The emergence, impact, and evolution of human metapneumovirus variants from 2014 to 2021 in Spain.

BACKGROUND: Human metapneumovirus (HMPV) is an important aetiologic agent of respiratory tract infection (RTI). This study aimed to describe the prevalence, genetic diversity, and evolutionary dynamics of HMPV. METHODS: Laboratory-confirmed HMPV were characterised based on partial-coding G gene sequences with MEGA.v6.0. WGS was performed with Illumina, and evolutionary analyses with Datamonkey and Nextstrain. RESULTS: HMPV prevalence was 2.5%, peaking in February-April and with an alternation in the predominance of HMPV-A and -B until the emergence of SARS-CoV-2, not circulating until summer and autumn-winter 2021, with a higher prevalence and with the almost only circulation of A2c111dup. G and SH proteins were the most variable, and 70% of F protein was under negative selection. Mutation rate of HMPV genome was 6.95 × 10-4 substitutions/site/year. CONCLUSION: HMPV showed a significant morbidity until the emergence of SARS-CoV-2 pandemic in 2020, not circulating again until summer and autumn 2021, with a higher prevalence and with almost the only circulation of A2c111dup, probably due to a more efficient immune evasion mechanism. The F protein showed a very conserved nature, supporting the need for steric shielding. The tMRCA showed a recent emergence of the A2c variants carrying duplications, supporting the importance of virological surveillance.

Derivation and external validation of a simple prediction rule for the development of respiratory failure in hospitalized patients with influenza.

BACKGROUND: Influenza viruses cause seasonal epidemics worldwide with a significant morbimortality burden. Clinical spectrum of Influenza is wide, being respiratory failure (RF) one of its most severe complications. This study aims to elaborate a clinical prediction rule of RF in hospitalized Influenza patients. METHODS: A prospective cohort study was conducted during two consecutive Influenza seasons (December 2016-March 2017 and December 2017-April 2018) including hospitalized adults with confirmed A or B Influenza infection. A prediction rule was derived using logistic regression and recursive partitioning, followed by internal cross-validation. External validation was performed on a retrospective cohort in a different hospital between December 2018 and May 2019. RESULTS: Overall, 707 patients were included in the derivation cohort and 285 in the validation cohort. RF rate was 6.8% and 11.6%, respectively. Chronic obstructive pulmonary disease, immunosuppression, radiological abnormalities, respiratory rate, lymphopenia, lactate dehydrogenase and C-reactive protein at admission were associated with RF. A four category-grouped seven point-score was derived including radiological abnormalities, lymphopenia, respiratory rate and lactate dehydrogenase. Final model area under the curve was 0.796 (0.714-0.877) in the derivation cohort and 0.773 (0.687-0.859) in the validation cohort (p < 0.001 in both cases). The predicted model showed an adequate fit with the observed results (Fisher's test p > 0.43). CONCLUSION: we present a simple, discriminating, well-calibrated rule for an early prediction of the development of RF in hospitalized Influenza patients, with proper performance in an external validation cohort. This tool can be helpful in patient's stratification during seasonal Influenza epidemics.

Influenza A-Associated In-Hospital Mortality in Very Older People: Does Inflammation Also Play a Role?

