Mortality of Patients With Severe COVID-19 in the Intensive Care Unit: An Observational Study From a Major COVID-19 Receiving Hospital

Clinical characteristics associated with mortality of COVID-19 patients admitted to an intensive care unit of a tertiary hospital in South Africa

BACKGROUND

Over 130 million people have been diagnosed with Coronavirus disease 2019 (COVID-19), and more than one million fatalities have been reported worldwide. South Africa is unique in having a quadruple disease burden of type 2 diabetes, hypertension, human immunodeficiency virus (HIV) and tuberculosis, making COVID-19-related mortality of particular interest in the country. The aim of this study was to investigate the clinical characteristics and associated mortality of COVID-19 patients admitted to an intensive care unit (ICU) in a South African setting.

METHODS AND FINDINGS

We performed a prospective observational study of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to the ICU of a South African tertiary hospital in Cape Town. The mortality and discharge rates were the primary outcomes. Demographic, clinical and laboratory data were analysed, and multivariable robust Poisson regression model was used to identify risk factors for mortality. Furthermore, Cox proportional hazards regression model was performed to assess the association between time to death and the predictor variables. Factors associated with death (time to death) at p-value < 0.05 were considered statistically significant. Of the 402 patients admitted to the ICU, 250 (62%) died, and another 12 (3%) died in the hospital after being discharged from the ICU. The median age of the study population was 54.1 years (IQR: 46.0-61.6). The mortality rate among those who were intubated was significantly higher at 201/221 (91%). After adjusting for confounding, multivariable robust Poisson regression analysis revealed that age more than 48 years, requiring invasive mechanical ventilation, HIV status, procalcitonin (PCT), Troponin T, Aspartate Aminotransferase (AST), and a low pH on admission all significantly predicted mortality. Three main risk factors predictive of mortality were identified in the analysis using Cox regression Cox proportional hazards regression model. HIV positive status, myalgia, and intubated in the ICU were identified as independent prognostic factors.

CONCLUSIONS

In this study, the mortality rate in COVID-19 patients admitted to the ICU was high. Older age, the need for invasive mechanical ventilation, HIV status, and metabolic acidosis were found to be significant predictors of mortality in patients admitted to the ICU.

A network Data Envelopment Analysis to estimate nations' efficiency in the fight against SARS-CoV-2

The ongoing outbreak of SARS-CoV-2 has been deeply impacting health systems worldwide. In this context, it is pivotal to measure the efficiency of different nations' response to the pandemic, whose insights can be used by governments and health authorities worldwide to improve their national COVID-19 strategies. Hence, we propose a network Data Envelopment Analysis (DEA) to estimate the efficiencies of fifty-five countries in the current crisis, including the thirty-seven Organisation for Economic Co-operation and Development (OECD) member countries, six OECD prospective members, four OECD key partners, and eight other countries. The network DEA model is designed as a general series structure with five single-division stages - population, contagion, triage, hospitalisation, and intensive care unit admission -, and considers an output maximisation orientation, denoting a social perspective, and an input minimisation orientation, denoting a financial perspective. It includes inputs related to health costs, desirable and undesirable intermediate products related to the use of personal protective equipment and infected population, respectively, and desirable and undesirable outputs regarding COVID-19 recoveries and deaths, respectively. To the best of the authors' knowledge, this is the first study proposing a cross-country efficiency measurement using a network DEA within the context of the COVID-19 crisis. The study concludes that Estonia, Iceland, Latvia, Luxembourg, the Netherlands, and New Zealand are the countries exhibiting higher mean system efficiencies. Their national COVID-19 strategies should be studied, adapted, and used by countries exhibiting worse performances. In addition, the observation of countries with large populations presenting worse mean efficiency scores is statistically significant.

A network Data Envelopment Analysis to estimate nations' efficiency in the fight against SARS-CoV-2

The ongoing outbreak of SARS-CoV-2 has been deeply impacting health systems worldwide. In this context, it is pivotal to measure the efficiency of different nations' response to the pandemic, whose insights can be used by governments and health authorities worldwide to improve their national COVID-19 strategies. Hence, we propose a network Data Envelopment Analysis (DEA) to estimate the efficiencies of fifty-five countries in the current crisis, including the thirty-seven Organisation for Economic Co-operation and Development (OECD) member countries, six OECD prospective members, four OECD key partners, and eight other countries. The network DEA model is designed as a general series structure with five single-division stages - population, contagion, triage, hospitalisation, and intensive care unit admission -, and considers an output maximisation orientation, denoting a social perspective, and an input minimisation orientation, denoting a financial perspective. It includes inputs related to health costs, desirable and undesirable intermediate products related to the use of personal protective equipment and infected population, respectively, and desirable and undesirable outputs regarding COVID-19 recoveries and deaths, respectively. To the best of the authors' knowledge, this is the first study proposing a cross-country efficiency measurement using a network DEA within the context of the COVID-19 crisis. The study concludes that Estonia, Iceland, Latvia, Luxembourg, the Netherlands, and New Zealand are the countries exhibiting higher mean system efficiencies. Their national COVID-19 strategies should be studied, adapted, and used by countries exhibiting worse performances. In addition, the observation of countries with large populations presenting worse mean efficiency scores is statistically significant.

