Lower Respiratory Tract Samples Research Articles

The Histopathologic Features of Early COVID Pneumonia in a Pediatric Patient: New Insight into the Role of Macrophages

A life-threatening complication of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is acute respiratory distress syndrome. Our understanding of the pathologic changes in coronavirus disease 2019 (COVID-19) is based almost exclusively on post-mortem analyses of adults. These studies established several hallmarks of SARS-CoV-2 lung infection, including diffuse alveolar damage, microvascular thrombi, and acute bronchopneumonia. We describe a fatal example of COVID pneumonia in a 9-year-old girl who presented with fever 10 months following the diagnosis of ALK-positive anaplastic large cell lymphoma (ALCL). A chest computed tomography scan revealed left upper lobe lung consolidation and nodular airspace disease, and an initial SARS-CoV-2 nasopharyngeal swab (RT-PCR) was negative. A subsequent lung biopsy performed due to concern for relapsed ALCL demonstrated sheets of intra-alveolar and interstitial macrophages, and macrophage-rich fibrinous exudates. Immunohistochemical and in-situ hybridization stains confirmed these macrophages as the predominant SARS-CoV-2-infected cell type. Subsequent RT-PCR testing of upper and lower respiratory tract samples was positive for SARS-CoV-2 infection. Whole genome sequencing confirmed the presence of the B.1.617.2 (Delta) variant. This biopsy illustrates the histopathologic features of early COVID pneumonia in antemortem lung tissue from a pediatric patient, and establishes macrophages as a potential source of SARS-CoV-2 amplification.

Clinical and Etiological Findings of Viral Pneumonia: A Single Centre Prospective Study

Introduction: Viral pneumonia is a prominent cause of illness that can occur in all age group throughout the year. Worldwide about 200 million cases of viral community acquired pneumonia occur every year of which 50% cases in children and 50% in adults [1]. Bacterial coinfection found only in 3% of cases [2]. The aim of our study is to find out most common viral pathogen causing pneumonia, most common bacterial co-infection, their typical clinical presentation, common abnormal lab parameters, CT findings, duration of ICU and hospital stay. Materials and Methods: All cases with sign and symptoms of respiratory infections with confirmed diagnosis of viral pneumonia (confirmed by BioFire FilmArray Pneumonia Panel from lower respiratory tract sample, confirmed by microscopy) were included in the study after proper consent. Demographic data, clinical history, laboratory investigations, all routine and radiological investigations are noted and evaluated. Results: Of the total 69 cases Influenza A virus (36%) is the predominant etiological agents followed by human rhinovirus (26%) in these cases. Human Rhinovirus predominate in the early part 2023 but towards end of this year Influenza A virus became the predominant cause for pneumonia. Patients of all age groups are affected but there is definitively a seasonal variation with more in the winter months. Most of the patients have typical respiratory findings like cough (83%) and fever (76%). CT scan showed bilateral ground glass opacity (56%) in most cases, and few had consolidation (29%) features. Blood CRP level (91%) was raised in most of these patients. Haemophilus Influenzae (34%) is the most common associated bacterial co-infection followed by Streptococcus Pneumoniae (26%). All patients responded well to conservative management. Conclusions: Viral pneumonia is not uncommon in the community. Though we found Influenza A followed by Human Rhinovirus are the two most common pathogens in these cases but only 59% of them have bacterial co-infection, so not all patients require antibiotics from the beginning. As most are infected with Haemophilus influenzae so aminopenicillin group is the antibiotics of choice for these patients. Hence as a pulmonologist we must be aware of these cases, their typical presentation and not to over treat these cases with high end antibiotics as most require only symptomatic treatment. Even though it is a single centre study, but it definitely throws a light on the pattern of viral pneumonia in our community

Molecular characterization of extended-spectrum β-lactamase-producing Escherichia coli isolated from lower respiratory tract samples between 2002 and 2019 in the Central Slovenia region

BackgroundAntibiotic resistance is one of the most serious global health problems and threatens the effective treatment of bacterial infections. Of greatest concern are infections caused by extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC). The aim of our study was to evaluate the prevalence and molecular characteristics of ESBL-EC isolated over an 18-year pre-COVID period from lower respiratory tract (LRT) samples collected from selected Slovenian hospitals.Objectives and methodsAll isolates were identified by MALDI-TOF and phenotypically confirmed as ESBLs by a disk diffusion assay. Using a PCR approach, 487 non-repetitive isolates were assigned to phylogroups, sequence type groups, and clonal groups. Isolates were also screened for virulence-associated genes (VAGs) and antimicrobial resistance genes.ResultsThe prevalence of ESBL-EC isolates from LRT in a large university hospital was low (1.4%) in 2005 and increased to 10.8% by 2019. The resistance profile of 487 non-repetitive isolates included in the study showed a high frequency of group 1 blaCTX-M (77.4%; n = 377), blaTEM (54.4%; n = 265) and aac(6')-Ib-cr (52%; n = 253) genes and a low proportion of blaSHV and qnr genes. Isolates were predominantly assigned to phylogroup B2 (73.1%; n = 356), which was significantly associated with clonal group ST131. The ST131 group accounted for 67.6% (n = 329) of all isolates and had a higher number of virulence factor genes than the non-ST131 group. The virulence gene profile of ST131 was consistent with that of other extraintestinal pathogenic E. coli (ExPEC) strains and was significantly associated with ten of sixteen virulence factor genes tested. Using ERIC-PCR fingerprinting, isolates with the same ERIC-profile in samples from different patients, and at different locations and sampling dates were confirmed, indicating the presence of “hospital-adapted” strains.ConclusionOur results suggest that the ESBL-EC isolates from LRT do not represent a specific pathotype, but rather resemble other ExPEC isolates, and may be adapted to the hospital environment. To our knowledge, this is the first study of ESBL-EC isolated from LRT samples collected over a long period of time.

Optimized Antibiotic Management of Critically Ill Patients with Severe Pneumonia Following Multiplex Polymerase Chain Reaction Testing: A Prospective Clinical Exploratory Trial.

