SARS-CoV-2: low virus load on surfaces in public areas

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led people to implement preventive measures, including surface and hand disinfection with a disinfectant to avoid viral transmission. The detection of coronaviruses on surfaces implies not always a high danger of infection. Different coronaviruses and SARS-CoV-2 can be detected under experimental conditions on surfaces for many days. However, there are no studies concerning the virus load and the risk for an infection. The aim of our study was to find out if we could detect SARS-CoV-2 with a virus load greater than 10⁶ copies/mL in public areas under real-life conditions. A total of 1200 swabs were performed on different environmental surfaces in public areas: handholds, press buttons in buses, tramways, tubes, elevators, shops, doorknobs in public buildings, public restrooms, touchscreens in shops and public transportation services, supermarket trolleys, banknotes and coins and immediately tested. We used Rapid Covid-19 Antigen Test (Clinitest®) by Siemens Healthineers (Healgen Scientific Limited Liability Company, Houston, USA, respectively, Shanghai International Holding Corp. GmbH (Europe), Hamburg, Germany). During our study, we were not able to detect SARS-CoV-2 with a virus load greater than 10⁶ copies/ml although we pooled the swabs. According to the negative antigen tests and with a theoretically probability calculation of 1/24.000, there seems no relevant risk of infection with SARS-CoV-2 in public areas. For people with underlying diseases or immunosuppression, the risk of transmission respectively infectivity cannot be excluded with this study.

Correctly performed nasal swabs

BACKGROUND

As the incidence of new cases of coronavirus disease increased exponentially, the use of viral swabs to collect nasopharyngeal specimens are increasing drastically. Therefore, healthcare workers military staff and uneducated nonprofessional's were ordered to make this swabs. Subsequently case reports reported about basal skull perforation, cerebrospinal fluid fistula and injury due to an incorrect technique.

METHODS

Search of the literature.

RESULTS

Only in 44% of the videos (Youtube) nasal swabs were correctly performed. Due to an false technique biological sampling resulted in false-negative COVID-19 tests.

CONCLUSION

Although professional societies started to report about this unacceptable situation, no publication reported about this health endangerment. In this time of overwhelming information and diversity of opinions, it is necessary to report about this in the hope, all media and TV reports will follow this article to show correctly performed nasal swabs to reduce false-negative COVID-19 tests and injury.

Human Cytomegalovirus Infection in Nonimmunocompromised Patients: A Retrospective Analysis and Review of the Literature

In a retrospective analysis of patients visiting the Outpatient Department of the Division of Infectious Diseases and Tropical Medicine over a period of 3 years, we found a high incidence of symptomatic nonsevere human cytomegalovirus (HCMV) infection in nonimmunocompromised patients. We present 11 symptomatic cases of HCMV infection in nonimmunocompromised patients with non-life-threatening symptoms like long-lasting depletion, fatigue, and subfebrile fever with or without muscular pain and arthralgia. Although the symptoms were not life-threatening, all of the patients suffered a prolonged duration of the disease until improvement. These cases reinforce the important fact that HCMV infections in nonimmunocompromised patients are not always asymptomatic. Therefore, HCMV infection should always be included in the differential diagnosis of patients with unspecific signs of disease like depletion, subfebrile fever, and arthralgia.

Feasibility and speed of insertion of seven supraglottic airway devices under simulated airway conditions

OBJECTIVES

Endotracheal intubation (ETI) is considered the gold standard for protecting the airway. Alternative devices for airway protection have been developed that can be used by untrained personnel, by those with less experience, and for when ETI is not possible. The main goals of our study were to evaluate the success rate and speed of insertion of different supraglottic airway devices and to determine whether the devices could be properly inserted under simulated critical conditions.

METHODS

Fifty medical students used an airway simulation trainer (Laerdal SimMan 3G) to assess the success rate and time used to insert seven different supraglottic airway devices under simulated physiologic and pathologic conditions in two different runs.

RESULTS

Although all airway devices could be inserted without problems, only the Combitube and the EasyTube could be successfully inserted in simulations of trismus, limited mobility of the cervical spine, or a combination of pathologic conditions such as trismus plus limited mobility of the spine and trismus plus tongue edema. The insertion time was significantly longer with LMA Unique, Fastrach, and I-Gel devices in both the first and second runs.

CONCLUSION

The Combitube and the EasyTube were most easily inserted under simulated conditions such as trismus, limited mobility of the cervical spine, and combined pathologic conditions. Although all devices are useful for establishing an airway by nontrained medical students in standard simulations, we suggest that the Combitube and the EasyTube may offer advantages in difficult airway situations.

