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Ye X, Li Y, Luo F, Xu Z, Kasimu K, Wang J, Xu P, Tan C, Yi H, Luo Y. Efficacy and safety of glucocorticoids in the treatment of COVID-19: a systematic review and meta-analysis of RCTs. Clin Exp Med 2024; 24:157. [PMID: 39003393 PMCID: PMC11246314 DOI: 10.1007/s10238-024-01405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/14/2024] [Indexed: 07/15/2024]
Abstract
In the realm of acute respiratory infections, coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a global public health challenge. The application of corticosteroids (CSs) in COVID-19 remains a contentious topic among researchers. Accordingly, our team performed a comprehensive meta-analysis of randomized controlled trials (RCTs) to meticulously evaluate the safety and efficacy of CSs in hospitalized COVID-19 patients. To explore efficacy of CSs in the treatment of COVID-19 patients, we meticulously screened RCTs across key databases, including PubMed, Web of Science, Embase, Cochrane Library, ClinicalTrials.gov, as well as China's CNKI and Wanfang Data. We focused on assessing the 28 days mortality rates. We evaluated the data heterogeneity using the Chi-square test and I2 values, setting significance at 0.1 and 50%. Data from 21 RCTs involving 5721 participants were analyzed. The analysis did not demonstrate a significant association between CSs intervention and the 28 days mortality risk in hospitalized COVID-19 patients (relative risk [RR] = 0.93; 95% confidence interval [95% CI]: 0.84-1.03; P = 0.15). However, subgroup analysis revealed a significant reduction in 28 days mortality among patients with moderate-to-severe COVID-19 (RR at 0.85; 95% CI: 0.76-0.95; P = 0.004). Specifically, short-term CS administration (≤ 3 days) was associated with a substantial improvement in clinical outcomes (RR = 0.24; 95% CI: 0.09-0.63; P = 0.004), as was longer-term use (≥ 8 days) (RR = 0.88; 95% CI: 0.77-0.99; P = 0.04). Additionally, in patients with moderate-to-severe COVID-19, the administration of dexamethasone increased the number of 28 days ventilator-free days (Mean Difference = 1.92; 95% CI: 0.44-3.40; P = 0.01). Methylprednisolone also demonstrated significant benefits in improving clinical outcomes (RR = 0.24; 95% CI: 0.09-0.63; P = 0.004). Our meta-analysis demonstrated that although there is no significant difference in 28 days mortality rates among hospitalized COVID-19 patients, the use of CSs may be beneficial in improving clinical outcomes in moderate or severe COVID-19 patients. There was no significant increase in the occurrence of adverse events associated with the use of CSs. Our meta-analysis provides evidence that while CSs may not be suitable for all COVID-19 patients, they could be effective and safe in severely ill COVID-19 patients. Consequently, it is recommended to administer CSs for personalized treatments in COVID-19 cases to improve the clinical outcomes while minimizing adverse events.
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Affiliation(s)
- Xiangrong Ye
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Ye Li
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Feng Luo
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Zhibin Xu
- Department of Organ Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kaidirina Kasimu
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Juan Wang
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Peihang Xu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chunjiang Tan
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Hui Yi
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Yifeng Luo
- Division of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Institute of Respiratory Diseases of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
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Kirkham AM, Bailey AJM, Shorr R, Lalu MM, Fergusson DA, Allan DS. Systematic review and meta-analysis of randomized controlled trials of mesenchymal stromal cells to treat coronavirus disease 2019: is it too late? Cytotherapy 2023; 25:341-352. [PMID: 36333234 PMCID: PMC9556962 DOI: 10.1016/j.jcyt.2022.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AIMS Evidence regarding the extent that mesenchymal stromal cells (MSCs) may improve clinical outcomes in patients with coronavirus disease 2019 (COVID-19) has been limited by marked inter-study heterogeneity, inconsistent product characterization and appreciable risk of bias (RoB). Given the evolution of treatment options and trajectory of the pandemic, an updated analysis of high-quality evidence from randomized controlled trials is needed for a timely and conclusive understanding of the effectiveness of MSCs. METHODS A systematic literature search through March 30, 2022, identified all English language, full-text randomized controlled trials examining the use of MSCs in the treatment of COVID-19. RESULTS Eight studies were identified (316 patients, 165 administered MSCs and 151 controls). Controls evolved significantly over time with a broad range of comparison treatments. All studies reported mortality at study endpoint. Random effects meta-analysis revealed that MSCs decreased relative risk of death (risk ratio, 0.63, 95% confidence interval, 0.42-0.94, P = 0.02, I2 = 14%) with no significant difference in absolute risk of death. MSCs decreased length of hospital stay and C-reactive protein levels and increased odds of clinical improvement at study endpoint compared with controls. Rates of adverse events and severe adverse events were similar between MSC and control groups. Only two (25%) studies reported all four International Society for Cell & Gene Therapy criteria for MSC characterization. Included studies had low (n = 7) or some (n = 1) concerns regarding RoB. CONCLUSIONS MSCs may reduce risk of death in patients with severe or critical COVID-19 and improve secondary clinical outcomes. Variable outcome reporting, inconsistent product characterization and variable control group treatments remain barriers to higher-quality evidence and may constrain clinical usage. A master protocol is proposed and appears necessary for accelerated translation of higher-quality evidence for future applications of MSC therapy.
