Daily tenofovir disoproxil fumarate/emtricitabine and hydroxychloroquine for pre-exposure prophylaxis of COVID-19: a double-blind placebo-controlled randomized trial in healthcare workers

OBJECTIVES

To assess the effect of hydroxychloroquine (HCQ) and Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis on COVID-19 risk.

METHODS

EPICOS is a double-blind, placebo-controlled randomized trial conducted in Spain, Bolivia, and Venezuela. Healthcare workers with negative SARS-CoV-2 IgM/IgG test were randomly assigned to the following: daily TDF/FTC plus HCQ for 12 weeks, TDF/FTC plus HCQ placebo, HCQ plus TDF/FTC placebo, and TDF/FTC placebo plus HCQ placebo. Randomization was performed in groups of four. Primary outcome was laboratory-confirmed, symptomatic COVID-19. We also studied any (symptomatic or asymptomatic) COVID-19. We compared group-specific 14-week risks via differences and ratios with 95% CIs.

RESULTS

Of 1002 individuals screened, 926 (92.4%) were eligible and there were 14 cases of symptomatic COVID-19: 220 were assigned to the TDF/FTC plus HCQ group (3 cases), 231 to the TDF/FTC placebo plus HCQ group (3 cases), 233 to the TDF/FTC plus HCQ placebo group (3 cases), and 223 to the double placebo group (5 cases). Compared with the double placebo group, 14-week risk ratios (95% CI) of symptomatic COVID-19 were 0.39 (0.00-1.98) for TDF + HCQ, 0.34 (0.00-2.06) for TDF, and 0.49 (0.00-2.29) for HCQ. Corresponding risk ratios of any COVID-19 were 0.51 (0.21-1.00) for TDF + HCQ, 0.81 (0.44-1.49) for TDF, and 0.73 (0.41-1.38) for HCQ. Adverse events were generally mild.

DISCUSSION

The target sample size was not met. Our findings are compatible with both benefit and harm of pre-exposure prophylaxis with TDF/FTC and HCQ, alone or in combination, compared with placebo.

Intestinal Spirochetosis in an HIV-positive Patient

We present the case of an HIV-positive patient admitted because of costal pain secondary to neoplasia. During investigations, a colonoscopy showed non-specific ulcerations. Histological examination resulted in a diagnosis of intestinal spirochetosis. This infection can be asymptomatic or cause non-specific symptoms such as diarrhoea or abdominal pain. Intestinal spirochetosis should be included in the differential diagnosis of colon lesions in patients with HIV infection.

LEARNING POINTS

Intestinal spirochetosis is associated with chronic diarrhoea and often with normal colonoscopy.This infection should be included in the differential diagnosis of HIV patients with digestive symptomatology in the absence of other more frequent causes.

Generation and validation of in-hospital mortality prediction score in COVID-19 patients: Alba-score

BACKGROUND

COVID-19 has a wide range of symptoms reported, which may vary from very mild cases (even asymptomatic) to deadly infections. Identifying high mortality risk individuals infected with the SARS-CoV-2 virus through a prediction instrument that uses simple clinical and analytical parameters at admission can help clinicians to focus on treatment efforts in this group of patients.

METHODS

Data was obtained retrospectively from the electronic medical record of all COVID-19 patients hospitalized in the Albacete University Hospital Complex until July 2020. Patients were split into two: a generating and a validating cohort. Clinical, demographical and laboratory variables were included. A multivariate logistic regression model was used to select variables associated with in-hospital mortality in the generating cohort. A numerical and subsequently a categorical score according to mortality were constructed (A: mortality from 0% to 5%; B: from 5% to 15%; C: from 15% to 30%; D: from 30% to 50%; E: greater than 50%). These scores were validated with the validation cohort.

RESULTS

Variables independently related to mortality during hospitalization were age, diabetes mellitus, confusion, SaFiO2, heart rate and lactate dehydrogenase (LDH) at admission. The numerical score defined ranges from 0 to 13 points. Scores included are: age ≥71 years (3 points), diabetes mellitus (1 point), confusion (2 points), onco-hematologic disease (1 point), SaFiO2 ≤ 419 (3 points), heart rate ≥ 100 bpm (1 point) and LDH ≥ 390 IU/L (2 points). The area under the curve (AUC) for the numerical and categorical scores from the generating cohort were 0.8625 and 0.848, respectively. In the validating cohort, AUCs were 0.8505 for the numerical score and 0.8313 for the categorical score.

CONCLUSIONS

Data analysis found a correlation between clinical admission parameters and in-hospital mortality for COVID-19 patients. This correlation is used to develop a model to assist physicians in the emergency department in the COVID-19 treatment decision-making process.

