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Pearce AK, Zawaydeh Q, McGuire WC, Husain A, Ayoub C, Sweeney DA, Cotton SA, Malhotra A. Secondary infections in critically ill patients with COVID-19 receiving steroid therapy. Sci Prog 2023; 106:368504231207209. [PMID: 37899703 PMCID: PMC10617276 DOI: 10.1177/00368504231207209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Secondary infections can occur during or after the treatment of an initial infection. Glucocorticoids may decrease mortality in patients with severe COVID-19; however, risk of secondary infection is not well described. Our primary objective was to investigate the risk of secondary infection among critically ill patients with COVID-19 treated with glucocorticoids. We examined patients with COVID-19 being treated in the intensive care unit at two academic medical centers from 1 to 7/2020. One hundred-seven patients were included. Of these, 31 received steroids and 76 patients did not. Analysis of the larger cohort was performed followed by a matched pairs analysis of 22 steroid and 22 non-steroid patients. Secondary infection was seen in 14 patients (45.2%) receiving steroids compared to 35(46.1%) not receiving steroids (p = 0.968). Secondary infections were most frequently encountered in the respiratory tract. Escherichia coli and Staphylococcus aureus were the most frequently identified organisms. Mortality was 16.1% in the steroid-treated group compared to 23.7% in the control group (p = 0.388). After performing matched pairs analysis and multivariable logistic regression there was no significant difference between secondary infection or mortality and steroid receipt. Secondary infections were common among critically ill patients with COVID-19, but the incidence of secondary infection was not significantly impacted by steroid treatment.
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Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Qais Zawaydeh
- Department of Internal Medicine, Eisenhower Health, Palm Springs,
CA, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Abdurrahman Husain
- Division of Pulmonary Critical Care Medicine, Texas A&M School of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Claudia Ayoub
- Department of Internal Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Shannon A Cotton
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, La Jolla, CA, USA
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Bouras M, Rello J, Roquilly A. Steroids in severe community-acquired pneumonia: dangerous, worthless, or miracle cure? The roller coaster of clinical trials. Anaesth Crit Care Pain Med 2023:101253. [PMID: 37245688 PMCID: PMC10214762 DOI: 10.1016/j.accpm.2023.101253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France; CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, F-44000 Nantes, France.
| | - Jordi Rello
- CHU Nîmes, FOREVA Recherche Group, Nîmes, France; Vall d'Hebron Institut of Research, Clinical Research in Pneumonia & Sepsis /CRIPS), 08035 Barcelona, Spain
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France; CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, F-44000 Nantes, France
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3
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Beloncle FM. Is COVID-19 different from other causes of acute respiratory distress syndrome? JOURNAL OF INTENSIVE MEDICINE 2023:S2667-100X(23)00008-7. [PMID: 37362866 PMCID: PMC10085872 DOI: 10.1016/j.jointm.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/28/2023]
Abstract
Coronavirus disease 2019 (COVID-19) pneumonia can lead to acute hypoxemic respiratory failure. When mechanical ventilation is needed, almost all patients with COVID-19 pneumonia meet the criteria for acute respiratory distress syndrome (ARDS). The question of the specificities of COVID-19-associated ARDS compared to other causes of ARDS is of utmost importance, as it may justify changes in ventilatory strategies. This review aims to describe the pathophysiology of COVID-19-associated ARDS and discusses whether specific ventilatory strategies are required in these patients.
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Affiliation(s)
- François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, Angers 49033, France
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4
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Managing the Next Wave of Influenza and/or SARS-CoV-2 in the ICU—Practical Recommendations from an Expert Group for CAPA/IAPA Patients. J Fungi (Basel) 2023; 9:jof9030312. [PMID: 36983480 PMCID: PMC10058160 DOI: 10.3390/jof9030312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
The aim of this study was to establish practical recommendations for the diagnosis and treatment of influenza-associated invasive aspergillosis (IAPA) based on the available evidence and experience acquired in the management of patients with COVID-19-associated pulmonary aspergillosis (CAPA). The CAPA/IAPA expert group defined 14 areas in which recommendations would be made. To search for evidence, the PICO strategy was used for both CAPA and IAPA in PubMed, using MeSH terms in combination with free text. Based on the results, each expert developed recommendations for two to three areas that they presented to the rest of the group in various meetings in order to reach consensus. As results, the practical recommendations for the management of CAPA/IAPA patients have been grouped into 12 sections. These recommendations are presented for both entities in the following situations: when to suspect fungal infection; what diagnostic methods are useful to diagnose these two entities; what treatment is recommended; what to do in case of resistance; drug interactions or determination of antifungal levels; how to monitor treatment effectiveness; what action to take in the event of treatment failure; the implications of concomitant corticosteroid administration; indications for the combined use of antifungals; when to withdraw treatment; what to do in case of positive cultures for Aspergillus spp. in a patient with severe viral pneumonia or Aspergillus colonization; and how to position antifungal prophylaxis in these patients. Available evidence to support the practical management of CAPA/IAPA patients is very scarce. Accumulated experience acquired in the management of CAPA patients can be very useful for the management of IAPA patients. The expert group presents eminently practical recommendations for the management of CAPA/IAPA patients.
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Ni H, Yu H, Lin Q, Zhong J, Sun W, Nie H. Analysis of risk factors of fungal superinfections in viral pneumonia patients: A systematic review and meta-analysis. Immun Inflamm Dis 2022; 11:e760. [PMID: 36705416 PMCID: PMC9804449 DOI: 10.1002/iid3.760] [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: 09/11/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Infections with fungi, such as Aspergillus species, have been found as common complications of viral pneumonia. This study aims to determine the risk factors of fungal superinfections in viral pneumonia patients using meta-analysis. OBJECTIVE This study aims to determine the risk factors of fungal infection s in viral pneumonia patients using meta-analysis. METHODS We reviewed primary literature about fungal infection in viral pneumonia patients published between January 1, 2010 and September 30, 2020, in the Chinese Biomedical Literature, Chinese National Knowledge Infrastructure, Wanfang (China), Cochrane Central Library, Embase, PubMed, and Web of Science databases. These studies were subjected to an array of statistical analyses, including risk of bias and sensitivity analyses. RESULTS In this study, we found a statistically significant difference in the incidence of fungal infections in viral pneumonia patients that received corticosteroid treatment as compared to those without corticosteroid treatment (p < .00001). Additionally, regarding the severity of fungal infections, we observed significant higher incidence of invasive pulmonary aspergillosis (IPA) in patients with high Acute Physiology and Chronic Health Evaluation (APACHE) II scores (p < .001), tumors (p = .005), or immunocompromised patients (p < .0001). CONCLUSIONS Our research shows that corticosteroid treatment was an important risk factor for the development of fungal infection in patients with viral pneumonia. High APACHE II scores, tumors, and immunocompromised condition are also important risk factors of developing IPA. The diagnosis of fungal infection in viral pneumonia patients can be facilitated by early serum galactomannan (GM) testing, bronchoalveolar lavage fluid Aspergillus antigen testing, culture, and biopsy.
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Affiliation(s)
- Haiyang Ni
- Department of Respiratory & Critical MedicineRenmin Hospital of Wuhan UniversityWuhanHubeiChina
| | - Hongying Yu
- Department of Respiratory & Critical MedicineRenmin Hospital of Wuhan UniversityWuhanHubeiChina
| | - Qibin Lin
- Department of Respiratory & Critical MedicineRenmin Hospital of Wuhan UniversityWuhanHubeiChina
| | - Jieying Zhong
- Department of Respiratory & Critical MedicineRenmin Hospital of Wuhan UniversityWuhanHubeiChina
| | - Wenjin Sun
- Department of infectious diseaseEzhou Central HospitalEzhouHubeiChina
| | - Hanxiang Nie
- Department of Respiratory & Critical MedicineRenmin Hospital of Wuhan UniversityWuhanHubeiChina
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Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Lamouche-Wilquin P, Souchard J, Pere M, Raymond M, Asfar P, Darreau C, Reizine F, Hourmant B, Colin G, Rieul G, Kergoat P, Frérou A, Lorber J, Auchabie J, La Combe B, Seguin P, Egreteau PY, Morin J, Fedun Y, Canet E, Lascarrou JB, Delbove A. Early steroids and ventilator-associated pneumonia in COVID-19-related ARDS. Crit Care 2022; 26:233. [PMID: 35918776 PMCID: PMC9344449 DOI: 10.1186/s13054-022-04097-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Early corticosteroid treatment is used to treat COVID-19-related acute respiratory distress syndrome (ARDS). Infection is a well-documented adverse effect of corticosteroid therapy. OBJECTIVES To determine whether early corticosteroid therapy to treat COVID-19 ARDS was associated with ventilator-associated pneumonia (VAP). METHODS We retrospectively included adults with COVID-19-ARDS requiring invasive mechanical ventilation (MV) for ≥ 48 h at any of 15 intensive care units in 2020. We divided the patients into two groups based on whether they did or did not receive corticosteroids within 24 h. The primary outcome was VAP incidence, with death and extubation as competing events. Secondary outcomes were day 90-mortality, MV duration, other organ dysfunctions, and VAP characteristics. MEASUREMENTS AND MAIN RESULTS Of 670 patients (mean age, 65 years), 369 did and 301 did not receive early corticosteroids. The cumulative VAP incidence was higher with early corticosteroids (adjusted hazard ratio [aHR] 1.29; 95% confidence interval [95% CI] 1.05-1.58; P = 0.016). Antibiotic resistance of VAP bacteria was not different between the two groups (odds ratio 0.94, 95% CI 0.58-1.53; P = 0.81). 90-day mortality was 30.9% with and 24.3% without early corticosteroids, a nonsignificant difference after adjustment on age, SOFA score, and VAP occurrence (aHR 1.15; 95% CI 0.83-1.60; P = 0.411). VAP was associated with higher 90-day mortality (aHR 1.86; 95% CI 1.33-2.61; P = 0.0003). CONCLUSIONS Early corticosteroid treatment was associated with VAP in patients with COVID-19-ARDS. Although VAP was associated with higher 90-day mortality, early corticosteroid treatment was not. Longitudinal randomized controlled trials of early corticosteroids in COVID-19-ARDS requiring MV are warranted.
