A living WHO guideline on drugs for covid-19

CITATION: Agarwal, A. et al. 2022. A living WHO guideline on drugs for covid-19. British Medical Journal, 370. doi:10.1136/bmj.m3379The original publication is available at https://jcp.bmj.com/This living guideline by Arnav Agarwal and colleagues (BMJ 2020;370:m3379, doi:10.1136/bmj.m3379) was last updated on 22 April 2022, but the infographic contained two dosing errors: the dose of ritonavir with renal failure should have read 100 mg, not 50 mg; and the suggested regimen for remdesivir should have been 3 days, not 5-10 days. The infographic has now been corrected.Publishers versio

Antibiotic therapy for skin and soft tissue infections: a protocol for a systematic review and network meta-analysis

Abstract Background Skin and soft tissue infections (SSTIs) in hospital and community settings impose a substantial socio-economic burden. Therapeutic uncertainty due to the availability of a wide range of antibiotics and the need for empirical treatment decisions complicate SSTI clinical management. Completion of numerous pairwise meta-analyses to account for this variability in antibiotics is impractical, and many head-to-head comparisons of potential interest are likely not available. In comparing multiple antibiotics simultaneously, this network meta-analysis aims to identify the antibiotic(s) with the greatest value in the treatment of SSTIs, in terms of patient-important outcomes such as efficacy and safety. Methods We will conduct a systematic review to identify randomized controlled trials of persons with suspected or confirmed SSTI assigned to orally or parenterally administered antibiotic therapy that report results on at least one outcome of interest. We will search MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL), along with trial registries. Our primary outcome of interest is clinical success at the test-of-cure visit. Secondary outcomes may include (1) early clinical success (2–3 days after the therapy starts), (2) mortality, (3) adverse events, (4) treatment duration, and (5) length of hospital stay. Independent reviewers will complete screening of titles, abstracts, and full texts, data extraction, risk of bias assessment (using the Cochrane Risk of Bias tool), and evaluation of the certainty of evidence (using the GRADE approach) in duplicate. We will complete pairwise and network meta-analyses within the Bayesian framework when possible using a random effects model. We will stratify SSTIs by severity into uncomplicated and complicated SSTIs when possible. Subgroup analyses by age, infection type, comorbidity, and suspected or confirmed methicillin-resistant Staphylococcus aureus (MRSA)-associated infection are planned. Discussion This study has several strengths compared to previous reviews: inclusion of a wider range of infection types, antibiotics, and outcomes; a comprehensive search strategy; a priori subgroup analyses; application of GRADE; and improved interpretability of findings through visual presentation of results. We hope our findings will inform future research, health care professionals, and policy makers resulting in improved evidence-based clinical management of SSTIs. Systematic review registration PROSPERO CRD4201808560

Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis

Objectives To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS).Design Systematic review and meta-analysis.Data sources MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies.Eligibility criteria Pairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest.Data extraction and synthesis We performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.Results One randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18–64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors.Conclusions Treatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors.PROSPERO registration number CRD42020166961

Influenza Transmission in the Mother-Infant Dyad Leads to Severe Disease, Mammary Gland Infection, and Pathogenesis by Regulating Host Responses

<div><p>Seasonal influenza viruses are typically restricted to the human upper respiratory tract whereas influenza viruses with greater pathogenic potential often also target extra-pulmonary organs. Infants, pregnant women, and breastfeeding mothers are highly susceptible to severe respiratory disease following influenza virus infection but the mechanisms of disease severity in the mother-infant dyad are poorly understood. Here we investigated 2009 H1N1 influenza virus infection and transmission in breastfeeding mothers and infants utilizing our developed infant-mother ferret influenza model. Infants acquired severe disease and mortality following infection. Transmission of the virus from infants to mother ferrets led to infection in the lungs and mother mortality. Live virus was also found in mammary gland tissue and expressed milk of the mothers which eventually led to milk cessation. Histopathology showed destruction of acini glandular architecture with the absence of milk. The virus was localized in mammary epithelial cells of positive glands. To understand the molecular mechanisms of mammary gland infection, we performed global transcript analysis which showed downregulation of milk production genes such as Prolactin and increased breast involution pathways indicated by a STAT5 to STAT3 signaling shift. Genes associated with cancer development were also significantly increased including JUN, FOS and M2 macrophage markers. Immune responses within the mammary gland were characterized by decreased lymphocyte-associated genes CD3e, IL2Ra, CD4 with IL1β upregulation. Direct inoculation of H1N1 into the mammary gland led to infant respiratory infection and infant mortality suggesting the influenza virus was able to replicate in mammary tissue and transmission is possible through breastfeeding. In vitro infection studies with human breast cells showed susceptibility to H1N1 virus infection. Together, we have shown that the host-pathogen interactions of influenza virus infection in the mother-infant dyad initiate immunological and oncogenic signaling cascades within the mammary gland. These findings suggest the mammary gland may have a greater role in infection and immunity than previously thought.</p></div

Human “normal” and adenocarcinoma mammary epithelial cells are susceptible and permissive to 2009 H1N1 infection <i>in vitro</i>.

<p>Mammary epithelial cells (MCF-7, MDA-MB-231, MCF-10A cells) inoculated at an MOI of 1 with A/Cal (H1N1) were fixed at 24 hours post-inoculation and stained for filamentous actin (red), DNA (green), and influenza A virus NP protein (blue), and imaged by confocal microscopy (<b>A</b>). Mammary epithelial cells (MCF-7, MDA-MB-231, MCF-10A cells) inoculated at an MOI of 1 with A/Cal (H1N1) were collected at 3, 24, 48, and 72 h post-inoculation for quantification of viral RNA segment 7 by qRT-PCR (<b>B</b>), determination of cell viability (<b>C</b>), and live virus quantification in supernatant (<b>D</b>). Confocal pictures are representative of three independent experiments. White arrows indicate nuclear localization of influenza NP protein. Yellow arrows show virus budding along the plasma membrane. BC, Baseline Control.</p

Transmission of H1N1 influenza from infants to mother ferrets causes upper and lower respiratory tract infection with significant pathology.

