Tocilizumab improves survival in severe COVID-19 pneumonia with persistent hypoxia: a retrospective cohort study with follow-up from Mumbai, India.

BACKGROUND: Cytokine storm triggered by Severe Coronavirus Disease 2019 (COVID-19) is associated with high mortality. With high Interleukin -6 (IL-6) levels reported in COVID-19 related deaths in China, IL-6 is considered to be the key player in COVID-19 cytokine storm. Tocilizumab, a monoclonal antibody against IL-6 receptor, is used on compassionate grounds for treatment of COVID-19 cytokine storm. The aim of this study was to assess effect of tocilizumab on mortality due to COVID-19 cytokine storm. METHOD: This retrospective, observational study included patients of severe COVID-19 pneumonia with persistent hypoxia (defined as saturation 94% or less on supplemental Oxygen of 15 L per minute through non-rebreathing mask or PaO2/FiO2 ratio of less than 200) who were admitted to a tertiary care center in Mumbai, India, between 31st March to 5th July 2020. In addition to standard care, single Inj. Tocilizumab 400 mg was given intravenously to 151 consecutive COVID-19 patients with persistent hypoxia, from 13th May to 5th July 2020. These 151 patients were retrospectively analysed and compared with historic controls, ie consecutive COVID-19 patients with persistent hypoxia, defined as stated above (N = 118, from our first COVID-19 admission on 31st March to 12th May 2020 i.e., till tocilizumab was available in hospital). Univariate and multivariate Cox regression analysis was performed for identifying predictors of survival. Statistical analysis was performed using IBM SPSS version 26. RESULTS: Out of 269 (151 in tocilizumab group and 118 historic controls) patients studied from 31st March to 5th July 2020, median survival in the tocilizumab group was significantly longer than in the control group; 18 days (95% CI, 11.3 to 24.7) versus 9 days (95% CI, 5.7 to 12.3); log rank p 0.007. On multivariate Cox regression analysis, independent predictors of survival were use of tocilizumab (HR 0.621, 95% CI 0.427-0.903, P 0.013) and higher oxygen saturation. CONCLUSION: Tocilizumab may improve survival in severe COVID-19 pneumonia with persistent hypoxia. Randomised controlled trials on use of tocilizumab as rescue therapy in patients of severe COVID-19 pneumonia with hypoxia (PaO2/FiO2 less than 200) due to hyperinflammatory state, are warranted.

Incidence and outcome of ventilator associated pneumonia.

BACKGROUND: Ventilator associated pneumonia (VAP) is one of the commonest infection acquired in intensive care unit. VAP is associated with increased patients mortality and morbidity. Many cases of VAP may be prevented by simple preventive strategies. AIMS AND OBJECTIVES: To note the incidence and outcome of patients with VAP. METHOD AND MATERIAL: Total 203 Patients, admitted over the period of 6 months from 1st July 2010 to 31st December 2010, requiring mechanical ventilator were studied. Disease profile and demography of the patients were studied. Ventilator associated complications were noted by treating intensivists. Mini brochoalveolar lavage were sent for culture and sensitivity testing. Incidence of VAP in patients with ALI (Acute lung injury) and ARDS (acute respiratory distress Syndrome) and without ALI and ARDS were noted. We also noted the incidence of other common complications like barotraumas and deep vein thrombosis/pulmonary embolism. RESULTS: A total of 203 patients were studied. Undifferentiated fever was the commonest diagnosis followed by malaria in our patients. 49 patients required mechanical ventilation for acute lung injury and 110 patients required for acute respiratory distress syndrome due to variety of etiologies. VAP developed in 19 of total patients. CONCLUSIONS: Careful monitoring, MiniBAL sample surveillance and implementation of VAP bundles are important in preventing and for early diagnosis of complications of mechanical ventilators. Non Invasive Ventilation is associated with far less complications as compared to invasive ventilators.