Infect. Dis. Rep., Volume 14, Issue 3 (June 2022) – 19 articles

Background: Coronavirus disease is a pandemic that has disrupted many human lives, threatening people’s physical and mental health. Each pandemic wave struck in different ways, infectiveness-wise and mortality-wise. This investigation focuses on critically ill patients affected by the last two variants, Delta and Omicron, and aims to analyse if any difference exists between the two groups. Methods: intensive care unit (ICU) COVID-19 consecutive admissions between 1 October 2021 and 31 March 2022 were recorded daily, and data concerning the patients’ demographics, variants, main comorbidities, ICU parameters on admission, and the outcome were analysed by a univariate procedure and by a multivariate analysis. Results: 65 patients were enrolled, 31 (47.69%) belonging to the Omicron versus 34 (52.31%) to the Delta group. The mortality rate was 52.94% for the Omicron group versus 41.9% for the Delta group. A univariate analysis showed that the Omicron variant was associated with total comorbidities number, Charlson Comorbidity Index (CCI), pre-existing pulmonary disease, vaccination status, and acute kidney injury (AKI). In stepwise multivariate analysis, the total number of comorbidities was positively associated with the Omicron group, while pulmonary embolism was negatively correlated with the Omicron group. Conclusion: Omicron appears to have lost some of the hallmarks of the Delta variant, such as endothelialitis and more limited cellular tropism when it comes to the patients in the ICU. Further studies are encouraged to explore different therapeutic approaches to treat critical patients with COVID-19. Full article

Crusted scabies is a rare form of scabies that presents with more severe symptoms than those of classic scabies. It is characterized by large crusted lesions, extensive scales, thick hyperkeratosis, and contains a large number of highly contagious itch mites. Crusted scabies is more prevalent in immunocompromised, malnourished, and disabled individuals. This disease has been linked to a variety of health problems, including delayed diagnosis, infection risk, and high mortality, mainly from sepsis, and it has the potential to cause an outbreak due to its hyper-infestation, which makes it highly infectious. This article reports three cases of crusted scabies in North Sulawesi, Indonesia. Recent updates and a comprehensive review of the literature on the disease are also included, emphasizing the critical importance of early diagnosis and effective medical management of patients, which are necessary to prevent the complications and spread in communities. Full article

Background: One of the main challenges in the management of COVID-19 patients is to early assess and stratify them according to their risk of developing severe pneumonia. The alveolar–arterial oxygen gradient (D(A-a)O₂) is defined as the difference between the alveolar and arteriolar concentration of oxygen, an accurate index of the ventilatory function. The aim of this study is to evaluate D(A-a)O₂ as a marker for predicting severe pneumonia in COVID-19 patients, in comparison to the PaO₂/FiO₂. Methods: This retrospective, multicentric cohort study included COVID-19 patients admitted to two Italian hospitals between April and July 2020. Clinical and laboratory data were retrospectively collected at the time of hospital admission and during hospitalization. The presence of severe COVID-19 pneumonia was evaluated, as defined by the Infectious Diseases Society of America (IDSA) criteria for community-acquired pneumonia (CAP). Patients were divided in severe and non-severe groups. Results: Overall, 53 COVID-19 patients were included in the study: male were 30/53 (57%), and 10/53 (19%) had severe pneumonia. Patients with severe pneumonia reported dyspnea more often than non-severe patients (90% vs. 39.5%; p = 0.031). A history of chronic obstructive pulmonary disease (COPD) was recalled by 5/10 (50%) patients with severe pneumonia, and only in 6/43 (1.4%) of non-severe cases (p = 0.023). A ROC curve, for D(A-a)O₂ >60 mmHg in detecting severe pneumonia, showed an area under the curve (AUC) of 0.877 (95% CI: 0.675–1), while the AUC of PaO₂/FiO₂ < 263 mmHg resulted 0.802 (95% CI: 0.544–1). D(A-a)O₂ in comparison to PaO₂/FiO₂ had a higher sensibility (77.8% vs. 66.7%), positive predictive value (75% vs. 71.4%), negative predictive value (94% vs. 91%), and similar specificity (94.4% vs. 95.5%). Conclusions: Our study suggests that the D(A-a)O₂ is more appropriate than PaO₂/FiO₂ to identify COVID-19 patients at risk of developing severe pneumonia early. Full article

