Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: On December 31st, 2019,
Speaker: China reported a cluster of cases of pneumonia associated with the Hunan seafood wholesale market in Wuhan.
Speaker: On January 7, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronavirus named 2019-nCoV.
Speaker: Since then, the number of cases and fatalities has increased, and the World Health Organization has declared the coronavirus outbreak a public health emergency of international concern.
Speaker: Several cases have now been reported in the United States.
Speaker: In today's episode of Critical Matters, we will discuss the current status and our current understanding of this novel coronavirus outbreak, especially how it might apply to patients being admitted to ICUs.
Speaker: Our guest is Dr. Raquel Nara, an infectious disease and critical care physician.
Speaker: Dr. Nara is Assistant Professor of Medicine in the Divisions of Infectious Disease and Critical Care Medicine at Cooper Medical School of Rowan University.
Speaker: She's a practicing critical care and infectious disease physician, as well as a hospital epidemiologist at Cooper University Hospital in Camden, New Jersey.
Speaker: Raquel, welcome to Critical Matters.
Speaker: Thank you, Sergio.
Speaker: So I'm sure that there's a lot of information that is coming in at a very rapid pace over the last several weeks with this coronavirus.
Speaker: And I think that one of the first things that I would like to get at
Speaker: is what the World Health Association has called an infodemic of really bad information out there in the internet and the press.
Speaker: And if you can maybe start by telling us where are you getting your best information and some resources that we'll later link in the podcast.
Speaker: So one of the best sites for the information is a website put in by John Hopkins from CSSE.
Speaker: And it is compilation of data sources from WHO, CDC, ECDC, which is the European CDC, NHS, NHC.
Speaker: And it allows us to give and gives you a very up-to-date information regarding where we are in terms of numbers, how many have deaths,
Speaker: how many people recovered, where's that, while it also gives you information about the critically ill patients, so on and so forth.
Speaker: So that's a very good website.
Speaker: The Lancet also, if you provide the link, has a little coronavirus library where you can put a lot of information there.
Speaker: ID Society will have all of the most recent publications regarding the 2019 novel coronavirus, and it will pull all the literature that has been published as of now.
Speaker: So it will pull from JAMA and New England Journal, so on and so forth.
Speaker: The CDC has good information relevant for practitioners in the U.S. In a sense, this is where you're going to get your information
Speaker: person under investigation criteria, and it's been updated almost like on a, like the, which the criteria change, I think, on February 2nd for the first time.
Speaker: But any other update that in regards to how you want to practice and test in the U.S. will be through the CDC website.
Speaker: So it's a good resource to have.
Speaker: Excellent.
Speaker: I think that we will definitely link all these, Raquel, but I think I wanted to start with that because
Speaker: Obviously, a lot of our listeners may have not seen a case of this novel coronavirus and might be hearing in the lay press a lot of information and misinformation.
Speaker: And I think as clinicians, obviously, we want to have good sources and up-to-date sources, especially in a very fluid situation as an outbreak such as this one.
Speaker: So just to give context to our listeners, we're recording this on February the 10th.
Speaker: And as of today, the latest report from the WHO indicated that there were 37,000 cases.
Speaker: Of those, the majority were in China.
Speaker: Outside of China, there's over 300 cases.
Speaker: And the fatality rate overall in China was around 800 deaths.
Speaker: And this, I'm sure, will be updated very quickly because this is information as of yesterday, which is February 9th.
Speaker: So before we start diving into what we know about the coronavirus, maybe you could just give us a very short synopsis of how do we get to this point and what has happened historically with this coronavirus.
Speaker: So that's a very good question.
Speaker: So just to go back a little bit in time, and I know you gave us an absence of how we got started there.
Speaker: I think the Chinese started in Hubei started to notice an increase in cases as of December 8th.
Speaker: From December 8th to December 31st,
Speaker: most of the cases were linked to having a contact with the seafood market.
Speaker: When on January 31st, they made a link, the market was closed on January 1st.
Speaker: On January 7th, the novel coronavirus was officially announced as the causative pathogen for the outbreak by China CDC.
Speaker: Moving forward from the
Speaker: January 7 onward, the number of cases that had a direct link to the Wuhan market has decreased.
Speaker: And I think the last link that I can see was maybe on January 13, where there was a possible contact with somebody who was incubating the infection after being last involved with the market, the Wuhan seafood market.
Speaker: And as you know, things have evolved to the point that now the Chinese government has quarantined several cities in China, including Wuhan.
Speaker: They have their emergency response at the level one since January 15.
Speaker: We've been having strict checking of people going in and out.
Speaker: you know, mostly out of China and other places in the world have established have established a path, either some kind of travel restriction for people coming back from China or very strict criteria about how, when they enter the U.S. In a sense, like if you come in and you have a fever or something of that sort, a cough, and you've been
Speaker: in China in the past 14 months, you are going to be checked for the coronavirus.
Speaker: But even if you're asymptomatic and you come from China, you might be asked to be quarantined at your own house or quarantined in a federal institution for the 14 days that will take to incubate the virus.
Speaker: So in terms of diving more into this specific novel outbreak,
Speaker: Maybe you could just give us a little bit of context in terms of coronaviruses in general and how they cause disease.
Speaker: There's obviously a lot of coronaviruses that cause very mild respiratory disease in humans, but there's also been some novel outbreaks over the last decades that are associated specifically with very severe respiratory distress and something that would be of great interest for critical care physicians in which this might be more like those.
Speaker: Can you talk a little bit about that, Raquel?
Speaker: Sure.
Speaker: So what do we know about the current virus or the coronavirus?
Speaker: It's usually, it has the name coronavirus because of the way it looks under electron microscopy, which has a spiked appearance that looks like a crown.
Speaker: It's usually a zoonotic transmission where it comes from usually a bat and you have an intermediary host for each one.
Speaker: I'll go over that in a minute.
Speaker: an intermediary host before it comes to humans.
Speaker: So as for very severe coronaviruses in the past, we have heard about SARS and MERS.
Speaker: Both of them had been implicated in outbreaks, SARS in 2002, 2003, and MERS later on in 2012.
Speaker: However, I just want to take you back a little bit further.
Speaker: Like in 2015, the New England Journal of Medicine published a case, published an article on the causes, causative pathogens of pneumonia.
Speaker: And in that paper, you can see that coronavirus is associated, as a family, has been associated in pneumonia and
Speaker: in a significant percentage of cases.
Speaker: I wouldn't say 53%, I'm sorry about that.
