PURPOSE:The pathogenesis of COVID-19, caused by the novel coronavirus SARS-CoV-2, is related to increased production of cytokines and a hyperinflammatory immune response.Elevated procalcitonin (PCT) in COVID-19 is considered a marker for the severity of the disease.Procalcitonin level rises in systemic inflammation especially bacterial in origin.However, there is no study available that reveals whether the elevated PCT in COVID -19 is associated with inflammation or superadded bacterial infection.Herein we aim to evaluate the association between Procalcitonin (PCT) levels and superadded bacterial infection in COVID-19 patients and also the effect of PCT-guided antibiotic de-escalation on patient outcomes.METHODS: This is a retrospective chart review of patients admitted with COVID-19 pneumonia at a single tertiary care center.We collected information on patient demographics, co-morbidities, PCT level, antibiotic use, culture results for bacterial infection, hospital length of stay (LOS), and mortality. RESULTS:We studied a total of 147 patients with COVID-19 pneumonia.101(69%) patients had a low PCT level (< 0.25ng/mL).Bacterial culture results were negative for all except 1 patient who had markedly elevated PCT level (141.ng/mL).In patients with low PCT, 42% received no antibiotics, 59% received antibiotics initially, 32(57%) patients had their antibiotics discontinued early (within 24 hours) and their culture remained negative for bacterial infections during hospitalizations.Outcome analysis shows a shorter length of stay, 6 days, in the low PCT group (< 0.25 ng/mL) compared to 9 days in the elevated PCT (> 0.25 ng/mL) group (P <0.001).In patients with low PCT (< 0.25 ng/mL), hospital LOS was 1 day shorter (5 days vs 6 days) in the 'no' antibiotic group compared to the 'yes' antibiotic group.CONCLUSIONS: Procalcitonin level remains low in absence of bacterial infection.Early de-escalation/discontinuation of antibiotic is safe without adverse outcomes in COVID-19 pneumonia.Early de-escalation/discontinuation of antibiotic is associated with a shorter hospital LOS.CLINICAL IMPLICATIONS: Our study supports the use of procalcitonin as an antibiotic stewardship tool for COVID-19 patients.Procalcitonin-guided early de-escalation of antibiotics can mitigate the unnecessary use of antibiotics in COVID-19 pneumonia, and may thus prevent the development of antimicrobial resistance, adverse drug effects, and help in the reduction of hospital expenses.Given that this is a retrospective review that supports the use of procalcitonin in the de-escalation of antibiotics, a prospective trial would further support its use.
PURPOSE: Inhaled nitric oxide (iNO) is a potent vasodilator that has been studied as a treatment for acute respiratory distress syndrome (ARDS).However, clinical trials have not been able to demonstrate a survival benefit, and its use in clinical practice has been relegated to "rescue" or "bridging" therapy in refractory hypoxemia.However, it's early use prior to endotracheal intubation and invasive mechanical ventilation for patients with ARDS has not been investigated.As a result of the COVID-19 pandemic causing resource constraints, as well as the potential anti-viral effects of iNO, our center had a significant number of patients who were treated with iNO prior to intubation, often in combination with a high-flow nasal cannula (HFNC) system.Given this large cohort, we aimed to explore whether pre-intubation iNO resulted in any improved clinical outcomes among patients with COVID-19 induced hypoxic respiratory failure.METHODS: This is a descriptive study of patients admitted with COVID-19 pneumonia at a single tertiary care center.The COVID-19 population was surveyed to gather data on iNO delivered via a high-flow nasal cannula (HFNC).We