Coinfection and superinfection in ICU critically ill patients with severe COVID-19 pneumonia and influenza pneumonia: are the pictures different?

Inflammatory Biomarkers Demonstrate Predictive Capacity for Mortality in COVID-19-Related ARDS Patients Receiving High-Dose Corticosteroids: A Longitudinal Analysis

Purpose

Patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) who lack clinical improvement are frequently treated with high-dose corticosteroids (HDS). Since HDS is used to reduce hyperinflammation in these patients, levels of (pro-)inflammatory biomarkers after commencing HDS treatment could be useful in predicting mortality. This study aims to evaluate biomarker levels after commencing HDS over time, along with their capacity to predict mortality.

Patients and Methods

This retrospective cohort study included patients with COVID-19 ARDS treated with HDS in the intensive care unit (ICU) at an academic hospital in the Netherlands between March 2020-March 2022. Inflammatory biomarkers (ie, C-reactive protein (CRP), D-dimer, ferritin, leukocyte count, interleukin-6 (IL-6), lactate dehydrogenase (LDH), neutrophil-to-lymphocyte ratio (NLR), and procalcitonin (PCT)) were assessed daily from start of HDS (ie baseline) until day 7. Associations between biomarker levels and all-cause-hospital-mortality were evaluated each day using logistic regression, with cut-offs identified by optimizing sensitivity (Se) and specificity (Sp).

Results

Of the 122 patients included, 53 (43.4%) died during hospitalization. HDS was initiated for a median 7 days (IQR=1-11) after ICU admission. At baseline, a moderately high predictive capacity for mortality was observed at a ferritin level >1281 µg/L (Se=62%/Sp=64%), leukocyte count >13.7 × 109/L (Se=42%/Sp=79%), and NLR >12.1 (Se=61%/Sp=77%). During follow-up, CRP >50 mg/L on day 6 (Se=50%/Sp=75%) and >42 mg/L on day 7 (Se=50%/Sp=75%), ferritin >1082 µg/L on day 6 (Se 63%/Sp=71%) and >1852 µg/L on day 7 (Se=31%/Sp=79%), IL-6 >67 mg/L on day 7 (Se=56%/Sp=79%) and LDH >396U/L on day 6 (Se=38%/Sp=83%) and >373 U/L on day 7 (Se=47%/Sp=72%) showed moderate capacity to predict mortality. NLR was consistently associated with mortality for all days, except day 1 (Se=36-68%/Sp=72-92%).

Conclusion

In COVID-19 ARDS patients receiving HDS, several clinically available inflammatory biomarkers moderately predicted all-cause-hospital-mortality after the start of HDS, particularly on days 6 and 7. NLR demonstrated the most consistent association with mortality over time. The use of these markers requires validation in larger cohorts.

Burden and Risk Factors for Coinfections in Patients with a Viral Respiratory Tract Infection

Which patients should be monitored for coinfections or should receive empirical antibiotic treatment, in patients with an acute viral respiratory infection, is largely unknown. We evaluated the prevalence, characteristics, outcomes of coinfected patients, and risk factors associated with a coinfection among patients with an acute viral infection. A retrospective, single-center study recruited consecutive patients from October 2022 to March 2023 presenting to the emergency department with signs of a respiratory tract infection. Patients were screened for respiratory viruses and bacterial/fungal secondary infections according to local standard procedures. Outcomes included severe disease, in-hospital complications, all-cause in-hospital and ICU-related mortality, time to death, time to discharge, and time to coinfection. The analysis included 652 patients. A viral infection and a secondary bacterial/fungal infection were detected in 39.1% and 40% of cases. Compared with the rest of the cohort, coinfected patients had more frequently severe disease (88.3%, p < 0.001; 51% in patients with SARS-CoV-2) and higher in-hospital mortality (16.5%, p = 0.010). Nephropathy (OR 3.649, p = 0.007), absence of COVID-19 vaccination (OR 0.160, p < 0.001), SARS-CoV-2 infection (OR 2.390, p = 0.017), and lower blood pressure at admission (OR 0.980, p = 0.007) were independent risk factors for coinfection. Multidrug-resistant pathogens were detected in 30.8% of all coinfections. Patients with a viral infection are at high risk of bacterial coinfections, which carry a significant morbidity and mortality burden.

