Alveolar-Arterial Gradient Is an Early Marker to Predict Severe Pneumonia in COVID-19 Patients.

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

Invasive cryptococcal disease in COVID-19: systematic review of the literature and analysis.

During the Coronavirus Disease 2019 (COVID-19) pandemic, an increasing number of fungal infections associated with SARS-CoV-2 infection have been reported. Among them, cryptococcosis could be a life-threatening disease. We performed a Systematic Review (PRISMA Statement) of cryptococcosis and COVID-19 co-infection, case report/series were included: a total of 34 cases were found, then we added our case report. We collected patients' data and performed a statistical analysis comparing two groups of patients sorted by outcome: "dead" and "alive". Three cases were excluded for lack of information. To compare categorical data, we used a Fisher-exact test (α=0.05). To compare quantitative variables a U Mann-Whitney test was used (α=0.05), with a 95% Confidence Interval. A total of 32 co-infected patients were included in the statistical analysis. Mortality rate was 17/32 (53.1%): these patients were included in "dead" group, and 15/32 (46.9%) patients survived and were included in "alive" group. Overall, males were 25/32 (78.1%), the median age was 60 years (IQR 53-70) with non-statistically significant difference between groups (p=0.149 and p=0.911, respectively). Three variables were associated with mortality: ARDS, ICU admission and inadequate treatment. Overall, 21 out of 24 (87.5%) patients were in ARDS with a statistically significant difference among two groups (p=0.028). ICU admission for COVID-19 was observed in 18/26 (69.2%), more frequently among dead group (p=0.034). Finally, 15/32 (46.9%) patients had adequate treatment (amphotericin B + flucytosine for invasive cryptococcosis) mostly among alive patients (p=0.039). In conclusion, mortality due to cryptococcal infection among COVID-19 patients remains high but an early diagnosis and appropriate treatment could reduce mortality.

Effectiveness of a screening program for HBV, HCV, and HIV infections in African migrants to Sicily.

BACKGROUND: Migrants from Africa are vulnerable to viral infections during their journey. METHODS: Migrants who arrived in western Sicily were offered early screening for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infection. A questionnaire was administered to evaluate risk factors, and antiviral therapy was offered to subjects with active infection. A multiple regression analysis and adjusted odds ratio were obtained to evaluate risk factors. RESULTS: Overall, 2,639 of 2,751 (95.9%) migrants who arrived between 2015 and 2017 accepted screening and 1,911 (72.4%) completed the questionnaire. HBsAg was positive in 257 (9.7%) migrants, 24 (0.9%) were anti-HCV positive and 57 (2.2%) had HIV infection. The prevalence of HBV infection was higher in women (aOR 2.47,95%CI 1.90-3.20),p = 0.003) and in people who endured physical and/or sexual violence (aOR 2.24,95%CI 1.87-3.55,p<0.001), while HIV infection was more frequent in women (aOR 5.40,95%CI 3.09-9.43, p <0.001) who were in Libya for a long period (aOR 5.66,95%CI 2.90-10.70,p = 0.004) and endured physical and/or sexual violence (aOR 14.77,95%CI 8.34-22.11,p<0.001). Being older than 18 was associated with HCV infection (p<0.001). Overall, 77% of 57 subjects with HIV infection were retained in care, 79% of 70 chronic HBV hepatitis cases started nucleot(s)ide analogues and 61% of 18 HCV-RNA positive cases received direct-acting antiviral therapy. CONCLUSIONS: These findings evidence the effectiveness and feasibility of infectious disease screening programs for migrants.

Tuberculosis among Migrant Populations in Sicily: A Field Report.

BACKGROUND: In the EU, tuberculosis (TB) mainly affects vulnerable people, including migrants. From 2014 to 2017, we have estimated the frequency of both tuberculosis and latent tuberculosis infection (LTBI) among the migrant population hosted in 41 reception centers in western Sicily (ITaCA network). MATERIALS AND METHODS: All migrants were consecutively recruited for the screening of TB infection with physical examination and TST in 1,020 migrants and with IGRA in the others 2,690. The screening was carried out 4-8 weeks after landing in Sicily. For all migrants with a positive screening test, chest X-ray and smear examination were performed. LTBI was defined by positivity of TST or IGRA with negative X-ray chest, clinical, and smear examination. Active TB was defined by radiological and/or clinical and/or sputum positivity in a patient with a TST or IGRA positivity. RESULTS: We evaluated a total of 3,710 migrants, of which 89% came from Sub-Saharan countries; 2,811 were males, 899 were females, with a median age of 22 years (IQR: 18-25). TB infection was diagnosed in 501 persons (13.5%) of which 440 (11.8%) had LTBI and 61 had active TB (1.6%): 1 had lymph node TB, 1 had intestinal TB, and 59 had pulmonary TB (38 sputum smear positive TB; no drug-resistant TB were observed). CONCLUSIONS: TB screening is critical to early diagnosis and treatment.

Multidrug-resistant Gram-negative post-neurosurgical meningitis and the role of intraventricular colistin: a case series.