Two Cases of Fulminant Hepatic Failure from Amanita phalloides Poisoning Treated Additively by Homeopathy

BACKGROUND

Intoxication with Amanita phalloides is associated with high morbidity and mortality. Treatment therapies include general support, toxin elimination, pharmacotherapy with agents such as the hepatoprotective agent silibinin, and, in extreme states, liver transplantation. Despite these therapeutic interventions, mortality remains relatively high.

CASE REPORTS

We present reports of 2 patients with severe hepatic failure following intoxication with Amanita phalloides. Both patients were admitted to the intensive care unit; 1 patient suffered from hepatic failure solely, and the second patient experienced severe 5-organ failure. In addition to conventional intensive care treatment, both patients were treated additively with classical homeopathy. The 2 patients survived without any residual pathological sequelae.

CONCLUSION

Based on the 2 cases, including 1 extreme situation, we suggest that adjunctive homeopathic treatment has a role in the treatment of acute Amanita phalloides-induced toxicity following mushroom poisoning. Additional studies may clarify a more precise dosing regimen, standardization, and better acceptance of homeopathic medicine in the intensive care setting.

Likelihood of inadequate treatment: a novel approach to evaluating drug-resistance patterns

OBJECTIVE

To provide a novel way to predict the likelihood that antibiotic therapy will result in prompt, adequate therapy on the basis of local microbiological data.

DESIGN AND SETTING

Prospective study conducted at 3 medical intensive care units at the Viennese General Hospital, a tertiary care medical university teaching hospital in Vienna, Austria.

PATIENTS

One hundred one patients who received mechanical ventilation and who met the criteria for having ventilator-associated pneumonia.

DESIGN

Fiberoptic bronchoscopic examination was performed, and bronchoalveolar samples were collected. Samples were analyzed immediately by a single technician. Minimum inhibitory concentrations were determined for imipenem, cephalosporins (cefepime and cefpirome), ciprofloxacin, and piperacillin-tazobactam, and drug resistance rates were calculated. These drug resistance rates were translated into the likelihood of inadequate therapy (LIT; the frequency of inadequately treated patients per antibiotic and drug-resistant strain), cumulative LIT (the cumulative frequency of inadequately treated patients), and syndrome-specific LIT.

RESULTS

Among the 101 bronchoalveolar samples, culture yielded significant (at least 1 x 10(4) colony-forming units per mL) polymicrobial findings for 34 and significant monomicrobial findings for 31; 36 culture results were negative. Of the isolates from patients with ventilator-associated pneumonia who had monomicrobial culture findings, 33% were gram-positive bacteria and 20% were gram-negative bacteria. LIT suggested that 1 of 2 patients was treated inadequately for Pseudomonas aeruginosa infection. The LIT for patients with ventilator-associated pneumonia revealed that the rank order of antibiotics for appropriate therapy was (1) imipenem, (2) cephalosporins, (3) ciprofloxacin, and (4) piperacillin-tazobactam. These calculations were based solely on microbiological data.

CONCLUSIONS

The novel ratio LIT may help clinicians use microbiological data on drug resistance to predict which antimicrobial agents will provide adequate therapy. In daily practice, this new approach may be helpful for choosing adequate antimicrobial therapy.

Evaluation of interleukin-6 and interleukin-10 in lung transplant patients with human cytomegalovirus infection

We hypothesized that interleukin-6 (IL-6) in plasma and bronchoalveolar lavage (BAL) might serve as additional diagnostic parameter in lung transplant patients with human cytomegalovirus (HCMV) infection. Therefore, we compared IL-6 levels in HCMV-positive vs. HCMV-negative patients. IL-6 was measured by ELISA in plasma and BAL in 111 patients. Furthermore, we investigated the influence of IL-10 on IL-6 production in HCMV-positive patients. For HCMV-DNA detection in plasma and BAL a quantitative polymerase chain reaction (PCR) assay was used. IL-6 levels were significantly higher in the HCMV-positive group (n = 39; BAL p = 0.045; plasma p = 0.017) in comparison to the HCMV-negative group (n = 72). IL-10 did not correlate with IL-6 concentration (p = 0.146). Donor (D) or recipient (R) HCMV-constellation did not influence IL-6 concentration. IL-6 levels were not influenced by elevated levels of HCMV copies. Our data suggest that IL-6 does not serve as a good diagnostic parameter for existence of HCMV infection in lung transplant patients. Because of the wide range of the IL-6 levels in both groups, we were not able to find a breakpoint differentiating between infected and not-infected patients. Another important finding was that IL-6 production is not dependent of the HCMV status of D/R.

