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Jensen TO, Murray TA, Grandits GA, Jain MK, Grund B, Shaw-Saliba K, Matthay MA, Abassi M, Ardelt M, Baker JV, Chen P, Dewar RL, Goodman AL, Hatlen TJ, Highbarger HC, Holodniy M, Lallemand P, Laverdure S, Leshnower BG, Looney D, Moschopoulos CD, Mugerwa H, Murray DD, Mylonakis E, Nagy-Agren S, Rehman MT, Rupert A, Stevens R, Turville S, Weintrob A, Wick K, Lundgren J, Ko ER. Early trajectories of virological and immunological biomarkers and clinical outcomes in patients admitted to hospital for COVID-19: an international, prospective cohort study. THE LANCET. MICROBE 2024:S2666-5247(24)00015-6. [PMID: 38815595 DOI: 10.1016/s2666-5247(24)00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Serial measurement of virological and immunological biomarkers in patients admitted to hospital with COVID-19 can give valuable insight into the pathogenic roles of viral replication and immune dysregulation. We aimed to characterise biomarker trajectories and their associations with clinical outcomes. METHODS In this international, prospective cohort study, patients admitted to hospital with COVID-19 and enrolled in the Therapeutics for Inpatients with COVID-19 platform trial within the Accelerating COVID-19 Therapeutic Interventions and Vaccines programme between Aug 5, 2020 and Sept 30, 2021 were included. Participants were included from 108 sites in Denmark, Greece, Poland, Singapore, Spain, Switzerland, Uganda, the UK, and the USA, and randomised to placebo or one of four neutralising monoclonal antibodies: bamlanivimab (Aug 5 to Oct 13, 2020), sotrovimab (Dec 16, 2020, to March 1, 2021), amubarvimab-romlusevimab (Dec 16, 2020, to March 1, 2021), and tixagevimab-cilgavimab (Feb 10 to Sept 30, 2021). This trial included an analysis of 2149 participants with plasma nucleocapsid antigen, anti-nucleocapsid antibody, C-reactive protein (CRP), IL-6, and D-dimer measured at baseline and day 1, day 3, and day 5 of enrolment. Day-90 follow-up status was available for 1790 participants. Biomarker trajectories were evaluated for associations with baseline characteristics, a 7-day pulmonary ordinal outcome, 90-day mortality, and 90-day rate of sustained recovery. FINDINGS The study included 2149 participants. Participant median age was 57 years (IQR 46-68), 1246 (58·0%) of 2149 participants were male and 903 (42·0%) were female; 1792 (83·4%) had at least one comorbidity, and 1764 (82·1%) were unvaccinated. Mortality to day 90 was 172 (8·0%) of 2149 and 189 (8·8%) participants had sustained recovery. A pattern of less favourable trajectories of low anti-nucleocapsid antibody, high plasma nucleocapsid antigen, and high inflammatory markers over the first 5 days was observed for high-risk baseline clinical characteristics or factors related to SARS-CoV-2 infection. For example, participants with chronic kidney disease demonstrated plasma nucleocapsid antigen 424% higher (95% CI 319-559), CRP 174% higher (150-202), IL-6 173% higher (144-208), D-dimer 149% higher (134-165), and anti-nucleocapsid antibody 39% lower (60-18) to day 5 than those without chronic kidney disease. Participants in the highest quartile for plasma nucleocapsid antigen, CRP, and IL-6 at baseline and day 5 had worse clinical outcomes, including 90-day all-cause mortality (plasma nucleocapsid antigen hazard ratio (HR) 4·50 (95% CI 3·29-6·15), CRP HR 3·37 (2·30-4·94), and IL-6 HR 5·67 (4·12-7·80). This risk persisted for plasma nucleocapsid antigen and CRP after adjustment for baseline biomarker values and other baseline factors. INTERPRETATION Patients admitted to hospital with less favourable 5-day biomarker trajectories had worse prognosis, suggesting that persistent viral burden might drive inflammation in the pathogenesis of COVID-19, identifying patients that might benefit from escalation of antiviral or anti-inflammatory treatment. FUNDING US National Institutes of Health.