Using new and original nineteenth-century sources, we analysed the epidemiology, clinical features and virology of the 1889 pandemic, which was referred to at the time as ‘Russian flu’ or ‘Asiatic flu’. However, we rejected this identification of the disease as an ‘influenza’, which we believe to have been based on insufficient knowledge of the causative agent and instead posit that the pandemic was caused by a coronavirus. We provide a new account of the 1889–1893 pandemic, with a more detailed chronology that included at least four epidemiological waves. At the end of 1889, a new virus appeared in Europe, which could be identified as the coronavirus HCoV-OC43, causing crude death rates of 1.3 per 1000 population in St Petersburg; 2.1 per 1000 in Paris; 2.8 per 1000 in Bilbao and on the French–Spanish border; between 2.9 and 5.2 per 1000 in small towns in the Basque Country; and 5.8 deaths per 1000 in Madrid, which had the highest death rate. The clinical features of the disease differed from classical influenza pandemics in terms of the latency phase, duration, symptomatology, convalescence, immunity, age and death rates. Another factor to be considered was the neurotropic capacity of the disease. The most frequent form of the 1889 pandemic was the ‘nervous form’, with specific symptoms such as ‘heavy headache’ (céphalalgie gravative), tiredness, fever and delirium. There are strong parallels between the 1889–1894 pandemic and the COVID-19 pandemic, and a better understanding of the former may therefore help us to better manage the latter. Full article

Coronavirus disease 2019 (COVID-19) and tuberculosis (TB) are currently the two leading causes of death among infectious diseases. As we progress towards a “new normal”, more information is required regarding post-COVID-19 syndromes. We present a case of latent tuberculosis reactivation 3 months after a successful inpatient treatment of COVID-19. A 74-year-old female from the Philippines presented with a new left mid-lung infiltrate with worsening shortness of breath and lethargy for one week prior to admission. The clinical course of the patient deteriorated despite broad-spectrum antibiotics, diuretics, and high-dose steroid therapy requiring intubation and mechanical ventilation. Her sputum culture yielded the microbiological diagnosis of TB. Anti-tubercular medications were started and the patient had a favorable clinical outcome. Our case demonstrates that immunosuppression secondary to COVID-19 and its treatments may promote the development of an active TB infection from a latent infection. It is important to be aware of this potential increase in risk during and after a COVID-19 treatment. This is especially important in high-risk populations to ensure an early diagnosis and prompt management as well as to reduce transmission. Full article

Ovarian cancer (OC) is a gynecological malignancy characterized by high morbidity and mortalities due to late-stage diagnosis because accurate early diagnostic biomarkers are lacking. Testing of Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Human immunodeficiency virus (HIV) infections in OC patients is pertinent in light of the emerging evidence of their contribution to poor prognosis. We, for the first time, investigated the prevalence of HBV, HCV, and HIV infections in a Kenyan cohort of OC to inform optimal management. We recruited a cohort of women above 18 years of age, comprising 86 OC patients and 50 healthy controls. Participants’ blood samples were serologically screened for HBV, HCV, and HIV. We found seroprevalence rates of 29.1%, 26.7%, and 1.2% for HBV, HIV, and HCV, respectively, in OC patients. The healthy control group had HBV and HIV seroprevalence rates of 3.9% for each with no positive HCV case. HBV/HIV coinfection was noted only in the OC group with a positivity rate of 17.4%. In summary, we found higher HBV and HIV seroprevalence in Kenyan OC patients compared to the healthy control group, whereas HCV prevalence was reflective of the general population. Hence, we recommend screening for HBV and HIV among OC patients destined for anticancer treatment. Full article