Usefulness of Interleukin-10 Detection in Lung Transplant Patients With Human Cytomegalovirus Infection With Respect to Virus Persistence

BACKGROUND

Human cytomegalovirus (HCMV) infection in lung transplant patients induces an inflammatory response, including local production of cytokines involved in viral clearance. The aim of this study was to evaluate the potential value of monitoring interleukin (IL)-10 with respect to HCMV persistence in blood and/or bronchoalveolar lavage (BAL).

METHODS

A quantitative polymerase chain reaction assay was used for HCMV-DNA detection in plasma and BAL. IL-10 was measured with an enzyme-linked immunosorbent assay in blood and with BAL in 101 lung transplant patients. IL-10 levels were correlated with clinical outcome.

RESULTS

A total of 23 patients of 35 (66%) with detectable HCMV in plasma and/or BAL exhibited increased levels of IL-10 in plasma and/or BAL. Complete clearance of HCMV was observed after 168 (median 130) days in the IL-10-positive group (n=23) in comparison with 87 (median 58) days in the IL-10-negative group (n=12; P<0.024). In the seven HCMV-positive patients with positive IL-10 levels in BAL only, HCMV persisted in BAL for a median of 579 days without signs of systemic infection (positive plasma levels) or clinical symptoms.

CONCLUSIONS

We show that in lung transplant patients with elevated levels of IL-10 in plasma and/or BAL, HCMV clearance is prolonged because of the influence of anti-inflammatory cytokines.

Ventilator-associated pneumonia: Increased bacterial counts in bronchoalveolar lavage by using urea as an endogenous marker of dilution

OBJECTIVE

Invasive diagnostic procedures such as bronchoalveolar lavage (BAL) with quantitative microbiological cultures are currently recommended for the diagnosis of nosocomial pneumonia. Commonly, in clinical practice, a threshold of > or =10 colony forming units/mL is used for therapeutic decisions. The use of these measurements in daily practice assumes that their repeatability is acceptable. However, many variations among the positive results have been noted. One of the most important is dilution of BAL, which may influence the quantitative results by minimizing bacterial counts. Knowledge of the extent of dilution may increase dramatically the value of quantitative cultures. The aim of this study was to determine to what extent specimens are diluted in BAL by measuring urea in BAL and blood. Furthermore, the impact of a potential dilution effect on the diagnosis of ventilator-associated pneumonia was studied.

PATIENTS AND SETTING

A total of 47 patients with ventilator-associated pneumonia in two medical intensive care units at the Vienna General Hospital, a university-affiliated facility.

DESIGN

Prospective study performed between January 2001 and July 2002.

METHODS

BAL fluid was divided immediately into two samples: one for direct microscopic examination of cytocentrifuge preparations for Gram staining to determine percentages of cells containing intracellular bacteria and one for quantitative cultures according to the Cumitech 7A guidelines. Epithelial lining fluid volume was calculated using urea as a marker of dilution and correlated with colony forming units per milliliter.

RESULTS

Nineteen out of 47 patients (40%) revealed significant bacterial growth (> or =10 colony forming units/mL). Eight additional patients (17%) would have reached the cutoff level after correction of the dilution effect, which varied between 1.8- and 130-fold.

CONCLUSIONS

Data suggest a great variation of dilution during BAL procedures, which influences quantitative results. Using urea to determine the dilution quotient could increase the value of bacterial thresholds in the diagnosis and therapeutic decision of ventilator-associated pneumonia.

ASSOCIATION OF CYTOMEGALOVIRUS DNA CONCENTRATION IN EPITHELIAL LINING FLUID AND SYMPTOMATIC CYTOMEGALOVIRUS INFECTION IN LUNG TRANSPLANT RECIPIENTS

BACKGROUND

The authors have investigated the effectiveness of virus detection from bronchoalveolar lavage (BAL) samples for the identification of symptomatic cytomegalovirus (CMV) infection in lung transplant recipients.

METHODS

Thus, 275 BAL samples taken from 105 lung transplant recipients during follow-up were analyzed by quantitative polymerase chain reaction (PCR) and virus isolation.

RESULTS

Quantitative PCR detected virus in all 24 BAL samples taken at onset of symptomatic disease, and virus culture in only 7 samples (29.2%). Twenty-three of 251 BAL samples (9.2%) were positive by PCR, although they were obtained in an asymptomatic phase. Quantitation of CMV DNA from BAL allowed no discrimination between symptomatic and asymptomatic infection in individual cases. However, when the urea dilution method was used to recalculate the CMV DNA concentration for the epithelial lining fluid (ELF) diluted in the BAL, a CMV DNA level of more than 10 copies/mL ELF was clearly associated with symptomatic disease.

