It has been recognised for a considerable time-period, that viral respiratory infections predispose patients to bacterial infections, and that these co-infections have a worse outcome than either infection on its own. However, it is still unclear what exact roles co-infections and/or superinfections play in patients with COVID-19 infection. This was an extensive review of the current literature regarding co-infections and superinfections in patients with SARS-CoV-2 infection. The definitions used were those of the Centers for Disease Control and Prevention (US), which defines coinfection as one occurring concurrently with the initial infection, while superinfections are those infections that follow on a previous infection, especially when caused by microorganisms that are resistant, or have become resistant, to the antibiotics used earlier. Some researchers have envisioned three potential scenarios of bacterial/SARS-CoV-2 co-infection; namely, secondary SARS-CoV-2 infection following bacterial infection or colonisation, combined viral/bacterial pneumonia, or secondary bacterial superinfection following SARS-CoV-2. There are a myriad of published articles ranging from letters to the editor to systematic reviews and meta-analyses describing varying ranges of co-infection and/or superinfection in patients with COVID-19. The concomitant infections described included other respiratory viruses, bacteria, including mycobacteria, fungi, as well as other, more unusual, pathogens. However, as will be seen in this review, there is often not a clear distinction made in the literature as to what the authors are referring to, whether true concomitant/co-infections or superinfections. In addition, possible mechanisms of the interactions between viral infections, including SARS-CoV-2, and other infections, particularly bacterial infections are discussed further. Lastly, the impact of these co-infections and superinfections in the severity of COVID-19 infections and their outcome is also described. The current review describes varying rates of co-infections and/or superinfections in patients with COVID-19 infections, although often a clear distinction between the two is not clear in the literature. When they occur, these infections appear to be associated with both severity of COVID-19 as well as poorer outcomes.

/pdf/the-role-of-co-infections-and-secondary-infections-in-2dkcb9fgmb.pdf

The role of co-infections and secondary infections in patients with COVID-19

Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.This first in a two-part series on COVID-19 updates provides a focused overview of the presentation and evaluation of COVID-19 for emergency clinicians.COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. Several variants exist, including a variant of concern known as Delta (B.1.617.2 lineage) and the Omicron variant (B.1.1.529 lineage). The Delta variant is associated with higher infectivity and poor patient outcomes, and the Omicron variant has resulted in a significant increase in infections. While over 80% of patients experience mild symptoms, a significant proportion can be critically ill, including those who are older and those with comorbidities. Upper respiratory symptoms, fever, and changes in taste/smell remain the most common presenting symptoms. Extrapulmonary complications are numerous and may be severe, including the cardiovascular, neurologic, gastrointestinal, and dermatologic systems. Emergency department evaluation includes focused testing for COVID-19 and assessment of end-organ injury. Imaging may include chest radiography, computed tomography, or ultrasound. Several risk scores may assist in prognostication, including the 4C (Coronavirus Clinical Characterisation Consortium) score, quick COVID Severity Index (qCSI), NEWS2, and the PRIEST score, but these should only supplement and not replace clinical judgment.This review provides a focused update of the presentation and evaluation of COVID-19 for emergency clinicians. 

https://doi.org/10.1016/j.ajem.2022.01.028

Clinical update on COVID-19 for the emergency clinician: Presentation and evaluation