Molecular diagnostic testing is assumed to enable fast respiratory pathogen identification and contribute to improved pneumonia management. We set up a prospective clinical trial at a tertiary hospital intensive care unit including adult patients suspected of severe pneumonia from whom a lower respiratory tract sample could be obtained. During control periods (CPs), routine testing was performed, and during intervention periods (IPs), this testing was completed with the FilmArray Pneumonia Panel plus test (FA-PNEU) executed 24/7. The main objective was to measure the impact of FA-PNEU results in terms of reduced time to targeted antimicrobial treatment administration. Over a 10-month period, analysis was performed on 35 CP and 50 IP patients. The median time to targeted antimicrobial treatment administration was reduced to 4.3 h in IPs compared to 26.4 h in CPs, with 54% of IP patients having FA-PNEU results that led to a treatment modification, of which all but one were targeted. Modifications included 10 (37%) de-escalations, 7 (25.9%) escalations, 3 (11.1%) regimen switches, and 7 (25.9%) complete antimicrobial discontinuations. FA-PNEU results were available with a 42.3 h gain compared to routine identification. This prospective study confirmed retrospective data demonstrating the benefit of FA-PNEU testing in severe pneumonia management of critically ill patients through improved antimicrobial use.

Treatments and Outcomes of Critically Ill Patients with Candida spp. Colonization of the Lower Respiratory Tract in Regina, Saskatchewan.

Among critically ill patients receiving mechanical ventilation, Candida spp. are commonly detected in the lower respiratory tract (LRT). This is generally considered to represent colonization. To evaluate the use of antifungal treatments and the clinical outcomes of patients with Candida colonization of the LRT. This retrospective analysis involved consecutive patients admitted to the intensive care unit between April 2016 and May 2021with positive results on Candida spp. testing of LRT samples. Data related to antifungal treatment and clinical outcomes were analyzed descriptively, and multivariable logistic regression was performed. Of 200 patients initially identified, 160 (80%) died in hospital. Antifungal therapy was given to 103 (51.5%) of the patients, with treatment being more likely among those with shock and those who received parenteral nutrition. Mortality was high among patients with positive Candida results on LRT culture, regardless of treatment. Multivariable logistic regression, with adjustment for age, sex, comorbidities, and sequential organ failure assessment (SOFA) score, showed that antifungal treatment was associated with lower odds of death (odds ratio 0.39, 95% confidence interval 0.17-0.87) compared with no treatment (p = 0.021). This study showed higher mortality rates than have been reported previously. Further investigation into the role of antifungal therapy among critically ill patients with Candida spp. colonization is required.

Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection.

Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs). This is an analysis of of a seven-center prospective cohort study. Seven PICUs within academic children's hospitals in the United States. Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours. We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement. Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001). Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.

Diagnostic utility of oropharyngeal swabs as an alternative to lower respiratory tract samples for PCR-based syndromic testing in patients with community-acquired pneumonia.

Syndromic PCR-based analysis of lower respiratory tract (LRT) samples in patients with community-acquired pneumonia (CAP) improves the bacterial yield and time-to-results compared to culture-based methods. However, obtaining adequate sputum samples can be challenging and is frequently not prioritized in the emergency department (ED). In this study, we assess the concordance of microbiological detections between oropharyngeal- (OP) and LRT samples from patients presenting to the ED with CAP using a syndromic PCR-based respiratory panel [Biofire FilmArray Pneumonia plus (FAP plus)]. Paired OP- and high-quality LRT samples were collected from 103 patients with confirmed CAP, who had been included in a randomized controlled trial (NCT04660084) or a subsequent observational study at Haukeland University Hospital, and analyzed using the FAP plus. The LRT samples were obtained mainly by sputum induction (88%). Using the LRT samples as a reference standard, the positive percent agreement (PPA), negative percent agreement (NPA), and overall percent agreement for the most common bacterial pathogens in CAP, Streptococcus pneumoniae and Haemophilus influenzae, were 85%, 99% and 95%, and 86%, 98% and 93%, respectively. For Moraxella catarrhalis, the PPA was lower (74%), while the NPA was 100%. For bacteria that are less likely causes of uncomplicated CAP (e.g., Staphylococcus aureus and Enterobacterales) the results were more divergent. In conclusion, the FAP plus detects the most common CAP pathogens S. pneumoniae and H. influenzae from OP samples with high PPAs and excellent NPAs when compared with LRT samples. For these pathogens, the PPAs for OP samples were higher than previous reports for nasopharyngeal samples. This suggests that analysis of OP samples with syndromic PCR panels could represent an alternative approach for rapid microbiological testing in the ED, especially in patients where LRT samples are difficult to obtain. Divergent results for bacteria that are less likely to cause uncomplicated CAP do, however, emphasize the need for clinical evaluation of positive test results.

Sampling from upper and/or lower respiratory tract when diagnosing coronavirus disease 2019 (COVID-19) – results from a Danish cohort study

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can replicate in the upper and lower respiratory tract. We aimed to evaluate whether symptom characteristics and symptom duration prior to sampling are associated with test positivity in upper or lower respiratory tract samples. Methods We conducted a retrospective cohort study in the Central Denmark Region from 14 April 2020 to 2 November 2020 including hospitalised patients with SARS-CoV-2 reverse transcriptase-polymerase chain reaction samples from both the upper and lower respiratory tract within 48 h and at least one positive test result. Results Of 122 patients, 101 were positive in both samples (83%), 7 (5%) were positive only in the upper respiratory tract sample, and 14 (11%) were only positive in the lower respiratory tract sample. The median number of symptoms was 4 (IQR 3, 5.75) and 5 (IQR 3, 7), respectively, in patients with only a positive upper respiratory tract sample and in concordant positive patients; while 1 (IQR 1, 3) in patients with only a positive upper respiratory tract sample. 98% (120/122) of patients would have been diagnosed with coronavirus disease 2019 if supplemental sampling from the lower respiratory tract was guided by lower respiratory tract symptoms. No substantial difference in the duration of symptoms was observed across the three patient groups. Conclusions The presence of lower respiratory tract symptoms could have been used to determine whether supplemental sampling from the lower respiratory tract was necessary. Symptom duration was not associated with test positivity in the upper or lower respiratory tract.

