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Tassaneeyasin T, Sungkanuparph S, Srichatrapimuk S, Charoensri A, Thammavaranucupt K, Jayanama K, Kirdlarp S. Prevalence and risk factors of cytomegalovirus reactivation in critically Ill patients with COVID-19 pneumonia. PLoS One 2024; 19:e0303995. [PMID: 38771836 PMCID: PMC11108163 DOI: 10.1371/journal.pone.0303995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/04/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUNDS In critically ill patients with COVID-19, secondary infections are potentially life-threatening complications. This study aimed to determine the prevalence, clinical characteristics, and risk factors of CMV reactivation among critically ill immunocompetent patients with COVID-19 pneumonia. METHODS A retrospective cohort study was conducted among adult patients who were admitted to ICU and screened for quantitative real-time PCR for CMV viral load in a tertiary-care hospital during the third wave of the COVID-19 outbreak in Thailand. Cox regression models were used to identify significant risk factors for developing CMV reactivation. RESULTS A total of 185 patients were studied; 133 patients (71.9%) in the non-CMV group and 52 patients (28.1%) in the CMV group. Of all, the mean age was 64.7±13.3 years and 101 patients (54.6%) were males. The CMV group had received a significantly higher median cumulative dose of corticosteroids than the non-CMV group (301 vs 177 mg of dexamethasone, p<0.001). Other modalities of treatments for COVID-19 including anti-viral drugs, anti-cytokine drugs and hemoperfusion were not different between the two groups (p>0.05). The 90-day mortality rate for all patients was 29.1%, with a significant difference between the CMV group and the non-CMV group (42.3% vs. 24.1%, p = 0.014). Median length of stay was longer in the CMV group than non-CMV group (43 vs 24 days, p<0.001). The CMV group has detectable CMV DNA load with a median [IQR] of 4,977 [1,365-14,742] IU/mL and 24,570 [3,703-106,642] in plasma and bronchoalveolar fluid, respectively. In multivariate analysis, only a cumulative corticosteroids dose of dexamethasone ≥250 mg (HR = 2.042; 95%CI, 1.130-3.688; p = 0.018) was associated with developing CMV reactivation. CONCLUSION In critically ill COVID-19 patients, CMV reactivation is frequent and a high cumulative corticosteroids dose is a significant risk factor for CMV reactivation, which is associated with poor outcomes. Further prospective studies are warranted to determine optimal management.
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Affiliation(s)
- Tanapat Tassaneeyasin
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Somnuek Sungkanuparph
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Sirawat Srichatrapimuk
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Attawit Charoensri
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Kanin Thammavaranucupt
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Kulapong Jayanama
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Suppachok Kirdlarp
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
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Gozukucuk R, Kilic HH. The relationship between CMV reactivation, anti-cytokine treatment and mortality in critical COVID-19 patients. Pak J Med Sci 2023; 39:1286-1290. [PMID: 37680795 PMCID: PMC10480725 DOI: 10.12669/pjms.39.5.7301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/16/2023] [Accepted: 06/18/2023] [Indexed: 09/09/2023] Open
Abstract
Objective To examine the use of anti-cytokine treatment in critical COVID-19 patients and their association with the frequency of CMV cases, viral load level, and mortality in these patients. Methods This is a retrospective study. A total of 170 critical and/or intensive care patients with COVID-19 admitted to Hisar Hospital Intercontinental from March 15, 2020, to December 31, 2021 were divided into the use of anti-cytokine treatment group and the no anti-cytokine treatment group. Furthermore, the relationship between CMV reactivation, mortality and anti-cytokine treatment in patients was also examined. Results A total of 170 critical COVID-19 patients were included in the study, three of them were excluded. One hundred sixty seven were included in the study of which 38 (22.7%) were found to be CMV DNA positive. As an anti-cytokine treatment, it was observed that tocilizumab was used in 53 patients, anakinra was used in 27 patients, and no anti-cytokine treatment was used in 77 patients. CMV positivity in patients treated with anti-cytokines (31.11%) was found to be significantly higher than in patients who were not treated with it (16.88%) (p:0.033). Furthermore, it was determined that anti-cytokine treatment significantly decreased mortality (p: 0.003) and that there was no significant relationship between CMV reactivation and mortality (p: 0.399). Conclusion Even though CMV reactivation was high in critical COVID-19 patients who received anti-cytokine treatment, decrease in mortality were observed with early diagnosis and effective treatment. Therefore, CMV infection should be considered in patients receiving immunosuppressive treatment.Clinical Trial Registration: HisarIH-101/NCT05419206.
