Opportunistic Infections in COVID-19: A Systematic Review and Meta-Analysis

Prevalence and mortality rate of healthcare-associated infections among COVID-19 patients: a retrospective cohort community-based approach

Background

The prevalence of HAI among COVID-19 patients ranged between 4.8% and 42.8% with the highest occurrence observed in critically ill patients. The present study aimed to evaluate the clinical features of HAI in severe and critical COVID-19 patients, their microbiological characteristics, and the attributable risk factors.

Methods

This is an analytical observational, retrospective single-center, cohort study that included 723 patients with severe-critical COVID-19 admitted to Saint George Hospital between September 2020 and February 2021. Data collection included demographic variables (sex, age), comorbidities, laboratory findings, HAI types and agents, COVID-19 treatment modalities, hospitalization settings, length of stay, and mortality rate. Data was analyzed using SPSS version 25.

Results

The prevalence of patients developing HAI was 7.3% (53 of 723). Five types of nosocomial bacterial infections were tracked noting ventilator-associated pneumonia (41.26%), catheter-associated urinary tract infection (28.6%), hospital-acquired pneumonia (17.44%), catheter-related bloodstream infection (6.35%), and bloodstream infection (6.35%). Binary logistic analysis showed that HAI are statistically affected by four factors noting patients' age (p = 0.039), Length of Stay (p < 0.001), BIPAP (p = 0.019), and mechanical ventilation (p < 0.001). The risk of having HAI increases 3.930 times in case of mechanical ventilation, 2.366 times in case of BIPAP, 1.148 times when the LOS increases 1 day, and 1.029 times when the age is higher with 1 year.

Conclusion

Since the prevalence of HAI is high among severe and critical COVID-19 patients, it is important to prepare a treatment with diagnostic, preventative, and control measures for this infection.

Super-infection by multiple microorganisms in COVID-19 patients

Introduction: This study aimed to describe the clinical characteristics of patients with COVID-19 co-infected with multiple multidrug-resistant bacteria.

Methods: Patients hospitalized in the AUNA network between January and May 2021, diagnosed with COVID-19 and at least two other infecting microorganisms, were retrospectively included in the analysis. Clinical and epidemiological data were extracted from clinical records. The susceptibility levels of the microorganisms were determined using automated methods. Antibiotic resistance was established among infecting bacteria accounting for ≥5 isolates.

Results: A total of 27 patients (21 male and 6 female patients) met the inclusion criteria, with a maximum of eight co-infecting bacteria or fungi during admission time. Seven patients (25.9%) died, with a higher but not significant lethality among women (50% vs. 19.0%). A total of 15 patients presented at least one established comorbidity, with hypertension being the most frequent. The time elapsed between COVID-19 diagnosis and hospital attendance was 7.0 days, with that of patients with a fatal outcome being longer than that of living patients (10.6 vs. 5.4). Up to 20 different microorganisms were isolated, with Pseudomonas aeruginosa being the most common (34 isolates). In general, antibiotic resistance levels were high, especially in Acinetobacter baumannii isolates, with resistance levels of 88.9% to all antimicrobial agents tested, except colistin (0%).

Conclusion: In conclusion, the present results show the presence of multiple microorganisms that co-infect COVID-19 patients. When fatal outcome rates are in the range of other reports, the presence of a series of multidrug-resistant microorganisms is of concern, showing the need to reinforce control measures to limit the expansion of almost untreatable microorganisms.

Atypical herpetic ulcerations in COVID-19 positive patients: A report of three cases

Since the global COVID-19 pandemic, numerous reports have been made regarding oral lesions seen in COVID-19 patients. It remains unclear whether or not these are true manifestations of COVID-19. Here we present 3 patients who were hospitalized for COVID-19 and who developed atypical herpetic ulcerations during their treatment with remdesivir (Veklury) and steroids. In healthy patients, recurrent infection by herpes simplex virus (HSV) presents as lesions only on the lips and the attached oral mucosa. Atypical herpetic ulcerations are seen in immunocompromised patients. They present as large, stellate shaped ulcerations with raised borders and may involve movable mucosa. The 3 cases presented in this report resembled the atypical herpetic ulcerations typically seen in patients with immunosuppression. Through our report, we aimed to introduce the possibility of atypical herpetic ulcers in patients being treated for COVID-19, to allow for their timely diagnosis and to raise awareness of the underlying immunocompromised state.

Risk factors and effect on mortality of superinfections in a newly established COVID-19 respiratory sub-intensive care unit at University Hospital in Rome

BACKGROUND

Little is known on the burden of co-infections and superinfections in a specific setting such as the respiratory COVID-19 sub-intensive care unit. This study aims to (i) assess the prevalence of concurrent and superinfections in a respiratory sub-intensive care unit, (ii) evaluate the risk factors for superinfections development and (iii) assess the impact of superinfections on in-hospital mortality.

METHODS

Single-center retrospective analysis of prospectively collected data including COVID-19 patients hospitalized in a newly established respiratory sub-intensive care unit managed by pneumologists which has been set up from September 2020 at a large (1200 beds) University Hospital in Rome. Inclusion criteria were: (i) COVID-19 respiratory failure and/or ARDS; (ii) hospitalization in respiratory sub-intensive care unit and (iii) age > 18 years. Survival was analyzed by Kaplan-Meier curves and the statistical significance of the differences between the two groups was assessed using the log-rank test. Multivariable logistic regression and Cox regression model were performed to tease out the independent predictors for superinfections' development and for mortality, respectively.

