Severe Sepsis Syndrome Research Articles

A tagging polymorphism in fat mass and obesity-associated (FTO) gene is associated with sepsis status in children.

Sepsis is one of the most common causes of death in patients admitted to intensive care units (ICUs). The development of sepsis is significantly influenced by genetic predisposition. In this study, we highlight a potential association between a variant of the fat mass and obesity-associated (FTO) gene and risk of sepsis in children and adolescents. We investigated a first-intron tagging FTO polymorphism (rs17817449) by comparing a severe condition (SC) group, comprising 598 paediatric patients (ages 0-19 years) admitted to an ICU with fever, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, or multiple organ dysfunction syndrome (MODS), with a control group consisting of 616 healthy young adults. We observed a lower prevalence (p < 0.01; OR = 0.59, 95% CI = 0.39-0.87) of the FTO TT genotype in febrile and SIRS patients compared to patients with severe illness. There was a borderline trend towards a lower prevalence of the FTO TT genotype in the control group compared to the SC group (p < 0.09, OR = 0.81, 95% CI = 0.62-1.06). Our findings suggest that rs17817449, a common FTO polymorphism, may be a predictor of sepsis in paediatric patients, and that higher body weight is protective against this clinical complication.

The efficacy of Omega-3 polyunsaturated fatty acids for severe burn patients: A systematic review and trial sequential meta-analysis of randomized controlled trials

Severe burns lead to metabolic changes, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. Omege-3 polyunsaturated fatty acids (PUFAs) have anti-inflammatory properties. In the absence of substantial evidence for use on major burns, we systematically reviewed the efficacy of omega-3 PUFAs for patients with severe burns. We comprehensively searched MEDLINE, Web of Science, Embase, Cochrane Library, China National Knowledge Internet, Wang Fang Data, Chinese Biomedicine Database, and Science Direct databases to collect randomised controlled trials of omega-3 PUFAs administered to patients with burns from January 2000 to June 2023. Two researchers independently screened the literatures, extracted the data, and assessed the risk of bias in the included studies. The outcomes were mortality, the risk of severe sepsis, septic shock, and multiple organ dysfunction syndrome. Data synthesis was conducted using Review Manager. Trial sequential analyses (TSA) for outcomes were performed. Three randomised controlled trials involving 140 patients were included. Of these, 71 patients received omega-3 PUFAs. The results showed that omega-3 PUFAs significantly reduced the incidence of severe sepsis, septic shock, multiple organ dysfunction syndrome (RR=0.38, 95% CI [0.19, 0.75], P=0.005), C-reactive protein levels (MD=-39.70[-81.63, 2.23], P=0.06), and improved respiratory outcomes. However, there was no difference in 14-day mortality (RR=1.10, 95%CI [0.59, 2.05], P=0.75). TSA showed that the results for the incidence of severe sepsis, septic shock, multiple organ dysfunction syndrome are insufficient and inconclusive. Omega-3 PUFAs may reduce inflammatory response and risk of sepsis, septic shock, and multiple organ dysfunction syndrome in severe burns patients and may shorten hospital stay but cannot reduce risk of death. Due to the limitation of the quantity and quality of the included studies, the evidence level is low, and the conclusions need to be verified by larger scale and higher quality randomised controlled trials.

Experience of management of pediatric upper gastrointestinal perforations: a series of 30 cases.

This study aimed to explore the characteristics of pediatric upper gastrointestinal (UGI) perforations, focusing on their diagnosis and management. Between January 2013 and December 2021, 30 children with confirmed UGI perforations were enrolled, and their clinical data were analyzed. Two groups were compared according to management options, including open surgical repair (OSR) and laparoscopic/gastroscopic repair (LR). A total of 30 patients with a median age of 36.0 months (1 day-17 years) were included in the study. There were 19 and 11 patients in the LR and OSR groups, respectively. In the LR group, two patients were treated via exploratory laparoscopy and OSR, and the other patients were managed via gastroscopic repair. Ten and three patients presented the duration from symptom onset to diagnosis within 24 h (p = 0.177) and the number of patients with hemodynamically unstable perforations was 4 and 3 in the LR and OSR groups, respectively. Simple suture or clip closure was performed in 27 patients, and laparoscopically pedicled omental patch repair was performed in two patients. There was no significant difference in operative time and length of hospital stay between the LR and OSR groups. Treatment failed in two patients because of severe sepsis and multiple organ dysfunction syndrome, including one with fungal peritonitis. Surgery for pediatric UGI perforations should be selected according to the general status of the patient, age of the patient, duration from symptom onset, inflammation, and perforation site and size. Antibiotic administration and surgical closure remain the main strategies for pediatric UGI perforations.