Evaluation of Pathogens and Antibiotic Resistance Profiles Isolated from Lower Respiratory Tract Samples

Objective: In this study, we aimed to guide clinicians in planning empirical treatment and contribute to regional data by presenting bacterial lower respiratory tract infection agents and antibiotic resistance profiles. Methods: All lower respiratory tract samples from patients admitted to our laboratory between January 01 and December 31, 2021 were evaluated retrospectively. Bacterial identification and susceptibility tests were performed using the VITEK 2 automated system and evaluated in accordance with the recommendations of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Results: Significant growth was detected in 461 of 923 lower respiratory tract samples. Antibiotic susceptibility test results of 340 samples were evaluated after excluding the repeated samples of same patient. Gram negative bacteria was isolated in 309 (90.9%), Staphylococcus aureus in 17 (5%) and Candida albicans in 14 (4.1%) of 340 samples. The most frequently isolated Gram-negative bacteria were Pseudomonas aeruginosa (121, 39.2%), Acinetobacter baumannii (88, 28.5%), Klebsiella pneumoniae (64, 20.7%) and Escherichia coli (36, 11.6%), respectively. Resistance rates of A. baumannii isolates to carbapenems, piperacillin/tazobactam, ceftazidime and fluoroquinolones were found to be over 90%, and higher resistance was observed in intensive care units (ICU) than in wards. Conclusion: The increased antibiotic resistance observed in lower respiratory tract infections from hospitalized patients in ICUs, is remarkable. As a result, knowing the causative agents and current resistance profiles is important, especially for hospitalized patients in ICUs, in order to initiate appropriate empirical treatment and to ensure treatment success. The data obtained from our study will guide clinicians in planning empirical treatment.

Vertical Transmission of Severe Acute Respiratory Syndrome Coronavirus 2: Current Evidence and Perspectives