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Affiliation(s)
- Aidan M Kirkham
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Adrian J M Bailey
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Risa Shorr
- Medical Information and Learning Services, The Ottawa Hospital, Ottawa, Canada
| | - Manoj M Lalu
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Anesthesia, The Ottawa Hospital, Ottawa, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada; Department of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - David S Allan
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada; Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, Canada.
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Massó M, Granés L, Cayuelas L, Gené-Badia J, Sequeira E, Catalán M. Predictive factors for hospitalization in a cohort of primary healthcare patients with suspected COVID-19. ATENCIÓN PRIMARIA PRÁCTICA 2023. [PMCID: PMC9841078 DOI: 10.1016/j.appr.2023.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Sarriá-Landete AJ, Crespo-Matas JA, Domínguez-Quesada I, Castellanos-Monedero JJ, Marte-Acosta D, Arias-Arias ÁJ. Predicting the response to methylprednisolone pulses in patients with SARS-COV-2 infection. MEDICINA CLINICA (ENGLISH ED.) 2022; 159:557-562. [PMID: 36536623 PMCID: PMC9752105 DOI: 10.1016/j.medcle.2022.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 02/23/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Treating systemic inflammation caused by SARS-COV 2 (COVID-19) has become a challenge for the clinician. Corticosteroids have been the turning point in the treatment of this disease. Preliminary data from Recovery clinical trial raises hope by showing that treatment with dexamethasone at doses of 6 mg/day shows a reduction on morbidity in patients requiring added oxygen therapy. However, both the start day or what kind of corticosteroid, are still questions to be clarified. Since the pandemic beginning, we have observed large differences in the type of corticosteroid, dose and initiation of treatment.Our objective is to assess the predictive capacity of the characteristics of patients treated with methylprednisolone pulses to predict hospital discharge. MATERIALS AND METHODS We presented a one-center observational study of a retrospective cohort. We included all patients admitted between 03/06/2020 and 05/15/2020 because of COVID-19. We have a total number of 1469 patients, of whom 322 received pulses of methylprednisolone. Previous analytical, radiographic, previous disease data were analyzed on these patients. The univariant analysis was performed using Chi-squared and the T test of Student according to the qualitative or quantitative nature of the variables respectively. For multivariate analysis, we have used binary logistic regression and ROC curves. RESULTS The analysis resulted statistically significant in dyspnea, high blood pressure, dyslipidemia, stroke, ischemic heart disease, cognitive impairment, solid tumor, C-reactive protein (CRP), lymphopenia and d-dimer within 5 days of admission. Radiological progression and FIO2 input are factors that are associated with a worst prognosis in COVID-19 that receive pulses of methylprednisolone. Multivariate analysis shows that age, dyspnea and C-reactive protein are markers of hospital discharge with an area below the curve of 0.816. CONCLUSIONS In patients with methylprednisolone pulses, the capacity of the predictive model for hospital discharge including variables collected at 5 days was (area under the curve) 0.816.
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Affiliation(s)
- Antonio J. Sarriá-Landete
- Departamento de Medicina Interna, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain,Corresponding author
| | - José A. Crespo-Matas
- Departamento de Medicina Interna, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | | | | | - Dinés Marte-Acosta
- Departamento de Neumología, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Ángel J. Arias-Arias
- Departamento de Investigación, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
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Sarriá-Landete AJ, Crespo-Matas JA, Domínguez-Quesada I, Castellanos-Monedero JJ, Marte-Acosta D, Arias-Arias ÁJ. Predicting the response to methylprednisolone pulses in patients with SARS-COV-2 infection. Med Clin (Barc) 2022; 159:557-562. [PMID: 35718548 PMCID: PMC9212640 DOI: 10.1016/j.medcli.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Treating systemic inflammation caused by SARS-COV 2 (COVID-19) has become a challenge for the clinician. Corticosteroids have been the turning point in the treatment of this disease. Preliminary data from Recovery clinical trial raises hope by showing that treatment with dexamethasone at doses of 6mg/day shows a reduction on morbidity in patients requiring added oxygen therapy. However, both the start day or what kind of corticosteroid, are still questions to be clarified. Since the pandemic beginning, we have observed large differences in the type of corticosteroid, dose and initiation of treatment. Our objective is to assess the predictive capacity of the characteristics of patients treated with methylprednisolone pulses to predict hospital discharge. MATERIALS AND METHODS We presented a one-center observational study of a retrospective cohort. We included all patients admitted between 03/06/2020 and 05/15/2020 because of COVID-19. We have a total number of 1469 patients, of whom 322 received pulses of methylprednisolone. Previous analytical, radiographic, previous disease data were analyzed on these patients. The univariant analysis was performed using Chi-squared and the T test of Student according to the qualitative or quantitative nature of the variables respectively. For multivariate analysis, we have used binary logistic regression and ROC curves. RESULTS The analysis resulted statistically significant in dyspnea, high blood pressure, dyslipidemia, stroke, ischemic heart disease, cognitive impairment, solid tumor, C-reactive protein (CRP), lymphopenia and d-dimer within 5 days of admission. Radiological progression and FIO2 input are factors that are associated with a worst prognosis in COVID-19 that receive pulses of methylprednisolone. Multivariate analysis shows that age, dyspnea and C-reactive protein are markers of hospital discharge with an area below the curve of 0.816. CONCLUSIONS In patients with methylprednisolone pulses, the capacity of the predictive model for hospital discharge including variables collected at 5 days was (area under the curve) 0.816.