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Affiliation(s)
- Tomas O Jensen
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas A Murray
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Greg A Grandits
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | | | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Magdalena Ardelt
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jason V Baker
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA; Division of Infectious Diseases, Hennepin Healthcare, Minneapolis, MN, USA
| | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robin L Dewar
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Anna L Goodman
- The Medical Research Council Clinical Trials Unit, University College London, London, UK; Department of Infectious Diseases, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Timothy J Hatlen
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Mark Holodniy
- VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Medicine, Infectious Diseases, Stanford University, Stanford, CA, USA
| | - Perrine Lallemand
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Sylvain Laverdure
- Laboratory of Human Retrovirology and Immunoinformatics, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - David Looney
- VA San Diego Healthcare Center, San Diego, CA, USA; Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA
| | | | | | - Daniel D Murray
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Eleftherios Mylonakis
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA; Infectious Diseases Division, Brown University, Providence, RI, USA
| | - Stephanie Nagy-Agren
- Salem Veterans Affairs Medical Center, Salem, VA, USA; Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - M Tauseef Rehman
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Adam Rupert
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Randy Stevens
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - Amy Weintrob
- Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Katherine Wick
- Department of Internal Medicine, University of California Davis, Davis, CA, USA
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Emily R Ko
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Gu Q, Wei J, Yoon CH, Yuan K, Jones N, Brent A, Llewelyn M, Peto TEA, Pouwels KB, Eyre DW, Walker AS. Distinct patterns of vital sign and inflammatory marker responses in adults with suspected bloodstream infection. J Infect 2024; 88:106156. [PMID: 38599549 DOI: 10.1016/j.jinf.2024.106156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES To identify patterns in inflammatory marker and vital sign responses in adult with suspected bloodstream infection (BSI) and define expected trends in normal recovery. METHODS We included patients ≥16 y from Oxford University Hospitals with a blood culture taken between 1-January-2016 and 28-June-2021. We used linear and latent class mixed models to estimate trajectories in C-reactive protein (CRP), white blood count, heart rate, respiratory rate and temperature and identify CRP response subgroups. Centile charts for expected CRP responses were constructed via the lambda-mu-sigma method. RESULTS In 88,348 suspected BSI episodes; 6908 (7.8%) were culture-positive with a probable pathogen, 4309 (4.9%) contained potential contaminants, and 77,131(87.3%) were culture-negative. CRP levels generally peaked 1-2 days after blood culture collection, with varying responses for different pathogens and infection sources (p < 0.0001). We identified five CRP trajectory subgroups: peak on day 1 (36,091; 46.3%) or 2 (4529; 5.8%), slow recovery (10,666; 13.7%), peak on day 6 (743; 1.0%), and low response (25,928; 33.3%). Centile reference charts tracking normal responses were constructed from those peaking on day 1/2. CONCLUSIONS CRP and other infection response markers rise and recover differently depending on clinical syndrome and pathogen involved. However, centile reference charts, that account for these differences, can be used to track if patients are recovering line as expected and to help personalise infection.
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Affiliation(s)
- Qingze Gu
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jia Wei
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chang Ho Yoon
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kevin Yuan
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - David W Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.