collected information on patient demographics, co-morbidities, iNO treatment, need for intubation, ABG values, patient labs, hospital length of stay, and mortality.Patients were divided into two groups based on the timing of iNO initiation: group 1 -"postintubation" (i.e.iNO started on the same day as or after endotracheal intubation and mechanical ventilation) and group 2 -"preintubation" (i.e.iNO started at least 1 day prior to endotracheal intubation, if any). RESULTS:We had a total of 45 COVID-19 patients (group 1, n¼20 [44.4%] vs group2, n¼25 [65.6%]) who had iNO use.Age and gender were similar between the groups.On comparing the two groups (group 1 vs group 2), iNO was started at a median of 1(IQR, 1-6) day vs 2(IQR, 1-3) days from hospital admission.The number of Ventilation-free days (VFD) was 6.7 [mean(x)] in group 1 as opposed to 4.7 (x) in group 2. The total length of mechanical ventilation (days) was 17.8(x) vs 11.6 (x) in group 1 vs group 2. The mean hospital length of stay from the beginning of iNO treatment until discharge or death was 23.5 vs 17.2 days, with 11 deaths (55%) vs 7 deaths (28%) in group 1 vs group 2, respectively.Severity of illness as indicated by the mean SOFA score was higher in group 1 (7.8) than in group 2 (3.3). CONCLUSIONS:The use of iNO prior to intubation among patients with COVID-19 hypoxic respiratory failure appears to be safe and comparable on important clinical outcomes, including the duration of mechanical ventilation, hospital length of stay, and possibly mortality.This suggests that a formal prospective investigation on the earlier pre-intubation use of iNO for patients affected by ARDS is warranted.CLINICAL IMPLICATIONS: This study suggests that pre-intubation use of iNO in COVID patients with hypoxemic respiratory failure is feasible and that a formal prospective clinical trial is warranted.
Abstract Background Ketamine, a dissociative anesthetic, induces remission of depression by antagonizing glutaminergic NMDA receptors. Ketamine has been used previously in outpatient setting for treatment-resistant depression, but we showcase its utility in depression management at the Intensive Care Unit (ICU). Research Question Can ketamine be used for depression treatment in ICU patients? Study Design and Methods A retrospective chart review of ICU patients was done at a tertiary center from 2018 to 2021, to assess the ketamine usage. Among the patients reviewed, ketamine was used for depression in 12, and for analgesia & sedation in 2322 patients. Ketamine was administered in doses of 0.5mg/kg & 0.75mg/kg for depression. Each course consisted of 3 doses of ketamine administered over 3 days. 7 in 12 patients received a single course of ketamine. The rest received 3-4 courses 1 week apart. Results Ketamine was found to improve mood and affect in most of the patients with depression. 11 in 12 patients had a positive response with better sleep. It has a major advantage over conventional anti-depressants since it takes only a few hours to induce remission. Patients who refused to eat and follow treatment protocol, and who would otherwise succumb to death if not for the rapid remission of depression, were administered ketamine. Conclusion A major drawback of ketamine is that the duration of remission is short, with the response lasting only up to 7 days after a single dose. Hence, all the patients in our study were weaned off ketamine with a supporting antidepressant. Ketamine has been documented to cause cardio-neurotoxicity; however, only one patient had worsening lethargy in our study. To conclude, ketamine has a monumental benefit in treating depression in the ICU. Although our study was associated with positive outcomes, there is a need for prospective studies with long-term follow-up assessments.
