Effect of Neutralizing Monoclonal Antibody Treatment on Early Trajectories of Virologic and Immunologic Biomarkers in Patients Hospitalized With COVID-19

BACKGROUND

Neutralizing monoclonal antibodies (nmAbs) failed to show clear benefit for hospitalized patients with coronavirus disease 2019 (COVID-19). Dynamics of virologic and immunologic biomarkers remain poorly understood.

METHODS

Participants enrolled in the Therapeutics for Inpatients with COVID-19 trials were randomized to nmAb versus placebo. Longitudinal differences between treatment and placebo groups in levels of plasma nucleocapsid antigen (N-Ag), anti-nucleocapsid antibody, C-reactive protein, interleukin-6, and D-dimer at enrollment, day 1, 3, and 5 were estimated using linear mixed models. A 7-point pulmonary ordinal scale assessed at day 5 was compared using proportional odds models.

RESULTS

Analysis included 2149 participants enrolled between August 2020 and September 2021. Treatment resulted in 20% lower levels of plasma N-Ag compared with placebo (95% confidence interval, 12%-27%; P < .001), and a steeper rate of decline through the first 5 days (P < .001). The treatment difference did not vary between subgroups, and no difference was observed in trajectories of other biomarkers or the day 5 pulmonary ordinal scale.

CONCLUSIONS

Our study suggests that nmAb has an antiviral effect assessed by plasma N-Ag among hospitalized patients with COVID-19, with no blunting of the endogenous anti-nucleocapsid antibody response. No effect on systemic inflammation or day 5 clinical status was observed.

CLINICAL TRIALS REGISTRATION

NCT04501978.

Clinical and Demographic Factors Associated With COVID-19, Severe COVID-19, and SARS-CoV-2 Infection in Adults: A Secondary Cross-Protocol Analysis of 4 Randomized Clinical Trials

Importance

Current data identifying COVID-19 risk factors lack standardized outcomes and insufficiently control for confounders.

Objective

To identify risk factors associated with COVID-19, severe COVID-19, and SARS-CoV-2 infection.

Design, Setting, and Participants

This secondary cross-protocol analysis included 4 multicenter, international, randomized, blinded, placebo-controlled, COVID-19 vaccine efficacy trials with harmonized protocols established by the COVID-19 Prevention Network. Individual-level data from participants randomized to receive placebo within each trial were combined and analyzed. Enrollment began July 2020 and the last data cutoff was in July 2021. Participants included adults in stable health, at risk for SARS-CoV-2, and assigned to the placebo group within each vaccine trial. Data were analyzed from April 2022 to February 2023.

Exposures

Comorbid conditions, demographic factors, and SARS-CoV-2 exposure risk at the time of enrollment.

Main Outcomes and Measures

Coprimary outcomes were COVID-19 and severe COVID-19. Multivariate Cox proportional regression models estimated adjusted hazard ratios (aHRs) and 95% CIs for baseline covariates, accounting for trial, region, and calendar time. Secondary outcomes included severe COVID-19 among people with COVID-19, subclinical SARS-CoV-2 infection, and SARS-CoV-2 infection.