BACKGROUND: The aim of the study was to analyze the clinical manifestations and outcome of the oldest old (people aged ≥85 years) who were admitted to the hospital with a confirmed influenza A virus infection in comparison with younger patients and to assess the role of inflammation in the outcome of influenza infection in this population. METHODS: This is an observational prospective study including all adult patients with influenza A virus infection hospitalized in a tertiary teaching hospital in Madrid, in 2 consecutive influenza seasons (2016-17 and 2017-18). RESULTS: Five hundred nine hospitalized patients with influenza A infection were included, of whom 117 (23%) were older than 85 years (median age: 89.3 ± 3.2). We compared the clinical characteristics and outcome with those of the rest of the population (median age: 72.8 ± 15.7). Overall, mortality was higher in older patients (10% vs. 4%; p = 0.03) with no differences in clinical presentation. Patients older than 85 years who ultimately died (12 out of 117) showed increased systemic inflammation expressed by higher levels of C-reactive protein (CRP) and ferritin compared to survivors who were discharged (odds ratio [OR] of CRP >20 mg/dL: 5.16, 95% confidence interval [CI]: 1.29-20.57, and OR of ferritin >500 mg: 4.3, 95% CI: 1.04-17.35). CONCLUSIONS: Patients aged 85 and older with influenza A virus infection presented a higher in-hospital mortality than younger subjects. CRP and ferritin levels were higher in the oldest old who died, suggesting that inflammation could play a key role in the outcome of this subset of patients.

A predictive score at admission for respiratory failure among hospitalized patients with confirmed 2019 Coronavirus Disease: a simple tool for a complex problem.

Coronavirus Disease 2019 (COVID-19) pandemic has implacably stricken on the wellness of many countries and their health-care systems. The aim of the present study is to analyze the clinical characteristics of the initial wave of patients with COVID-19 attended in our center, and to identify the key variables predicting the development of respiratory failure. Prospective design study with concurrent data retrieval from automated medical records of all hospitalized adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rRT-PCR assay performed on respiratory samples from March 2nd to 18th, 2020. Patients were followed up to May 1st, 2020 or death. Respiratory failure was defined as a PaO2/FiO2 ratio ≤ 200 mm Hg or the need for mechanical ventilation (either non-invasive positive pressure ventilation or invasive mechanical ventilation). We included 521 patients of whom 416 (81%) had abnormal Chest X-ray on admission. Median age was 64.6 ± 18.2 years. One hundred eighty-one (34.7%) developed respiratory failure after a median time from onset of symptoms of 9 days (IQR 6-11). In-hospital mortality was 23.8% (124/521). The modeling process concluded into a logistic regression multivariable analysis and a predictive score at admission. Age, peripheral pulse oximetry, lymphocyte count, lactate dehydrogenase and C-reactive protein were the selected variables. The model has a good discriminative capacity with an area under the ROC curve of 0.85 (0.82-0.88). The application of a simple and reliable score at admission seems to be a useful tool to predict respiratory failure in hospitalized COVID-19 patients.

Severe Acute Respiratory Syndrome Coronavirus 2 Vertical Transmission from an Asymptomatic Mother.

In utero transmission of severe acute respiratory syndrome coronavirus 2 infection is a point of debate. We report a case of severe acute respiratory syndrome coronavirus 2 vertical transmission from asymptomatic mother, with molecular detection in mother's blood at delivery and neonatal nasopharyngeal swabs at 5 and 28 hours of life and later IgG seroconversion. The newborn was asymptomatic.

Cognitive Impairment Is a Common Comorbidity in Deceased COVID-19 Patients: A Hospital-Based Retrospective Cohort Study.

We analyzed the frequency of cognitive impairment (CI) in deceased COVID-19 patients at a tertiary hospital in Spain. Among the 477 adult cases who died after admission from March 1 to March 31, 2020, 281 had confirmed COVID-19. CI (21.1% dementia and 8.9% mild cognitive impairment) was a common comorbidity. Subjects with CI were older, tended to live in nursing homes, had shorter time from symptom onset to death, and were rarely admitted to the ICU, receiving palliative care more often. CI is a frequent comorbidity in deceased COVID-19 subjects and is associated with differences in care.

Universal screening for SARS-CoV-2 before labor admission during Covid-19 pandemic in Madrid.

