Acute Kidney Injury in Patients with COVID – 19 Infection: Α Tertiary Referral Hospital Experience

The emersion of the new coronavirus SARS COV 2 (Severe Acute Respiratory SyndromeCoronavirus 2) was rapidly characterized as a pandemic by WHO. The majormanifestation of the virus is respiratory distress; however, the involvement of other organsshould not be overlooked. The kidney is one of the most important target organsof the specific virus with acute kidney injury (AKI) described in 5-36% of COVIDpositive patients and an average 25% within the severely ill.Purp ose: The purpose of this study was to consider the incidence of AKI in patientswith COVID 19 in our cohort and to better understand risk factors associated withAKI. Further, we wanted to investigate the impact of AKI on survival and in hospitalmortality.Methods: Patients admitted to Evagelismos General Hospital with confirmed COVID-19 infection from 11th March until 22th May were investigated. Patients 18 yearsold as well as transplanted patients were excluded from this study. AKI was definedaccording to the AKI criteria.Results : From 99 patients with COVID-19 infection, AKI occurred in 41 (41.4%).A total of 44 patients (44.4%) were admitted to Intensive Care Unit (ICU) and 31 ofthem (70.5%) developed AKI. Of the 44 patients with AKI, 16 (39%) required renalreplacement therapy. Hospital mortality, in total, was 16.2% (37% among patientswith AKI versus 0.02% among those without AKI, p=0.000).Conclusion: AKI was common among patients hospitalized with COVID 19. AKIwas associated with older age, clinical severity and existing CKD

Relationship between ventilator-associated pneumonia and mortality in COVID-19 patients: a planned ancillary analysis of the coVAPid cohort

Background Patients with SARS-CoV-2 infection are at higher risk for ventilator-associated pneumonia (VAP). No study has evaluated the relationship between VAP and mortality in this population, or compared this relationship between SARS-CoV-2 patients and other populations. The main objective of our study was to determine the relationship between VAP and mortality in SARS-CoV-2 patients. Methods Planned ancillary analysis of a multicenter retrospective European cohort. VAP was diagnosed using clinical, radiological and quantitative microbiological criteria. Univariable and multivariable marginal Cox's regression models, with cause-specific hazard for duration of mechanical ventilation and ICU stay, were used to compare outcomes between study groups. Extubation, and ICU discharge alive were considered as events of interest, and mortality as competing event. Findings Of 1576 included patients, 568 were SARS-CoV-2 pneumonia, 482 influenza pneumonia, and 526 no evidence of viral infection at ICU admission. VAP was associated with significantly higher risk for 28-day mortality in SARS-CoV-2 group (adjusted HR 1.65 (95% CI 1.11-2.46), p = 0.013), but not in influenza (1.74 (0.99-3.06), p = 0.052), or no viral infection groups (1.13 (0.68-1.86), p = 0.63). VAP was associated with significantly longer duration of mechanical ventilation in the SARS-CoV-2 group, but not in the influenza or no viral infection groups. VAP was associated with significantly longer duration of ICU stay in the 3 study groups. No significant difference was found in heterogeneity of outcomes related to VAP between the 3 groups, suggesting that the impact of VAP on mortality was not different between study groups. Interpretation VAP was associated with significantly increased 28-day mortality rate in SARS-CoV-2 patients. However, SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, did not significantly modify the relationship between VAP and 28-day mortality

