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Chastain DB, Kung VM, Vargas Barahona L, Jackson BT, Golpayegany S, Franco-Paredes C, Thompson GR, Henao-Martínez AF. Characteristics and Outcomes of Cryptococcosis among Patients with and without COVID-19. J Fungi (Basel) 2022; 8:jof8111234. [PMID: 36422055 PMCID: PMC9695249 DOI: 10.3390/jof8111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022] Open
Abstract
The effect of COVID-19 on the risk and prognosis of cryptococcosis is unclear. We compared the characteristics and outcomes of cryptococcosis in patients with and without COVID-19. Patients 18 years and older with cryptococcosis were identified from TriNetX and separated into two cohorts based on a diagnosis of COVID-19 within 3 months of the index diagnosis of cryptococcosis. Differences examined between groups included comorbidities, immunosuppressive medications, ED visits, hospitalizations, ICU admissions, mechanical ventilation, and deaths. The propensity score matching was performed based on demographics and comorbidities. Of the 6998 patients with cryptococcosis included, 4.4% (n = 306) had COVID-19 prior to cryptococcosis. Mortality was higher in patients with COVID-19 compared to those without COVID-19 (14% vs. 11%, p = 0.032). Additionally, those with COVID-19 were older (55.2 ± 14.4 vs. 51.9 ± 15.2 years, p < 0.001) with higher rates of transplant (29% vs. 13%, p < 0.001), neoplastic disease (37% vs. 21%, p < 0.001), chronic kidney disease (42% vs. 18%, p < 0.001), or diabetes (35% vs. 19%, p < 0.001) but not HIV (30% vs. 31%, p = 0.618). Glucocorticoid use was more common in those with COVID-19 (52% vs. 27%, p < 0.001). More patients with COVID-19 required ED visits (29% vs. 23%, p = 0.025) and ICU admission (18% vs. 11%, p < 0.001). After propensity score matching, patients with COVID-19 had higher rates of neoplastic disease, heart failure, chronic kidney disease, and glucocorticoid use but did not experience worse outcomes compared to those without COVID-19. Patients with COVID-19 who developed cryptococcosis had independently higher rates of comorbidities and glucocorticoid use but similar outcomes, including death, versus those without COVID-19.
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Affiliation(s)
- Daniel B. Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA 31701, USA
- Correspondence: ; Tel.: +1-229-312-2156; Fax: +1-229-312-2155
| | - Vanessa M. Kung
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Lilian Vargas Barahona
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Sahand Golpayegany
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA 31701, USA
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City 06720, Mexico
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - George R. Thompson
- Department of Medicine, Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, CA 95616, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
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Pidiyar V, Kumraj G, Ahmed K, Ahmed S, Shah S, Majumder P, Verma B, Pathak S, Mukherjee S. COVID-19 management landscape: A need for an affordable platform to manufacture safe and efficacious biotherapeutics and prophylactics for the developing countries. Vaccine 2022; 40:5302-5312. [PMID: 35914959 PMCID: PMC9148927 DOI: 10.1016/j.vaccine.2022.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 05/19/2022] [Indexed: 12/23/2022]
Abstract
To gain world-wide control over COVID-19 pandemic, it is necessary to have affordable and accessible vaccine and monoclonal antibody technologies across the globe. In comparison to the western countries, Asian and African countries have less percentage of vaccination done which warrants urgent attention. Global manufacturer production capacities, dependency on advanced nations for the supply of vaccines or the raw material, national economy, limited research facilities, and logistics could be the factors. This review article elaborates the existing therapeutic and prophylactic strategies available for COVID-19, currently adopted vaccine and monoclonal antibody platforms for SARS-CoV-2 along with the approaches to bridge the gap prevailing in the challenges faced by low- and middle-income countries. We believe adoption of yeast-derived P. pastoris technology can help in developing safe, proven, easy to scale-up, and affordable recombinant vaccine or monoclonal antibodies against SARS-CoV-2. This platform has the advantage of not requiring a dedicated or specialized facility making it an affordable option using existing manufacturing facilities, without significant additional capital investments. Besides, the technology platform of multiantigen vaccine approach and monoclonal antibody cocktail will serve as effective weapons to combat the threat posed by the SARS-CoV-2 variants. Successful development of vaccines and monoclonal antibodies using such a technology will lead to self-sufficiency of these nations in terms of availability of vaccines and monoclonal antibodies.
