Bacterial coinfection and antimicrobial use among patients with COVID-19 infection in a referral center in the Philippines: A retrospective cohort study.

Objective: This study aimed to describe community-acquired bacterial coinfection (CAI) and antimicrobial use among COVID-19 patients. Methods: Electronic records were retrospectively reviewed, and clinical data, laboratory data, antibiotic use, and outcomes of patients with and without CAI were compared. Results: Of 1116 patients, 55.1% received antibiotics within 48 hours, but only 66 (5.9%) had documented CAI, mainly respiratory (40/66, 60.6%). Patients with CAI were more likely to present with myalgia (p = 0.02), nausea/vomiting (p = 0.014), altered sensorium (p = 0.007), have a qSOFA ≥ 2 (p = 0.016), or require vasopressor support (p < 0.0001). Patients with CAI also had higher median WBC count (10 vs 7.6 cells/mm3), and higher levels of procalcitonin (0.55 vs 0.13, p = 0.0003) and ferritin (872 vs 550, p = 0.028). Blood cultures were drawn for almost half of the patients (519, 46.5%) but were positive in only a few cases (30/519, 5.8%). Prescribing frequency was highest at the start and declined only slightly over time. The mortality of those with CAI (48.5%) was higher compared with those without CAI (14.3%). Conclusion: Overall CAI rate was low (5.9%) and antimicrobial use disproportionately high (55.0%), varying little over time. The mortality rate of coinfected patients was high. Certain parameters can be used to better identify those with CAI and those who need blood cultures.

Predictors of mortality among inpatients with COVID-19 infection in a tertiary referral center in the Philippines.

Objectives: The aim of this study was to determine the predictors of mortality and describe laboratory trends among adults with confirmed COVID-19. Methods: The medical records of adult patients admitted to a referral hospital with COVID-19 were retrospectively reviewed. Demographic and clinical characteristics, and laboratory parameters, were compared between survivors and non-survivors. Predictors of mortality were determined by multivariate analysis. Mean laboratory values were plotted across illness duration. Results: Of 1215 patients, 203 (16.7%) had mild, 488 (40.2%) moderate, 183 (15.1%) severe, and 341 (28.1%) critical COVID-19 on admission. In-hospital mortality was 18.2% (0% mild, 6.1% moderate, 15.8% severe, 47.5% critical). Predictors of mortality were age ≥ 60 years, COPD, qSOFA score ≥ 2, WBC > 10 × 109/L, absolute lymphocyte count < 1000, neutrophil ≥ 70%, PaO2/FiO2 ratio ≤ 200, eGFR < 90 mL/min/1.73 m2, LDH > 600 U/L, and CRP > 12 mg/L. Non-survivors exhibited an increase in LDH and decreases in PaO2/FiO2 ratio and eGFR during the 2nd-3rd week of illness. Conclusion: The overall mortality rate was high. Predictors of mortality were similar to those of other reports globally. Marked inflammation and worsening pulmonary and renal function were evident among non-survivors by the 2nd-3rd week of illness.

Clinical characteristics of patients with asymptomatic and symptomatic COVID-19 admitted to a tertiary referral centre in the Philippines.

Objectives: To describe the clinical profile and outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19) across the spectrum of disease severity. Methods: This retrospective study included adult patients with confirmed COVID-19 infection admitted to a referral hospital. Descriptive statistics, tests for trend, Kaplan-Meier curve and log-rank test were used to compare characteristics and outcomes across disease severity categories. Results: Of 1500 patients with COVID-19, 14.8% were asymptomatic, 13.5% had mild disease, 36.6% had moderate disease, 12.3% had severe disease and 22.7% had critical disease. Asymptomatic patients were admitted for a concurrent condition or for isolation. Patients aged >60 years, male gender and with co-morbidities had more severe disease. Fever, cough, shortness of breath, malaise, gastrointestinal symptoms and decreased sensorium were more common in patients with severe disease. Bilateral pulmonary infiltrates were common (51.1%), with sicker patients having more abnormal findings. The overall mortality rate was 15.1%. Adopting a symptom-based strategy reduced the length of hospitalization from a median of 13 [interquartile range (IQR) 7-21] days to 9 (IQR 5-14) days. Conclusion: The clinical profile and outcomes for this cohort of patients with COVID-19 was consistent with published reports. Asymptomatic infection was common, and universal testing may be a valuable strategy in the correct context, given the implications for infection control. A symptom-based strategy was found to reduce the length of hospitalization considerably.

High TB burden and low notification rates in the Philippines: The 2016 national TB prevalence survey.

