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Ramonfaur D, Salto-Quintana JN, Aguirre-García GM, Hernández-Mata NM, Villanueva-Lozano H, Torre-Amione G, Martínez-Reséndez MF. Cumulative steroid dose in hospitalized patients and COVID-19-associated pulmonary aspergillosis. J Hosp Infect 2023; 142:26-31. [PMID: 37499762 DOI: 10.1016/j.jhin.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Severe COVID-19 elicits a hyperimmune response frequently amenable to steroids, which in turn increase the risk for opportunistic infections. COVID-19 associated pulmonary aspergillosis (CAPA) is a complication known to be associated with immunomodulatory treatment. The role of cumulative steroid dose in the development of CAPA is unclear. This study evaluates the relationship between cumulative steroid dose in hospitalized individuals with COVID-19 pneumonia and the risk for CAPA. METHODS This retrospective cohort study includes 135 hospitalized patients with PCR-confirmed COVID-19 pneumonia at a tertiary centre in north Mexico. Patients who developed CAPA were matched by age and gender to two controls with COVID-19 pneumonia who did not develop CAPA defined and classified as possible, probable, or proven according to 2020 ECMM/ISHAM criteria. Cumulative steroid dose in dexamethasone equivalents was obtained from admission until death, discharge, or diagnosis of CAPA (whichever occurred first). The risk of CAPA by the continuous cumulative steroid dose was assessed using a logistic regression model. RESULTS Forty-five patients were diagnosed with CAPA and matched to 90 controls. Mean age was 61 ± 14 years, and 72% were male. Mean cumulative steroid dose was 66 ± 75 mg in patients without CAPA vs 195 ± 226 mg in patients with CAPA (P<0.001). The risk for CAPA increased with higher cumulative dose of steroids (OR 1.0075, 95% CI: 1.0033-1.0116). CONCLUSIONS Patients who developed CAPA had a history of higher cumulative steroid dose during hospitalization. The risk for CAPA increases ∼8% for every 10 mg of dexamethasone used.
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Affiliation(s)
- D Ramonfaur
- Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA, USA
| | - J N Salto-Quintana
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - G M Aguirre-García
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - N M Hernández-Mata
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - H Villanueva-Lozano
- Department of Infectious Diseases, ISSSTE Regional Monterrey, Monterrey, Nuevo Leon, Mexico
| | - G Torre-Amione
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico; The Methodist Hospital, Cornell University, Houston, TX, USA
| | - M F Martínez-Reséndez
- School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, Nuevo Leon, Mexico; Epidemiological Surveillance Unit, Hospital San Jose-Tec Salud, Monterrey, Nuevo Leon, Mexico.
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Aguirre-García GM, Ramonfaur D, Torre-Amione G, Ramírez-Elizondo MT, Lara-Medrano R, Moreno-Hoyos JF, Velázquez-Ávila ES, Diaz-Garza CA, Sanchez-Nava VM, Castilleja-Leal F, Rhoades GM, Martínez-Reséndez MF. Stratifying risk outcomes among adult COVID-19 inpatients with high flow oxygen: The R4 score. Pulmonology 2021; 29:200-206. [PMID: 34728168 PMCID: PMC8506226 DOI: 10.1016/j.pulmoe.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background High flow oxygen therapy (HFO) is a widely used intervention for pulmonary complications. Amid the coronavirus infectious disease 2019 (COVID-19) pandemic, HFO became a popular alternative to conventional oxygen supplementation therapies. Risk stratification tools have been repurposed –and new ones developed– to estimate outcome risks among COVID-19 patients. This study aims to provide a simple risk stratification system to predict invasive mechanical ventilation (IMV) or death among COVID-19 inpatients on HFO. Methods Among 529 adult inpatients with COVID-19 pneumonia, we selected unadjusted clinical risk factors for developing the composite endpoint of IMV or death. The risk for the primary outcome by each category was estimated using a Cox proportional hazards model. Bootstrapping was used to validate the results. Results Age above 62, eGFR under 60 ml/min, room air SpO2 ≤89 % upon admission, history of hypertension, history of diabetes, and any comorbidity (cancer, cardiovascular disease, COPD/ asthma, hypothyroidism, or autoimmune disease) were considered for the score. Each of the six criteria scored 1 point. The score was further simplified into 4 categories: 1) 0 criteria, 2) 1 criterion, 3) 2-3 criteria, and 4) ≥4 criteria. Taking the first category as the reference, risk estimates for the primary endpoint were HR; 2.94 [1.67 – 5.26], 4.08 [2.63 – 7.05], and 6.63 [3.74 – 11.77], respectively. In ROC analysis, the AUC for the model was 0.72. Conclusions Our score uses simple criteria to estimate the risk for IMV or death among COVID-19 inpatients with HFO. Higher category reflects consistent increases in risk for the endpoint.
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Affiliation(s)
- G M Aguirre-García
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - D Ramonfaur
- Harvard Medical School, Division of Postgraduate Medical Education, 25 Shattuck St, Boston, MA 02115, United States
| | - G Torre-Amione
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - M T Ramírez-Elizondo
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - R Lara-Medrano
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - J F Moreno-Hoyos
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - E S Velázquez-Ávila
- Hospital San Jose-Tec Salud, Epidemiological Surveillance Unit, Monterrey, Nuevo Leon, Mexico
| | - C A Diaz-Garza
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - V M Sanchez-Nava
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - F Castilleja-Leal
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - G M Rhoades
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico
| | - M F Martínez-Reséndez
- Instituto Tecnologico y de Estudios Superiores de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo Leon, Mexico; Hospital San Jose-Tec Salud, Epidemiological Surveillance Unit, Monterrey, Nuevo Leon, Mexico.
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