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Elhazmi A, Rabie AA, Al-Omari A, Mufti HN, Sallam H, Alshahrani MS, Mady A, Alghamdi A, Altalaq A, Azzam MH, Sindi A, Kharaba A, Al-Aseri ZA, Almekhlafi GA, Tashkandi W, Alajmi SA, Faqihi F, Alharthy A, Al-Tawfiq JA, Melibari RG, Arabi YM. Tocilizumab Outcomes in Critically Ill COVID-19 Patients Admitted to the ICU and the Role of Non-Tocilizumab COVID-19-Specific Medical Therapeutics. J Clin Med 2023; 12:jcm12062301. [PMID: 36983304 PMCID: PMC10053430 DOI: 10.3390/jcm12062301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Background: Tocilizumab is a monoclonal antibody proposed to manage cytokine release syndrome (CRS) associated with severe COVID-19. Previously published reports have shown that tocilizumab may improve the clinical outcomes of critically ill patients admitted to the ICU. However, no precise data about the role of other medical therapeutics concurrently used for COVID-19 on this outcome have been published. Objectives: We aimed to compare the overall outcome of critically ill COVID-19 patients admitted to the ICU who received tocilizumab with the outcome of matched patients who did not receive tocilizumab while controlling for other confounders, including medical therapeutics for critically ill patients admitted to ICUs. Methods: A prospective, observational, multicenter cohort study was conducted among critically ill COVID-19 patients admitted to the ICU of 14 hospitals in Saudi Arabia between 1 March 2020, and October 31, 2020. Propensity-score matching was utilized to compare patients who received tocilizumab to patients who did not. In addition, the log-rank test was used to compare the 28 day hospital survival of patients who received tocilizumab with those who did not. Then, a multivariate logistic regression analysis of the matched groups was performed to evaluate the impact of the remaining concurrent medical therapeutics that could not be excluded via matching 28 day hospital survival rates. The primary outcome measure was patients’ overall 28 day hospital survival, and the secondary outcomes were ICU length of stay and ICU survival to hospital discharge. Results: A total of 1470 unmatched patients were included, of whom 426 received tocilizumab. The total number of propensity-matched patients was 1278. Overall, 28 day hospital survival revealed a significant difference between the unmatched non-tocilizumab group (586; 56.1%) and the tocilizumab group (269; 63.1%) (p-value = 0.016), and this difference increased even more in the propensity-matched analysis between the non-tocilizumab group (466.7; 54.6%) and the tocilizumab group (269; 63.1%) (p-value = 0.005). The matching model successfully matched the two groups’ common medical therapeutics used to treat COVID-19. Two medical therapeutics remained significantly different, favoring the tocilizumab group. A multivariate logistic regression was performed for the 28 day hospital survival in the propensity-matched patients. It showed that neither steroids (OR: 1.07 (95% CI: 0.75–1.53)) (p = 0.697) nor favipiravir (OR: 1.08 (95% CI: 0.61–1.9)) (p = 0.799) remained as a predictor for an increase in 28 day survival. Conclusion: The tocilizumab treatment in critically ill COVID-19 patients admitted to the ICU improved the overall 28 day hospital survival, which might not be influenced by the concurrent use of other COVID-19 medical therapeutics, although further research is needed to confirm this.
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Affiliation(s)
- Alyaa Elhazmi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh 11643, Saudi Arabia
- Correspondence: or (A.E.); or (A.A.R.)
| | - Ahmed A. Rabie
- Critical Care Department, King Saud Medical City, Riyadh 11196, Saudi Arabia
- Correspondence: or (A.E.); or (A.A.R.)