Multisystem inflammatory syndrome in children (MIS-C) may develop as a rare complication following COVID-19. MIS-C presentation varies substantially, but fever and gastrointestinal symptoms are the most prominent. Indeed, gastrointestinal involvement may be severe enough to present as acute abdomen, posing challenges to clinicians. We present herein the case of a healthy five-year-old male who presented with fever, vomiting, and abdominal pain, resembling acute abdomen. The patient had no history of SARS-CoV-2 infection or exposure, and MIS-C diagnosis was initially surpassed unnoticed. The patient underwent exploratory laparotomy that only revealed mesenteric lymphadenitis. Postoperatively, the patient met the clinical and laboratory diagnostic criteria of MIS-C. SARS-CoV-2 exposure was serologically confirmed and MIS-C treatment was commenced, resulting in defervescence and a satisfactory outcome. In young patients presenting with acute abdomen, surgeons should be aware of MIS-C, so that earlier diagnosis and appropriate treatment are made prior to surgical interventions. Full article

Healthcare associated meningitis and ventriculitis (HCAMV) are serious complications of neurosurgical procedures. We conducted a retrospective cohort study of patients with HCAMV treated at the University Hospital for Infectious Diseases Zagreb during the 2013–2019 period. A total of 144 patients with 151 episodes of HCAMV were included. The most common indications for neurosurgical procedures were brain tumor, hemorrhage and hydrocephalus. Etiology was identified in 90 (59.6%) episodes (either positive CSF culture or positive PCR), and in other 61 (40.39%) the diagnosis of HCAMV was made based on clinical and CSF parameters, without microbiologic confirmation. Carbapenem-resistant Acinetobacter baumannii was the most common pathogen (15.89%), followed by Staphylococcus aureus (13.91%), Pseudomonas aeruginosa (13.25%) and Coagulase negative staphylococci (7.95%). Overall, 24 (16.3%) patients died, and the majority had adverse outcomes, persistent vegetative state (8, 5.56%) and severe disability (31, 21.53%). The worst clinical outcomes were observed in A. baumannii infections. High rate of complications, the need for external ventricular drainage (re)placement often complicated with nosocomial infections and prolonged stay in intensive care units were observed. Clinicians should be aware of local microbial epidemiology on guiding proper empirical antimicrobial treatment in patients with HCAMV. Full article

Warm autoimmune hemolytic anemia (AIHA) is a rare complication of COVID-19 infection. We report a case of warm AIHA in a patient with COVID-19 pneumonia treated with methylprednisolone and several red blood cell transfusions. Despite treatment of the warm AIHA, the patient’s reticulocyte count remained low, and his biochemical markers were suggestive of pure red cell aplasia, which was later attributed to a concurrent parvovirus B19 infection. This case highlights an unusual situation of two separate hematological processes caused by two separate and simultaneous viral infections. Full article