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3
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Cidade JP, Coelho L, Póvoa P. Kinetics of C-Reactive Protein and Procalcitonin in the Early Identification of ICU-Acquired Infections in Critically Ill COVID-19 Patients. J Clin Med 2023; 12:6110. [PMID: 37834754 PMCID: PMC10573639 DOI: 10.3390/jcm12196110] [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: 08/24/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
The SARS-CoV-2 infection is a cause of hypoxemic acute respiratory failure, leading to frequent intensive care unit (ICU) admission. Due to invasive organ support and immunosuppressive therapies, these patients are prone to nosocomial infections. Our aim was to assess the value of daily measurements of C-reactive protein (CRP) and Procalcitonin (PCT) in the early identification of ICU-acquired infections in COVID-19 patients. METHODS We undertook a prospective observational cohort study (12 months). All adult mechanically ventilated patients admitted for ≥72 h to ICU with COVID-19 pneumonia were divided into an infected group (n = 35) and a non-infected group (n = 83). Day 0 was considered as the day of the diagnosis of infection (infected group) and Day 10 was that of ICU stay (non-infected group). The kinetics of CRP and PCT were assessed from Day -10 to Day 10 and evaluated using a general linear model, univariate, repeated-measures analysis. RESULTS 118 patients (mean age 63 years, 74% males) were eligible for the analysis. The groups did not differ in patient age, gender, CRP and PCT serum levels at ICU admission. However, the infected group encompassed patients with a higher severity (SOFA score at ICU admission, p = 0.009) and a higher 28-day mortality (p < 0.001). Before D0, CRP kinetics showed a significant increase in infected patients, whereas in noninfected it remained almost unchanged (p < 0.001), while PCT kinetics did not appear to retain diagnostic value to predict superinfection in COVID-19 patients (p = 0.593). CONCLUSION COVID-19 patients who developed ICU-acquired infections exhibited different biomarker kinetics before the diagnosis of those infections. Daily CRP monitoring and the recognition of the CRP kinetics could be useful in the prediction of ICU-acquired infections.
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Affiliation(s)
- José Pedro Cidade
- Intensive Care Unit 4, Department of Intensive Care, São Francisco Xavier Hospital, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisbon, Portugal;
- Nova Medical School, Clinical Medicine, CHRC, NOVA University of Lisbon, 1169-056 Lisbon, Portugal;
| | - Luís Coelho
- Nova Medical School, Clinical Medicine, CHRC, NOVA University of Lisbon, 1169-056 Lisbon, Portugal;
- Public Health Department, CDP Dr. Ribeiro Sanches, Regional Health Authority for Lisbon and Tagus Valley, 1700 Lisbon, Portugal
| | - Pedro Póvoa
- Intensive Care Unit 4, Department of Intensive Care, São Francisco Xavier Hospital, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisbon, Portugal;
- Nova Medical School, Clinical Medicine, CHRC, NOVA University of Lisbon, 1169-056 Lisbon, Portugal;
- Center for Clinical Epidemiology, Research Unit of Clinical Epidemiology, OUH Odense University Hospital, 5000 Odense, Denmark
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Soetjahjo B, Malueka RG, Nurudhin A, Purwoko, Sumardi, Wisaksana R, Adhiputri A, Sudadi, Soeroto AY, Sidharta BRA, Thobari JA, Murni TW, Soewondo W, Herningtyas EH, Sudjud RW, Trisnawati I, Ananda NR, Faried A. Effectiveness and safety of normoxic allogenic umbilical cord mesenchymal stem cells administered as adjunctive treatment in patients with severe COVID-19. Sci Rep 2023; 13:12520. [PMID: 37532730 PMCID: PMC10397314 DOI: 10.1038/s41598-023-39268-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 07/22/2023] [Indexed: 08/04/2023] Open
Abstract
Inflammatory response in COVID-19 contributes greatly to disease severity. Mesenchymal Stem Cells (MSCs) have the potential to alleviate inflammation and reduce mortality and length of stay in COVID-19 patients. We investigated the safety and effectiveness of normoxic-allogenic umbilical cord (NA-UC)-MSCs as an adjunctive treatment in severe COVID-19 patients. A double-blind, multicentric, randomized, placebo-controlled trial involving severe COVID-19 patients was performed from January to June 2021 in three major hospitals across Java, Indonesia. Eligible participants (n = 42) were randomly assigned to two groups (1:1), namely the intervention (n = 21) and control (n = 21) groups. UC-MSCs dose was 1 × 106 /kg body weight on day D0, D3, and D6. The primary outcome was the duration of hospitalization. Meanwhile, the secondary outcomes were radiographical progression (Brixia score), respiratory and oxygenation parameters, and inflammatory markers, in addition to the safety profile of NA-UC-MSCs. NA-UC-MSCs administration did not affect the length of hospital stay of severe COVID-19 patients, nor did it improve the Brixia score or mMRC dyspnoea scale better than placebo. Nevertheless, NA-UC-MSCs led to a better recuperation in oxygenation index (120.80 ± 72.70 baseline vs. 309.63 ± 319.30 D + 22, p = 0.038) and oxygen saturation (97.24 ± 4.10% vs. 96.19 ± 3.75% in placebo, p = 0.028). Additionally, compared to the placebo group, the treatment group had a significantly smaller increase in PCT level at D + 22 (1.43 vs. 12.76, p = 0.011). No adverse effects, including serious ones, were recorded until D + 91. NA-UC-MSCs therapy is a very safe adjunct for COVID-19 patients. It improves the oxygenation profile and carries potential to suppress inflammation.
