Re-Evaluating Cross-Contamination: Additional Trials on Co-Ventilation.

BACKGROUND: Medical equipment can become scarce in disaster scenarios. Prior work has reported that four sheep could be ventilated together on a single ventilator. Others found that this maneuver is possible when needed, but no one has yet investigated whether cross-contamination occurs in co-ventilated individuals. OBJECTIVE: Our goal was to investigate whether an infection could spread between co-ventilated individuals. METHODS: Four 2-L anesthesia bags were connected to a sterilized ventilator circuit that used heat and moisture exchange filters and bacterial and viral filters, as would be expected in this dire scenario. Serratia marcescens was inoculated into "lung" no. 1. After running for 24 h, each lung and three additional points in the circuit were cultured to see whether S. marcescens had spread. These cultures were examined at 24 and 48 h to assess for cross-contamination. This entire procedure was performed three times. RESULTS: S. marcescens was not found in lung no. 2, 3, or 4 or the three additional sites on the expiratory limb at 24 and 48 h in all three trials. CONCLUSIONS: Cross-contamination does not occur within 24 h using the described ventilator circuit configuration.

Reportable infections following colon surgery in a large public healthcare system in New York City: The consequences of being a level 1 trauma center.

OBJECTIVES: To examine differences in risk factors and outcomes of patients undergoing colon surgery in level 1 trauma centers versus other hospitals and to investigate the potential financial impact of these reportable infections. DESIGN: Retrospective cohort study between 2015 and 2022. SETTING: Large public healthcare system in New York City. PARTICIPANTS: All patients undergoing colon surgery; comparisons were made between (1) all patients undergoing colon surgery at the level 1 trauma centers versus patients at the other hospitals and (2) the nontrauma and trauma patients at the level 1 trauma centers versus the nontrauma patients at other hospitals. RESULTS: Of 5,217 colon surgeries reported, 3,531 were at level 1 trauma centers and 1686 at other hospitals. Patients at level 1 trauma centers had significantly increased American Society of Anesthesiology (ASA) scores, durations of surgery, rates of delayed wound closure, and rates of class 4 wounds, resulting in higher SIRs (1.1 ± 0.15 vs 0.75 ± 0.18; P = .0007) compared to the other hospitals. Compared to the nontrauma patients at the other hospitals, both the nontrauma and trauma patients at the level 1 trauma centers had higher ASA scores, rates of delayed wound closure, and of class 4 wounds. The SIRs of the nontrauma patients (1.16 ± 1.29; P = .008) and trauma patients (1.26 ± 2.69; P = .066) at the level 1 trauma center were higher than the SIRs of nontrauma patients in the other hospitals (0.65 ± 1.18). CONCLUSIONS: Patients undergoing colon surgery at level 1 trauma centers had increased complexity of surgery compared to the patients in other hospitals. Until there is appropriate adjustment for these risk factors, the use of infections following colon surgery as a reportable quality measure should be re-evaluated.

Reduction in catheter-associated urinary tract infections following a diagnostic stewardship intervention.

Catheter-associated urinary tract infections (CAUTIs) are a frequent hospital-acquired infection and public health concern. In an attempt to reduce the number of CAUTIs, an intervention that emphasized the appropriate laboratory evaluation by ordering providers was implemented. This intervention supplemented ongoing standard bundle protocols. Compared to the 16 months before the intervention, there was a significant decrease in the number of CAUTIs during the 12-month intervention period.

Do risk adjustment calculations used by governmental agencies adequately assess risk for infection after colon surgery?

BACKGROUND: Surgical site infections (SSIs) following colon surgery are associated with clinical and financial consequences. The Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) use risk adjustment variables to determine quality measure scores. METHODS: Among patients in a large public system, surgical risk variables were compared between patients with and without SSIs. Propensity score matching, using CMS and NYSDOH risk variables, created control groups. Receiver Operating Characteristics (ROC) curves were created using current and augmented risk adjustment variables. RESULTS: When matched using CMS risk variables, more patients with SSIs had contaminated/dirty wounds, longer duration of surgery, and emergency surgery. The addition of these variables significantly improved the CMS ROC curve. When matching NYSDOH variables, more SSI patients were male, had contaminated/dirty wounds, and tended to be younger. The addition of these variables to the current NYSDOH adjustment criteria did not significantly improve the ROC curve. DISCUSSION: The CMS adjustment criteria for colon SSIs do not adequately account for complicated surgeries. The inclusion of additional variables significantly improved the performance of CMS risk adjustment. CONCLUSIONS: Until more robust risk adjustment criteria are developed, the reporting of SSIs following colon surgery as a quality measure should be suspended.