Results

A total of 57 692 participants (median [range] age, 51 [18-95] years; 11 720 participants [20.3%] aged ≥65 years; 31 058 participants [53.8%] assigned male at birth) were included. The analysis population included 3270 American Indian or Alaska Native participants (5.7%), 7849 Black or African American participants (13.6%), 17 678 Hispanic or Latino participants (30.6%), and 40 745 White participants (70.6%). Annualized incidence was 13.9% (95% CI, 13.3%-14.4%) for COVID-19 and 2.0% (95% CI, 1.8%-2.2%) for severe COVID-19. Factors associated with increased rates of COVID-19 included workplace exposure (high vs low: aHR, 1.35 [95% CI, 1.16-1.58]; medium vs low: aHR, 1.41 [95% CI, 1.21-1.65]; P < .001) and living condition risk (very high vs low risk: aHR, 1.41 [95% CI, 1.21-1.66]; medium vs low risk: aHR, 1.19 [95% CI, 1.08-1.32]; P < .001). Factors associated with decreased rates of COVID-19 included previous SARS-CoV-2 infection (aHR, 0.13 [95% CI, 0.09-0.19]; P < .001), age 65 years or older (aHR vs age <65 years, 0.57 [95% CI, 0.50-0.64]; P < .001) and Black or African American race (aHR vs White race, 0.78 [95% CI, 0.67-0.91]; P = .002). Factors associated with increased rates of severe COVID-19 included race (American Indian or Alaska Native vs White: aHR, 2.61 [95% CI, 1.85-3.69]; multiracial vs White: aHR, 2.19 [95% CI, 1.50-3.20]; P < .001), diabetes (aHR, 1.54 [95% CI, 1.14-2.08]; P = .005) and at least 2 comorbidities (aHR vs none, 1.39 [95% CI, 1.09-1.76]; P = .008). In analyses restricted to participants who contracted COVID-19, increased severe COVID-19 rates were associated with age 65 years or older (aHR vs <65 years, 1.75 [95% CI, 1.32-2.31]; P < .001), race (American Indian or Alaska Native vs White: aHR, 1.98 [95% CI, 1.38-2.83]; Black or African American vs White: aHR, 1.49 [95% CI, 1.03-2.14]; multiracial: aHR, 1.81 [95% CI, 1.21-2.69]; overall P = .001), body mass index (aHR per 1-unit increase, 1.03 [95% CI, 1.01-1.04]; P = .001), and diabetes (aHR, 1.85 [95% CI, 1.37-2.49]; P < .001). Previous SARS-CoV-2 infection was associated with decreased severe COVID-19 rates (aHR, 0.04 [95% CI, 0.01-0.14]; P < .001).

Conclusions and Relevance

In this secondary cross-protocol analysis of 4 randomized clinical trials, exposure and demographic factors had the strongest associations with outcomes; results could inform mitigation strategies for SARS-CoV-2 and viruses with comparable epidemiological characteristics.

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Lessons from an international trial evaluating vaccination strategies for recovered inpatients with COVID-19 (VATICO)

The protection provided by natural versus hybrid immunity from COVID-19 is unclear. We reflect on the challenges from trying to conduct a randomized post-SARS-CoV-2 infection vaccination trial study with rapidly evolving scientific data, vaccination guidelines, varying international policies, difficulties with vaccine availability, vaccine hesitancy, and a constantly evolving virus.

Burden of Hyperglycemia in Patients Receiving Corticosteroids for Severe COVID-19

Although corticosteroid therapy is the standard of care for all patients hospitalized with severe coronavirus disease 2019 (COVID-19), the studies demonstrating the mortality–benefit ratio of corticosteroids were limited to fully evaluate their adverse effects. To determine the severity of corticosteroid-induced hyperglycemia in patients with and without diabetes mellitus, we retrospectively collected data from the medical records of patients hospitalized with COVID-19 before and after corticosteroids were the standard of care. Corticosteroid-induced hyperglycemia was more severe in patients hospitalized with COVID-19 with diabetes than those without diabetes. Additionally, patients with diabetes required higher doses of correctional insulin per day when on corticosteroid therapy, suggesting that intensive point-of-care glucose monitoring could be limited in patients without diabetes mellitus and support cautionary use of corticosteroids in patients with COVID-19 discharged with supplemental oxygen.

Oral fosfomycin use for pyelonephritis and complicated urinary tract infections: a 1 year review of outcomes and prescribing habits in a large municipal healthcare system

BACKGROUND

The rising incidence of MDR uropathogens has driven increased use of oral fosfomycin for treatment of complicated urinary tract infections (cUTIs). However, there are limited data to support its use for cUTI, especially pyelonephritis.

METHODS

We performed a retrospective review of all oral fosfomycin prescriptions between 1 January and 31 December 2017 in the Los Angeles County Department of Health Service system, the second largest US municipal health system. We examined demographics, clinical characteristics, adverse events and 30 day treatment success for patients with cUTI. Follow-up urine cultures till 31 December 2018 were examined for emergence of fosfomycin resistance.

RESULTS

Of 154 patients prescribed fosfomycin, 99 (64%) had cUTI. Of these, 39 (39%) had lower tract, 37 (37%) pyelonephritis and 23 (23%) non-pyelonephritis upper tract cUTI. Escherichia coli ESBL producers were the predominant pathogens (73%). Of the 63 patients with 30 day follow-up, 49 (78%) had clinical success, including 16/20 (80%) treated for pyelonephritis. Treatment failure was associated with male sex (P < 0.01), urological abnormalities (P = 0.05), non-E. coli cUTI (P = 0.03) and receipt of <25% IV therapy prior to fosfomycin switch (P = 0.03). Of patients prescribed fosfomycin (n = 154), fosfomycin-resistant E. coli were found in 9/64 (14%) of the patients with follow-up urine cultures >30 days after initial treatment.