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Affiliation(s)
- Pauline Lamouche-Wilquin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 01, France
| | - Jérôme Souchard
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France.,Service de Réanimation Chirurgicale, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Morgane Pere
- Plateforme de Méthodologie et Biostatistique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Matthieu Raymond
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 01, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Cédric Darreau
- Service de Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | - Florian Reizine
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Baptiste Hourmant
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Gwenhaël Colin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Guillaume Rieul
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Pierre Kergoat
- Service de Réanimation Polyvalente, Centre Hospitalier de Cornouaille, Quimper, France
| | - Aurélien Frérou
- Service de Réanimation Polyvalente, Centre Hospitalier de Saint-Malo, Saint-Malo, France
| | - Julien Lorber
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint-Nazaire, Saint-Nazaire, France
| | - Johann Auchabie
- Service de Réanimation Polyvalente, Centre Hospitalier de Cholet, Cholet, France
| | - Béatrice La Combe
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne Sud, Lorient, France
| | - Philippe Seguin
- Service de Réanimation Chirurgicale, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Pierre-Yves Egreteau
- Service de Réanimation Polyvalente, Centre Hospitalier de Morlaix, Morlaix, France
| | - Jean Morin
- Service de Soins Intensifs de Pneumologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Yannick Fedun
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 01, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 01, France.
| | - Agathe Delbove
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France
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Salazar F, Bignell E, Brown GD, Cook PC, Warris A. Pathogenesis of Respiratory Viral and Fungal Coinfections. Clin Microbiol Rev 2022; 35:e0009421. [PMID: 34788127 PMCID: PMC8597983 DOI: 10.1128/cmr.00094-21] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Individuals suffering from severe viral respiratory tract infections have recently emerged as "at risk" groups for developing invasive fungal infections. Influenza virus is one of the most common causes of acute lower respiratory tract infections worldwide. Fungal infections complicating influenza pneumonia are associated with increased disease severity and mortality, with invasive pulmonary aspergillosis being the most common manifestation. Strikingly, similar observations have been made during the current coronavirus disease 2019 (COVID-19) pandemic. The copathogenesis of respiratory viral and fungal coinfections is complex and involves a dynamic interplay between the host immune defenses and the virulence of the microbes involved that often results in failure to return to homeostasis. In this review, we discuss the main mechanisms underlying susceptibility to invasive fungal disease following respiratory viral infections. A comprehensive understanding of these interactions will aid the development of therapeutic modalities against newly identified targets to prevent and treat these emerging coinfections.
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Affiliation(s)
- Fabián Salazar
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Elaine Bignell
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Gordon D. Brown
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Peter C. Cook
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Adilia Warris
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
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9
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Mairpady Shambat S, Gómez-Mejia A, Schweizer TA, Huemer M, Chang CC, Acevedo C, Bergada-Pijuan J, Vulin C, Hofmaenner DA, Scheier TC, Hertegonne S, Parietti E, Miroshnikova N, Wendel Garcia PD, Hilty MP, Buehler PK, Schuepbach RA, Brugger SD, Zinkernagel AS. Hyperinflammatory environment drives dysfunctional myeloid cell effector response to bacterial challenge in COVID-19. PLoS Pathog 2022; 18:e1010176. [PMID: 35007290 PMCID: PMC8782468 DOI: 10.1371/journal.ppat.1010176] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/21/2022] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
COVID-19 displays diverse disease severities and symptoms including acute systemic inflammation and hypercytokinemia, with subsequent dysregulation of immune cells. Bacterial superinfections in COVID-19 can further complicate the disease course and are associated with increased mortality. However, there is limited understanding of how SARS-CoV-2 pathogenesis and hypercytokinemia impede the innate immune function against bacterial superinfections. We assessed the influence of COVID-19 plasma hypercytokinemia on the functional responses of myeloid immune cells upon bacterial challenges from acute-phase COVID-19 patients and their corresponding recovery-phase. We show that a severe hypercytokinemia status in COVID-19 patients correlates with the development of bacterial superinfections. Neutrophils and monocytes derived from COVID-19 patients in their acute-phase showed an impaired intracellular microbicidal capacity upon bacterial challenges. The impaired microbicidal capacity was reflected by abrogated MPO and reduced NETs production in neutrophils along with reduced ROS production in both neutrophils and monocytes. Moreover, we observed a distinct pattern of cell surface receptor expression on both neutrophils and monocytes, in line with suppressed autocrine and paracrine cytokine signaling. This phenotype was characterized by a high expression of CD66b, CXCR4 and low expression of CXCR1, CXCR2 and CD15 in neutrophils and low expression of HLA-DR, CD86 and high expression of CD163 and CD11b in monocytes. Furthermore, the impaired antibacterial effector function was mediated by synergistic effect of the cytokines TNF-α, IFN-γ and IL-4. COVID-19 patients receiving dexamethasone showed a significant reduction of overall inflammatory markers in the plasma as well as exhibited an enhanced immune response towards bacterial challenge ex vivo. Finally, broad anti-inflammatory treatment was associated with a reduction in CRP, IL-6 levels as well as length of ICU stay and ventilation-days in critically ill COVID-19 patients. Our data provides insights into the transient functional dysregulation of myeloid immune cells against subsequent bacterial infections in COVID-19 patients and describe a beneficial role for the use of dexamethasone in these patients.
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Affiliation(s)
- Srikanth Mairpady Shambat
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Alejandro Gómez-Mejia
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Tiziano A. Schweizer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Markus Huemer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Chun-Chi Chang
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Claudio Acevedo
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Judith Bergada-Pijuan
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Clément Vulin
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Daniel A. Hofmaenner
- Institute of Intensive Care, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas C. Scheier
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Sanne Hertegonne
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Elena Parietti
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Nataliya Miroshnikova
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Pedro D. Wendel Garcia
- Institute of Intensive Care, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias P. Hilty
- Institute of Intensive Care, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Karl Buehler
- Institute of Intensive Care, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Reto A. Schuepbach
- Institute of Intensive Care, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Silvio D. Brugger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Annelies S. Zinkernagel
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
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10
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Novel Immunomodulatory Therapies for Respiratory Pathologies. COMPREHENSIVE PHARMACOLOGY 2022. [PMCID: PMC8238403 DOI: 10.1016/b978-0-12-820472-6.00073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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11
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Han JY, Yang EA, Rhim JW, Han SB. Effects of Antiviral Therapy and Glucocorticoid Therapy on Fever Duration in Pediatric Patients with Influenza. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121385. [PMID: 34946330 PMCID: PMC8707365 DOI: 10.3390/medicina57121385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 01/20/2023]
Abstract
Background and Objectives: Considering developing resistance against neuraminidase inhibitors (NAIs) and their adverse reactions, restricted use of NAIs and use of alternative drugs should be considered for treating influenza. Although glucocorticoids (GCs) have been used for severe influenza, their effects on non-severe influenza have rarely been evaluated. This study aimed to evaluate the clinical responses to NAI therapy and GC therapy in pediatric patients with non-severe influenza. Materials and Methods: A total of 601 pediatric patients (<19 years of age) diagnosed with non-severe influenza were retrospectively recruited to evaluate the effects of NAI therapy and GC therapy. Post-admission fever duration and hospitalization duration were compared among four patient groups divided by the administered treatment: No therapy (n = 52), NAI therapy (n = 154), GC therapy (n = 123), and Both therapies (n = 272). Results: In a multivariate analysis with adjustment for confounding variables, the post-admission fever duration was not significantly different among the four patient groups. The post-admission fever duration tended to shorten with increasing age, longer pre-admission fever duration, and incidence of influenza A virus infection and lower respiratory tract infection. The type of administered treatment showed no significant effects on the post-admission fever duration in any subgroups according to patient age, pre-admission fever duration, influenza virus subtype, and clinical diagnosis. Conclusions: Symptomatic treatment rather than antiviral or GC therapy seems to be sufficient for patients with non-severe influenza, although the effects of NAI therapy and GC therapy according to their administered time and dose should be further evaluated.
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Affiliation(s)
- Ji Yoon Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.Y.H.); (E.A.Y.); (J.-W.R.)
- Department of Pediatrics, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon 34943, Korea
| | - Eun Ae Yang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.Y.H.); (E.A.Y.); (J.-W.R.)
- Department of Pediatrics, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon 34943, Korea
| | - Jung-Woo Rhim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.Y.H.); (E.A.Y.); (J.-W.R.)
- Department of Pediatrics, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon 34943, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.Y.H.); (E.A.Y.); (J.-W.R.)
- Department of Pediatrics, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon 34943, Korea
- Correspondence: ; Tel.: +82-42-220-9218
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12
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Crisan Dabija R, Antohe I, Trofor A, Antoniu SA. Corticosteroids in SARS-COV2 infection: certainties and uncertainties in clinical practice. Expert Rev Anti Infect Ther 2021; 19:1553-1562. [PMID: 34015985 PMCID: PMC8171006 DOI: 10.1080/14787210.2021.1933437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The SARS-COV-2 pandemic is a worldwide public health problem due to the large medical burden and limited number of therapies available. Corticosteroids have a rather unclear efficacy in viral non-SARS-COV-2 pneumonias and therefore their use is not universally recommended. In SARS-COV-2 pneumonia however, it is expected that they can reduce the deleterious consequences of the virus-related systemic inflammation. AREAS COVERED a MEDLINE search covering the period 1995-2020 was completed to identify relevant papers. SARS-COV-2 pathogenesis is very complex and is represented by the interplay of many cytokine-driven inflammation pathways. Its most severe form so called cytokine storm, is an exaggerate reaction of the host infected by the virus rapidly resulting in multiple organ dysfunction (MODS). Corticosteroids have the potential to blunt the inflammation response in such patients, but their efficacy is not the same for all patients. Further on the certainties and uncertainties regarding the efficacy of this therapy in SARS-COV-2 pneumonia are discussed. EXPERT OPINION In patients with severe SARS-COV-2 pneumonia, corticosteroids can be efficacious, but it is still not clear if they can be safely used in patients with comorbid cardiovascular disease or how the optimal duration of therapy can be established.
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Affiliation(s)
- Radu Crisan Dabija
- Faculty of Medicine-Pulmonary Disease, University of Medicine and Pharmacy Grigore T Popa, Iasi, Romania
| | - Ileana Antohe
- Faculty of Medicine-Nursing, University of Medicine and Pharmacy Grigore T Popa Iasi, Romania
| | - Antigona Trofor
- Faculty of Medicine-Pulmonary Disease, University of Medicine and Pharmacy Grigore T Popa, Iasi, Romania
| | - Sabina A Antoniu
- Faculty of Medicine-Nursing/Palliative Care, University of Medicine and Pharmacy Grigore T Popa, Iasi, Romania
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13
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Clinical Characteristics and Outcomes of Influenza-Associated Pulmonary Aspergillosis Among Critically Ill Patients: A Systematic Review and Meta-Analysis. J Hosp Infect 2021; 120:98-109. [PMID: 34843812 DOI: 10.1016/j.jhin.2021.11.016] [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: 08/23/2021] [Revised: 10/27/2021] [Accepted: 11/21/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Invasive pulmonary aspergillosis is increasingly identified as a complication of influenza infection, termed influenza-associated pulmonary aspergillosis (IAPA). AIMS Assess the morbidity and mortality of critically ill influenza patients with and without IAPA. METHODS We searched the Pubmed, Cochrane Library, Scopus, and Embase databases for studies containing comparative data of critically ill influenza patients with IAPA. Primary outcomes were all-cause in-hospital and ICU mortality. The secondary outcomes were clinical characteristics, invasive mechanical ventilation (IMV) duration, ICU and hospital length of stay (LOS), requirement of vasopressor, renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO). FINDINGS IAPA incidence was 28.8% in 853 critically ill influenza patients, with an overall mortality rate of 33.4%. No difference in age and comorbidities were observed. IAPA patients were predominantly male and received chronic corticosteroids. In-hospital (49.2% vs. 27.0%; P= 0.002) and ICU (46.8% vs. 20.8%; P< 0.001) mortality rates were higher among IAPA patients than non-IAPA patients. Greater proportion of IAPA patients required IMV and prolonged IMV duration (mean 17.3 vs. 10.5 days; P< 0.001), ICU (mean 26.8 vs. 12.8 days; P= 0.001) and hospital LOS (mean 38.7 vs. 27.0 days; P= 0.003). IAPA patients had greater disease severity requiring a significant amount of vasopressor (76.4% vs. 57.9%; P< 0.001), RRT (45.7% vs. 19.1%; P< 0.001), and ECMO (25.9% vs. 12.8%; P= 0.004) support than non-IAPA patients. CONCLUSIONS IAPA diagnosis in critically ill patients is associated with greater morbidity and mortality. Early recognition and more research are needed to determine better diagnostic and treatment strategies.