Impact of Prophylactic Antibiotic Selection on the Prevention and Bacterial Flora of Surgical Site Infections After Colorectal Surgery.

Background: Deep incisional and organ/space surgical site infections (SSIs) after colorectal surgery are associated with adverse outcomes. Multiple antibiotic regimens are recommended for peri-operative prophylaxis, with no particular regimen preferred over another. We compared the prophylaxis regimens used in patients with and without SSIs, and the impact of regimens on the flora involved in SSIs. Patients and Methods: Information was extracted from the National Healthcare Safety Network databank of patients undergoing colorectal surgery from 2015 to 2022 in a large public healthcare system in New York City. Patients with SSIs were identified, and controlling for nine variables, propensity score matching was used to create a matched control group without SSIs. Prophylactic regimens were compared between the matched groups with and without SSIs. Also, for the patients with SSIs, the impact of the prophylactic regimen on the subsequent pathogens involved the infection was examined. Results: A total of 275 patients with SSIs were compared to a matched cohort without SSIs. The prophylactic regimens were extremely similar between the SSI and control groups. Among the patients who developed SSIs, more patients who received cefoxitin had emergence of select cephalosporin-resistant Enterobacterales and Bacteroides spp. when compared with those who received ß-lactam-ß-lactamase inhibitors. Conclusions: The distribution of surgical prophylaxis regimens was remarkably similar between patients developing serious SSIs and a closely matched cohort that did not develop an SSI. However, given the downstream effects of more resistant and anaerobic flora should an infection develop, use of cefoxitin should be re-evaluated as a prophylactic agent.

Carbapenem-Resistant Klebsiella pneumoniae in Large Public Acute-Care Healthcare System, New York, New York, USA, 2016-2022.

Controlling the spread of carbapenem-resistant Enterobacterales is a global priority. Using National Healthcare Safety Network data, we characterized the changing epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) in a large public health system in New York, New York, USA. During 2016-2020, CRKP cases declined; however, during 2021-June 2022, a notable increase occurred. Of 509 cases, 262 (51%) were considered community-onset, including 149 in patients who were living at home. Of 182 isolates with proven or presumptive (ceftazidime/avibactam susceptible) enzymes, 143 were serine carbapenemases; most confirmed cases were K. pneumoniae carbapenemase. The remaining 39 cases were proven or presumptive metallo-ß-lactamases; all confirmed cases were New Delhi metallo-ß-lactamases. After 2020, a marked increase occurred in the percentage of isolates possessing metallo-ß-lactamases. Most patients with metallo-ß-lactamases originated from long-term care facilities. An aggressive and universal program involving surveillance and isolation will be needed to control the spread of CRKP in the city of New York.

Comparison of Tocilizumab vs Baricitinib in Clinical Outcomes Among Hospitalized Patients With COVID-19: Experience From a Public Hospital System in New York City.

Background: Tocilizumab and baricitinib are immunomodulators that have been repurposed for the treatment of coronavirus disease 2019 (COVID-19). Whether one medication should be preferred over the other has not been established. Methods: This multicenter retrospective cohort study comprised hospitalized patients with COVID-19 who received either tocilizumab or baricitinib. The primary outcome was improvement in respiratory status (at least 1-point reduction on the respiratory ordinal scale) at day 7 and up to day 28. Secondary outcomes included mortality, disposition, deep vein thrombosis, pulmonary embolism, or positive blood culture. Outcomes were stratified by baseline respiratory status and variant-predominating periods. Results were reported for the overall and propensity-matched cohorts. Results: A total of 921 patients received tocilizumab and 638 received baricitinib. The propensity-matched cohort included 597 patients in each group. At day 7 in the overall and propensity-matched cohorts, significantly more patients had improvement in respiratory status in the baricitinib group. These improvements were seen in patients requiring supplemental oxygen and noninvasive ventilation/high-flow oxygen but not in patients requiring mechanical ventilation. Favorable outcomes with baricitinib were observed during the Alpha and Omicron periods. By day 28, there were no differences in the changes of respiratory status for the treatment groups in either cohort. Also, no differences were seen in mortality, disposition, development of deep vein thrombosis/pulmonary embolism, or bloodstream infections. Conclusions: Baricitinib treatment was associated with more favorable respiratory improvement at day 7 when compared with tocilizumab, but no differences were observed up to day 28.