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Affiliation(s)
- Ramazan Gozukucuk
- Ramazan Gozukucuk, Department of Infectious Disease and Clinical Microbiology, Faculty of Dentist, Istanbul Galata University, Evliya Çelebi, Meşrutiyet Cd. No:62, Beyoglu, Istanbul, 34430 Turkey. Hisar Hospital Intercontinental,Saray Mah. Siteyolu Cad.No:7, Umraniye, Istanbul, 34768 Turkey
| | - Hasan Huseyin Kilic
- Hasan Huseyin Kilic, Department of Anesthesiology and Reanimation, Istanbul Dogus Universty Dudullu Yerleşkesi Dudullu Osb Mah. Nato Yolu Cad. 265/ 1 Ümraniye, Istanbul 34775 Turkey. Hisar Hospital Intercontinental,Saray Mah. Siteyolu Cad.No:7, Umraniye, Istanbul, 34768 Turkey
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Trirattanapikul A, Pasomsub E, Siriyotha S, Pattanaprateep O, Phuphuakrat A. Diagnostic stewardship to limit repeat plasma cytomegalovirus viral load testing. BMC Infect Dis 2023; 23:387. [PMID: 37296377 DOI: 10.1186/s12879-023-08355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals. METHODS A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model. RESULTS After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht. CONCLUSIONS The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.
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Affiliation(s)
- Akeatit Trirattanapikul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Angsana Phuphuakrat
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Yildirim E, Kilickan L, Aksoy SH, Gozukucuk R, Kilic HH, Tomak Y, Dalkilic O, Tanboga IH, Kilickan FDB. Does the variant positivity and negativity affect the clinical course in COVID-19?: A cohort study. Medicine (Baltimore) 2023; 102:e33132. [PMID: 36862905 PMCID: PMC9981248 DOI: 10.1097/md.0000000000033132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
The primary aim of the current study is to analyze the clinical, laboratory, and demographic data comparing the patients with Coronavirus Disease 2019 (COVID-19) admitted to our intensive care unit before and after the UK variant was first diagnosed in December 2020. The secondary objective was to describe a treatment approach for COVID-19. Between Mar 12, 2020, and Jun 22, 2021, 159 patients with COVID-19 were allocated into 2 groups: the variant negative group (77 patients before December 2020) and the variant positive group (82 patients after December 2020). The statistical analyses included early and late complications, demographic data, symptoms, comorbidities, intubation and mortality rates, and treatment options. Regarding early complications, unilateral pneumonia was more common in the variant (-) group (P = .019), whereas bilateral pneumonia was more common in the variant (+) group (P < .001). Regarding late complications, only cytomegalovirus pneumonia was observed more frequently in the variant (-) group (P = .023), whereas secondary gram (+) infection, pulmonary fibrosis (P = .048), acute respiratory distress syndrome (ARDS) (P = .017), and septic shock (P = .051) were more common in the variant (+) group. The therapeutic approach showed significant differences in the second group such as plasma exchange and extracorporeal membrane oxygenation which is more commonly used in the variant (+) group. Although mortality and intubation rates did not differ between the groups, severe challenging early and late complications were observed mainly in the variant (+) group, necessitating invasive treatment options. We hope that our data from the pandemic will shed light on this field. Regarding the COVID-19 pandemic, it is clear that there is much to be done to deal with future pandemics.