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14
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Shafiekhani M, Shahabinezhad F, Niknam T, Tara SA, Haem E, Mardani P, Zare Z, Jafarian S, Mirzad Jahromi K, Arabsheybani S, Moeini YS, Alavi J, Jalali SS, Salimi M, Shahriarirad R, Malekhosseini SA. Evaluation of the therapeutic regimen in COVID-19 in transplant patients: where do immunomodulatory and antivirals stand? Virol J 2021; 18:228. [PMID: 34809657 PMCID: PMC8607221 DOI: 10.1186/s12985-021-01700-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The management of COVID-19 in organ transplant recipients is among the most imperative, yet less discussed, issues based on their immunocompromised status along with their vast post-transplant medication regimens. No conclusive study has been published to evaluate proper anti-viral and immunomodulator medications effect in treating COVID-19 patients to this date. METHOD This retrospective study was conducted in Shiraz Transplant Hospital, Iran from March 2020 to May 2021 and included COVID-19 diagnosed patients based on SARS-CoV-2 RT-PCR positive test who had been hospitalized for at least 48 h before enrolling in the study. Clinical and demographic information of patients, along with their treatment course and the medication used were evaluated and analyzed using multiple regression analysis. RESULTS A total of 245 patients with a mean age of 49.59 years were included with a mortality rate of 8.16%. The administration of Remdesivir as an anti-viral drug (P value < 0.001) and Tocilizumab as an immunomodulator drug (P value < 0.001) could reduce the hospitalization period in the hospital and the intensive care unit, as well as the mortality rates significantly. Meanwhile, the patients treated with Lopinavir/Ritonavir experienced a lower chance of survival (OR < 1, P value = 0.04). No significant difference was observed between various therapeutic regimens in clinical complications such as bacterial coinfections, cardiovascular and gastrointestinal adverse reactions, and liver or kidney dysfunctions. CONCLUSION The administration of Remdesivir as an anti-viral and Tocilizumab as an immunomodulatory drug in solid-organ transplant recipients could be promising treatments of choice to manage COVID-19.
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Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farbod Shahabinezhad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tahmoores Niknam
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ahmad Tara
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Haem
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mardani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Zare
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigheh Jafarian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khatereh Mirzad Jahromi
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Arabsheybani
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Yalda Sadat Moeini
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jalile Alavi
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Soroush Jalali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Seyed Ali Malekhosseini
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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15
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Hamed DM, Belhoul KM, Al Maazmi NA, Ghayoor F, Moin M, Al Suwaidi M, Narainen M, Makki M, AbdulRahman M. Intravenous methylprednisolone with or without tocilizumab in patients with severe COVID-19 pneumonia requiring oxygen support: A prospective comparison. J Infect Public Health 2021; 14:985-989. [PMID: 34153729 PMCID: PMC8191304 DOI: 10.1016/j.jiph.2021.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cytokine storm is a marker of severity and severe mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia. Immunomodulatory treatments may reduce morbidity and mortality. OBJECTIVES To determine whether a 7-day course of methylprednisolone (MP) administered with and without tocilizumab improves outcomes in patients with severe COVID-19 (SARS-CoV-2) pneumonia requiring oxygen therapy, relative to historical controls. STUDY DESIGN AND METHOD In this randomized controlled study, patients hospitalized with severe COVID-19 at Rashid Hospital, Dubai, in June 2020 were randomized 1:1 to receive intravenous MP (40 mg twice daily for 7 days) with or without a single dose of intravenous tocilizumab (400 mg). While data from the control arm, consisting of patients administered usual care, were obtained through retrospective review of their electronic medical records. The patients in the three arms were matched by disease severity and inclusion and exclusion criteria. The primary outcomes were day 45 all-cause mortality after randomization, rate of admission to the intensive care unit (ICU), length of ICU stay, days on ventilators, and length of hospital stay. RESULTS In total, 76 patients were recruited, including 23 treated with MP, 26 with MP plus tocilizumab, and 27 historical controls. The rates of admission to the ICU and invasive mechanical ventilation were lowest in patients treated with MP alone, with the rates in this group being significantly lower than the rates in the control group (p = 0.04). Time on a ventilator was lowest in the MP group (1.09 ± 3.68 days) and highest in the control group (7.93 ± 14.86 days). The number of days in the ICU was significantly lower in the MP group than in the control and MP plus tocilizumab groups (p = 0.043). One patient (4.3%) in the MP group and five (18.5%) in the control arm died within 45 days. Survival was highest in patients treated with MP alone, with the addition of tocilizumab not improving survival or any of the other outcomes significantly. INTERPRETATION/CONCLUSION In patients with severe COVID-19 pneumonia on oxygen support, administration of MP daily for 7 days had reduced mortality at 45 days and was associated with significantly lower ICU admission and ventilation rates compared with usual. Adding tocilizumab to MP did not improve any of the studied outcomes significantly.
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Affiliation(s)
- Dujana Mostafa Hamed
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
| | | | | | - Farah Ghayoor
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
| | - Muneeba Moin
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
| | - Mahra Al Suwaidi
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
| | - Meeruna Narainen
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
| | - Maryam Makki
- Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab Emirates
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16
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Clinical Characteristics and Predictors of Mortality in Critically Ill Adult Patients with Influenza Infection. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073682. [PMID: 33916073 PMCID: PMC8037506 DOI: 10.3390/ijerph18073682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
Patients with influenza infection may develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. Some patients with ARDS receiving extracorporeal membrane oxygenation (ECMO) support die of infectious complications. We aimed to investigate the risk factors affecting the clinical outcomes in critically ill patients with influenza. We retrospectively reviewed the medical records of influenza patients between January 2006 and May 2016 at the Kaohsiung Veterans General Hospital in Taiwan. Patients aged below 20 years or without laboratory-confirmed influenza were excluded. Critically ill patients who presented with ARDS (P = 0.004, odds ratio (OR): 8.054, 95% confidence interval (CI): 1.975–32.855), a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.008, OR: 1.102, 95% CI: 1.025–1.184), or higher positive end-expiratory pressure (P = 0.008, OR: 1.259, 95% CI: 1.061–1.493) may have a higher risk of receiving ECMO. Influenza A (P = 0.037, OR: 0.105, 95% CI: 0.013–0.876) and multiple organ failure (P = 0.007, OR: 0.056, 95% CI: 0.007–0.457) were significantly associated with higher mortality rates. In conclusion, our study showed critically ill influenza patients with ARDS, higher APACHE II scores, and higher positive end-expiratory pressure have a higher risk of receiving ECMO support. Influenza A and multiple organ failure are predictors of mortality.
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17
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Abstract
PURPOSE OF REVIEW This review aims to evaluate the evidence and recommendations for the prescription of corticosteroids as adjunctive therapy in patients with severe community-acquired pneumonia. RECENT FINDINGS Corticosteroids have been prescribed with the objective to attenuate the marked and persistent activation of the immune system. However, some causes of community-acquired pneumonia, namely viral, are associated with unexpected low levels of cytokines and depressed cellular immunity. As a result, several recent randomized controlled trials and large prospective observational studies repeatedly showed that corticosteroids had no impact on survival, and in some types of pneumonia like influenza, its use was associated with potential harmful effects like invasive aspergillosis. Apart from this, adverse effects, namely hyperglycemia, superinfections and increased length-of-stay, were frequent findings in the corticosteroid-treated patients. SUMMARY According to the current evidence, corticosteroids are recommended in Pneumocystis jiroveci pneumonia in HIV-infected patients and recommendations are against its use in influenza. In all other forms of severe community-acquired pneumonia, with the exclusion of SARS-CoV-2 pneumonia, the strength of the evidence does not support the safe and widespread use of corticosteroids as adjunctive therapy. Further studies are needed to identify subgroups of severe community-acquired pneumonia that can benefit or not from corticosteroids.
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18
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Zheng S, Zou Q, Wang X, Bao J, Yu F, Guo F, Liu P, Shen Y, Wang Y, Yang S, Wu W, Sheng J, Vijaykrishna D, Gao H, Chen Y. Factors Associated With Fatality Due to Avian Influenza A(H7N9) Infection in China. Clin Infect Dis 2021; 71:128-132. [PMID: 31418813 DOI: 10.1093/cid/ciz779] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/09/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The high case fatality rate of influenza A(H7N9)-infected patients has been a major clinical concern. METHODS To identify the common causes of death due to H7N9 as well as identify risk factors associated with the high inpatient mortality, we retrospectively collected clinical treatment information from 350 hospitalized human cases of H7N9 virus in mainland China during 2013-2017, of which 109 (31.1%) had died, and systematically analyzed the patients' clinical characteristics and risk factors for death. RESULTS The median age at time of infection was 57 years, whereas the median age at time of death was 61 years, significantly older than those who survived. In contrast to previous studies, we found nosocomial infections comprising Acinetobacter baumannii and Klebsiella most commonly associated with secondary bacterial infections, which was likely due to the high utilization of supportive therapies, including mechanical ventilation (52.6%), extracorporeal membrane oxygenation (14%), continuous renal replacement therapy (19.1%), and artificial liver therapy (9.7%). Age, time from illness onset to antiviral therapy initiation, and secondary bacterial infection were independent risk factors for death. Age >65 years, secondary bacterial infections, and initiation of neuraminidase-inhibitor therapy after 5 days from symptom onset were associated with increased risk of death. CONCLUSIONS Death among H7N9 virus-infected patients occurred rapidly after hospital admission, especially among older patients, followed by severe hypoxemia and multisystem organ failure. Our results show that early neuraminidase-inhibitor therapy and reduction of secondary bacterial infections can help reduce mortality.Characterization of 350 hospitalized avian influenza A(H7N9)-infected patients in China shows that age >65 years, secondary bacterial infections, and initiation of neuraminidase-inhibitor therapy after 5 days from symptom onset were associated with increased risk of death.