The aim of this study was to report the clinical experience of intraventricular colistin for the treatment of multi-resistant Gram-negative post-surgical meningitis in a tertiary hospital. Post-neurosurgical meningitis (PNM) is one of the life-threatening complications of neurosurgical procedures, and is frequently sustained by Acinetobacter baumannii and Klebsiella pneumoniae. Here we describe our experience of five cases of PNM caused by gram-negative multi-drug resistant (MDR) bacteria, treated with intraventricular (IVT) colistin, admitted to the Neurosurgery Unit of A.R.N.A.S. Civico of Palermo, Italy, from January 2016 to June 2020. In four patients the cerebrospinal fluid (CSF) culture was positive for A. baumannii, while in one patient it was positive for K. pneumoniae. IVT colistin therapy was administered for a median time of 18 days (range 7-29). The median time to CSF negativization was seven days (range 5-29). IVT colistin administration was associated with intravenous administration of meropenem and colistin in all patients. As regards clinical outcome, four patients were successfully treated and were subsequently discharged, while one patient died following respiratory complications and subsequent brain death. IVT colistin administration is an effective therapy for MDR post-neurosurgical meningitis and its administration is also prescribed by guidelines. However, IVT therapy for Gram-negative ventriculitis is mostly understudied. Our paper adds evidence for such treatment that can actually be considered life-saving.

Urinary schistosomiasis in migrant population: a case series from a single centre in southern Italy.

PURPOSE: To understand the frequency of urinary schistosomiasis, in migrants in clinical follow-up at the infectious disease outpatient clinic of ARNAS Civico Hospital in Palermo Italy, to raise awareness on this neglected tropical disease. METHODS: A retrospective analysis of migrant patients in clinical care in our centre during the triennium 2015-2017. RESULTS: 2639 migrants have been in clinical care during the triennium 2015-2017, 72% are male and 28% are female. 214 patients were tested for the presence of Schistosoma eggs in urine, these patients are all male. All the patients tested, reported macroscopic haematuria and the 54% had an increase in the peripheral blood eosinophil count. Ninety subjects had a positive microscopic examination for Schistosoma haematobium eggs. Patients were treated with a standard dose of praziquantel (40 mg/kg), and tested for Schistosoma 1 month after the end of therapy. All the subjects fully recovered. CONCLUSIONS: Considering the migration phenomenon, the observation of these tropical diseases in European hospitals is becoming more and more common and an increasing number of health care professionals will be dealing with migrants. Searching for haematuria and eosinophilia and then testing for Schistosoma in this specific population will increase the number of diagnosis and correct treatment of urinary schistosomiasis, improving the patients' quality of life and preventing severe complications of the disease.

HBV virological suppression: still not enough to save from hepatocellular carcinoma. A case report on a 15-year, real-life story

Among HIV-infected patients worldwide, 2-4 million are chronically infected with HBV. We report a 15-year, real-life story of a patient with HBV-HIV coinfection, who developed HCC despite high treatment adherence and complete viral suppression. The aim of our report is to alert the infectious diseases community to monitor the possible development of HCC regardless of high treatment adherence and complete viral suppression.

Infectious diseases among foreign prisoners: results of a hospital-based management model in Palermo.

Foreign prisoners have a high vulnerability in terms of morbidity and access to care in overcrowded Italian prisons. This paper presents and comments on the management model of infectious diseases in foreign prisoners at our outpatient clinic, in order to describe a model of management for these conditions. Overall, 133 subjects (mean age 35.5 years) from 29 countries were followed for a period of 15 years. The most commonly represented area of origin (54.1%) was the Maghreb region. HCV infection (40.6%), HIV (22.5%), HBV (9.8%) and co-infection (15%, HIV/HCV or HIV/HBV) were observed. Ten subjects had tuberculosis, and only 30% of them were compliant with the treatment. Only 46.3% of HCV mono-infected patients completed the entire diagnostic process and even a lower percentage (37%) of them took treatment regularly. 90% of HBV mono-infected patients and 84% of those HIV mono- and co-infected completed the diagnostic workout. 77% of patients in each group took therapy regularly. Overall, the results show limited effectiveness. Therefore, it would be necessary to improve communication between healthcare professionals and correctional systems. Moreover, it appears urgent to reduce overcrowding in prisons to limit morbidity in prisoners.

[Contact tracing and partner notification among a cohort of HIV-1 infected patients. A prospective study carried out in Palermo in 2012]. / Contact tracing e partner notification in una coorte di pazienti con infezione da HIV. Uno studio prospettico condotto a Palermo nel 2012.