The Effect of Therapeutic Hypothermia on Prognosis in Patients Receiving Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is a commonly used therapeutic modality in the pediatric intensive care unit (PICU) for the treatment of severe acute kidney injury, as well as for addressing metabolic abnormalities, fluid-electrolyte imbalances, and acid-base disorders. According to reports, therapeutic hypothermia treatment has demonstrated the ability to decrease cellular metabolism, oxygen consumption, formation of free radicals, cell death, and inflammatory signals. The study encompassed all individuals who underwent CRRT at both Manisa City Hospital and Manisa Celal Bayar University Hospital throughout the period from February 2021 to November 2022. A total of 14 patients who received CRRT were subjected to a warming procedure utilizing an external blanket and an external heater attached to the CRRT venous return line, resulting in the attainment of a body temperature exceeding 36°C. Therapeutic hypothermia was implemented on 12 patients to maintain their body temperature within the range of 32-35°C. The study population exhibited a median age of 24.5 months, with males comprising 61.5% of the sample. A therapeutic hypothermia treatment was administered to a cohort of 12 patients. The patients who had therapeutic hypothermia exhibited a significantly reduced vasoactive-inotropic score (p = 0.038). Patients who did not receive therapeutic hypothermia exhibited a prolonged need for mechanical ventilation (p = 0.020). The duration of stay in the PICU for patients who underwent therapeutic hypothermia was shown to be considerably shorter compared to those who did not receive therapeutic hypothermia (p = 0.047). The potential efficacy of moderate therapeutic hypothermia appears promising, particularly in the context of patients who are receiving CRRT for severe sepsis and acute respiratory distress syndrome. This is attributed to the anti-inflammatory properties and hypometabolic effects associated with this intervention. To the best of our current understanding, this study represents the initial investigation showcasing the effectiveness of combining therapeutic hypothermia with CRRT in the pediatric population.

Pathogenetic correlation of severe sepsis and multiple organ dysfunction syndrome provoked by multiple infections in perinatal period of women

Introduction. Despite significant advances in diagnosis, medical management and antimicrobial therapy, sepsis in the puerperium remains an important cause of maternal morbidity and mortality. The abnormalities associated with the clinical syndrome of sepsis result from a nonspecific innate inflammatory response. This is due to the fact that sepsis represents a systemic inflammatory response syndrome (SIRS) to infection or injury; therefore, it can rapidly progress to septic shock and death despite aggressive treatment. Severe sepsis with MODS has a mortality rate of 20– 40%, rising to around 60% if septicemic shock develops. Symptoms of sepsis may be less distinctive than in the non-pregnant population and are not necessarily present in all cases; therefore, a high index of suspicion is necessary. The major pathogens causing sepsis in the puerperium are: group A streptococcus (GAS), also known as Streptococcus pyogenes, Escherichia coli, Staphylococcus aureus, Streptococcus pneumonia, methicillin-resistant S. aureus (MRSA), Clostridium septicum, Morganella morganii and antibiotic-resistant Stenotrophomonas Moltrophilia. Multiple risk factors for maternal sepsis have been identified: obesity, impaired glucose tolerance/diabetes, impaired immunity/immunosuppressant medication, anemia, vaginal discharge, history of pelvic infection, amniocentesis and other invasive procedures, cervical cerclage, prolonged spontaneous rupture of membranes, caesarean section, wound hematomas, retained products of conception, GAS infection, vaginal trauma. Material and methods. Presentation of case report using the following key-words: „infection”, „systemic inflammatory response syndrome (SIRS)”, „severe sepsis”, „septic shock”, „multiorgan dysfunction syndrome (MODS)”. Results. We present a case of perinatal infections complicated with MODS. Conclusions. The presence of pelvic hematomas triggers the sepsis caused by multiple infections in perinatal period and can significantly increase the morbidity related to bleeding, infection, surgery and blood product transfusion. The clinical situation may worsen in the presence of pre-existing pathological conditions before pregnancy.