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Affiliation(s)
- Shufa Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Qianda Zou
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiaochen Wang
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jiaqi Bao
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Fei Yu
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Feifei Guo
- Department of Infectious Diseases, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China
| | - Peng Liu
- Department of Infectious Diseases, Second Hospital of Ningbo, Ningbo, People's Republic of China
| | - Yinzhong Shen
- Department of Infectious and Immune Diseases, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People's Republic of China
| | - Yimin Wang
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Shigui Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Wei Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jifang Sheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Dhanasekaran Vijaykrishna
- Department of Microbiology, Biomedicine Discovery Institute, Monash University, Victoria, Australia.,World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Hainv Gao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Department of Infectious Diseases, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China
| | - Yu Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Zhejiang University, Hangzhou, People's Republic of China.,Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Hagiwara A, Tanaka N, Inaba Y, Gando S, Shiraishi A, Saitoh D, Otomo Y, Ikeda H, Ogura H, Kushimoto S, Kotani J, Sakamoto Y, Shiino Y, Shiraishi SI, Takuma K, Tarui T, Tsuruta R, Nakada TA, Hifumi T, Yamakawa K, Takeyama N, Yamashita N, Abe T, Ueyama M, Okamoto K, Sasaki J, Masuno T, Mayumi T, Fujishima S, Umemura Y, Fujimi S. Predictors of severe sepsis-related in-hospital mortality based on a multicenter cohort study: The Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study. Medicine (Baltimore) 2021; 100:e24844. [PMID: 33663106 PMCID: PMC7909210 DOI: 10.1097/md.0000000000024844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/28/2021] [Indexed: 01/05/2023] Open
Abstract
This study aimed to identify prognostic factors for severe sepsis-related in-hospital mortality using the structural equation model (SEM) analysis with statistical causality. Sepsis data from the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study (FORECAST), a multicenter cohort study, was used. Forty seven observed variables from the database were used to construct 4 latent variables. SEM analysis was performed on these latent variables to analyze the statistical causality among these data. This study evaluated whether the variables had an effect on in-hospital mortality. Overall, 1148 patients were enrolled. The SEM analysis showed that the 72-hour physical condition was the strongest latent variable affecting mortality, followed by physical condition before treatment. Furthermore, the 72-hour physical condition and the physical condition before treatment strongly influenced the Sequential Organ Failure Assessment (SOFA) score with path coefficients of 0.954 and 0.845, respectively. The SOFA score was the strongest variable that affected mortality after the onset of severe sepsis. The score remains the most robust prognostic factor and can facilitate appropriate policy development on care.
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Affiliation(s)
- Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Saitama
| | - Noriko Tanaka
- Biostatistics Section, Department of Data Science, Clinical Science Center, National Center for Global Health and Medicine, Tokyo
| | - Yosuke Inaba
- Biostatistics Section, Department of Data Science, Clinical Science Center, National Center for Global Health and Medicine, Tokyo
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushima Hospital, Sapporo
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical, and Dental University
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Miyagi
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Chūō, Tokyo
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Aichi
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Fukuoka
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Aichi
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku City
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo City, Tokyo
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku City, Tokyo
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
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20
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Liang MY, Chen P, He M, Tang J, Li H, He XL, Zhou YY, Feng SW, Xue YE, Liu Y, Ma YL, Zhang JC. Corticosteroids Treatment of Patients with Coronavirus Disease 2019: A Propensity Score Matching Study. Curr Med Sci 2021; 41:24-30. [PMID: 33582901 PMCID: PMC7881915 DOI: 10.1007/s11596-021-2313-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/01/2021] [Indexed: 12/25/2022]
Abstract
The role of corticosteroids in the treatment of Coronavirus disease 2019 (COVID-19) is controversial. In the present study, we evaluated the effects of adjuvant corticosteroids treatment on the outcome of patients with COVID-19 (n=966), using Propensity Score Matching to adjust for potential differences between the corticosteroids group (n=289) and the non-corticosteroids group (n=677). Analysis of data without adjusting differences in baseline characteristics indicated that the proportion of mechanical ventilation and the mortality was higher in the corticosteroids treatment group in total or severe/critical patients. The duration of viral shedding was longer in the non-corticosteroids treatment group in total or general/mild patients. After adjusting the difference between the corticosteroids and non-corticosteroids treatment group, the analysis revealed that the use of corticosteroids had no effect on the duration of viral shedding, in-hospital mortality or 28-day mortality.
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Affiliation(s)
- Meng-Yuan Liang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ping Chen
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Miao He
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jian Tang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hui Li
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin-Liang He
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ya-Ya Zhou
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si-Wei Feng
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yu-E Xue
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yao Liu
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yan-Ling Ma
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Jian-Chu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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21
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Martin-Loeches I, Torres A. Corticosteroids for CAP, influenza and COVID-19: when, how and benefits or harm? Eur Respir Rev 2021; 30:30/159/200346. [PMID: 33568526 PMCID: PMC7877325 DOI: 10.1183/16000617.0346-2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Corticosteroids have been considered in medicine for a long time, and they are broadly prescribed. In infectious diseases, corticosteroids have been regarded as a thread due to their immunosuppressive effects and therefore their anti-inflammatory properties. MAIN: In recent years, there have been several studies published that aimed to determine the role of corticosteroids in patients with community-acquired pneumonia (CAP), because, despite significant advances in new antibiotics and supportive care, deaths of patients with CAP remain unacceptably high. While the 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) CAP guidelines did not mention the use of corticosteroids in the management of CAP, the recently published 2019 IDSA/ATS guidelines recommended their use in patients with septic shock refractory to vasopressors and fluid resuscitation. Regarding viral infection, the use of corticosteroids in patients with influenza has shown to be associated with significantly higher mortality and higher incidence of nosocomial infection, while in patients with coronavirus disease 2019 (COVID-19) there is a good body of evidence of the benefit of corticosteroids in terms of mortality. CONCLUSIONS The use of corticosteroids has been considered as a potential alternative co-adjuvant treatment in patients with pneumonia. In patients with COVID-19, the evidence is quite strong and there is a clear benefit of the use of corticosteroids in those patients presenting severe forms of disease.
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Affiliation(s)
- Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Dept of Intensive Care Medicine, St James's University Hospital, Dublin, Ireland .,Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain.,CIBERes, Barcelona, Spain
| | - Antoni Torres
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain.,CIBERes, Barcelona, Spain
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22
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Abstract
PURPOSE OF REVIEW Influenza represents a significant treatment burden to critical care services. A variety of treatment strategies exist, with more and more therapeutic avenues opening up as research progresses. We examined both pharmacological and supportive treatment strategies currently available to see how they might be applied in an ICU setting. RECENT FINDINGS Supportive care in Influenza centres around optimizing respiratory failure, particularly through well established and recognized ventilatory strategies. Noninvasive ventilation and high-flow nasal oxygen may have a limited role in selected patients under carefully monitored circumstances. Drug therapy exerts only a modest clinical effect and has been poorly studied in the critically ill, though there is some evidence to support the use of neuraminidase inhibitors (NAI) - particularly oseltamivir - as early as possible in this cohort. Newer agents have failed to demonstrate superiority over NAIs but may be useful options if the patient fails to respond or should resistant influenza strains emerge. Steroid therapy, in the absence of another indication, must be recommended against given the repeated trend towards increased mortality in this group. SUMMARY Influenza management is an evolving field of significant interest to any critical care provider. Currently, good respiratory supportive care and early enteral oseltamivir are the best supported treatment strategies. Further study in the intensive care setting will be needed before the use of novel agents can be recommended.
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23
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Okuno D, Kido T, Muramatsu K, Tokutsu K, Moriyama S, Miyamura T, Hara A, Ishimoto H, Yamaguchi H, Miyazaki T, Sakamoto N, Obase Y, Ishimatsu Y, Fujino Y, Yatera K, Matsuda S, Mukae H. Impact of Corticosteroid Administration within 7 Days of the Hospitalization for Influenza Pneumonia with Respiratory Failure: A Propensity Score Analysis Using a Nationwide Administrative Database. J Clin Med 2021; 10:jcm10030494. [PMID: 33572558 PMCID: PMC7866855 DOI: 10.3390/jcm10030494] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 12/15/2022] Open
Abstract
Influenza pneumonia, which causes acute respiratory distress syndrome and multiple organ failure, has no established management protocol. Recently, corticosteroid therapy was used to treat coronavirus disease 2019 with respiratory failure; however, its effectiveness as a treatment for influenza pneumonia remains controversial. To investigate the impact of corticosteroid therapy for the early phase of severe influenza pneumonia, we compared influenza pneumonia patients with respiratory failure treated with or without corticosteroids within 7 days after hospital admission using a Japanese nationwide administrative database. The primary endpoint was the mortality rate. The secondary endpoints were duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. The inverse probability weighting method with estimated propensity scores was used to minimize the data collection bias. We included 3519 patients with influenza pneumonia with respiratory failure. Of these, 875 were treated with corticosteroids. There was no significant difference between the groups regarding 30-day and 90-day mortality, duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. However, the in-hospital mortality rate was higher in the corticosteroid group. The use of systematic corticosteroid therapy in patients with influenza pneumonia was associated with a higher in-hospital mortality rate.
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Affiliation(s)
- Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
- Correspondence: ; Tel.: +81-95-819-7273
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Kei Tokutsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Sakiko Moriyama
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Takuto Miyamura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Atsuko Hara
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Hiroyuki Yamaguchi
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Taiga Miyazaki
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan;
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Science, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan;
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan;
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
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24
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Li Y, Zhou X, Li T, Chan S, Yu Y, Ai JW, Zhang H, Sun F, Zhang Q, Zhu L, Shao L, Xu B, Zhang W. Corticosteroid prevents COVID-19 progression within its therapeutic window: a multicentre, proof-of-concept, observational study. Emerg Microbes Infect 2020; 9:1869-1877. [PMID: 32795143 PMCID: PMC7473313 DOI: 10.1080/22221751.2020.1807885] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
Abstract
Critically ill patients with coronavirus diseases 2019 (COVID-19) are of grave concern. Those patients usually underwent a stage of excessive inflammation before developing acute respiratory distress syndrome. In this study, we test the hypothesis that short-term, low-to-moderate-dose corticosteroids would benefit patients when used in the early phase of excessive inflammation, namely, the therapeutic window. Among a Shanghai cohort and a validation cohort, we enrolled COVID-19 patients showing marked radiographic progression. Short-term, low-to-moderate-dose corticosteroids were considered for them. After identifying the possible markers for the therapeutic window, we then divided the patients, based on whether they were treated with corticosteroids within the therapeutic window, into the early-start group and control group. We identified that the therapeutic window for corticosteroids was characterized by a marked radiographic progression and lactase dehydrogenase (LDH) less than two times the upper limit of normal (ULN). The Shanghai cohort comprised of 68 patients, including 47 in the early-start group and 21 in the control group. The proportion of patients requiring invasive mechanical ventilation was significantly lower in the early-start group than in the control group (10.6% vs. 33.3%, difference, 22.7%, 95% confidence interval 2.6-44.8%). Among the validation cohort of 51 patients, similar difference of the primary outcome was observed (45.0% vs. 74.2%, P = 0.035). Among COVID-19 patients with marked radiologic progression, short-term, low-to-moderate-dose corticosteroids benefits patients with LDH levels of less than two times the ULN, who may be in the early phase of excessive inflammation.