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Affiliation(s)
- Antonio J. Sarriá-Landete
- Departamento de Medicina Interna, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain,Corresponding author
| | - José A. Crespo-Matas
- Departamento de Medicina Interna, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | | | | | - Dinés Marte-Acosta
- Departamento de Neumología, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Ángel J. Arias-Arias
- Departamento de Investigación, Hospital La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
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The Efficacy of Methylprednisolone in Clinical Manifestations, Inflammatory Biomarkers, and Antioxidant Changes in the COVID-19 Patients. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2022. [DOI: 10.5812/archcid-129799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The application of methylprednisolone in ARDS patients has led to a sustained reduction in inflammatory plasma cytokines and chemokines and has recently been used in the treatment of patients with SARS-CoV-2 infection. Objectives: In this study, the effect of methylprednisolone on clinical symptoms and antioxidant changes of patients with COVID-19 has been investigated. Methods: In the present study, patients with moderate to severe COVID-19 who required hospitalization were entered into the study phase. Then, in addition to standard treatment, patients received methylprednisolone at a dose of 250 mg intravenously over three days. Necessary evaluations include analysis of arterial blood gases, pulse oximetry, monitoring of patient clinical signs, examination of inflammatory biomarkers, and also receiving 10 cc of peripheral blood samples to check for antioxidant changes, at the beginning of the study, after 24 hours, and 72 hours after receiving methylprednisolone was on the agenda. Results: Changes in fever, superoxide dismutase (SOD, Glutathione-S-Transferase (GST, the ferric reducing ability of plasma (FRAP, malondialdehyde (MDA, Nitric oxide, Ferritin, and TNF-α before treatment and 72 hours after treatment were significantly different between the two stages (P < 0.05). Conclusions: The use of methylprednisolone improves the balance of antioxidants and immunological factors in patients with COVID-19 and thus improves some clinical indicators in these patients.
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Patel C, Parmar K, Patel D, Patel S, Sheth D, Beladiya JV. Effect of corticosteroid therapy on mortality in COVID-19 patients-A systematic review and meta-analysis. Rev Med Virol 2022; 32:e2386. [PMID: 35971278 PMCID: PMC9538928 DOI: 10.1002/rmv.2386] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 12/15/2022]
Abstract
The effect of corticosteroid therapy is still controversial on prevention of mortality in coronavirus disease‐2019 (COVID‐19). The objective of this study is to investigate the effect of corticosteroids on mortality. This systematic review was performed as per preferred reporting items for systematic reviews and meta‐analyses guidelines. A systematic search was performed at different databases namely Medline/PubMed, Cochrane and Google scholar on 10 February 2022. A pooled estimate for effect of corticosteroid therapy on mortality was calculated as outcome of study. Risk bias analysis and Newcastle Ottawa Scale were used to assess the quality of randomized control trial (RCT) and cohort studies, respectively. Cochran's Q test and the I2 statistic were conducted for heterogeneity and accordingly study model was applied. A total 43 studies were included, having sample size of 96,852 patients. Amongst them, 19,426 and 77,426 patients received corticosteroid therapy (intervention group) or standard treatment without corticosteroid (control group), respectively. Mortality observed in the intervention and control group was 14.2% (2749) and 7.1% (5459), respectively. The pooled estimate 2.173 (95% CI: 2.0690–2.2820) showed significantly increased mortality in intervention as compared to control. The pooled estimate of methyprednisolone 1.206 (95% CI: 1.0770–1.3500) showed significantly increased mortality while the pooled estimate of dexamethasone 1.040 (95% CI: 0.9459–1.1440) showed insignificantly increased mortality as compared to control. In conclusion, corticosteroid therapy produced a negative prognosis as depicted by increased mortality among COVID‐19 patients. The possible reasons might be delay in virus clearance and secondary infections due to corticosteroids initiated at high dose in the early stage of infection.
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Affiliation(s)
- Chirag Patel
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
| | - Krupanshu Parmar
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
| | - Dipanshi Patel
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
| | - Sandip Patel
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
| | - Devang Sheth
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
| | - Jayesh V Beladiya
- Department of Pharmacology, L. M. College of Pharmacy, Ahmedabad, Gujarat, India
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El-Saber Batiha G, Al-Gareeb AI, Saad HM, Al-kuraishy HM. COVID-19 and corticosteroids: a narrative review. Inflammopharmacology 2022; 30:1189-1205. [PMID: 35562628 PMCID: PMC9106274 DOI: 10.1007/s10787-022-00987-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/30/2022] [Indexed: 02/06/2023]
Abstract
It has been reported that corticosteroid therapy was effective in the management of severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome (MERS), and recently in coronavirus disease 2019 (COVID-19). Corticosteroids are potent anti-inflammatory drugs that mitigate the risk of acute respiratory distress syndrome (ARDS) in COVID-19 and other viral pneumonia, despite a reduction of viral clearance; corticosteroids inhibit the development of cytokine storm and multi-organ damage. The risk-benefit ratio should be assessed for critical COVID-19 patients. In conclusion, corticosteroid therapy is an effective way in the management of COVID-19, it reduces the risk of complications primarily acute lung injury and the development of ARDS. Besides, corticosteroid therapy mainly dexamethasone and methylprednisolone are effective in reducing the severity of COVID-19 and associated comorbidities such as chronic obstructive pulmonary diseases (COPD), rheumatoid arthritis, and inflammatory bowel disease (IBD).