Objectives Asymptomatic women admitted to labor may act as silent spreaders of COVID-19. Therefore, universal screening at admission has been proposed. The objective of the study was to evaluate the performance of universal screening for SARS-CoV-2 using quantitative reverse transcription polymerase-chain-reaction (qRT-PCR) tests in women admitted to labor. Methods Observational retrospective study of a cohort of pregnant women admitted to labor and delivery between April 8 and May 2, 2020 in a large maternity in Madrid. SARS-CoV-2 screening with qRT-PCR from combined nasopharyngeal and oropharyngeal swabs was carried out systematically. Screening performance was described. Results We attended 212 deliveries. Nine cases with COVID-19 diagnosis before admission were excluded. In the remaining 203 women, seven referred COVID-19-related symptoms but only one had a positive qRT-PCR. Among the 194 asymptomatic women, only one case (0.5%) was positive. Conclusions The percentage of positive tests in asymptomatic women admitted to delivery was only 0.5% during the post-peak period.

Influence of viral load in the outcome of hospitalized patients with influenza virus infection.

The role of viral load in the outcome of patients requiring hospital admission due to influenza is not well established. We aim to assess if there is an association between the viral load and the outcome in hospitalized patients with a confirmed influenza virus infection. A retrospective observational study including all adult patients who were hospitalized in our center with a confirmed influenza virus infection from January to May 2016. Viral load was measured by real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) cycle threshold (Ct) value on upper respiratory tract samples. Its value was categorized into three groups (low Ct, ≤ 20; intermediate Ct, > 20-30; and high Ct, > 30). Two hundred thirty-nine patients were included. Influenza A/H1N1pdm09 was isolated in 207 cases (86.6%). The mean Ct value was 26.69 ± 5.81. The viral load was higher in the unvaccinated group when compared with the vaccinated patients (Ct 25.17 ± 5.55 vs. 27.58 ± 4.97, p = 0.004). Only 27 patients (11.29%) presented a high viral load. Patients with a high viral load more often showed abnormal findings on chest X-ray (p = 0.015) and lymphopenia (p = 0.097). By contrast, there were no differences between the three groups (according to viral load), in associated pneumonia, respiratory failure, need for mechanical ventilation, sepsis, or in-hospital mortality. Our findings suggest that in patients admitted to the hospital with confirmed influenza virus infection (mostly A/H1N1pdm09), a high viral load is associated with a higher presence of abnormal findings on chest X-ray but not with a significant worse prognosis. In these cases, standardized quantitative PCR could be useful.

Diagnóstico precoz de la infección congénita por citomegalovirus: oportunidades perdidas / Early diagnosis of congenital cytomegalovirus infection: lost opportunities

Introducción: La infección por citomegalovirus (CMV) es la infección congénita más frecuente en Europa. El 10% de los niños infectados presentan síntomas al nacimiento, y hasta el 30-40% tienen algún grado de hipoacusia. Métodos Se ha realizado un estudio descriptivo retrospectivo incluyendo todos los pacientes diagnosticados de infección congénita por CMV fuera del período neonatal a lo largo de 4 años a partir de las muestras de sangre del talón en papel de filtro del cribado metabólico neonatal. Resultados Presentamos 5 pacientes diagnosticados de infección congénita por CMV fuera del periodo neonatal. Los principales motivos de consulta fueron la hipoacusia y/o el retraso psicomotor en los primeros meses de vida. Conclusión La infección por CMV puede ser poco sintomática al nacimiento y presentarse como un déficit auditivo y/o retraso psicomotor en la infancia. Es preciso un alto grado de sospecha para establecer un diagnóstico temprano que permita ofrecer tratamiento específico y mejorar el pronóstico a largo plazo (AU)

Introduction: Cytomegalovirus (CMV) infection is the most common congenital infection in Europe. Symptoms are present at birth in 10% of infected children, and up to 30-40% have some degree of hearing loss after the newborn period. Methods: A retrospective study was performed over a period of 4 years and included all patients with congenital CMV infection diagnosed after the neonatal period using the dried blood spots from neonatalmetabolic screening. Results: We present 5 patients diagnosed with congenital CMV infection outside the neonatal period. The main reasons for consultation were hearing loss and/or neurological impairment in the first few months of life. Discussion: Congenital CMV infection may be mildly symptomatic at birth, and present as hearing loss and/or neurological impairment in infancy. Therefore, a high degree of suspicion is necessary in order to make an accurate diagnosis and start specific treatment to improve the outcome (AU)

[Early diagnosis of congenital cytomegalovirus infection: lost opportunities]. / Diagnóstico precoz de la infección congénita por citomegalovirus: oportunidades perdidas.

