Is empirical antibiotic treatment required in COVID-19 patients? What lessons have we learnt over the past 1 year?

Background: Secondary bacterial infections manifest during or after a viral infection(s) and can lead to negative outcomes and sometimes fatal clinical complications. The choice for an empiric antibiotic therapy requires a broad spectrum of activity against pathogens including beta-lactamase producing pathogens. Ceftriaxone+sulbactam+disodium EDTA is one of the antibiotic combinations used to prevent secondary infections. The objective was to evaluate rate of secondary bacterial infections in patients receiving empirical antibiotic therapy through retrospective analysis of data from a tertiary care center.Methods: A single center, retrospective analysis of data from hospital of COVID-19 patients treated in the ICU or wards was conducted. Patients who received empirical antibiotic therapy including ceftriaxone+sulbactam+disodium EDTA were included in the study.Results: 99 patients (mena age 75±9.89 years) were included in the retrospective analysis. Diabetes and hypertension were the most common comorbidities in the patients. The total WBC count was raised (12.36±9.01). All the biological markers were raised. 45% patients had abnormalities in chest X-ray. The mean CT severity index was 13.81±5.64. Bacterial superinfection was observed only in 1 patient.Conclusions: Bacterial co infections and secondary bacterial infections are a major risk factor for adverse COVID-19 outcomes. The use of appropriate prophylactic antibiotics such as ceftriaxone+sulbactam+disodium EDTA has significantly reduced the prevalence of secondary bacterial infections in patients with severe COVID.

Efficacy and safety of intravenous and/or oral levonadifloxacin in the management of secondary bacterial pulmonary infections in COVID-19 patients: findings of a retrospective, real-world, multi-center study

Background: Owing to dysregulated immune response, secondary bacterial pulmonary infections involving both gram-positive and gram-negative pathogens are common in COVID-19 patients and are often associated with higher mortality. This is a first ever report on the safety and efficacy of levonadifloxacin in the treatment of secondary bacterial pulmonary infections in patients with COVID-19 pneumonia.Methods: This multi-center, retrospective, post-marketing and real-world study assessed the safety and efficacy of IV and/or oral levonadifloxacin in the treatment of bacterial infections encountered in COVID-19 patients. Data for 154 male/female patients above 18 years of age who received levonadifloxacin (injectable and/or oral) was collected from 44 participating sites. Study outcomes were the clinical and microbial success at the end of therapy. Safety was assessed based on clinical and laboratory adverse events.Results: Among the 154 patients assessed, 121 (78.6%) were males and 142 (92.2%) were hospitalized. Majority of the patients (119) received all-IV therapy while 11 patients were prescribed with IV followed by oral regimen. All-oral therapy was received by 24 patients. The most common co-morbid conditions were diabetes (19.6%) and hypertension (19.2%). Post-treatment with levonadifloxacin, clinical and microbial success rates were 96.8% and 97.0% respectively.Conclusions: Levonadifloxacin showed promising safety and efficacy when used as IV and/or oral therapy for the treatment of secondary bacterial pulmonary infections in COVID-19 patients. Clinically relevant features of levonadifloxacin such as availability of both IV and oral options, broad spectrum coverage and reassuring safety in patients with significant co-morbidities could help simplify the management.Trial registration no. CTRI/2020/09/028152 [Registered on: 30/09/2020]

Complicated urinary tract infection with Extensive Drug resistant Klebsiella pneumoniae treated with combinatorial therapy of CSE-1034 along with Carbapenems. A case report and the review of literature

Colistin is considered one of the last available therapeutic options to treat infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP).However, with an increase in the use of colistin to treat CRKP infections, colistin resistance is emerging and there are no standard treatment regimensfor these type of infections. In the present case report, we are discussing a case of 64-year-old male patient having complicated urinary tract infection(cUTI) by CRKP, treated successfully with ceftriaxone+sulbactam+EDTA (CSE-1034) and carbapenem combination therapy. Conclusively, CSE-1034 incombination with or without carbapenems could be a successful therapeutic option for the treatment of CRKP cUTI cases