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Affiliation(s)
- Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, 22511 AlBeheira Egypt
| | - Ali I. Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, Mustansiriyiah University, Baghdad, Iraq
| | - Hebatallah M. Saad
- Department of Pathology, Faculty of Veterinary Medicine, Matrouh University, Matrouh, 51744 Matrouh Egypt
| | - Hayder M. Al-kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, Mustansiriyiah University, Baghdad, Iraq
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Zhou F, Deng J, Heybati K, Zuo QK, Ali S, Hou W, Wong CY, Ramaraju HB, Chang O, Dhivagaran T, Silver Z. Efficacy and safety of corticosteroid regimens for the treatment of hospitalized COVID-19 patients: a meta-analysis. Future Virol 2022; 17:463-489. [PMID: 35814934 PMCID: PMC9249165 DOI: 10.2217/fvl-2021-0244] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 04/08/2022] [Indexed: 12/15/2022]
Abstract
Aim To evaluate the efficacy and safety of corticosteroids for treating hospitalized COVID-19 patients. Materials & methods Efficacy outcomes included time to negative SARS-CoV-2 tests, length of stay, duration and incidence of intensive unit care stay, incidence of mortality and duration and incidence of mechanical ventilation. Safety outcomes included the incidence of adverse events and severe adverse events, incidence of hyperglycemia and incidence of nosocomial infections. Results Ninety-five randomized controlled trials (RCTs) and observational studies (n = 42,205) were included. Corticosteroids were associated with increased length of stay (based on RCT only), increased time to negative tests, decreased length of mechanical ventilation and increased odds of hyperglycemia. Conclusion Corticosteroids should be considered in patients requiring mechanical ventilation, and glycemic monitoring may be needed when administering corticosteroids.
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Affiliation(s)
- Fangwen Zhou
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Qi Kang Zuo
- Department of Anesthesiology, Rutgers, New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
- Faculty of Science, McGill University, 845 Sherbrooke St W, Montreal, QC, H3A 0G5, Canada
| | - Saif Ali
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Wenteng Hou
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Chi Yi Wong
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | | | - Oswin Chang
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Thanansayan Dhivagaran
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
- Integrated Biomedical Engineering & Health Sciences Program (iBioMed), McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Zachary Silver
- Faculty of Science, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
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Chen Z, Yin X, Tan X, Wang J, Jiang N, Tian M, Li H, Lu Z, Xiong N, Gong Y. Effectiveness of Systemic Corticosteroids Therapy for Nonsevere Patients With COVID-19: A Multicenter, Retrospective, Longitudinal Cohort Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:709-716. [PMID: 35219601 PMCID: PMC8866099 DOI: 10.1016/j.jval.2021.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 10/27/2021] [Accepted: 12/09/2021] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Corticosteroids were clinically used in the treatment of nonsevere patients with COVID-19, but the efficacy of such treatment lacked sufficient clinical evidence, and the impact of dose had never been studied. This study aimed to evaluate the effect of systemic corticosteroid use (SCU) in nonsevere patients with COVID-19. METHODS We conducted a multicenter retrospective cohort study in Hubei Province. A total of 1726 patients admitted with nonsevere type COVID-19 were included. Mixed-effect Cox model, mixed-effect Cox model with time-varying exposure, multiple linear regression, and propensity score analysis (inverse probability of treatment weight and propensity score matching) were used to explore the association between SCU and progression into severe type, all-cause mortality, and length of stay. RESULTS During the follow-up of 30 days, 29.8% of nonsevere patients with COVID-19 received treatment with systemic corticosteroids. The use of systemic corticosteroids was associated with higher probability of developing severe type (adjusted hazard ratio 1.81; 95% confidence interval 1.47-2.21), all-cause mortality (adjusted hazard ratio 2.92; 95% confidence interval 1.39-6.15) in time-varying Cox analysis, and prolonged hospitalization (β 4.14; P < .001) in multiple linear regression. Analysis with 2 propensity score cohorts displayed similar results. Besides, increased corticosteroid dose was significantly associated with elevated probability of developing severe type (P < .001) and prolonged hospitalization (P < .001). CONCLUSIONS Corticosteroid treatment against nonsevere patients with COVID-19 was significantly associated with worse clinical outcomes. The higher dose was significantly associated with elevated risk of poor disease progression. We recommend that SCU should be avoided unless necessary among nonsevere patients with COVID-19.