INTRODUCTION: Cytomegalovirus (CMV) infection is the most common congenital infection in Europe. Symptoms are present at birth in 10% of infected children, and up to 30-40% have some degree of hearing loss after the newborn period. METHODS: A retrospective study was performed over a period of 4 years and included all patients with congenital CMV infection diagnosed after the neonatal period using the dried blood spots from neonatal metabolic screening. RESULTS: We present 5 patients diagnosed with congenital CMV infection outside the neonatal period. The main reasons for consultation were hearing loss and/or neurological impairment in the first few months of life. DISCUSSION: Congenital CMV infection may be mildly symptomatic at birth, and present as hearing loss and/or neurological impairment in infancy. Therefore, a high degree of suspicion is necessary in order to make an accurate diagnosis and start specific treatment to improve the outcome.

Utilidad de las pruebas rápidas de detección antigénica en el diagnóstico de la nueva gripe A (H1N1) en niños / Rapid influenza diagnostic tests for detection of novel influenza A (H1N1) virus in children

Introducción Utilidad de la prueba rápida BD Directigen® EZ Flu A+B frente a gripe A (H1N1) en niños. Metódos Estudio descriptivo retrospectivo con 140 niños a los que se realizó la prueba rápida y la reacción en cadena de la polimerasa en tiempo real frente a gripe A (H1N1).Resultados Sensibilidad del 70,4% (IC: 58,9–79,7), especificidad de 100% (IC: 94,7–100), valor predictivo negativo del 76,6% (IC: 66,9–84,2) y valor predictivo positivo del 100% (IC: 92,8–100).Conclusión La prueba presenta buena sensibilidad y buena especificidad en niños, siendo similares a los de la gripe estacional (AU)

Introduction Accuracy of rapid BD Directigen® EZ Flu A+B diagnostic test against Influenza A (H1N1) Virus in children. Methods A descriptive retrospective study was performed. One hundred and forty children underwent the rapid influenza test and the RT-PCR against Influenza A (H1N1) Virus. Results The sensitivity was 70.4% (95% CI: 58.9–79.7), specificity 100 % (95% CI: 94.7–100), NPV 76.6% (95% CI: 66.9–84,2) and PPV 100% (95% CI: 92.8–100).Conclusion This test showed high sensitivity and specificity, very similar to the seasonal influenza, in children (AU)

[Rapid influenza diagnostic tests for detection of novel influenza A (H1N1) virus in children]. / Utilidad de las pruebas rápidas de detección antigénica en el diagnóstico de la nueva gripe A (H1N1) en niños.

INTRODUCTION: Accuracy of rapid BD Directigen(®) EZ Flu A+B diagnostic test against Influenza A (H1N1) Virus in children. METHODS: A descriptive retrospective study was performed. One hundred and forty children underwent the rapid influenza test and the RT-PCR against Influenza A (H1N1) Virus. RESULTS: The sensitivity was 70.4% (95% CI: 58.9-79.7), specificity 100 % (95% CI: 94.7-100), NPV 76.6% (95% CI: 66.9-84,2) and PPV 100% (95% CI: 92.8-100). CONCLUSION: This test showed high sensitivity and specificity, very similar to the seasonal influenza, in children.

Clinical implications of respiratory virus infections in solid organ transplant recipients: a prospective study.

