Invasive fungal infections in wars, following explosives and natural disasters: A narrative review.

Infections are well-known complications in patients following traumatic injuries, frequently leading to high morbidity and mortality. In particular, trauma occurring in disaster settings, both natural and man-made, such as armed conflicts and explosives detonation, results in challenging medical conditions that impede the best management practices. The incidence of invasive fungal infections (IFI) is increasing in trauma patients who lack the typical risk factors like an immune compromised state or others. This narrative review will focus on IFI as a direct complication after natural disasters, wars, and man-made mass destruction with a summary of the available evidence about the epidemiology, clinical manifestations, risk factors, microbiology, and proper management. In this setting, the clinical manifestations of IFI may include skin and soft tissue infections, osteomyelitis, visceral infections, and pneumonia. IFI should be considered in the war inflicted patients who are exposed to unsterile environments or have wounds contaminated with soil and decaying organic matter.

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon.

BACKGROUND: Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI. METHODS AND RESULTS: We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR. CONCLUSION: Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

The Impact of COVID-19 on the Epidemiology and Outcomes of Candidemia: A Retrospective Study from a Tertiary Care Center in Lebanon.

Invasive fungal infections, notably candidemia, have been associated with COVID-19. The epidemiology of candidemia has significantly changed during the COVID-19 pandemic. We aim to identify the microbiological profile, resistance rates, and outcomes of COVID-19-associated candidemia (CAC) compared to patients with candidemia not associated with COVID-19. We retrospectively collected data on patients with candidemia admitted to the American University of Beirut Medical Center between 2004 and 2022. We compared the epidemiology of candidemia during and prior to the COVID-19 pandemic. Additionally, we compared the outcomes of critically ill patients with CAC to those with candidemia without COVID-19 from March 2020 till March 2022. Among 245 candidemia episodes, 156 occurred prior to the pandemic and 89 during the pandemic. Of the latter, 39 (43.8%) were CAC, most of which (82%) were reported from intensive care units (ICU). Non-albicans Candida (NAC) spp. were predominant throughout the study period (67.7%). Candida auris infection was the most common cause of NAC spp. in CAC. C. glabrata had decreased susceptibility rates to fluconazole and caspofungin during the pandemic period (46.1% and 38.4%, respectively). The mortality rate in the overall ICU population during the pandemic was 76.6%, much higher than the previously reported candidemia mortality rate observed in studies involving ICU patients. There was no significant difference in 30-day mortality between CAC and non-CAC (75.0% vs. 78.1%; p = 0.76). Performing ophthalmic examination (p = 0.002), CVC removal during the 48 h following the candidemia (p = 0.008) and speciation (p = 0.028) were significantly associated with a lower case-fatality rate. The epidemiology of candidemia has been significantly affected by the COVID-19 pandemic at our center. Rigorous infection control measures and proper antifungal stewardship are essential to combat highly resistant species such as C. auris.

The Utility of EQUAL Candida Score in Predicting Mortality in Patients with Candidemia.

In an effort to standardize practice, the European Confederation of Medical Mycology (ECMM) developed the European Confederation of Medical Mycology Quality of Clinical Candidaemia Management (EQUAL) Candida score. This study investigated the utility of the EQUAL Candida score in predicting mortality in patients with candidemia admitted between January 2004 and July 2019. A total of 142 cases were included in the study, and 43.6% died within 30 days of candidemia diagnosis. There were no significant differences between survivors and non-survivors in terms of comorbidities predisposing to candidemia, except for malignancy (p = 0.021). The overall mean EQUAL score was 11.5 in the total population and 11.8 ± 3.82 and 11.03 ± 4.59 in survivors and non-survivors, respectively. When patients with a central venous catheter (CVC) were considered alone, survivors were found to have significantly higher scores than non-survivors (13.1 ± 3.19 vs. 11.3 ± 4.77, p = 0.025). When assessing components of the EQUAL Score separately, only candida speciation (p = 0.013), susceptibility testing (p = 0.012) and echocardiography results (p = 0.012) were significantly associated with a lower case-fatality rate. A higher EQUAL Candida score was able to predict a lower case-fatality rate in patients with a CVC.

The Role of Herbal and Nutritional Treatments in the Fight against COVID-19 and Other Respiratory Tract Infections.