Successful treatment of a patient with severe sepsis and multiple organ failure syndrome complicating the course of purulent wounds of various locations

The article describes the complex surgical treatment of a patient with a bilateral hip phlegmon complicated by severe sepsis, multiple organ failure syndrome (cardiac, respiratory), as well as deep pressure ulcers of various depths and localization under the primarily diagnosed diabetes mellitus.

High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19

Intravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated. This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest. From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439). HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.

Infecciones por estreptococo

Microorganisms of the Streptococcus spp. genus form a group of gram-positive cocci that includes notable human pathogens, such as Streptococcus pneumoniae, Streptococcus pyogenes, and Streptococcus agalactiae. Streptococci form part of the human microbiota of the nasopharynx, digestive system, skin, and mucosa and are the etiological agents of a large number of infectious diseases such as various respiratory system infections, skin and soft tissue infections, bacteremia, endocarditis, meningitis, severe sepsis, necrotizing fasciitis, and toxic shock syndrome. The diagnosis of infections caused by streptococci is based on the combination of signs and symptoms and the results of a microbiological study. The identification of streptococci as etiological agents requires a bacteria culture of the samples of interest combined with rapid antigen tests or molecular biology techniques. Streptococci are sensitive to beta-lactam antibiotics. Third- generation cephalosporins are the antibiotics of choice for invasive infections such as bacteremia or meningitis and clindamycin is of great use in necrotizing fasciitis due to its immunomodulating effects and its inhibition of exotoxins and other virulence factors. Given the current rates of macrolide resistance, their use is advised against. Prevention is fundamental.

A Fatal Case of Febrile Ulceronecrotic Mucha-Habermann Disease in a 10-Year-Old Boy.

A Fatal Case of Febrile Ulceronecrotic Mucha-Habermann Disease in a 10-Year-Old Boy.

Gene Co-Expression Analysis Identified Preserved and Survival-Related Modules in Severe Blunt Trauma, Burns, Sepsis, and Systemic Inflammatory Response Syndrome.

BackgroundSevere trauma and burns accompanied by sepsis are associated with high morbidity and mortality. Little is known about the transcriptional similarity between trauma, burns, sepsis, and systemic inflammatory response syndrome (SIRS). Uncovering key genes and molecular networks is critical to understanding the biology of disease. Conventional analysis of gene changes (fold change) analysis is difficult for time-serial data such as post-injury blood transcriptome.MethodsWeighted gene co-expression network analysis (WGCNA) was applied to the trauma dataset to identify modules and hub genes. Module stability was tested by half sampling. Module preservations of burns, sepsis, and SIRS were calculated using trauma as reference. Module functional enrichment was analyzed in gProfiler server. Candidate drugs were screened using Connectivity Map based on hub genes. The modules were visualized in Cytoscape.ResultsSeventeen modules were identified. The modules were robust to the exclusion of half the sample. They were involved in lymphocyte and platelet activation, erythrocyte differentiation, cell cycle, translation, and interferon signaling. In addition, highly connected hub genes were identified in each module, such as GUCY1B1, BCL11B, HMMR, and CEACAM6. High BCL11B (M13) or low CEACAM6 (M27) expression indicates better survival prognosis in sepsis patients regardless of endotype class and age. Network preservation in burns, sepsis, and SIRS showed a general similarity between trauma and burns. M4, M5, M13, M16, M20, and M27 were significantly associated with injury time in trauma and burns. High M13 (T cell activation), low M15 (cell cycle), and low M27 (neutrophil activation) indicate better survival of sepsis patients, regardless of endotype class and age. Moreover, the modules can efficiently separate patients with different diseases. Some modules and hub genes have good prognostic performance in sepsis. Based on the hub genes of each module, six candidate drugs were screened.ConclusionThis study first compared the gene co-expression modules in trauma, burns, sepsis, and SIRS. The identified modules are useful for disease prognosis and drug discovery. BCL11B and CEACAM6 may be promising biomarkers for sepsis risk assessment.

