Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage were associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin converting enzyme 2 (ACE2). As a result of SARS‐Cov‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT
1
R) axis associated with oxidative stress. This leads to insulin resistanceas well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block the AT
1
R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are given: Kimchi in Korea, westernized foods and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects helpful in mitigating COVID‐19 severity.
Two patients with history of cardiac ablation presented with massive hemoptysis secondary to pulmonary vein stenosis. They underwent successful pulmonary vein angioplasty and stenting. Although the second patient ended up having a lobectomy, the successful opening of the Left Superior Pulmonary Vein helped sparing the superior lobe and lingula.
Background: The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM), the Lebanese Society of Critical Care Medicine (LSCCM), and the Lebanese Pulmonary Society (LPS) play a major role in guiding clinicians across Lebanon in prescribing antibiotics for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Members of these societies have tailored the international recommendations for the management of HAP/VAP to local epidemiological and microbiological data. The aims of these local guidelines are to guide clinicians in the prevention of VAP, selection of appropriate empiric and targeted antimicrobial regimens for VAP/HAP and to contribute to improving patient outcomes.
Methods: Recommendations in these guidelines are adapted from international guidelines and are modeled based on locally-derived epidemiological and microbiological data, as well as the availability of antimicrobial agents and other resources.
Results: These guidelines aim to combine both clinical and bacteriological strategies to appropriately diagnose and manage HAP/VAP. They recommend implementing evidence-based preventive measures to lower the rate of VAP and improve patient outcomes. The recommended duration of treatment with antibiotics in general should not exceed 7 days in patients with HAP whereas it should be 7–8 days in patients with VAP. Imunnosuppressed patients with Pseudomonas aeruginosa infection might require longer courses. Ceftolozane/tazobactam (CFT/TAZ) and ceftazidime/avibactam (CAZ/AVI) are considered good options in patients with HAP/VAP caused by extended spectrum beta-lactamase-producing Enterobacterales and multidrug-resistant Pseudomonas aeruginosa. They also play a key role in the implementation of a carbapenem-sparing strategy in an antimicrobial stewardship program.
Conclusion: These guidelines represent a major step towards establishing Lebanese national guidelines for the management of HAP/VAP. They also emphasize on timeliness and appropriateness of antibiotic therapy for the management of HAP/VAP.
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