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Affiliation(s)
- Vyankatesh Pidiyar
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Ganesh Kumraj
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Kafil Ahmed
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Syed Ahmed
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India.
| | - Sanket Shah
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Piyali Majumder
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Bhawna Verma
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Sarang Pathak
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
| | - Sushmita Mukherjee
- Techinvention Lifecare Pvt. Ltd. #1004, The Summit Business Park, Off WEH Metro Station, Andheri Kurla Road, Andheri East, Mumbai 400093. India
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Chastain DB, Kung VM, Golpayegany S, Jackson BT, Franco-Paredes C, Barahona LV, Thompson GR, Henao-Martínez AF. Cryptococcosis among hospitalized patients with COVID-19: a multicenter research network study. Mycoses 2022; 65:815-823. [PMID: 35657109 PMCID: PMC9348105 DOI: 10.1111/myc.13476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is unclear if there is an association between COVID-19 and cryptococcosis. Therefore, this study aimed to describe the clinical features, risk factors, and outcomes associated with cryptococcosis in hospitalized patients with COVID-19. OBJECTIVES To determine the incidence of and examine factors associated with cryptococcosis after a diagnosis of COVID-19. METHODS We used TriNetX to identify and sort patients 18 years and older hospitalized with COVID-19 into two cohorts based on the presence or absence of a diagnosis of cryptococcosis following diagnosis of COVID-19. Outcomes of interest included the incidence of cryptococcosis following the diagnosis of COVID-19 as well as the proportion of patients in each group who had underlying comorbidities, received immunomodulatory therapy, required ICU admission or mechanical ventilation (MV), or who died. Propensity score matching was used to adjust for confounding. RESULTS Among 212,479 hospitalized patients with COVID-19, 65 developed cryptococcosis. The incidence of cryptococcosis following COVID-19 was 0.022%. Patients with cryptococcosis were more likely to be male and have underlying comorbidities. Among cases, 32% were people with HIV. Patients with cryptococcosis were more likely to have received tocilizumab (p<0.0001) or baricitinib (p<0.0001), but not dexamethasone (p=0.0840). ICU admission (38% vs 29%), MV (23% vs 11%), and mortality (36% vs 14%) were significantly higher among patients with cryptococcosis. Mortality remained elevated after adjusted propensity score matching. CONCLUSION Cryptococcosis occurred most often in hospitalized patients with COVID-19 who had traditional risk factors, comparable to findings in patients without COVID-19. Cryptococcosis was associated with increased ICU admission, MV, and mortality.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Vanessa M Kung
- Division of Infectious Diseases, University of Colorado, Aurora, CO, USA
| | - Sahand Golpayegany
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | | | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado, Aurora, CO, USA.,Hospital Infantil de México, Federico Gómez, México City, México
| | | | - George R Thompson
- Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis Medical Center, Sacramento, CA, USA
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Safety of Tocilizumab in COVID-19 Patients and Benefit of Single-Dose: The Largest Retrospective Observational Study. Pharmaceutics 2022; 14:pharmaceutics14030624. [PMID: 35335998 PMCID: PMC8953525 DOI: 10.3390/pharmaceutics14030624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 12/13/2022] Open
Abstract
Severe acute respiratory coronavirus-2 (SARS-CoV-2) still presents a public threat and puts extra strain on healthcare facilities. Without an effective antiviral drug, all available treatment options are considered supportive. Tocilizumab as a treatment option has to date shown variable results. In this retrospective study, we aimed to assess predictors of mortality of COVID-19 patients (n = 300) on tocilizumab and the clinical effectiveness of this drug. The results showed that ICU admission OR = 64.6 (95% CI: 8.2, 507.4); age of the patient OR = 1.1 (95% CI: 1.0, 1.1); and number of tocilizumab doses administered by the patient OR(two doses) = 4.0 (95% CI: 1.5, 10.9), OR(three doses) = 1.5 (95% CI: 0.5, 5.1), and OR(four doses or more) = 7.2 (95% CI: 2.0, 25.5) presented strong correlation factors that may be linked to COVID-19 mortality. Furthermore, our study showed the beneficial effects of early administration of tocilizumab OR = 1.2 (95% CI: 1.1, 1.4) and longer hospital length of stay OR = 0.974 (95% CI: 0.9, 1.0) in reducing COVID-19 mortalities. High blood D-dimer concentration OR = 1.1 (95% CI: 1.0, 1.2) and reciprocal blood phosphate concentration OR = 0.008 (95% CI: 0.0, 1.2) were correlated to high mortality under SARS-CoV-2 infection. The short-term effect of a single dose of tocilizumab was a significant increase in blood BUN and liver enzymes (ALT, AST, and LDH) above their normal ranges. Furthermore, it significantly reduced CRP blood concentration, but not to normal levels (13.90 to 1.40 mg/dL, p < 0.001). Assessing the effect of different doses of tocilizumab (in terms of the number of doses, total mg, and total mg/kg administered by the patients) indicated that administering more than one dose may lead to increases in ICU length of stay and hospital length of stay of up to 14 and 22 days after the last dose of tocilizumab (6 to 14, p = 0.06, and 10 to 22, p < 0.001), with no improvement in 28- and 90-day mortality, as confirmed by Kaplan−Meier analysis. There were also clear correlations and trends between the number of doses of tocilizumab and increased blood CO2, MCV, RDW, and D-dimer concentrations and between number of doses of tocilizumab and decreased CRP, AST, and hemoglobin concentrations. Microbiology analysis showed a significant increase in the incidence of infection after tocilizumab administration (28 to 119, p < 0.001) with a median time of incidence within 6 days of the first dose of tocilizumab. A significant correlation was also found between the number of tocilizumab doses and the number of incidences of infections after tocilizumab administration r (298) = 0.396, p = 1.028 × 10−12. Based on these results and depending on the pharmacokinetic parameters of the drug, we recommend single-dose administration of tocilizumab as the optimal dosage for COVID-19 patients who do not have active bacterial infection or liver diseases, to be administered as soon as the patient is admitted to the hospital.