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Affiliation(s)
- Bintang Soetjahjo
- Department of Orthopaedics and Traumatology, Universitas Sebelas Maret-Dr. Moewardi Hospital, Solo, Indonesia
| | - Rusdy Ghazali Malueka
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Arief Nurudhin
- Department of Internal Medicine, Universitas Sebelas Maret-Dr. Moewardi Hospital, Solo, Indonesia
| | - Purwoko
- Department of Anesthesiology and Intensive Therapy, Universitas Sebelas Maret-Dr. Moewardi Hospital, Solo, Indonesia
| | - Sumardi
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Rudi Wisaksana
- Department of Internal Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Artrien Adhiputri
- Department of Pulmonology and Respiratory Medicine, Universitas Sebelas Maret-Dr. Moewardi Hospital, Solo, Indonesia
| | - Sudadi
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Arto Yuwono Soeroto
- Department of Internal Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | | | - Jarir At Thobari
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Tri Wahyu Murni
- Department of Surgery, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Widiastuti Soewondo
- Department of Radiology, Universitas Sebelas Maret-Dr. Moewardi Hospital, Solo, Indonesia
| | - Elizabeth Henny Herningtyas
- Department of Clinical Pathology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Reza Widianto Sudjud
- Department of Anesthesiology-Intensive Therapy, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Ika Trisnawati
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Nur Rahmi Ananda
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada-Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Ahmad Faried
- Department of Neurosurgery, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, 40161, Indonesia.
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Zong K, Li W, Fu Y, Zhang S, Liu Y, Li S. Bacterial co-infection raises in-hospital mortality of COVID-19 patients: a retrospective study. Front Microbiol 2023; 14:1206476. [PMID: 37455733 PMCID: PMC10345203 DOI: 10.3389/fmicb.2023.1206476] [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: 04/15/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Background We aim to explore whether the bacterial co-infection with COVID-19 will raise the in-hospital mortality. Methods COVID-19 patients' information were collected for analysis in our retrospective study. Neutrophil count and procalcitonin (PCT) were used to estimate whether there was a suspected bacterial co-infection. Results The main baselines between the suspected bacterial infection (SBI) and no evidence of bacterial infection (NBI) groups were no significant differences. In SBI group, patients required more therapies than NBI group. There was significantly higher in-hospital mortality (26% vs.9%, P < 0.001) between SBI and NBI groups in overall population. And in each subgroup based on pneumonia inflammation index (PII), it also showed higher in-hospital mortality of COVID-19 patients with bacterial co-infection. With logistic regression models, it showed that bacterial co-infection was associated with significantly higher in-hospital mortality in overall population (OR 1.694, 95% CI 1.179-2.434, p = 0.004) and mild subgroup (OR 2.374, 95% CI 1.249-4.514, p = 0.008). The rate of bacterial co-infection in overall population was 51%. At the same time, it showed a significantly higher rate of bacterial co-infection in critical subgroup than severe subgroup (63% vs. 49%, p = 0.003), and than that in moderate subgroup (63% vs. 48%, p = 0.002) based on clinical classification. It showed a significantly higher rates of bacterial co-infection in severe subgroup than moderate subgroup (66% vs. 49%, p = 0.001) based on PII. The result showed that the risk factor associated with significantly higher in-hospital mortality was PII (OR 1.018, 95%CI 1.012 to 1.024, P < 0.001) with logistic regression models. Interpretation Bacterial co-infection estimated by Neutrophil count and procalcitonin significantly raises in-hospital mortality of COVID-19 patients in overall population in our study. Its impact is more significant in mild and moderate PII subgroups. PII based on CT imaging combined with neutrophil count and PCT is beneficial for accurate differentiation of bacterial co-infection of COVID-19.