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Affiliation(s)
- Erkan Yildirim
- Department of Thoracic Surgery, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
- * Correspondence: Erkan Yildirim, Department of Thoracic Surgery, Hisar Intercontinental Hospital, Saray mah, Site Yolu cad, N0: 7, Umraniye 34768, Istanbul, Turkiye (e-mail: )
| | - Levent Kilickan
- Department of Anesthesiology and Reanimation, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
| | - Suleyman Hilmi Aksoy
- Department of Radiology, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
- Department of Medical Imaging Techniques, Istanbul Galata University, Beyoglu, Istanbul, Turkiye
| | - Ramazan Gozukucuk
- Department of Infectious Diseases, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
- Faculty of Dentist, Istanbul Galata University, Beyoglu, Istanbul, Turkiye
| | - Hasan Huseyin Kilic
- Department of Anesthesiology and Reanimation, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
- Department of Anesthesiology, Dogus University, Istanbul, Turkiye
| | - Yakup Tomak
- Department of Anesthesiology and Reanimation, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
- School of Health Sciences, Dogus University, Istanbul, Turkiye
| | - Orhan Dalkilic
- Department of Chest Diseases, Hisar Intercontinental Hospital, Umraniye, Istanbul, Turkiye
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Pérez-Granda MJ, Catalán P, Muñoz P, Aldámiz T, Barrios JC, Ramírez C, García-Martínez R, Villalba MV, Puente L, Bouza E. Cytomegalovirus reactivation in patients diagnosed with severe COVID-19: A point prevalence study in a general hospital. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2023; 36:45-51. [PMID: 36408974 PMCID: PMC9910675 DOI: 10.37201/req/068.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the prevalence of CMV reactivation in a population admitted for severe COVID-19 to a general hospital. METHODS Point prevalence study in all hospitalized patients with severe COVID-19 (admitted either to general wards or ICU). Determination of the presence of CMV DNA in circulating blood. COVID-19 was confirmed in patients with compatible clinical manifestations, usually with pneumonia and a positive nasopharyngeal PCR test. RESULTS We included 140 hospitalized patients with COVID-19 who consented to participate. A total of 16 patients (11.42%), had circulating CMV-DNA in peripheral blood at the time of the study. Patients with positive CMV viral load were mainly ICU patients (11/37 -29,7%) and only 5/103 cases (4,85%) were hospitalized into general wards. The accumulated doses of corticosteroids (prednisone equivalents) in the study day were (median and IQR) 987.50 mg (396.87-2,454.68) and 187.50 mg (75.00-818.12) respectively in CMV positive and negative patients (p < 0.001). A significant proportion of CMV positive patients were discovered because of the study and were clinically unsuspected by their physicians. The coinfected COVID-CMV positive population had a higher risk of accumulated secondary nosocomially-acquired infections and a worse prognosis. CONCLUSIONS CMV reactivation should be systematically searched in patients in COVID-19 cases admitted to the ICU.
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Affiliation(s)
- María Jesús Pérez-Granda
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain,Correspondence: Maria Jesus Pérez Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46 28007 Madrid, Spain E-mail:
| | - Pilar Catalán
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Teresa Aldámiz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Camilo Barrios
- Department of Critical Care, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Carlos Ramírez
- Department of Critical Care, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rita García-Martínez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Victoria Villalba
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Luis Puente
- Department of Pneumology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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6
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Perera MR, Greenwood EJD, Crozier TWM, Elder EG, Schmitt J, Crump CM, Lehner PJ, Wills MR, Sinclair JH. Human Cytomegalovirus Infection of Epithelial Cells Increases SARS-CoV-2 Superinfection by Upregulating the ACE2 Receptor. J Infect Dis 2022; 227:543-553. [PMID: 36408607 PMCID: PMC9927080 DOI: 10.1093/infdis/jiac452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has caused widespread morbidity and mortality since its onset in late 2019. Here, we demonstrate that prior infection with human cytomegalovirus (HCMV) substantially increases infection with SARS-CoV-2 in vitro. HCMV is a common herpesvirus carried by 40%-100% of the population, which can reactivate in the lung under inflammatory conditions, such as those resulting from SARS-CoV-2 infection. We show in both endothelial and epithelial cell types that HCMV infection upregulates ACE2, the SARS-CoV-2 cell entry receptor. These observations suggest that HCMV reactivation events in the lung of healthy HCMV carriers could exacerbate SARS-CoV-2 infection and subsequent COVID-19 symptoms. This effect could contribute to the disparity of disease severity seen in ethnic minorities and those with lower socioeconomic status, due to their higher CMV seroprevalence. Our results warrant further clinical investigation as to whether HCMV infection influences the pathogenesis of SARS-CoV-2.