Contribution of Iron-Transport Systems and ß-Lactamases to Cefiderocol Resistance in Clinical Isolates of Acinetobacter baumannii Endemic to New York City.

The development of resistance to cefiderocol among multidrug resistant Acinetobacter baumannii has been attributed to downregulation in iron transport systems and a variety of ß-lactamases. However, the precise contribution of each in clinical isolates remains to be determined. Sixteen clinical isolates with varying degrees of cefiderocol resistance were investigated. Susceptibility testing was performed with and without the presence of iron and avibactam. Expression of 10 iron transport systems and blaADC and blaOXA-51-type were analyzed by real time RT-PCR. The acquisition of a variety of ß-lactamases was also determined. In 2 isolates the impact of silencing the blaADC gene was achieved using a target specific group II intron. For most resistant isolates, MICS for cefiderocol were similar with or without the presence of iron, and there was an overall decrease in expression of receptors (including pirA and piuA) involved in ferric uptake. However, expression of the ferrous uptake system (faoA) persisted. The addition of avibactam (4 µg/mL) lowered most cefiderocol MICs to 2 to 4 µg/mL. Most isolates possessed ADC-25 or ADC-33. Cefiderocol resistance correlated with over-expression of blaADC; silencing of this ß-lactamase resulted in a ≥ 8-fold decrease in cefiderocol MICs. Over-expression of specific blaADC subtypes, in a background of generalized repression of ferric uptake systems, were consistent features in clinical isolates of cefiderocol-resistant A. baumannii.

Methicillin-resistant Staphylococcus aureus bacteremia during the coronavirus disease 2019 (COVID-19) pandemic: Trends and distinguishing characteristics among patients in a healthcare system in New York City.

During the pandemic, the rate of healthcare facility-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was 5 times greater in patients admitted with coronavirus disease 2019 (COVID-19). The presence of central lines and mechanical ventilation likely contribute to this increased rate. The number of central-line-associated bacteremia cases may be underestimated in patients with COVID-19.

Is remdesivir safe in patients with renal impairment? Experience at a large tertiary urban medical center.

PURPOSE: Remdesivir is FDA-approved for treatment of patients hospitalized with COVID-19 pneumonia, but not recommended in patients with severe renal failure. This study aims to evaluate the safety of remdesivir in this patient population. METHODS: This was a single-center, retrospective cohort study including patients ≥ 18 years old, admitted between May 1, 2020 and April 30, 2021 who received remdesivir. Patients were divided into two groups: estimated creatinine clearance (eCrCl) < 30 mL/min and eCrCl ≥ 30 ml/min. Primary outcomes were development of acute kidney injury (AKI) after remdesivir initiation and hepatotoxicity (alanine aminotransferase [ALT] or aspartate aminotransferase [AST] > 5 × upper limit of normal) both at end of treatment (EOT) or 5 days after EOT. Secondary outcomes were length of stay (days) and mortality. RESULTS: 513 patients were assessed with 416 patients included in the study (eCrCl < 30 mL/min, n = 55; eCrCl ≥ 30 mL/min n = 361). Incidence of AKI (eCrCl < 30 mL/min 11% vs eCrCl ≥ 30 mL/min 7%, OR 1.57, 95% CI 0.57, 4.3) and hepatotoxicity (ALT: 2% vs 4%, OR 0.47, 95% CI 0.05, 3.7 and AST: 2% vs 2%, OR 1.26, 95% CI 0.14, 11.04) were similar between the two groups. Length of stay was longer in the eCrCl < 30 mL/min group (mean 18.6 vs 11.9, difference 6.7, 95% CI 3.8, 9.6), and no difference in mortality was observed (21.8% vs 18.8%, OR 1.2, 95% CI 0.6, 2.4). CONCLUSION: Remdesivir was not associated with development of AKI or hepatotoxicity in patients with eCrCl < 30 mL/min compared to patients with eCrCl ≥ 30 mL/min, and warrants further investigation.

