IVIG Compared With IVIG Plus Infliximab in Multisystem Inflammatory Syndrome in Children

OBJECTIVES

To compare initial treatment with intravenous immunoglobulin (IVIG) versus IVIG plus infliximab in multisystem inflammatory syndrome in children (MIS-C).

METHODS

Single-center retrospective cohort study of patients with MIS-C who met Centers for Disease Control and Prevention criteria and received treatment from April 2020 to February 2021. Patients were included and compared on the basis of initial therapy of either IVIG alone or IVIG plus infliximab. The primary outcome was need for additional therapy 24 hours or more after treatment initiation.

RESULTS

Seventy-two children with MIS-C met inclusion criteria. Additional therapy was needed in 13 of 20 (65%) who received IVIG alone and 16 of 52 (31%) who received IVIG plus infliximab (P = .01). The median (interquartile range) ICU lengths of stay were 3.3 (2.2 to 3.8) and 1.8 (1.1 to 2.1) days, respectively (P = .001). New or worsened left ventricular dysfunction developed in 4 of 20 (20%) and 2 of 52 (4%) (P = .05), and new vasoactive medication requirement developed in 3 of 20 (15%) and 2 of 52 (4%), respectively (P = .13). The median percentage changes in the C-reactive protein level at 24 hours posttreatment compared with pretreatment were 0% (-29% to 66%) and -46% (-62% to -15%) (P < .001); and at 48 hours posttreatment, -5% (-41% to 57%) and -70% (-79% to -49%) respectively (P < .001). There was no significant difference in hospital length of stay, time to fever resolution, vasoactive medication duration, or need for diuretics.

CONCLUSIONS

Patients with MIS-C initially treated with IVIG plus infliximab compared with those treated with IVIG alone were less likely to require additional therapy and had decreased ICU length of stay, decreased development of left ventricular dysfunction, and more rapid decline in C-reactive protein levels.

Quality assurance and outcomes in outpatient parenteral antibiotic therapy

The quality improvement process in outpatient parenteral antibiotic therapy (OPAT) is driven by outcome measurement. Collection and analysis of outcome data will be an essential component of an OPAT program. Data collected must be measurable, consistently defined and transformed through analysis into understandable results that can be used to improve care.

Ceftriaxone compared with doxycycline for the treatment of acute disseminated Lyme disease

BACKGROUND

Localized Lyme disease, manifested by erythema migrans, is usually treated with oral doxycycline or amoxicillin. Whether acute disseminated Borrelia burgdorferi infection should be treated differently from localized infection is unknown.

METHODS

We conducted a prospective, open-label, randomized, multicenter study comparing parenteral ceftriaxone (2 g once daily for 14 days) with oral doxycycline (100 mg twice daily for 21 days) in patients with acute disseminated B. burgdorferi infection but without meningitis. The erythema migrans skin lesion was required for study entry, and disseminated disease had to be indicated by either multiple erythema migrans lesions or objective evidence of organ involvement.

RESULTS

Of 140 patients enrolled, 133 had multiple erythema migrans lesions. Both treatments were highly effective. Rates of clinical cure at the last evaluation were similar among the patients treated with ceftriaxone (85 percent) and those treated with doxycycline (88 percent); treatment was considered to have failed in only one patient in each group. Among patients whose infections were cured, 18 of 67 patients in the ceftriaxone group (27 percent) reported one or more residual symptoms at the last follow-up visit, as did 10 of 71 patients in the doxycycline group (14 percent, P > or = 0.05). Mild arthralgia was the most common persistent symptom. Both regimens were well tolerated; only four patients (6 percent) in each group withdrew because of adverse events.

CONCLUSIONS

In patients with acute disseminated Lyme disease but without meningitis, oral doxycycline and parenterally administered ceftriaxone were equally effective in preventing the late manifestations of disease.

Outpatient parenteral antibiotic therapy. Management of serious infections. Part I: Medical, socioeconomic, and legal issues. Quality assurance

At present, there are no accepted guidelines for quality assurance in the outpatient setting, although they are being developed. Greater emphasis is being placed on ongoing rather than retrospective improvement of quality, as measured by the care-giving process and outcome. Thus, programs need to incorporate sound methods for teamwork, communication, and documentation of services.

Norfloxacin use in urinary tract infection by urologists and infectious disease specialists

One hundred thirty-one patients of urologists and infectious disease specialists were entered into an open trial of norfloxacin in the therapy of urinary tract infections (UTIs). All patients were evaluable for tolerability and 98 were evaluable for efficacy. The patient population in this study was older (mean age 53 years) and had more underlying urogenital disorders (30%) or recent invasive urologic procedures (20%) than the typical patient population with UTIs. Over 50% of the patients had infections due to organisms other than Escherichia coli, including Pseudomonas aeruginosa (14), Klebsiella pneumoniae (5), Enterobacter spp (3) and Group D streptococcus (6). Clinical and bacteriologic cure rates were 90 and 91%, respectively. Side effects occurred in 5 patients and were generally mild.

Imipenem/cilastatin: general experience in a community hospital

Imipenem/cilastatin is a new carbapenem antibiotic with broad spectrum antimicrobial activity. Forty two patients with infections of various types, including skin and soft tissue, respiratory tract, bone and joint, and urinary tract, were treated with this antibiotic in an open noncomparative study. Clinical responses to therapy were excellent and failures were only encountered with infections caused by Pseudomonas aeruginosa strains that developed resistance during therapy. Superinfection rates were minimal as were toxicities. Imipenem/cilastatin appears to be a relatively safe and highly effective broad spectrum antibiotic.

Cefonicid in a once-daily regimen for treatment of osteomyelitis in an ambulatory setting

Fifteen patients with bone joint infections were treated with 1.0 g of cefonicid administered intravenously or intramuscularly once daily. Single organisms isolated included Staphylococcus aureus (from six patients), Staphylococcus epidermidis (three), and Peptococcus species (one). For four patients infection was polymicrobial, and for one patient no organism was isolated. The mean duration of therapy was 40.4 days, only 10.9 days of which were spent in the hospital. The remainder of therapy was administered intramuscularly in an ambulatory setting. Therapy was successful in all 12 assessable patients. No clinical or bacteriologic relapse occurred in the follow-up period of three to 13 months. The occurrence of adverse effects prompted discontinuation of cefonicid therapy in three patients. Minimum savings in hospital-bed costs alone were $64,350, with 390 hospital days avoided. The minimum savings in work income were $10,010, with 182 days of absenteeism avoided. These data are preliminary but suggest efficacy of cefonicid in a mode of therapy that could have profound cost benefits.