With the growing spread of COVID-19 worldwide, the appeal to alternative and nutritional therapies in conjunction with medical therapies has been heightened. This article aims to review studies assessing the roles of Chinese traditional medicine and nutrition in upper respiratory infections, including COVID-19. Various Chinese herbal protocols have been shown to fight respiratory infections, with several having been tested on the novel coronavirus. Additionally, promising findings have been reported when medical treatments were complemented with nutritional interventions. Supplementation with vitamins C and D, Zinc and Selenium are discussed, in addition to certain phytochemicals and food that also possess immunoregulatory and antiviral properties. Further clinical studies are needed to establish these alternative treatments as part of the management of emerging respiratory infections.

Recommendations to Improve Palliative Care Provision for Marginalized Populations: Summary of a Roundtable Discussion.

Palliative care is increasingly recognized as fundamental to health and human dignity. However, a growing body of evidence highlights the variations in access to palliative care based on personal characteristics, belonging to a certain group, and socioeconomic background. Discriminatory attitudes and behaviors and lack of legal reform protecting the rights of marginalized populations are still common, particularly across Lebanon and the Middle East and North Africa region. This article presents a summary of a roundtable discussion organized by the Lebanese Medical Association for Sexual Health in collaboration with the Lebanese Center for Palliative Care-Balsam, focusing on improving palliative care provision for the following populations: prisoners; lesbian, gay, bisexual, and transgender people; refugees; migrant domestic workers; and people with substance use disorder. It also offers recommendations based on the key themes identified from the discussion, in the hope that they will guide the development of guidelines and policy to advance equity in palliative care provision for marginalized populations.

Human herpes virus-6 (HHV-6) pneumonitis and meningitis with viraemia in an immunocompetent adult patient.

Human herpes virus-6 (HHV-6) infection is a common infection in the paediatric population and is increasingly reported in immunosuppressed adult patients. It has been reported as the causative agent of disease in few case reports in immunocompetent adults. We report herein an unusual case of HHV-6-associated viraemia, pneumonitis and meningitis in a patient who presented with dyspnoea, hypoxia, dry cough and headache. She was treated for atypical pneumonia with no improvement. Meningitis was suspected as headache kept worsening. HHV-6B was detected by PCR in the cerebrospinal fluid, and subsequently, in the bronchoalveolar lavage and serum samples. Studies were negative for the most common primary and secondary immunodeficiency syndromes, and serology could not be performed to differentiate virus reactivation from a primary infection. The patient was successfully treated with ganciclovir and had no residual sequelae.

Cytomegalovirus reactivation in left ventricular assist device patients: case series and literature review.

BACKGROUND: Cytomegalovirus (CMV) reactivation after placing left ventricular assist device (LVAD) is not a well-known entity with few cases reported in the literature. Here, we are presenting three cases of CMV reactivation after placing LVAD. A literature review of all reported cases in the literature was done. CASE SUMMARY: Three cases of advanced heart failure with reduced ejection fraction (Stage D9) had placed (LVAD) at the American University of Beirut Medical Center, a tertiary care centre in Lebanon. Within the first 2 weeks after LVAD implantation, the three patients spiked a high-grade fever for which sepsis workup was done, and antibiotics were initiated. Despite the escalating antibiotic regimens, the three patients had a persistent high-grade fever. The negative cultures and the continuous fever prompted an investigation for other causes of fever. Therefore, CMV polymerase chain reaction in blood was performed and revealed high titres. Patients received a full course of treatment with ganciclovir. The fever and the CMV titres declined after completing the antiviral therapy with better clinical outcomes. This raises the concern of CMV reactivation in LVAD patients. DISCUSSION: This case series and literature review highlight the epidemiology, incidence, and management of CMV reactivation among LVAD patients. Awareness about this clinical entity should be raised, especially with the increase of LVAD surgeries.

Imaging of abdominal and pelvic infections in the cancer patient.

Infections are the most commonly encountered complications in patients with cancer. The classical signs and symptoms of infections are often not present in this patient population, which makes the diagnosis more challenging. Host factors play a major role in the development and prognosis of infections in cancer patients; these can be related to the underlying type of malignancy (solid organ versus hematological), tumor burden, anatomic obstruction, altered integrity of barriers (skin or mucosa), treatment-related factors (from chemotherapy, radiation treatment, surgery, interventional procedures, and/or medical device placement) and the degree of immunosuppression. This article reviews common, as well as less common, imaging manifestations of infections and their potential mimics in the abdomen and pelvis in cancer patients and discusses their differentiating features, with the role of imaging in various organs in the abdomen and pelvis taking into consideration relevant clinical background information and the main risk factors.