BACKGROUND: There is limited information about clinical consequences of respiratory virus infections (RVI) in solid organ transplant recipients. No prospective epidemiological study has been published previously. METHODS: We selected a cohort of 152 transplant recipients (cardiac, hepatic and renal transplant recipients). Median time from transplantation was 17 months (range 1-50). They were prospectively followed-up for RVI during 7 months (October to April). Clinical and microbiological evaluation (cell culture, shell vial and polymerase chain reaction technique) of each RVI episode was made. RESULTS: We detected 81 RVI (0.91 episodes/patient/year). Complications were detected in 15/81 episodes (18.5%): acute bronchitis (10 cases), pneumonia (three cases; 3.7% of RVI episodes) and bacterial sinusitis (2 cases). In 4 of 81 episodes (5%), patients needed hospitalization. A respiratory virus was isolated in 17 of 68 nasopharyngeal samples (six respiratory syncytial virus, six influenza, four picornavirus, one adenovirus). Fever presented an 83% positive predictive value for the diagnosis of influenza virus infection among those with a positive microbiological isolation. There were no episodes of acute rejection coincidentally with RVI. Only 54% of the subjects had been previously vaccinated against influenza. CONCLUSIONS: Incidence of RVI among solid organ transplant recipients is similar to general population but complications are higher. A relationship between RVI and rejection was not detected. The rate of influenza vaccination was lower than expected. The presence of fever in a transplant recipient with RVI strongly suggests influenza infection.

Valganciclovir preemptive therapy for the prevention of cytomegalovirus disease in high-risk seropositive solid-organ transplant recipients.

BACKGROUND: The role of valganciclovir in the prevention of cytomegalovirus (CMV) disease in high-risk seropositive transplant patients is not known. METHODS: We prospectively followed 301 seropositive solid organ transplant recipients to assess the efficacy and safety of valganciclovir (VGCV) in the prevention of CMV disease in high-risk patients. Asymptomatic patients with an antigenemia test >or=25 positive cells/2x10(5) polymorphonuclear cells received valganciclovir 900 mg twice a day as preemptive therapy until resolution of antigenemia (minimum 14 days). Additionally, patients treated with antilymphocytic drugs for more than 6 days received prophylaxis with VGCV 900 mg once a day during 90 days. Mean follow-up was 14 months (range 6-20 months). RESULTS: Thirty-eight patients received VGCV; 24 as preemptive therapy and 14 due to the use of antilymphocytic drugs. No patient developed CMV disease during the follow-up. Viral load (antigenemia) decreased a mean of 78% from baseline after 7 days of VGCV therapy (P=0.024) and 98% at day 14 (P=0.029). Two patients showed a relapse of the antigenemia test >or=25 positive cells and were successfully treated with a repeated course of VGCV. Leukopenia (<2500/mm3) developed in 3/24 (12.5%) recipients in the preemptive therapy group and required to discontinuing the drug in one of them. CONCLUSIONS: VGCV is safe and highly efficacious in the prevention of CMV disease in high-risk seropositive organ transplant recipients.

Interferon gamma quantification in cerebrospinal fluid compared with PCR for the diagnosis of tuberculous meningitis.

PURPOSE: To assess the utility of interferon gamma (INF-gamma) levels in cerebrospinal fluid (CSF), for the diagnosis of tuberculous meningitis (TBM), and compare these results with aPCR technique. METHODS: We studied CSF samples from patients with proven or probable TBM and a control group, composed by patients with other causes of meningitis and without meningitis. INFgamma levels were measured by radioimmunoassay. A PCR technique was performed using IS6110 primers. RESULTS: Of the 127 patients studied, 20 (15.6%) had TBM, 59 (46%) had meningitis of another aetiology and 49 (38.4%) had were HIV and non-HIV patients with normal CSF. The area below the ROC curve for interferon gamma levels in the diagnosis of TBM was 0.94. A cut-off of 6.4 IU/mL yielded a sensitivity of 70% and a specificity of 94%. False positive results were observed in 7 of the 59 patients (11.8%) with non-TB meningitis, (patients with herpetic meningoencephalitis and meningitis due to intracellular microorganisms). INF-gamma sensitivity was higher than PCR (70% vs. 65%). Both tests performed together showed higher sensitivity (80%) and specificity (92.6%). CONCLUSION: CSF INF-gamma levels (> 6.4 IU/mL) are very valuable in TBM diagnosis. PCR and INF-gamma could be simultaneously used to increase the diagnostic yield.