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Chastain DB, Henao-Martínez AF, Dykes AC, Steele GM, Stoudenmire LL, Thomas GM, Kung V, Franco-Paredes C. Missed opportunities to identify cryptococcosis in COVID-19 patients: a case report and literature review. Ther Adv Infect Dis 2022; 9:20499361211066363. [PMID: 35070297 PMCID: PMC8771738 DOI: 10.1177/20499361211066363] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
SARS-CoV-2 may activate both innate and adaptive immune responses ultimately leading to a dysregulated immune response prompting the use of immunomodulatory therapy. Although viral pneumonia increases the risk of invasive fungal infections, it remains unclear whether SARS-CoV-2 infection, immunomodulatory therapy, or a combination of both are responsible for the increased recognition of opportunistic infections in COVID-19 patients. Cases of cryptococcosis have previously been reported following treatment with corticosteroids, interleukin (IL)-6 inhibitors, and Janus kinase (JAK) inhibitors, for patients with autoimmune diseases, but their effect on the immunologic response in patients with COVID-19 remains unknown. Herein, we present the case of a patient with COVID-19 who received high-dose corticosteroids and was later found to have cryptococcosis despite no traditional risk factors. As our case and previous cases of cryptococcosis in patients with COVID-19 demonstrate, clinicians must be suspicious of cryptococcosis in COVID-19 patients who clinically deteriorate following treatment with immunomodulatory therapies.
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Affiliation(s)
- Daniel B. Chastain
- Department of Clinical & Administrative Pharmacy, College of Pharmacy, University of Georgia, 1000 Jefferson Street, Albany, GA 31701, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Austin C. Dykes
- Department of Clinical & Administrative Pharmacy, College of Pharmacy, University of Georgia, Albany, GA, USA
| | - Gregory M. Steele
- Infectious Diseases, Phoebe Putney Memorial Hospital, Albany, GA, USA
| | | | - Geren M. Thomas
- Department of Pharmacy, John D. Archbold Memorial Hospital, Thomasville, GA, USA
| | - Vanessa Kung
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO, USAHospital Infantil de México, Federico Gómez, México City, México
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Sarabia De Ardanaz L, Andreu-Ubero JM, Navidad-Fuentes M, Ferrer-González MÁ, Ruíz Del Valle V, Salcedo-Bellido I, Barrios-Rodríguez R, Cáliz-Cáliz R, Requena P. Tocilizumab in COVID-19: Factors Associated With Mortality Before and After Treatment. Front Pharmacol 2021; 12:620187. [PMID: 34276355 PMCID: PMC8281134 DOI: 10.3389/fphar.2021.620187] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 06/14/2021] [Indexed: 01/08/2023] Open
Abstract
Tocilizumab (TCZ) has been administered in SARS-CoV-2 pneumonia but the factors associated with mortality before and after treatment remain unclear. Cox regression models were used to estimate the predictors of time to death in a cohort of hospitalized patients with COVID-19 receiving TCZ. In addition, the mean differences between discharged and deceased patients in laboratory parameters measured before and 3, 6 and 9 days after TCZ administration were estimated with weighted generalized estimation equations. The variables associated with time to death were immunosuppression (Hazard Ratio-HR 3.15; 95% confidence interval-CI 1.17, 8.51), diabetes mellitus (HR 2.63; 95% CI 1.23-5.64), age (HR 1.05; 95% CI 1.02-1.09), days since diagnosis until TCZ administration (HR 1.05, 95% CI 1.00-1.09), and platelets (HR 0.27; 95% CI: 0.11, 0.69). In the post-TCZ analysis and compared to discharged patients, deceased patients had more lactate dehydrogenase (p = 0.013), troponin I (p = 0.013), C-reactive protein (p = 0.013), neutrophils (p = 0.024), and fewer platelets (p = 0.013) and lymphocytes (p = 0.013) as well as a lower average PaO2/FiO2 ratio. In conclusion, in COVID-19 diagnosed patients receiving TCZ, early treatment decreased the risk of death, while age, some comorbidities and baseline lower platelet counts increased that risk. After TCZ administration, lower platelet levels were again associated with mortality, together with other laboratory parameters.