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Affiliation(s)
- Zhenyuan Chen
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xiangping Tan
- Lichuan Center for Disease Control and Prevention, Enshi Tujia and Miao Autonomous Prefecture, P. R. China
| | - Jing Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Nan Jiang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Mengge Tian
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Hui Li
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Zuxun Lu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Nian Xiong
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
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11
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Swaminathan L, Kaatz S, Chubb H, Tae K, Ramesh MS, Fadel R, Big C, Jones J, Flanders SA, Prescott HC. Impact of Early Corticosteroids on Preventing Clinical Deterioration in Non-critically Ill Patients Hospitalized with COVID-19: A Multi-hospital Cohort Study. Infect Dis Ther 2022; 11:887-898. [PMID: 35267172 PMCID: PMC8908754 DOI: 10.1007/s40121-022-00615-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/23/2022] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION While guidelines stronglyrecommend dexamethasone in critical COVID-19, the optimal threshold to initiate corticosteroids in non-critically ill patients with COVID-19 remains unclear. Using data from a state-wide COVID-19 registry, we evaluated the effectiveness of early corticosteroids for preventing clinical deterioration among non-critically ill patients hospitalized for COVID-19 and receiving non-invasive oxygen therapy. METHODS This was a target trial using observational data from patients hospitalized for COVID-19 at 39 hospitals participating in the MI-COVID19 registry between March 16, 2020 and August 24, 2020. We studied the impact of corticosteroids initiated within 2 calendar days of hospitalization ("early steroids") versus no early steroids among non-ICU patients with laboratory-confirmed SARS-CoV2 receiving non-invasive supplemental oxygen therapy. Our primary outcome was a composite of in-hospital mortality, transfer to intensive care, and receipt of invasive mechanical ventilation. We used inverse probability of treatment weighting (IPTW) and propensity score-weighted regression to measure the association of early steroids and outcomes. RESULTS Among 1002 patients meeting study criteria, 231 (23.1%) received early steroids. After IPTW, to balance potential confounders between the treatment groups, early steroids were not associated with a decrease in the composite outcome (aOR 1.1, 95%CI 0.8-1.6) or in any components of the primary outcome. CONCLUSION We found no evidence that early corticosteroid therapy prevents clinical deterioration among hospitalized non-critically ill COVID-19 patients receiving non-invasive oxygen therapy. Further studies are needed to determine the optimal threshold for initiating corticosteroids in this population.
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Affiliation(s)
- Lakshmi Swaminathan
- Division of Hospital Medicine, St. Joseph Mercy Hospital, 5301 McAuley Dr, Ypsilanti, 48197, USA.
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Heather Chubb
- Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), Ann Arbor, USA
| | - Kim Tae
- Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), Ann Arbor, USA
| | - Mayur S Ramesh
- Division of Infectious Disease, Henry Ford Hospital, Detroit, MI, USA
| | - Raef Fadel
- Division of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Cecilia Big
- Division of Infectious Disease, Beaumont Hospital-Dearborn, Dearborn, MI, USA
| | - Jessica Jones
- Department of Pharmacy, Beaumont Hospital-Dearborn, Dearborn, MI, USA
| | - Scott A Flanders
- Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, USA
- Michigan Hospital Medicine Safety Consortium, Ann Arbor, MI, USA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
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12
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Ebrahimi Chaharom F, Pourafkari L, Ebrahimi Chaharom AA, Nader ND. Effects of corticosteroids on Covid-19 patients: A systematic review and meta-analysis on clinical outcomes. Pulm Pharmacol Ther 2021; 72:102107. [PMID: 34933068 PMCID: PMC8684054 DOI: 10.1016/j.pupt.2021.102107] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/31/2021] [Accepted: 12/14/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Covid-19 disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although corticosteroids have shown some promising results in Covid-19 patients, their effectiveness remains controversial. In this systematic review, we evaluated the effect of corticosteroids in mortality, Hospitalization, ICU admission, intubation, and mechanical ventilation in Covid-19 patients. METHODS We searched major databases from March-2020 to Jan-2021. Twenty-nine studies were included after evaluating the eligibility of the literature. The extracted data for mortality, hospitalization, admission to the ICU, intubation, and mechanical ventilation were analyzed with RevMan® 5.4. Categorical variables are presented with odds ratios (OR), and numerical variables are shown with the mean difference. RESULT Corticosteroid treatment had no impact on mortality in 18,190 covid patients with OR = 1.12[0.83-1.50]. When we include the randomized controlled trials, corticosteroids reduced the mortality by 20% (OR = 0.80 [0.73, 0.88]; P < 0.001). Additionally, the risk of admission to the ICU, the need for endotracheal intubation, and mechanical ventilation were comparable between patients receiving corticosteroids and controls. The duration of hospitalization was also similar in the two groups. CONCLUSION Corticosteroid therapy may not be effective for reducing mortality, length of hospitalization, the likelihood of intubation and mechanical ventilation, and ICU admission in patients suffering from Covid-19 pneumonia.
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Affiliation(s)
| | - Leili Pourafkari
- Catholic Health Systems; University at Buffalo, Jacobs School of Medicine, USA.
| | | | - Nader D Nader
- University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, USA.