With the widespread transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the medical community has organized efforts to determine a series of clinical questions about the virus. Critical questions have also arisen in the area of maternal-fetal medicine and received increasing attention, as physiological and immunologic changes in pregnancy might potentially increase the susceptibility to SARS-CoV-2 infection and complications of the virus.1 Many early reports indicated that pregnant women with SARS-CoV-2 infection were not prone to experiencing severe disease.2–4 However, later studies supported pregnancy as a risk factor for severe disease associated with SARS-CoV-2 infection, like ICU admissions, invasive ventilation, extracorporeal membrane oxygen (ECMO) utilization and death.5,6 Additionally, pregnant women with severe or critical SARS-CoV-2 infection are at risk for various perinatal complications, such as cesarean section, hypertensive disorders of pregnancy, and preterm birth.2,7 Risk factors for severe or critical SARS-CoV-2 infection include advanced maternal age, increased body mass index, and underlying medical comorbidities such as asthma, chronic hypertension, and pregestational diabetes.2,7 However, the risk of fetal infection due to vertical transmission of SARS-CoV-2 is still a major concern and debated issue.8 Vertical transmission is defined as the transmission of the infectious pathogen from the mother to fetus via the placenta or ascending infection in utero (intrauterine), body fluid contact during delivery (intrapartum), or through breastfeeding after birth (postpartum). At present, the extent to which vertical transmission of SARS-CoV-2 occurs and when it occurs is unclear. This article reviews the current evidence and perspectives. Incidence Yan et al.3 conducted a cohort study with 116 pregnant patients with SARS-CoV-2 infection who delivered 100 babies. Of these neonates, 86 tested negative for SARS-CoV-2 via nasopharyngeal swab testing. An analysis by 3 major Harvard-affiliated hospitals showed that among 149 of 159 newborns (94%) that underwent testing for SARS-CoV-2 within 24 hours of delivery, none showed a positive result for SARS-CoV-2 (0/149).9 The largest cohort study was from the United Kingdom, which included 427 pregnant women with SARS-CoV-2 infection. In that study, 12 of 244 neonates who were tested by nasopharyngeal swabbing after birth were positive for SARS-CoV-2 (12/244); 6 of them were tested within 12 hours of birth.10 A systematic review and meta-analysis that included 38 cohort or case series studies showed that a pooled proportion of 3.2% for vertical transmission through testing 936 neonatal nasopharyngeal SARS-CoV-2 RNA, either immediately after birth or within 48 h of birth.11 A recent meta-analysis that included 206 cohort studies and 266 case series and case reports showed that in cohort studies, 1.8% of the 14,271 babies born to mothers with SARS-CoV-2 infection had positive results for SARS-CoV-2 based on reverse-transcriptase polymerase chain reaction (RT-PCR) analysis after birth. When the analysis was limited to babies tested in the first 24 hours after birth, the positivity rate was 0.9%. When combined the cohort studies with case series and case reports to further assess the timing of mother-to-child transmission based on the in utero exposure testing and viral persistence testing according to the categorization of World Health Organization (WHO) classification system.12 The results showed that of the 536 SARS-CoV-2–positive babies with sufficient data to apply the WHO classification system for timing of exposure and likelihood of infection, 14 were categorized as having confirmed mother-to-child transmission: seven with in utero transmission (448 assessed), two with intrapartum transmission (18 assessed), and five with early postnatal exposure (70 assessed).13 Evidence of SARS-CoV-2 intrauterine vertical transmission Since the onset of the pandemic, worldwide efforts were made to explore the possibility of vertical transmission of SARS-CoV-2. The first study from China reported a retrospective cohort of 9 pregnant women with SARS-CoV-2 infection, by RT-PCR analyses of the virus, on babies born to mothers with SARS-CoV-2 infection and their paired amniotic fluid and cord blood. The study indicated no evidence for intrauterine vertical transmission in late pregnancy.14 Subsequently, more studies have reported similar results and failed to demonstrate the intrauterine vertical transmission of SARS-CoV-2, including negative testing in newborn’s nasopharyngeal swab, placental tissues, umbilical cord blood, amniotic fluid, and vaginal swabs.3,4,15,16 However, with the increasing number of published studies on SARS-CoV-2 infection during pregnancy, few cases have suggested probable intrauterine vertical transmission of SARS-CoV-2. However, most reports have been based on single positive results of neonatal nasopharyngeal SARS-CoV-2 detected by RT-PCR tests with significant differences in sample collection times.8,17–19 Thus, although strict isolation measures were undertaken for neonates, the lag time to neonatal nasopharyngeal swab raises the possibility of postnatal transmission. However, several published literatures have described the detection of SARS-CoV-2 in intrauterine tissue samples such as amniotic fluid, placenta, and umbilical cord plasma,20–29 which further supports the hypothesis that, even uncommon, there may be intrauterine vertical transmission of SARS-CoV-2. First trimester Shende et al. reported a pregnant woman tested positive for SARS-CoV-2 at 8 weeks of gestation, despite being symptomless. At 13 weeks of gestation, the ultrasound indicated fetal demise and the patient underwent dilation and curettage. SARS-CoV-2 RNA was detected in the placenta cells. In addition, viral RNA was found in the amniotic fluid and the Spike proteins of SARS-CoV-2 were immunolocalized in cytotrophoblast and syncytiotrophoblast cells of the placental villi. However, in this case, no fetal tissue was available for testing of viral particles.20 Valdespino et al.21 reported a case of spontaneous twin abortion in early pregnancy from a SARS-CoV-2 infected symptomatic mother. RT-PCR of the placenta, kidneys, and lungs for SARS-CoV-2 of 1 fetus was positive, confirmed by immunofluorescence and electron microscopy. Second trimester In one case, a SARS-CoV-2–positive pregnant mother miscarried at 19 gestational weeks. Fetal axillae, mouth, meconium, and blood samples obtained within minutes after the birth all tested negative for SARS-CoV-2 by RT-PCR. However, placental swabs from the fetal side taken within minutes of birth were positive for SARS-CoV-2 RNA.22 The second case reported a patient with SARS-CoV-2 infection who delivered at 22 weeks of gestation because of severe preeclampsia and placental abruption. SARS-CoV-2 RNA detected by RT-PCR tests in the placenta and umbilical cord samples were positive; furthermore, viral capsids were found in the trophoblast cells by electron microscopy, confirming infection of the fetal side of the placenta. However, fetal tissues (lung, myocardium, liver, kidney) showed normal histology without inflammation.23 The third case was of a premature neonate delivered at 26 weeks of gestation. SARS-CoV-2 RNA was positive in the placenta and umbilical cord blood samples. In addition, SARS-CoV-2 nucleocapsid and SARS-CoV-2 spike protein in the cytotrophoblast and syncytotrophoblast were shown to be positive by immunohistochemical analysis. No fetal tissues were tested for SARS-CoV-2.24 Another study was of a second-trimester twin stillbirth in a woman with SARS-CoV-2 infection. Placental histology and immunohistochemistry of both fetuses demonstrated SARS-CoV-2 infection, and SARS-CoV-2 RNA was detected by using RT-PCR in all tissue samples (fetal lung, kidney, heart, and liver and maternal placenta, cords, and membranes), except for the kidney of the second fetus.25 Third trimester Zamaniyan et al.26 described the detection of SARS-CoV-2 in the amniotic fluid obtained during cesarean section from a pregnant woman with severe SARS-CoV-2 infection who delivered at 32 gestational weeks. Neonatal nasopharyngeal SARS-CoV-2 just after birth was negative, but positive on the second test within 24 hours of