Speaker: It's in a significant number of cases where you do not have a culture positive, bacterial culture positive.
Speaker: Moving from there, and just to focus a little bit on MERS,
Speaker: and SARS, because most of our clinical knowledge currently now that we are using has been extrapolated from those outbreaks.
Speaker: SARS, as I said, the thought is it's a bat virus that got, whose intermediary animal was a civet.
Speaker: Civet is a form of cat.
Speaker: At that time, when it happened in 2002, 2003, it made more than 8,000 people ill.
Speaker: was around 800 deaths.
Speaker: So it had a mortality of around 10%.
Speaker: The way it's presented, it's a biphasic illness with the patient becoming viremic and subsequently systemically ill with recurrent fever.
Speaker: And that progressed to hypoxia and pneumonia in up to 20% of cases.
Speaker: We'll progress to ARDS.
Speaker: Now, with SARS, we saw a lot of household and healthcare providers being infected.
Speaker: And that created the concept of super spreaders that I think we can address at some point.
Speaker: With MERS coronavirus, it's also from bats.
Speaker: And however, the intermediary host is a camel.
Speaker: It made around, in 2012 till now, we had approximately 2,500 persons with 850 deaths.
Speaker: Most of those cases happened in Saudi Arabia.
Speaker: When we first identified it was in Korea, one patient, a single patient went to an ED there and from there infected around 80 other patients.
Speaker: approximately 80 other healthcare providers slash patients.
Speaker: In the U.S., we had two cases.
Speaker: It usually presents a severe acute respiratory illness, fever and cough and shortness of breath.
Speaker: And as I mentioned, it did show some household and healthcare work spread.
Speaker: However, it was not sustained as much as we saw it with SARS or what we're seeing right now with the new coronavirus.
Speaker: Now, why we say that this 2019 new coronavirus is a little bit, it's not SARS.
Speaker: So they did phylogenetics analysis where they looked at the genome of the 2019 new coronavirus and they compared it to different, to other coronavirus.
Speaker: And the sequencing clearly showed that
Speaker: It's a coronavirus, but it's a different coronavirus than the one with SARS and MERS.
Speaker: It does suggest, though, that there is a lineage to BAS.
Speaker: That's why I'm saying it probably came through the BAS.
Speaker: We don't know yet what is the intermediary host.
Speaker: Excellent.
Speaker: And in terms of diving a little bit more into this specific outbreak,
Speaker: Before we talk about Dota, there were some terms I wanted to ask you about because I've been reading about this in the last several weeks, and these are obviously things that I think are very common in the world of epidemiology, but I think are relevant, especially as clinicians try to understand what's going on and how this compares to some of the coronavirus outbreaks that you mentioned.
Speaker: And the first, I mean, would be just what's the difference between an epidemic and a pandemic, and where are we today?
Speaker: Okay, so an epidemic is a...
Speaker: sudden increase in the number of cases of a disease above your normal.
Speaker: So for instance, if you see a spike in diabetes, like in kids, you link that to obesity and you see an epidemic of obesity in kids in the US, that would be an epidemic.
Speaker: So you have a sudden spike from what your endemic rate is.
Speaker: And that's what we saw with SARS in 2003.
Speaker: And that's what we're seeing now with the coronavirus.
Speaker: We've never seen cases of the 2019 new coronavirus, and suddenly we see this huge increase that will make concern for epidemic.
Speaker: The pandemic, though, it refers to an epidemic that has spread over several countries and continents and maintained transmission in those places.
Speaker: So the reason the current epidemic is not the pandemic yet is because even though we have
Speaker: more than 27 other countries involved, we did not see sustained transmission of the virus in those other countries.
Speaker: It was the exception of few countries like in Hong Kong and Macau, but it's not something that's been sustained and been to the point that we can call it a pandemic.
Speaker: So just to give you an idea of an example of a pandemic,
Speaker: HIV AIDS in the 1980s was considered a pandemic.
Speaker: The way it was spreading and how many countries were involved, that put in the pandemic.
Speaker: H1N1, back in the 2008, 2009 time, also was considered a pandemic.
Speaker: Spanish flu in 1918 was considered a pandemic.
Speaker: So it's really depending on transmission to other countries and sustaining transmission amongst the population.
Speaker: That's very useful.
Speaker: And in terms of understanding the specific dynamics of the epidemic itself, two terms that came up several times in multiple of these or first studies were the epidemic doubling time and the basic reproductive number.
Speaker: Could you shed some light into those, Raquel?
Speaker: Yeah.
Speaker: So the epidemic doubling time characterized the sequence of times at which the incidence of the cases had doubled.
Speaker: So an increase in doubling time means that the outbreak is slowing down because it means that it's taking longer to infect more people.
Speaker: So that's for doubling time.
Speaker: For basic reproductive time, we're what we call an R0, and it's an R with a zero underscore in the lower part of the R. And this means the number of cases one person,
Speaker: can infect on average.
Speaker: So for instance, for the 2019 new coronavirus, the R0 has been ranging between 2.4 to 3.5.
Speaker: It depends on where you're talking in the outbreak, in time in the outbreak.
Speaker: At this point in time, it's around 2.4, meaning each person will spread the virus to 2.4 persons.
Speaker: Anything above one would suggest that the epidemic is still progressing and we did not control it.
Speaker: We know we controlled an epidemic when the R0 is under 1.
Speaker: So this is a way of looking at the progression of an outbreak.
Speaker: And I think that another aspect of this that's very important is as we're very early in identifying a novel outbreak, there's also numbers that are just related to reporting and identification, right?
Speaker: We don't really know yet.
Speaker: I mean, there's more and more people are being tested now
Speaker: But it's very hard, I mean, to really know what the R0 is right now because that's a very fluid number, I would presume.
Speaker: Absolutely.
Speaker: So the R0 and the epidemic double time is very much affected about how many cases are there that we don't know about.
Speaker: So it's all dependent on how good we are about testing.
Speaker: Right now, the testing is geared towards people who are sick or, you know, sick with fever or cough.
Speaker: There just recently published a paper, you know, one patient presented with abdominal pain, had no cough and no fever.
Speaker: So how many of those cases we are missing and we don't know about?
Speaker: And it's going to be hard to know.
Speaker: So the doubling time, as well as the R0, are affected by our limitations in testing for the virus.
Speaker: whether it's availability of the testing kits or bringing those patients up to our attention.
Speaker: Because remember, as opposed to SARS, where if you had the infection or the virus, you will show symptoms.