CONCLUSIONS

Despite the lack of data supporting its use, we found that most patients receiving oral fosfomycin off-label for cUTI, including pyelonephritis, had clinical success. However, emergence of subsequent resistance warrants caution. Prospective comparative studies should be done to better evaluate oral fosfomycin use for cUTI.

Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy

Introduction

Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector.

Discussion

We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed.

Conclusion

Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.

2263. Fosfomycin Trometerol Use for Complicated UTIs Including Pyelonephritis, a 1-year Review of Outcomes and Prescribing Habits

Background

Methods

Results

Conclusion

Disclosures

Targeting the third '90': introducing the viral load champion

Objective: To move closer to achieving the third target of the UNAIDS 90-90-90 goals, we prospectively implemented a viral load (VL) champion (VLC) program aimed at enhancing VL monitoring and recognition of treatment failure. Design: Three clinics in eThekwini, Kwa-Zulu Natal (low-, medium- and high-volume, encompassing 9184 patients overall) were each assigned a VLC. We employed a descriptive analysis (chart audit) to compare the pre-intervention period to a 1-year post-intervention period. The number of patients with a VL test performed 6 and 12 months after the intervention was calculated as a proportion of VL tests due at those time points (VL completion rate). Results: The pre-implementation VL completion rate at the three sites was respectively 68% (140/205 patients), 54% (84/155 patients) and 64% (323/504 patients), and the 6-month post-implementation completion rate increased to 83% (995/1194 patients), 90% (793/878 patients) and 99% (3101/3124 patients) (P < 0.0001 for each site). VL completion rates remained significantly higher at 12 months post-implementation, with an average cumulative VL completion rate of >90% across all facilities. Conclusion: We demonstrate a successful, multifaceted, quality-improvement intervention centered on a clinic-level VLC which, taken to scale, has important implications for attaining the third UNAIDS 90-90-90 target.

High-Dose Fluconazole Consolidation Therapy for Cryptococcal Meningitis in Sub-Saharan Africa: Much to Gain, Little to Lose

Cryptococcal meningitis accounts for an estimated 25% of AIDS-associated mortality in sub-Saharan Africa. Accumulating animal and human evidence suggest that a higher, more fungicidal, dose of fluconazole during consolidation therapy could be more effective in controlling residual infection and may help significantly reduce posthospitalization mortality. Although the potential for toxicity is low, the use of fluconazole at a dose of 800 mg/day during consolidation therapy requires examination in a randomized clinical trial. In the interim, within countries where postdischarge mortality from cryptococcal meningitis is high and amphotericin-flucytosine combination therapy remains unavailable, the use of high-dose fluconazole consolidation therapy deserves serious consideration as a strategy with limited risk and the potential for considerable public health benefit.

Nonprogrammable and programmable cerebrospinal fluid shunt valves: a 5-year study

OBJECT

Programmable valves (PVs) for shunting CSF have increasingly replaced nonprogrammable valves (NPVs). There have been only a few longer-term studies (≥ 5 years) conducted that have compared the effectiveness of NPVs with that of PVs for children with hydrocephalus, and only 1 study has reported NPVs as being favorable over PVs. The objective of this retrospective study was to compare the long-term survival of these 2 types of shunt valves.

METHODS

The authors collected data for all patients who underwent CSF shunt insertion or revision between January 1, 2000, and December 31, 2008. Patients underwent follow-up for a minimum of 2 years postoperatively. Statistical analyses were done using chi-square, Kaplan-Meier survival curve, and multivariate analyses.

RESULTS

A total of 616 valves were implanted, of which 313 were PVs and 303 were NPVs. Of these, 253 were original shunt implantations and 363 were revisions. The proportion of 5-year survival for NPVs (45.8%) was significantly higher than that for PVs (19.8%) (p = 0.0005, log-rank). The NPVs that survived longer than 6 months also survived through the 5th year better than the PVs (p = 0.0001).

CONCLUSIONS

The authors' data suggest that NPVs survive longer than PVs in children, but there is a need for prospective, case-control studies to confirm these data.