Small islands have been considered at an advantage when dealing with infectious diseases, including COVID-19, but the evidence is still lacking. Crude mortality rates (CMRs) and excess mortality rates (EMRs) were calculated for 35 municipalities on the Italian small islands for 2020 and 2021, and the corresponding estimates were compared to those of the parent provinces and the national estimates. Notification rates for COVID-19 were retrieved, but detailed data at the municipality level were not available. A relatively low CMR (1.069 per 100 per year, 95% confidence interval [95% CI] 0.983–1.164) was identified in 2020, compared to 1.180, 95% CI 1.098–1.269 for 2021. EMRs of small islands ranged between −25.6% and +15.6% in 2020, and between −13.0% and +20.9% in 2021, with an average gain of +0.3% (95% CI −5.3 to +5.8) for the entirety of the assessed timeframe, and no substantial differences between 2020 and 2021 (pooled estimates of −4.1%, 95% CI −12.3 to 4.1 vs. 4.6%, 95% CI −3.1 to 12.4; p = 0.143). When dealing with COVID-19 notification rates, during the first wave, parent provinces of Italian small islands exhibited substantially lower estimates than those at the national level. Even though subsequent stages of the pandemic (i.e., second, third, and fourth waves) saw a drastic increase in the number of confirmed cases and CMR, estimates from small islands remained generally lower than those from parent provinces and the national level. In regression analysis, notification rates and mortality in the parent provinces were the main effectors of EMRs in the small islands ($\mathsf{\beta }$ = 0.469 and $\mathsf{\beta }$ = 22.768, p < 0.001 and p = 0.007, respectively). Contrarily, the management of incident cases in hospital infrastructures and ICUs was characterized as a negative predictor for EMR ($\mathsf{\beta }$ = −11.208, p = 0.008, and −59.700, p = 0.003, respectively). In summary, the study suggests a potential role of small geographical and population size in strengthening the effect of restrictive measures toward countering the spread and mortality rate of COVID-19. Full article

Bacterial infections, especially those in hospital settings, represent a major complication of COVID-19 patients, complicating management and worsening clinical outcomes. Corynebacterium striatum is a non-diphtheric actinobacterium that has been reported as being the causative agent of several different infections, affecting both immunocompetent and immunocompromised patients. Recently, C. striatum has been recognized as a nosocomial pathogen that is responsible for severe infection in critical patients, as well as in fragile and immunocompromised subjects. C. striatum has been described as the etiological agent of bacteremia, central line infections, and endocarditis. We report a case of a 91-year-old woman who was hospitalized due to SARS-CoV-2 infection, who developed C. striatum bacteremia and died despite antimicrobial therapy and clinical efforts. Furthermore, we discuss C. striatum diagnosis and treatment based on evidence from the scientific literature. Full article

The use of immune suppressive drugs combined with the natural immune suppression caused by SARS-CoV-2 can lead to a surge of secondary bacterial and fungal infections. The aim of this study was to estimate the incidence of superinfections in hospitalized subjects with COVID-19. We carried out an observational retrospective single center cohort study. We enrolled patients admitted at the “Garibaldi” hospital for ≥72 h, with a confirmed diagnosis of COVID-19. All patients were routinely investigated for bacterial, viral, and fungal pathogens. A total of 589 adults with COVID-19 were included. A total of 88 infections were documented in different sites among 74 patients (12.6%). As for the etiology, 84 isolates were bacterial (95.5%), while only 4 were fungal (4.5%). A total of 51 episodes of hospital-acquired infections (HAI) were found in 43 patients, with a bacterial etiology in 47 cases (92.2%). Community-acquired infections (CAIs) are more frequently caused by Streptococcus pneumoniae, while HAIs are mostly associated with Pseudomonas aeruginosa. A high rate of CAIs and HAIs due to the use of high-dose corticosteroids and long hospital stays can be suspected. COVID-19 patients should be routinely evaluated for infection and colonization. More data about antimicrobial resistance and its correlation with antibiotic misuse in COVID-19 patients are required. Full article

Two years have passed since WHO declared a pandemic state for SARS-CoV-2 infection. COVID-19 pathogenesis consists of a first viral phase responsible for early symptoms followed by an inflammatory phase, cytokine-mediated, responsible for late-onset manifestations up to ARDS. The dysregulated immune response has an outstanding role in the progression of pulmonary damage in COVID-19. IL-6, through the induction of pro-inflammatory chemokines and cytokines, plays a key role in the development and maintenance of inflammation, acting as a pioneer of the hyperinflammatory condition and cytokine storm in severe COVID-19. Therefore, drugs targeting both IL-6 and IL-6 receptors have been evaluated in order to blunt the abnormal SARS-CoV-2-induced cytokine release. Sarilumab, a high-affinity anti-IL-6 receptor antibody, may represent a promising weapon to treat the fearsome hyperinflammatory phase by improving the outcome of patients with moderate-to-severe COVID-19 pneumonia. Further prospective and well-designed clinical studies with larger sample sizes and long-term follow-up are needed to assess the efficacy and the safety of this therapeutic approach to achieve improved outcomes in COVID-19. Full article