Speaker: So your pyramid, because we talk a lot about pyramids in epidemics, your pyramid, surveillance pyramid,
Speaker: has a tipped shape, which means the tip of the pyramid is facing down, meaning the clinical detection for SARS is very high.
Speaker: You have the virus, often you have clinical symptoms.
Speaker: With this new coronavirus, which seems to be the case, is a certain number of people are presenting with severe and fatal disease, but there is a significant number of people that we don't know who they are.
Speaker: that might have mild or asymptomatic presentation.
Speaker: A group of that would be children, for instance.
Speaker: Excellent.
Speaker: And I think that we'll dive into a little bit more, but I have two more questions or two more terms that I wanted to get your thoughts on.
Speaker: So there's this concept of pneumonia of unknown etiology, which I think from a surveillance standpoint was very important because that is what tipped people in China
Speaker: into something was going on and led to the identification of this novel coronavirus.
Speaker: Could you tell us a little bit about what it really stands for?
Speaker: What is an example?
Speaker: What are the characteristics of a pneumonia of unknown origin and how people should think about these?
Speaker: So pneumonia of unknown etiology would be a pneumonia where you do sputum cultures and you do other available PCRs and you do not find any clear etiology for those.
Speaker: And that's what I think tipped, was those patients had similar presentation, similar scan findings, and yet, and they presented in high numbers, and yet we couldn't find the culture or any of the PCRs that will, even the SARS coronavirus, that will suggest that it has a known etiology.
Speaker: So I think when SARS first
Speaker: came up, it was also known etiology until the virus was identified.
Speaker: And I think that's what happened with the 2019 new coronavirus, which, by the way, still doesn't have a final name.
Speaker: This is just a temporary name.
Speaker: That was identified in those sputum when you have regular workup for pneumonia, which would be sputum culture, influenza, PCR, so on and so forth.
Speaker: And I think also, just to recap for our clinicians, because if you see a case, right, like this in terms of thinking about it, no causative organism by extensive testing, usually these patients present with true pneumonia in clinical picture, so have a real fever, have real evidence radiographically of pneumonia.
Speaker: I think that also important to mention, Raquel, is that they usually have either low lymphocytes, normal or low white count,
Speaker: and don't respond to usual treatments with antibiotics, right?
Speaker: So these are all things that when you see this together, you should start thinking, could this be some viral pneumonia?
Speaker: Could this be something that is novel?
Speaker: Correct.
Speaker: And I guess- But the term has been applied, I'm sorry, the term has been applied for cases where, like let's say strep pneumonia was, end up being identified as the organism.
Speaker: But when you did the culture and extensive workup, you couldn't find an etiology.
Speaker: Just to put things into concept that, yes, you do need to have the fever, the pneumonia, and the findings of pneumonia and extensive workup that did not show a specific virus or a specific organism etiology.
Speaker: Okay.
Speaker: And I guess the other side of that coin or the extreme in this particular outbreak, just to share the term, is the idea of the
Speaker: NCIP or novel coronavirus infected pneumonia, which is, I think is patients who present with severe pneumonia who now have a confirmed coronavirus diagnosis, right?
Speaker: That's the syndrome that we're going to talk about today.
Speaker: Okay, excellent.
Speaker: So let's dive into the novel coronavirus infected pneumonia and how this might be of relevance to our listeners and our clinicians in the ICU.
Speaker: And maybe we can start by telling us
Speaker: Who are we seeing right now in hospitals?
Speaker: Who's getting sick?
Speaker: And you did mention something about kids not being part of that cohort, but maybe you can just tell us what are we seeing in terms of patients presenting at least for care and in the hospital?
Speaker: All right.
Speaker: So all we know for this current outbreak is what we have pulled from the different papers published in New England, Lancet, and most recently JAMA.
Speaker: And what we know about those patients who present is that by the time they present to a hospital, they were pretty sick.
Speaker: They had a very high percentage of them presented with fever, which seems to be a common denominator.
Speaker: They also have fatigue, dry cough.
Speaker: all two things that you would expect a viral illness would give those patients, an individual.
Speaker: Diarrhea seems to be present in a good percentage of those patients, as well as the abdominal pain to a lesser extent.
Speaker: So most of the patients, what seems to be a constant denominator is the fever.
Speaker: Of the 138 patients presented in the
Speaker: JAMA paper published on February 7, 2020, was that 136 out of the 138 patients had fever.
Speaker: And then the next common one would be fatigue, which is 96% of those patients having fatigue, followed by a dry cough.
Speaker: So those seem to be a common presenting illness or presentation for those patients.
Speaker: It's
Speaker: Is there a particular predilection for certain ages or for patients who have certain comorbidities?
Speaker: So again, the ones who are presenting to the hospital, so this would be the tip of your iceberg, the ones who are the sickest, they tend to be male.
Speaker: I think part of the bias with the male is because where the outbreak started, it was in a market where there was a predominance of male workers.
Speaker: And most of them had some kind of cardiovascular risk factors as part of their comorbidities.
Speaker: So of the 138 patients who presented to the hospital,
Speaker: 43% had hypertension, 20% had cardiovascular disease, and 14% had diabetes.
Speaker: So there is some kind of predisposition there.
Speaker: Again, the outbreak is still too early to make a linkage, to make it, you know, those people are sicker.
Speaker: than others, but those are the ones who are presenting to a hospital.
Speaker: And as you said, I mean, this is a very fluid situation, and a lot of the information that we have is based on the patients who have seeked medical care and who have been hospitalized.
Speaker: And among those that we know, I mean, that have been confirmed, what's the current mortality, and how does this compare to maybe some of the other outbreaks that you discussed earlier?
Speaker: Right.
Speaker: So as of now, the mortality for SARS is around between 2.2 to 2.4%.
Speaker: If you compare that to your influenza, for instance, every year influenza will have a mortality of 0.1%.
Speaker: But if you put things into perspective, influenza tends to infect more people.
Speaker: So to give you an idea, as of now, we have
Speaker: 15 million Americans infected with influenza.
Speaker: So we do have a higher number of influenza cases and the mortality tends to be in the 30,000 a year, bringing down your mortality with seasonal flu to be around 0.1%.
Speaker: And I think that, so we're talking about a mortality of 2.2%, but obviously a very
Speaker: dynamic situation with the epidemic.
Speaker: So we still don't know, but it's significantly higher than percent wise than influenza.
Speaker: And I think that ultimately what I would say is we should take all of these viruses, including influenza, very seriously, because if we don't put in place the proper interventions, it's when things really can spread and get out of context.
Speaker: So Raquel, tell me a little bit more about the natural history.