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Affiliation(s)
- Marianne R Perera
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Edward J D Greenwood
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Thomas W M Crozier
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Elizabeth G Elder
- Department of Microbiology, National Veterinary Institute Uppsala, Sweden
| | - Janika Schmitt
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Colin M Crump
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom
| | - Paul J Lehner
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Mark R Wills
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - John H Sinclair
- Correspondence: John H. Sinclair, PhD, Box 157, Level 5, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK ()
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Effect of Cytomegalovirus on the Immune System: Implications for Aging and Mental Health. Curr Top Behav Neurosci 2022; 61:181-214. [PMID: 35871707 DOI: 10.1007/7854_2022_376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Human cytomegalovirus (HCMV) is a major modulator of the immune system leading to long-term changes in T-lymphocytes, macrophages, and natural killer (NK) cells among others. Perhaps because of this immunomodulatory capacity, HCMV infection has been linked with a host of deleterious effects including accelerated immune aging (premature mortality, increased expression of immunosenescence-linked markers, telomere shortening, speeding-up of epigenetic "clocks"), decreased vaccine immunogenicity, and greater vulnerability to infectious diseases (e.g., tuberculosis) or infectious disease-associated pathology (e.g., HIV). Perhaps not surprisingly given the long co-evolution between HCMV and humans, the virus has also been associated with beneficial effects, such as increased vaccine responsiveness, heterologous protection against infections, and protection against relapse in the context of leukemia. Here, we provide an overview of this literature. Ultimately, we focus on one other deleterious effect of HCMV, namely the emerging literature suggesting that HCMV plays a pathophysiological role in psychiatric illness, particularly depression and schizophrenia. We discuss this literature through the lens of psychological stress and inflammation, two well-established risk factors for psychiatric illness that are also known to predispose to reactivation of HCMV.
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Schoninger S, Dubrovskaya Y, Marsh K, Altshuler D, Prasad P, Louie E, Weisenberg S, Hochman S, Fridman D, Trachuk P. Outcomes of Cytomegalovirus Viremia Treatment in Critically Ill Patients with COVID-19 Infection. Open Forum Infect Dis 2022; 9:ofac286. [PMID: 35859993 PMCID: PMC9214167 DOI: 10.1093/ofid/ofac286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/08/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with COVID-19 admitted to the intensive care unit (ICU) have poor outcomes and frequently develop comorbid conditions, including cytomegalovirus (CMV) reactivation. The implications of CMV reactivation in this setting are unknown. We aimed to investigate if treatment of CMV viremia improved in-hospital mortality in ICU patients with COVID-19.
Methods
In this single center retrospective study, we analyzed clinical outcomes in patients diagnosed with COVID-19 pneumonia and CMV viremia admitted to an ICU from March 1, 2020, to April 30, 2021, who either received treatment (ganciclovir and/or valganciclovir) or no treatment. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were total hospital length of stay (LOS), ICU LOS, requirement for extracorporeal membrane oxygenation (ECMO) support, duration of mechanical ventilation (MV), and predictors of in-hospital mortality.
Results
A total of 80 patients were included, 43 patients in the treatment group and 37 in the control. Baseline characteristics were similar in both groups. CMV-treated patients were more likely to test positive for CMV earlier in their course, more likely to be on ECMO and received higher total steroid doses on average. In-hospital mortality was similar between the two groups (37.2% vs 43.2.0% p-value = 0.749). There was no significant difference in hospital LOS, though CMV-treated patients had a longer ICU LOS.
Conclusions
Treatment of CMV viremia did not decrease in-hospital mortality in ICU patients with COVID-19, but sample size was limited. CMV viremia was significantly associated with total steroid dose received and longer ICU stay.