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Affiliation(s)
- Kaican Zong
- Department of Respiratory Medicine, The Seventh People’s Hospital of Chongqing, Affiliated Central Hospital of Chongqing University of Technology, Chongqing, China
| | - Wen Li
- Department of Respiratory Medicine, The Seventh People’s Hospital of Chongqing, Affiliated Central Hospital of Chongqing University of Technology, Chongqing, China
| | - Yingya Fu
- Department of Respiratory Medicine, The Seventh People’s Hospital of Chongqing, Affiliated Central Hospital of Chongqing University of Technology, Chongqing, China
| | - Sha Zhang
- Department of Respiratory Medicine, The Seventh People’s Hospital of Chongqing, Affiliated Central Hospital of Chongqing University of Technology, Chongqing, China
| | - Yi Liu
- Department of Infectious Diseases, Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Institute for Viral Hepatitis, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Shiying Li
- Department of Infectious Diseases, Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Institute for Viral Hepatitis, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Langford BJ, So M, Simeonova M, Leung V, Lo J, Kan T, Raybardhan S, Sapin ME, Mponponsuo K, Farrell A, Leung E, Soucy JPR, Cassini A, MacFadden D, Daneman N, Bertagnolio S. Antimicrobial resistance in patients with COVID-19: a systematic review and meta-analysis. THE LANCET. MICROBE 2023; 4:e179-e191. [PMID: 36736332 PMCID: PMC9889096 DOI: 10.1016/s2666-5247(22)00355-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/08/2022] [Accepted: 11/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Frequent use of antibiotics in patients with COVID-19 threatens to exacerbate antimicrobial resistance. We aimed to establish the prevalence and predictors of bacterial infections and antimicrobial resistance in patients with COVID-19. METHODS We did a systematic review and meta-analysis of studies of bacterial co-infections (identified within ≤48 h of presentation) and secondary infections (>48 h after presentation) in outpatients or hospitalised patients with COVID-19. We searched the WHO COVID-19 Research Database to identify cohort studies, case series, case-control trials, and randomised controlled trials with populations of at least 50 patients published in any language between Jan 1, 2019, and Dec 1, 2021. Reviews, editorials, letters, pre-prints, and conference proceedings were excluded, as were studies in which bacterial infection was not microbiologically confirmed (or confirmed via nasopharyngeal swab only). We screened titles and abstracts of papers identified by our search, and then assessed the full text of potentially relevant articles. We reported the pooled prevalence of bacterial infections and antimicrobial resistance by doing a random-effects meta-analysis and meta-regression. Our primary outcomes were the prevalence of bacterial co-infection and secondary infection, and the prevalence of antibiotic-resistant pathogens among patients with laboratory-confirmed COVID-19 and bacterial infections. The study protocol was registered with PROSPERO (CRD42021297344). FINDINGS We included 148 studies of 362 976 patients, which were done between December, 2019, and May, 2021. The prevalence of bacterial co-infection was 5·3% (95% CI 3·8-7·4), whereas the prevalence of secondary bacterial infection was 18·4% (14·0-23·7). 42 (28%) studies included comprehensive data for the prevalence of antimicrobial resistance among bacterial infections. Among people with bacterial infections, the proportion of infections that were resistant to antimicrobials was 60·8% (95% CI 38·6-79·3), and the proportion of isolates that were resistant was 37·5% (26·9-49·5). Heterogeneity in the reported prevalence of antimicrobial resistance in organisms was substantial (I2=95%). INTERPRETATION Although infrequently assessed, antimicrobial resistance is highly prevalent in patients with COVID-19 and bacterial infections. Future research and surveillance assessing the effect of COVID-19 on antimicrobial resistance at the patient and population level are urgently needed. FUNDING WHO.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Miranda So
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada
| | | | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada; Toronto East Health Network, Toronto, ON, Canada
| | - Jennifer Lo
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tiffany Kan
- North York General Hospital, Toronto, ON, Canada
| | | | - Mia E Sapin
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Mponponsuo
- University of Calgary, Calgary, AB, Canada; Alberta Health Services, Calgary, AB, Canada
| | | | - Elizabeth Leung
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, UK
| | - Jean-Paul R Soucy
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Derek MacFadden