birth. Kirtsman et al.27 reported a woman with SARS-CoV-2 infection who delivered at 35 gestational weeks by cesarean section, and SARS-CoV-2 PCR testing of the placental tissue had a positive result, as did the RT-PCR test of the neonatal nasopharyngeal swabs, plasma, and stool samples, highly suggestive of utero vertical transmission. Vivanti et al28 reported a probable case of transplacental transmission of SARS-CoV-2 during late pregnancy. The amniotic fluid and placental sample tested positive for SARS-CoV-2 by RT-PCR. In addition, the placenta showed signs of intervillous inflammation that was consistent with the severe maternal systemic inflammatory status triggered by SARS-CoV-2. RT-PCR on neonatal nasopharyngeal and rectal swabs collected 1 hours after birth and blood and nonbronchoscopic bronchoalveolar lavage fluid collected in the first 6 hours after birth were all positive for SARS-CoV-2 genes. This is probably the best evidence to date for intrauterine vertical transmission of SARS-CoV-2.28 A recent multicenter prospective study including 31 pregnant women with confirmed SARS-CoV-2 infection showed that 2 of 31 newborns tested positive for SARS-CoV-2. In addition, the SARS-CoV-2 genome was detected in one umbilical cord blood sample and in 2 at-term placentas.29 A systematic review by Kotlyar et al.11 indicated that vertical transmission of SARS-CoV-2 infection in the third trimester is possible but rare. Their results showed that of 936 neonates from mothers with SARS-CoV-2 infection, 27 tested positive for SARS-CoV-2 RNA by RT-PCR with a nasopharyngeal swab. Furthermore, SARS-CoV-2 RNA was positive for 1 neonatal cord blood sample (1/34, 2.9%), 2 placenta samples (2/26, 7.7%), and 3 fecal or rectal swab samples (3/31, 9.7%), but 51 amniotic fluid samples and 17 urine samples tested negative. In addition, neonatal serology analysis based on the presence of immunoglobulin M was positive for 3 of 82 samples (3.7%).11 Serologic assessments were also performed in neonatal serum samples to explore the possibility of intrauterine vertical transmission of SARS-CoV-2.30–34 However, thus far, no conclusive and concrete evidence was found for in utero vertical transmission of SARS-CoV-2.35 Pathological basis of SARS-CoV-2 intrauterine vertical transmission The low reported rate of SARS-CoV-2 intrauterine vertical transmission is likely because in most studies, pregnant women had mild-to-moderate symptoms that manifested during the third trimester of pregnancy, and in some cases, cesarean sections were carried out immediately given the uncertainty about the risk of mother-to-fetus transmission of the virus, especially in the early pandemic. Therefore, the nonserious condition and short time interval from clinical manifestation of SARS-CoV-2 to delivery might have weakened the fetus’ chances of intrauterine infection of the virus.14,35 Notably, from a pathophysiologic viewpoint, the intrauterine SARS-CoV-2 infection for fetuses has a biological plausibility. First, it has been found that angiotensin-converting enzyme 2 receptor and transmembrane protease serine 2 required for SARS-CoV-2 entering the cells is expressed in the placenta.36–38 Although the data regarding their expression is inconsistent, and whether they have different expressions due to different gestational weeks are not clear, the angiotensin-converting enzyme 2/transmembrane protease serine 2 pathway is considered the main mechanism of transplacental invasion of SARS-CoV-2. SARS-CoV-2 can directly damage the placenta by inducing apoptosis and vascular damage. As a result, the virus can infect the fetus without the need for placental cell infection.36 In addition, the rare viraemia associated with severe SARS-CoV-2 infection may let the virus spread via the bloodstream to the uterus and then infect the fetus. Therefore, the possibility of intrauterine vertical transmission of SARS-CoV-2 requires further careful study. Knowledge gaps in SARS-CoV-2 intrauterine vertical transmission The available research until now regarding the possibility of intrauterine vertical transmission of SARS-CoV-2 has mainly involved the third trimester and shows large differences in study quality and in what data were reported. Furthermore, the finding of SARS-CoV-2 in amniotic fluid or placental tissues does not necessarily correlate with a positive RT-PCR result in the fetus or neonate.22,26,39 Thus, it is a challenge to aggregate and compare the data across studies. To date, there is a shortage of standardized international consensus definitions for the evaluation of vertical transmission of SARS-CoV-2. However, several classification systems have been initially developed to help categorize the likelihood of intrauterine transmission of SARS-CoV-2, and they all have a few requirements: (1) evidence of maternal SARS-CoV-2 infection, (2) in utero fetal SARS-CoV-2 exposure, and (3) SARS-CoV-2 persistence or immune response in the neonate.12,40,41 The studies outlining these systems emphasize that collection of appropriate specimens at appropriate times is essential to understanding of SARS-CoV-2 vertical transmission. Taking the World Health Organization12 classification system as an example to make a definite diagnosis of in utero vertical transmission, it requires 2 components. (1) Evidence of in utero exposure (RT-PCR from amniotic fluid, placental tissue, neonatal blood, upper and lower respiratory tract samples, stool, or cerebrospinal fluid; or immunoglobulin M positive); and (2) evidence of viral persistence, that is, a positive result upon repeat testing in 24 to 48 hours in sterile samples (amniotic fluid, neonatal blood, lower respiratory tract sample, or cerebrospinal fluid). In the case of fetal demise in early pregnancy, it requires fetal tissues (lung, liver, brain) for a confirmed positive result. However, in clinical practice, it is difficult to repeat the testing in 24 to 48 hours in amniotic fluid, neonatal blood, or lower respiratory tract or cerebrospinal fluid samples, making the definite diagnosis difficult. With increasing knowledge of SARS-CoV-2 vertical transmission and its clinical consequences for the fetus and neonate, the classification system might be further updated and refined. Additionally, many questions remain to be answered concerning intrauterine vertical transmission of this virus. For example, whether susceptibility to the virus is different by gestational age and whether there is a period during pregnancy when the fetus is more likely to be infected. Furthermore, does the severity of maternal illness determine the likelihood of viral transmission? Are new variants—like the Delta variant which is more aggressive and highly transmissible—able to cause more severe disease?42,43 Moreover, whether the effects of SARS-CoV-2 on the uterine vasculature and placenta can cause adverse outcomes, such as fetal growth restriction or stillbirth. To address these questions, further high-quality studies with a large sample size are needed. Longitudinal follow-up of infants born to mothers with SARS-CoV-2 infection are also needed. Furthermore, the use of animal models might accelerate our knowledge. Evidence of intrapartum and postpartum vertical transmission of SARS-CoV-2 SARS-CoV-2 is rarely detected in the vaginal swabs in infected pregnant women.3,11,44 Regarding studies about evaluation for SARS-CoV-2 in breast milk, although the virus was occasionally positive tested,45 to the potential for contamination is questionable. Furthermore, the detected SARS-CoV-2 RNA in the human milk was particle of the virus but not live virus46 Moreover, an observational cohort study reported that if correct hygiene precautions are undertaken, like consistent use of surgical masks, hand hygiene, and breast cleansing, breastfeeding can be safely carried out without the fear of SARS-CoV-2 transmission.47 Conclusions Vertical transmission of SARS-CoV-2 is possible, but rare. The relevant knowledge regarding the possible risks is still limited and controversial. Further studies investigating this issue and the subsequent fetal and neonatal consequences are needed. Further conclusive evidence regarding SARS-CoV-2 vertical transmission will help guide patient counseling and provide better obstetrical care for women with SARS-CoV-2 infection.