CONCLUSION

The CMV DNA level in ELF may be a marker for symptomatic CMV infection.

Pacemaker endocarditis due to Propionibacterium acnes

Propionibacterium acnes belongs to the cutaneous flora of humans; it is often considered to be contaminant but has also been found to be a pathogen in human diseases. It is an uncommon causal agent in infective endocarditis and appears to have a predilection for prosthetic valves and foreign bodies. We describe a case of pacemaker endocarditis which shows that so-called harmless bacteria like P. acnes must be considered to be potential pathogens.

Omeprazole treatment diminishes intra- and extracellular neutrophil reactive oxygen production and bactericidal activity

OBJECTIVE

Neutrophils play a crucial role in host defense against infectious disease. The objective was to analyze the effect of omeprazole treatment on indexes of neutrophil function in healthy subjects.

DESIGN

Open.

SETTING

University hospital.

SUBJECTS

Ten healthy subjects.

INTERVENTION

Analysis of blood samples before and after omeprazole administration.

MEASUREMENTS AND MAIN RESULTS

Neutrophil Escherichia coli phagocytosis was assessed by microscopy and flow cytometry. Intracellular production of reactive oxygen intermediates was measured by flow cytometry. Extracellular reactive oxygen intermediate production was assessed with a cytochrome c reduction assay. Neutrophil bactericidal capacity and intracellular concentrations of Ca2+ were determined by fluorometry. Four hours after a single 40-mg dose of omeprazole, intra- and extracellular reactive oxygen intermediate production by neutrophils was significantly reduced compared with pretreatment values: -30% (24% to 42%) (median and range) and -22% (21% to 68%; p <.05 for both). The intracellular Ca2+ concentrations in resting neutrophils were significantly increased (+33%, 21% to 39%, compared with pretreatment concentrations, p <.001) and neutrophilic bactericidal activity was decreased (-30%, 19% to 47%, compared with pretreatment concentrations, p <.0001). Intracellular Ca2+ concentrations correlated with intracellular reactive oxygen intermediate production and neutrophilic bactericidal capacity (r =.730 and r =.618, p <.05 for both, respectively). In contrast, phagocytosis rates were not impaired by omeprazole.

CONCLUSIONS

Our results imply that omeprazole impairs production of reactive oxygen intermediates by neutrophils. Whether specific impairments of neutrophil host defenses occur in vivo remains uncertain. Reduced bactericidal activity is associated with an increase of intracellular Ca2+ concentrations in resting neutrophils.

Prosthetic valve endocarditis due to Candida tropicalis complicated by multiple pseudoaneurysms

Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. We describe a case of prosthetic valve endocarditis due to Candida tropicalis, complicated by multiple pseudoaneurysms.

Severe hemolytic anemia and excessive leukocytosis masking mycoplasma pneumonia

The formation of cold agglutinins is frequently observed during Mycoplasma pneumoniae infections. Nevertheless, severe hemolysis is exceptional. We report a case of life-threatening hemolytic anemia caused by M. pneumoniae. As the leucocyte count was excessively elevated, the differential diagnosis primarily comprised hematological malignancies. The presence of cold agglutinins indicated the correct diagnosis, which was confirmed by highly elevated levels of both IgG and IgM antibodies to M. pneumoniae and a chest X-ray suggestive of atypical pneumonia. The patient was treated with roxithromycin and showed a favorable recovery within ten days after admission. This case demonstrates that, even in patients with clinically mild pneumonia, M. pneumoniae may be the cause of severe anemia.

Intestinal tuberculosis presenting as fever of unknown origin in a heart transplant patient

Patients undergoing transplantation have an increased risk of developing infections such as tuberculosis, Pneumocystis carinii pneumonia, Candida infections or cytomegalovirus infections because of their immunosuppressive therapy with cyclosporin A, azathioprine and steroids. Mycobacterial infection is well recognized as a complication in the immunocompromised host but diagnosis and therapy are very difficult.

Prospective randomized comparison of cefodizime versus cefuroxime for perioperative prophylaxis in patients undergoing coronary artery bypass grafting

