study was to investigate the biofilm production among Candida species that were isolated from hospitalized patients and to compare the in vitro activities of antifungal agents with biofilm production. A total of 116 Candida spp. (79 C. albicans and 37 non-albicans Candida spp.) isolated from various specimens (blood, sterile body fluids, mucosal and skin lesion samples) were included to the study. Fluconazole, itraconazole, amphotericin B and caspofungin susceptibilities of the isolates were determined by broth microdilution method according to CLSI M27-A2 standards. Biofilm production of Candida spp. was determined by microplate method, using brain heart infusion broth supplemented with 0.25% glucose as a growth medium. Biofilm formation was detected in 33 of 116 isolates (28%) and 11 of them (33%) were the strains isolated from hemocultures. Biofilm production was determined more commonly in blood isolates than the strains isolated from other samples (p < 0.05). The biofilm production rate of non-albicans Candida species (41%) was found higher than C. albicans (23%), which the difference was statistically significant (p < 0.05). Amphotericin B and caspofungin were found the most effective antifungals with the MIC90 values of 0.06 microg/ml and 0.5 microg/ml for C. albicans, and 0.5 microg/ml and 1 microg/ml for non-albicans Candida species respectively. The observed positive correlation between the biofilm production and amphotericin B MIC values were found significant (p < 0.05). In conclusion, high biofilm production rates of Candida species may explain the increase in the rate of catheter-related Candida infections.

Risk of contamination of nasal sprays in otolaryngologic practice

Background

Reusable nasal-spray devices are frequently used in otolaryngologic examinations, and there is an increasing concern about the risk of cross-contamination from these devices. The aim of our study was to determine, by means of microbiologic analysis, the safety of a positive-displacement or pump-type atomizer after multiple uses.

Methods

A reusable nasal spray bottle, pump, and tips were used in the nasal physical examination of 282 patients admitted to a tertiary otolaryngology clinic. The effectiveness of 2 different methods of prophylaxis against microbiologic contamination (the use of protective punched caps or rinsing the bottle tip with alcohol) was compared with that of a control procedure.

Results

Although there was no statistically significant difference in positive culture rates among the types of nasal spray bottles tested, methicillin-resistant coagulase-negative staphylococci were isolated in 4 of 198 cultures.

Conclusion

Given these findings, we concluded that additional precautions (such as the use of an autoclave between sprays, disposable tips, or disposable devices) are warranted to avoid interpatient cross-contamination from a reusable nasal spray device.

Nocardial epidural abscess of the thoracic spinal cord and review of the literature

Nocardia is a potential cause of opportunistic infection in organ-transplant recipients. We report an epidural abscess causing acute paraparesis in a patient with a rejected renal transplant and chronic liver disease. Early drainage and treatment with imipenem and trimethoprim-sulfamethoxasole improved the patient's neurologic status.