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Affiliation(s)
- Scott Schoninger
- Division of Internal Medicine, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Yanina Dubrovskaya
- Department of Pharmacy, NYU Langone Health, New York , New York , United States
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Kassandra Marsh
- Department of Pharmacy, NYU Langone Health, New York , New York , United States
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Health, New York , New York , United States
| | - Prithiv Prasad
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Eddie Louie
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Scott Weisenberg
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Sarah Hochman
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - David Fridman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
| | - Polina Trachuk
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York , New York , United States
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Weber S, Kehl V, Erber J, Wagner KI, Jetzlsperger AM, Burrell T, Schober K, Schommers P, Augustin M, Crowell CS, Gerhard M, Winter C, Moosmann A, Spinner CD, Protzer U, Hoffmann D, D’Ippolito E, Busch DH. CMV seropositivity is a potential novel risk factor for severe COVID-19 in non-geriatric patients. PLoS One 2022; 17:e0268530. [PMID: 35613127 PMCID: PMC9132318 DOI: 10.1371/journal.pone.0268530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/02/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND COVID-19 has so far affected more than 250 million individuals worldwide, causing more than 5 million deaths. Several risk factors for severe disease have been identified, most of which coincide with advanced age. In younger individuals, severe COVID-19 often occurs in the absence of obvious comorbidities. Guided by the finding of cytomegalovirus (CMV)-specific T cells with some cross-reactivity to SARS-CoV-2 in a COVID-19 intensive care unit (ICU) patient, we decided to investigate whether CMV seropositivity is associated with severe or critical COVID-19. Herpes simplex virus (HSV) serostatus was investigated as control. METHODS National German COVID-19 bio-sample and data banks were used to retrospectively analyze the CMV and HSV serostatus of patients who experienced mild (n = 101), moderate (n = 130) or severe to critical (n = 80) disease by IgG serology. We then investigated the relationship between disease severity and herpesvirus serostatus via statistical models. RESULTS Non-geriatric patients (< 60 years) with severe COVID-19 were found to have a very high prevalence of CMV-seropositivity, while CMV status distribution in individuals with mild disease was similar to the prevalence in the German population; interestingly, this was not detectable in older patients. Prediction models support the hypothesis that the CMV serostatus, unlike HSV, might be a strong biomarker in identifying younger individuals with a higher risk of developing severe COVID-19, in particular in absence of other co-morbidities. CONCLUSIONS We identified 'CMV-seropositivity' as a potential novel risk factor for severe COVID-19 in non-geriatric individuals in the studied cohorts. More mechanistic analyses as well as confirmation of similar findings in cohorts representing the currently most relevant SARS-CoV-2 variants should be performed shortly.
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Affiliation(s)
- Simone Weber
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
| | - Victoria Kehl
- Institute for AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johanna Erber
- Department of Internal Medicine II, University Hospital Rechts Der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| | - Karolin I. Wagner
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
| | | | - Teresa Burrell
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
| | - Kilian Schober
- Mikrobiologisches Institut–Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Philipp Schommers
- Medical Faculty and University Hospital Cologne, Department I of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Bonn-Cologne, Germany
| | - Max Augustin
- Medical Faculty and University Hospital Cologne, Department I of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Bonn-Cologne, Germany
| | - Claudia S. Crowell
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| | - Markus Gerhard
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| | - Christof Winter
- Institute of Clinicl Chemistry and Pathobiochemistry, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas Moosmann
- German Center for Infection Research (DZIF), Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Christoph D. Spinner
- Department of Internal Medicine II, University Hospital Rechts Der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| | - Ulrike Protzer
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dieter Hoffmann
- Institute of Virology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Elvira D’Ippolito
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
| | - Dirk H. Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
- * E-mail:
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10
