Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic.Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment.Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat.Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial’s use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Objective: We aimed at investigating and describing the drug and material resources in health shortage in the Brazilian services during the COVID-19 pandemic. Methods: We conducted a cross-sectional study in the format of an online survey with closed questions. Information was sought about the institutional and care profile, pharmaceutical service organization, non-compliance in the stock, or lack of drugs and other health products between April and October 2020. We performed descriptive, univariate, and multivariate statistical analyses, such as Fisher's t-test, chi-square test, and the Multiple Correspondence and Hierarchical Cluster analyses. A p-value below 0.05 and a 95% significance level were considered. Results: 228 Brazilian institutions, most located in the capital cities, with specific beds for COVID-19 and public administration, were included in the study. Grouping by similarity separated the study sample into five heterogeneous clusters. Eighty-four percent of the services indicated a drugs shortage, especially neuromuscular blocking agents (64.9%), hypnotics and sedatives (52.9%), vasoactive drugs (37.3%), and antiinfective agents (30%). Conclusion: In all the clusters, there were reports of a shortage of items considered essential in the management of critically-ill patients, corroborating the perception that this was a significant challenge for pharmaceutical assistance in various Brazilian services during the COVID-19 pandemic.

Low levels of testosterone may lead to reduced diaphragm excursion and inspiratory time during COVID-19 infection. We report the case of a 38-year-old man with a positive result on a reverse transcriptase-polymerase chain reaction test for SARS-CoV-2, admitted to the intensive care unit with acute respiratory failure. After several days on mechanical ventilation and use of rescue therapies, during the weaning phase, the patient presented dyspnea associated with low diaphragm performance (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 37%, 1.7 cm, and 2.6 cm/s, respectively) by ultrasonography and reduced testosterone levels (total testosterone, bioavailable testosterone and sex hormone binding globulin (SHBG) levels were 9.3 ng/dL, 5.8 ng/dL, and 10.5 nmol/L, respectively). Testosterone was administered three times 2 weeks apart (testosterone undecanoate 1000 mg/4 mL intramuscularly). Diaphragm performance improved significantly (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 70%, 2.4 cm, and 3.0 cm/s, respectively) 45 and 75 days after the first dose of testosterone. No adverse events were observed, although monitoring was required after testosterone administration. Testosterone replacement therapy led to good diaphragm performance in a male patient with COVID-19. This should be interpreted with caution due to the exploratory nature of the study.

Kidney injury is an important outcome associated with COVID-19 severity. In this regard, alterations in urinary extracellular vesicles (uEVs) could be detected in the early phases of renal injury and may be reflective of the inflammatory process. This is an observational study performed with a case series of COVID-19 hospitalized patients presenting mild-to-critical disease. Total and podocyte-derived uEVs were identified by nanoscale flow cytometry, and urinary immune mediators were assessed by a multiplex assay. We studied 36 patients, where 24 (66.7%) were considered as mild/moderate and 12 (33.3%) as severe/critical. Increased levels of total uEVs were observed (p = 0.0001). Importantly, total uEVs were significantly higher in severe/critical patients who underwent hemodialysis (p = 0.03) and were able to predict this clinical outcome (AUC 0.93, p = 0.02). Severe/critical patients also presented elevated urinary levels (p < 0.05) of IL-1β, IL-4, IL-6, IL-7, IL-16, IL-17A, LIF, CCL-2, CCL-3, CCL-11, CXCL-10, FGFb, M-CSF, and CTAcK. Lastly, we observed that total uEVs were associated with urinary immune mediators. In conclusion, our results show that early alterations in urinary EVs could identify patients at higher risk of developing renal dysfunction in COVID-19. This could also be relevant in different scenarios of systemic and/or infectious disease.

statistical method for before and after studies, but the purpose of this study was to verify whether there was a statistical difference in the incidence of resistant bacteria between prepandemic years and during the early months of the pandemic. While time series events on preliminary or indicator data can be useful 3 -as Lima et al demonstrate, we are deferring a time series analysis of our data until after the pandemic is over.We were able to identify the outbreaks and both are well described in the article, but the increased use of the number of invasive devices is only a hypothesis, as neither study compared their usage rates in the pre and pandemic periods, although we know that COVID patients are more severe and require a greater number of invasions.We recognize the limitations of our study, as it is a single center, but with exclusive dedication to the care of COVID for 5 months. We believe that in this period exclusively dedicated and with 200 beds of ICU the impact of COVID-19 can really be measured, despite the biases described.In summary, the results found by Lima et al may show a transient impact on the incidence of A. baumannii MDR by their definition, but they are different from our results. We agree that the impact of COVID-19 on hospital-acquired MDR infections may be heterogeneous across healthcare settings.