Factors associated with poor outcomes among hospitalized patients with COVID-19: Experience from a MERS-CoV referral hospital

BACKGROUND

Coronavirus disease 2019 (COVID-19) has resulted in millions of deaths, including more than 6000 deaths in the Kingdom of Saudi Arabia (KSA). Identifying key predictors of intensive care unit (ICU) admission and mortality among infected cases would help in identifying individuals at risk to optimize their care. We aimed to determine factors of poor outcomes in hospitalized patients with COVID-19 in a large academic hospital in Riyadh, KSA that serves as a Middle East Respiratory Syndrome coronavirus (MERS-CoV) referral center.

METHODS

This is a single-center retrospective cohort study of hospitalized patients between March 15 and August 31, 2020. The study was conducted at King Saud University Medical City (KSUMC). COVID-19 infection was confirmed using real-time reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-COV-2. Demographic data, clinical characteristics, laboratory, radiological features, and length of hospital stay were obtained. Poor outcomes were, admission to ICU, need for invasive mechanical ventilation (IMV), and in-hospital all-cause mortality.

RESULTS

Out of 16,947 individuals tested in KSUMC, 3480 (20.5%) tested positive for SARS-CoV-2 and of those 743 patients (21%) were hospitalized. There were 62% males, 77% were younger than 65 years. Of all cases, 204 patients (28%) required ICU admission, 104 (14%) required IMV, and 117 (16%) died in hospital. In bivariate analysis, multiple factors were associated with mortality among COVID-19 patients. Further multivariate analysis revealed the following factors were associated with mortality: respiratory rate more than 24/min and systolic blood pressure <90 mmHg in the first 24h of presentation, lymphocyte count <1 × 109/L and aspartate transaminase level >37 units/L in the first 48 h of presentation, while a RT-PCR cycle threshold (Ct) value ≤24 was a predictor for IMV.

CONCLUSION

Variable factors were identified as predictors of different outcomes among COVID-19 patients. The only predictor of IMV was a low initial Ct values of SARS-CoV-2 PCR. The presence of tachypnea, hypotension, lymphopenia, and elevated AST in the first 48h of presentation were independently associated with mortality. This study provides possible independent predictors of mortality and invasive mechanical ventilation. The data may be helpful in the early identification of high-risk COVID-19 patients in areas endemic with MERS-CoV.

Clinical Characteristics and Outcome of Hospitalized COVID-19 Patients in a MERS-CoV Endemic Area

Background: The Kingdom of Saudi Arabia (KSA) reported 170,639 cases and 1430 deaths from COVID-19 since the first case emerged in the country on March 2 through June 25, 2020. The objective of this report is to describe the characteristics and outcome observed among 99 hospitalized COVID-19 patients in the largest academic hospital in KSA, and assess co-infection with the Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

Methods: This single-center case series data included select epidemiological, clinical, radiological features and laboratory findings of all confirmed hospitalized cases of COVID-19 in King Saud University Medical City (KSUMC), Riyadh, KSA, from March 22 until May 31, 2020, followed through June 6, 2020. We conducted retrospective analysis of listed data from 99 hospitalized patients and present characteristics and factors associated with severity in percentages and univariate odds ratios. Cases were confirmed using nasopharyngeal or throat swab by real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and MERS-CoV by RT-PCR.

Results: The 99 hospitalized COVID-19 patients included in this analysis constitute 16% of 632 positive SARS-CoV-2 among 6633 persons who were tested at the KSUMC (positivity rate, 9.4%). MERS-CoV PCR was negative in all 99 patients tested. The majority of these 99 hospitalized patients were males (66%), had a mean age of 44 years (range, 19–87), and a quarter (25.3%) were health care workers. Patients with comorbid conditions accounted for 52.5% of patients including the 8.1% who were asymptomatic; diabetes mellitus being the most frequent (31.3%), followed by hypertension (22.2%). The most common presenting symptoms were fever (67.7%), cough (60.6%), dyspnea (43.4%), upper respiratory symptoms (27.3%), fatigue (26.3%), diarrhea (19.2%) and loss of smell (9.1%). The clinical conditions among these 99 patients included upper respiratory tract infection (47.5%), abnormal chest X-ray, lymphopenia, high inflammatory markers a fifth (21%) of patients had moderate pneumonia, while 7% had severe pneumonia with 22.2% requiring admission to the intensive care unit and 12.1% died. Late presentation with severe disease, an abnormal chest X-ray, lymphopenia, high inflammatory markers (C-reactive protein, ferritin, and procalcitonin), and end organ damage (high creatinine or high aspartate aminotransferase) were predictors for admission to critical care unit or died.

Conclusion: We observed no MERS-CoV co-infection in this early cohort of hospitalized COVID-19 patients who were relatively young, more than half had comorbid conditions, presented with fever and/or cough, an abnormal chest X-ray, lymphopenia, and high inflammatory markers. Given MERS-CoV endemicity in the country, co-monitoring of MERS-CoV and SARS-CoV-2 coinfection is critical.