Speaker: So we talked about how these patients present
Speaker: with the fever, the cough.
Speaker: But it seems, I mean, when you look at these natural history of these patients, there seems to be a period since the first symptoms to when they really start getting sicker and when they might develop worsening respiratory failure that would lead them to an ICU.
Speaker: If you could share with us a little bit of what we know so far, understanding that it's limited on small case numbers of those 130 plus patients, et cetera.
Speaker: Yes.
Speaker: So, um,
Speaker: What we know so far is, as you said, very fluid, but for the patients who tend to present to the hospital, we know that by the time they present, they have, from time of infection to presentation is usually about seven days.
Speaker: We also know that from time of presentation to ICU admission is around eight days.
Speaker: And I think that has been very nicely delineated in this study.
Speaker: recent JAMA paper that I just quoted.
Speaker: If the patient will end up in the ICU, usually the time of hospital admission to ICU admission is usually one day.
Speaker: So they tend to deteriorate, as you can see, pretty rapidly.
Speaker: And the
Speaker: just to give you an idea about, you know, to compare to others, infections or other progression, like your white counts tend also to start drifting down within three or five days of admission with an increase in your renal dysfunction starts to be seen around day nine of admission, where you see the people who tend to be
Speaker: the non-survivors or the ones who are more likely to die, you start seeing them going into an AKI.
Speaker: So this is just a few trends that, you know, to bring to the attention.
Speaker: Again, by the time they present, it's usually seven days of infection.
Speaker: Okay.
Speaker: And in terms of before we start diving more into the specific clinical behavior or therapeutics and diagnosis,
Speaker: Can you just tell us what we know so far about how this is spreading and being transmitted right now?
Speaker: Because I think that we are probably getting to a point where just asking if you were in Hunan in China is not going to be enough.
Speaker: I mean, there's other ways people now can be infected.
Speaker: So just understanding how it's transmitted, I think, is important, but also in terms of protection for health care providers.
Speaker: Right.
Speaker: So the transmissibility, again, this is, as you said, is very full, but as we know now, it's droplet.
Speaker: Droplet transmission with possible fecal-oral transmission.
Speaker: So that will put you into, if you want to think of it as, you know, what kind of PPE I'm going to put on.
Speaker: For droplet, you usually wear a surgical mask.
Speaker: For droplet,
Speaker: contact, you usually put a gown.
Speaker: Having said that, at this point in time, because of the novelty of the virus and because of the way the epidemic is behaving, we still are required to put in a N95 mask with goggles for eye protection along with your gown and your gloves.
Speaker: And I have to say that hand hygiene is
Speaker: is one of the most important measures we can implement dealing with this kind of outbreaks.
Speaker: I can't emphasize that enough.
Speaker: So an alcohol-based hand hygiene product that has at least 60% alcohol is what the CDC is recommending.
Speaker: Excellent.
Speaker: That I think is very important.
Speaker: We did talk about a little bit at the beginning, you did allude to the super spreading events.
Speaker: And can you talk about that and how it impacts healthcare workers and what we know so far?
Speaker: Yeah.
Speaker: So super spreaders were first described with the SARS outbreak.
Speaker: And part of the thing is that, if you'll recall at that time, patients were admitted with SARS and with SARS,
Speaker: the contact person being somebody who was in the hotel or who didn't have direct contact with them.
Speaker: And the thought was that the transmission happened through either a convection system in some of the facilities.
Speaker: The other way that you can think of it is when the patients have been going from the Canadian group, when the patient traveled, I think it was from Hong Kong,
Speaker: and went to Canada and then infected in that institution around 44 other people.
Speaker: At that time, it was felt that most of the transmission that happened in our healthcare workers were related to high-risk, what we call high-risk behaviors that will predispose the healthcare workers to specific infections.
Speaker: And just to go over those high-risk behaviors, I'm just going to
Speaker: I want to cite a few because I think there is importance in our line of practice.
Speaker: For instance, non-invasive ventilation, putting the patient with a face mask or a vapotherm, anything above six liters per minute has been associated with the super spreading effect.
Speaker: Staff working whilst experiencing symptoms.
Speaker: So if you come to work and we all think guilty of that,
Speaker: and you have a slight fever or a slight cough, you just suck it up and do it, has been associated with a super spreading effect.
Speaker: Doing CPR or resuscitation during colds, you can imagine how chaotic that can be, has been a risk factor.
Speaker: And then moving from there, if you, let's say you have what we call like a common changing area for the staff, those places that have those kinds of facilities or facilities,
Speaker: has been associated with spreading.
Speaker: And again, for the patients, like, you know, from staff to patient or patient to patient, it was found that rooms that had core share, like if you're not single-roomed or your room was more than one person, if the distance between one bed and the other is less than one meter, it seems to have significantly associated with spread from patient to patient.
Speaker: As for procedures that has been associated with increased transmission to healthcare workers,
Speaker: I want to cite tracheal intubation.
Speaker: I mentioned already non-invasive ventilation.
Speaker: Doing a tracheostomy and manual ventilation of the patient before intubating.
Speaker: Think of it.
Speaker: Once you intubate the patient, you are in a closed system and you are less likely to transmit the infection.
Speaker: As long as you are in an open system of non-invasive ventilation or bagging of the patient, that tends to aerosolize the
Speaker: the organism or the virus and contribute to the super spreading effect.
Speaker: So before we move on, in terms of precautions, these patients, if we have a suspected or confirmed case, should be placed in droplet precautions.
Speaker: If you have negative isolation rooms, is that something that you recommend for these patients, Raquel, in the ICU?
Speaker: So at this
Speaker: Yes.
Speaker: At this point in time, in ICU euphoric, if you admit to a patient, you should put them in airborne precautions.
Speaker: So it would be a negative pressured room.
Speaker: You will wear an N95 mask and you will put a goggle.
Speaker: And then what we usually don't do for tuberculosis is we put on a gown and gloves.
Speaker: Do you cover your head?
Speaker: you don't have to cover your hair, even though the media portrays that you're covering your hair and your shoes.
Speaker: This is not yet recommended by the CDC.
Speaker: Okay.
Speaker: And that is obviously very important.
Speaker: I think that especially, like you said, in emergency situations, high risk procedures for us would be manipulating the airway before intubation, which I think is something that we obviously in a lot of these patients, if they get really sick, might have to do.
Speaker: So I think these are very, very, very important.
Speaker: Now,
Speaker: Talk a little bit about the 14-day quarantine and where that information came from.
