Study: IVIG Should Be Given on Case-by-Case Basis, Based on Lack of Large Trial Evidence

The risk of developing acute renal failure and septic shock were higher for individuals with necrotizing soft-tissue infections treated with immunoglobulins, investigators say.

Immunoglobulin intravenous (IVIG) should be administered on a case-by-case basis, because of a lack of evidence about the benefit of immunoglobulins, especially from large randomized controlled trials, results of a study published in BMC Infectious Diseases showed.

Investigators included individuals with necrotizing soft-tissue infections (NSTI) who were hospitalized at a tertiary intensive care unit (ICU) in the University Hospital of Zurich, Switzerland, between 2008 and 2020.

They also analyzed the association among immunoglobulin administration, in-hospital survival, length of stay in the ICU, and incidences of acute renal failure, acute respiratory distress syndrome (ARDS), and septic shock.

After adjustments, investigators found no difference in development of ARDS, in-hospital survival, and ICU length of stay among those treated with or without immunoglobulin.

However, they did find that the Simplified Acute Physiology Score II (SAPS II), the risk of developing acute renal failure, and septic shock were higher for individuals treated with immunoglobulins. Investigators suspected that this could reflect higher disease severity.

Investigators included 48 individuals in the study, and 22 were treated with IVIG.

The individuals treated with IVIG tended to be female and younger with higher SAPS II scores. Overall, 35 individuals survived their hospital stays, with a median ICU length of stay of 11.5 days. The median length of a hospital stay was 28.5 days.

Renal failure occurred in approximately 64.6% of individuals, with incidences of ARDS and septic shock in 22.9% and 60.4%, respectively.

Overall, approximately 64.6% of individuals had a monomicrobial etiology of NSTI, about 25.4% had a monomicrobial group A streptococcal infection, and the rest had other monomicrobial causes.

For those who died in the hospital, 30.8% were not receiving IVIG, and 22.7% were being treated with IVIG. The median ICU length of stay for those not treated with IVIG was 11.5 days compared with 11 for those treated with IVIG.

Acute renal failure occurred in 50% of those not treated with IVIG and 81.8% of those treated with IVIG, and ARDS occurred in 23.1% and 22.7%, respectively.

Additionally, septic shock occurred in 46.2% of individuals not treated with IVIG and 77.3% of individuals treated with IVIG.

After adjusting for affected body surface area, age, sex, affected body surface area, and SAPS II score, which could affect the outcome, there was no difference for development of ARDS, in-hospital survival, and ICU length of stay, between both groups.

The risk of acute renal failure and septic shock was higher in individuals treated with IVIG.

All the individuals in the study received antibiotics, including beta lactams and clindamycin.

Individuals were excluded from the study if they had incomplete or implausible electronic medical records or if their acting physicians disagreed with the NSTI diagnosis according to the medical records.

Investigators acknowledged the limitations of the study. The study was observational, which only showed association, not causality. Additionally, the sample size was low, because of the rare incidence of NSTI, which limited the number of factors that could be used in the analysis. Furthermore, individuals with NSTI related to various microorganisms were included, instead of just focusing on streptococci alone, which could affect the findings.

Finally, the inclusion of individuals based on diagnosis codes and surgical reports could have influenced results, investigators said.

Reference

Hofmaenner DA, Wendel Garcia PD, Blum MR et al. The importance of intravenous immunoglobulin treatment in critically ill patients with necrotizing soft tissue infection: a retrospective cohort study. BMC Infect Dis. 2022;22(1):168. doi: 10.1186/s12879-022-07135-6