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Affiliation(s)
- Yang Li
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Xian Zhou
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Tao Li
- Department of Tuberculosis, Shanghai Public Health Clinical Center, Fudan University, Shanghai, People’s Republic of China
| | - Shiji Chan
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, People’s Republic of China
| | - Yiqi Yu
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jing-Wen Ai
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Haocheng Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Feng Sun
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Qiran Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Lei Zhu
- Departments of Respiratory Diseases, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Lingyun Shao
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Bin Xu
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Wenhong Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, State Key Laboratory of Genetic Engineering, School of Life Science, Key Laboratory of Medical Molecular Virology (MOE/MOH) and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
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25
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Gao Y, Wang C, Kang K, Peng Y, Luo Y, Liu H, Yang W, Zhao M, Yu K. Cytokine Storm May Not Be the Chief Culprit for the Deterioration of COVID-19. Viral Immunol 2020; 34:336-341. [PMID: 33202195 DOI: 10.1089/vim.2020.0243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
COVID-19 is spreading and ravaging all over the world, and the number of deaths is increasing day by day without downward trend. However, there is limited knowledge of pathogenesis on the deterioration of COVID-19 at present. In this study we aim to determine whether cytokine storm is really the chief culprit for the deterioration of COVID-19. The confirmed COVID-19 patients were divided into moderate group (n = 89), severe group (n = 37), and critical group (n = 41). Demographic data were collected and recorded on admission to ICU. Clinical data were obtained when moderate, severe, or critical COVID-19 was diagnosed, and then compared between groups. The proportion of enrolled COVID-19 patients was slightly higher among males (52.5%) than females (47.5%), with an average age of 64.87 years. The number of patients without comorbidities exceed one third (36.1%), and patients with 1, 2, 3, 4 kinds of comorbidities accounted for 23.0%, 23.0%, 13.1%, and 4.9%, respectively. IL-6, IL-10, TNF, and IFN-γ, including oxygenation index, sequential organ failure assessment score, white blood cell count, lymphocyte count, lymphocyte percentage, platelet, C-reaction protein, lactate dehydrogenase, creatine kinase isoenzyme, albumin, D-Dimer, and fibrinogen showed significant difference between groups. Some, but not all, cytokines and chemokines were involved in the deterioration of COVID-19, and thus cytokine storm maybe just the tip of the iceberg and should be used with caution to explain pathogenesis on the deterioration of COVID-19, which might be complex and related to inflammation, immunity, blood coagulation, and multiple organ functions. Future studies should focus on identification of specific signaling pathways and mechanisms after severe acute respiratory syndrome coronavirus 2 infections (IRB number: IRB-AF/SC-04/01.0).
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Affiliation(s)
- Yang Gao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Changsong Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China.,Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, China
| | - Kai Kang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Yahui Peng
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Yunpeng Luo
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haitao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, China
| | - Wei Yang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
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26
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Waterer GW, Rello J. Steroids and COVID-19: We Need a Precision Approach, Not One Size Fits All. Infect Dis Ther 2020; 9:1-5. [PMID: 32953385 PMCID: PMC7492684 DOI: 10.1007/s40121-020-00338-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
COVID-19 is a new infectious disease causing severe respiratory failure and death for which optimal treatment is currently unclear. Many therapies have been proven to be ineffective; however, promising findings related to corticosteroid therapy have been published. Analysis of published data including in this issue suggests that therapy with corticosteroids in the range of 6 mg of dexamethasone (or equivalent) per day likely has a positive effect in patients requiring mechanical ventilation but there remains considerable doubt in patients over the age of 70, in patients with diabetes and patients with milder disease. Clinicians must consider the individual potential risks and benefits of corticosteroid in patients with COVID-19 rather than routinely using them until more data is available.
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Affiliation(s)
- Grant W. Waterer
- University of Western Australia, Perth, Australia
- Northwestern University, Chicago, IL USA
| | - Jordi Rello
- Centro de Investigación Biomedica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
- Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
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27
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Verweij PE, Rijnders BJA, Brüggemann RJM, Azoulay E, Bassetti M, Blot S, Calandra T, Clancy CJ, Cornely OA, Chiller T, Depuydt P, Giacobbe DR, Janssen NAF, Kullberg BJ, Lagrou K, Lass-Flörl C, Lewis RE, Liu PWL, Lortholary O, Maertens J, Martin-Loeches I, Nguyen MH, Patterson TF, Rogers TR, Schouten JA, Spriet I, Vanderbeke L, Wauters J, van de Veerdonk FL. Review of influenza-associated pulmonary aspergillosis in ICU patients and proposal for a case definition: an expert opinion. Intensive Care Med 2020; 46:1524-1535. [PMID: 32572532 PMCID: PMC7306567 DOI: 10.1007/s00134-020-06091-6] [Citation(s) in RCA: 255] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/07/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Invasive pulmonary aspergillosis is increasingly reported in patients with influenza admitted to the intensive care unit (ICU). Classification of patients with influenza-associated pulmonary aspergillosis (IAPA) using the current definitions for invasive fungal diseases has proven difficult, and our aim was to develop case definitions for IAPA that can facilitate clinical studies. METHODS A group of 29 international experts reviewed current insights into the epidemiology, diagnosis and management of IAPA and proposed a case definition of IAPA through a process of informal consensus. RESULTS Since IAPA may develop in a wide range of hosts, an entry criterion was proposed and not host factors. The entry criterion was defined as a patient requiring ICU admission for respiratory distress with a positive influenza test temporally related to ICU admission. In addition, proven IAPA required histological evidence of invasive septate hyphae and mycological evidence for Aspergillus. Probable IAPA required the detection of galactomannan or positive Aspergillus culture in bronchoalveolar lavage (BAL) or serum with pulmonary infiltrates or a positive culture in upper respiratory samples with bronchoscopic evidence for tracheobronchitis or cavitating pulmonary infiltrates of recent onset. The IAPA case definitions may be useful to classify patients with COVID-19-associated pulmonary aspergillosis (CAPA), while awaiting further studies that provide more insight into the interaction between Aspergillus and the SARS-CoV-2-infected lung. CONCLUSION A consensus case definition of IAPA is proposed, which will facilitate research into the epidemiology, diagnosis and management of this emerging acute and severe Aspergillus disease, and may be of use to study CAPA.
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Affiliation(s)
- Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, PO box 9101, 6500 HB, Nijmegen, The Netherlands.
- Centre of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.
| | - Bart J A Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Centre of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Matteo Bassetti
- Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
- Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Stijn Blot
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Burns, Trauma, and Critical Care Research Centre, Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011, Lausanne, Switzerland
| | - Cornelius J Clancy
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department of Internal Medicine, ECMM Center of Excellence for Medical Mycology, German Centre for Infection Research, Partner Site Bonn-Cologne (DZIF), University of Cologne, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Tom Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Daniele Roberto Giacobbe
- Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Nico A F Janssen
- Centre of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart-Jan Kullberg
- Centre of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Russell E Lewis
- Infectious Diseases Hospital, S'Orsola-Malpighi, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Peter Wei-Lun Liu
- Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Olivier Lortholary
- Necker - Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris University, Paris, France
- Molecular Mycology Unit National Reference Center for Invasive Mycoses and Antifungals, CNRS, UMR 2000, Institut Pasteur, Paris, France
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Thomas F Patterson
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care Center, San Antonio, TX, USA
| | - Thomas R Rogers
- Department of Clinical Microbiology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Lore Vanderbeke
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Frank L van de Veerdonk
- Centre of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Yang JW, Yang L, Luo RG, Xu JF. Corticosteroid administration for viral pneumonia: COVID-19 and beyond. Clin Microbiol Infect 2020; 26:1171-1177. [PMID: 32603802 PMCID: PMC7320691 DOI: 10.1016/j.cmi.2020.06.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/12/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023]
Abstract
Background Corticosteroids are commonly used as adjuvant therapy for acute respiratory distress syndrome by many clinicians because of their perceived anti-inflammatory effects. However, for patients with severe viral pneumonia, the corticosteroid treatment is highly controversial. Objectives The purpose of this review is to systematically evaluate the effect and potential mechanism of corticosteroid administration in pandemic viral pneumonia. Sources We comprehensively searched all manuscripts on corticosteroid therapy for influenza, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and SARS coronavirus 2 (SARS-CoV-2) viral pneumonia from the PubMed, EMBASE, Web of Science and Cochrane Library databases. Content We systematically summarized the effects of corticosteroid therapy for pandemic viral pneumonia and the potential mechanism of action for corticosteroids in coronavirus disease 2019 (COVID-19). Implications Observational studies showed that corticosteroid treatment was associated with increased mortality and nosocomial infections for influenza and delayed virus clearance for SARS-CoV and MERS-CoV. Limited data on corticosteroid therapy for COVID-19 were reported. Corticosteroids were used in about a fifth of patients (670/2995, 22.4%). Although clinical observational studies reported the improvement in symptoms and oxygenation for individuals with severe COVID-19 who received corticosteroid therapy, case fatality rate in the corticosteroid group was significantly higher than that in the non-corticosteroid group (69/443, 15.6% versus 56/1310, 4.3%). Compared individuals with non-severe disease, those with severe disease were more likely to receive corticosteroid therapy (201/382, 52.6% versus 201/1310, 15.3%). Although there is no evidence that corticosteroid therapy reduces mortality in people with COVID-19, some improvements in clinical symptoms and oxygenation were reported in some clinical observational studies. Excessive inflammatory response and lymphopenia might be critical factors associated with severity of and mortality from COVID-19. Sufficiently powered randomized controlled trials with rigorous inclusion/exclusion criteria and standardized dose and duration of corticosteroids are needed to verify the effectiveness and safety of corticosteroid therapy.