Construction activities in healthcare settings potentially expose building occupants to waterborne pathogens including Legionella and have been associated with morbidity and mortality. A Water Management for Construction—Infection Control Risk Assessment (WMC-ICRA) tool was developed addressing gaps in building water management programs. This enables healthcare organizations to meet the requirements of ANSI/ASHRAE Standard 188 referenced in numerous guidelines and regulations. A WMC-ICRA was modeled after the ICRA required for prevention and control of airborne pathogens to reduce the risk of healthcare associated infections. The tool allows users to evaluate risk from waterborne pathogen exposure by analyzing construction activities by project category and building occupant risk group. The users then select an appropriate level of risk mitigation measures. Technical aspects (e.g., water age/stagnation, flushing, filtration, disinfection, validation testing), are presented to assist with implementation. An exemplar WMC-ICRA tool is presented as ready for implementation by infection prevention and allied professionals, addressing current gaps in water management, morbidity/mortality risk, and regulatory compliance. To reduce exposure to waterborne pathogens in healthcare settings and improve regulatory compliance, organizations should examine the WMC-ICRA tool, customize it for organization-specific needs, while formulating an organizational policy to implement during all construction activities. Full article

The end of the acute phase of the COVID-19 pandemic is near in some countries as declared by World Health Organization (WHO) in January 2022 based on some studies in Europe and South Africa despite unequal distribution of vaccines to combat the disease spread globally. The heterogeneity in individual age and the reaction to biological and environmental changes that has been observed in COVID-19 dynamics in terms of different reaction to vaccination by age group, severity of infection per age group, hospitalization and Intensive Care Unit (ICU) records show different patterns, and hence, it is important to improve mathematical models for COVID-19 pandemic prediction to account for different proportions of ages in the population, which is a major factor in epidemic history. We aim in this paper to estimate, using the Usher model, the lifespan loss due to viral infection and ageing which could result in pathological events such as infectious diseases. Exploiting epidemiology and demographic data firstly from Cameroon and then from some other countries, we described the ageing in the COVID-19 outbreak in human populations and performed a graphical representation of the proportion of sensitivity of some of the model parameters which we varied. The result shows a coherence between the orders of magnitude of the calculated and observed incidence numbers during the epidemic wave, which constitutes a semi-quantitative validation of the mathematical modelling approach at the population level. To conclude, the age heterogeneity of the populations involved in the COVID-19 outbreak needs the consideration of models in age groups with specific susceptibilities to infection. Full article

We present a brief commentary illustrating the current COVID-19 outpatient treatment options in Italy. We also report our experience setting up a service dedicated to these patients in the wake of the rise in COVID-19 cases observed in January 2022. We also gathered data on the daily costs faced by our outpatient service, based at a tertiary care center located in Florence, Italy. We present them with some considerations on future outlooks on the use of outpatient treatment in COVID-19. Full article

We performed a prospective longitudinal cohort study in two healthcare settings. In total, 909 HCWs out of 3982 (23.35%) were diagnosed with COVID-19 before the vaccination era. Eighty-five per cent of COVID-19 positive HCWs (n = 774) were asymptomatic or mild, and 15% were moderate or severe. The mean age of the infected HCWs in the moderate or severe group was higher than the mild or asymptomatic group (35.4 vs. 31.3 years, p < 0.001). Thirty-two per cent of HCWs were male and the rate of male gender was more frequent in the moderate/severe group (p = 0.009). The rate of those who have cardiovascular diseases (p = 0.003) and diabetes mellitus (p = 0.044) were significantly higher among the HCWs with moderate or severe COVID-19. In multivariate analysis, male gender (OR:1.65, CI:1.11–2.46, p = 0.013), BMI > 30 (OR: 1.9, CI: 1.09–3.51, p = 0.024), and being physician (OR: 2.56, CI:1.45–4.52, p = 0.001) were found to be associated with moderate or severe COVID-19. Full article

