Prevalence of Depression, Anxiety, Post-Traumatic Stress, and Insomnia Symptoms Among Frontline Healthcare Workers in a COVID-19 Hospital in Northeast Mexico.

OBJECTIVE: Frontline healthcare workers (FHCWs) exposed to COVID-19 patients are at an increased risk of developing psychological burden. This study aims to determine the prevalence of mental health symptoms and associated factors among Mexican FHCWs attending COVID-19 patients. METHODS: FHCWs, including attending physicians, residents/fellows, and nurses providing care to COVID-19 patients at a private hospital in Monterrey, Mexico, were invited to answer an online survey between August 28, and November 30, 2020. Symptoms of depression, anxiety, post-traumatic stress, and insomnia were evaluated with the Patient Health Questionnaire (PHQ)-9, Generalized Anxiety Disorder (GAD)-7, Impact of Event Scale-Revised (IES-R), and Insomnia Severity Index (ISI). Multivariate analysis was performed to identify variables associated with each outcome. RESULTS: 131 FHCWs, 43.5% attending physicians, 19.8% residents/fellows, and 36.6% nurses were included. The overall prevalence of depression, anxiety, post-traumatic stress, and insomnia was 36%, 21%, 23%, and 24% respectively. Multivariate analysis revealed that residents/fellows and nurses reported more depression and insomnia than attending physicians. Although not significant, residents/fellows were more likely to experience all symptoms than nurses. CONCLUSIONS: Mexican FHCWs, especially nurses and residents/fellows, experienced a significant psychological burden while attending to COVID-19 patients. Tailored interventions providing support to FHCWs during future outbreaks are required.

Early increase of serum ferritin among COVID-19 patients is associated with need of invasive mechanical ventilation and with in-hospital death.

BACKGROUND: COVID-19 may trigger an acute hyperinflammatory syndrome characterised by heightened levels of acute phase reactants and is associated with adverse outcomes among hospitalised individuals. The relationship between 48-hour changes in acute phase reactants and adverse outcomes is unclear. This study evaluated the relationship between change in four acute phase reactants (interleukin-6, procalcitonin, ferritin, and C-reactive protein), and the risk for in-hospital death and invasive mechanical ventilation. METHODS: A retrospective cohort among 2,523 adult patients hospitalised with COVID-19 pneumonia was conducted. Changes in IL-6, procalcitonin, ferritin, and CRP from admission to 48 h after admission were recorded. Delta was calculated using the difference in each acute phase reactant at admission and at 48-hours. Delta in acute phase reactants and the risk for in-hospital death and invasive mechanical ventilation was assessed using logistic regression models adjusting for demographics and comorbidities. RESULTS: Patients with both admission and 48-hour measurement for interleukin-6 (IL-6) (n = 541), procalcitonin (n = 828), ferritin (n = 1022), and C-reactive protein (CRP) (n = 1919) were included. Baseline characteristics were similar across all four populations. Increases in ferritin associated with a heightened risk of in-hospital death (OR 1.00032; 95%CI 1.00007- 1.00056; p < .001) and invasive mechanical ventilation (OR 1.00035; 95%CI 1.00014- 1.00055; p = .001). Therefore, for every 100 ng/mL increase in ferritin, the odds for in-hospital death and invasive mechanical ventilation increase by 3.2% and 3.5%, respectively. CONCLUSIONS: Delta in ferritin is associated with in-hospital death and invasive mechanical ventilation. Other acute phase reactants were not associated with these outcomes among COVID-19 inpatients.

The effect of chlorhexidine on Acinetobacter baumannii in intensive care units.

Background and Objectives: Measures to prevent the emergence of hospital-acquired infections (HAIs) include a daily bath with chlorhexidine gluconate (CHG). The aim of this study was to determine the effect of patients bathing daily with CHG on the bacterial colonization on patient surfaces, environmental surrounding areas, and attending healthcare workers (HCWs). Materials and Methods: Patients were randomized by a 1:1 in two groups. Patients in group 1 were bathed daily with CHG; patients in group 2 were bathed with a placebo. Microbiological sampling of patients, environment, and HCWs were carried out on days 0, 3, and 10. The clonal relatedness of selected isolates collected was determined through pulsed-field gel electrophoresis. Clinical and demographic data were obtained from medical files. Results: Thirty-three patients were included (18 in group 1 and 15 in group 2). The more common species was Acinetobacter baumannii (n=144), followed by Klebsiella pneumoniae (n=81). A. baumannii was isolated more frequently on environmental surfaces in group 2 than group 1 (day 0 vs. day 3 vs. day 10; p = 0.0388). Twelve clones of A. baumannii were detected, with predominant clone A detected in patients and environmental surfaces. No pathogens were detected in HCWs. Conclusion: Our data support that CHG bathing decreases A. baumannii surviving on the environmental surfaces of critically ill patients.

Species distribution and antifungal susceptibility patterns of Aspergillus isolates from clinical specimens and soil samples in Mexico.