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Taherifard E, Movahed H, Kiani Salmi S, Taherifard A, Abdollahifard S, Taherifard E. Cytomegalovirus coinfection in patients with severe acute respiratory syndrome coronavirus 2 infection: a systematic review of reported cases. Infect Dis (Lond) 2022; 54:543-557. [PMID: 35522073 DOI: 10.1080/23744235.2022.2070273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Dysfunction of both the innate and the adaptive immune systems is observed in severe coronavirus disease 2019 which, together with administration of immunosuppressive drugs, could lead to cytomegalovirus coinfection or reactivation associated with a poorer outcome. The current study aimed to systematically review the pattern, presentations, clinical course and outcome of patients with severe acute respiratory syndrome coronavirus 2 and cytomegalovirus coinfection. METHODS Three online databases, PubMed, Scopus and Web of Science, were searched, and after excluding duplicates and irrelevant reports, eligible articles were identified. Information about patients' age and gender, comorbidities, presentations of coronavirus disease 2019 and cytomegalovirus, treatment courses and outcomes were extracted. RESULTS A total of 34 reports with 59 patients with coinfection were considered to be eligible for data extraction. A majority of patients were middle-aged or elderly (84.5%). More than three-fourths (79.2%) had at least one comorbidity. Cytomegalovirus viremia was documented in 43 patients. The most common end organ involved was the gastrointestinal tract in 13 patients (48.1% of 27 patients with end organ involvement), mostly as cytomegalovirus colitis, followed by the respiratory tract in 12 patients. There was a significant association between intubation and fatal outcome (p = .011). CONCLUSION We comprehensively reviewed published cases with coronavirus disease 2019 and cytomegalovirus reactivation. The findings may assist in appraising signs and symptoms for early suspicion, detection and treatment in patients with unusual clinical courses or with severe, prolonged or unexplained deterioration of end organ function.
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Affiliation(s)
| | - Hamed Movahed
- Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Sima Kiani Salmi
- Radiology Department, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Ali Taherifard
- Radiology Department, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Saeed Abdollahifard
- Research Center for Neuromodulation and Pain, Shiraz, Fars, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
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11
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Siddiqui SS, Chatterjee S, Yadav A, Rai N, Agrawal A, Gurjar M, Yadav G, Prakash S, Kumar A, Muzaffar SN. Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus 2019 Disease: Pathogens or Spectators? Indian J Crit Care Med 2022; 26:376-380. [PMID: 35519914 PMCID: PMC9015933 DOI: 10.5005/jp-journals-10071-24130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Coronavirus disease-2019 (COVID-19) pandemic is raging all over the world. As we are delving more into management of COVID-19, certain new challenges are emerging. One of these is emergence or reactivation of viral infections belonging to Herpesviridae family, especially cytomegalovirus (CMV). Although we have come across the threat of fungal and resistant bacterial infections, experience regarding reactivation or coinfection with concomitant viral infections like CMV during the COVID pandemic is still limited. Whether CMV is a bystander or pathogen is difficult to say categorically and needs further research. In this case series, we intend to describe three patients of COVID-19 with CMV coinfections. To our knowledge, this is the first case series from India.
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Affiliation(s)
- Suhail S Siddiqui
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Soumyadip Chatterjee
- Department of Infectious Diseases, Tata Medical Centre, Kolkata, West Bengal, India
| | - Ambuj Yadav
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Nitin Rai
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Avinash Agrawal
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Geeta Yadav
- Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Shantanu Prakash
- Department of Microbiology (Virology), King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amit Kumar
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Syed N Muzaffar
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
- Syed N Muzaffar, Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India, Phone: +91 9648084011, e-mail:
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12
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Jaiswal SR, Arunachalam J, Bhardwaj A, Saifullah A, Lakhchaura R, Soni M, Bhagawati G, Chakrabarti S. Impact of adaptive natural killer cells, KLRC2 genotype and cytomegalovirus reactivation on late mortality in patients with severe COVID-19 lung disease. Clin Transl Immunology 2022; 11:e1359. [PMID: 35035954 PMCID: PMC8752325 DOI: 10.1002/cti2.1359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 12/23/2022] Open
Abstract
Objective SARS-CoV-2 infection results in severe lung disease in up to 50% of hospitalised patients. The aetiopathogenesis in a subset of such patients, who continue to have progressive pulmonary disease following virus clearance, remains unexplored. Methods We investigated the role of NKG2C+/NKG2A- adaptive natural killer (ANK) cells, KLRC2 genotype and cytomegalovirus (CMV) reactivation in 22 such patients. Results The median duration of virus positivity was 23 days, and the median duration of hospitalisation was 48 days. The overall survival at 60 days in this group was 50%. Older age and comorbidities impacted survival negatively. CMV viraemia was documented in 11 patients, with a survival of 25% vs 80% in those without viraemia with viral load correlating with mortality. Both NK and T cells were markedly depressed in all patients at day 15. However, only persistently low ANK cells at 30 days along with an inversely high NKG2C-/NKG2A+ inhibitory NK cells significantly correlated with high CMV viraemia and mortality, irrespective of KLRC2 genotype. However, day 30 ANK cells were significantly lower in the KLRC2 deletion group. The release of IFN-γ and perforin was severely compromised in all patients at day +15, with significant improvement in the survivors at day +30, but not in those with adverse outcome. Conclusion Patients with progressive lung disease even after negative SARS-CoV-2 status, with persistently reduced and functionally compromised ANK cells, are more likely to have CMV reactivation and an adverse outcome, independent of KLRC2 genotype.
