COVID-19 Scan for Jul 01, 2020

News brief

Under half of COVID-19 patients know their infection source, studies show

Yesterday, Morbidity and Mortality Weekly Report (MMWR) published studies showing that only 46% of COVID-19 patients reported recent contact with an infected person and that only 27% did so in Colorado.

In the first study, researchers from the Centers for Disease Control and Prevention (CDC) conducted a telephone survey of 350 COVID-19 outpatients and inpatients at 11 US academic medical centers from Apr 15 to May 24.

Of the 46% of participants who reported recent exposure to the coronavirus, 45% said that they had contact with an infected family member, while 34% said they had been exposed to an infected coworker. The authors noted that, while two thirds of participants were employed, only 17% said they were able to work remotely.

"Case investigation, contact tracing, and isolation of infected persons are needed to prevent ongoing community transmission, given the frequent lack of a known contact," the authors wrote. "Enhanced measures to ensure workplace safety, including social distancing and more widespread use of cloth face coverings, are warranted."

In the second study, CDC researchers randomly polled 364 COVID-19 patients from nine Colorado counties about their exposures to the coronavirus before the state issued stay-at-home orders on Mar 26. Of the 99 participants who reported contact with at least one infected person, 27 (27%) said their contact had been a family member, while 25 (25%) said it was a coworker. About three quarters of those polled said that their exposure occurred at work (47 [47%]) or at home (24 (24%).

Of the 47% who reported workplace exposure, 28 (60%) were healthcare workers, followed by those in public administration or the armed forces (6 [13%]) and manufacturing (5 [11%]). The activities reported most often in the 2 weeks before illness onset were attending gatherings of more than 10 people (44%), traveling domestically (29%), working in a healthcare setting (28%), visiting a healthcare setting (23%), and using public transportation (22%).
Jun 30 MMWR US study and Colorado study

Study: High COVID-19 viral load correlates to intubation, death

A study yesterday in Clinical Infectious Diseases details the viral loads of hospitalized patients with COVID-19 at two New York City hospitals between Mar 30 and Apr 30. High viral loads were associated with higher in-hospital death and intubation rates.

The study included 678 patients with COVID-19, with SARS-CoV-2 viral load assessed from a reverse transcription-polymerase chain reaction assay applied to nose-throat swab samples. According to the study authors, patients with higher viral loads were likely to be older, have underlying conditions, be smokers, and report recent receipt of chemotherapy.

In-hospital mortality was 35.0% with a high viral load, 17.6% with a medium viral load, and 6.2% with a low viral load. The risk of intubation was also higher in patients with a high viral load, at 29.1%, compared with those with a medium (20.8%) or low viral load (14.9%), the authors found.

"This association persisted even when adjusting for age, comorbidities, presenting symptoms, chest radiography findings, and degree of presenting hypoxia," the authors concluded. They added that assessing viral load at hospital admission may be useful in allocating therapeutic interventions.
Jun 30 Clin Infect Dis study

Formerly healthy kids with COVID-linked syndrome had neurologic signs

Four of 27 previously healthy children with COVID-19–linked multisystem inflammatory syndrome (14.8%) had evidence of new-onset neurologic changes in a study published today in JAMA Neurology.

Researchers studied the electronic medical record data of children hospitalized at the Great Ormond Street Hospital for Children in London with COVID-19 and neurologic symptoms from Mar 1 to May 8. Their symptoms included encephalopathy (brain damage or disease) (4 patients), headache (3), brainstem and cerebellar signs (2), muscle weakness (4), and impaired reflexes (2).

Systemic manifestations were fever (4 patients), cardiovascular shock (4), rash (4), and shortness of breath (2).

All four patients needed intensive care and mechanical ventilation for shock, while one experienced respiratory distress. All showed abnormal signals from the splenium region of the brain on magnetic resonance imaging. In the three patients who underwent electroencephalography (measurement of electrical activity in the brain), somewhat slower activity was detected. And in the three who had both nerve conduction studies and electromyography (measurement of electrical activity in the muscles), mild muscle and nerve changes were noted.

Median intensive care unit stay was 6.5 days, and mechanical ventilation was needed for a median of 5 days.

The authors said that, because the main receptor for the virus that causes COVID-19 is angiotensin-converting enzyme 2 and that this enzyme is expressed by both neurons and glial cells in the brain, neurologic symptoms may be the result of direct viral invasion of the central nervous system.

All patients improved neurologically, and two had completely recovered by the end of the study. "Children with COVID-19 may present with new neurological symptoms involving both the central and peripheral nervous system and splenial changes on imaging, in the absence of respiratory symptoms; this diagnosis should be considered within the differential diagnosis of splenial lesions," the authors wrote.
Jul 1 JAMA Neurol study

News Scan for Jul 01, 2020

News brief

Tests confirm 3 more Ebola cases in DRC's Equateur province outbreak

Three more Ebola cases have been confirmed in a recently emerged outbreak centered in the Democratic Republic of the Congo's (DRC's) Equateur province, raising the total to 33, the World Health Organization (WHO) African regional office said on Twitter today.