Speaker: You did mention earlier, Raquel, that I could be asymptomatic and be contagious, right?
Speaker: So the idea is that in 14 days, either you're not contagious anymore or you've declared yourself.
Speaker: Is that the thought process?
Speaker: Well, that remains an answer.
Speaker: So what we think is if you got the virus, you will show some kind of symptoms within 14 days.
Speaker: That seems to be the incubation period for
Speaker: the virus from what we saw early on in the outbreak.
Speaker: So patients who have been exposed often, like for instance, looking at the closure of the market, the market was closed on the 31st or the first, the last case seen with the connection with the market was on the 13th of January.
Speaker: So that puts into perspective that probably the incubation period is 14 days.
Speaker: What we don't have data so far is, are you shedding the virus after
Speaker: after you recover.
Speaker: We don't have an answer for that.
Speaker: So what places have been done, for instance, is recommending to check a PCR at the end when you're done with the illness twice.
Speaker: And if you're twice negative, you can say, well, probably you're not infective anymore.
Speaker: We don't have a lot of data there.
Speaker: As for transmissibility, if you are not
Speaker: like if you're not showing signs.
Speaker: That first came to light with the German case, and I'm going to go briefly over that.
Speaker: So the first cases in Germany happened after an automobile meeting that involved a person from Shanghai.
Speaker: That person from Shanghai had hosted her parents' tour from Hubei in her home in Shanghai before she traveled to Germany.
Speaker: the parents reportedly were okay, did not show signs and symptoms when she was there.
Speaker: They started to be symptomatic after she left.
Speaker: She was okay during her meeting.
Speaker: And then it's only on her way back to Shanghai in the airplane that she started to show signs and symptoms of being infected.
Speaker: One of the co-workers that were working with her got her infections.
Speaker: the coronavirus.
Speaker: And that constituted the first case of coronavirus in Germany and kind of pointed to us that you do have asymptomatic transmission.
Speaker: However, we do know, for instance, for SARS, that one of the theories that we have this super spreading effect is that you have peak viremia around day 14 of sickness
Speaker: usually those patients are in the hospital at that point.
Speaker: So they are bound to be shedding more.
Speaker: So that could explain a little bit of the super spreading effect.
Speaker: With this virus, we don't have this kind of information.
Speaker: We also have a bias in the case definition.
Speaker: As I mentioned before, for instance, in the U.S. and most of the world, you're only testing people who present with fever and or shortness of breath and or
Speaker: travel to China or contact with somebody who had the coronavirus.
Speaker: So the person who presents with a slight cough and no fever and no contact with somebody who has the coronavirus will not be checked.
Speaker: Doesn't mean he doesn't have it.
Speaker: He won't be checked.
Speaker: So that creates a bias in detection.
Speaker: And that's what I call a bias of the case definition.
Speaker: The other group of people is children.
Speaker: who usually are asymptomatic or have very little signs of infection.
Speaker: And those have, you know, also will contribute to transmissibility of the virus.
Speaker: And I think it's important because what we don't know yet here is like those non-very sick patients, how many are they, where are they?
Speaker: And we're talking like a 2.2% mortality is based on people who have been tested in the hospital, which by definition,
Speaker: has preselected to those who have more symptoms or worse symptoms to present for care, right?
Speaker: Right.
Speaker: So in the hospital, I want to clarify, in the hospital or outside of the hospital.
Speaker: So if the patients are not sick enough to be admitted, there have been recommendations to implement care outside of the hospital and just keep on observing because at that point in time, it's still all supportive treatment.
Speaker: And until we have zero surveys done for the first wave of this epidemic,
Speaker: we won't really know how transmissibility happens.
Speaker: So I think there is more to come in a few months when we start doing more testing and surveillance, you know, serology surveillance, so on and so forth to identify the extent of this epidemic.
Speaker: So let's dive into a little bit more detail about what potentially could be the type of patients that listeners of the podcast might encounter.
Speaker: And I think, like you mentioned earlier, Raquel,
Speaker: It really starts with these patients usually will seek hospital care or be admitted to the hospital seven days after starting with symptoms.
Speaker: And once they get admitted, the ones who end up being very sick and will probably have the more severe forms of the novel coronavirus infected pneumonia are coming to the ICU within 24 hours of admission, developing ARDS, requiring higher levels of support in day nine,
Speaker: 10, 11, and forward.
Speaker: So let's start by, we talked about obviously some of the things that would make you think about these patients in terms of the pneumonia of unknown etiology or people who have the right travel history or contact history.
Speaker: But in terms of those patients that we see and we suspect may have a normal coronavirus associated pneumonia, we talked about how we should isolate them.
Speaker: How do we confirm the diagnosis?
Speaker: So the diagnosis at this point in time is done through the CDC in the U.S. And you will need a specimen.
Speaker: You will need to collect specimens from lower respiratory tract, upper respiratory tract, and serum specimens.
Speaker: This is an active discussion with the CDC and your local DOH, you know, because first the patient has to meet criteria of person under investigation or PUI.
Speaker: And once this criteria is met, those are the specimens that need to be sent.
Speaker: Your lab will collaborate with those institutions so they can send those specimens.
Speaker: Then additional specimens will be taken, and those include the stool, urine.
Speaker: They might be collected and stored or collected and sent.
Speaker: This is the prerogative of the CDC.
Speaker: The CDC will, yes.
Speaker: Yeah, and I was going to ask, and the diagnosis in the CDC is confirmed by a real-time test
Speaker: reverse transfer states PCR, right?
Speaker: That's the way we're diagnosing this.
Speaker: That's how we're diagnosing it.
Speaker: So, Artie.
Speaker: So, I think on February 2nd, if I'm not mistaken, the FDA released approval for local, for state, at the state level, you can have testing done.
Speaker: So, the CDC shipped a whole lot of kits that will allow the test to be done at the state level.
Speaker: So, not yet commercial, but we're getting there, I think.
Speaker: And I think that we can...
Speaker: review, I think, for our listeners, some of the characteristics that would make a patient a likely suspect as opposed to a false alarm.
Speaker: I think that obviously with all the press, some people might feel that, oh my God, this person has, maybe has coronavirus.
Speaker: And really, when you really ask about the travel history, it's not present.
Speaker: But more importantly, clinically, it sounds that, like you mentioned, real documented fever is important.
Speaker: symptoms of a respiratory infection with cough that is usually dry are very important.
Speaker: Clearly these patients, from what I have seen, Raquel, please correct me if I'm wrong, but consistently the ones that are hospitalized and especially those who are sicker have objective evidence of pneumonia, usually by bilateral on radiographic, either x-ray or CT, which I think is important, right?