<p>Inoculated infants (A/Cal H1N1 influenza (10⁵ EID₅₀)) were housed with their nursing-mothers. Nasal washes were collected daily from infants and mothers. Live viral loads were determined by MDCK titration assay in nasal wash (NW) (<b>A</b>) and mother trachea and mother lungs at specific time points (<b>B</b>). Lungs were harvested on Day 3/4 and 7 post-infant-inoculation for hematoxylin & eosin (H&E) histopathological assessment from nursing-mothers of inoculated infants and directly inoculated adult ferrets as control (<b>C</b>). Green arrows denote dense cell accumulation; black arrows denote diffuse immune cell infiltration. Black arrows not included on Day 7 adult tissue due to widespread infiltration. High resolution scans were performed using an Aperio ScanScope XT, Leica Biosystems, Nußloch, Germany. The left and central columns of mother images represent a low and high magnification of each lung scan. The scale bars indicate the relative 100 μm. Results of <b>A</b> are representative of 3 independent litter inoculations where nasal washes were collected from 3 mothers and 9 infants (3 per litter) daily. Results of <b>B</b> and <b>C</b> are from 6 independent litter inoculations of serial tissue collections (3 collected Day 3/4 and 3 collected Day 7). Error bars indicate +/- SD. Mock: mother ferrets nursing mock-inoculated 4-week-old infant ferrets. Results show the mean or are representative of independent litter inoculations/infections.</p

Intranasal 2009 H1N1 infection in infant ferrets leads to severe disease and mortality in both mother and infant ferrets.

<p>Schematic of experimental design for mother-infant dyad inoculations (<b>A</b>). Infants were intranasally inoculated with the A/Cal strain of 2009 H1N1 influenza (10⁵ EID₅₀) and housed with their nursing-mothers. Temperature (<b>B</b>) and weight (<b>C</b>) were recorded for 14 days post-infant-inoculation. Control mock inoculated infants (grey lines) were used to assess natural fluctuations in growing infants. Survival of mothers and infants was determined over 14 days (<b>D</b>). Results show the mean or are representative of 3 independent litter inoculations/infections (3 mother ferrets and 19 infant ferrets) and 3 litter mock inoculations (3 mother ferrets and 11 infant ferrets). * indicates a p-value less than 0.05 determined by ANOVA comparing 2009 H1N1 inoculated/infected to mock controls. Error bars indicate +/- SE.</p

STAT5 protein is decreased and STAT3 protein is nuclear localized in H1N1+ Mammary Glands.

<p>STAT5 (right panels) and STAT3 (left panels) protein expression was visualized in Control and H1N1+MG on Day 7 post-infant-inoculation by IHC. IHC analysis of paraffin-embedded mammary sections from nursing-mothers of infected infants stained with STAT5 or STAT3 antibodies were visualized using an Aperio ScanScope XT, Leica Biosystems, Nußloch, Germany for high resolution scans. The inset picture shows a magnification of the scanned image to show cellular detail. Scale bars indicate 100 μm or 10 μm. The images show a representative of mammary glands collected from infant intranasal virus or mock inoculations (three inoculations each).</p

2009 H1N1 virus positive mammary glands have distinct genetic signatures linked to the regulation of milk production, cancer and immune responses.

<p>A clustergram of the global expression analysis of H1N1+ MGs is shown and the most prominent functional groups are indicated for each cluster (<b>A</b>). Clustergrams of H1N1+ MG gene expression for specific signaling pathways and gene networks were produced (described in methods) (<b>B</b>). Immune Responses were analyzed by comparing the genes expression profiles of 2009 H1N1 infected Adult Ferret Lungs against the H1N1+ MGs (<b>C</b>). Clustergrams for immune response analysis were generated with genes exhibiting statistically significant differential regulation in either ferret mammary glands or lungs. Gene enrichment scores for KEGG-defined signaling cascades among significantly upregulated (red) and downregulated (red) gene subsets at Days 3/4 and Days 6/7 are shown (<b>D</b>). Values above threshold (α = 0.05) indicate statistically significant enrichment among upregulated or downregulated gene subsets at a given time-point. Samples were collected and analyzed from 3 independent litter experiments of inoculated/infected infants and 3 mothers per time point.</p

Virus replication and pathology in mammary glands of mothers nursing 2009 H1N1-infected infants.

<p>Infant ferrets were intranasally inoculated with A/Cal and housed with mother ferrets for a 7 Day time course where mammary glands, milk, blood, and feces were collected as shown in the schematic (<b>A</b>). Live virus was quantified by MDCK titration of homogenized mammary tissue (<b>B</b>), nipples (<b>C</b>), and expressed milk (<b>D</b>) from nursing-mothers of intranasal inoculated infant ferrets. qRT-PCR was performed on expressed milk for 2009 H1N1 viral RNA (vRNA) (<b>E</b>). Viral presence was also determined by qRT-PCR in infant feces (post-direct-inoculation) (<b>F</b>) and infant, mother, and adult ferret blood (3/4 days post-inoculation) (<b>G</b>). ND = Not Detected. Samples were collected and analyzed from at least 3 independent litter inoculated/infected infants and 3 mothers per time point. Results show the mean or are representative of 3 litters per time point. Mother ferrets have variable numbers of active mammary glands per pregnancy/postpartum.</p