RESULTS

A total of 201 patients were included. The majority (106, 52%) presented severe COVID-19. Co-infections were 4 (1.9%), whereas 46 patients (22%) developed superinfections, mostly primary bloodstream infections and pneumonia. In 40.6% of cases, multi-drug resistant pathogens were detected, with carbapenem-resistant Acinetobacter baumannii (CR-Ab) isolated in 47%. Overall mortality rate was 30%. Prior (30-d) infection and exposure to antibiotic therapy were independent risk factors for superinfection development whereas the development of superinfections was an independent risk factors for in-hospital mortality. CR-Ab resulted independently associated with 14-d mortality.

CONCLUSION

In a COVID-19 respiratory sub-intensive care unit, superinfections were common and represented an independent predictor of mortality. CR-Ab infections occurred in almost half of patients and were associated with high mortality. Infection control rules and antimicrobial stewardship are crucial in this specific setting to limit the spread of multi-drug resistant organisms.

Rare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection

BACKGROUND On rare occasions, viral infections are known to also depress immune cell lines, further worsening clinical outcomes. We describe a patient who presented 3 weeks after recovery from mild COVID-19 disease with clinical features of an atypical pneumonia and was found to have a low CD4+ T-cell count. CASE REPORT An 82-year-old man with a past medical history of coronary artery disease, rheumatoid arthritis, gout, hypertension, and atrial fibrillation presented with a 1-week history of progressively worsening shortness of breath and cough. He was noted to have recovered from mild SARS-CoV-2 infection 3 weeks prior to his current presentation and had been at his baseline level of health following infection. A T cell subset panel was obtained, which revealed an absolute CD3 count of 92 (reference range 840-3060), absolute CD4 count of 52 (reference range 500-1400), absolute CD8 count of 37 (reference range 180-1170), and a normal CD4: CD8 ratio. He was subsequently started on atovaquone for pneumocystis jiroveci pneumonia prophylaxis. CONCLUSIONS This case highlights the need for a high index of suspicion for lymphocyte depletion in older patients with multiple comorbidities who present during or after SARS-CoV-2 infection with atypical symptoms that are suggestive of immunosuppression. In such instances, there should be a low threshold to start prophylactic therapy for possible opportunistic infections.

Coinfection with Strongyloides and Ascaris in a COVID-19-positive male presenting with acute abdomen: a case report

Ascaris lumbricoides and Strongyloides stercoralis are soil-transmitted helminthic infections usually seen in people with poor socioeconomic conditions, hygiene and fecal sanitation living in endemic countries. Here, we present a case of coinfection in a COVID-positive older adult male presenting to our facility with symptoms of acute abdomen. Investigative workup guided timely diagnosis of the case. Prompt initiation of antihelminthic drugs together with antibiotics/antivirals for COVID symptoms resulted in favorable outcome in the case. A high index of suspicion on the part of the treating and diagnosing doctor is required in the COVID era. This will help not only in diagnosis but will also give an understanding to the exact pathogenesis for better patient outcome.

Co-Infections and Superinfections in COVID-19 Critically Ill Patients Are Associated with CT Imaging Abnormalities and the Worst Outcomes

Background: Bacterial and fungal co-infections and superinfections have a critical role in the outcome of the COVID-19 patients admitted to the Intensive Care Unit (ICU). Methods: The present study is a retrospective analysis of 95 patients admitted to the ICU for COVID-19-related ARDS during the first (February−May 2020) and second waves of the pandemic (October 2020−January 2021). Demographic and clinical data, CT imaging features, and pulmonary and extra-pulmonary complications were recorded, as well as the temporal evolution of CT findings when more than one scan was available. The presence of co-infections and superinfections was registered, reporting the culprit pathogens and the specimen type for culture. A comparison between patients with and without bacterial and/or co-infections/superinfections was performed. Results: Sixty-three patients (66.3%) developed at least one confirmed co-infection/superinfection, with 52 (82.5%) developing pneumonia and 43 (68.3%) bloodstream infection. Gram-negative bacteria were the most common co-pathogens identified and Aspergillus spp. was the most frequent pulmonary microorganism. Consolidations, cavitations, and bronchiectasis were significantly associated with the presence of co-infections/superinfections (p = 0.009, p = 0.010 and p = 0.009, respectively); when considering only patients with pulmonary co-pathogens, only consolidations remained statistically significative (p = 0.004). Invasive pulmonary aspergillosis was significantly associated with the presence of cavitations and bronchiectasis (p < 0.001). Patients with co-infections/superinfections presented a significantly higher mortality rate compared to patients with COVID-19 only (52.4% vs. 25%, p = 0.016). Conclusions: Bacterial and fungal co-infections and superinfections are frequent in COVID-19 patients admitted to ICU and are associated with worse outcomes. Imaging plays an important role in monitoring critically ill COVID-19 patients and may help detect these complications, suggesting further laboratory investigations.

Hypertonic Solution in Severe COVID-19 Patient: A Potential Adjuvant Therapy

Coronavirus disease 2019 (COVID-19) features hyper-inflammation, cytokine storm, neutrophil function changes, and sodium chloride (NaCl) homeostasis disruption, while the treatment with NaCl hypertonic solutions (HS) controls electrolytic body homeostasis and cell functions. HS treatment is a simple, popular, economic, and feasible therapy to regulate leukocyte function with a robust anti-inflammatory effect in many inflammatory diseases. The purpose of this narrative review is to highlight the knowledge on the use of HS approaches against viral infection over the past years and to describe the mechanisms involved in the release of neutrophil extracellular traps (NETs) and production of cytokine in severe lung diseases, such as COVID-19. We reported the consequences of hyponatremia in COVID-19 patients, and the immunomodulatory effects of HS, either in vitro or in vivo. We also described the relationship between electrolyte disturbances and COVID-19 infection. Although there is still a lack of clinical trials, hypertonic NaCl solutions have marked effects on neutrophil function and NETs formation, emerging as a promising adjuvant therapy in COVID-19.