The incidence of cardiomyopathy in athletes contributes significantly to the public health burden in developing countries. Most effective management strategies primarily rely on the modification of risk factors, and it is less expensive compared to other advanced investigations. Moreover, limited data is available concerning the incidence of adverse events including cardiac arrest and the strategies to prevent them, especially in this population subset. Therefore, devising preventative strategies that can easily be implemented in athletes and provide a cost-effective approach is warranted. We aim to discuss the incidence of major adverse cardiac events in athletes with cardiomyopathies and their associated risk factors and to evaluate the various strategies proposed to prevent the progression of cardiomyopathy in this population, with the initial hypothesis that the treatment of these pathologies poses a substantial challenge in this population. With regard to methodology, this is a narrative review. Search terms were described using the Population, Exposure, and Outcome (PEO) framework. A comprehensive search strategy was used to screen and identify any relevant literature in the PubMed and Google Scholar databases. This was done in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Four studies were identified in the final analysis. The incidence of sudden cardiac arrest varied between 0.3% and 0.33% among the athletes affected with cardiomyopathies. Routine and pre-participation screening has shown success in reducing the incidence of sudden cardiac death in athletes as a result of undiagnosed cardiomyopathies. Supervised exercise regimes have been proposed to reduce the incidence of cardiomyopathy in athletes. Beyond identification strategies, the prevention of cardiomyopathies revolves around the modification of risk factors. To conclude, the challenges athletes face, suffering from cardiomyopathy, have been an ongoing issue with unexpected cardiac arrest as the end result. Despite the decreased incidence of cardiomyopathies observed in athletes, the challenge in diagnosis can result in catastrophic outcomes, especially in developing countries. Therefore, adopting prevention strategies can have a profound impact on the identification and management of these pathologies.
Herpes simplex virus type 1 (HSV-1) is a member of the Alphaherpesviridae subfamily. Its structure is composed of linear dsDNA, an icosahedral capsid that is 100 to 110 nm in diameter, with a spikey envelope. In general, the pathogenesis of HSV-1 infection follows a cycle of primary infection of epithelial cells, latency primarily in neurons, and reactivation. HSV-1 is responsible for establishing primary and recurrent vesicular eruptions, primarily in the orolabial and genital mucosa. HSV-1 infection has a wide variety of presentations, including orolabial herpes, herpetic sycosis (HSV folliculitis), herpes gladiatorum, herpetic whitlow, ocular HSV infection, herpes encephalitis, Kaposi varicelliform eruption (eczema herpeticum), and severe or chronic HSV infection. Antiviral therapy limits the course of HSV infection.
Introduction: A significant number of patients who are initially diagnosed with sepsis may be culture-negative. Multiple studies have compared the outcomes of culture-negative and culture-positive patients, but the findings are conflicting. The purpose of this study is to compare these two groups based on our own patient cohort’s data. Methods: We performed a retrospective analysis of 5,159 patients, who presented to the Mayo Clinic Enterprise sites between August 2018 to November 2020 with suspected sepsis and had a blood culture done. Culture-positive patients were compared to culture-negative patients in terms of demographics, clinical parameters, and hospitalization outcomes. The primary outcome of interest was inpatient mortality; and the secondary outcomes of interest were hospital length of stay, ICU admission, mechanical ventilation, new onset dialysis, vasopressor use, and 30-day mortality. Comparisons were done using Fisher’s exact test or Wilcoxon rank-sum test. Results: Of 5,159 patients, 5092 (98.7%) were culture-negative and 67 (1.3%) were culture-positive. Compared to culture-negative patients, culture-positive patients were more likely to be male [70% vs 55%; p=0.018] and less likely to have COPD (5% vs. 13%, p=0.041). We did not find differences in demographic characteristics (age, race, weight, and BMI) or other comorbid factors (obesity, diabetes, hypertension, coronary artery disease, CKD, and CHF) between the two groups (all p≥0.17). The median length of hospital stay was 1 day longer for culture-positive patients (median 5 vs. 4 days), but this was not statistically significant (p=0.09). We did not find differences in other clinical outcomes, such as inpatient mortality [9% vs. 7%; p=0.47], ICU admission rate [25% vs. 26%; p=1.00], mechanical ventilation [12% vs. 8%; p=0.26], new onset dialysis [0% vs 0.5%; p=1.00], vasopressor use [15% vs 9%; p=0.080] and 30-day mortality [19% vs. 14%; p= 0.29]. Conclusions: Our study found that culture-positive patients were more likely to be male and less likely to have COPD compared to culture-negative patients. We did not find differences in clinical outcomes between the two cohorts. Given the low number of culture-positive patients, we must consider the possibility of a type II error (i.e. false-negative finding) when interpreting the results.