Respiratory virus infections in children with cancer or HIV infection.

Most studies focusing on respiratory infections in immunocompromised children have been addressed to bacterial etiology. However, respiratory virus infections in this population can also lead to severe disease. The objective of this study is to evaluate the clinical significance of respiratory virus infections in children with cancer or human immunodeficiency virus (HIV) infection. Retrospective study conducted in a teaching hospital in Madrid. Medical records from children

Blood and urine samples as useful sources for the direct detection of tuberculosis by polymerase chain reaction.

The aim of the study was to assess the utility of the polymerase chain reaction (PCR) assay in blood and urine for the diagnosis of tuberculosis (TB). We prospectively evaluated the usefulness of PCR performed in blood and urine samples from patients with proved or probable TB compared with a control group of patients. The PCR technique was performed using IS6110 primers. We included in the study 57 patients (43 with definite TB and 14 with probable TB) and 26 controls. Blood and urine samples were drawn at the time of microbiologic diagnosis and 3, 6, 9, and 12 months later. Cultures were positive in the early period (<1 month after treatment) in 11 of 57 patients (19%) with probable or definite TB, in comparison with 42% of patients (24/57) who yielded a positive PCR (P = 0.02). Urine samples increased the sensitivity of PCR determination in blood samples by 10%. The PCR in blood and/or urine was positive in 41% of patients with pulmonary TB, in 36% of patients with extrapulmonary TB, and in 50% of patients with disseminated TB. Mycobacterium tuberculosis was still detectable by PCR in 5 of 13 patients with cured TB after 1 or more months of antituberculous treatment. The PCR detection of M. tuberculosis in blood and urine samples is useful for the diagnosis of different clinical forms of TB, mostly in those patients in which sample extraction is difficult or requires aggressive techniques. The sensitivity of this technique could be improved studying more than 1 sample in each patient, even after initiating an antituberculous treatment.

[Nosocomial outbreak of influenza in high-risk hematological patients. Efficacy of control measures and the use of zanamivir]. / Brote nosocomial de gripe en pacientes hematológicos de alto riesgo. Eficacia de las medidas de control y del uso de zanamivir.

INTRODUCTION: This study describes a nosocomial outbreak of influenza in high-risk-hematological patients, and the usefulness of epidemiological measures and zanamivir administration for its control. METHODS: Fifteen patients who had been in contact with a patient with influenza A were included in the study. Viral culture of nasopharyngeal exudate was performed and the epidemiological data, risk factors and clinical outcome were evaluated. The efficacy of early therapy and preventive use of zanamivir was also assessed. RESULTS: Seven out of 15 patients (46.6%) developed symptoms and in 5 of these 7 cases (71.4%), influenza A virus was isolated. Eight patients did not develop symptoms and viral culture was sterile. All symptomatic patients were isolated, and treatment with inhaled zanamivir (10 mg/12 h, 5 days) was initiated as soon as possible; only one patient developed respiratory failure; the remaining cases had self-limited upper respiratory tract symptoms. There was no associated mortality. Zanamivir prophylaxis was used in three non-symptomatic patients considered to be at high risk. Tolerance to zanamivir was excellent. No new cases were observed after initiation of the preventive measures and use of zanamivir. CONCLUSION: The attack rate in a nosocomial influenza outbreak can be very high in immunocompromised patients. Prompt initiation of preventive measures, early treatment and prophylaxis with zanamivir may help to limit the extension of these outbreaks.