No new deaths were reported, keeping the total at 13. Of the 33 cases, 30 are lab confirmed, and 3 are listed as probable. No other details were noted about the three most recent cases.

The latest outbreak is occurring in the country's northwest region, in the same area as its ninth such outbreak, which occurred in 2018, resulting in 54 illnesses, 33 of them fatal. Some health zones affected are in remote forested areas, though some cases have been detected in Mbandaka, the provincial capital located on a river, raising worries about further spread.

Also, some of the latest confirmed and suspected cases are still in the community, a factor known to increase the risk of community transmission.
Jul 1 WHO African regional office tweet
Jun 30 CIDRAP News scan "DRC's Equateur province outbreak total rises to 30"

Study: Hospital patients allergic to penicillin twice as likely to receive beta-lactam alternatives

Hospitalized patients with a documented penicillin allergy are nearly twice as likely to receive a potentially harmful beta-lactam antibiotic alternative, US researchers reported in JAMA Internal Medicine.

In a cross-sectional study of 10,992 patients receiving antibiotics at 106 US hospitals, a team led by researchers from Massachusetts General Hospital (MGH) found that 1,741 patients (16%) had a documented penicillin allergy. Compared with patients without a documented penicillin allergy, those with a documented allergy had higher beta-lactam alternative antibiotic use (1,114 of 1,741 [64%] vs 4,438 of 9,251 [48%]) and lower narrow-spectrum beta-lactam use (227 of 1,741 [13%] vs 2,811 of 9,251 [30%]).

In the fully adjusted model, the adjusted odds ratio (aOR) for receiving beta-lactam alternative antibiotics was 1.94 (95% confidence interval [CI], 1.74 to 2.17) for patients with a documented penicillin allergy, with especially high odds of clindamycin use (aOR, 5.34; 95% CI, 3.99 to 7.13), which is associated with an increased risk of Clostridioides difficile infection. Patients with a documented allergy also had lower odds of receiving a narrow-spectrum beta-lactam (aOR, 0.35; 95% CI, 0.31 to 0.40).

The association between a documented penicillin allergy and alternative antibiotic use was stronger among patients receiving prophylactic antibiotics for surgery (aOR, 7.31; 95% CI, 5.01 to 10.69) and those receiving antibiotics for urinary tract infection (aOR, 2.07; 95% CI, 1.51 to 2.85).

The authors of the study note that since studies have found that only a small percentage of patients with documented penicillin allergies are truly allergic, at least 90% of the alternative antibiotic recommendations were likely unnecessary.

"Unfortunately, antibiotic decisions are often made based on limited information or without a thorough investigation," senior author Rochelle Walensky, MD, MPH, chief of infectious diseases at MGH, said in a press release. "We learned from our study that antibiotic prescribing without full allergy information can ultimately do the patient more harm than good."

Walensky and her colleagues suggest hospitals should conduct inpatient penicillin allergy interventions on patients prescribed clindamycin and those with planned surgical procedures.
Jun 29 JAMA Internal Med research letter
Jun 30 MGH press release

WHO experts urge antimicrobial stewardship during pandemic response

Antimicrobial resistance (AMR) experts from the WHO are urging that antimicrobial stewardship activities be integrated into the COVID-19 pandemic response.

In an editorial published in the Bulletin of the World Health Organization, scientists with the WHO's Department of Global Coordination and Partnership on Antimicrobial Resistance note that while the WHO's interim guidance on COVID-19 treatment incorporates antibiotic stewardship principles with specific recommendations, a broader strategy to address antimicrobial use during the pandemic is needed. They call for five specific measures to be integrated into the pandemic response across the broader health system.

The first measure they recommend is increased training for healthcare workers treating COVID-19 patients, with a focus on improving the recognition of signs of severe COVID-19 and superimposed bacterial or fungal infections, eliminating unnecessary antibiotic use, evaluating the need for medical devices that may increase the risk of bacterial infections, and implementing strict infection prevention and control measures.

The other recommended measures include improving COVID-19 testing to reduce turnaround time and the urge to initiate empiric antibiotics; ensuring the continuity of essential health services that, if interrupted, could lead to increased use of antibiotics; exercising maximum caution on the use of biocides for environmental and personal disinfection; using biocides with a low selection pressure for antibiotic resistance; and addressing research gaps to ensure that antimicrobial stewardship activities become an integral part of the pandemic response.

"These measures would stem the emergence of untreatable drug-resistant infections and diseases that could potentially lead to another public health emergency," the authors write.
July 2020 Bull World Health Organ editorial