301. Use of a multiplex PCR assay for detection of respiratory co-infections in COVID-19 hospitalized non-ICU patients: an ace up a clinician’s sleeve

Abstract Background Bacterial co-infections in COVID-19 patients represent a significant challenge for clinicians and can impact outcomes. Rapid identification of bacterial co-pathogens improves management, and is crucial to avoid inappropriately administered antimicrobials. We evaluated the use of a multiplex PCR assay in the early detection of respiratory co-infections in COVID-19 hospitalized patients. Methods The study included non-ICU patients with high clinical suspicion of respiratory co-infection. Lower respiratory tract samples (sputum/bronchial secretions), were analyzed using BIOFIRE® FILMARRAY® pneumonia panel plus [(bioMerieux, USA), FA]. Specimens were considered as acceptable based on Gram stain. Conventional cultures were also performed. Results A total of 28 samples from 27 patients (20 males, median age 60 years, IQR 49-71) were analyzed. 8/27 patients were intubated, 5 were treated with high flow nasal canula oxygenation and 11 with high or low oxygen mask. 18 patients received dexamethasone. Co-infection was detected in 17/27 patients (62.9%). 11 specimens were collected in less than 48 hours from admission and no target was identified in 6/11. Detected pathogens and AMR genes, per sample tested, are presented in the table. Bacterial pathogens and any AMR genes were detected in 15 and 4 samples, respectively, leading to modifications of antimicrobial treatment. The semi-quantitative results along with patients’ clinical presentation assisted with differentiation of bacterial colonization versus infection, especially in cases where multiple targets were identified. De-escalation was implemented for 12 patients, for whom no co-infection or a viral co-pathogen (n=2) was detected. One patient was co-infected with another Coronavirus; further analysis, using the FA respiratory panel, detected Human coronavirus HKU-1 along with SARS-CoV-2. Median time until discharge or death was 13.5 days (IQR 9-24). Overall mortality was 33.3%. Detected pathogens, microbial load and AMR genes, per sample tested. Conclusion Implementation of FA assay proved effective for the rapid detection of respiratory co-infections in COVID-19 non-ICU patients. Molecular panel-based assays can contribute to timely adaptation of antimicrobial treatment, benefiting patient management and antibiotic stewardship strategies. Disclosures All Authors: No reported disclosures.

Bilateral Lung Transplantation With Donor Positive for COVID-19 Infection on Bronchoalveolar Lavage: A Case Report

Initial experience with lung transplant of COVID-19-positive donors was marked by disappointing results, including a reported case of mortality through donor to recipient transmission of infection. However, since that time a number of improvements in preventative and therapeutic measures against COVID-19 have been developed. We present the case of a 51-year-old woman with scleroderma-associated interstitial lung disease who was awaiting lung transplant. A potential donor with excellent lung physiology was located; however, initial testing on bronchoalveolar lavage (BAL) was positive for COVID-19. The donor had tested positive 2 weeks prior and had symptomatically recovered. Our patient had been fully vaccinated but not seroconverted. Given the history of a donor with recovering COVID infection and a fully immunized recipient, our multidisciplinary team elected to proceed with the transplant. The patient successfully underwent bilateral lung transplant with standard induction immunosuppression. Bebtelovimab was given post-transplant day 1 because the recipient remained seronegative to COVID-19. Serial bronchoalveolar lavages post transplant have been negative for COVID-19. The patient has done well after transplant. She was seen in the clinic 2 months post transplant and is ambulatory without supplemental oxygen requirements. To our knowledge, this represents the first reported successful case of lung transplant with a donor positive for COVID-19 on lower respiratory tract sampling.

Molecular detection of equid herpesvirus in bronchoalveolar lavage fluid from asymptomatic horses in Southern Brazil.

Molecular approaches to diagnose respiratory viruses have provided an opportunity for early and subclinical pathogen detection, particularly in samples from the upper respiratory tract. This study aimed to investigate the presence of herpesviruses, particularly equid herpesvirus (EHV)-2 and EHV-5, in samples from the lower respiratory tract of healthy racehorses from Southern Brazil. Samples from the lower respiratory tract (i.e., bronchoalveolar lavage fluid [BALF]) were assessed by video endoscopy, cytological evaluation of BALF, and tracheal aspirates (TA), along with quantitative polymerase chain reaction (qPCR), to detect equine herpesvirus infection in the lower respiratory tract samples and compare corresponding cytological and endoscopic findings. At least one abnormality per horse during endoscopy examination was observed, including, but not limited to, mucous secretion in the airways and pharyngeal lymphoid hyperplasia. The presence of EHV-2 and/or EHV-5 was detected by qPCR in 3/10 animals. One horse was positive for EHV-2 alone, one for EHV-5 alone, and one for both. To the authors' knowledge, this is the first molecular detection of EHV-2 and EHV-5 in Brazilian thoroughbred horses. These findings may provide new insights into the epidemiology of EHV-2 and EHV-5 in Brazilian horses, evidencing the importance of the molecular investigation, early detection, and prevention of respiratory diseases.

Respiratory virus detection in returning travelers and pilgrims from the Middle East

BackgroundPilgrims travelling to Saudi Arabia are commonly infected with respiratory viruses. Since the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) emerged in 2012, patients with acute respiratory symptoms returning from an endemic area can be suspected to be infected by this virus. Methods: 98 patients suspected to have MERS-CoV infection from 2014 to 2019 were included in this retrospective cohort study. Upper and lower respiratory tract samples were tested by real-time RT-PCR for the detection of MERS-CoV and other respiratory viruses. Routine microbiological analyses were also performed. Patient data were retrieved from laboratory and hospital databases retrospectively. Results: All patients with suspected MERS-CoV infection travelled before their hospitalization. Most frequent symptoms were cough (94.4%) and fever (69.4%). 98 specimens were tested for MERS-CoV RNA and none of them was positive. Most frequently detected viruses were Enterovirus/Rhinovirus (40/83; 48.2%), Influenzavirus A (34/90; 37.8%) and B (11/90; 12.2%), H-CoV (229E and OC43 10/83; 12% and 7/83; 8.4%, respectively). Conclusion: From 2014 to 2019, none of 98 patients returning from endemic areas was MERS-CoV infected. However, infections with other respiratory viruses were frequent, especially with Enterovirus/Rhinoviruses and Influenzaviruses.

The Additional Value of Lower Respiratory Tract Sampling in the Diagnosis of COVID-19: A Real-Life Observational Study.

Background: Since December 2019, SARS-CoV-2 has been causing cases of severe pneumonia in China and has spread all over the world, putting great pressure on health systems. Nasopharyngeal swab (NPS) sensitivity is suboptimal. When the SARS-CoV-2 infection is suspected despite negative NPSs, other tests may help to rule out the infection. Objectives: To evaluate the yield of the lower respiratory tract (LRT) isolation of SARS-CoV-2. To evaluate the correlations between SARS-CoV-2 detection and clinical symptoms, and laboratory values and RSNA CT review scores in suspect patients after two negative NPSs. To assess the safety of bronchoscopy in this scenario. Method: A retrospective analysis of data from LRT sampling (blind nasotracheal aspiration or bronchial washing) for suspected COVID-19 after two negative NPS. Chest CT scans were reviewed by two radiologists using the RSNA imaging classification. Results: SARS-CoV-2 was detected in 14/99 patients (14.1%). A correlation was found between SARS-CoV2 detection on the LRT and the presence of a cough as well as with typical CT features. Typical CT resulted in 57.1% sensitivity, 80.8% accuracy and 92.3% NPV. Neither severe complications nor infections in the personnel were reported. Conclusions: In suspect cases after two negative swabs, CT scan revision can help to rule out COVID-19. In selected cases, with consistent CT features above all, LRT sampling can be of help in confirming COVID-19.