Enteral feeding and the microbiome in critically ill children: a narrative review

ObjectiveThis narrative review summarizes our current knowledge on the interplay between enteral nutrition (EN) and gut microbiota in critically ill children, using examples from two commonly encountered diagnoses in the pediatric intensive care unit (PICU): severe sepsis and acute respiratory distress syndrome (ARDS). This review will also highlight potential areas of therapeutic interventions that should be explored in future studies.BackgroundCritically ill children display extreme dysbiosis in their gut microbiome. Factors within the PICU that are often associated with dysbiosis include the use of broad-spectrum antibiotics, proton-pump inhibitors (PPIs), intravenous morphine, and fasting. Dysbiosis can potentially lead to adverse clinical outcomes (e.g., nosocomial infection, and prolonged hospitalization). EN may modulate dysbiosis. The gut microbiota is involved in the breaking down of macronutrients, mainly carbohydrates and proteins. Fermentation of undigestible carbohydrate (e.g., inulin and oligosaccharides), and amino acids by large intestine microbiota produces short chain fatty acids (SCFAs). SCFAs serve as the main fuel source for enterocytes and help to maintain healthy gut lining. Changes to selected components of macronutrients can result in alterations in gut microbiome and have potentially beneficial effects in patients in the PICU.MethodsA comprehensive search of the MEDLINE, Cochrane Library and Google Scholar databases was conducted using appropriate MESH terms and keywords. In this narrative review, we provide a summary of current knowledge on effect of EN on gut microbiota in pediatric studies, but also describes animal- and lab-based, as well as adult studies where relevant.ConclusionsThe gut microbiome can be altered by dietary modifications and common PICU practices and treatment. Although there are strong associations in restoring eubiosis and improvement in clinical outcomes, proving causality remains challenging. Further microbiome research is needed to provide mechanistic insights into the impact of the ever changing gut microbiome. In the future, new microbiota targeted therapies could potentially be the treatment of challenging PICU conditions and restore homeostasis in these children.

Neurological Outcome According to the Site of Cannulation in Septic Children Supported by Venoarterial Extracorporeal Membrane Oxygenation.

The impact of cervical cannulation on neurologic outcome has not been yet studied among children receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the context of severe sepsis or septic shock. A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. A total of 559 children weighing less than 20 kg with a primary or secondary diagnosis of severe sepsis, septic shock or toxic shock syndrome were included between January 1, 2010, and December 31, 2019. Cervical cannulation was performed in 485 children (87%) and central cannulation in 74 children (13%). The prevalence of acute neurologic event (ANE) was 32%, including clinical and/or electroencephalographic seizures, cerebral infarction, cerebral hemorrhage, and/or brain death. In multivariable analysis, we did not find an association between cervical cannulation and greater/lesser odds of ANE during ECMO (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] 0.72-2.65; P = 0.326). Only pre-ECMO acidosis was independently associated with the development of ANE (pH < 6.99; aOR = 2.71, 95% CI 1.34-5.49; P = 0.006; pH 6.99 to <7.12; aOR = 2.57, 95% CI 1.37-4.82; P = 0.003). Thus, the site of cannulation appears not as a modifiable neurologic risk factor in this young septic population.