Introduction. Contact tracing and partner notification are tools to prevent the spread of the HIV and other sexually transmitted infections. These tools protect the rights of the individual contrasting healthcare policies that encourage dangerous kinds of discrimination. Objective. Pointing out the opinion of a sample of HIV-1 infected patients about the possibility of starting a support helpdesk for contract tracing and partner notification. Design and setting. A survey about contact tracing and partner notification procedures was conducted through anonymous questionnaires filled by a sample of 110 HIV-infected patients, involved in a follow-up stage at the Infectious Diseases Outpatients Clinic from the Civic Hospital Benfratelli in Palermo. The survey took place in May 2012. Results. An efficient partner notification is considered essential, both to protect people with whom the patient has come into contact and to contribute to the reduction of HIV spread. The questions dealing with this issue recorded more than 90% of positive answers. The questions about protecting the privacy during the diagnosis notification processes enlightened that notifying the partner is always felt as a greater need compared to the risk of losing one's own privacy; in fact, the positive answers were 81%. As for the role played by the physician during the contact tracing and partner notification process, 34% of the interviewees think that the physician should ask the patient to disclose the names of partners with whom he/she had a risky behavior. Finally, as for the question concerning how partner notification should happen, the results showed that 31% of the interviewees declare to be favorable to a full mandate by the physician, while just above 25% would choose to notify it personally, even though with the physician's help. Conclusion. Overall, the survey showed that more than 70% of people interviewed are favorable to a personal notification, against 25% of the interviewees who would like to have the support of a healthcare operator during the partner notification process. The percentage of patients who would rather completely delegate the notification to the physician is drastically reduced to less than 2%.

[Sexually transmitted infections in a cohort of female sex workers in Palermo]. / Infezioni sessualmente trasmesse osservate in una coorte di prostitute straniere a Palermo.

AIM: To evaluate the prevalence of sexually transmitted infections (HIV, HBV, HCV, Treponema pallidum) in a cohort of foreign female sex workers observed in Palermo from 1999 to 2008. MATERIALS AND METHODS: Authors conducted a prospective observational study on 239 foreign female sex workers aged between 18 and 36 years old. The nation of origin was Nigeria, Romania, Ucraina, Bulgaria. RESULTS: Overall, the diagnosis of IST was placed in 17 women, 7.1% of the population under study. In 14 cases we observed a single infection: HIV in 5 cases; syphilis and HBV in 4 cases; HCV in only one case. In the remaining three women were diagnosed a co-infection with HIV and HBV, HIV and HCV, HIV and syphilis LUE. In our study, a statistically significant correlation (p<0.0001) was observed between the non-constant condom use and a higher frequency of HIV, HCV and syphilis infection. This correlation was not statistically significant in the women with HBV infection. CONCLUSIONS: The results of this study show a higher morbidity of this specific population, and, consequently, the need to start as soon as possible specific programs of intervention which can ensure the health of these women. Language and cultural barriers, as well as immigration concern among all vulnerable populations, form barriers to healthcare access.

[Infectious diseases and health in the migrant people: experience from Lampedusa 2011]. / Salute e malattie infettive nella popolazione migrante: l'esperienza della "Coorte di Lampedusa 2011"

Migration is one of the possible points of contact between the rich world and the poor world. This paper analyzes and quantifies the presence of infectious diseases in a cohort of about 25,000 immigrants from Africa who landed in Lampedusa in 2011. The main clinical presentations of a cohort of migrants in Lampedusa were observed consecutively in 2011 during landing and then within the reception centers. In over 75% of the cases observed, the population was healthy. In 23% of cases diseases were observed in relation to the migration route, especially the precarious conditions of the crossing of the Channel of Sicily. Infectious diseases or female genital pathologies were observed in less than 2% of the population. The experience of Lampedusa in 2011 confirmed the Healthy Migrant theory, a population predominantly represented by young people who are at risk of becoming ill during the difficult migration or in the host country due to poor living conditions. Taking care of such people is an act of civilization and ensures the health of this population and of the whole community.

[Infectious diseases and sexual transmitted diseases in two different cohort of extra communitarian people in Palermo (Sicily, Italy) from 2000 to 2004]. / Prevalenza di patologie infettive e malattie sessualmente trasmesse in due differenti popolazioni di extracomunitari residenti in Palermo ed osservati nel quinquennio 2000-2004.

UNLABELLED: The Authors have studied the prevalence of Infectious and Sexually Transmitted Diseases (STD) in a cohort of 109 Nigerian prostitutes and 37 extra communitarian drug addicts, with the aim to quantify the circulation of infectious and diffusive diseases in these groups of people. RESULTS: HIV infection was diagnosed in 2 prostitutes (1.8%) and in 4 drug addicts (10.8%). In the female population it has not been evidence of STD, neither tuberculosis neither active infection from hepatitis virus B and C. In the drug addicts, in a single case it has been evidence active infection from HBV. The search of antibodies anti-HCV has turned out positive in 20 of 37 subject heads (54%). Neither case of tuberculosis nor of syphilis infection was diagnosed in the all population. The analysis of the collected data supplies elements for some considerations: HIV infection in young Nigerian prostitutes with short history is bounded (1.8%) and it correlates with the absence of sexually transmitted diseases (thanks to the use of condom). More in a generalized manner, they are young healthy women probably "selected" at the origin by people interested to protect them from diseases that would compromise their rendering. As far as the population of the drug addicts, the prevalence of HIV infection is meaningfully higher regarding that one of the Italian drug addicts observed in our Division and that their style of life hinders the access to the necessary therapeutic approaches.