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13
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Goyal D, Inada-Kim M, Mansab F, Iqbal A, McKinstry B, Naasan AP, Millar C, Thomas S, Bhatti S, Lasserson D, Burke D. Improving the early identification of COVID-19 pneumonia: a narrative review. BMJ Open Respir Res 2021; 8:8/1/e000911. [PMID: 34740942 PMCID: PMC8573292 DOI: 10.1136/bmjresp-2021-000911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
Delayed presentation of COVID-19 pneumonia increases the risk of mortality and need for high-intensity healthcare. Conversely, early identification of COVID-19 pneumonia grants an opportunity to intervene early and thus prevent more complicated, protracted and less successful hospital admissions. To improve the earlier detection of COVID-19 pneumonia in the community we provide a narrative review of current evidence examining the clinical parameters associated with early disease progression. Through an evolving literature review, we examined: the symptoms that may suggest COVID-19 progression; the timing of deterioration; the utility of basic observations, clinical examination and chest X-ray; the value of postexertion oxygen saturations; and the use of CRP to monitor disease progression. We go on to discuss the challenges in monitoring the COVID-19 patient in the community and discuss thresholds for further assessment. Confusion, persistent fever and shortness of breath were identified as worrying symptoms suggestive of COVID-19 disease progression necessitating urgent clinical contact. Importantly, a significant proportion of COVID-19 pneumonia patients appear not to suffer dyspnoea despite severe disease. Patients with this asymptomatic hypoxia seem to have a poorer prognosis. Such patients may present with other signs of hypoxia: severe fatigue, exertional fatigue and/or altered mental status. We found duration of symptoms to be largely unhelpful in determining risk, with evidence of deterioration at any point in the disease. Basic clinical parameters (pulse, respiratory rate, blood pressure, temperature and oxygen saturations (SpO2)) are likely of high value in detecting the deteriorating community COVID-19 patient and/or COVID-19 mimickers/complications (eg, sepsis, bacterial pneumonia and pulmonary embolism). Of these, SpO2 carried the greatest utility in detecting COVID-19 progression. CRP is an early biochemical parameter predictive of disease progression and used appropriately is likely to contribute to the early identification of COVID-19 pneumonia. Identifying progressive COVID-19 in the community is feasible using basic clinical questions and measurements. As such, if we are to limit the mortality, morbidity and the need for complicated, protracted admissions, monitoring community COVID-19 cases for signs of deterioration to facilitate early intervention is a viable strategy.
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Affiliation(s)
- Daniel Goyal
- Department of Acute Internal Medicine, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Matthew Inada-Kim
- Department of Infection, Antimicrobial Resistance and Deterioration, NHS England, Redditch, Worcestershire, UK.,Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust, Winchester, Hampshire, UK
| | - Fatam Mansab
- Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Amir Iqbal
- Department of Covid-19 Remote Monitoring of Patients During Response & Recovery, NHS Grampian, Aberdeen, Aberdeen, UK
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Adeeb P Naasan
- Department of General Medicine, Islands Hospital, Oban, UK
| | - Colin Millar
- Department of General Medicine, Islands Hospital, Oban, UK
| | - Stephen Thomas
- Department of Respiratory Medicine, Raigmore Hospital, Inverness, Highland, UK
| | - Sohail Bhatti
- Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Daniel Lasserson
- Hospital at Home, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK.,Department of Ambulatory Medicine, University of Warwick, Coventry, West Midlands, UK
| | - Derek Burke
- Department of Clinical Governance, Gibraltar Health Authority, Gibraltar, Gibraltar
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14
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Burgaña Agoües A, Serra Gallego M, Hernández Resa R, Joven Llorente B, Lloret Arabi M, Ortiz Rodriguez J, Puig Acebal H, Campos Hernández M, Caballero Ayala I, Pavón Calero P, Losilla Calle M, Bueno Nieto R, Oliver Messeguer L, Madridejos Mora R, Abellana Sangrà R, Perez-Porcuna TM. Risk Factors for COVID-19 Morbidity and Mortality in Institutionalised Elderly People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10221. [PMID: 34639522 PMCID: PMC8507792 DOI: 10.3390/ijerph181910221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND SARS-CoV-2 has caused a high mortality in institutionalised individuals. There are very few studies on the involvement and the real impact of COVID-19 in nursing homes. This study analysed factors related to morbidity and mortality of COVID-19 in institutionalised elderly people. METHODS This cohort study included 842 individuals from 12 nursing homes in Sant Cugat del Vallès (Spain) from 15 March to 15 May 2020. We evaluated individual factors (demographic, dependence, clinical, and therapeutic) and those related to the nursing homes (size and staff) associated with infection and mortality by SARS-CoV-2. Infection was diagnosed by molecular biology test. RESULTS Of the 842 residents included in the analysis, 784 underwent a Polymerase Chain Reaction (PCR) test; 74.2% were women, the mean age was 87.1 years, and 11.1% died. The PCR test was positive in 44%. A total of 33.4% of the residents presented symptoms compatible with COVID-19 and of these, 80.9% were PCR-positive for SARS-CoV-2. Infection by SARS-CoV-2 among residents was associated with the rate of staff infected in the homes. Mortality by SARS-CoV-2 was related to male sex and a greater grade of dependence measured with the Barthel index. CONCLUSIONS SARS-Cov-2 infection in institutionalised people is associated with the infection rate in nursing home workers and mortality by SARS-Cov-2 with sex and greater dependency according to the Barthel index. Adequate management of nursing home staff and special attention to measures of infection control, especially of individuals with greater dependence, are keys for successful management of future pandemic situations.
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Affiliation(s)
- Ander Burgaña Agoües
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Marta Serra Gallego
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Raquel Hernández Resa
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Beatriz Joven Llorente
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Maria Lloret Arabi
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Jessica Ortiz Rodriguez
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Helena Puig Acebal
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Mireia Campos Hernández
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Itziar Caballero Ayala
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Pedro Pavón Calero
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Montserrat Losilla Calle
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Rosario Bueno Nieto
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Laura Oliver Messeguer
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | - Rosa Madridejos Mora
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
| | | | - Tomás M. Perez-Porcuna
- Atenció Primària, Fundació Assitencial Mútua Terrassa, 08221 Terrassa, Spain; (A.B.A.); (M.S.G.); (R.H.R.); (B.J.L.); (M.L.A.); (J.O.R.); (H.P.A.); (M.C.H.); (I.C.A.); (P.P.C.); (M.L.C.); (R.B.N.); (L.O.M.); (R.M.M.); (T.M.P.-P.)