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Affiliation(s)
- J-W Yang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - L Yang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - R-G Luo
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - J-F Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
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Waldeck F, Boroli F, Suh N, Wendel Garcia PD, Flury D, Notter J, Iten A, Kaiser L, Schrenzel J, Boggian K, Maggiorini M, Pugin J, Kleger GR, Albrich WC. Influenza-associated aspergillosis in critically-ill patients-a retrospective bicentric cohort study. Eur J Clin Microbiol Infect Dis 2020; 39:1915-1923. [PMID: 32494955 PMCID: PMC7266735 DOI: 10.1007/s10096-020-03923-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/01/2020] [Indexed: 01/11/2023]
Abstract
Influenza was recently reported as a risk factor for invasive aspergillosis (IA). We aimed to describe prognostic factors for influenza-associated IA (IAA) and poor outcome and mortality in critically ill patients in Switzerland. All adults with confirmed influenza admitted to the ICU at two Swiss tertiary care centres during the 2017/2018 influenza season were retrospectively evaluated. IAA was defined by clinical, mycological and radiological criteria: a positive galactomannan in bronchoalveolar lavage or histopathological or cultural evidence in respiratory specimens of Aspergillus spp., any radiological infiltrate and a compatible clinical presentation. Poor outcome was defined as a composite of in-hospital mortality, ICU length of stay (LOS), invasive ventilation for > 7 days or extracorporeal membrane oxygenation. Of 81 patients with influenza in the ICU, 9 (11%) were diagnosed with IAA. All patients with IAA had poor outcome compared to 26 (36%) patients without IAA (p < 0.001). Median ICU-LOS and mortality were 17 vs. 3 days (p < 0.01) and 3/9 (33%) vs. 13/72 (18%; p = 0.37) in patients with vs. without IAA, respectively. Patients with IAA had significantly longer durations of antibiotic therapy, vasoactive support and mechanical ventilation. Aspergillus was the most common respiratory co-pathogen (9/40, 22%) followed by classical bacterial co-pathogens. IAA was not associated with classical risk factors. Aspergillus is a common superinfection in critically ill influenza patients associated with poor outcome and longer duration of organ supportive therapies. Given the absence of classical risk factors for aspergillosis, greater awareness is necessary, particularly in those requiring organ supportive therapies.
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Affiliation(s)
- Frederike Waldeck
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH - 9007, St. Gallen, Switzerland
| | - Filippo Boroli
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Noémie Suh
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Pedro David Wendel Garcia
- Medical Intensive Care Unit, Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Domenica Flury
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH - 9007, St. Gallen, Switzerland
| | - Julia Notter
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH - 9007, St. Gallen, Switzerland
| | - Anne Iten
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Jacques Schrenzel
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Katia Boggian
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH - 9007, St. Gallen, Switzerland
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Gian-Reto Kleger
- Division of Intensive Care, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Werner Christian Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, CH - 9007, St. Gallen, Switzerland.
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Abstract
The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.
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31
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Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, Deshpande R, Zhang L, Meng J, Tong C, Liu H, Xiong L. Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience. Anesthesiology 2020; 132:1317-1332. [PMID: 32195705 PMCID: PMC7155908 DOI: 10.1097/aln.0000000000003296] [Citation(s) in RCA: 380] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023]
Abstract
The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.
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Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut (L.M., R.D.) the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China (H.Q.) the Department of Anesthesiology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, Hubei, China (L.W.) the Departments of Critical Care Medicine (Y.A., L.Z.) Anesthesiology (Q.G.) Respiratory Medicine (J.M.), Xiangya Hospital, Central South University, Changsha, Hunan Province, China the Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China (Z.X.) the Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina (C.T.) the Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, California (H.L.) the Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China (L.X.)
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32
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Vandroux D, Kerambrun H, Ferdynus C, Allou N, Allyn J, Gaüzère BA, Martinet O, Jabot J. Postpandemic Influenza Mortality of Venovenous Extracorporeal Membrane Oxygenation–Treated Patients in Reunion Island: A Retrospective Single Center Study. J Cardiothorac Vasc Anesth 2020; 34:1426-1430. [DOI: 10.1053/j.jvca.2019.12.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
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33
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Clement Y, Jankie S, Pooransingh S, Ignacio D, Reid A, Sampson-Francis S, Giddings S, Watson H. A literature review of drugs for the treatment of COVID-19. CARIBBEAN MEDICAL JOURNAL 2020. [DOI: 10.48107/cmj.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To review the published evidence of repurposed drugs, antivirals and biologics for the treatment of COVID-19.
Materials and Methods: A literature review was conducted in several databases and research portals. Search terms included COVID-19, SARS-Cov-2, MERS, MERS-CoV, SARS, SARS-CoV, coronavirus, beta-coronavirus, influenza, pneumonia and several drugs considered for use in COVID-19.
Results: There is a paucity of clinical evidence regarding the safety and efficacy of most agents being considered for the treatment of COVID-19. However, based on promising preliminary research the US Food and Drugs Administration has authorized the emergency use of hydroxychloroquine and remdesivir for hospitalized COVID-19 patients. To date, the most robust evidence for lopinavir-ritonavir (LPV/r) found that it was no better than standard care. Overwhelming evidence suggests that corticosteroids increase mortality, nosocomial infections and lengthen hospitalization in SARS and MERS patients, and should be used cautiously in patients with severe respiratory symptoms. Additionally, low level evidence suggests that tocilizumab may be useful to reduce the cytokine storm precipitated by SARS-CoV-2 infection.
Conclusions: Hydroxychloroquine and remdesivir have surged to the front of the race to repurpose drugs in the fight against COVID-19. With hundreds of ongoing trials it is envisaged that indisputable evidence would be provided for prophylactic and therapeutic use of drugs and biologics within the next few months. However, in our setting it would be worthwhile to consider the availability and accessibility of some of these agents.
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Affiliation(s)
- Yuri Clement
- Department of Para-clinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Satish Jankie
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Shalini Pooransingh
- Department of Para-clinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Diane Ignacio
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Avril Reid
- Medical Sciences Library, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Shurla Sampson-Francis
- Department of Para-clinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Stanley Giddings
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St, Augustine, Trinidad and Tobago
| | - Harold Watson
- Department of Medicine, Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2020; 68:e1-e47. [PMID: 30566567 DOI: 10.1093/cid/ciy866] [Citation(s) in RCA: 328] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital.,University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada.,Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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35
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Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting. Med Intensiva 2020; 45:347-353. [PMID: 34294232 DOI: 10.1016/j.medine.2019.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/19/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. DESIGN A cohort study was carried out. SCOPE A mixed ICU (16 beds) in a teaching hospital. PATIENTS Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. MEASUREMENTS Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. RESULTS A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; p=0.04), with a higher SOFA score (7 vs. 4; p=0.01) and greater early hemodynamic failure (61.1 vs. 8%; p=0.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; p=0.01) and hospital stay (32.78 vs. 18.8 days; p=0.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; p=0.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. CONCLUSIONS Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality.
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36
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Li L, Li R, Wu Z, Yang X, Zhao M, Liu J, Chen D. Therapeutic strategies for critically ill patients with COVID-19. Ann Intensive Care 2020; 10:45. [PMID: 32307593 PMCID: PMC7167303 DOI: 10.1186/s13613-020-00661-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
Since the 2019 novel coronavirus disease (COVID-19) outbreak originated from Wuhan, Hubei Province, China, at the end of 2019, it has become a clinical threat to the general population worldwide. Among people infected with the novel coronavirus (2019-nCoV), the intensive management of the critically ill patients in intensive care unit (ICU) needs substantial medical resource. In the present article, we have summarized the promising drugs, adjunctive agents, respiratory supportive strategies, as well as circulation management, multiple organ function monitoring and appropriate nutritional strategies for the treatment of COVID-19 in the ICU based on the previous experience of treating other viral infections and influenza. These treatments are referable before the vaccine and specific drugs are available for COVID-19.
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Affiliation(s)
- Lei Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Ranran Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Zhixiong Wu
- Department of Surgical Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People's Republic of China
| | - Xianghong Yang
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, 310014, People's Republic of China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Hospital Affiliated to Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201800, People's Republic of China.
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China. .,Department of Critical Care Medicine, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201800, People's Republic of China.
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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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38
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Hernández Garcés H, Navarro Lacalle A, Lizama López L, Zaragoza Crespo R. Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting. Med Intensiva 2020. [PMID: 31924443 DOI: 10.1016/j.medin.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. DESIGN A cohort study was carried out. SCOPE A mixed ICU (16 beds) in a teaching hospital. PATIENTS Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. MEASUREMENTS Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. RESULTS A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; P=.04), with a higher SOFA score (7 vs. 4; P=.01) and greater early hemodynamic failure (61.1 vs. 8%; P=.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; P=.01) and hospital stay (32.78 vs. 18.8 days; P=.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; P=.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. CONCLUSIONS Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality.
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Affiliation(s)
- H Hernández Garcés
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España.
| | - A Navarro Lacalle
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
| | - L Lizama López
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
| | - R Zaragoza Crespo
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
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39
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Xing X, Hu S, Chen M, Zhan F, Liu H, Chen Z, Zhang H, Zeng G, Xu Q, Zhang H, Liu M, Liu H, Gao L, Zhang L. Severe acute respiratory infection risk following glucocorticosteroid treatment in uncomplicated influenza-like illness resulting from pH1N1 influenza infection: a case control study. BMC Infect Dis 2019; 19:1080. [PMID: 31878888 PMCID: PMC6933691 DOI: 10.1186/s12879-019-4669-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 11/29/2019] [Indexed: 01/07/2023] Open
Abstract
Background Current studies regarding glucocorticosteroid treatment of influenza have only estimated risk of critical illness or death which can be easily confounded by timing of treatment administration. We used severe acute respiratory infection (sARI) as an endpoint and investigated risk associated with receiving glucocorticosteroids before sARI onset. Methods sARI cases were defined as influenza-like illness (ILI) with pH1N1 infection and respiratory distress. Controls were defined as pH1N1 cases other than sARI and randomly selected from the community. We compared glucocorticosteroids and other medications used before sARI onset using a matched case control study adjusted for age group as well as underlying disease. Time-dependent risk and dose responses at different time periods over the course of sARI cases were also examined. Results Of the sARI cases, 34% received glucocorticosteroids before sARI onset compared to 3.8% of controls during equivalent days (ORM-H = 17,95%CI = 2.1–135). Receiving glucocorticosteroids before sARI onset increased risk of developing subsequent critical illness or death (ORM-H = 5.7,95%CI = 1.6–20.2), and the ORM-H increased from 5.7 to 8.5 for continued glucocorticosteroid use after sARI onset. However, only receiving glucocorticosteroids after sARI onset did not increase risk of severe illness (ORM-H = 1.1,95%CI = 0.3–4.6). Each increase in glucocorticosteroids dose of 1 mg/kg/day before sARI onset resulted in an increase of 0.62 (R2 = 0.87) in the pMEWS score at the time of sARI onset. Conclusions Early glucocorticosteroid treatment increased risk of sARI and subsequent critical illness or death; however, only receiving glucocorticosteroids after sARI onset did not increase risk of severe illness.
