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Letter to the Editor| Volume 86, ISSUE 2, P154-225, February 2023

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Real-life practice of the Egyptian Kelleni's protocol in the current tripledemic: COVID-19, RSV and influenza

Published:December 09, 2022DOI:https://doi.org/10.1016/j.jinf.2022.12.007
      Dear Editor
      Currently, we are dealing in Africa as elsewhere globally, with a tripledemic of SARS CoV-2 Omicron numerous sub-variants, respiratory syncytial virus (RSV), and several influenza viruses including novel
      • Cheng D
      • Dong Y
      • Wen S
      • Shi C.
      A child with acute respiratory distress syndrome caused by avian influenza H3N8 virus.
      and potential reassortment influenza subtypes’ infection
      • Li P
      • Niu M
      • Li Y
      • et al.
      Human infection with H3N8 avian influenza virus: a novel H9N2-original reassortment virus.
      • Yu Y
      • Wu M
      • Cui X
      • et al.
      Pathogenicity and transmissibility of current H3N2 swine influenza virus in Southern China: a zoonotic potential.
      • Liu T
      • Huang Y
      • Xie S
      • et al.
      A characterization and an evolutionary and a pathogenicity analysis of reassortment H3N2 avian influenza virus in South China in 2019-2020.
      . The clinical manifestations of these and other respiratory viral infections are mostly similar
      • Treanor J
      Viral infections of the lung and respiratory tract.
      especially when the patients are seeking an early medical advice as we highly recommended and continue to recommend, to be noted that the vast majority of our African patients can't afford to perform any investigations due to economic reasons and again we had to adjust our practice to best serve all patients.
      Interestingly, though the above mentioned viruses might share in sore throat, rhinitis, cough and fever. I suggest that influenza virus infection in adults is more characterized by the sudden onset of severe body ache, marked physical exhaustion (loss of energy as described by many patients), as well as the sudden troublesome nausea, while RSV infection in young children is more common to be associated with otalgia, and conjunctivitis. Similarly, diarrhea was a predominant GIT manifestation that accompanied or even preceded the usual respiratory manifestations and/or complications in an increasing number of patients in this wave of SARS CoV-2 Omicron infection with/without anosmia, ageusia.
      Since SARS CoV-2 has been introduced to our medical challenges in November, 2019, physicians in Africa were obliged to take care of COVID-19 patients basing on our best clinical judgment and we can proudly and humbly announce, three years later, that the minimal COVID-19 mortality in Africa has proved us right when we decided to boost our natural immunity with safe, effective and generic drugs as best scientifically revealed in Kelleni's protocol
      • Kelleni MT.
      NSAIDs and Kelleni's protocol as potential early COVID-19 treatment game changer: could it be the final countdown?.
      ,
      • Kelleni MT.
      NSAIDs/nitazoxanide/azithromycin repurposed for COVID-19: potential mitigation of the cytokine storm interleukin-6 amplifier via immunomodulatory effects.
      .
      From a daily real-life experience in my clinic which is focusing in management of COVID-19 and Post COVID syndrome, I wish to declare that early treatment using Kelleni's COVID-19 protocol is as safe and effective in management of this tripledemic as it was in SARS CoV-2 pre Omicron variants in pediatric, geriatric, immune-compromised and pregnant patients
      • Kelleni MT.
      NSAIDs/Nitazoxanide/azithromycin immunomodulatory protocol used in adult, geriatric, pediatric, pregnant, and immunocompromised COVID-19 patients: a real-world experience.
      . Noteworthy, nitazoxanide, an integral part of Kelleni's COVID-19 protocol, was previously shown to inhibit the in-vitro replication of Paramyxoviridae including RSV and parainfluenza viruses
      • Piacentini S
      • La-Frazia S
      • Riccio A
      • et al.
      Nitazoxanide inhibits paramyxovirus replication by targeting the Fusion protein folding: role of glycoprotein-specific thiol oxidoreductase.
      and human influenza viruses
      • Tilmanis D
      • van Baalen C
      • Oh DY
      • Rossignol JF
      • Hurt AC.
      The susceptibility of circulating human influenza viruses to tizoxanide, the active metabolite of nitazoxanide.
      .
      However, as more immune-evasive SARS CoV-2 variants are continuing to emerge, I adjusted my clinical practice and I wish to recommend a full 5-day-course of Kelleni's protocol rather than the usual 3-day-course
      • Kelleni MT.
      NSAIDs/Nitazoxanide/azithromycin immunomodulatory protocol used in adult, geriatric, pediatric, pregnant, and immunocompromised COVID-19 patients: a real-world experience.
      in all high risk populations especially kids under 5 years, elderly above 75 years and immune-compromised patients to avoid COVID-19 rebound that was seldom encountered in my clinical practice until recently in a young child who did not receive azithromycin in the initial 3-day-course and after 4 days of clinical resolution, runny nose, cough nausea and low grade fever reappeared and was perfectly and promptly controlled by another 3-day-course of nitazoxanide and azithromycin. Notably, bacterial co-infection is suggested to be considered in such clinical scenario; i.e. in virally infected patients who deteriorate after initial improvement
      • Uyeki TM
      • Bernstein HH
      • Bradley JS
      • et al.
      Clinical practice guidelines by the infectious diseases society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenzaa.
      . I currently use and recommend the full Kelleni's protocol, including azithromycin, for 5 days in all high risk groups as I suggest a favorable risk benefit ratio is obvious considering its high safety and efficacy as well as the additional potential benefits when using azithromycin prophylactically in those populations
      • Mosquera RA
      • Gomez-Rubio AM
      • Harris T
      • et al.
      Anti-inflammatory effect of prophylactic macrolides on children with chronic lung disease: a protocol for a double-blinded randomised controlled trial.
      .

      Funding/Financial exposure

      None

      Declaration of Competing Interest

      The author declares that there is no conflict of interest.

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