Triazole resistance is an increasing problem in invasive aspergillosis (IA). Small case series show mortality rates of 50%-100% in patients infected with a triazole-resistant Aspergillus fumigatus, but a direct comparison with triazole-susceptible IA is lacking. A 5-year retrospective cohort study (2011-2015) was conducted to compare mortality in patients with voriconazole-susceptible and voriconazole-resistant IA. Aspergillus fumigatus culture-positive patients were investigated to identify patients with proven, probable, and putative IA. Clinical characteristics, day 42 and day 90 mortality, triazole-resistance profiles, and antifungal treatments were investigated. Of 196 patients with IA, 37 (19%) harbored a voriconazole-resistant infection. Hematological malignancy was the underlying disease in 103 (53%) patients, and 154 (79%) patients were started on voriconazole. Compared with voriconazole-susceptible cases, voriconazole resistance was associated with an increase in overall mortality of 21% on day 42 (49% vs 28%; P = .017) and 25% on day 90 (62% vs 37%; P = .0038). In non-intensive care unit patients, a 19% lower survival rate was observed in voriconazole-resistant cases at day 42 (P = .045). The mortality in patients who received appropriate initial voriconazole therapy was 24% compared with 47% in those who received inappropriate therapy (P = .016), despite switching to appropriate antifungal therapy after a median of 10 days. Voriconazole resistance was associated with an excess overall mortality of 21% at day 42 and 25% at day 90 in patients with IA. A delay in the initiation of appropriate antifungal therapy was associated with increased overall mortality.

Since December 2019, the world has been in the grip of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19).¹ On February 27, 2020, the first patient with COVID-19 was detected in the Netherlands, after a trip to northern Italy between February 18, 2020, and February 21, 2020.² From then until March 6, 2020, another 127 COVID-19 cases were identified in the Netherlands, including 9 health care workers (HCWs) in 2 Dutch teaching hospitals in the southern part of the Netherlands who received a diagnosis of COVID-19 between March 2, 2020, and March 6, 2020. Eight of these 9 HCWs had no history of travel to China or northern Italy, raising the question of whether undetected community circulation was occurring. Because these findings coincided with the seasonal influenza peak³ and because SARS-CoV-2 infection in HCWs could lead to both sick leave and introduction of the virus into the hospital, this finding prompted a demand for testing HCWs. After initial observations of SARS-CoV-2 detection in persons with mild symptoms who did not meet the definition for case finding,¹ screening for SARS-CoV-2 was implemented to determine the prevalence and the clinical presentation of COVID-19 among HCWs with self-reported fever or respiratory symptoms in these 2 hospitals.

We describe four secondary fungal infections caused by Mucorales species in COVID-19 patients. Three COVID-19 associated mucormycosis (CAM) occurred in ICU, one outside ICU. All were men aged > 50 years, three died. Clinical presentations included pulmonary, rhino-orbital cerebral and disseminated infection. Infections occurred in patients with and without diabetes mellitus. CAM is an emerging disease and our observations underscore the need to be aware of invasive mucormycosis, including in COVID-19 patients without (poorly controlled) diabetes mellitus and outside ICU.

Background: On February 27, 2020, the first patient with COVID-19 was reported in the Netherlands. During the following weeks, nine healthcare workers (HCWs) were diagnosed with COVID-19 in two Dutch teaching hospitals, eight of whom had no history of travel to China or Northern-Italy. A low-threshold screening regimen was implemented to determine the prevalence and clinical presentation of COVID-19 among HCWs in these two hospitals. Methods: HCWs who suffered from fever or respiratory symptoms were voluntarily tested for SARS-CoV-2 by real-time reverse-transcriptase PCR on oropharyngeal samples. Structured interviews were conducted to document symptoms for all HCWs with confirmed COVID-19. Findings: Thirteen-hundred fifty-three (14%) of 9,705 HCWs employed were tested, 86 (6%) of whom were infected with SARS-CoV-2. Most HCWs suffered from relatively mild disease and only 46 (53%) reported fever. Eighty (93%) HCWs met a case definition of fever and/or coughing and/or shortness of breath. None of the HCWs identified through the screening reported a travel history to China or Northern Italy, and 3 (3%) reported to have been exposed to an inpatient known with COVID-19 prior to the onset of symptoms. Interpretation: Within two weeks after the first Dutch case was detected, a substantial proportion of HCWs with fever or respiratory symptoms were infected with SARS-CoV-2, probably caused by acquisition of the virus in the community during the early phase of local spread. The high prevalence of mild clinical presentations, frequently not including fever, asks for less stringent use of the currently recommended case-definition for suspected COVID-19. RESEARCH IN PERSPECTIVE: Evidence before this study: This study was conducted in response to the global spread of SARS-CoV-2, and the detection of eight healthcare workers (HCWs) in two Dutch teaching hospitals within two weeks after the first patient with COVID-19 was detected in the Netherlands who had no history of travel to China or Northern-Italy, raising the question of whether undetected community circulation was occurring. Added value of this study: To the best of our knowledge, this report is the first to describe the prevalence, the clinical presentation and early outcomes of COVID-19 in HCWs, which may be helpful for others seeking to identify HCWs suspected for COVID-19 in an outbreak situation. Implications of all the available evidence: We describe that within two weeks after the first Dutch case was detected, a substantial proportion of HCWs with fever or (mild) respiratory symptoms were infected with SARS-CoV-2, probably caused by acquisition of the virus in the community during the early phase of local spread. The high prevalence of mild clinical presentations, frequently not including fever, asks for less stringent use of the currently recommended case-definition for suspected COVID-19.

The increase in smartphone use and mobile health applications (apps) holds potential to use apps to reduce and detect healthcare-associated infections (HAIs) in clinical practice. To obtain an overview of available apps for HAI prevention, by selecting the clinically relevant apps and scoring functionality, quality and usefulness. This scoping review of available apps in the iOS and Android app stores uses an in-house-developed tool (scraper https://holtder.github.io/talos) to systematically aggregate available apps relevant for HAI prevention. The apps are evaluated on functionality, assessed on quality using the 'Mobile Application Rating Scale' (MARS), and assessed on potential use in clinical infection prevention. Using the scraper with CDC HAI topics through 146 search terms resulted in 92,726 potentially relevant apps, of which 28 apps met the inclusion criteria. The majority of these apps have the functionality to inform (27 of 28 apps) or to instruct (20/28). MARS scores for the 28 apps were high in the following domains: functionality (4.19/5), aesthetics (3.49/5), and information (3.74/5), with relatively low scores in engagement (2.97/5), resulting in a good average score (3.57/5). Low engagement scores restrict apps that intend to inform or instruct, possibly explained by the often-academic nature of the development of these apps. Although the number of HAI prevention apps increased by 60% in 5 years, the proportion of clinically relevant apps is limited. The variation in HAI app quality and lack of user engagement, could be improved by co-creation and development in the clinical setting.