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

Background: In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg–800 mg (depending on weight) given intravenously. A second dose could be given 12–24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). Findings: Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76–0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12–1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77–0·92; p<0·0001). Interpretation: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research

Some problems associated with the identification of Corynebacterium equi

One hundred strains of Corynebacterium equi were examined using standard laboratory procedures. Variations in colonial morphology were noted. The ability to reduce nitrate and to produce urease was shown to be valuable for confirmation of identification of C. equi. Production of hydrogen sulphide was a variable characteristic of C. equi. It is concluded that for those situations where the source of the organism gives no clue as to its identify, positive identification of C. equi may be difficult because of variability in colonial appearance and biochemical reactions

The immunological response of foals to Rhodococcus equi: A review

• Normal horses of all ages regularly show evidence of having responded immunologically to R. equi, thus adding serological support to epidemiological evidence that this organism is a normal intestinal inhabitant. More animals from "diseased" farms show a stronger antibody response when compared with foals from "healthy" farms. • Various serological tests have been used to detect evidence of infection and to release antibody level to severity of disease. Anti-R. equi IgG antibody levels, as measured by ELISA, are raised significantly during natural infection. Clinical severity of pneumonia can be correlated with lower specific antibody responses. Following experimental infection, immunological responses can be detected by complement fixation, indirect immunofluorescence, ELISA, lymphocyte blastogenesis and skin testing. • Very little work has been carried out to evaluate vaccines against R. equi infection and results have not been encouraging. Success in treatment has been reported following passive immunisation. Administration of immune leucocyte extracts has had no effect on morbidity or mortality rates. • The widespread distribution of this organism, together with the relative infrequency of disease caused by it, suggest that R. equi may initiate infection only in such circumstances as a very high infectious challenge, immunological immaturity or deficiency in the host and genetic predisposition