Carboxyhemoglobin, Methemoglobin and Lactate Levels in Patients with Systemic Inflammatory Response Syndrome

Background: Systemic inflammatory response syndrome (SIRS) is a common, severe inflammatory condition. This condition forms the basis of the definitions of sepsis, severe sepsis, septic shock, and multiple organ failure syndromes. The diagnosis can be made earlier with arterial blood gas analysis, which can provide a lot of information within minutes. This study aimed to determine the value of carboxyhemoglobin (COHb), methemoglobin (metHb), and lactate levels in the prognosis and mortality of patients with SIRS. Methods: Patients who met the SIRS criteria with the first vital signs and laboratory values and who had arterial blood gas analysis according to the clinician’s decision were included in the study. The demographic characteristics, prognosis and correlation of 1-month mortality rates of patients with baseline COHb, metHb and lactate levels were investigated. Results: Among non-smoker patients, no significant difference was found between fCOHb values and age, gender, presence of infection, blood pressure, department of hospitalization, and 1-month mortality rates (p>0.05). Also, the relationship between fCOHb values and length of stay in the hospital was not statistically significant (r = -0.013, p = 0.883). Among the patients included in the study; there was no significant difference in metHb values between age groups (p = 0.9941), gender (p = 0.6422), presence of infection (p = 0.1311), blood pressure (p = 0.7711), length of stay in hospital (p = 0.737), inpatient clinics (p = 0.6722) and 1-month mortality (p = 0.8752). Lactate values were found to be correlated with the 1-month mortality of the patients (p = 0.005). Lactate levels were significantly higher in patients who died within 1-month compared to those who survived. Conclusions: In patients with SIRS, initial COHb and metHb values cannot be considered a predictor for prognosis and mortality. However, lactate values may be useful to predict SIRS mortality even during hospital admission.

Severe acute myopathy following SARS-CoV-2 infection: a case report and review of recent literature

BackgroundSARS-CoV2 virus could be potentially myopathic. Serum creatinine phosphokinase (CPK) is frequently found elevated in severe SARS-CoV2 infection, which indicates skeletal muscle damage precipitating limb weakness or even ventilatory failure.Case presentationWe addressed such a patient in his forties presented with features of severe SARS-CoV2 pneumonia and high serum CPK. He developed severe sepsis and acute respiratory distress syndrome (ARDS) and received intravenous high dose corticosteroid and tocilizumab to counter SARS-CoV2 associated cytokine surge. After 10 days of mechanical ventilation (MV), weaning was unsuccessful albeit apparently clear lung fields, having additionally severe and symmetric limb muscle weakness. Ancillary investigations in addition with serum CPK, including electromyogram, muscle biopsy, and muscle magnetic resonance imaging (MRI) suggested acute myopathy possibly due to skeletal myositis.ConclusionWe wish to stress that myopathogenic medication in SARS-CoV2 pneumonia should be used with caution. Additionally, serum CPK could be a potential marker to predict respiratory failure in SARS-CoV2 pneumonia as skeletal myopathy affecting chest muscles may contribute ventilatory failure on top of oxygenation failure due to SARS-CoV2 pneumonia.

AN OVERVIEW THE USE OF VITAMIN C FOR COVID-19 PATIENT

Coronavirus disease 2019 (COVID-19) as an emerging disease has not yet been accompanied by standardized treatment. One of the potential medicines used to treat COVID-19 cases is vitamin C, which can be used in COVID-19 therapy because it can boost the immune system and function as an antioxidant. Consuming vitamin C can increase the work of white blood cells, reduce tissue and cell damage, and minimize virus proliferation. Vitamin C insufficiency is thought to create an individual more helpless to illness. Meanwhile, someone suffering from a disease will have an increased need for vitamin C due to a high inflammatory and metabolic process. For Indonesians, the nutritional adequacy ratio (RDA) of vitamin C is 90 mg/day for men over 15 years of age and 75 mg/day for women over 15 years of age. This sufficiency can be met from food, such as vegetables and fruit. However, if you cannot fulfill it from food alone, you can add supplements. Several clinical trials regarding the administration of vitamin C in patients with severe Covid-19 sepsis and acute respiratory distress syndrome (ARDS) and complications of sepsis have shown results as empirical therapy.

Incidence and Outcomes of Acute Kidney Injury in Critically Ill Patients with Coronavirus Disease 2019.