SETTING: The 3rd national tuberculosis (TB) survey in the Philippines in 2007 reported a significant decline in the prevalence of TB. Since then, more significant investments for TB control have been made, yet TB burden estimates from routine surveillance data remain relatively stable. OBJECTIVE: To estimate the prevalence of bacteriologically confirmed pulmonary TB in the Philippines amongst individuals aged ≥15 years in 2016. DESIGN: In March-December 2016, we conducted a population-based survey with stratified, multi-stage cluster sampling of residents in 106 clusters aged ≥15 years. Survey participants were screened for TB by symptom-based interview and digital chest X-ray. Those with cough ≥2 weeks and/or haemoptysis and/or chest X-ray suggestive of TB were requested to submit 2 sputum specimens for Xpert MTB/RIF, direct sputum smear microscopy using LED fluorescent microscopy, and mycobacterial solid culture (Ogawa method). Bacteriologically confirmed pulmonary TB was defined as MTB culture positive and/or Xpert positive. RESULTS: There were 46,689 individuals interviewed, and 41,444 (88.8%) consented to a chest X-ray. There were 18,597 (39.8%) eligible for sputum examination and 16,242 (87.3%) submitted at least one specimen. Out of 16,058 sputum-eligible participants, 183 (1.1%) were smear-positive. There were 466 bacteriologically confirmed TB cases: 238 (51.1%) Xpert positive, 69 (14.8%) culture positive, and 159 (34.1%) positive by both Xpert and culture. The estimated TB prevalence per 100,000 population aged ≥15 years was 434 (95% CI: 350-518) for smear-positive TB, and 1,159 (95% CI: 1,016-1,301) for bacteriologically confirmed TB. CONCLUSION: This nationally representative survey found that the TB burden in the Philippines in 2016 was higher than estimated from routine TB surveillance data. There was no evidence of a decline in smear and culture positive TB from the 2007 survey despite significant investments in TB control. New strategies for case-finding and patient-centered care must be intensified and expanded.

Recommendations for Intersectoral Collaboration for the Prevention and Control of Vector-Borne Diseases: Results From a Modified Delphi Process.

BACKGROUND: Intersectoral collaboration in the context of the prevention and control of vector-borne diseases has been broadly described in both the literature and the current global strategy by the World Health Organization. Our aim was to develop a framework that will distill the currently known multiple models of collaboration. METHODS: Qualitative content analysis and logic modeling of data abstracted from 69 studies included in a scoping review done by the authors were used to develop 9 recommendation statements that summarized the composition and attributes of multisectoral approaches, which were then subjected to a modified Delphi process with 6 experts in the fields of health policy and infectious diseases. RESULTS: Consensus for all statements was achieved during the first round. The recommendation statements were on (1-3) sectoral engagement to supplement government efforts and augment public financing; (4) development of interventions for most systems levels; (5-6) investment in human resource, including training; (7-8) intersectoral action to implement strategies and ensure sustainability of initiatives; and (9) research to support prevention and control efforts. CONCLUSIONS: The core of intersectoral action to prevent vector-borne diseases is collaboration among multiple stakeholders to develop, implement, and evaluate initiatives at multiple levels of intervention.

3-in-1: bilateral subcutaneous leg abscesses and liver abscess from Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae are known to cause liver abscesses and other metastatic infections. Being Asian and having diabetes are known host risk factors. Here we present an unusual case of a Filipino ballet dancer-choreographer with diabetes presenting with bilateral leg pains initially thought to be cellulitis, but was eventually diagnosed as bilateral subcutaneous leg abscesses. He also had a liver abscess, thankfully asymptomatic, which was only discovered on imaging. The occurrence of three distant abscesses in one patient, hence '3-in-1,' makes this case worth reporting. Bilateral subcutaneous leg abscesses as the presenting manifestation of this infection have not been reported yet. We hypothesise that his occupation which makes use of frequent contractions of leg muscles led to increased blood flow and preferentially directed blood-borne bacteria to localise in both legs. We have also characterised the pathogen with regards to its hypermucoviscous phenotype, capsular type, virulence genes and phylogeny.

Bilateral adrenal histoplasmosis presenting as adrenal insufficiency in an immunocompetent host in the Philippines.

Disseminated histoplasmosis, with the adrenal glands as being the only site of demonstrable disease in an immunocompetent adult, is a rare infection leading to adrenal insufficiency. This disease carries high mortality when unrecognised. We describe the first reported case of adrenal histoplasmosis in the Philippines in a 72-year-old immunocompetent, Filipino man who presented with a 3-month history of intermittent flank pain, weight loss and generalised weakness. His imaging demonstrated bilateral adrenal masses on ultrasonography and contrast-enhanced CT scan. The initial impression was adrenal cancer, however, fine-needle aspiration cytology revealed the presence of yeast cells and blood culture grew Histoplasma capsulatum The diagnosis of the case represents a diagnostic challenge in immunocompetent individuals because they manifest with non-specific symptoms. A heightened suspicion is therefore needed to prevent significant morbidity and mortality.

