One-year evolution of DLCO changes and respiratory symptoms in patients with post COVID-19 respiratory syndrome.

PURPOSE: During a follow-up program of patients admitted for COVID-19 at our non-ICU Unit, we found that 37% of them had decreased diffusing lung capacity for carbon monoxide (DLCO) 3-6 months after discharge. This prospective observational study aimed to evaluate the evolution of changes in DLCO and respiratory symptoms at the 1-year follow-up visit. METHODS: Seventeen (mean age 71 years; 8 males) of 19 eligible patients (DLCO < 80% of predicted at the 3-6 months follow-up visit) completed the 1-year follow-up visit. One patient refused to participate and 1 patient had died 3 months earlier from myocardial infarction. The visit included a self-reported structured questionnaire, physical exam, blood tests, ECG, and spirometry with DLCO. RESULTS: Mean DLCO was significantly improved at the 1-year visit (from 64% of predicted at 3-6 months to 74% of predicted at 1 year; P = 0.003). A clinically significant increase in DLCO (10% or greater) was observed in 11 patients (65%) with complete normalization (> 80% of predicted) in 6 (35%); in the other 6 (35%) it remained unchanged. The prevalence of exertional dyspnea (65-35%, P = 0.17), cough (24-18%, P = 1), and fatigue (76-35%, P = 0.04) decreased at the 1-year visit. CONCLUSION: These results suggest that DLCO and respiratory symptoms tend to normalize or improve 1 year after hospitalization for COVID-19 in most patients. However, there is also a non-negligible number of patients (about one-third) in whom respiratory changes persist and will need prolonged follow-up.

COVID-19: persistence of symptoms and lung alterations after 3-6 months from hospital discharge.

PURPOSE: Few data are currently available on persistent symptoms and late organ damage in patients who have suffered from COVID-19. This prospective study aimed to evaluate the results of a follow-up program for patients discharged from a nonintensive COVID-19 ward. METHODS: 3-6 months after hospital discharge, 59 of 105 COVID-19 patients (31 males, aged 68.2 ± 12.8 years) were recruited in the study. Forty-six patients were excluded because of nontraceability, refusal, or inability to provide informed consent. The follow-up consisted of anamnesis (including a structured questionnaire), physical examination, blood tests, ECG, lower limb compression venous ultrasound (US), thoracic US, and spirometry with diffusion lung capacity for carbon monoxide (DLCO). RESULTS: 22% of patients reported no residual symptoms, 28.8% 1 or 2 symptoms and 49.2% 3 or more symptoms. The most frequently symptoms were fatigue, exertional dyspnea, insomnia, and anxiety. Among the inflammatory and coagulation parameters, only the median value of fibrinogen was slightly above normal. A deep vein thrombosis was detected in 1 patient (1.7%). Thoracic US detected mild pulmonary changes in 15 patients (25.4%), 10 of which reported exertional dyspnea. DLCO was mildly or moderately reduced in 19 patients (37.2%), 13 of which complained of exertional dyspnea. CONCLUSION: These results highlight that a substantial percentage of COVID-19 patients (77.8%) continue to complain of symptoms 3-6 months after hospital discharge. Exertional dyspnea was significantly associated with the persistence of lung US abnormalities and diffusing capacity alterations. Extended follow-up is required to assess the long-term evolution of postacute sequelae of COVID-19.

Effectiveness and safety of noninvasive positive pressure ventilation in the treatment of COVID-19-associated acute hypoxemic respiratory failure: a single center, non-ICU setting experience.