The utility of chest X-ray vs. computed tomography in febrile neutropenia patients presenting to the emergency department.

INTRODUCTION: Pulmonary infections are not uncommon in patients with febrile neutropenia. Physicians have agreed to perform a chest X-ray (CXR) for all febrile neutropenic patients presenting with respiratory signs/symptoms. Nevertheless, they were divided into two groups when it came to asymptomatic febrile neutropenic patients (i.e. without respiratory signs/symptoms). A superior alternative to CXR is Computed Tomography (CT). CT, in comparison to CXR, was shown to have better sensitivity in detecting pulmonary foci. The aim of our study is to compare the diagnostic performance of CT and CXR in febrile neutropenic patients presenting to the emergency department, regardless of their clinical presentation. We are also interested in the predictors of pneumonia on chest imaging. METHODOLOGY: This is a retrospective cohort study conducted on febrile neutropenic adult cancer patients presenting to the emergency department of the American University of Beirut Medical Center. RESULTS: 11.4% of 263 patients had pneumonia although 27.7% had respiratory signs/symptoms. 17.1% of those who were symptomatic and did a CXR were found to have pneumonia. 41.7% of those who were symptomatic and did a CT were found to have pneumonia. 30% had negative findings on CXR but pneumonia on CT. CONCLUSION: Patients with positive findings of pneumonia on chest imaging mainly had solid tumors, profound neutropenia, a higher CCI and a longer LOS. The presence of respiratory signs is the main predictor of positive pneumonia on chest imaging. CT is superior to CXR in detecting pulmonary foci in the population studied.

Palliative Care via Telemedicine: A Qualitative Study of Caregiver and Provider Perceptions.

Background: Telemedicine has been proposed as a means to improve access to palliative care. There is limited information about how health care workers feel about providing this kind of care and how families feel about receiving it. Objective: This study assesses provider and caregiver perceptions of the safety and efficacy of the Distance Support Program (DSP) of a home-based palliative care provider in Beirut, Lebanon. Design: Interviews were conducted with 8 physicians and nurses who provided that care through the DSP as well as 49 caregivers of patients who received care between January 2015 and December 2017. Interviews were analyzed thematically. Results: Although they would have preferred having access to home visits, caregivers reported that they valued the information, guidance, and emotional support they received through the DSP and they appreciated having telephone access to providers. Health providers reported the DSP was more efficient than home visits. They felt it was safest when delivered by an experienced provider, they had access to a reliable caregiver, and the patient was assessed at least once. They felt it was important to communicate clear expectations to patients and caregivers when delivering care by telephone. Conclusions: Telemedicine can be a useful tool to provide palliative care services in settings where they would otherwise not be available.

Baseline Chest Computed Tomography as Standard of Care in High-Risk Hematology Patients.

Baseline chest computed tomography (BCT) in high-risk hematology patients allows for the early diagnosis of invasive pulmonary aspergillosis (IPA). The distribution of BCT implementation in hematology departments and impact on outcome is unknown. A web-based questionnaire was designed. International scientific bodies were invited. The estimated numbers of annually treated hematology patients, chest imaging timepoints and techniques, IPA rates, and follow-up imaging were assessed. In total, 142 physicians from 43 countries participated. The specialties included infectious diseases (n = 69; 49%), hematology (n = 68; 48%), and others (n = 41; 29%). BCT was performed in 57% (n = 54) of 92 hospitals. Upon the diagnosis of malignancy or admission, 48% and 24% performed BCT, respectively, and X-ray was performed in 48% and 69%, respectively. BCT was more often used in hematopoietic cell transplantation and in relapsed acute leukemia. European centers performed BCT in 59% and non-European centers in 53%. Median estimated IPA rate was 8% and did not differ between BCT (9%; IQR 5-15%) and non-BCT centers (7%; IQR 5-10%) (p = 0.69). Follow-up computed tomography (CT) for IPA was performed in 98% (n = 90) of centers. In high-risk hematology patients, baseline CT is becoming a standard-of-care. Chest X-ray, while inferior, is still widely used. Randomized, controlled trials are needed to investigate the impact of BCT on patient outcome.

Ten-year surveillance study of ventilator-associated pneumonia at a tertiary care center in Lebanon.