The initial and lingering impact of coronavirus disease 2019 (COVID-19) on catheter-associated infections in a large healthcare system in New York City.

Catheter-related infections increased during surges of coronavirus disease 2019 (COVID-19) in an 11-hospital system in New York City. A disproportionate number of central-line infections occurred in larger hospitals. Patients with COVID-19 had shorter times from catheter insertion to infection and a higher incidence of infections with enterococci.

Trends in Clostridioides difficile infection across a public health hospital system in New York City 2019-2021: A cautionary note.

Contrary to national reports, rates of healthcare facility-onset Clostridioides difficile infection across an 11-hospital system rose after the spring of 2020, when New York City was the epicenter for the COVID-19 pandemic. Antibiotic pressure from an escalation in cephalosporin usage correlated with this increase. The majority of cases of Clostridioides difficile were in patients without COVID-19, suggesting the pandemic has adversely impacted the healthcare of other inpatients.

In Vitro and In Vivo Activity of Amoxicillin-Clavulanate Combined with Ceftibuten or Cefpodoxime Against Extended-Spectrum ß-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae.

Infections due to extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales are an increasingly common problem. For many of these infections, no oral treatment options are available. The activity of amoxicillin-clavulanate combined with ceftibuten or cefpodoxime was evaluated against a group of Escherichia coli and Klebsiella pneumoniae clinical isolates possessing a variety of CTX-M- and SHV-type ESBLs; some possessed blaTEM1 as well. In time-kill studies, the combination of subinhibitory concentrations of amoxicillin-clavulanate with ceftibuten was bactericidal and synergistic for all strains with an amoxicillin-clavulanate MIC ≤32 µg/mL, regardless of the type of ESBL and the cephalosporin minimal inhibitory concentration (MIC). The combination with cefpodoxime was also bactericidal and synergistic against all but one of these strains. These combinations were further tested against two strains of K. pneumoniae and one E. coli in a sepsis model using Galleria mellonella larvae. The combination of amoxicillin-clavulanate with ceftibuten demonstrated a synergistic survival benefit against all three strains. The combination with cefpodoxime also improved survival against the two K. pneumoniae strains, but not the E. coli strain. These findings support combining amoxicillin-clavulanate with ceftibuten, and possibly cefpodoxime, for the treatment of infections due to ESBL producers and suggest that having an amoxicillin-clavulanate MIC of 32 µg/mL or less may predict activity at clinically achievable concentrations. Clinical studies are warranted to further evaluate this therapeutic approach.

Relationship of TonB-dependent receptors with susceptibility to cefiderocol in clinical isolates of Pseudomonas aeruginosa.

OBJECTIVES: Cefiderocol maintains activity against most MDR Gram-negative pathogens including Pseudomonas aeruginosa. In laboratory-derived isolates, down-regulation of TonB-dependent siderophore receptors have been implicated in resistance to cefiderocol. METHODS: In this report, the expression of seven TonB-dependent siderophore receptors was examined in 10 clinical isolates with cefiderocol MICs ranging from ≤0.03-8 mg/L. In addition, genetic sequences of the siderophore receptors were analysed to identify potentially disruptive mutations. RESULTS: There was no clear association between expression of the receptors with cefiderocol susceptibility, including the receptors piuA/piuD and pirA previously implicated in cefiderocol uptake. In addition, there were no disabling mutations identified in the receptors. Acquired ß-lactamase activity also could not explain the range in cefiderocol susceptibility. CONCLUSIONS: The aetiology of reduced susceptibility to cefiderocol in clinical isolates of P. aeruginosa remains an enigma and worthy of further investigation.

Trends in Healthcare Facility-Onset Clostridioides difficile Infection and the Impact of Testing Schemes in an Acute Care Hospital System in New York City, 2016-2019.