The role of noninvasive positive pressure ventilation (NIPPV) in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) is uncertain, as no direct evidence exists to support NIPPV use in such patients. We retrospectively assessed the effectiveness and safety of NIPPV in a cohort of COVID-19 patients consecutively admitted to the COVID-19 general wards of a medium-size Italian hospital, from March 6 to May 7, 2020. Healthcare workers (HCWs) caring for COVID-19 patients were monitored, undergoing nasopharyngeal swab for SARS-CoV-2 in case of onset of COVID-19 symptoms, and periodic SARS-CoV-2 screening serology. Overall, 50 patients (mean age 74.6 years) received NIPPV, of which 22 (44%) were successfully weaned, avoiding endotracheal intubation (ETI) and AHRF-related death. Due to limited life expectancy, 25 (50%) of 50 NIPPV-treated patients received a "do not intubate" (DNI) order. Among these, only 6 (24%) were weaned from NIPPV. Of the remaining 25 NIPPV-treated patients without treatment limitations, 16 (64%) were successfully weaned, 9 (36%) underwent delayed ETI and, of these, 3 (33.3%) died. NIPPV success was predicted by the use of corticosteroids (OR 15.4, CI 1.79-132.57, p 0.013) and the increase in the PaO2/FiO2 ratio measured 24-48 h after NIPPV initiation (OR 1.02, CI 1-1.03, p 0.015), while it was inversely correlated with the presence of a DNI order (OR 0.03, CI 0.001-0.57, p 0.020). During the study period, 2 of 124 (1.6%) HCWs caring for COVID-19 patients were diagnosed with SARS-CoV-2 infection. Apart from patients with limited life expectancy, NIPPV was effective in a substantially high percentage of patients with COVID-19-associated AHRF. The risk of SARS-CoV-2 infection among HCWs was low.

Yield and clinical impact of blood cultures in patients admitted to an internal medicine ward.

The purpose of this prospective observational study was to evaluate the yield and clinical impact of blood cultures in a 78-bed Internal Medicine ward of a medium-sized Italian acute care hospital. During a two-month study period, 154 (mean age: 75.2 ++ 12.2 years; 94 males) out of 620 (24.8%) hospitalized patients underwent 174 blood cultures and were enrolled in the study. The rate of true-positive cultures was 11.5% (20/174) and the rate of false-positive (contaminants) was 5.7% (10/174). A total of 23 microorganisms (5 multidrug resistant strains), most frequently Escherichia coli (n = 10), Klebsiella pneumoniae (n = 3) and Staphylococcus aureus (n = 3), were isolated. The positivity rate was significantly higher in patients with urinary tract infection (31%) and abdomen infection (26.1%) than in patients with pneumonia (4.9%; p<0.01). Although the positivity rate in patients exposed to antibiotics was lower than in those not exposed, the difference was not statistically significant. Therapy changes due to blood culture positivity were observed in 7.1% of the patients overall. In-hospital death was observed in nine of the 136 patients with negative blood cultures (6.6%) and in none of the 18 patients with positive blood cultures. These results indicate that the yield and clinical impact of blood cultures is quite low in patients admitted to an Internal Medicine ward and suggest the need to improve the adequacy of the indications to perform the test.

Fourteen years of severe arthralgia in a man without gastrointestinal symptoms: atypical Whipple's disease.

We report here the case of Whipple's disease in a 60-year-old man with severe arthralgia and systemic disorders but without gastrointestinal manifestations. The patient had different clinical diagnoses over a period of 14 years. We identified Tropheryma whipplei by real-time PCR. Molecular typing was also performed by sequencing the 16S-23S rRNA intergenic spacer region and domain III of the 23S rRNA gene.

Effect of antibiotic pretreatment on resistance.

The emergence of bacterial resistance to antibiotics limits the efficacy of technical developments in the field of infectious diseases. This is particularly true for respiratory tract infections, which are by far the main reason for antibiotic use in developed countries. Antimicrobial resistance among respiratory pathogens involves both gram-positive (primarily Streptococcus pneumoniae) and gram-negative (Haemophilus influenzae, Moraxella catarrhalis, and the more rare enterobacteriaceae) microorganisms. A number of epidemiologic studies show a relationship between antibiotic use and antibiotic resistance, and how antibiotic pretreatment can reduce the range of effective drugs for optimal therapy of infections in general and of respiratory tract infections in particular. An appropriate use of antimicrobials is of crucial importance to limit the emergence and spread of bacterial resistance to antibiotics. This can be achieved by avoiding usage in nonspecific, probably viral, infections that are unlikely to be influenced by antibiotic therapy, and by using narrow-spectrum drugs to minimize selective pressure.