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Affiliation(s)
| | - Jose M Andreu-Ubero
- Departamento de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Navidad-Fuentes
- Departamento de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Victor Ruíz Del Valle
- Departamento de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Inmaculada Salcedo-Bellido
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Granada, Granada, España.,Instituto de Investigación Biosanitaria (ibs.Granada), Granada, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Rocío Barrios-Rodríguez
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Granada, Granada, España.,Instituto de Investigación Biosanitaria (ibs.Granada), Granada, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Rafael Cáliz-Cáliz
- Departamento de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Pilar Requena
- Departamento de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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Gutierrez MDM, Mur I, Mateo MG, Vidal F, Domingo P. Pharmacological considerations for the treatment of COVID-19 in people living with HIV (PLWH). Expert Opin Pharmacother 2021; 22:1127-1141. [PMID: 33634724 PMCID: PMC7919104 DOI: 10.1080/14656566.2021.1887140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION When coronavirus infectious disease-2019 (COVID-19) blew up, ill-fated auguries on the collision between COVID-19 and the human immunodeficiency virus (HIV) epidemics loomed. AREAS COVERED Data from observational studies suggest similar incidence attacks of SARS-CoV-2 infection in people living with HIV (PLWH) and HIV-uninfected populations. The mortality rate of COVID-19 is similar in both populations too. The authors discuss the role of combination antiretroviral therapy (cART) in preventing infection or reducing COVID-19 severity. They also discuss the pharmacological interventions for COVID-19 in PLWH. EXPERT OPINION Management of COVID-19 in PLWH is no different from the general population. It should be based on careful supportive care, emphasizing lung-protective ventilation, and wise pharmacological interventions. The antiviral drug remdesivir and dexamethasone are the only pharmacological interventions with clinical benefit for COVID-19, whereas anticoagulation may prevent thrombotic complications. The experience with using these drugs in PLWH is limited, which prevents from rendering well-founded conclusions. Until more data on COVID-19 in PLWH become available, the best weapons within our reach are sound supportive care and sensible use of RDV and dexamethasone, bearing in mind the potential for drug-drug interactions of most corticosteroids and antiretroviral drugs.
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Affiliation(s)
- María Del Mar Gutierrez
- Infectious Diseases Unit. Hospital De La Santa Creu I Sant Pau, Institut De Recerca Del Hospital De La Santa Creu I Sant Pau, Barcelona, Spain
| | - Isabel Mur
- Infectious Diseases Unit. Hospital De La Santa Creu I Sant Pau, Institut De Recerca Del Hospital De La Santa Creu I Sant Pau, Barcelona, Spain
| | - María Gracia Mateo
- Infectious Diseases Unit. Hospital De La Santa Creu I Sant Pau, Institut De Recerca Del Hospital De La Santa Creu I Sant Pau, Barcelona, Spain
| | - Francesc Vidal
- Infectious Diseases Unit. Hospital Universitari Joan XXIII, Universitat Rovira I Virgili, Tarragona, Spain
| | - Pere Domingo
- Infectious Diseases Unit. Hospital De La Santa Creu I Sant Pau, Institut De Recerca Del Hospital De La Santa Creu I Sant Pau, Barcelona, Spain
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Fernández-Ruiz M, Aguado JM. Immunomodulatory Therapies for COVID-19 in Solid Organ Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2020; 7:379-389. [PMID: 33110739 PMCID: PMC7581948 DOI: 10.1007/s40472-020-00306-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 02/06/2023]
Abstract