Patients with more severe cases of coronavirus disease-19 (COVID-19) may be at greater risk for developing acute kidney injury (AKI). The aim of our study was to analyze incidence and outcomes of AKI in critically ill patients with COVID-19. Our study prospectively followed about 198 patients with COVID-19 admitted to intensive care unit (ICU), Al Adan Hospital, Kuwait, for developing AKI and outcomes. Age, gender, nationality, history of hypertension, diabetes mellitus, ischemic heart disease, congestive heart failure, bronchial asthma, and chronic obstructive pulmonary disease were analyzed. The need for mechanical ventilation (MV), extracorporeal membrane oxygenation, inotropes, and medications was recorded. Causes of AKI, indication of dialysis, dialysis modality, dialysis outcomes, and mortality were analyzed. Our study reported that61 out of 198 (30.8%) ICU patients positive for COVID-19, developed AKI according to the Kidney Disease Improving Global Outcomes definition of AKI. Forty-eight out of 61 (79%) patients need continuous renal replacement therapy using continuous venovenous hemodiafiltration. Thirty-seven (61%) out of 61 patients were with severe sepsis syndrome. The most common cause of AKI was sepsis, cytokine storm, hypovolemia, heart failure, MV, and nephrotoxic drugs. Twenty-four patients (39%) out of 61 patients died, and the most common cause of death was sepsis, cytokine storm with respiratory failure, heart failure, and AKI. The outcome of AKI was as follows: six patients (10%) had complete recovery, five patients had partial recovery (8%), and 26 (43%) patients became dialysis dependent. Incidence of AKI is high in ICU COVID-19 patients and is associated with poor outcomes and high mortality. Early detection and specific therapy of kidney changes, including adequate hemodynamic support and avoidance of nephrotoxic drugs, may help to improve critically ill patients with COVID-19.

Short and long-term mortality in severe sepsis/septic Shock in a setting with low antibiotic resistance centers

Background: Sepsis, which is a common inflammatory response to severe infection, is one of the major causes of mortality in hospitalized patients. Sepsis, severe sepsis or sepsis syndrome, and eventually septic shock, may be seen in the development of infection. The aim of this study was to evaluate the short-term and long-term mortality in patients with severe sepsis and septic shock in centers with low antibiotic resistance. Methods: In this cross-sectional study, blood culture samples and peripheral blood samples were taken from all patients for para-clinical tests. The severity of severe sepsis and septic shock was assessed by the APACHE II and SOFA clinical criteria. Sepsis risk factors and primary causes of sepsis were recorded. Results: From 100 patients, 55% had severe sepsis and 45% had septic shock. SOFA24h and SOFA96h scores were significantly higher in patients with septic shock. The most common primary cause of sepsis was related to abdominal infections with a frequency of 42%. The frequency of confirmed positive blood culture was 53%. The most commonly isolated pathogen was E.coli with a frequency of 66%. Short-term mortality was 29% and long-term mortality was 28.2%. Conclusion: The main risk factors affecting the mortality of patients were age-related septic shock, cardiovascular disease; hypertension, immunosuppression, and SOFA score.

Clinical Characteristics and Outcomes of Hospitalized and Critically Ill Children and Adolescents with Coronavirus Disease 2019 at a Tertiary Care Medical Center in New York City

ObjectiveTo describe the clinical profiles and risk factors for critical illness in hospitalized children and adolescents with coronavirus disease 2019 (COVID-19).Study designChildren 1 month to 21 years of age with COVID-19 from a single tertiary care children's hospital between March 15 and April 13, 2020 were included. Demographic and clinical data were collected.ResultsIn total, 67 children tested positive for COVID-19; 21 (31.3%) were managed as outpatients. Of 46 admitted patients, 33 (72%) were admitted to the general pediatric medical unit and 13 (28%) to the pediatric intensive care unit (PICU). Obesity and asthma were highly prevalent but not significantly associated with PICU admission (P = .99). Admission to the PICU was significantly associated with higher C-reactive protein, procalcitonin, and pro-B type natriuretic peptide levels and platelet counts (P < .05 for all). Patients in the PICU were more likely to require high-flow nasal cannula (P = .0001) and were more likely to have received Remdesivir through compassionate release (P < .05). Severe sepsis and septic shock syndromes were observed in 7 (53.8%) patients in the PICU. Acute respiratory distress syndrome was observed in 10 (77%) PICU patients, 6 of whom (46.2%) required invasive mechanical ventilation for a median of 9 days. Of the 13 patients in the PICU, 8 (61.5%) were discharged home, and 4 (30.7%) patients remain hospitalized on ventilatory support at day 14. One patient died after withdrawal of life-sustaining therapy because of metastatic cancer.ConclusionsWe describe a higher than previously recognized rate of severe disease requiring PICU admission in pediatric patients admitted to the hospital with COVID-19.