BACKGROUND: Ventilator-associated pneumonia (VAP) is associated with significant adverse outcomes in critically-ill patients admitted to the Intensive Care Unit (ICU). Systematic data from Lebanon on VAP are not available and large epidemiological studies from the region are scarce. METHODS: We conducted a retrospective study over a 10-year period at the American University of Beirut Medical Center (AUBMC), a tertiary referral center in Lebanon in order to describe the incidence, microbiology, and temporal trends of VAP in the medical/surgical ICU. RESULTS: A total of 162 patients developed VAP over the study period and the overall incidence of VAP was 7.9 per 1000 ventilator-days. There was a statistically significant decrease over time in the incidence of VAP, from 13.1 in 2008 to 1.1 per 1000 ventilator-days in 2017. Multidrug-resistant (MDR) Acinetobacter spp. was the predominant pathogen, both in early- as well as late-onset VAP, followed by Pseudomonas aeruginosa. CONCLUSIONS: Following significant efforts from the Infection Control and Prevention Program, a considerable reduction in the incidence of VAP was achieved at AUBMC. The predominance of MDR Acinetobacter spp. should be taken into consideration when deciding on empirical therapy in patients with VAP.

Mucormycosis in hospitalized patients at a tertiary care center in Lebanon: a case series.

PURPOSE: Mucormycosis (MCM) is a rare fungal infection affecting people with impaired immunity. Data related to MCM from Lebanon are scarce. The aim of this study is to shed light on the epidemiology, incidence, and outcome of patients with MCM hospitalized at a tertiary care center in Lebanon. METHODS: We conducted a retrospective chart review between Jan 1, 2008 and Jan 10, 2018. All patients with proven or probable MCM were included. RESULTS: A total of 20 patients were included. Their median age was 49 years and the majority were males. Comorbidities included mainly hematologic malignancy and diabetes mellitus. Most common sites of involvement were rhino-orbital and pulmonary, respectively. The number of MCM cases/10.000 hospital admissions increased significantly between 2008 and 2017 (0.47 vs. 1.18; P < 0.05). A liposomal amphotericin B formulation alone or in combination with other antifungals was used as a first line agent in all patients. All-cause mortality was 60%; however, death was attributed to MCM in 20% of cases. CONCLUSION: The incidence of MCM has significantly increased over the past 10 years at our institution, most likely due to the increasing patient population at risk. Understanding the epidemiology of MCM in our setting would help guide antifungal therapy.

Cytomegalovirus reactivation in lymphoma and myeloma patients undergoing autologous peripheral blood stem cell transplantation.

BACKGROUND: Cytomegalovirus reactivation is often diagnosed in allogeneic hematopoietic cell transplant recipients and therefore could lead to CMV-related disease, involving many organs in these immunocompromised patients. In contrast, few studies investigated CMV reactivation and end-organ disease in patients undergoing Autologous Peripheral Blood Stem Cell Transplant (ASCT) since they are considered at low risk for both reactivation and disease. OBJECTIVES: The primary outcome of the analysis was to understand the difference in incidence of CMV reactivation between MM and Lymphoma patients. Secondary outcomes included the difference between MM and Lymphoma patients when considering the effect of CMV reactivation on transplant related mortality (TRM) overall survival (OS) progression free survival (PFS), risk factors for reactivation, and median time to reactivation. STUDY DESIGN: In this report, we retrospectively compared the incidence, risk factors, and outcome of CMV reactivation in adult patients with Myeloma (MM) and Lymphoma undergoing ASCT at the American university of Beirut Medical Center in Lebanon (AUBMC). A total of 324 consecutive ASCT were performed between January 2005 and March 2016. Serial weekly monitoring for CMV quantification was done using a quantitative PCR, starting from transplantation until the hospital discharge and afterwards based on the clinical symptoms in cases of clinical suspicion of reactivation after discharge from the hospital. RESULTS: The cumulative incidence of CMV reactivation was 16% (n=53) with a median time of 16 (range, 4-242) days after ASCT. The incidence of reactivation was significantly higher in the MM (22%) and NHL (20%) groups, when compared to the HL (4%) (P=0.001). There was a higher incidence of CMV reactivation according to age (≥50 vs ≤50 years) with higher incidence in the older population 24% vs 10% respectively (p=0.0043). The mean time to CMV reactivation was significantly higher in the NHL group with a mean of 53.7days when compared to the HL and MM groups with mean 19.75days and 12.66 (range, 4-34) days respectively (P=0.003). Twenty-two patients (76%) and three patients (75%) patients required specific antiviral therapy in the MM group and HL groups respectively; which was significantly higher (P<0.001) then the NHL group with 13 (65%) patients requiring specific antiviral therapy. Five patients (1.5%) developed CMV disease at a median of 60days (range, 7-107) post ASCT: there was significant difference in the mean-time to reactivation based on disease type MM versus lymphoma 10 versus 33days (P=0.007). In multivariate analysis, a higher age was associated with an increased risk of CMV reactivation; MM and NHL had higher risk of CMV reactivation when compared to HL, and progressive disease at transplant was associated with increased risk of CMV reactivation. After a median follow-up of 21.5 months (range: 1-125), there was no significant impact on PFS, however there was significant decrease in OS of lymphoma patients who had CMV reactivation when compared to those without CMV reactivation (204 and 112days respectively P=0.045). TRM increased from 1.1% in patients with no CMV reactivation to 13% in patients with CMV reactivation (P=0.003). CONCLUSION: Our data suggests that CMV reactivation is not uncommon in ASCT recipients and may contribute to increase TRM. MM patients may have a higher incidence, of CMV reactivation with more anti-viral treatment requirements when compared to lymphoma patients, especially in older population.