OBJECTIVE: To evaluate whether early initiation of prophylactic anticoagulation compared with no anticoagulation was associated with decreased risk of death among patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United States DESIGN: Observational cohort study SETTING: Nationwide cohort of patients receiving care in the Department of Veterans Affairs, a large integrated national healthcare system PARTICIPANTS: All 4297 patients admitted to hospital from 1 March to 31 July 2020 with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and without a history of anticoagulation MAIN OUTCOME MEASURES: The main outcome was 30 day mortality Secondary outcomes were inpatient mortality, initiating therapeutic anticoagulation (a proxy for clinical deterioration, including thromboembolic events), and bleeding that required transfusion RESULTS: Of 4297 patients admitted to hospital with covid-19, 3627 (844%) received prophylactic anticoagulation within 24 hours of admission More than 99% (n=3600) of treated patients received subcutaneous heparin or enoxaparin 622 deaths occurred within 30 days of hospital admission, 513 among those who received prophylactic anticoagulation Most deaths (510/622, 82%) occurred during hospital stay Using inverse probability of treatment weighted analyses, the cumulative incidence of mortality at 30 days was 143% (95% confidence interval 131% to 155%) among those who received prophylactic anticoagulation and 187% (151% to 229%) among those who did not Compared with patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30 day mortality (hazard ratio 073, 95% confidence interval 066 to 081) Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation Receipt of prophylactic anticoagulation was not associated with increased risk of bleeding that required transfusion (hazard ratio 087, 071 to 105) Quantitative bias analysis showed that results were robust to unmeasured confounding (e-value lower 95% confidence interval 177 for 30 day mortality) Results persisted in several sensitivity analyses CONCLUSIONS: Early initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with covid-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events These findings provide strong real world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial treatment for patients with covid-19 on hospital admission

https://www.bmj.com/content/bmj/372/bmj.n311.full.pdf

Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study.

COVID-19 and thrombosis: From bench to bedside.

To review current literature on endothelial dysfunction with previous coronaviruses, and present available data on the role of endothelial dysfunction in coronavirus disease-2019 (COVID-19) infection in terms of pathophysiology and clinical phenotype Recent evidence suggests that signs and symptoms of severe COVID-19 infection resemble the clinical phenotype of endothelial dysfunction, implicating mutual pathophysiological pathways. Dysfunction of endothelial cells is believed to mediate a variety of viral infections, including those caused by previous coronaviruses. Experience from previous coronaviruses has triggered hypotheses on the role of endothelial dysfunction in the pathophysiology of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), which are currently being tested in preclinical and clinical studies. Endothelial dysfunction is the common denominator of multiple clinical aspects of severe COVID-19 infection that have been problematic for treating physicians. Given the global impact of this pandemic, better understanding of the pathophysiology could significantly affect management of patients.

/pdf/endothelial-dysfunction-in-covid-19-lessons-learned-from-3hmph6o11e.pdf

Endothelial Dysfunction in COVID-19: Lessons Learned from Coronaviruses.

Acute upper limb ischemia in a patient with COVID-19.

The World Health Organization has declared novel coronavirus disease 2019 (COVID-19) a global public health emergency. Although respiratory symptoms predominate in COVID-19, thrombosis can occur in patients with COVID-19. This paper reports a case of an 82-year-old female with a prior medical history of hypertension, diabetes presenting with fever and cough, and was diagnosed with COVID-19. The patient subsequently developed progressively worsening of abdominal distention, tenderness, and underwent emergent laparotomy. She was found to have a gangrenous colon. This case adds to the limited literature regarding the extrapulmonary complications of COVID-19. (Korean J Gastroenterol 2020;76:164-166)

/pdf/acute-intestinal-ischemia-in-a-patient-with-covid-19-40afy9xzvt.pdf

Acute Intestinal Ischemia in a Patient with COVID-19 Infection

COVID-19 and acute mesenteric ischemia: A review of literature.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19.

COVID-19 Presenting as Acute Limb Ischaemia

Coronavirus disease 2019 (COVID-19) is a global public health emergency. COVID-19 is most well known for affecting the respiratory system, although it can also result in several extrapulmonary manifestations. Limited literature is available regarding rhabdomyolysis in COVID-19. We report four cases of rhabdomyolysis in COVID-19 patients. High index of suspicion is required for the appropriate clinical scenario to recognize this life-threatening situation so that complications can be avoided.

/pdf/rhabdomyolysis-in-covid-19-report-of-four-cases-t0w71bvcnw.pdf

Rhabdomyolysis in COVID-19: Report of Four Cases

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