a retrospective multicenter study

Funding This study was supported in part by a grant from the French government through the « Programme Investissement d’Avenir» (I-SITE ULNE) managed by the Agence Nationale de la Recherche (coVAPid project). Prof. Ignacio Martin-Loeches has been supported by SFI (Science Foundation Ireland), Grant number 20/COV/0038. The funders of the study had no role in the study design, data collection, analysis or interpretation, writing of the report or deci sion to submit for publication.BACKGROUND: Ventilator-associated pneumonia (VAP) is common in patients with severe SARS-CoV-2 pneumonia. The aim of this ancillary analysis of the coVAPid multicenter observational retrospective study is to assess the relationship between adjuvant corticosteroid use and the incidence of VAP. METHODS: Planned ancillary analysis of a multicenter retrospective European cohort in 36 ICUs. Adult patients receiving invasive mechanical ventilation for more than 48 h for SARS-CoV-2 pneumonia were consecutively included between February and May 2020. VAP diagnosis required strict definition with clinical, radiological and quantitative microbiological confirmation. We assessed the association of VAP with corticosteroid treatment using univariate and multivariate cause-specific Cox's proportional hazard models with adjustment on pre-specified confounders. RESULTS: Among the 545 included patients, 191 (35%) received corticosteroids. The proportional hazard assumption for the effect of corticosteroids on the incidence of VAP could not be accepted, indicating that this effect varied during ICU stay. We found a non-significant lower risk of VAP for corticosteroid-treated patients during the first days in the ICU and an increased risk for longer ICU stay. By modeling the effect of corticosteroids with time-dependent coefficients, the association between corticosteroids and the incidence of VAP was not significant (overall effect p = 0.082), with time-dependent hazard ratios (95% confidence interval) of 0.47 (0.17-1.31) at day 2, 0.95 (0.63-1.42) at day 7, 1.48 (1.01-2.16) at day 14 and 1.94 (1.09-3.46) at day 21. CONCLUSIONS: No significant association was found between adjuvant corticosteroid treatment and the incidence of VAP, although a time-varying effect of corticosteroids was identified along the 28-day follow-up.publishersversionpublishe

a planned ancillary analysis of the coVAPid cohort

Funding: This study was supported in part by a grant from the French government through the «Programme Investissement d’Avenir» (I-SITE ULNE) managed by the Agence Nationale de la Recherche (coVAPid project). The funders of the study had no role in the study design, data collection, analysis, or interpreta tion, writing of the report, or decision to submit for publication.BACKGROUND: Patients with SARS-CoV-2 infection are at higher risk for ventilator-associated pneumonia (VAP). No study has evaluated the relationship between VAP and mortality in this population, or compared this relationship between SARS-CoV-2 patients and other populations. The main objective of our study was to determine the relationship between VAP and mortality in SARS-CoV-2 patients. METHODS: Planned ancillary analysis of a multicenter retrospective European cohort. VAP was diagnosed using clinical, radiological and quantitative microbiological criteria. Univariable and multivariable marginal Cox's regression models, with cause-specific hazard for duration of mechanical ventilation and ICU stay, were used to compare outcomes between study groups. Extubation, and ICU discharge alive were considered as events of interest, and mortality as competing event. FINDINGS: Of 1576 included patients, 568 were SARS-CoV-2 pneumonia, 482 influenza pneumonia, and 526 no evidence of viral infection at ICU admission. VAP was associated with significantly higher risk for 28-day mortality in SARS-CoV-2 (adjusted HR 1.70 (95% CI 1.16-2.47), p = 0.006), and influenza groups (1.75 (1.03-3.02), p = 0.045), but not in the no viral infection group (1.07 (0.64-1.78), p = 0.79). VAP was associated with significantly longer duration of mechanical ventilation in the SARS-CoV-2 group, but not in the influenza or no viral infection groups. VAP was associated with significantly longer duration of ICU stay in the 3 study groups. No significant difference was found in heterogeneity of outcomes related to VAP between the 3 groups, suggesting that the impact of VAP on mortality was not different between study groups. INTERPRETATION: VAP was associated with significantly increased 28-day mortality rate in SARS-CoV-2 patients. However, SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, did not significantly modify the relationship between VAP and 28-day mortality. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov, number NCT04359693.publishersversionpublishe