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15
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Climente‐Martí M, Ruiz‐Millo O, López‐Cruz I, Atienza‐García Á, Martínez‐Moragón E, Garijo‐Gómez E, López‐Grima ML, Zaragoza‐Crespo R, Llau‐Pitarch JV, Bautista‐Rentero D, Nogueira‐Coito JM, Ripollés‐González T, Marco‐Artal MA, Romero‐Serrano R, Dolz‐Sinisterra F, López‐Estudillo R. Impact of intermediate to high doses of methylprednisolone on mortality rate in patients with COVID-19 pneumonia-induced severe systemic inflammation. Int J Clin Pract 2021; 75:e14479. [PMID: 34107137 PMCID: PMC8237058 DOI: 10.1111/ijcp.14479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/09/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION In addition to respiratory support needs, patients' characteristics to guide indication or timing of corticosteroid treatment in COVID-19 patients are not completely established. This study aimed to evaluate the impact of methylprednisolone on mortality rate in patients with COVID-19 pneumonia-induced severe systemic inflammation (PI-SSI). METHODS Between 9 March and 5 May 2020 (final follow-up on 2 July 2020), a retrospective cohort study was conducted in hospitalised patients with COVID-19 PI-SSI (≥2 inflammatory biomarkers [IBs]: temperature ≥38℃, lymphocyte ≤800 cell/µL, C-reactive protein ≥100 mg/L, lactate dehydrogenase ≥300 units/L, ferritin ≥1000 mcg/L, D-dimer ≥500 ng/mL). Patients received 0.5-1.0 mg/kg of methylprednisolone for 5-10 days or standard of care. The primary outcome was 28-day all-cause mortality. Secondary outcomes included ≥2 points improvement on a 7-item WHO-scale (Day 14), transfer to intensive care unit (ICU) (Day 28) and adverse effects. Kaplan-Meier method and Cox proportional hazard regression were implemented to analyse the time to event outcomes. RESULTS A total of 142 patients (corticosteroid group n = 72, control group n = 70) were included. A significant reduction in 28-day all-cause mortality was shown with methylprednisolone in patients with respiratory support (HR: 0.15; 95% CI 0.03-0.71), with ≥3 (HR: 0.17; 95% CI 0.05-0.61) or ≥4 altered IB (HR: 0.15; 95% CI 0.04-0.54) and in patients with both respiratory support and ≥3 (HR: 0.11; 95% CI 0.02-0.53] or ≥4 altered IB (HR: 0.14; 95% CI 0.04-0.51). No significant differences were found in secondary outcomes. CONCLUSION Intermediate to high doses of methylprednisolone, initiated between 5 and 12 days after symptom onset, was associated with a significant reduction in 28-day all-cause mortality in patients with COVID-19 pneumonia and ≥3 o ≥ 4 altered IB, independently of the need of respiratory support.
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Affiliation(s)
| | - Oreto Ruiz‐Millo
- Pharmacy DepartmentDoctor Peset University HospitalValenciaSpain
| | - Ian López‐Cruz
- Internal Medicine DepartmentDoctor Peset University HospitalValenciaSpain
| | | | | | | | | | | | - Juan Vicente Llau‐Pitarch
- Anaesthesiology and Postsurgical Critical Care DepartmentDoctor Peset University HospitalValenciaSpain
| | | | | | | | | | - Ramón Romero‐Serrano
- Health Information Management DepartmentDoctor Peset University HospitalValenciaSpain
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16
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Ahmad B, Manzar A, Khrshid S, Ul Hassan N, Muhammad A. Methylprednisolone for COVID-19 Patients Admitted to a Tertiary Care Hospital: A Single-Centre Study. Cureus 2021; 13:e17693. [PMID: 34650867 PMCID: PMC8487664 DOI: 10.7759/cureus.17693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of various corticosteroids in the management of COVID-19 is evolving. Following an initial lack of evidence, the relatively novel data, supporting the survival benefit to severe and critical COVID-19 patients, is of limited scale. MATERIALS AND METHODS This retrospective study observed medical records and disease outcomes of 200 patients with moderate, severe and critical COVID-19 receiving methylprednisolone (MP). The dose of methylprednisolone was 0.5 to 2 mg per kg in these patients. RESULTS Median age of presentation was 59 years. The median duration of symptoms at presentation was five days. The most common presenting symptoms were cough (77.5%), fever (67.5%) and shortness of breath (63.5%). Majority of patients (85%) presented in the first week of illness. One or more comorbidities were present in 75% of patients. Complications seen in the study cohort were cytokine release syndrome (CRS) 92 (46%), acute respiratory distress syndrome (ARDS) 44 (22%) and multi-organ dysfunction 17 (8.5%). The median time for initiation of corticosteroid therapy was four hours. Overall survival (OS) in patients receiving methylprednisolone was 83.5%. The OS for patients with moderate, severe and critical diseases was 97.8%, 86.2% and 62%, respectively (p<0.001). CONCLUSION Steroids like methylprednisolone are useful in COVID-19 admitted patients and provide excellent survival outcomes.