Speaker: I mean, this is something that is very important in terms of qualifying
Speaker: And then I think the last ones would be that these patients usually have either low white counts or lymphopenia, and they really have no other source of infection.
Speaker: So if you are seeing a bacterial pneumonia, it's not necessarily due to a novel coronavirus, right?
Speaker: I think it's very important also in terms of thinking about these patients.
Speaker: That's correct.
Speaker: Not to say that they cannot develop a nosocomial bacterial infection.
Speaker: So that can happen down the line, like we've seen with influenza or
Speaker: even not nosocomial, you know, having the viral infection and presenting later on with the bacterial pneumonia.
Speaker: But for now, the person under investigation criteria is very well defined by the CDC.
Speaker: And as you said, you have to have fever or assigned symptoms of low respiratory illness, like a cough or shortness of breath.
Speaker: And you have to have contact with a person who
Speaker: who has either close contact with a lab-confirmed coronavirus infection within the past 14 days, or a travel history to Hubei province in China.
Speaker: Now, if you travel to mainland China within the past 14 days and have fevers and signs and symptoms of lower respiratory tract infection,
Speaker: that will require you to be hospitalized.
Speaker: Like if you present to the hospital with those symptoms and you have a history of being in China, then within the past 14 days, then you will qualify to be tested for the 2019 coronavirus.
Speaker: Again, fever is very subjective, right?
Speaker: So if you take Tylenol or Motrin, you might mask a fever.
Speaker: So those are all relevant questions to ask your patient to see if they have any other condition that will mask the fever.
Speaker: And that's why they might not be mounting a fever.
Speaker: And we still have small data sets in terms of knowing what happens to the sicker patients.
Speaker: But before we dive into a little bit more of the treatment,
Speaker: There's two questions I wanted to ask you, Raquel.
Speaker: One is, do we know what the pathophysiology is and why it's mostly respiratory?
Speaker: And number two is, what other non-restrict complications have been described in the sicker patients?
Speaker: Those are very good questions.
Speaker: So the short answer is we don't really know the pathophysiology.
Speaker: However, the longer answer is we can extrapolate from what we know from SARS-CoV-2.
Speaker: And the thought is that the pathogenesis of SARS, for instance, seems to be related to a receptor in your lung tissues.
Speaker: And that receptor is an ACE2, ACE angiotensin-converting enzyme 2.
Speaker: which is a metallopeptidase that is expressed mostly in human organs.
Speaker: And once the virus enters the cell through this receptor, it tends to bring in or pull in all kinds of fluid giving you into the alveolar space, causing this kind of dysregulation.
Speaker: that we see enhanced progression to ARDS or SARS, because this is what has been described with SARS.
Speaker: Coronavirus preliminary analysis showed that the 2019 new cause coronavirus has some of the amino acids homology similar to the SARS coronavirus.
Speaker: And that's how we think it might be the same pathophysiology.
Speaker: We carry this receptor in many organs.
Speaker: We have respiratory, intestinal mucosal, venal tubes, neurons, and lymphoid slash reticolendothelial system.
Speaker: And when you think of it, the way the virus is presenting, if you let me just for one second go over that, for instance, the leukopenia, that will explain that.
Speaker: The fact that you have some patients presenting with diarrhea and GI discomfort,
Speaker: That also will explain that.
Speaker: If you look at the, even though patients tend to develop severe AKI requiring potentially renal replacement therapy later on in the course of on day nine, upon presentation, quoting the JAMA paper, their creatinine was slightly, was
Speaker: was slightly above normal.
Speaker: So that makes you think that there might be a component where you have a, where those receptors are being affected.
Speaker: Interesting.
Speaker: And like you said, I mean, this is extrapolating from what we know of the previous coronavirus severe infections.
Speaker: And in terms of, you did mention some of the
Speaker: the systems that might be affected.
Speaker: Are there other findings that are non-respiratory complications that are of significance?
Speaker: Yeah.
Speaker: So most of the patients, the complication-wise was related to arrhythmias.
Speaker: So it was respiratory, then arrhythmias.
Speaker: And then some of them, I think, developed shock.
Speaker: Okay.
Speaker: So just, I mean, things to have in mind.
Speaker: Let's talk about treatment now.
Speaker: We did talk about
Speaker: the isolation precautions and the proper protective gear that a clinician should use.
Speaker: We talked about what constitutes a suspected case and how we should obviously engage our local health authorities, but also CDC to confirm the diagnosis.
Speaker: Now let's assume that we have a patient who is admitted to our ICU who we've confirmed has coronavirus.
Speaker: How do we treat that patient based on what we know today, Raquel?
Speaker: So most of the literature, so supportive care is what we know works.
Speaker: However, from the SARS outbreak, some antiviral concoctions have been tried in the past and have shown some animal data, some in vitro data that it might work.
Speaker: I'm going to go over some of the treatments that you should not try, and that would be ribavirin.
Speaker: And the reason is, even though there's like a good number of papers, I think around 24 papers published on the use of ribavirin, they never used a controlled group to compare.
Speaker: They also saw a high number, like 36% of those patients developed hemolysis, making the risk of using ribavirin kind of high.
Speaker: Those were used mostly in a Toronto outbreak, like what they saw in Toronto.
Speaker: So the data is very inconclusive, and there is a potential for harm.
Speaker: The other one that you might hear about is corticosteroids.
Speaker: Even in the most recent paper published, they did mention corticosteroids used.
Speaker: I will caution against that.
Speaker: The data is very inconclusive.
Speaker: There is some suggestion that it could be harmful for the patient, and it could potentiate further transmission of the virus.
Speaker: So you prolong the viremia, you prolong shedding of the virus.
Speaker: So there is too many.
Speaker: I think at the end, it might be more harmful than useful.
Speaker: However, immediately in the SARS period, when they used steroids,
Speaker: They saw resolution of fever, which is expected, and improvement of the lung consolidation.
Speaker: Again, I would caution against the use of corticosteroids.
Speaker: Now, other treatment that have been tried would be interferon alpha.
Speaker: And it's only two studies that have shown that use that.
Speaker: It's very inconclusive.
Speaker: And the
Speaker: They only showed benefit in use of steroids that I already told you not to use.
Speaker: And I think those patients, everything was thrown at them.
Speaker: So it's really hard to say interferon alpha steroids, what made the difference?
Speaker: It was too many interventions at the same time.
Speaker: Convalescent plasma seemed to be promising.
