Prevention of congenital syphilis using ceftriaxone in a woman with Stevens-Johnson syndrome reaction to penicillin: A case report.

Introduction: The purpose of this report is to increase awareness of ceftriaxone as an alternative therapy for the prevention of congenital syphilis (CS) when the mother is allergic to penicillin, especially when desensitization to penicillin cannot be performed or is unsafe. Case: A 37-year-old pregnant woman who was syphilis positive reacted to penicillin with Stevens-Johnson syndrome (SJS); her rapid plasma reagin (RPR) was 1:64 at presentation to the infectious disease clinic. CS was prevented with two courses of ceftriaxone: 10 days 1 g IV daily at week 12 followed by 10 days of 250 mg IM daily at week 28 achieved a 4-fold fall in RPR titer to 1:16, indicating cure. Full work-up of the neonate according to the guidelines of the American Academy of Pediatrics (AAP) when penicillin is not used in the mother was conducted at birth. In addition to physical exam, syphilis antibodies in blood had an undetectable RPR, a lumbar puncture produced normal cerebrospinal fluid (CSF), and roentgenography of long bones was normal. The child was administered 50,000 units/kg of benzathine penicillin intramuscularly. There were no concerns for allergy or sequela in the mother or neonate at 2-month follow-up with the pediatrician. Conclusion: The goal of this report is to increase awareness of ceftriaxone as an alternative to penicillin in the prevention of CS and to raise the possibility of adjusting AAP guidelines accordingly. However, studies to determine the best route and timing of therapy are necessary.

Tocilizumab: A retrospective multi-center cohort study of critically ill patients with COVID-19.

BACKGROUND: Coronavirus disease 19 (COVID-19) can have a severe presentation characterized by a dysregulated immune response requiring admission to the intensive care unit (ICU). Immunomodulatory treatments like tocilizumab were found to improve inflammatory markers and lung injury over time. We aim to evaluate the effectiveness of tocilizumab treatment on critically ill patients with severe COVID-19. MATERIALS AND METHODS: We conducted a multi-center retrospective cohort study of 154 adult patients admitted to the ICU for severe COVID-19 pneumonia between March 15 and May 8, 2020. Data were obtained by electronic medical record (EMR) review. The primary outcome of interest was mortality. RESULTS: Of 154 patients, 34 (21.4%) received tocilizumab. Compared to the non-treated group, the treated group was significantly younger, had fewer comorbidities, lower creatinine and procalcitonin levels, and higher alanine aminotransferase levels on admission. The treated group was more likely to receive supportive measures in the context of critical illness. The overall case fatality rate was 71.4%, and it was significantly lower in the treated than the non-treated (52.9 vs. 76.7%, p = 0.007). In multivariable survival analysis, tocilizumab treatment was associated with a 2.1 times lower hazard of mortality when compared to those who were not treated (hazard ratio: 0.47; 95% CI: 0.27, 0.83; p = 0.009). The prevalence of secondary infection was higher in the treated group compared to the non-treated without significant difference (p = 0.17). CONCLUSION: Tocilizumab treatment for critically ill patients with COVID-19 resulted in a lower likelihood of mortality.

Clinical Features and Risk Factors for In-Hospital Mortality From COVID-19 Infection at a Tertiary Care Medical Center, at the Onset of the US COVID-19 Pandemic.

BACKGROUND: Mortality from COVID-19 has been associated with older age, black race, and comorbidities including obesity, Understanding the clinical risk factors and laboratory biomarkers associated with severe and fatal COVID-19 will allow early interventions to help mitigate adverse outcomes. Our study identified risk factors for in-hospital mortality among patients with COVID-19 infection at a tertiary care center, in Detroit, Michigan. METHODS: We conducted a single-center, retrospective cohort study at a 776-bed tertiary care urban academic medical center. Adult inpatients with confirmed COVID-19 (nasopharyngeal swab testing positive by real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay) from March 8, 2020, to June 14, 2020, were included. Clinical information including the presence of comorbid conditions (according to the Charlson Weighted Index of Comorbidity (CWIC)), initial vital signs, admission laboratory markers and management data were collected. The primary outcome was in-hospital mortality. RESULTS: Among 565 hospitalized patients, 172 patients died for a case fatality rate of 30.4%. The mean (SD) age of the cohort was 64.4 (16.2) years, and 294 (52.0%) were male. The patients who died were significantly older (mean [SD] age, 70.4 [14.1] years vs 61.7 [16.1] years; P < 0.0001), more likely to have congestive heart failure (35 [20.3%] vs 47 [12.0%]; P = 0.009), dementia (47 [27.3%] vs 48 [12.2%]; P < 0.0001), hemiplegia (18 [10.5%] vs 18 [4.8%]; P = 0.01) and a diagnosis of malignancy (16 [9.3%] vs 18 [4.6%]; P = 0.03).From multivariable analysis, factors associated with an increased odds of death were age greater than 60 years (OR = 2.2, P = 0.003), CWIC score (OR = 1.1, P = 0.023), qSOFA (OR = 1.7, P < 0.0001), WBC counts (OR = 1.1, P = 0.002), lymphocytopenia (OR = 2.0, P = 0.003), thrombocytopenia (OR = 1.9, P = 0.019), albumin (OR = 0.6, P = 0.014), and AST levels (OR = 2.0, P = 0.004) on admission. CONCLUSIONS: This study identified risk factor for in-hospital mortality among patients admitted with COVID-19 in a tertiary care hospital at the onset of U.S. Covid-19 pandemic. After adjusting for age, CWIC score, and laboratory data, qSOFA remained an independent predictor of mortality. Knowing these risk factors may help identify patients who would benefit from close observations and early interventions.

Staphylococcus aureus Descending Necrotizing Mediastinitis in a Healthy Adult.

Descending necrotizing mediastinitis (DNM) is a severe form of mediastinitis with high mortality rates due to the rapid progression of infection into the mediastinum through tissue planes, often from a dental or pharyngeal source. We present a case of monomicrobial methicillin-resistant Staphylococcus aureus DNM in a healthy young man who was initially misdiagnosed with strep throat. This is well described in the pediatric literature; however, DNM in adults is typically polymicrobial and occurs in those with comorbidities such as diabetes mellitus and older age. Survival is excellent with early identification of mediastinitis, prompt surgical intervention, and appropriate antibiotics.