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital, Ottawa, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Jeyapalina S, Wei G, Stoddard GJ, Sudduth JD, Lundquist M, Huntsman M, Marquez JL, Agarwal JP. Serum procalcitonin level is independently associated with mechanical ventilation and case-fatality in hospitalized COVID-19-positive US veterans-A potential marker for disease severity. PLoS One 2023; 18:e0284520. [PMID: 37068086 PMCID: PMC10109491 DOI: 10.1371/journal.pone.0284520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/02/2023] [Indexed: 04/18/2023] Open
Abstract
The Coronavirus-19 disease (COVID-19) has claimed over 6.8 million lives since first being reported in late 2019. The virus that causes COVID-19 disease is highly contagious and spreads rapidly. To date, there are no approved prognostic tools that could predict why some patients develop severe or fatal disease outcomes. Early COVID-19 studies found an association between procalcitonin (PCT) and hospitalization or duration of mechanical ventilation and death but were limited by the cohort sizes. Therefore, this study was designed to confirm the associations of PCT with COVID-19 disease severity outcomes in a large cohort. For this retrospective data analysis study, 27,154 COVID-19-positive US veterans with post-infection PCT laboratory test data and their disease severity outcomes were accessed using the VA electronic healthcare data. Cox regression models were used to test the association between serum PCT levels and disease outcomes while controlling for demographics and relevant confounding variables. The models demonstrated increasing disease severity (ventilation and death) with increasing PCT levels. For PCT serum levels above 0.20 ng/ml, the unadjusted risk increased nearly 2.3-fold for mechanical ventilation (hazard ratio, HR, 2.26, 95%CI: 2.11-2.42) and in-hospital death (HR, 2.28, 95%CI: 2.16-2.41). Even when adjusted for demographics, diabetes, pneumonia, antibiotic use, white blood cell count, and serum C-reactive protein levels, the risks remained relatively high for mechanical ventilation (HR, 1.80, 95%CI: 1.67-1.94) and death (HR, 1.76, 95%CI: 1.66-1.87). These data suggest that higher PCT levels have independent associations with ventilation and in-hospital death in veterans with COVID-19 disease, validating previous findings. The data suggested that serum PCT level may be a promising prognostic tool for COVID-19 severity assessment and should be further evaluated in a prospective clinical trial.
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Affiliation(s)
- Sujee Jeyapalina
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Guo Wei
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jack D Sudduth
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Margaret Lundquist
- Research, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Merodean Huntsman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jessica L Marquez
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jayant P Agarwal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
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8
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Omer I, Abuthiyab N, Al Zaid N, Alkanani R, Abualnaja R, Khan G. Procalcitonin as a Tool to Antimicrobial Stewardship in COVID-19 Patients with Superimposed Bacterial Infections: A Systematic Review. J Inflamm Res 2022; 15:6055-6064. [PMID: 36353123 PMCID: PMC9639592 DOI: 10.2147/jir.s377644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/20/2022] [Indexed: 07/30/2023] Open
Abstract
ABSTRACT Procalcitonin is an inflammatory marker that had shown marked potential as an antimicrobial stewardship tool for administering antibiotics when needed in patients with pneumonia as it raises concurrently with other inflammatory markers, yet no systematic review has assessed its potential in COVID-19 patients. This systematic review aimed to assess the potential appropriateness of procalcitonin as an antimicrobial stewardship tool in COVID-19 patients with superimposed bacterial and non-bacterial infections. All study designs published after 2019 were included in this systematic review. We included all studies that had reported procalcitonin levels in COVID-19 patients with suspected superimposed secondary infection(s). We searched MEDLINE, Scopus, and the Directory for Open Access Journal from April 2022 to May 2022 and retrieved all related articles for screening with no restrictions on language. We conducted risk of bias assessment according to the Critical Appraisal Skills Programme (CASP) criteria for cohort and case-control studies. Results were presented according to procalcitonin cut-off values, gold standard test used to confirm infection, and overall study conclusion(s), among other variables. This systematic review included 18 articles with 7196 patients in 8 countries. Despite different cut-off values of procalcitonin used, thirteen studies had indicated the appropriateness of using procalcitonin as antimicrobial stewardship tool in COVID-19 patients. We urge physicians to take this into account when treating COVID-19 patients suspected of superimposed infections and we look forward to further studies with standardized procalcitonin cut-off values that may provide appropriate quantitative data that can contribute to clinical guidelines. REGISTRATION PROSPERO CRD42022315013.
