Purpose: The purpose of this study was to compare how treatment with convalescent plasma (CP) monotherapy, remdesivir (RDV) monotherapy, and combination therapy (CP + RDV) in patients with COVID-19 affected clinical outcomes. Methods: Patients with COVID-19 infection who were admitted to the hospital received CP, RDV, or combination of both. Mortality, discharge disposition, hospital length of stay (LOS), intensive care unit (ICU) LOS, and total ventilation days were compared between each treatment group and stratified by ABO blood group. An exploratory analysis identified risk factors for mortality. Adverse effects were also evaluated. Results: RDV monotherapy showed an increased chance of survival compared to combination therapy or CP monotherapy (p = 0.052). There were 15, 3, and 6 deaths in the CP, RDV, and combination therapy groups, respectively. The combination therapy group had the longest median ICU LOS (8, IQR 4.5-15.5, p = 0.220) and hospital LOS (11, IQR 7-15.5, p = 0.175). Age (p = 0.036), initial SOFA score (p = 0.013), and intubation (p = 0.005) were statistically significant predictors of mortality. Patients with type O blood had decreased ventilation days, ICU LOS, and total LOS. Thirteen treatment-related adverse events occurred. Conclusion: No significant differences in clinical outcomes were observed between patients treated with RDV, CP, or combination therapy. Elderly patients, those with a high initial SOFA score, and those who require intubation are at increased risk of mortality associated with COVID-19. Blood type did not affect clinical outcomes.
Background In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab—a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody—has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking. Case presentation We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri’s during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm3; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm3, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor—12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died. Conclusions In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.
Inappropriate utilization of antibiotics has led to the emergence of multi-drug resistant bacterial infections, limiting our options for effective antibiotics. Measurement of biomarkers in bacterial infection has been suggested as an additional tool to assist in the decision of de-escalation or discontinuation of antibiotics. Procalcitonin (PCT) is upregulated by cytokines in response to systemic inflammation, especially from a bacterial source. Previous studies have shown that a PCT-guided decision may reduce the total duration of antibiotic therapy and antibiotic exposure. This study aimed to evaluate the utilization of PCT testing by in-training house staff and its impact on the antimicrobial duration and appropriate de-escalation. METHODS: This was a retrospective, observational chart review study at a community hospital with residency teaching programs for family medicine, internal medicine, general surgery, and pharmacy. Patients admitted between June through August 2019 and had PCT levels obtained during hospitalization were included. Pregnant patients and pediatric (<18-years-old) were excluded.The primary endpoints included evaluation of the total antibiotic duration or de-escalation once a negative or $ 80% decrease from peak PCT level was obtained. Secondary endpoints evaluated the incidence of disconjugate results and the number of PCT levels obtained.Patients with positive cultures, confounding variables, infections of the skin, heart, or bone, and antibiotics used for surgical prophylaxis were excluded from primary endpoint evaluation. RESULTS: 256 patients had at least one PCT level obtained and 44 patients met inclusion criteria for primary endpoint evaluation. Based on serial negative PCT levels or an $80% decrease from peak PCT level, there was no difference in antibiotic duration however there was an appropriate de-escalation in antibiotics in 24 of 44 patients (71%). Of the 256 patients, 197 patients had a single PCT level (77%) and of that, the single PCT level was obtained at the time of admission in 140 patients (55%). 59 patients (23%) had serial PCT levels drawn during hospitalization. Disconjugate results were also seen in many patients. Notably, 45 patients (22%) had positive cultures but negative PCT levels and 38 patients (19%) had a negative culture but positive PCT. CONCLUSIONS: The majority of patients did not have a serial PCT done, suggesting inappropriate utilization of the test. However, when PCT was monitored correctly with serial checks, it resulted in de-escalation or discontinuation of antibiotics in 71% of patients. CLINICAL IMPLICATIONS: Obtaining a single PCT level at admission is non-beneficial whereas serial PCT levels can be a useful tool for antibiotic stewardship in residency teaching programs.
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