COVID-19 vs. non-COVID-19 related nosocomial pneumonias: any differences in etiology, prevalence, and mortality?

PURPOSE OF REVIEW

This review explores the similarities and differences between coronavirus disease 2019 (COVID-19)-related and non-COVID-related nosocomial pneumonia, particularly hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It critically assesses the etiology, prevalence, and mortality among hospitalized patients, emphasizing the burden of these infections during the period before and after the severe acute respiratory syndrome coronavirus 2 pandemic.

RECENT FINDINGS

Recent studies highlight an increase in nosocomial infections during the COVID-19 pandemic, with a significant rise in cases involving severe bacterial and fungal superinfections among mechanically ventilated patients. These infections include a higher incidence of multidrug-resistant organisms (MDROs), complicating treatment and recovery. Notably, COVID-19 patients have shown a higher prevalence of VAP than those with influenza or other respiratory viruses, influenced by extended mechanical ventilation and immunosuppressive treatments like corticosteroids.

SUMMARY

The findings suggest that COVID-19 has exacerbated the frequency and severity of nosocomial infections, particularly VAP. These complications not only extend hospital stays and increase healthcare costs but also lead to higher morbidity and mortality rates. Understanding these patterns is crucial for developing targeted preventive and therapeutic strategies to manage and mitigate nosocomial infections during regular or pandemic care.

Efficacy of a Multistrain Synbiotic Treatment in Acute and Post-Acute COVID-19 Patients: A Double-Blind, Placebo-Controlled Randomized Trial

BACKGROUND AND AIMS

Several studies reported the effect of COVID-19 on inducing gut dysbiosis, which is also correlated with disease severity. This study aims to investigate the effect of a nutraceutical formula on the shift of microbiota profiles and, secondly, on the clinical-pathological parameters of acute and post-acute COVID-19 patients.

METHODS

In this randomised, double-blind, placebo-controlled trial conducted at National Institute for Infectious diseases (INMI) Lazzaro Spallanzani (Italy), 52 patients were randomly assigned (1:1) to receive a multistrain synbiotic formula (Kebirah®) or placebo orally for 35 days at COVID-19 diagnosis. Health professionals, investigators, and patients were masked to group assignments. The V3-V4 hypervariable region of 16S rRNA gene sequencing was employed to study the gut microbiota composition in the two groups.

RESULTS

Supplementation with Kebirah® prevented the decrease in the Shannon diversity index of gut microbiota, which was instead observed in patients receiving the placebo. In addition, decreases in lymphocyte count and haemoglobin levels were observed only in the placebo group and not in the treated group, which was also characterised by an amelioration of the gut microbial profile, with an enrichment in beneficial bacteria and a preservation of species diversity.

CONCLUSIONS

Our data suggest that modulating the gut microbiota in acute disease through administration of a specific symbiotic formula could be a useful strategy in the frame of SARS-CoV-2 infections.

Viral Pneumonia: From Influenza to COVID-19

Respiratory viruses are increasingly recognized as a cause of community-acquired pneumonia (CAP). The implementation of new diagnostic technologies has facilitated their identification, especially in vulnerable population such as immunocompromised and elderly patients and those with severe cases of pneumonia. In terms of severity and outcomes, viral pneumonia caused by influenza viruses appears similar to that caused by non-influenza viruses. Although several respiratory viruses may cause CAP, antiviral therapy is available only in cases of CAP caused by influenza virus or respiratory syncytial virus. Currently, evidence-based supportive care is key to managing severe viral pneumonia. We discuss the evidence surrounding epidemiology, diagnosis, management, treatment, and prevention of viral pneumonia.