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Affiliation(s)
- Ibrahim Omer
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Noorah Abuthiyab
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nura Al Zaid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Raghad Alkanani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Reema Abualnaja
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ghadeer Khan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
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9
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Diagnostic Accuracy of Procalcitonin upon Emergency Department Admission during SARS-CoV-2 Pandemic. Antibiotics (Basel) 2022; 11:antibiotics11091141. [PMID: 36139922 PMCID: PMC9495046 DOI: 10.3390/antibiotics11091141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 01/08/2023] Open
Abstract
Highlights Abstract Introduction: Procalcitonin is a marker for bacterial diseases and has been used to guide antibiotic prescription. Procalcitonin accuracy, measured at admission, in patients with community-acquired pneumonia (CAP), is unknown in the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Objectives: To evaluate the diagnostic accuracy of procalcitonin to assess the need for antibiotic treatment in patients with CAP presenting to the emergency department during the SARS-CoV-2 pandemic. Methods: We performed a real-world diagnostic retrospective accuracy study of procalcitonin in patients admitted to the emergency department. Measures of diagnostic accuracy were calculated based on procalcitonin results compared to the reference standard of combined microbiological and radiological analysis. Sensitivity, specificity, positive and negative predictive values, and area under (AUC) the receiver-operating characteristic (ROC) curve were calculated in two analyses: first assessing procalcitonin ability to differentiate microbiologically proven bacteria from viral CAP and then clinically diagnosed bacterial CAP from viral CAP. Results: When using a procalcitonin threshold of 0.5 ng/mL to identify bacterial etiology within patients with CAP, we observed sensitivity and specificity of 50% and 64.1%, and 43% and 82.6%, respectively, in the two analyses. The positive and negative predictive values of a procalcitonin threshold of 0.5 ng/mL to identify patients for whom antibiotics should be advised were 46.4% and 79.7%, and 48.9% and 79% in the two analyses, respectively. The AUC for the two analyses was 0.60 (95% confidence interval [CI] 0.52–0.68) and 0.62 (95% CI, 0.55–0.69). Conclusions: Procalcitonin measured upon admission during the SARS-CoV-2 pandemic should not guide antibiotic treatment in patients with CAP.
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10
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Ming DK, Myall AC, Hernandez B, Weiße AY, Peach RL, Barahona M, Rawson TM, Holmes AH. Correction to: Informing antimicrobial management in the context of COVID-19: understanding the longitudinal dynamics of C-reactive protein and procalcitonin. BMC Infect Dis 2021; 21:988. [PMID: 34548046 PMCID: PMC8454290 DOI: 10.1186/s12879-021-06696-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Damien K Ming
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK. .,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
| | - Ashleigh C Myall
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,Department of Mathematics, Imperial College London, London, UK
| | - Bernard Hernandez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Andrea Y Weiße
- School of Informatics, University of Edinburgh, Scotland, UK.,School of Biological Science, University of Edinburgh, Scotland, UK
| | - Robert L Peach
- Department of Neurology, University Hospital of Würzburg, 97080, Würzburg, Germany.,Department of Mathematics, Imperial College London, London, UK
| | | | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
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