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.