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Affiliation(s)
- Xuesen Xing
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, Hubei Province, China. .,Chinese Field Epidemiology Training Program, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China.
| | - Shixiong Hu
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Meihua Chen
- Wuhan No. 1 Hospital, Wuhan, Hubei Province, China
| | - Faxian Zhan
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, Hubei Province, China
| | - Huihui Liu
- Chinese Field Epidemiology Training Program, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China
| | - Zhang Chen
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Hengjiao Zhang
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Ge Zeng
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Qiaohua Xu
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Hong Zhang
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| | - Man Liu
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, Hubei Province, China
| | - Honghui Liu
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, Hubei Province, China
| | - Lidong Gao
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China.
| | - Lijie Zhang
- Chinese Field Epidemiology Training Program, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China.
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Clinical Characteristics and Prognosis of Influenza B Virus-Related Hospitalizations in Northern China during the 2017-18 Influenza Season: A Multicenter Case Series. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8756563. [PMID: 31828141 PMCID: PMC6885173 DOI: 10.1155/2019/8756563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/16/2019] [Accepted: 10/11/2019] [Indexed: 01/20/2023]
Abstract
Background By weekly monitoring of China's influenza situation, Chinese National Influenza Center observed that the 2017-18 season was predominated by influenza B virus (IBV)/Yamagata. No studies regarding hospitalizations in adults with IBV infections have been performed. We aimed to describe the clinical characteristics of hospitalized patients with IBV infection in northern China. Methods In this multicenter and retrospective study, we reviewed all consecutive adult patients with confirmed IBV infections at two level A tertiary teaching hospitals in northern China during the 2017-18 influenza season. Patients' clinical and diagnostic findings, as well as administered treatments and mortality data, were analyzed. Results A total of 573 patients with a confirmed diagnosis of IBV infection were identified, of whom 22 cases were analyzed because of IBV-related hospitalization. Most patients were admitted to the intensive care unit (ICU) and had at least one underlying disease. The total in-hospital mortality was 27.3%. An elevated initial pneumonia severity index score, elevated direct bilirubin values, and lower platelet levels were associated with mortality (p=0.020, 0.013, and 0.049, respectively). The quick development of bilateral diffuse alveolar infiltrates was the most common imaging characteristics, following consolidation and pleural effusion(s). Risk factors such as HIV infection, pregnancy, underlying medical conditions, coinfections, and treatment delays were not associated with mortality. Conclusions IBV should not be neglected because of its significant mortality. The elderly and patients with comorbidities, such as hypertension, diabetes, and connective tissue diseases, are more likely to have severe IBV-related pneumonia. Higher heart rates, direct bilirubin levels, initial PSI scores, and lower platelet levels are correlated with hospital mortality. Increased uptake in tetravalent influenza vaccine should be very helpful in preventing future cases of IBV hospitalizations.
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Are Community Acquired Respiratory Viral Infections an Underestimated Burden in Hematology Patients? Microorganisms 2019; 7:microorganisms7110521. [PMID: 31684063 PMCID: PMC6920795 DOI: 10.3390/microorganisms7110521] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 12/25/2022] Open
Abstract
Despite a plethora of studies demonstrating significant morbidity and mortality due to community-acquired respiratory viral (CRV) infections in intensively treated hematology patients, and despite the availability of evidence-based guidelines for the diagnosis and management of respiratory viral infections in this setting, there is no uniform inclusion of respiratory viral infection management in the clinical hematology routine. Nevertheless, timely diagnosis and systematic management of CRV infections in intensively treated hematology patients has a demonstrated potential to significantly improve outcome. We have briefly summarized the recently published data on CRV infection epidemiology, as well as guidelines on the diagnosis and management of CRV infections in patients intensively treated for hematological malignancies. We have also assessed available treatment options, as well as mentioned novel agents currently in development.
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Arabi YM, Mandourah Y, Al-Hameed F, Sindi AA, Almekhlafi GA, Hussein MA, Jose J, Pinto R, Al-Omari A, Kharaba A, Almotairi A, Al Khatib K, Alraddadi B, Shalhoub S, Abdulmomen A, Qushmaq I, Mady A, Solaiman O, Al-Aithan AM, Al-Raddadi R, Ragab A, Balkhy HH, Al Harthy A, Deeb AM, Al Mutairi H, Al-Dawood A, Merson L, Hayden FG, Fowler RA. Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome. Am J Respir Crit Care Med 2019; 197:757-767. [PMID: 29161116 DOI: 10.1164/rccm.201706-1172oc] [Citation(s) in RCA: 762] [Impact Index Per Article: 152.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Corticosteroid therapy is commonly used among critically ill patients with Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients' clinical condition at the time of corticosteroid therapy initiation. OBJECTIVES To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS. METHODS ICU patients with MERs were included from 14 Saudi Arabian centers between September 2012 and October 2015. We performed marginal structural modeling to account for baseline and time-varying confounders. MEASUREMENTS AND MAIN RESULTS Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (quartile 1 [Q1]-Q3, 1.0-7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141 of 151 [93.4%] vs. 121 of 158 [76.6%]; P < 0.0001) and had higher 90-day crude mortality (112 of 151 [74.2%] vs. 91 of 158 [57.6%]; P = 0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio, 0.75; 95% confidence interval, 0.52-1.07; P = 0.12) but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio, 0.35; 95% CI, 0.17-0.72; P = 0.005). CONCLUSIONS Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.
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Affiliation(s)
| | - Yasser Mandourah
- 3 Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fahad Al-Hameed
- 4 Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Anees A Sindi
- 5 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ghaleb A Almekhlafi
- 3 Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Jesna Jose
- 6 Department of Biostatistics and Bioinformatics, and
| | - Ruxandra Pinto
- 7 Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Awad Al-Omari
- 8 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,9 Department of Intensive Care, Dr. Sulaiman Al-Habib Group Hospitals, Riyadh, Saudi Arabia
| | - Ayman Kharaba
- 10 Department of Critical Care, King Fahad Hospital, Al-Madinah Al-Monawarah, Saudi Arabia.,11 Department of Critical Care, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia
| | - Abdullah Almotairi
- 12 Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kasim Al Khatib
- 13 Intensive Care Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Basem Alraddadi
- 8 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,14 Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Sarah Shalhoub
- 15 Division of Infectious Diseases, Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Ahmed Abdulmomen
- 16 Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ismael Qushmaq
- 14 Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ahmed Mady
- 17 Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt.,18 Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman Solaiman
- 19 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Rajaa Al-Raddadi
- 21 Department of Research, Ministry of Health, Jeddah, Saudi Arabia
| | - Ahmed Ragab
- 22 Intensive Care Department, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Hanan H Balkhy
- 1 College of Medicine.,23 Department of Infection Prevention and Control, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Al Harthy
- 17 Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Ahmad M Deeb
- 24 Research Office, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hanan Al Mutairi
- 24 Research Office, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Laura Merson
- 25 International Severe Acute Respiratory and Emerging Infection Consortium, Infectious Diseases Data Observatory, Oxford University, Oxford, United Kingdom
| | - Frederick G Hayden
- 25 International Severe Acute Respiratory and Emerging Infection Consortium, Infectious Diseases Data Observatory, Oxford University, Oxford, United Kingdom.,26 Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Robert A Fowler
- 27 Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and.,28 Department of Critical Care Medicine and.,29 Department of Medicine, Sunnybrook Hospital, Toronto, Ontario, Canada
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Abstract
RATIONALE H7N9 infection causes acute respiratory distress syndrome with high mortality. The use of glucocorticoids in the acute phase lessened inflammatory responses. Some case reports suggested that secondary organizing pneumonia (SOP) could occur at the recovery stage of the influenza virus infection, and the treatment with glucocorticoid was effective. However, the reports of organizing pneumonia after H7N9 infection are lacking. This study reported a patient with H7N9 virus infection who presented a suspected SOP during the recovery stage. PATIENT CONCERN A 68-year-old woman who was diagnosed with H7N9 viral pneumonia. After standard antiviral treatment, venous-venous extracorporeal membranous oxygenation (VV-ECMO) and other supportive treatment, the antigen in the alveolar lavage fluid turned negative, and the shadow in the lung was partially absorbed. However, the imaging manifestations were deteriorated at 3 weeks after disease onset, presented as exudation and consolidation shadow distributed under the pleura and along the bronchial vascular bundles. The oxygenation could not be improved. Repeated sputum, alveolar lavage fluid, and blood pathogen examinations showed negative results. Broad-spectrum anti-infective treatment was ineffective. However, the autoantibodies (ANA, anti-SSA/Ro60, anti-SSA/Ro52) were detected. DIAGNOSIS SOP was considered. INTERVENTIONS Glucocorticoid treatment begun at week 4 from the disease onset. The regimen was methylprednisolone at an initial dose of 40 mg twice a day for 1 week, tapering within 70 days until total withdrawal. OUTCOMES The oxygenation was rapidly improved after initiation of methylprednisolone. The shadow in the lung gradually resolved, and the patient was discharged after improvement of the disease condition. The clinical disease course, imaging findings, and treatment effects in the previous cases of SOP after influenza virus infection were similar to those in this case, suggesting the occurrence of SOP after H7N9 virus infection. LESSONS Organizing pneumonia might occur during the recovery stage of influenza virus infection. When the clinical symptoms do not improve and the shadow in the lung shows no obvious absorption after elimination of the H7N9 influenza virus, or the clinical symptoms are aggravated again after improvement, the probability of transforming into the organizing pneumonia should be taken into consideration.
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Affiliation(s)
| | | | | | - Jiahao Su
- Department of Neurosurgery, Zhongshan City People's Hospital, Zhongshan, China
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44
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Magira EE, Chemaly RF, Jiang Y, Tarrand J, Kontoyiannis DP. Outcomes in Invasive Pulmonary Aspergillosis Infections Complicated by Respiratory Viral Infections in Patients With Hematologic Malignancies: A Case-Control Study. Open Forum Infect Dis 2019; 6:ofz247. [PMID: 31338382 PMCID: PMC6639596 DOI: 10.1093/ofid/ofz247] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/05/2019] [Indexed: 01/27/2023] Open
Abstract
Background Data regarding invasive pulmonary aspergillosis (IPA) following respiratory viral infections (RVIs) in patients with leukemia and/or hematopoietic stem cell transplantation (LHSCT) are limited. Methods We conducted a retrospective case-control study of post-RVI IPA (2006–2016). Cases were patients who underwent LHSCT and had RVI due to respiratory syncytial virus (RSV), influenza virus (INF), or parainfluenza virus (PIV) followed by culture-documented IPA within 6 weeks. Controls had IPA only. Results We identified 54 cases and 142 controls. Among cases, 29 (54%) had PIV infection, 14 (26%) had INF infection, and 11 (20%) had RSV infection. The median time to IPA after RVI was 7 days. A greater percentage of cases (37 [69%]) than controls (52 [37%]) underwent allogeneic HSCT (P < .0001). Cases were more likely to be nonneutropenic (33 [61%] vs 56 [39%]; P = .009) and in hematologic remission (27 [50%] vs 39 [27%]; P = .003) before IPA. Cases were more likely to have monocytopenia (45 [83%] vs 99 [70%]; P = .05) and less likely to have severe neutropenia (21 [39%] vs 86 [61%]; P = .007) at IPA diagnosis. Prior use of an Aspergillus-active triazole was more common in cases (27 of 28 [96%] vs 50 of 74 [68%]; P = .0017). Median time to empirical antifungal therapy initiation was 2 days in both groups. Crude 42-day mortality rates did not differ between cases (22%) and controls (27%), but the 42-day mortality rate was higher among cases with IPA after RSV infection (45%) than among those with IPA following INF or PIV infection (13%; P = .05). Conclusions IPA had comparable outcomes when it followed RVI in patients who underwent LHSCT, and post-RVI IPA occurred more frequently in patients with prior allogeneic HSCT and was associated with leukemia relapse and neutropenia.