The effects of cefodizime and cefuroxime on neutrophil phagocytosis and reactive oxygen production in 54 patients undergoing elective coronary artery bypass grafting were studied. Both drugs were administered twice at a dosage of 40 mg/kg of body weight (pre- and intraoperative). Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labeled Escherichia coli and Staphylococcus aureus by flow cytometry. Reactive oxygen generation after phagocytosis was estimated by determining the amount of dihydrorhodamine 123 converted to rhodamine 123 intracellularly. In both groups the mean phagocytic ability for E. coli and S. aureus decreased during surgery (-21 and -8%, respectively, for the cefodizime group and -39 and -38%, respectively, for the cefuroxime group; P < 0.05 for all). In the cefodizime group a normalization of mean E. coli and S. aureus neutrophil phagocytosis was seen on day 5 (+9 and -4% compared to preoperative values; P > 0.35 for both), whereas in cefuroxime-treated patients phagocytic ability remained depressed (-37 and -31%; P < 0.04 for both). In both groups mean neutrophil reactive oxygen intermediate (ROI) production after E. coli and S. aureus phagocytosis increased during cardiopulmonary bypass (+44 and +83%, respectively, in the cefodizime group and +58 and +73%, respectively, in the cefuroxime group; P < 0.05 for all). One day after surgery E. coli- and S. aureus-driven neutrophil ROI production was not different from the preoperative values (-2 and +12%, respectively, for the cefodizime group and +7 and +15%, respectively, for the cefuroxime group; P > 0.15 for all). Postoperative serum levels of the C-reactive protein on days 2 and 7 were lower in cefodizime-treated patients (19 +/- 6 and 4 +/- 2 mg/liter versus 23 +/- 6 and 11 +/- 5 mg/liter; P < 0.05 for both). In addition to cefodizime's antimicrobial activity during perioperative prophylaxis, its use in coronary artery bypass grafting can prevent procedure-related prolonged postoperative neutrophil phagocytosis impairment.

Rapid susceptibility testing of fungi by flow cytometry using vital staining

A 1-h assay for antifungal susceptibility testing measuring the impairment of fungal metabolic activity was developed. Yeast viability was analyzed by flow cytometry with a novel fluorescent probe, FUN-1, which emits a red fluorescence when the yeast is metabolically active. For nine Candida albicans strains tested, this method yielded results comparable to those obtained by the standard M27 procedure for amphotericin B, flucytosine, fluconazole, and ketoconazole. Whether the flow cytometry antifungal susceptibility test results correlate with the in vivo activities of the drugs remains to determined.

Effect of single oral dose of azithromycin, clarithromycin, and roxithromycin on polymorphonuclear leukocyte function assessed ex vivo by flow cytometry

Azithromycin was given as a single oral dose (20 mg/kg of body weight) to 12 volunteers in a crossover study with roxithromycin (8 to 12 mg/kg) and clarithromycin (8 to 12 mg/kg). Flow cytometry was used to study the phagocytic functions and the release of reactive oxygen products following phagocytosis by neutrophil granulocytes prior to administration of the three drugs, 16 h after azithromycin administration, and 3 h after clarithromycin and roxithromycin administration. Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labeled bacteria. Reactive oxygen generation after phagocytosis of unlabeled bacteria was estimated by the amount of dihydrorhodamine 123 converted to rhodamine 123 intracellularly. Azithromycin resulted in decreased capacities of the cells to phagocytize Escherichia coli (median [range], 62% [27 to 91%] of the control values; P < 0.01) and generate reactive oxygen products (75% [34 to 26%] of the control values; P < 0.01). Clarithromycin resulted in reduced phagocytosis (82% [75 to 98%] of control values; P < 0.01) but did not alter reactive oxygen production (84% [63 to 113%] of the control values; P > 0.05). Roxithromycin treatment did not affect granulocyte phagocytosis (92% [62 to 118%] of the control values; P > 0.05) or reactive oxygen production (94% [66 to 128%] of the control value; P > 0.05). No relation between intra- and/or extracellular concentrations of azithromycin and/or roxithromycin and the polymorphonuclear phagocyte function and/or reactive oxygen production existed (P > 0.05 for all comparisons). These results demonstrate that the accumulation of macrolides in neutrophils can suppress the response of phagocytic cells to bacterial pathogens after a therapeutic dose.

Quinolones in gastrointestinal infections

Fluoroquinolones are efficient antimicrobial drugs for the treatment of enteric fever, shigellosis, Escherichia coli diarrhea, cholera, and traveler's diarrhea. They also play a role in the therapy of yersiniosis, campylobacteriosis, and intestinal salmonellosis. A single dose of quinolones has been effective in the treatment of traveler's diarrhea and cholera. Uncomplicated typhoid fever was cured by norfloxacin, pefloxacin, and ofloxacin 400 mg twice daily (b.i.d.) for 7-14 days or ciprofloxacin 500 mg b.i.d. for 10 days. A single daily dose of 400 mg fleroxacin for 3 days has been shown to be effective in this indication. A few reports suggest that the newer quinolones can eliminate the carrier state. The efficacy of quinolones in the prophylaxis and treatment of intra-abdominal infections following abdominal surgery requires further investigation.