Factors associated with non-compliance with anti-malarial treatment among malaria patients in Puerto Princesa, Palawan

OBJECTIVE: Malaria is a life-threatening, mosquito-borne disease that continues to cause numerous deaths worldwide. In the Philippines, malaria remains an important problem, with five provinces having >1000 cases of malaria a year. The objective of this cross-sectional analytical study was to determine the association of selected factors with non-compliance to anti-malarial treatment among malaria patients in Puerto Princesa, Palawan, specifically: perceived susceptibility to malaria, perceived seriousness and severity of malaria, perceived benefits of medication, perceived barriers to treatment compliance and cues to action.METHODS: Using an interviewer-administered structured questionnaire, 320 individuals diagnosed with and treated for malaria from January to October 2010 were interviewed regarding compliance to anti-malarial treatment and the factors related to compliance. Descriptive statistics and multiple logistic regression were used to analyze the data.RESULTS: The rate of non-compliance to anti-malaria treatment was 17% (95% Cl 12.1%-21.2%). After multivariate analysis using logistic regression, symptom perception as a cue to action and forgetfulness as a perceived barrier to treatment compliance were found to be significantly associated with non-compliance to treatment. The odds of non-compliance were three times higher for individuals who perceived that an improvement in symptoms implied cure of malaria. An individual who forgot to take at least one dose of medication was 17 times more likely to be non-compliant with treatment compared to someone who did not forget to take a single dose.CONCLUSION: Given the factors found to be associated with non­compliance to treatment, more effective ways of ensuring compliance with anti-malaria treatment may be explored e.g., doing directly observed treatment and utilizing treatment partners that may help address the problem of forgetfulness. The fact that symptom improvement is not equivalent to cure must be stressed when advising patients. Emphasizing compliance to treatment and the consequences of noncompliance when conducting patient education activities may also help boost treatment compliance.

Geographical distribution of human Schistosoma japonicum infection in The Philippines: tools to support disease control and further elimination.

Schistosoma japonicum infection is believed to be endemic in 28 of the 80 provinces of The Philippines and the most recent data on schistosomiasis prevalence have shown considerable variability between provinces. In order to increase the efficient allocation of parasitic disease control resources in the country, we aimed to describe the small-scale spatial variation in S. japonicum prevalence across The Philippines, quantify the role of the physical environment in driving the spatial variation of S. japonicum, and develop a predictive risk map of S. japonicum infection. Data on S. japonicum infection from 35,754 individuals across the country were geo-located at the barangay level and included in the analysis. The analysis was then stratified geographically for the regions of Luzon, the Visayas and Mindanao. Zero-inflated binomial Bayesian geostatistical models of S. japonicum prevalence were developed and diagnostic uncertainty was incorporated. Results of the analysis show that in the three regions, males and individuals aged ⩾20years had significantly higher prevalence of S. japonicum compared with females and children <5years. The role of the environmental variables differed between regions of The Philippines. Schistosoma japonicum infection was widespread in the Visayas whereas it was much more focal in Luzon and Mindanao. This analysis revealed significant spatial variation in the prevalence of S. japonicum infection in The Philippines. This suggests that a spatially targeted approach to schistosomiasis interventions, including mass drug administration, is warranted. When financially possible, additional schistosomiasis surveys should be prioritised for areas identified to be at high risk but which were under-represented in our dataset.

Entomological survey of artificial container breeding sites of dengue vectors in Batasan Hills, Quezon City

OBJECTIVE: Dengue fever remains a public health problem in the Philippines. Eliminating key container artificial breeding sites of mosquito vectors is a vital part of dengue control. The objective of this descriptive cross-sectional study was to conduct an entomological survey of artificial container breeding sites of Aedes mosquitoes in households of two puroks in Batasan Hills, Quezon City. METHODS: All potential artificial container breeding sites of dengue in each household were inspected for mosquito larvae. Water was sampled from all containers that had mosquito larvae. Water was sampled from all containers that had mosquito larvae and the larval species determined through microscopic examination. Using the World Health Organization list of recognized containers, each container was classified as recognized or an unrecognized container. RESULTS: The larval indices computed were: container index = 6.4%, household index = 23.9% and Breteau index = 29%. The proportion of containers positive for A. aegypti larvae was significantly higher for the unrecognized containers (9.9%) than that of the recognized containers (3.9%) (p=0.002). CONCLUSION: The high household index and Breteau index indicate that the potential for dengue transmission is high in the study area. Unrecognized artificial containers contributed significantly to the number of Aedes breeding sites. "Search-and-destroy" campaigns in the community should be expanded to include these containers. Crafting specific vector control messages that address the problem of particular unrecognized containers as well as those of recognized containers with the highest proportion positive for Aedes larvae will also aid dengue control and prevention. Repeat surveys to monitor larval indices may be used to help ascertain the effectiveness of these messages in decreasing mosquito breeding sites.