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Affiliation(s)
- Sarita Rani Jaiswal
- Cellular Therapy and Immunology Manashi Chakrabarti Foundation New Delhi India.,Department of Blood and Marrow Transplantation Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India.,Amity Institute of Molecular Medicine and Stem Cell Research Amity University Noida, Uttar Pradesh India
| | | | - Ashutosh Bhardwaj
- Department of Intensive Care Medicine Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
| | - Ashraf Saifullah
- Department of Blood and Marrow Transplantation Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
| | - Rohit Lakhchaura
- Department of Blood and Marrow Transplantation Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
| | - Mayank Soni
- Department of Blood and Marrow Transplantation Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
| | - Gitali Bhagawati
- Department of Pathology and Microbiology Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
| | - Suparno Chakrabarti
- Cellular Therapy and Immunology Manashi Chakrabarti Foundation New Delhi India.,Department of Blood and Marrow Transplantation Dharamshila Narayana Super-speciality Hospital, Research & Development New Delhi India
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13
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Abdoli A, Falahi S, Kenarkoohi A. COVID-19-associated opportunistic infections: a snapshot on the current reports. Clin Exp Med 2022; 22:327-346. [PMID: 34424451 PMCID: PMC8381864 DOI: 10.1007/s10238-021-00751-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/30/2021] [Indexed: 02/07/2023]
Abstract
Treatment of the novel Coronavirus Disease 2019 (COVID-19) remains a complicated challenge, especially among patients with severe disease. In recent studies, immunosuppressive therapy has shown promising results for control of the cytokine storm syndrome (CSS) in severe cases of COVID-19. However, it is well documented that immunosuppressive agents (e.g., corticosteroids and cytokine blockers) increase the risk of opportunistic infections. On the other hand, several opportunistic infections were reported in COVID-19 patients, including Aspergillus spp., Candida spp., Cryptococcus neoformans, Pneumocystis jiroveci (carinii), mucormycosis, Cytomegalovirus (CMV), Herpes simplex virus (HSV), Strongyloides stercoralis, Mycobacterium tuberculosis, and Toxoplasma gondii. This review is a snapshot about the main opportunistic infections that reported among COVID-19 patients. As such, we summarized information about the main immunosuppressive agents that were used in recent clinical trials for COVID-19 patients and the risk of opportunistic infections following these treatments. We also discussed about the main challenges regarding diagnosis and treatment of COVID-19-associated opportunistic infections (CAOIs).