Speaker: However, we don't have enough studies.
Speaker: And those were done...
Speaker: along other treatments.
Speaker: So it's hard to say conclusively that it's made a difference.
Speaker: Two other treatments stand out, and this is the protease inhibitors, so drugs that we are using for HIV.
Speaker: Again, this is SARS.
Speaker: So back then, Kalitra, which is lopinavir, ritonavir, was part of your backbone for treatment of HIV, and they tried that treatment for SARS.
Speaker: The studies were inconclusive in the sense there was too many interventions done at the same time.
Speaker: However, more recently, with this current outbreak, we had reports that in Thailand, they used the combination successfully.
Speaker: And there is currently an ongoing randomized trial where they're using the combination to see if it's helpful.
Speaker: So that would be, for me, one of the reasonable options.
Speaker: In those two trials that used lopinavir and ritonavir, they used 400 milligrams of lopinavir
Speaker: Ritonavir, 100 milligrams, both are oral meds that you give every 12 hours.
Speaker: The death rate from the lopinavir, ritonavir group was 2.3% compared to 15.6%.
Speaker: This is, again, SARS.
Speaker: And if you used it as a rescue, it was 12.9%.
Speaker: in the rescue compared to a control of 14%.
Speaker: So if you use later on in the course.
Speaker: So there is logic.
Speaker: This was a study that was published, that came out of Hong Kong Medical Journal in 2003.
Speaker: And the other one that came from Thorax in 2004 explored the same drugs and the composite outcomes was severe hypoxemia and death.
Speaker: And the lopinavir, ritonavir group,
Speaker: had a better outcome.
Speaker: So I don't think given the tolerability of this drug, that if we are faced with this situation, it wouldn't be a bad idea to try either one.
Speaker: Of course, when, if we do have a case, this is going to be a decision made along with the CDC that will help us with those kinds of decisions.
Speaker: I'm assuming.
Speaker: Absolutely.
Speaker: Given how recent and how novel this is.
Speaker: Now, the other drug I want to mention is because it was used in a patient in Washington, and that's called Remdesivir, or it has a number still, which is GCS5734.
Speaker: And it was obtained as a compassionate use.
Speaker: It was used on day seven of illness.
Speaker: It seems at that point, if you look at the case report, the patient starts to have more respiratory symptoms.
Speaker: I want to point out that this antiviral agent was initially developed for Ebola and Marburg viruses and has been on as an accelerated type of development.
Speaker: And then it turns out that it works against coronavirus.
Speaker: And the way it works against coronavirus is that it inhibits the proofreading mechanism that the virus has once it becomes mutated.
Speaker: Now that the virus is mutated, it has a lower level of resistance towards the drug.
Speaker: So this will impair fitness and virulence of the virus.
Speaker: And the other two questions I was going to ask you before we kind of recap the treatment was I know that in the Chinese series, they've used Tamiflu or Sotamivir in a lot of cases.
Speaker: And then in a lot of cases, people have added antibiotics for presumed or potential superimposed bacterial infections.
Speaker: Any comments on what we know so far about that, Raquel?
Speaker: Even the authors concluded that it doesn't work for the coronavirus.
Speaker: So I don't think the Ose tamivir will work for this virus.
Speaker: Okay.
Speaker: And what about antibiotics?
Speaker: What would be your approach to this?
Speaker: My approach will be like we would do for any, you know, those patients are at risk, not that you have a damaged epithelium, you are at risk of, you know, getting a bacterial pneumonia.
Speaker: So if you have BALs or if you have sputum, you know, sputum traps that suggest positive bacterial culture, by all means, treat it.
Speaker: If those patients are not yet in renal failure, we do know that procalcitonin, and not that I'm advocating for using that, but most of the series so far,
Speaker: showed us that the procalcitonin is low in those cases.
Speaker: So an increase in procalcitonin in absence of phenyl failure might be a suggestion that you're dealing with a bacterial superinfection.
Speaker: So I don't think we should just say no antibiotics.
Speaker: I think you have to take each patient at a time and decide if it fits your current patient presentation or clinical status.
Speaker: But I think that going back to your first point, obviously, as of now,
Speaker: the mainstay of treatment, like in most cases in the ICU is supportive care and executing the best we can, our usual supportive measures in terms of these patients and applying all the things we know work for respiratory failure and supporting them.
Speaker: And as I think cases grow, we'll probably hear or might hear more details on specifics for the ICU.
Speaker: That's correct.
Speaker: I would try those to steer off use of steroids.
Speaker: Excellent.
Speaker: And in terms of other issues or other areas of uncertainty that you think are still very important to be defined, obviously, we talked about this is a very fluid situation, but anything from your perspective, big questions that we're trying to figure out as things move along?
Speaker: So, I mean, I think one thing that needs to be determined will be, you know,
Speaker: Once we identify a treatment, is early therapy something that is beneficial to prevent progression of this disease?
Speaker: We know that works for influenza.
Speaker: So will that have the same impact for this new coronavirus?
Speaker: The other thing is, I think we need more information.
Speaker: I think time will tell us about the extent of
Speaker: of infectivity of this virus and how many folks have been infected by this virus and did not present.
Speaker: So that's some important information.
Speaker: Is this going to be our next, you know, chronic seasonal influenza that we're going to be dealing with for the next years or so?
Speaker: I'm also very curious to know how they're going to name the new virus.
Speaker: Obviously, it's not going to remain novel forever.
Speaker: And I know there is specific criteria put in by the WHO
Speaker: that a group of virologists will get together and come up with a new name for the virus.
Speaker: And that's something I'm curious to see how they're going to come up with that.
Speaker: So those are a few of the things that remain, you know, we don't have an answer for that and will have an impact whether the way we manage those patients and even sometimes economically, if you think of it.
Speaker: You know, when they called swine flu flu,
Speaker: swine flu, Egypt mandated the killing of so many numbers of pigs, even though pigs have nothing related to the transmission of the virus.
Speaker: It's just a perception of how we look at those virus that will affect how we deal with them.
Speaker: So I think it's an important part of this definition.
Speaker: And I think that from the perspective of the amount of information that is flowing right now and misinformation is really, I mean, amazing.
Speaker: And
Speaker: for the clinicians involved with caring for patients, I think seeking the right information, understanding what we know and what we don't know and what makes sense and what doesn't make sense, I think based on that information is very important.
Speaker: And I think that Raquel, obviously with all the question marks that still remain, I really appreciate your time in terms of giving us clarity where clarity exists and understanding what we know and what we don't know.