Case-Control Study of Telavancin as an Alternative Treatment for Gram-Positive Bloodstream Infections in Patients with Cancer.

Gram-positive bacterial infections are an important cause of morbidity and death among cancer patients, despite current therapy. In this case-control study, we evaluated the clinical outcomes and safety of telavancin in cancer patients with uncomplicated Gram-positive bloodstream infections (BSIs). Between March 2011 and May 2013, we enrolled cancer patients with uncomplicated Gram-positive BSIs to receive intravenous telavancin therapy for at least 14 days for Staphylococcus aureus and 7 days for other Gram-positive cocci. Patients with baseline creatinine clearance (CLCR) values of >50 ml/min received 10 mg/kg/day of telavancin, and those with CLCR values between 30 and 49 ml/min received 7.5 mg/kg/day. Patients were compared with a retrospective cohort of 39 historical patients with Gram-positive BSIs, matched for underlying malignancy, infecting organism, and neutropenia status, who had been treated with vancomycin. A total of 78 patients were analyzed, with 39 in each group. The most common pathogen causing BSIs was S. aureus (51%), followed by alpha-hemolytic streptococci (23%), Enterococcus spp. (15%), coagulase-negative staphylococci (8%), and beta-hemolytic streptococci (3%). Sixty-two percent of patients had hematological malignancies, and 38% had solid tumors; 51% of the patients were neutropenic. The overall response rate determined by clinical outcome and microbiological eradication at 72 h following the initiation of therapy, in the absence of relapse, deep-seated infections, and/or infection-related death, was better with telavancin than with vancomycin (86% versus 61%; P = 0.013). Rates of drug-related adverse events were similar in the two groups (telavancin, 31%; vancomycin, 23%; P = 0.79), with similar rates of renal adverse events. Telavancin may provide a useful alternative to standard vancomycin therapy for Gram-positive BSIs in cancer patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01321879.).

The use of minocycline-rifampin coated central venous catheters for exchange of catheters in the setting of staphylococcus aureus central line associated bloodstream infections.

BACKGROUND: Central venous catheters (CVC) removal and reinsertion of a new CVC in the setting of central line associated bloodstream infections (CLABSI) is not always possible in septic patients. The purpose of this study was to evaluate the outcome of patients with Staphylococcus aureus-CLABSI (SA-CLABSI) who had their CVCs exchanged over guidewire for minocycline/rifampin-coated (M/R)-CVC within seven days of bacteremia. METHODS: Each case was matched with two control patients who had SA-CLABSI and had their CVC removed within seven days and two control patients who had their CVC retained beyond seven days. In addition, an in vitro model was developed for exchange of catheters. RESULTS: We identified 40 patients with SA-CLABSI. Eight patients had their CVC exchanged over guidewire with M/R-CVC and were compared to 16 patients who had their CVC removed and 16 other patients who had their CVC retained. Patients who had their CVC exchanged over guidewire had a similar clinical response and relapse rates compared to patients whose CVC was removed or retained. However the rate of overall mortality was higher in patients who retained their CVC compared to those whose CVC was exchanged or removed (p = 0.034). The in vitro catheter exchange model showed that catheter exchange over guidewire using M/R-CVC completely prevented biofilm colonization compared to exchange using uncoated CVC (p < 0.0001). CONCLUSIONS: In the setting of SA-CLABSI, exchanging the CVC over guidewire with M/R-CVC could be an alternative to removing the CVC and reinserting another CVC at a different site and may be associated with a lower rate of overall mortality. Further large prospective randomized clinical trials are warranted.