Hospital length of stay for COVID-19 patients: A systematic review and meta-analysis

The length of stay in the hospital for COVID-19 can aid in understanding the disease's prognosis. Thus, the goal of this study was to collectively estimate the hospital length of stay (LoS) in COVID-19 hospitalized individuals. To locate related studies, international databases (including Google Scholar, Science Direct, PubMed, and Scopus) were searched. The I² index, the Cochran Q test, and T² were used to analyze study heterogeneity. The mean LoS in COVID- 19 hospitalized patients was estimated using a random-effects model. COVID-19's total pooled estimated hospital LoS was 15.35, 95%CI:13.47-17.23; p<0.001, I² = 80.0). South America had the highest pooled estimated hospital LoS of COVID-19 among the continents, at 20.85 (95%CI: 14.80-26.91; p<0.001, I² = 0.01), whereas Africa had the lowest at 8.56 8 (95%CI: 1.00-22.76). The >60 age group had the highest pooled estimated COVID-19 hospital LoS of 16.60 (95%CI: 12.94-20.25; p<0.001, I² = 82.6), while the 40 age group had the lowest hospital LoS of 10.15 (95% CI: 4.90-15.39, p<0.001, I² = 22.1). The metanalysis revealed that COVID-19's hospital LoS was more than 10 days. However, it appears that this duration varies depending on a number of factors, including the patient's age and the availability of resources.

Evaluation of the Relationship between Nutritional Status of COVID-19 Patients Admitted to the ICU and Patients' Prognosis: A Cohort Study

Background

Malnutrition in COVID-19 critically ill patients can lead to poor prognosis. This study aimed to evaluate the association between nutritional status (or risk) and the prognosis of critically ill COVID-19 patients. In this study, prognosis is the primary outcome of "hospital mortality" patients. The second outcome is defined as "need for mechanical ventilation."

Methods and Materials

In this single-center prospective cohort study, 110 patients admitted to the Intensive Care Unit of Imam Khomeini Hospital Complex (Tehran, Iran) between April and September 2021 were enrolled. Participants formed a consecutive sample. MNA-SF, NRS-2002, mNUTRIC, and PNI scores were used to evaluate nutritional assessment. Patients' lab results and pulse oximetric saturation SpO₂/FiO₂ (SF) ratio at the time of intensive care unit (ICU) admission were collected. Patients were screened for nutritional status and categorized into two groups, patients at nutritional risk and nonrisk.

Results

Sixty-five (59.1%) of all patients were men. The overall range of age was 52 ± 15. Thirty-six (32.7%) of patients were obese (BMI ≥ 30). The hospital mortality rate was 59.1% (n = 65). According to the different criteria, malnutrition rate was 67.3% (n = 74) (NRS), 28.2% (n = 31) (MNA), 34.5% (n = 38) (mNUTRIC), and 58.2% (n = 64) (PNI). There was a statistically significant association between chronic kidney disease (CKD) and mNUTRIC risk (OR = 13.5, 95% CI (1.89-16.05), P=0.002), diabetes mellitus (DM) and MNA risk (OR = 2.82, 95% CI (1.01-7.83), P=0.041), hypertension (HTN) and MNA risk (OR = 5.63, 95% CI (2.26-14.05), P < 0.001), and malignancy and mNUTRIC risk (P=0.048). The nutritional risk (all tools) significantly increased the odds of in-hospital death and need for mechanical ventilation. The length of stay was not significantly different in malnourished patients.

Conclusion

In the critical care setting of COVID-19 patients, malnutrition is prevalent. Malnutrition (nutritional risk) is associated with an increased risk of need for mechanical ventilation and in-hospital mortality. Patients with a history of HTN, CKD, DM, and cancer are more likely to be at nutritional risk at the time of ICU admission.

Clinicodemographic profile, intensive care unit utilization and mortality rate among COVID-19 patients admitted during the second wave in Bangladesh

INTRODUCTION

The second wave of COVID-19 arrived in Bangladesh in March 2021. This pilot research from a tertiary care COVID-dedicated hospital observed the clinicodemographic profile, intensive care unit (ICU) utilization, and mortality rate among COVID-19 patients admitted during the second wave.

METHODS

Reverse transcription-polymerase chain reaction or chest high-resolution computed tomography confirmed 972 COVID-19 cases included in this cross-sectional study from 24 March to 23 June 2021, recruited using convenience sampling. Data regarding clinicodemographic profile, ICU utilization and mortality rate were analyzed.