Immunogenetics elements of pulmonary tuberculosis

Pulmonary tuberculosis (PTB) remains the single largest infectious disease causing high mortality in humans leading to two million deaths annually. It is extremely interesting that ninety per cent of the people infected with the mycobacterium tuberculosis never develop the disease. Inherited genetic factors may at least in part explain why some people resist infection more successfully than others. We therefore evaluated the distribution of the human leukocyte antigens (HLA) since they influence antigen specific immune responses. Class II (DRB1 and DQB1) and Class I (A, B, Cw) gene polymorphisms were evaluated in 86 non-immunosuppressed unrelated Greek patients with pulmonary tuberculosis (PTB) as confirmed by the presence of acid-fast bacilli in sputum, along with clinical and radiographic criteria and 46 healthy unrelated people who did not have a history of PTB but where all tested PPD positive (>10mm). Allele and specific amino acid residue analysis demonstrated that the DRβ polymorphic residues N37 and K71 were independently and significantly increased among the PTB patients as compared to controls (N37: patients 39.5%, controls 17.3%, p=0.01), (K71: patients 25.5%, control 8.6%, p=0.022), suggesting a susceptibility role for these amino acids. Residues 71 and 37 participate in the formation of pocket 4, and 9 respectively and they may be functionally important and influence disease susceptibility. Furthermore the DQβ epitope F9 was significantly decreased in the patients and as such has a protective role. The increase of the DQβD57 residue among PTB Cambodian patients, previously reported, was not confirmed in our population. The analysis of the HLA class I typing results revealed that HLA-A E76S77 (patients: 11.6%, controls 26%, p=0.047) and HLA-R114 (patients 60%, controls 41,3%, p=0.04) were also important residues for both protection and susceptibility respectively. The differential distribution of these epitopes of susceptibility and protection and their interactive relationship in the PTB and control groups are discussed with respect to their potential influence on disease susceptibility.Το Μυκοβακτηρίδιο της Φυματίωσης (ΜΦ) έχει χαρακτηρισθεί ως ένα εκπληκτικά «έξυπνος» και «υψηλής» νοημοσύνης μικροοργανισμός με εξαιρετικά πλούσιο ερευνητικό ενδιαφέρον, αφού το 40% του γονιδιώματος του είναι αγνώστου λειτουργικής σημασίας αν και έχει προσβάλει το 30% του παγκόσμιου πληθυσμού. Παράγοντες που σχετίζονται με τις περιβαλλοντικές συνθήκες (όπως εγγύτητα και διάρκεια επαφής) καθώς και με την ευαισθησία ή την προδιάθεση και συνεπώς την γενετική σύσταση του ατόμου-ξενιστή, παίζουν σημαντικό ρόλο στη γένεση της λοίμωξης από το μυκοβακτηρίδιο της φυματίωσης. Η δυναμική αλληλεπίδραση μεταξύ του ξενιστή και του βακίλου που εκφράζεται διαμέσου της κυτταρικής ανοσολογική απάντησης, κατά την διάρκεια της λανθάνουσας κατάστασης αλλά και κατά τη φάση της ενεργού λοίμωξης αναζητήθηκε σε ογδόντα έξι ανοσοεπαρκείς ασθενείς ελληνικής καταγωγής με πνευμονική φυματίωση και σε 46 άτομα-μάρτυρες απολύτως φυσιολογικά (επίσης ελληνικής καταγωγής και με ηλικιακή αντιστοιχία) που όμως είχαν έρθει σε επαφή με το ΜΦ. Τον κεντρικό ρόλο στην κυτταρική ανοσολογική απάντηση σε εισβολής κάποιου αντίγονου, κατέχει το Μείζων Σύμπλεγμα Ιστοσυμβατότητας (MHC). Η τυποποίηση αυτού έδειξε κάποιες θέσεις-επιτόπους με ιδιαίτερη σημασία. Οι θέσεις αυτές είναι, οι HLA-DRβK71, -DRβN37, DQβF9 για τα τάξης ΙΙ και HLA-A E76S77, HLA-Α R114 για τα τάξης Ι αντίγονα. Οι θέσεις αυτές τόσο στα μόρια της τάξης ΙΙ όσο και της τάξης Ι δεν είναι τυχαίες. Η κρυσταλλογραφία του HLA-DR και HLA-Α μορίου τις εντοπίζει σε σημαντικούς και καθοριστικούς για τη λειτουργικότητα του μορίου δομικούς σχηματισμούς, που αποτελούν τις θέσεις δέσμευσης πεπτιδίων, και επαφής με το Τ κυτταρικό υποδοχέα. Η αυξημένη παρουσία των επιδεκτικών επιτόπων (HLA-DRβK71, -DRβN37, HLA-Α R114) στους πάσχοντες και των προστατευτικών (HLA-DQβF9, HLA-A ES76-77) στους μάρτυρες, εγείρει την σοβαρή πιθανότητα ότι η ανοσογενετική υπόσταση της νόσου αποτελεί έναν από τους κύριους λόγους αντοχής ή ευαισθησίας διαφόρων ατόμων στην πνευμονική φυματίωση