Molecular point-of-care testing for lower respiratory tract pathogens improves safe antibiotic de-escalation in patients with pneumonia in the ICU: Results of a randomised controlled trial

Effective treatment of pneumonia requires timely administration of appropriate antimicrobials but standard diagnostic tests take around 48h to generate results. Highly accurate, rapid molecular tests have been developed for identifying organisms in lower respiratory tract samples, however their impact on antibiotic use is unknown. The aim of this study was to assess the impact of syndromic molecular point-of-care testing compared to conventional diagnostic testing, on antibiotic use. In this pragmatic, randomised controlled trial, we enrolled critically ill adults with pneumonia. Patients were assigned (1:1) to molecular testing of samples at the point-of-care or routine clinical care. The primary outcome was the proportion of patients who received results-directed antimicrobial therapy. 200 patients were randomly assigned to point-of-care testing (n=100) or the control group (n=100). 85 patients had community acquired pneumonia (42 in the mPOCT group and 43 in the control group), 69 hospital acquired pneumonia (30 in mPOCT and 39 in control) and 46 ventilator associated pneumonia (28 in mPOCT and 18 in control). The median [IQR] time to results was 1.7 [1.6-1.9] hours for point-of-care testing and 66.7 [56.7-88.5] hours for standard diagnostics (difference of -65.0h, 95%CI -68.0 to -62.0; p<0.0001). 71 (71%) patients in the point-of-care testing arm had pathogens detected compared to 51 (51%) in the control arm (difference of 20%, 95%CI 7 to 33; p=0.004). 80 (80%) of patients in the point-of-care group received results-directed therapy, compared with 29 (29%) of 99 in the control group (difference of 51%, 95%CI 39-63; p<0.0001). Time to results-directed therapy was 2.3 [1.8-7.2] hours in the mPOCT group and 46.1 [23.0-51.5] hours in the control group (difference of -43.8h, 95% CI -48.9 to -38.6; p<0.0001). 42 (42%) patients in mPOCT group had antibiotics de-escalated compared with 8 (8%) of 98 in the control group (difference of 34%, 95%CI 23-45; p<0.0001). Time to de-escalation was 4.8 [2.4-13.0] hours in the mPOCT group compared with 46.5 [26.3-48.6] hours in the control group (difference of -41.4h, 95%CI -53 to -29.7; p<0.0001). There was no major difference in antibiotic duration or in clinical or safety outcomes between the two groups. Use of molecular point-of-care testing in patients with pneumonia returned results more rapidly and identified more pathogens than conventional testing. This was associated with improvements in appropriate antimicrobial use and appeared safe.

Epidemiology of Community-Acquired Respiratory Tract Infections in Patients Admitted at the Emergency Departments

Objectives: Community-acquired respiratory infections (CARTIs) are responsible for serious morbidities worldwide. Identifying the aetiology can decrease the use of unnecessary antimicrobial therapy. In this study, we intend to determine the pathogenic agents responsible for respiratory infections in patients presenting to the emergency department of several Lebanese hospitals. Methods: A total of 100 patients presenting to the emergency departments of four Lebanese hospitals and identified as having CARTIs between September 2017 and September 2018 were recruited. Specimens of upper and lower respiratory tract samples were collected. Pathogens were detected by a multiplex polymerase chain reaction respiratory panel. Results: Of 100 specimens, 84 contained at least one pathogen. Many patients were detected with ≥2 pathogens. The total number of pathogens from these 84 patients was 163. Of these pathogens, 36 (22%) were human rhinovirus, 28 (17%) were Streptococcus pneumoniae, 16 (10%) were metapneumovirus, 16 (10%) were influenza A virus, and other pathogens were detected with lower percentages. As expected, the highest occurrence of pathogens was observed between December and March. Respiratory syncytial virus accounted for 2% of the cases and only correlated to paediatric patients. Conclusion: CARTI epidemiology is important and understudied in Lebanon. This study offers the first Lebanese data about CARTI pathogens. Viruses were the most common aetiologies of CARTIs. Thus, a different approach must be used for the empirical management of CARTI. Rapid testing might be useful in identifying patients who need antibiotic therapy.

[Shedding of SARS-CoV-2 Virus in COVID-19 Patients and Neutralizing Antibody Level].