RESULTS

The mean study cohort age was 54.47±12.73 years, with most patients (48.3%) aged 41-60; 64.1% were men. Fever (77.9%) and cough (75.9%) were the most common symptoms, and hypertension (43.6%) and diabetes (42.15%) the most common comorbidities. Nearly half of patients had total lung involvement of 26%-50%, and 23.8% required ICU. Overall mortality was 16.5%, whereas the mortality rate among ICU admitted patients was 56.1%. The most important predictors of mortality were older age, chronic renal illness, the proportion of lung involvement and ICU requirement.

CONCLUSIONS

We found higher mortality and ICU utilization rate and greater total lung involvement during the second wave. The mortality rate among the elderly and ICU patients was also higher than earlier.

Adrenomedullin Therapy in Moderate to Severe COVID-19

The 2019 coronavirus (COVID-19) pandemic is still in progress, and a significant number of patients have presented with severe illness. Recently introduced vaccines, antiviral medicines, and antibody formulations can suppress COVID-19 symptoms and decrease the number of patients exhibiting severe disease. However, complete avoidance of severe COVID-19 has not been achieved, and more importantly, there are insufficient methods to treat it. Adrenomedullin (AM) is an endogenous peptide that maintains vascular tone and endothelial barrier function. The AM plasma level is markedly increased during severe inflammatory disorders, such as sepsis, pneumonia, and COVID-19, and is associated with the severity of inflammation and its prognosis. In this study, exogenous AM administration reduced inflammation and related organ damage in rodent models. The results of this study strongly suggest that AM could be an alternative therapy in severe inflammation disorders, including COVID-19. We have previously developed an AM formulation to treat inflammatory bowel disease and are currently conducting an investigator-initiated phase 2a trial for moderate to severe COVID-19 using the same formulation. This review presents the basal AM information and the most recent translational AM/COVID-19 study.

Clinical Management of Adult Patients with COVID-19 Outside Intensive Care Units: Guidelines from the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP)

INTRODUCTION

The Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP) constituted an expert panel for developing evidence-based guidance for the clinical management of adult patients with coronavirus disease 2019 (COVID-19) outside intensive care units.

METHODS

Ten systematic literature searches were performed to answer ten different key questions. The retrieved evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation methodology (GRADE).

RESULTS AND CONCLUSION

The literature searches mostly assessed the available evidence on the management of COVID-19 patients in terms of antiviral, anticoagulant, anti-inflammatory, immunomodulatory, and continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) treatment. Most evidence was deemed as of low certainty, and in some cases, recommendations could not be developed according to the GRADE system (best practice recommendations were provided in similar situations). The use of neutralizing monoclonal antibodies may be considered for outpatients at risk of disease progression. For inpatients, favorable recommendations were provided for anticoagulant prophylaxis and systemic steroids administration, although with low certainty of evidence. Favorable recommendations, with very low/low certainty of evidence, were also provided for, in specific situations, remdesivir, alone or in combination with baricitinib, and tocilizumab. The presence of many best practice recommendations testified to the need for further investigations by means of randomized controlled trials, whenever possible, with some possible future research directions stemming from the results of the ten systematic reviews.

The Drug Repurposing for COVID-19 Clinical Trials Provide Very Effective Therapeutic Combinations: Lessons Learned From Major Clinical Studies

SARS-CoV-2 has spread across the globe in no time. In the beginning, people suffered due to the absence of efficacious drugs required to treat severely ill patients. Nevertheless, still, there are no established therapeutic molecules against the SARS-CoV-2. Therefore, repurposing of the drugs started against SARS-CoV-2, due to which several drugs were approved for the treatment of COVID-19 patients. This paper reviewed the treatment regime for COVID-19 through drug repurposing from December 8, 2019 (the day when WHO recognized COVID-19 as a pandemic) until today. We have reviewed all the clinical trials from RECOVERY trials, ACTT-1 and ACTT-2 study group, and other major clinical trial platforms published in highly reputed journals such as NEJM, Lancet, etc. In addition to single-molecule therapy, several combination therapies were also evaluated to understand the treatment of COVID-19 from these significant clinical trials. To date, several lessons have been learned on the therapeutic outcomes for COVID-19. The paper also outlines the experiences gained during the repurposing of therapeutic molecules (hydroxychloroquine, ritonavir/ lopinavir, favipiravir, remdesivir, ivermectin, dexamethasone, camostatmesylate, and heparin), immunotherapeutic molecules (tocilizumab, mavrilimumab, baricitinib, and interferons), combination therapy, and convalescent plasma therapy to treat COVID-19 patients. We summarized that anti-viral therapeutic (remdesivir) and immunotherapeutic (tocilizumab, dexamethasone, and baricitinib) therapy showed some beneficial outcomes. Until March 2021, 4952 clinical trials have been registered in ClinicalTrials.gov toward the drug and vaccine development for COVID-19. More than 100 countries have participated in contributing to these clinical trials. Other than the registered clinical trials (medium to large-size), several small-size clinical trials have also been conducted from time to time to evaluate the treatment of COVID-19. Four molecules showed beneficial therapeutic to treat COVID-19 patients. The short-term repurposing of the existing drug may provide a successful outcome for COVID-19 patients. Therefore, more clinical trials can be initiated using potential anti-viral molecules by evaluating in different phases of clinical trials.