What do beta-lactams add to vancomycin or daptomycin in the treatment of patients with methicillin-resistant Staphylococcus aureus bacteraemia? A review

Several studies have documented the synergy between vancomycin/daptomycin and various beta-lactams, and clinical studies have studied this combination therapy in humans. We review the published literature on this topic to know the utility of the combined treatment with beta-lactams in treating bacteraemia methicillin-resistant Staphylococcus aureus (MRSA) infections. Fifteen observational studies, three randomised clinical trials and three systematics reviews are analysed in this article. Observational studies used ceftaroline, cefazolin, piperacillin/tazobactam or cefepime among the beta-lactams. Clinical trials used cloxacillin or flucloxacillin as the most used beta-lactam in two trials and ceftaroline in one. Three systematic reviews are published. One of them only includes studies with vancomycin and included six studies. The other two systematic reviews include patients with daptomycin or vancomycin and included 15 and 9 studies, respectively. Adding a beta-lactam to vancomycin or daptomycin may help shorten bacteraemia and avoid recurrences in patients with MRSA bacteraemia. There is no evidence that combined therapy improves mortality. Nephrotoxicity in clinical trials precludes the use of combination therapy mainly with cloxacillin or flucloxacillin, but systematic reviews have not found a significant difference in this point in observational studies with other beta-lactams. The role of other beta-lactams such as ceftaroline should be thoroughly studied in these patients.

Childhood acute lymphoblastic leukemia: prognostic value of initial peripheral blast count in good responders to prednisone

PURPOSE

To assess the value of initial peripheral blast count in patients with acute lymphoblastic leukemia (ALL) and prednisone good response (PGR).

PATIENTS AND METHODS

From January 1990 to December 1995, 403 consecutive patients with newly diagnosed ALL were enrolled in the authors' protocol 1-ALL90-BFM/HPG. Prednisone good response was defined as a blast count of less than 1,000/microL and a prednisone poor response (PPR) as a blast count of at least 1,000/microL, both in peripheral smears, after 7 days of oral prednisone (60 mg/m2 per day) and one intrathecal dose of methotrexate. In the PGR group, patients were divided into two subgroups: patients who had less than 1,000 blasts/microL at diagnosis and those with at least 1,000 blasts/microL at diagnosis.

RESULTS

Three-hundred thirty-seven patients (90%) had PGR and 37 had (10%) PPR. At 5-year follow-up, event-free survival estimates were 67 +/- 3.8% and 38 +/- 8% for PGR and PPR, respectively (P = 0.0001). In the PGR group, 114 patients (34%) had an initial blast count of less than 1,000/microL and 223 (66%) had an initial blast count of at least 1,000/microL. The authors compared the clinical and laboratory characteristics of these subgroups at diagnosis and outcome and detected significant differences in white cell count, incidence of T immunophenotype, and presence of mediastinal or spleen enlargement. However, there were no differences in response to induction treatment, death in complete remission, relapses, or event-free survival probability.

CONCLUSIONS

In the PGR group, regardless of the initial blast count, both subgroups had the same outcome. The PGR group with an initial blast count of at least 1,000/microL had significantly higher white cell counts. T markers, and mediastinal or spleen enlargement at diagnosis. Response to prednisone is a practical, inexpensive, and good prognostic factor in childhood ALL.

Good outcome of children with acute myeloid leukemia and t(8;21)(q22;q22), even when associated with granulocytic sarcoma: a report from a single institution in Argentina

BACKGROUND

The association between t(8;21) and granulocytic sarcoma (GS) is well known, but to the authors' knowledge the prognostic significance of GS in these patients has not been defined clearly.

METHODS

Between January 1990 and July 1999 174 children with acute myeloid leukemia were admitted to the study institution. Translocation (8;21) was identified in 20 patients (11.5%). Eighteen patients were evaluable for the current study and 8 presented with GS at the time of diagnosis (GS+).

RESULTS

The authors defined two groups of patients: those who were GS+ and those who were GS-. One patient in the GS+ group and two patients in the GS- group died during the induction phase of the study. Complete remission was achieved in seven patients in the GS+ group and eight patients in the GS- group. Two patients developed a recurrence in the GS+ group as did one patient in the GS- group. The event free-survival probability (the standard error) was 58% (18%) in the GS+ group and 70% (14%) in the GS- group. Localization of GS was in only one site in seven patients and at multiple sites in one patient. Patients with an epidural mass received local radiotherapy (one patient) or surgery (two patients). Two of these patients developed paraplegia as sequelae: one patient after surgery and one patient after radiotherapy. One patient with orbital GS received local radiotherapy because of progressive proptosis. The remaining four patients had a complete resolution of the GS with chemotherapy only.

CONCLUSIONS

In the current study of patients with t(8;21)(q22;q22), the presence of granulocytic sarcoma was not found to be an adverse prognostic factor. However, careful attention should be paid, especially to patients with an epidural site, to avoid sequelae. Chemotherapy appears to be the optimum treatment for these children.