Current Issues in Fungal Infections and COVID-19

The COVID-19 pandemic has brought up a new host for fungal invasive infections [...

Acute generalized livedo racemosa caused by Capnocytophaga canimorsus identified by MALDI-TOF MS

Independent of the size of the dog and the type of injury, serious infections may follow a dog bite and these may result in the abrupt onset of multiorgan failure. Early recognition of the warning signs with regard to the underlying severity of the infection is of the utmost importance. Reticulate skin eruptions constitute a precursory phenomenon

189. Bacteremia among COVID-19 and Non-Covid-19 Patients Admitted in the ICU

BACKGROUND: The aim of this work were to investigate the rate and aetiology of bloodstream infection collected from COVID and non-COVID patients admitted in the ICU METHODS: A retrospective cohort study was conducted on PCR Covid-19 positive patients admitted in the ICU from 20th March to 30th April 2020. Corresponding data from the same period in 2019 collected of all consecutive patients admitted in the same ICU were retrospectively reviewed for the presence of microbiologically documented bloodstream infections at least 8 hours after admission. All patients in the cohort study were on mechanical ventilation, or at some point during their ICU admission required mechanical ventilation. RESULTS: We identified a total of 19 (38%) BSIs in the COVID-19 group and 10 (12%) BSI in the non-COVID-19 group (p=0,8). COVID-19 patients had an increased probability to develop ICU-BSI, at a median of 8 days of ICU admission as opposed to 6 in the non-COVID-19 group. Patients were comparable in terms of age, and APACHE II score. Out of 19 BSI CoVID-19 patients, 14 (73%) were male vs 5 (50%) in the non-CoVID-19 BSI patients (p=0.0007). Of all BSI-CoVID-19 patients, 7 cases (37%), 3 (16%), and 3(16%) had underlying diseases such as hypertension, diabetes, and obesity vs 1(9%), 0(0%), and 0 (0%) in the BSI-non CoVID-19 patients statistically significant at p=0.004, p=0.05, and p=0.05, respectively. ICU-acquired BSIs were mostly due to multi-drug-resistant pathogens. Clinical outcomes were statistically significantly different between patients with CoVid-19 BSI 7(37% ) and 2(20%)in BSI- non-CoVID-19 pneumonia (p=0.02). CONCLUSION: Our findings emphasize that although the incidence of BSI in CoVID-19 positive ICU admitted patients slightly increased their impact on overall outcome was significantly worse. Consequently, it is important to pay attention to bacterial superinfections in critical patients positive for COVID-19. DISCLOSURES: All Authors: No reported disclosure

Febrile Shock is not Always Septic

A 47-year-old woman with a history of poorly treated tachyarrhythmia was admitted to the intensive care unit (ICU) with hemodynamic instability of uncertain etiology. Two days earlier the patient presented at the Emergency Department of a rural hospital with febrile diarrhea of recent onset. The ECG showed rapid atrial fibrillation. She was initially admitted to the Internal Medicine ward and within 24 hours she developed high fever with signs of circulatory collapse, acute pulmonary edema and was subsequently intubated with a working diagnosis of septic shock. At the time of the ICU admission, the patient had already developed multi-organ dysfunction with renal insufficiency and liver failure. Right heart catheterization revealed a profile of high cardiac output with very low systemic vascular resistance. A high index of clinical suspicion led to the diagnosis of thyroid storm. Despite prompt initiation of the appropriate therapy and rigorous supportive care the patient died 9 days later due to disseminated intravascular coagulation and acute liver failure