Methicillin resistant Staphylococcus aureus: a review of the present Indian scenario and drug treatment

Methicillin-resistant strains of S. aureus cause infections that are associated with higher mortality rates and increased length of hospital stays, than infections caused by methicillin-susceptible strains. The mechanism by which MRSA strains develop resistance is by the production of an altered penicillin-binding protein (PBP), which has a decreased affinity for most semisynthetic penicillins. MRSA has increased in prevalence and has become endemic in the Indian subcontinent, with incidence varying from 25% in Western regions to 50% in Southern India. A multi-centric study conducted across 15 tertiary care centers in India from 2008 to 2009 showed overall prevalence of MRSA infection to be 41% among S. aureus isolates, and recent Indian studies from 2014 and 2018 have also suggested an increasing prevalence of MRSA. Transmission is mainly horizontal and concerns high risk populations (patients with prolonged hospital stay, on haemodialysis, receiving cancer treatment or specific medications that affect immune function, intravenous drug users and individuals who have had surgery in the recent past. Community Acquired MRSA has emerged as significant pathogen responsible for potentially fatal infections including life-threatening pneumonia, necrotizing fasciitis, endocarditis, osteomyelitis, severe sepsis, and toxic shock syndrome. Diagnosis is mainly by gram stain, culture and quantitative PCR. Newer techniques include Multi-locus sequence typing (MLST), Pulsed-field gel electrophoresis (PFGE), Bacteriophage typing, spa locus typing and SCCmec typing. Although Vancomycin was previously considered the definitive treatment for serious MRSA infections, the emergence of less-susceptible strains, poor clinical outcomes, and increased nephrotoxicity with high-dose therapy have deterred its use as first-line therapy in many cases. Although a number of new and effective antimicrobial agents are now available for the treatment of MRSA, their exact role and choice of agent needs to be well-defined.

Clinical outcomes of patients treated with intravenous zanamivir for severe influenza A(H1N1)pdm09 infection: a case report series

BackgroundIntravenous (IV) zanamivir could be a suitable alternative for the treatment of severe influenza A(H1N1)pdm09 infection in patients who are unable to take oral or inhaled medication, for example, those on mechanical ventilation and extracorporeal membrane oxygenation (ECMO). However, data on the clinical outcomes of such patients is limited.Case presentationWe report the clinical outcomes of four patients who were admitted at the intensive care unit during the 2017–2018 influenza season with severe sepsis (SOFA score > 11) and acute respiratory distress syndrome requiring ECMO and mechanical ventilation. Two patients were immune-compromised. The A(H1N1)pdm09 genome was confirmed by polymerase chain reaction (PCR) on nasopharyngeal specimen swabs prior to administration of IV zanamivir at a dose of 600 mg twice daily. Weekly qualitative PCR analysis was done to monitor viral clearance, with zanamivir treatment being discontinued upon receipt of negative results. In addition, the patients were managed for concomitant multidrug-resistant bacterial infections, with infection resolution confirmed with blood cultures.The median time for zanamivir treatment was 10 days (IQR 10–17). The clinical outcome was favourable with all four patients surviving and improving clinically. All four patients achieved viral clearance of A(H1N1)pdm09 genome, and resolution of multidrug-resistant bacterial infections.ConclusionsIV zanamivir could be a good therapeutic option in patients with severe influenza A(H1N1)pdm09 infection who are unable to take oral or aerosolised antiviral medication. We recommend prospective randomized control trials to support this hypothesis.