Unexpected outcomes are usually associated with interventions in complex systems. Excess winter mortality (EWM) is a measure of the net effect of all competing forces operating each winter, including influenza(s) and non-influenza pathogens. In this study over 2400 data points from 97 countries are used to look at the net effect of influenza vaccination rates in the elderly aged 65+ against excess winter mortality (EWM) each year from the winter of 1980/81 through to 2019/20. The observed international net effect of influenza vaccination ranges from a 7.8% reduction in EWM estimated at 100% elderly vaccination for the winter of 1989/90 down to a 9.3% increase in EWM for the winter of 2018/19. The average was only a 0.3% reduction in EWM for a 100% vaccinated elderly population. Such outcomes do not contradict the known protective effect of influenza vaccination against influenza mortality per se—they merely indicate that multiple complex interactions lie behind the observed net effect against all-causes (including all pathogen causes) of winter mortality. This range from net benefit to net disbenefit is proposed to arise from system complexity which includes environmental conditions (weather, solar cycles), the antigenic distance between constantly emerging circulating influenza clades and the influenza vaccine makeup, vaccination timing, pathogen interference, and human immune diversity (including individual history of host-virus, host-antigen interactions and immunosenescence) all interacting to give the observed outcomes each year. We propose that a narrow focus on influenza vaccine effectiveness misses the far wider complexity of winter mortality. Influenza vaccines may need to be formulated in different ways, and perhaps administered over a shorter timeframe to avoid the unanticipated adverse net outcomes seen in around 40% of years. Full article

Low serum albumin (SA) correlates with mortality in critically ill patients, including those with COVID-19. We aimed to identify SA thresholds to predict the risk of longer hospital stay, severe respiratory failure, and death in hospitalized adult patients with COVID-19 pneumonia. A prospective longitudinal study was conducted at the Infectious Diseases Unit of Trieste University Hospital (Italy) between March 2020 and June 2021. The evaluated outcomes were: (1) need of invasive mechanical ventilation (IMV); (2) length of hospital stay (LOS); and (3) 90-day mortality rate. We enrolled 864 patients. Hypoalbuminemia (<3.5 g/dL) was detected in 586 patients (67.8%). SA on admission was significantly lower in patients who underwent IMV (2.9 vs. 3.4 g/dL; p < 0.001). The optimal SA cutoff predicting the need of IMV was 3.17 g/dL (AUC 0.688; 95% CI: 0.618–0.759; p < 0.001) and this threshold appeared as an independent risk factor for the risk of IMV in multivariate Cox regression analysis. The median LOS was 12 days and a higher SA was predictive for a shorter LOS (p < 0.001). The overall 90-day mortality rate was 15%. SA was significantly lower in patients who died within 90 days from hospital admission (3.1 g/dL; IQR 2.8–3.4; p < 0.001) as compared to those who survived (3.4 g/dL; IQR 3.1–3.7). The optimal SA threshold predicting high risk of 90-day mortality was 3.23 g/dL (AUC 0.678; 95% CI: 0.629–0.734; p < 0.001). In a multivariate Cox regression analysis, SA of <3.23 g/dL appeared to be an independent risk factor for 90-day mortality. Our results suggest that low SA on admission may identify patients with COVID-19 pneumonia at higher risk of severe respiratory failure, death, and longer LOS. Clinicians could consider 3.2 g/dL as a prognostic threshold for both IMV and mortality in hospitalized COVID-19 patients. Full article