Upper extremity deep vein thrombosis

A 56-year-old female, recently (3 months) diagnosed with chronic kidney disease (CKD), on maintenance dialysis through jugular hemodialysis lines with a preexisting nonfunctional mature AV fistula made at diagnosis of CKD, presented to the hospital for a peritoneal dialysis line. The recently inserted indwelling dialysis catheter in left internal jugular vein had no flow on hemodialysis as was the right-sided catheter which was removed a day before insertion of the left-sided line. The left-sided line was removed and a femoral hemodialysis line was cannulated for maintenance hemodialysis, and the next day, a peritoneal catheter was inserted in the operation theater. However, 3 days later, there was progressive painful swelling of the left hand and redness with minimal numbness. The radial artery pulsations were felt. There was also massive edema of forearm, arm and shoulder region on the left side. Doppler indicated a steal phenomena due to a hyperfunctioning AV fistula for which a fistula closure was done. Absence of relief of edema prompted a further computed tomography (CT) angiogram (since it was not possible to evaluate the more proximal venous segments due to edema and presence of clavicle). Ct angiogram revealed central vein thrombosis for which catheter-directed thrombolysis and venoplasty was done resulting in complete resolution of signs and symptoms. Upper extremity DVT (UEDVT) is a very less studied topic as compared to lower extremity DVT and the diagnostic and therapeutic modalities still have substantial areas that need to be studied. We present a review of the present literature including incidences, diagnostic and therapeutic modalities for this entity. Data Sources: MEDLINE, MICROMEDEX, The Cochrane database of Systematic Reviews from 1950 through March 2011

Abdominal wall fungal co-infection mucormycosis associated with COVID-19: a case report.

The Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has posed a public health system challenge across the globe. A retrospective analysis of COVID-19 globally surmises that the fungal co-infections associated with COVID-19 might be missed or misdiagnosed. However, data regarding all the signs and symptoms of COVID-19 are insufficient. The available few publications conclude that patients with COVID-19 have a higher susceptibility to fungal coinfections. Mucormycosis is a rare and often lifethreatening fungal disease characterized by vascular invasion by hyphae, resulting in thrombosis and necrosis. Based on the available data it seems COVID-19 patients, especially severely ill or immunocompromised, have a higher susceptibility to invasive mycoses. Therefore, it is important to assess the risk factors, the types of invasive mycosis, the strengths and limitations of diagnostic methods, clinical settings, and the need for standard or individualized treatment in COVID-19 patients. A 33 years old female operated case of laparoscopic ectopic removal with salpingectomy and tubectomy, at post-operative Day 5 had redness and pus discharge from the operative site and was diagnosed with abdominal wall cellulitis. She underwent local exploration and wound wash. At post operative day 5, the patient came to our emergency room with mild disorientation, cellulitis, and pain at the port insertion site. On examination, we highlight BP 90/50 mmg and blood test analysis with HB-8.3, leucocyte count 29.91×109/L, CRP 333mg/L. CT scan revealed necrotizing fasciitis. She then underwent wide local excision and debridement. Post debridement the next day during dressing, the wound showed a cotton fluffy appearance at the edges and part of the base with black necrotic areas. Wound swab was sent for fungal culture, KOH mount, blood culture, pus culture, and tissue for histopathology. In the meantime, she was started on empirical antifungal amphotericin B, meropenem and minocycline antibiotics. Covid antibodies test was done which were reactive: 1.96. Tissue histopathology revealed mucormycosis. A high degree of suspicion and promptness in starting antifungal prevented fatal outcome

Indirect calorimetry versus usual care: a retrospective cohort study.

NTRODUCTION: : This is a study evaluating the effect of Indirect calorimetry on the length of stay. The study comprises of the comparison between the use of indirect calorimetry versus usual care in critically ill mechanically ventilated patients with respect to the length of stay in the intensive care unit, and duration of time on ventilator. Patients were divided on basis of their nutrition risk to study the effect of Indirect calorimetry on the length of stay. MATERIAL AND METHODS: This was a retrospective cohort study of 166 mechanical ventilated patients in S .L Raheja Hospital. Data was collected from 83 patients who were mechanically ventilated between January 2019 and November 2019 on whom indirect calorimetry was used to measure energy requirements. This cohort was compared to 83 patients between January 2018 and November 2918 where the energy requirements were calculated with the use of predictive equations. Both groups were matched for age, sex, comorbidities, APACHE score and use of vasopressors. RESULTS: Significant difference in the sicker group of patients was seen in the Length of stay in the intensive care unit. (9.23 ± 8.14 vs. 11.52 ± 5.65, p = 0.0034) Patients at risk for malnutrition demonstrated reduced length of time on ventilation as compared to those not at risk. (10.2 ± 11.01 vs. 13 ± 5.87; p = 0.0042). CONCLUSIONS: The use of indirect calorimetry may be associated with a lower length of ICU stay among ventilated patients in a reasonably sick group of mixed surgical patients

Higher vs. Lower Doses of Dexamethasone in Patients with COVID-19 and Severe Hypoxia (COVID STEROID 2) trial: protocol and statistical analysis plan.

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low-dose corticosteroids have proven clinical benefit in patients with severe COVID-19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID-19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID-19 is unclear. METHODS The COVID STEROID 2 trial is an investigator-initiated, international, parallel-grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID-19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all-cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health-related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol. DISCUSSION The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID-19 patients with severe hypoxia with important implications for patients, their relatives and society