Speaker: So I hope that as we progress, I mean, we might have a chance to talk a little bit more about this and clarify some of those questions.
Speaker: But again, I think there's a lot of great information that is available right now.
Speaker: And I think it'd be a great use for all our clinicians in terms of understanding that.
Speaker: So a tradition at our podcast is to close the podcast with some questions that are unrelated to the topic that we discussed.
Speaker: And I really try to tap into the wisdom of our guest
Speaker: Would that be okay?
Speaker: Of course.
Speaker: So the first question, Raquel, relates to books.
Speaker: And I would like to know if there's a book or books that have influenced you greatly or books that you have gifted to others on a frequent basis.
Speaker: So one book that comes to mind, this is a tough question, by the way.
Speaker: One book that comes to mind, especially in the current situation, is a book I read a while ago.
Speaker: It's called Waiting for Godot.
Speaker: I don't know if you're familiar, it's actually a play.
Speaker: And it's written in the 1940s, end of 1940s.
Speaker: It relates to, literally, they're waiting for somebody who never shows up.
Speaker: So it's two men who are waiting for Godot who never shows up.
Speaker: And every time they get so desperate, they're about to commit suicide.
Speaker: And then
Speaker: A kid shows up and says, well, he's not coming today, maybe tomorrow.
Speaker: And then the scene starts over again.
Speaker: And it feels that many things in life are this way.
Speaker: We work and we do things and we're waiting for something that we don't really know what it is that we're waiting for, but we just do it.
Speaker: And when it doesn't show up, you just keep going.
Speaker: It's an interesting book.
Speaker: If you haven't read it, it's very interesting.
Speaker: I have not, but I definitely will pick it up and I'll definitely link it in the show notes.
Speaker: And I think it also speaks, Raquel, to a lot of what we see with these outbreaks, right?
Speaker: Is that a lot of the anxiety, a lot of the stress in life is what we imagine about things and not what is really happening or what really has happened.
Speaker: And really understanding that in terms of living in the present moment, I think, and what we can control is something that's very powerful.
Speaker: So I would definitely look this up because I have not heard about it, but it sounds like a very, very interesting read.
Speaker: A very interesting book.
Speaker: I mean, something to be said about this outbreak that I don't, it's like, even though this is a novel coronavirus, the way we are experiencing the outbreak is very novel.
Speaker: Like if you remember the SARS or MERS, we were not as connected through internet and Twitter and all of those apps as we are right now.
Speaker: And it makes it very interesting to see how this is progressing and the amount of hysteria that you're seeing with it.
Speaker: Yeah.
Speaker: And I think that the term, I mean, that the WHO uses of infodemic is really interesting because there's an abundance of information, but it's not all good information and that it can be problematic also.
Speaker: Yeah.
Speaker: Yes.
Speaker: Yes.
Speaker: So the second question relates to something that you believe to be true in medicine or in life.
Speaker: that many other people or most other people don't believe to be true or don't behave like it's true?
Speaker: So one thing that always comes to mind, and I hope it doesn't come out the wrong way, but one thing that it's hard for us to admit is that not everybody's equal.
Speaker: And that's something that we do not see it or do not admit on a daily basis.
Speaker: And it took for me a while to accept this truth.
Speaker: in the sense that even your patients presenting with the same illness, they never behave the same.
Speaker: And part of it is their physiology, their chronic illnesses, and so on and so forth.
Speaker: And I think this is a touchy subject.
Speaker: So you won't hear people talking about that.
Speaker: But I think we should acknowledge it and understand it so we can provide equal opportunity of treatment because that's something we can control.
Speaker: So we can provide an equal expertise in treatment or equal expertise in or equal education, whatever you want to call equal that we can provide by acknowledging that at the baseline, not everybody's equal, like not everybody's born with the same health or with the same opportunities.
Speaker: However, we can provide them with something to try to gauge this inequality.
Speaker: Absolutely.
Speaker: And I think that it speaks very highly, I mean, to
Speaker: really the concept of, there's a difference between everybody having equal opportunities to access to certain things versus the uniqueness of people and individuals with their social determinants, their genetic determinants, their history, right?
Speaker: That is very unique and means that they might experience things or present with things in a very different way than somebody else.
Speaker: But I think that you speak to it in terms of
Speaker: equality of opportunity and not necessarily equality of circumstances or presentation, which I think is very powerful.
Speaker: And I agree, these are sometimes hard topics to talk about.
Speaker: The last question, Raquel, is what would you want every intensivist listening to us today to know?
Speaker: It could be a quote, a fact, or something related to what we talked about.
Speaker: So I would like to
Speaker: Something that's been interesting a lot, been interesting to me a lot lately has been relating again to this uniqueness of people is when we talk about pharmacokinetics and the way we should be dosing, mostly antibiotics I'm talking, and not to have a one stamp, you know, one dose treat all for every patient.
Speaker: And just to think about your patient as a unique person, which has its own metabolism that's
Speaker: require maybe a higher dose.
Speaker: So if you have an IV drug user, for instance, you might need a higher dose of a certain antibiotics.
Speaker: So that's something that I've been very interested in the past few years in trying to come up with more data to support that fact and how we can address it.
Speaker: Because even though we can talk about it, it's hard to quantify how much more do I give.
Speaker: So that's one of the things that I've been focused on lately.
Speaker: But I think it also starts with thinking about it, right?
Speaker: Because like you said, I mean, when we think of infections, traditionally, durations of treatments with antibiotics, for example, have been multiples of seven, not because that's what works for everybody, but because that's been convenient for maybe the drug companies in terms of how they think about these things.
Speaker: But we both have the same pneumonia or the same pathogen.
Speaker: I might be fine with seven days of antibiotics and you might need only five.
Speaker: And trying to figure out or more and try to personalize that type of care, I think, as we move forward and get more information is something that I think is very important.
Speaker: I absolutely agree.
Speaker: Absolutely, yes.
Speaker: So, Raquel, it's been a real pleasure talking with you about this very rapidly evolving topic.
Speaker: I'm sure that we will have much more to talk as time comes by.
Speaker: And I think that we will share all the valuable links that you have shared with us at the beginning so that people can actually reach them and see what's going on and read in more detail as we have more information and stay informed with valuable information that can actually help us not only take care of patients, but give people who ask the right advice and make decisions based on data and support them based on data, not based on whatever the latest
Speaker: perception or misconception on this is.
Speaker: So again, thank you for your time and hope to have you back on the podcast soon.
Speaker: Thank you very much.
Speaker: I enjoyed that, Sergio.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a sound critical care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