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Affiliation(s)
- Amir Abdoli
- Zoonoses Research Center, Jahrom University of Medical Sciences, Jahrom, Iran ,Jahrom University of Medical Sciences, Ostad Motahari Ave, POBox 74148-46199, Jahrom, Iran
| | - Shahab Falahi
- Zoonotic Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Azra Kenarkoohi
- Department of Microbiology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
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14
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Shimizu K, Hirata H, Kabata D, Tokuhira N, Koide M, Ueda A, Tachino J, Shintani A, Uchiyama A, Fujino Y, Ogura H. Ivermectin administration is associated with lower gastrointestinal complications and greater ventilator-free days in ventilated patients with COVID-19: A propensity score analysis. J Infect Chemother 2021; 28:548-553. [PMID: 35016823 PMCID: PMC8718885 DOI: 10.1016/j.jiac.2021.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/11/2021] [Accepted: 12/26/2021] [Indexed: 12/15/2022]
Abstract
Introduction COVID-19 patients have been reported to have digestive symptoms with poor outcome. Ivermectin, an antiparasitic drug, has been used in COVID-19 patients. The objective of this study was to evaluate whether ivermectin has effects on gastrointestinal complications and ventilator-free days in ventilated patients with COVID-19. Methods COVID-19 patients who were mechanically ventilated in the ICU were included in this study. The ventilated patients who received ivermectin within 3 days after admission were assigned to the Ivermectin group, and the others were assigned to the Control group. Patients in the Ivermectin group received ivermectin 200 μg/kg via nasal tube. The incidence of gastrointestinal complications and ventilator-free days within 4 weeks from admission were evaluated as clinical outcomes using a propensity score with the inverse probability weighting method. Results We included 88 patients in this study, of whom 39 patients were classified into the Ivermectin group, and 49 patients were classified into the Control group. The hazard ratio for gastrointestinal complications in the Ivermectin group as compared with the Control group was 0.221 (95% confidence interval [CI], 0.057 to 0.855; p = 0.029) in a Cox proportional-hazard regression model. The odds ratio for ventilator-free days as compared with the Control group was 1.920 (95% CI, 1.076 to 3.425; p = 0.027) in a proportional odds logistic regression model. Conclusions Ivermectin improved gastrointestinal complications and the number of ventilator-free days in severe COVID-19 patients undergoing mechanical ventilation. Prevention of gastrointestinal symptoms by SARS-Cov-2 might be associated with COVID-19 outcome.
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Affiliation(s)
- Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-0051, Japan.
| | - Natsuko Tokuhira
- Intensive Care Unit, Osaka University Hospital, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Moe Koide
- Intensive Care Unit, Osaka University Hospital, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Akiko Ueda
- Laboratory for Clinical Investigation, Osaka University Hospital, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-0051, Japan.
| | - Akinori Uchiyama
- Intensive Care Unit, Osaka University Hospital, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yuji Fujino
- Intensive Care Unit, Osaka University Hospital, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
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15
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Multiple Secondary Healthcare-Associated Infections Due to Carbapenem-Resistant Organisms in a Critically Ill COVID-19 Patient on Extensively Prolonged Venovenous Extracorporeal Membrane Oxygenation Support-A Case Report. Microorganisms 2021; 10:microorganisms10010019. [PMID: 35056467 PMCID: PMC8781848 DOI: 10.3390/microorganisms10010019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 12/30/2022] Open
Abstract
Patients with severe Coronavirus disease 2019 (COVID-19) are at high risk for secondary infection with multidrug-resistant organisms (MDROs). Secondary infections contribute to a more severe clinical course and longer intensive care unit (ICU) stays in patients with COVID-19. A man in his 60s was admitted to the ICU at a university hospital for severe COVID-19 pneumonia requiring mechanical ventilation. His respiratory condition worsened further due to persistent bacteremia caused by imipenem-non-susceptible Klebsiella aerogenes and he required VV-ECMO. Subsequently, he developed a catheter-related bloodstream infection (CRBSI) due to Candida albicans, ventilator-associated pneumonia (VAP) due to multidrug-resistant Pseudomonas aeruginosa (MDRP), and a perianal abscess due to carbapenem-resistant K. aerogenes despite infection control procedures that maximized contact precautions and the absence of MDRO contamination in the patient’s room environment. He was decannulated from VV-ECMO after a total of 72 days of ECMO support, and was eventually weaned off ventilator support and discharged from the ICU on day 138. This case highlights the challenges of preventing, diagnosing, and treating multidrug-resistant organisms and healthcare-associated infections (HAIs) in the critical care management of severe COVID-19. In addition to the stringent implementation of infection prevention measures, a high index of suspicion and a careful evaluation of HAIs are required in such patients.
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