This study aimed to assess the species distribution and antifungal susceptibility patterns of 200 strains of Aspergillus isolated from clinical specimens (n = 146) and soil samples (n = 54) in Mexico. ITS, ß-tubulin, and calmodulin DNA sequencing was performed for species identification. Broth microdilution susceptibility testing for amphotericin B, voriconazole, posaconazole, itraconazole, isavuconazole, anidulafungin, caspofungin, and micafungin was done according to CLSI for all strains. A. fumigatus was most frequently recovered from clinical specimens, while A. niger was commonly encountered in soil, both followed by A. flavus in the second place. A total of 60 (30%) cryptic species were identified, with A. tubingensis and A. tamarii being the most commonly found. The decreased susceptibility to amphotericin B and azoles was 32% for both, and were mainly led by A. fumigatus, whereas this percentage decreased to 9% for caspofungin, particularly in A. terreus. More than 75% of cryptic species were susceptible in vitro to all antifungals. Multi-azole decreased susceptibility was detected only in seven isolates. Given that antifungal resistance in Aspergillus spp. is an increasing worldwide threat that causes major challenges in the clinical management of aspergillosis, these data highlight the need for continuous epidemiological surveillance of these pathogens for the implementation of locally adequate treatment strategies. LAY SUMMARY: This is an epidemiological study in Mexico. A. fumigatus was most frequent in clinical specimens and A. niger in soil samples. A. tubingensis and A. tamarii were the most common cryptic species. Resistance to amphotericin B and azoles was 32% each, and 9% for caspofungin.

Azithromycin effect on multidrug resistant Acinetobacter baumannii biofilm production and composition.

OBJECTIVES: To evaluate the effect of azithromycin (AZM) on biofilm formation and composition in multidrug resistant (MDR) Acinetobacter baumannii. MATERIAL AND METHODS: Ninety-six A. baumannii isolates were studied. Antimicrobial susceptibility and sub-minimum inhibitory concentration (sub-MIC) were determined by the broth microdilution method. Carbapenemase genes were detected by polymerase chain reaction and clonal diversity by pulsed-field gel electrophoresis (PFGE). Biofilm formation without AZM and AZM sub-MIC were determined by crystal violet staining. AZM-free biofilm composition and AZM sub-MIC were determined by detachment assays. RESULTS: The selected A. baumannii were MDR; 93.8% were carbapenem-resistant and 24 were OXA-24-positive. PFGE showed predominance of clones A (53%), B (34.7%) and C (12.5%). Biofilm production at AZM sub-MICs decreased in 53.1%, increased in 34.7% and showed no differences in 12.5% of isolates, in comparison with biofilm production without AZM. CONCLUSION: AZM sub-MIC can reduce biofilm production in A. baumannii MDR isolates with decreased protein and DNA in the biofilm. Our results may be useful in synergy studies for new therapeutic alternatives.

OBJETIVOS: Evaluar el efecto de la azitromicina (AZM) en la formación y composición de biopelículas en Acinetobacter baumannii resistente a múltiples fármacos (MDR). MATERIAL Y MÉTODOS: Se estudiaron 96 aislamientos de A. baumannii. La susceptibilidad antimicrobiana y la concentración inhibitoria submínima (sub-MIC) se determinaron por el método de microdilución del caldo. Los genes carbapenemasa fueron detectados por reacción en cadena de la polimerasa y la diversidad clonal por electroforesis en gel de campos pulsados (PFGE). La formación de biopelículas sin AZM y la sub-MIC de AZM por tinción de cristal violeta. La composición de la biopelícula sin AZM y la sub-MIC de AZM se determinaron mediante ensayos de desprendimiento. RESULTADOS: Los A. baumannii seleccionados fueron MDR; el 93.8% resistentes al carbapenem y 24 OXA-24 positivos. El PFGE demostró predominancia en los clones A (53%), B (34.7%) y C (12.5%). La producción de biopelículas en sub-MIC de AZM disminuyó en un 53.1%, aumentó en un 34.7% y no mostró diferencias en un 12.5% de los aislamientos, comparado con la producción de biopelículas sin AZM. CONCLUSIÓN: La sub-MIC de AZM puede reducir la producción de biopelículas en aislamientos de A. baumannii MDR con disminución de proteínas y el ADN en la biopelícula. Nuestros resultados pueden ser útiles en estudios de sinergia para nuevas alternativas terapéuticas.

First case of Candida auris isolated from the bloodstream of a Mexican patient with serious gastrointestinal complications from severe endometriosis.

A 58-year-old woman was diagnosed with severe endometriosis and had multiple gastrointestinal tract complications for many years. Candida auris and C. parapsilosis were isolated from the bloodstream. Identification of C. auris was confirmed by amplification and sequencing of the internal transcriber spacer and the D1/D2 domain of the large rRNA gene subunit. Antifungal susceptibility was tested in both isolates using the Clinical Laboratory Standards Institute protocol M27-A3/S4. The patient evolved favorably with systemic antifungal therapy consisting of caspofungin and liposomal amphotericin B.