| | - Awad Al-Omari
- Research Center, Dr. Sulaiman Alhabib Medical Group, Riyadh 11643, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Hani N. Mufti
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 11481, Saudi Arabia
| | - Hend Sallam
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Jeddah 23431, Saudi Arabia
| | - Mohammed S. Alshahrani
- Department of Emergency and Critical Care, King Fahad Hospital of the University, Dammam University, Al Khobar 31952, Saudi Arabia
| | - Ahmed Mady
- Critical Care Department, King Saud Medical City, Riyadh 11196, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospital, Tanta 31527, Egypt
| | - Adnan Alghamdi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Ali Altalaq
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Mohamed H. Azzam
- Intensive Care Department, King Abdullah Medical Complex, Jeddah 23816, Saudi Arabia
| | - Anees Sindi
- Department of Medicine, Intensive Care, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, King Fahad Hospital, Al Medina Al Munawara 41477, Saudi Arabia
| | - Zohair A. Al-Aseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
- College of Medicine, Dar Al Uloom University, Riyadh 13314, Saudi Arabia
| | - Ghaleb A. Almekhlafi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Wail Tashkandi
- Department of Adult Critical Care, Fakeeh Care Group, Jeddah 23323, Saudi Arabia
- Department of Surgery, Intensive Care, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Saud A. Alajmi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Fahad Faqihi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh 11643, Saudi Arabia
| | | | - Jaffar A. Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran 34464, Saudi Arabia
- Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Rami Ghazi Melibari
- Department of Critical Care, King Abdullah Medical City, Makah 24246, Saudi Arabia
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
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Elhazmi A, Al-Omari A, Sallam H, Mufti HN, Rabie AA, Alshahrani M, Mady A, Alghamdi A, Altalaq A, Azzam MH, Sindi A, Kharaba A, Al-Aseri ZA, Almekhlafi GA, Tashkandi W, Alajmi SA, Faqihi F, Alharthy A, Al-Tawfiq JA, Melibari RG, Al-Hazzani W, Arabi YM. Machine learning decision tree algorithm role for predicting mortality in critically ill adult COVID-19 patients admitted to the ICU. J Infect Public Health 2022; 15:826-834. [PMID: 35759808 PMCID: PMC9212964 DOI: 10.1016/j.jiph.2022.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 12/03/2021] [Revised: 06/02/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Coronavirus disease-19 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is currently a major cause of intensive care unit (ICU) admissions globally. The role of machine learning in the ICU is evolving but currently limited to diagnostic and prognostic values. A decision tree (DT) algorithm is a simple and intuitive machine learning method that provides sequential nonlinear analysis of variables. It is simple and might be a valuable tool for bedside physicians during COVID-19 to predict ICU outcomes and help in critical decision-making like end-of-life decisions and bed allocation in the event of limited ICU bed capacities. Herein, we utilized a machine learning DT algorithm to describe the association of a predefined set of variables and 28-day ICU outcome in adult COVID-19 patients admitted to the ICU. We highlight the value of utilizing a machine learning DT algorithm in the ICU at the time of a COVID-19 pandemic. Methods This was a prospective and multicenter cohort study involving 14 hospitals in Saudi Arabia. We included critically ill COVID-19 patients admitted to the ICU between March 1, 2020, and October 31, 2020. The predictors of 28-day ICU mortality were identified using two predictive models: conventional logistic regression and DT analyses. Results There were 1468 critically ill COVID-19 patients included in the study. The 28-day ICU mortality was 540 (36.8 %), and the 90-day mortality was 600 (40.9 %). The DT algorithm identified five variables that were integrated into the algorithm to predict 28-day ICU outcomes: need for intubation, need for vasopressors, age, gender, and PaO2/FiO2 ratio. Conclusion DT is a simple tool that might be utilized in the ICU to identify critically ill COVID-19 patients who are at high risk of 28-day ICU mortality. However, further studies and external validation are still required.
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Affiliation(s)
- Alyaa Elhazmi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Awad Al-Omari
- Research Center, Dr. Sulaiman Alhabib Medical Group, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hend Sallam
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Saudi Arabia
| | - Hani N Mufti
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR, Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia. King Abdullah International Medical Research Center, Jeddah, Saudi Arabia Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Rabie
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Mohammed Alshahrani
- Emergency and Critical Care Department, King Fahad Hospital of The University, Imam Abdul Rahman ben Faisal University, Dammam, Saudi Arabia
| | - Ahmed Mady
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Adnan Alghamdi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Ali Altalaq
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Intensive Care Department, King Abdullah Medical Complex, Jeddah, Saudi Arabia
| | - Anees Sindi
- Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, King Fahad Hospital, Al Medina Al Monawarah, Saudi Arabia
| | - Zohair A Al-Aseri
- Departments Of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia; College Of Medicine, Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Ghaleb A Almekhlafi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Wail Tashkandi
- Department of Critical Care, Fakeeh Care Group, Jeddah, Saudi Arabia; Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Saud A Alajmi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Fahad Faqihi
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Jaffar A Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rami Ghazi Melibari
- Department of Critical Care, King Abdullah Medical City, Makah, Saudi Arabia
| | - Waleed Al-Hazzani
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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