ABSTRACT
Aims of the study: To investigate the effect of clinical predictors on admission and the set of therapeutic interventions on length of stay, ICU admission, need for MV and mortality.
Methods used to conduct the study: Retrospective cohort of inpatients with RT-PCR positive for COVID-19 from March to July 2020. Multivariate models were used to assess risk for ICU admission, need for MV and hospital mortality. Logistic regression analysis was conducted to examine factors associated with the results.
Results of the study: 459 patients were enrolled (median age 60.0 years old). For patients treated with AZM-Corticosteroid (46.8%) the risk for ICU admission was 0.17 (OR; 95%CI 0.05-0.57), for MV 0.16 (OR; 95%CI 0.04-0.74) and for mortality 0.16 (OR; 95%CI 0.03-0.91). AZM-Corticosteroid also decreased the length of stay in 1.5 day. AZM-Corticosteroid and anticoagulation when indicated (17.2%), also reduced the ICU stay in 1.5 and MV in 4 days. When included HCQ, the benefits were lost and the times increased. Age >65 years, presence of up one comorbidity, pulmonary involvement more than or equal to 50%, saturation <93%, lymphocytes <900 mm3, D-dimers >1,250 ng/mL and CRP >8.0 mg/dL at admission were clinical predictors for death. HFNC was able to prevent intubation by 38.1%.
Conclusion drawn from the study and clinical implications:AZM-Corticosteroids and anticoagulation represented a favorable combination for inpatients with COVID-19, reducing length of hospitalization, risk of MV and mortality. HCQ did not yield benefits to combination therapy and we do not support its use for inpatients. HFNC was able to prevent intubation in one third of patients. Already on admission some clinical predictors may help to estimate a higher risk of poor evolution.
What’s known? Studies show the ineffectiveness of HCQ in the therapeutic context of COVID-19.
What’s new? We were able to describe clinical predictors of the patient’s arrival at the hospital associated with the worst outcomes for the evaluated outcomes. Moreover, considering that it is a real-life study, we demonstrated the combination of favorable treatment related to decreased length of stay and risk for ICU admission, need for MV and mortality.
Keywords: COVID-19; treatment effective; cohort Brazil; hydroxychloroquine; azithromycin.
Abbreviations: ICU, intensive care unit; MV, mechanical ventilation; AZM, azithromycin; HCQ, hydroxychloroquine; HFNC, high flow nasal cannula; CRP, C-reactive protein;
INTRODUCTION
Doctors and hospitals have learned a lot about how best to treat people infected with the novel coronavirus disease 2019 (COVID-19) in the last months since the pandemic began. A significant percentage of patients develop health conditions that require hospital care¹. The practice has varied widely across the world and several therapeutic interventions have been proposed and methodological studies have been published, although far from overwhelming evidence they closely follow and analyze updates on this outbreak², but there is no consensus on the best decisions.
Therapeutic strategies using hydroxychloroquine (HCQ), antibiotics, corticosteroid, anticoagulants and others, in combination or not, were introduced to the clinical practice. However, there is not yet consensus about the best pharmacological combination to prove effectiveness and safety, incorporated in the usual care in the COVID-19 treatment. Despite that, recently a Brazilian guideline³ recommended a number of therapeutic strategies in the management of COVID-19 patients based on available scientific evidence, discouraging the use of HCQ.
Our objective was to retrospectively evaluate medical practice in the real world, considering the impact of clinical predictors evaluated on the arrival and the use of different therapeutic combinations on the length of stay, the need for admission to the intensive care unit (ICU) or mechanical ventilation (MV) and mortality during the outbreak of COVID-19 in our center.