BACKGROUND: Healthcare facility-onset Clostridioides difficile infection is associated with adverse clinical outcomes and hospital reimbursement. A four-year review involving eleven hospitals of the NYC Health + Hospital system was undertaken. METHODS: From 2016-2019, infection rates and standardized infection ratios (SIRs) were gathered from National Healthcare Safety Network. The C. difficile testing scheme at each facility was recorded. RESULTS: For the eleven hospitals, declines in rates of C. difficile infection and SIRs were documented. However, this decline was driven by two hospitals that had high rates of infection in 2016; for the remaining nine hospitals, rates of infection and SIRs were at a plateau. Most hospitals used a testing scheme that fell into the nucleic acid amplification test (NAAT) category for SIR risk adjustment. Hospitals that used the algorithm glutamate dehydrogenase (GDH) and toxin A/B immunoassay (EIA) followed by NAAT for discrepant results had significantly lower rates of C. difficile infection but similar SIRs. CONCLUSIONS: For most hospitals in this system, rates of C. difficile remained level. Within the NAAT test categories, SIRs may not correlate with infection rates. Given the controversies regarding testing and calculation of SIRs, alternatives to C. difficile infection should be sought as a hospital quality measurement.

Effectiveness of Fluconazole Prophylaxis in a Targeted High-Risk Group in a Surgical Intensive Care Unit.

Background: Candidemia is an important nosocomial infection in intensive care units (ICUs), with total parenteral nutrition (TPN) a well-recognized risk factor. Antifungal prophylaxis may be an effective intervention to prevent candidemia in high-risk patients. In this report, the effectiveness of fluconazole prophylaxis was examined in patients located in a combined surgical-neurosurgical ICU serving an urban Level 1 trauma center who were receiving prolonged courses of TPN. Methods: Fluconazole was administered prophylactically for patients receiving TPN for more than six days. Rates of candidemia during the intervention were compared with those prior to the intervention. Results: During the 27-month pre-intervention period, seven episodes of candidemia occurred during 1,277 days of parenteral nutrition therapy. During the 17-month post-intervention period, there were zero episodes during 852 days of therapy (p = 0.03). Similarly, during the pre-intervention period, there were six episodes of candidemia during 867 high-risk days of therapy, compared with zero during 643 days of high-risk therapy in the post-intervention period (p = 0.04). The rates of bacteremia did not change, and emergence of fluconazole-resistant Candida species was not evident. Conclusions: At our surgical ICU, this fluconazole prophylaxis was associated with a significant decrease in the number of patients with candidemia, without emergence of resistant species.

Activity of Omadacycline and Other Tetracyclines Against Contemporary Gram-Negative Pathogens from New York City Hospitals.

Antibiotic-resistant Enterobacteriaceae and Acinetobacter baumannii are problematic pathogens, with few treatment options for multidrug-resistant (MDR)-A. baumannii and few oral options for extended spectrum ß-lactamase (ESBL)-producing and MDR-Enterobacteriaceae. Omadacycline, a newer tetracycline derivative, has activity against some of these pathogens. We tested the in vitro activity of omadacycline against a contemporary collection of over 2,600 consecutive unique clinical isolates of Enterobacteriaceae and A. baumannii, a previous collection of carbapenem-resistant Klebsiella pneumoniae and A. baumannii from a surveillance study in 2013-2014, and a group of K. pneumoniae and A. baumannii isolates with previously defined resistance mechanisms. For the contemporary collection, over 96% of Escherichia coli and 70% of K. pneumoniae isolates were inhibited by omadacycline at ≤4 µg/mL including 95% of E. coli and 49% of K. pneumoniae with presumptive ESBLs. Nearly 90% of A. baumannii were inhibited by omadacycline at ≤4 µg/mL. The omadacycline MIC50/90 was 1/4 µg/mL, 4/>8 µg/mL, and 0.5/8 for E. coli, K. pneumoniae, and A. baumannii, respectively. For the carbapenem-resistant collection of isolates, 56% of A. baumannii were inhibited by omadacycline at ≤4 µg/mL, but only 30% of Klebsiella pneumoniae carbapenemase (KPC)-possessing K. pneumoniae were susceptible. Expression of the efflux gene adeB appeared to affect the activity of omadacycline against A. baumannii, but could not fully explain resistance to this agent. Omadacycline may prove to be a parenteral or oral option for some infections due to ESBL-producing Enterobacteriaceae and carbapenem-resistant A. baumannii, and clinical studies are warranted.

Evaluating cross contamination on a shared ventilator.