Early Determinants of Length of Hospital Stay: A Case Control Survival Analysis among COVID-19 Patients admitted in a Tertiary Healthcare Facility of East India

BACKGROUND

Length of hospital stay (LOS) for a disease is a vital estimate for healthcare logistics planning. The study aimed to illustrate the effect of factors elicited on arrival on LOS of the COVID-19 patients.

MATERIALS AND METHODS

It was a retrospective, record based, unmatched, case control study using hospital records of 334 COVID-19 patients admitted in an East Indian tertiary healthcare facility during May to October 2020. Discharge from the hospital (cases/survivors) was considered as an event while death (control/non-survivors) as right censoring in the case-control survival analysis using cox proportional hazard model.

RESULTS

Overall, we found the median LOS for the survivors to be 8 days [interquartile range (IQR): 7-10 days] while the same for the non-survivors was 6 days [IQR: 2-11 days]. In the multivariable cox-proportional hazard model; travel distance (>16 km) [adjusted hazard ratio (aHR): 0.69, 95% CI: (0.50-0.95)], mode of transport to the hospital (ambulance) [aHR: 0.62, 95% CI: (0.45-0.85)], breathlessness (yes) [aHR: 0.56, 95% CI: (0.40-0.77)], number of co-morbidities (1-2) [aHR: 0.66, 95% CI: (0.47-0.93)] (≥3) [aHR: 0.16, 95% CI: (0.04-0.65)], COPD/asthma (yes) [ [aHR: 0.11, 95% CI: (0.01-0.79)], DBP (<60/≥90) [aHR: 0.55, 95% CI: (0.35-0.86)] and qSOFA score (≥2) [aHR: 0.33, 95% CI: (0.12-0.92)] were the significant attributes affecting LOS of the COVID-19 patients.

CONCLUSION

Factors elicited on arrival were found to be significantly associated with LOS. A scoring system inculcating these factors may be developed to predict LOS of the COVID-19 patients.

Mortality and Clinical Interventions in Critically ill Patient With Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

Objective: The aims of this systematic review and meta-analysis were to summarize the current existing evidence on the outcome of critically ill patients with COVID-19 as well as to evaluate the effectiveness of clinical interventions.

Data Sources: We searched MEDLINE, the Cochrane library, Web of Science, the China Biology Medicine disc, China National Knowledge Infrastructure, and Wanfang Data from their inception to May 15, 2021. The search strings consisted of various search terms related to the concepts of mortality of critically ill patients and clinical interventions.

Study Selection: After eliminating duplicates, two reviewers independently screened all titles and abstracts first, and then the full texts of potentially relevant articles were reviewed to identify cohort studies and case series that focus on the mortality of critically ill patients and clinical interventions.

Main Outcomes and Measures: The primary outcome was the mortality of critically ill patients with COVID-19. The secondary outcomes included all sorts of supportive care.

Results: There were 27 cohort studies and six case series involving 42,219 participants that met our inclusion criteria. All-cause mortality in the intensive care unit (ICU) was 35% and mortality in hospital was 32% in critically ill patients with COVID-19 for the year 2020, with very high between-study heterogeneity (I² = 97%; p < 0.01). In a subgroup analysis, the mortality during ICU hospitalization in China was 39%, in Asia—except for China—it was 48%, in Europe it was 34%, in America it was 15%, and in the Middle East it was 39%. Non-surviving patients who had an older age [−8.10, 95% CI (−9.31 to −6.90)], a higher APACHE II score [−4.90, 95% CI (−6.54 to −3.27)], a higher SOFA score [−2.27, 95% CI (−2.95 to −1.59)], and a lower PaO₂/FiO₂ ratio [34.77, 95% CI (14.68 to 54.85)] than those who survived. Among clinical interventions, invasive mechanical ventilation [risk ratio (RR) 0.49, 95% CI (0.39–0.61)], kidney replacement therapy [RR 0.34, 95% CI (0.26–0.43)], and vasopressor [RR 0.54, 95% CI (0.34–0.88)] were used more in surviving patients.

Conclusions: Mortality was high in critically ill patients with COVID-19 based on low-quality evidence and regional difference that existed. The early identification of critical characteristics and the use of support care help to indicate the outcome of critically ill patients.