Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

NICE neonatal early onset sepsis guidance:greater consistency, but more investigations, and greater length of stay

BACKGROUND: In August 2012, new national guidance (National Institute of Health and Care Excellence (NICE) CG149) for management of early onset sepsis (EOS) was introduced in the UK. The guidance outlined a consistent approach for septic screens in newborn infants based on risk factors, and suggested biochemical and clinical parameters to guide management. In particular, it advised a second C-reactive protein level (CRP) 18-24 h into treatment to help determine length of antibiotic course, need for lumbar puncture (LP), and suggested review of blood culture at 36 h.OBJECTIVE: We evaluated impact of this guidance in our neonatal unit.METHODS: We compared two time periods, before and following the guidance. We evaluated length of stay, second CRP 18-24 h into treatment, percentage of babies having LP and duration of antibiotics.RESULTS: Before NICE guidance, 38.1% of screened babies stayed &lt;72 h. This reduced to 18.4% following guidance. Before guidance, 20.9% babies stayed &gt;5 days, which increased to 27.7% following NICE recommendations. Repeat CRP measurements increased from 45% to 97%. In 58% of these babies, repeat CRPs influenced management and hospital stay. An increase in LPs performed from 14% to 23% was noted. There were no positive blood cultures or LP results.CONCLUSIONS: We envisaged shorter hospital stays with new NICE standards, particularly, with the aim of 36 h blood culture reporting. However, repeat CRP led to further investigations, increased LPs and longer durations of treatment and stay. This, in turn, impacted on workload and cost, and influenced parental experience in the first few days of life.</p

A Genome-Wide Association Study of Respiratory Syncytial Virus Infection Severity in Infants

Background. Respiratory syncytial virus (RSV) is a significant cause of infant morbidity and mortality worldwide. Most children experience at least one 1 RSV infection by the age of two 2 years, but not all develop severe disease. However, the understanding of genetic risk factors for severe RSV is incomplete. Consequently, we conducted a genome-wide association study of RSV severity. Methods. Disease severity was assessed by the ReSVinet scale, in a cohort of 251 infants aged 1 week to 1 year. Genotyping data were collected from multiple European study sites as part of the RESCEU Consortium. Linear regression models were used to assess the impact of genotype on RSV severity and gene expression as measured by microarray. Results. While no SNPs reached the genome-wide statistical significance threshold (P < 5 × 10−8), we identified 816 candidate SNPs with a P-value of <1 × 10−4. Functional annotation of candidate SNPs highlighted genes relevant to neutrophil trafficking and cytoskeletal functions, including LSP1 and RAB27A. Moreover, SNPs within the RAB27A locus significantly altered gene expression (false discovery rate, FDR P < .05). Conclusions. These findings may provide insights into genetic mechanisms driving severe RSV infection, offering biologically relevant information for future investigations

A genome-wide association study of respiratory syncytial virus infection severity in infants

Respiratory syncytial virus (RSV) is a significant cause of infant morbidity and mortality worldwide; however, understanding the genetic risk factors of severe RSV is incomplete. Neutrophils and monocytes have been previously identified as major cell subsets involved in airway inflammation, however the pathophysiology of these events is also not fully characterised. Given that the majority of children experience at least one RSV infection by the age of two years, but not all develop severe disease, we used genomic and transcriptomic data to explore potential mechanistic biomarkers of disease severity. We conducted a genome-wide association study (GWAS) to investigate the genetic factors underlying RSV severity, assessed by the ReSVinet scale, in a cohort of 251 infants aged from 1 week old to 1 year of age. Genotyping data was collected from multiple European study sites as part of the RESCEU Consortium. Data and were analysed following quality control and genotype imputation using the TOPMed server. Generalised linear regression models were employed to assess the impact of genotype on RSV severity. Matrix eQTL in R was used to model the impact of candidate SNPs genotype on gene expression as measured by microarray. While no SNPs reached the genome-wide statistical significance threshold (p < 5 × 10-8), we identified 816 candidate SNPs with a p-value of < 1 × 10-4 and 75 SNPs with a p-value of < 1 × 10-5. Subsequent functional annotation of candidate SNPs highlighted variants previously identified in GWAS studies of inflammatory diseases, and genes relevant to neutrophil trafficking and cytoskeletal functions, including LSP1 and RAB27A. Furthermore, the eQTL analysis revealed that SNPs within the RAB27A locus significantly altered gene expression (FDR p < 0.05). These findings may provide insights into genetic mechanisms driving severe RSV infection, offering biologically relevant information for future investigations