Assessment of Acute Acral Lesions in a Case Series of Children and Adolescents During the COVID-19 Pandemic

Importance

A novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recently been identified as the cause of a pandemic called coronavirus disease 2019 (COVID-19). In this context, some associated skin diseases have been described. Cutaneous lesions referred to as acute acro-ischemia have been reported as a possible sign of COVID-19 in adolescents and children.

Objective

To evaluate the pathogenesis of these newly described acute acral lesions.

Design, Setting, and Participants

This prospective case series was conducted at La Fe University Hospital, a tertiary referral hospital in Valencia, Spain, between April 9 and April 15, 2020. Among 32 referred patients, 20 children and adolescents with new-onset inflammatory lesions did not have a diagnosis.

Exposures

Patients were not exposed to any drug or other intervention.

Main Outcomes and Measures

We performed reverse transcriptase-polymerase chain reaction for SARS-CoV-2 and a range of blood tests for possible origins of the lesions. Skin biopsies were performed in 6 patients.

Results

Of the 20 patients enrolled, 7 were female and 13 were male, with an age range of 1 to 18 years. Clinical findings fit into the following patterns: acral erythema (6 patients), dactylitis (4 patients), purpuric maculopapules (7 patients), and a mixed pattern (3 patients). None of the patients had remarkable hematologic or serologic abnormalities, including negative antibodies to SARS-CoV-2. Biopsies performed in 6 patients showed histologic findings characteristic of perniosis.

Conclusions and Relevance

The clinical, histologic, and laboratory test results were compatible with a diagnosis of perniosis, and no evidence was found to support the implication of SARS-CoV-2 infection.

Clinical and Microbiological Impact of Implementing a Decision Support Algorithm through Microbiologic Rapid Diagnosis in Critically Ill Patients: An Epidemiological Retrospective Pre-/Post-Intervention Study

BACKGROUND

Data on the benefits of rapid microbiological testing on antimicrobial consumption (AC) and antimicrobial resistance patterns (ARPs) are scarce. We evaluated the impact of a protocol based on rapid techniques on AC and ARP in intensive care (ICU) patients.

METHODS

A retrospective pre- (2018) and post-intervention (2019-2021) study was conducted in ICU patients. A rapid diagnostic algorithm was applied starting in 2019 in patients with a lower respiratory tract infection. The incidence of nosocomial infections, ARPs, and AC as DDDs (defined daily doses) were monitored.

RESULTS

A total of 3635 patients were included: 987 in the pre-intervention group and 2648 in the post-intervention group. The median age was 60 years, the sample was 64% male, and the average APACHE II and SOFA scores were 19 points and 3 points. The overall ICU mortality was 17.2% without any differences between the groups. An increase in the number of infections was observed in the post-intervention group (44.5% vs. 17.9%, p < 0.01), especially due to an increase in the incidence of ventilator-associated pneumonia (44.6% vs. 25%, p < 0.001). AC decreased from 128.7 DDD in 2018 to 66.0 DDD in 2021 (rate ratio = 0.51). An increase in Pseudomonas aeruginosa susceptibility of 23% for Piperacillin/tazobactam and 31% for Meropenem was observed.

CONCLUSION

The implementation of an algorithm based on rapid microbiological diagnostic techniques allowed for a significant reduction in AC and ARPs without affecting the prognosis of critically ill patients.

Ten-Year Evaluation of Ventilator-Associated Pneumonia (VAP) According to Initial Empiric Treatment: A Retrospective Analysis Using Real-World Data

Background/Objectives: Ventilator-associated pneumonia (VAP) is the main nosocomial infection in intensive care units (ICUs) that causes the highest morbidity and mortality. The aim of our study is to investigate variations in crude ICU mortality among patients with VAP over the past decade. We also wish to identify associated risk factors, evaluate changes in the etiology, and assess the incidence and impact of inappropriate empirical antibiotic treatment (IEAT). Methods: We conducted a retrospective, observational, single-center study over a 10-year period (2014-2024), including critically ill patients who developed VAP. The population was divided into three periods: (P1) from 2014 to 2018 (pre-COVID-19); (P2) from 2019 to 2021 (COVID-19); and (P3) from 2022 to 2024 (post-COVID-19). Binary logistic regression was used to identify which variables were independently associated with ICU mortality. Results: A total of 220 patients were included in the study (P1 = 47, P2 = 96, and P3 = 77 patients). The most prevalent microorganisms identified were P. aeruginosa, Klebsiella spp., and S. aureus. Significant variations in etiology were not observed over the years. The incidence of IEAT was 4.5%, with no observed differences between the study periods. Crude ICU mortality was 33.6%, with higher rates observed in IEAT (40% vs. 33.3%, p = 0.73). In patients with appropriate empiric antibiotic treatment (AEAT), there was a significant decrease in crude mortality over the years from 42.2% in P1 to 22.2% in P3 (p < 0.001). Age (OR = 1.04; 95% CI = 1.01-1.08) and P2 (OR = 2.8; 95% CI = 1.1-7.4) were found to be independently associated with an increased risk of mortality. Conversely, a lower risk of death was associated with mean arterial pressure (OR = 0.94; 95% CI = 0.69-0.99) and the use of syndromic respiratory panel (OR = 0.23; 95% CI = 0.07-0.68). Conclusions: A reduction in crude VAP mortality over the years was observed, with no change in the etiology or rate of IEAT. The implementation of protocols using respiratory syndromic panels could be a measure to implement to reduce VAP mortality.