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Affiliation(s)
- Eleni E Magira
- Department of Infectious Disease, Infection Control and Employee Health
| | - Roy F Chemaly
- Department of Infectious Disease, Infection Control and Employee Health
| | - Ying Jiang
- Department of Infectious Disease, Infection Control and Employee Health
| | - Jeffrey Tarrand
- Department of Microbiology, The University of Texas MD Anderson Cancer Center, Houston
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45
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Abstract
Influenza pandemics with different extent occur every year in the world. It can cause high morbidity and mortality, arouse fear panic in public, and attract extensive attention worldwide. This paper reviews the research progress in epidemiological characteristics, detection methods, pathogenesis, treatment and prophylactic measures of influenza in China. It will be helpful for us to understand the current situation of influenza.
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46
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Rolfes MA, Gross FL, Flannery B, Meyers AFA, Luo M, Bastien N, Fowler RA, Katz JM, Levine MZ, Kumar A, Uyeki TM. Kinetics of Serological Responses in Critically Ill Patients Hospitalized With 2009 Pandemic Influenza A(H1N1) Virus Infection in Canada, 2009-2011. J Infect Dis 2019; 217:1078-1088. [PMID: 29342251 DOI: 10.1093/infdis/jiy013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/11/2018] [Indexed: 12/19/2022] Open
Abstract
Background The kinetics of the antibody response during severe influenza are not well documented. Methods Critically ill patients infected with 2009 pandemic influenza A(H1N1) virus (A[H1N1]pdm09), confirmed by reverse-transcription polymerase chain reaction analysis or seroconversion (defined as a ≥4-fold rise in titers), during 2009-2011 in Canada were prospectively studied. Antibody titers in serially collected sera were determined using hemagglutinin inhibition (HAI) and microneutralization assays. Average antibody curves were estimated using linear mixed-effects models and compared by patient outcome, age, and corticosteroid treatment. Results Of 47 patients with A(H1N1)pdm09 virus infection (median age, 47 years), 59% had baseline HAI titers of <40, and 68% had baseline neutralizing titers of <40. Antibody titers rose quickly after symptom onset, and, by day 14, 83% of patients had HAI titers of ≥40, and 80% had neutralizing titers ≥40. Baseline HAI titers were significantly higher in patients who died compared with patients who survived; however, the antibody kinetics were similar by patient outcome and corticosteroid treatment. Geometric mean titers over time in older patients were lower than those in younger patients. Conclusions Critically ill patients with influenza A(H1N1)pdm09 virus infection had strong HAI and neutralizing antibody responses during their illness. Antibody kinetics differed by age but were not associated with patient outcome.
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Affiliation(s)
- Melissa A Rolfes
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - F Liaini Gross
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia.,Battelle, Atlanta, Georgia
| | - Brendan Flannery
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adrienne F A Meyers
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg.,Department of Medical Microbiology and Infectious Diseases, Winnipeg.,Department of Medical Microbiology, University of Nairobi, Kenya
| | - Ma Luo
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg
| | - Nathalie Bastien
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg
| | - Robert A Fowler
- Sunnybrook Hospital, Department of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jacqueline M Katz
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Min Z Levine
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anand Kumar
- Section of Critical Care Medicine, Winnipeg.,Section of Infectious Diseases, University of Manitoba, Winnipeg
| | - Timothy M Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
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47
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Abstract
Annual seasonal influenza epidemics of variable severity result in significant morbidity and mortality in the United States (U.S.) and worldwide. In temperate climate countries, including the U.S., influenza activity peaks during the winter months. Annual influenza vaccination is recommended for all persons in the U.S. aged 6 months and older, and among those at increased risk for influenza-related complications in other parts of the world (e.g. young children, elderly). Observational studies have reported effectiveness of influenza vaccination to reduce the risks of severe disease requiring hospitalization, intensive care unit admission, and death. A diagnosis of influenza should be considered in critically ill patients admitted with complications such as exacerbation of underlying chronic comorbidities, community-acquired pneumonia, and respiratory failure during influenza season. Molecular tests are recommended for influenza testing of respiratory specimens in hospitalized patients. Antigen detection assays are not recommended in critically ill patients because of lower sensitivity; negative results of these tests should not be used to make clinical decisions, and respiratory specimens should be tested for influenza by molecular assays. Because critically ill patients with lower respiratory tract disease may have cleared influenza virus in the upper respiratory tract, but have prolonged influenza viral replication in the lower respiratory tract, an endotracheal aspirate (preferentially) or bronchoalveolar lavage fluid specimen (if collected for other diagnostic purposes) should be tested by molecular assay for detection of influenza viruses.Observational studies have reported that antiviral treatment of critically ill adult influenza patients with a neuraminidase inhibitor is associated with survival benefit. Since earlier initiation of antiviral treatment is associated with the greatest clinical benefit, standard-dose oseltamivir (75 mg twice daily in adults) for enteric administration is recommended as soon as possible as it is well absorbed in critically ill patients. Based upon observational data that suggest harms, adjunctive corticosteroid treatment is currently not recommended for children or adults hospitalized with influenza, including critically ill patients, unless clinically indicated for another reason, such as treatment of asthma or COPD exacerbation, or septic shock. A number of pharmaceutical agents are in development for treatment of severe influenza.
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Affiliation(s)
- Eric J Chow
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA
| | - Joshua D Doyle
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA
| | - Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA.
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48
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Chow EJ, Doyle JD, Uyeki TM. Influenza virus-related critical illness: prevention, diagnosis, treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:214. [PMID: 31189475 PMCID: PMC6563376 DOI: 10.1186/s13054-019-2491-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/26/2019] [Indexed: 01/20/2023]
Abstract
Annual seasonal influenza epidemics of variable severity result in significant morbidity and mortality in the United States (U.S.) and worldwide. In temperate climate countries, including the U.S., influenza activity peaks during the winter months. Annual influenza vaccination is recommended for all persons in the U.S. aged 6 months and older, and among those at increased risk for influenza-related complications in other parts of the world (e.g. young children, elderly). Observational studies have reported effectiveness of influenza vaccination to reduce the risks of severe disease requiring hospitalization, intensive care unit admission, and death. A diagnosis of influenza should be considered in critically ill patients admitted with complications such as exacerbation of underlying chronic comorbidities, community-acquired pneumonia, and respiratory failure during influenza season. Molecular tests are recommended for influenza testing of respiratory specimens in hospitalized patients. Antigen detection assays are not recommended in critically ill patients because of lower sensitivity; negative results of these tests should not be used to make clinical decisions, and respiratory specimens should be tested for influenza by molecular assays. Because critically ill patients with lower respiratory tract disease may have cleared influenza virus in the upper respiratory tract, but have prolonged influenza viral replication in the lower respiratory tract, an endotracheal aspirate (preferentially) or bronchoalveolar lavage fluid specimen (if collected for other diagnostic purposes) should be tested by molecular assay for detection of influenza viruses.Observational studies have reported that antiviral treatment of critically ill adult influenza patients with a neuraminidase inhibitor is associated with survival benefit. Since earlier initiation of antiviral treatment is associated with the greatest clinical benefit, standard-dose oseltamivir (75 mg twice daily in adults) for enteric administration is recommended as soon as possible as it is well absorbed in critically ill patients. Based upon observational data that suggest harms, adjunctive corticosteroid treatment is currently not recommended for children or adults hospitalized with influenza, including critically ill patients, unless clinically indicated for another reason, such as treatment of asthma or COPD exacerbation, or septic shock. A number of pharmaceutical agents are in development for treatment of severe influenza.
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Affiliation(s)
- Eric J Chow
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA
| | - Joshua D Doyle
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA
| | - Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 Clifton Road, N.E., Atlanta, GA, 30329, USA.
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49
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Ni YN, Chen G, Sun J, Liang BM, Liang ZA. The effect of corticosteroids on mortality of patients with influenza pneumonia: a systematic review and meta-analysis. Crit Care 2019; 23:99. [PMID: 30917856 PMCID: PMC6437920 DOI: 10.1186/s13054-019-2395-8] [Citation(s) in RCA: 255] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/15/2019] [Indexed: 02/07/2023] Open
Abstract
Background The effect of corticosteroids on clinical outcomes in patients with influenza pneumonia remains controversial. We aimed to further evaluate the influence of corticosteroids on mortality in adult patients with influenza pneumonia by comparing corticosteroid-treated and placebo-treated patients. Methods The PubMed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Information Sciences Institute (ISI) Web of Science databases were searched for all controlled studies that compared the effects of corticosteroids and placebo in adult patients with influenza pneumonia. The primary outcome was mortality, and the secondary outcomes were mechanical ventilation (MV) days, length of stay in the intensive care unit (ICU LOS), and the rate of secondary infection. Results Ten trials involving 6548 patients were pooled in our final analysis. Significant heterogeneity was found in all outcome measures except for ICU LOS (I2 = 38%, P = 0.21). Compared with placebo, corticosteroids were associated with higher mortality (risk ratio [RR] 1.75, 95% confidence interval [CI] 1.30 ~ 2.36, Z = 3.71, P = 0.0002), longer ICU LOS (mean difference [MD] 2.14, 95% CI 1.17 ~ 3.10, Z = 4.35, P < 0.0001), and a higher rate of secondary infection (RR 1.98, 95% CI 1.04 ~ 3.78, Z = 2.08, P = 0.04) but not MV days (MD 0.81, 95% CI − 1.23 ~ 2.84, Z = 0.78, P = 0.44) in patients with influenza pneumonia. Conclusions In patients with influenza pneumonia, corticosteroid use is associated with higher mortality. Trial registration PROSPERO (ID: CRD42018112384). Electronic supplementary material The online version of this article (10.1186/s13054-019-2395-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Guo Chen
- Department of Geriatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Jiankui Sun
- State Key Laboratory of Oral Diseases, West China School of Stomatology, Sichuan University, No. 14, Section 3 Renmin Nanlu, Chengdu, 610041, Sichuan, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China.
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
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50
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2019; 68. [PMID: 30566567 PMCID: PMC6653685 DOI: 10.1093/cid/ciy866 10.1093/cid/ciz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital
- University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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