BACKGROUND: Disasters have the potential to cause critical shortages of life-saving equipment. It has been postulated that during patient surge, multiple individuals could be maintained on a single ventilator. This was supported by a previous trial that showed one ventilator could support four sheep. The goal of our study is to investigate if cross contamination of pathological agents occurs between individuals on a shared ventilator with strategically placed antimicrobial filters. METHODS: A multipatient ventilator circuit was assembled using four sterile, parallel standard tubing circuits attached to four 2 L anaesthesia bags, each representing a simulated patient. Each 'patient' was attached to a Heat and Moisture Exchange filter. An additional bacterial/viral filter was attached to each expiratory limb. 'Patient-Lung' number 1 was inoculated with an isolate of Serratia marcescens, and the circuit was run for 24 hours. Each 'lung' and three points in the expiratory limb tubing were washed with broth and cultured. All cultures were incubated for 48 hours with subcultures performed at 24 hours. RESULTS: Washed cultures of patient 2, 3 and 4 failed to demonstrate growth of S. marcescens. Cultures of the distal expiratory tubing, expiratory limb connector and expiratory limb prefilter tubing yielded no growth of S. marcescens at 24 or 48 hours. CONCLUSION: Based on this circuit configuration, it is plausible to maintain four individuals on a single ventilator for 24 hours without fear of cross contamination.

Trends in central-line-associated bloodstream infections and catheter-associated urinary tract infections in a large acute-care hospital system in New York City, 2016-2019.

BACKGROUND: Central-line bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) negatively impact clinical outcomes and hospital reimbursement. In this report, 4 year trends involving 11 hospitals in New York City were examined. METHODS: Data from the National Healthcare Safety Network (NHSN) were extracted for 11 acute-care hospitals belonging to the NYC Health + Hospital system from 2016 through 2019. Trends in device infections per 1,000 patient days, device utilization ratios, and standardized infection ratios (SIRs) were examined for the 11 hospitals and for the entire system. RESULTS: Over the 4-year period, there were progressive declines in central-line days, infections per 1,000 central-line days, and device utilization ratios for the system. The average annual SIRs for the system also declined: 1.40 in 2016, 1.09 in 2017, 1.04 in 2018, and 0.82 in 2019. Case-mix indices correlated with SIRs for CLABSIs. Level 1 trauma centers had higher SIRs and a disproportionately greater number of CLABSIs in patients located in NHSN-defined surgical intensive care units. Similar trends with CAUTIs were noted, with progressive declines in catheter days, infections per 1,000 patient days, device utilization ratios, and SIRs (1.42 in 2016, 0.93 in 2017, 1.18 in 2018, and 0.78 in 2019) over the 4-year period. CONCLUSIONS: Across an 11-hospital system, continuing efforts to reduce device utilization and infection rates resulted in declining SIRs for CLABSIs and CAUTIs. Hospitals with higher case-mix indices, and particularly level 1 trauma centers, had significantly higher central-line infection rates and SIRs.

Tocilizumab therapy for COVID-19: A comparison of subcutaneous and intravenous therapies.

BACKGROUND: The release of pro-inflammatory cytokines, resulting in cytokine storm syndrome, contributes to the morbidity and mortality associated with COVID-19 disease. This study aimed to compare the effects of intravenous (IV) and subcutaneous (SC) tocilizumab, an IL-6 receptor antagonist, on respiratory parameters and clinical outcome in patients with COVID 19. METHODS: We performed a retrospective cohort study of hospitalized patients with COVID-19 treated with either IV or SC tocilizumab from March 26, 2020, to May 18, 2020. Respiratory parameters seven days after receiving tocilizumab therapy were compared to baseline measurements. All patients were assessed until discharged from the hospital. RESULTS: Tocilizumab was administered to 125 patients: 65 received IV, and 60 received SC therapy. At day seven, 52% of the IV group patients demonstrated improvement in respiratory parameters, compared to 28% in the SC group (P = 0.01). Mortality rates at days seven and 28 were 15% and 37%, respectively, in the IV group and 17% and 50%, respectively, in the SC group (PNS). The in-hospital mortality rate was 38% for the IV group versus 57% for the SC group (P = 0.04). More than 90% of patients in each group received corticosteroids; however, significantly more patients received convalescent plasma in the IV group. CONCLUSIONS: At the doses used in this study, IV tocilizumab is preferred over SC therapy to treat cytokine storm syndrome due to COVID-19.