Evaluation of the expanding spectrum of sertraline against uncommon fungal pathogens.

The emergence of non-Aspergillus mold pathogens has increased notoriously in the last decades with serious health consequences. The options of treatment for these microorganisms often resistant to a wide variety of antifungals is limited. Sertraline is an antidepressant with in vitro and in vivo antifungal properties which has been recently studied as an adjuvant in the treatment of invasive infections. In this study, we evaluated the in vitro interaction of sertraline with voriconazole and amphotericin B against Lomentospora prolificans, Scedosporium spp., Fusarium spp., Paecilomyces spp., Alternaria spp. and Curvularia spp. The minimum inhibitory concentration and minimum fungicidal concentration for sertraline were in the range of 8-32 µg/mL. Sertraline showed antifungal capacity against all fungi tested and synergism in combination with amphotericin B against some strains of Lomentospora prolificans, Scedosporium apiospermum and Alternaria alternata, antagonism with voriconazole against Purpureocillium lilacinum and indifference in both combinations for most of the other strains tested. These results suggest a potential role of sertraline as an adjuvant in the treatment of some of these serious mycoses.

Clinical evaluation of the antifungal effect of sertraline in the treatment of cryptococcal meningitis in HIV patients: a single Mexican center experience.

PURPOSE: Cryptococcal meningitis is a potentially fatal fungal infection associated with a significant attributable morbidity and mortality, especially among HIV/AIDS patients. The first-line therapy for the treatment of this clinical entity is the combinatory therapy of amphotericin B plus flucytosine. However, the high cost, toxic effects, and limited repertoire of effective antifungal drugs have led to the investigation of novel molecules. This is a prospective, double-blinded, and randomized study performed in a Mexican tertiary care center to evaluate the antifungal activity of sertraline in the treatment of cryptococcal meningitis in HIV patients. METHODS: During June 2015-December 2016, patients were recruited and included in one of two study groups: group A was given standard antifungal treatment plus sertraline 200 mg/day, while group B was given standard antifungal plus placebo. Lumbar punctures were performed on days 0, 7, and 14 of the study, and cryptococcal antigenemia and quantitative fungal culture in cerebrospinal fluid at each time point were evaluated to measure the rate of fungal clearance. RESULTS: The fungal loads and cryptococcal antigenemia titers showed a marked tendency to decrease by day 14 in both groups. Otherwise, group B exhibited a slightly higher nonstatistical rate of fungal clearance (-0.2868 ± 0.08275 log CFU/ml/day) than group A (-0.2496 ± 0.08340 log CFU/ml/day). CONCLUSIONS: A statistical difference between study groups was not found. This is the first study in Latin America that reports the experience of using sertraline as an adjuvant in the antifungal management of cryptococcal meningitis in HIV patients.

An unusual case of Candida ciferrii fungemia in an immunocompromised patient with Crohn's and Mycobacterium bovis disease.

We present a case report of a fungal bloodstream infection due to an unusual pathogen. This is a 30 years-old female patient diagnosed with Crohn's disease and a disseminated Mycobacterium bovis infection subsequently complicated by fungemia due to the emergent yeast pathogen Candida ciferrii, who was unresponsive to fluconazole and made a full recovery after treatment with posaconazole. To our knowledge, this is the first report of Candida ciferrii isolation from blood in an adult associated to a central venous catheter and which was successfully treated with posaconazole.

Activity of sertraline against Cryptococcus neoformans: in vitro and in vivo assays.

Cryptococcus neoformans infection is an important cause of meningitis in HIV/AIDS endemic regions. Antifungals for its management include amphotericin B, flucytosine, and fluconazole. Recently, treatment of this mycosis with sertraline has been studied with variable clinical outcomes. The aim of the study was to assess the in vitro antifungal effect of sertraline against clinical isolates of Cryptococcus spp. as well as its in vivo activity in a murine model of cryptococcal meningoencephalitis. The in vitro susceptibility to fluconazole, amphotericin B, voriconazole and sertraline of 153 Cryptococcus spp. strains were evaluated according to CLSI procedures. Fungal tissue burden, serum antigenaemia and histopathology, together with the therapeutic efficacy of amphotericin B (3 mg/kg), fluconazole (15 mg/kg), and sertraline (3, 10, and 15 mg/kg) were evaluated in mice intracranially inoculated with one isolate of Cryptococcus neoformans. All strains were susceptible to the antifungals studied and exhibited growth inhibition with sertraline at clinically relevant concentrations. Sertraline at a dose of 15 mg/kg reduced the fungal burden in the brain and spleen with an efficacy comparable to that of fluconazole. In conclusion, sertraline exhibited an excellent in vitro-in vivo anti-cryptococcal activity, representing a possible new alternative for the clinical management of meningeal cryptococcosis.