The coronavirus disease 2019 (COVID-19) turned into a pandemic shortly after emerging in December 2019, in the city of Wuhan, China. In this study, it was aimed to investigate the presence of severe acute respiratory system coronavirus-2 (SARS-CoV-2) RNA in various clinical samples and the scattering profile of the virus and the variation of anti-SARS-CoV-2 IgG and neutralizing antibody levels over time in infected patients during and after the period of COVID-19 disease. The study included COVID-19 patients from the community (CCP) (n= 47) (May-June 2020) and healthcare workers (HCWP) (n= 30) (November-December 2020). To investigate the presence of SARS-CoV-2 in clinical samples, oropharynx (OF), nasopharynx (NF), sputum, stool, blood and urine samples were taken from the CCP group on days 0, 3, 7, 14 and 28. For the detection of anti SARS-CoV-2 IgG and neutralizing antibodies serum samples were taken from the CCP group on days 0, 3, 7, 14, 28, 60, 90 and 120 and on days 14, 28, 60, 90, 120 and 150 from HCWP group. Virus RNA was detected by reverse transcription polymerase chain reaction (RT-PCR), anti SARS-CoV-2 IgG antibody levels by enzyme-linked immunosorbent assay (ELISA), neutralizing antibody levels (NAb) by cell culture neutralization and representative neutralization test (sVNT) methods. With the onset of the vaccination program in our country, 11 of the HCWP group patients had SARS-CoV-2 vaccine after the second month serum samples were taken, the remaining HCWP group patients did not get vaccinated during the study period. SARS-CoV-2 RNA was detected with the highest rates in NF (100%), stool (65.8%), sputum (45.7%), OF (41.3%), blood (5.3%), and urine (2.2%) samples, respectively. It was found that viral shedding continued for 14 days in respiratory tract samples and up to 60 days in stool samples, and no virus was detected in blood samples after the third day. It was observed that the viral load was highest at the time of diagnosis in both upper and lower respiratory tract samples, peaking on the seventh day in stool samples and following an irregular course throughout the disease. Anti-SARS-CoV-2 IgG antibody positivity was found in 41.4% of CCP group patients on the first day of diagnosis, and seroconversion was observed in all patients at the fourth month. During the study period, seropositivity was detected in only 82.1% of the patients in the HCWP group. It was observed that the IgG antibody levels peaked at the 7th day in the CCP group patients and at the third month in the HCWP group patients (S/Co: 9.6 and 2.8, respectively). Anti-SARS-CoV-2 IgG antibody levels detected in the CCP group were found to be significantly higher than the HCWP group (p<0.05). At the end of the first month, NAb was detected in all (100%) patients in the CCP group. It was found that NAb titers peaked (1/256) on the 28th day and showed a decreasing trend from the second month. NAb median titers were observed to peak earlier in the severe HCWP group (14 days in the severe group, 28 days in the mild group, p> 0.05). It was observed that 6 (26.1%) of HCWP group patients had low, 11 (47.8%) moderate, 6 (26.1%) high titers of representative NAb. The distribution of representative NAb levels by vaccine status was examined and no statistically significant difference was found (p= 0.400, p= 0.077 and p= 0.830, respectively). As a result; SARS-CoV-2 RNA was detected in many samples such as sputum, stool, blood and urine, and it was observed that viral shedding in stool samples could continue for months. Anti-SARS-CoV-2 IgG antibody positivity was observed in most of the patients in the fourth month, and it was found that the antibody titers decreased after the third month. It was determined that protective antibody levels continued in the fourth month. These findings are important in vaccination strategies and in the fight against the pandemic. However, considering the emergence of new mutant forms of the virus in today's conditions where the pandemic continues, more detailed and comprehensive studies are needed for viral shedding and antibody titer studies.

Is obesity paradox valid for critically-ill COVID-19 patients with respiratory failure?

OBJECTIVE:We aimed to analyze the association between body mass index and mortality in patients with coronavirus disease 2019 induced acute respiratory distress syndrome.MATERIAL AND METHODS:In this retrospective cohort study, we analyzed 108 consecutive patients admitted in the intensive care unit for coronavirus disease 2019-induced lung disease in a single center between March 2020 and February 2021. Coronavirus disease 2019 infection was confirmed by real-time reverse transcription-polymerase chain reaction assay of nasal swabs or lower respiratory tract samples. Acute respiratory distress syndrome was defined using Berlin criteria. Acute respiratory distress syndrome severity was assessed with partial pressure of arterial oxygen/fraction of inspired oxygen ratio. We categorized patients according to the body mass index as underweight, <18.5 kg/m2; normal weight, from 18.5 kg/m2 to <25 kg/m2; overweight, from 25 kg/m2 to <30 kg/m2; obese, ≥30 kg/m2. Clinical characteristics and mortality were compared among groups. Demographic and clinical data were collected from electronic medical records of the hospital system.Results:The mean age was 67.3 ± 13.3 years. Study participants were predominantly males (66.7%). The mean BMI was 28.2 ± 5.6 kg/m2. There were 2 patients (2%), 28 (26%), 42 (39%), and 36 patients (33%) in the underweight, normal-weight, overweight, and obese groups, respectively. The hospital mortality was 40.7%. There was no association between body mass index and mortality (P = .09). In multivariate analysis, mortality was associated with the presence of cancer [odds ratio = 7.338 (1.636-32.914), P = .009], and time between diagnosis and intubation [odds ratio = 1.318 (1.150-1.509), P ≤ .001].Conclusion:Neither acute respiratory distress syndrome severity nor mortality was higher in patients with higher body mass index compared to the ones with normal body mass index.

Short-term kidney transplant outcomes from severe acute respiratory syndrome coronavirus 2 lower respiratory tract positive donors.

ObjectiveIn this study, we aim to assess short‐term allograft outcomes following deceased donor kidney transplantation from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) lower respiratory tract (LRT) nucleic acid testing (NAT) positive donors.MethodsFrom September to December 2021, SARS‐CoV‐2 NAT positive organ donors, whose solid abdominal organs were transplanted at our academic medical center were identified. Donors were stratified into having tested positive for SARS‐CoV‐2 in an upper respiratory tract (URT) or LRT sample. For this study, the SARS‐CoV‐2 LRT NAT positive deceased kidney donors and their respective recipients were examined. Donor and recipient demographic data, coronavirus disease 2019 (COVID‐19)‐related history, patient outcomes, as well as postoperative graft function were evaluated.ResultsThirteen SARS‐CoV‐2 positive deceased donors were identified. Of these, eight were LRT NAT positive and yielded nine kidneys. These allografts were successfully transplanted into vaccinated and unvaccinated recipients. All recipients received standard induction immunosuppression and did not receive any prophylactic therapy for SARS‐CoV‐2. Two recipients had delayed graft function. At 1‐month post‐transplant, there was no clinical evidence of donor‐derived COVID‐19 or graft loss, and all recipients were free from dialysis.ConclusionWe describe the first case series of SARS‐CoV‐2 LRT NAT positive deceased kidney donors for vaccinated and unvaccinated recipients with excellent short‐term allograft outcomes and no clinical evidence of donor‐derived COVID‐19 post‐transplantation. Given the increasing prevalence of SARS‐CoV‐2 in the population, utilization of SARS‐CoV‐2 LRT NAT positive deceased donors could be considered an acceptable source of organs for renal transplantation, especially as multi‐center experiences and longer‐term follow‐up emerge.