Purpose of Review Severe coronavirus disease 2019 (COVID-19) is characterized by the development of a deleterious hyperinflammatory response, in which the pleiotropic cytokine interleukin (IL)-6 plays a pivotal role. The administration of immunomodulatory therapies has been proposed to revert the tissue damage induced by COVID-19-related cytokine release syndrome (CRS). The present review summarizes the biological rationale and available clinical experience with this therapeutic strategy in the specific scenario solid organ transplantation (SOT). Recent Findings A number of case reports, case series, and non-controlled cohort studies have assessed the efficacy and safety of the anti-IL-6-receptor monoclonal tocilizumab in SOT (namely kidney transplantation) recipients with COVID-19 pneumonia and CRS. Although the heterogeneity in patient management and the lack of a control group limit the interpretation of these results, tocilizumab therapy appears to provide some clinical benefit in post-transplant COVID-19 and to be reasonably safe in terms of bacterial superinfection. A large randomized clinical trial (RCT) has shown survival benefit with adjuvant corticosteroids in non-transplant patients, but supporting evidence is scarce for SOT recipients and confounded by the variable adjustment of baseline immunosuppression. Anecdotal experiences have been reported with the use of the anti-IL-1 agent anakinra and the NLRP3 inflammasome inhibitor colchicine in this population. Summary Immunomodulation has emerged as a promising option for SOT recipients with COVID-19-related CRS, with available experience mainly restricted to the anti-IL-6 agent tocilizumab. However, the supporting evidence is scarce and of low quality. In the absence of RCT, observational studies including well-matched control groups should be designed in future.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Centro de Actividades Ambulatorias, 2ª planta, bloque D. Avda. de Córdoba, s/n, 28041 Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Centro de Actividades Ambulatorias, 2ª planta, bloque D. Avda. de Córdoba, s/n, 28041 Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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Antony SJ, Davis MA, Davis MG, Almaghlouth NK, Guevara R, Omar F, Del Rey F, Hassan A, Arian MU, Antony N, Prakash BV. Early use of tocilizumab in the prevention of adult respiratory failure in SARS-CoV-2 infections and the utilization of interleukin-6 levels in the management. J Med Virol 2020; 93:491-498. [PMID: 32644254 PMCID: PMC7361804 DOI: 10.1002/jmv.26288] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023]
Abstract
Respiratory failure in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears related to cytokine release syndrome that often results in mechanical ventilation (MV). We investigated the role of tocilizumab (TCZ) on interleukin-6 (IL-6) trends and MV in patients with SARS-CoV-2. In this longitudinal observational study, 112 patients were evaluated from 1 February to 31 May 2020. TCZ was administered followed by methylprednisolone to patients with >3L oxygen requirement and pneumonia severity index score ≤130 with computed tomography scan changes. IL-6, C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), D-dimer, and procalcitonin were monitored on days 0, 3, and 6 of therapy. Statistical analyses were performed with significance ≤0.05. Eighty out of 112 SARS-CoV-2-positive patients (45 males, 56.96%; 34 females, 43.04%) were included in this study. Seven patients expired (8.75%) and nine patients required MV (11.25%). Median IL-6 levels pre-administration of TCZ was 342.50 (78.25-666.25) pg/mL compared with post-administration on day 3 (563; 162-783) pg/mL (P < .00001). On day 6, the median dropped to 545 (333.50-678.50) pg/mL compared with day 3 (P = .709). CRP, ferritin, LDH, and D-dimer levels were reduced after TCZ therapy. Early use of TCZ may reduce the need for MV and decrease CRP, ferritin, LDH, and D-dimer levels. The sequential use of methylprednisolone for 72 hours seems to potentiate the effect and prolong the suppression of the cytokine storm. IL-6 levels may be helpful as a prognostic tool.
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Affiliation(s)
- Suresh J. Antony
- Department of MedicineTexas Tech University Health Sciences CenterEl PasoTexas
| | - Michelle A. Davis
- Department of MedicineBurrell College of Osteopathic MedicineLas CrucesNew Mexico
| | - Monique G. Davis
- Department of MedicineBurrell College of Osteopathic MedicineLas CrucesNew Mexico
| | - Nouf K. Almaghlouth
- Department of Medicine, Mountain View Regional Medical CenterBurrell College of Osteopathic MedicineLas CrucesNew Mexico
| | - Roberto Guevara
- Department of Clinical PharmacyThe Hospitals of Providence Transmountain CampusEl PasoTexas
| | - Fahad Omar
- Department of Pulmonary and Critical CareLas Palmas Del Sol HealthcareEl PasoTexas
| | | | - Ali Hassan
- Department of MedicineLas Palmas Del Sol HealthcareEl PasoTexas
| | | | - Nishaal Antony
- Department of MedicineTexas Tech University Health Sciences CenterEl PasoTexas
| | - Bharat V. Prakash
- Department of MedicineTexas Tech University Health Sciences CenterEl PasoTexas
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