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Affiliation(s)
- Bilal Ahmad
- Endocrinology and Diabetes, Pak-Emirates Military Hospital Rawalpindi, Rawalpindi, PAK
| | - Adnan Manzar
- Internal Medicine, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | - Saba Khrshid
- Internal Medicine, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | - Naeem Ul Hassan
- Internal Medicine, Combined Military Hospital, Rawalpindi, PAK
| | - Anjum Muhammad
- Dermatology, Pak-Emirates Military Hospital, Rawalpindi, PAK
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17
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Efficacy and Safety of Corticosteroid Use in Coronavirus Disease 2019 (COVID-19): A Systematic Review and Meta-Analysis. Infect Dis Ther 2021; 10:2447-2463. [PMID: 34389970 PMCID: PMC8363240 DOI: 10.1007/s40121-021-00518-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/27/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction We conducted a comprehensive literature review to synthesize evidence for the relationship between corticosteroid use and mortality in patients with COVID-19. Methods The PUBMED, EMBASE, and Cochrane Library were searched from inception to March 13, 2021. We searched and analyzed randomized controlled trials (RCTs) and observational studies (OSs) that examined corticosteroid use in patients with COVID-19. The primary outcome was in-hospital mortality, while the secondary outcome was the need for mechanical ventilation (MV) and serious adverse events. Results A total of 11 RCTs and 44 OSs involving 7893 and 41,164 patients with COVID-19 were included in the study. Corticosteroid use was associated with lower COVID-19 mortality in RCTs, but was not statistically significant (OR 0.91, 95% CI 0.77–1.07; I2 = 63.4%). The subgroup analysis of pulse dose corticosteroid showed survival benefit statistically (OR 0.29, 95% CI 0.15–0.56). Moreover, the corticosteroid use may reduce the need for MV (OR 0.67, 95% CI 0.51–0.90; I2 = 7.5%) with no significant increase in serious adverse reactions (OR 0.84, 95% CI 0.30–2.37; I2 = 33.3%). In addition, the included OSs showed that the pulse dose (OR 0.66, 95% CI 0.45–0.95; I2 = 30.8%) might lower the mortality in patients with COVID-19. The pulse dose of methylprednisolone (OR 0.60, 95% CI 0.45–0.80; I2 = 0%) had a beneficial effect on survival. It was especially significant when the duration of pulse methylprednisolone use was less than 7 days (OR 0.59, 95% CI 0.43–0.80; I2 = 0%). Conclusions This meta-analysis indicated that corticosteroid use might cause a slight reduction in COVID-19 mortality. However, it could significantly reduce the MV requirement in patients with COVID-19 and restrict serious adverse events. Additionally, the pulse dose of methylprednisolone for less than 7 days may be a good treatment choice for patients with COVID-19. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00518-3.
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Zhan Y, Shang J, Gu Y, Huang Q, Xie J. Efficacy of corticosteroid in patients with COVID-19: A multi-center retrospective study and meta-analysis. J Med Virol 2021; 93:4292-4302. [PMID: 33666250 PMCID: PMC8014848 DOI: 10.1002/jmv.26914] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/05/2021] [Accepted: 02/27/2021] [Indexed: 01/08/2023]
Abstract
To evaluate the efficacy of corticosteroids on coronavirus disease 2019 (COVID-19) patients with different levels of disease severity. In our multicenter study, 543 patients with confirmed COVID-19 were classified as non-severe group and severe group, and then were compared respectively for all-cause mortality and length of hospital stay between those who received corticosteroids and not. By searching in PubMed, Web of Science, Embase, and CNKI, we identified 13 retrospective studies and 6 random control trials eligible for criteria of inclusion, and conducted comprehensive meta-analyses assessing the impacts of corticosteroids on mortality, length of stay, duration of RNA clearance and duration of fever. Our multicenter study demonstrated that low-dose corticosteroids can reduce mortality in the multivariable Cox regression analysis for severe patients (p = .03), while presented no influence in univariable analysis for non-severe patients (p = .14). From multivariable analyses, patients with corticosteroids in non-severe group had longer duration of hospitalization (p = .003), but did not in severe group (p = .18). Moreover, for severe patients, corticosteroids can evidently shorten duration of fever. The same results were summarized in the meta-analyses supplemented with the result that corticosteroids delayed viral clearing in non-severe patients. Corticosteroids should be considered based on patient's condition. For patients with non-severe COVID-19, corticosteroid was not recommended as a routine therapeutic initiative as that presented prolonged duration of hospitalization and delayed viral clearing, as well as no positive impact on prognosis. While low-dose corticosteroids may benefit patients with severe COVID-19 for it can manifestly lower risk of death and improve the clinical status to some extent.
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Affiliation(s)
- Yuan Zhan
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jin Shang
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yiya Gu
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Qian Huang
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jungang Xie
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Pérez-de-Llano L, Romay-Lema EM, Baloira-Villar A, Anchorena C, Torres-Durán ML, Sousa A, Corbacho-Abelaira D, Paz-Ferrin J, Diego-Roza C, Vilariño-Maneiro L, Marcos PJ, Montero-Martínez C, de la Iglesia-Martínez F, Riveiro-Blanco V, Rodríguez-Núñez N, Abal-Arca J, Bustillo-Casado M, Golpe R. COVID-19 pneumonia in Galicia (Spain): Impact of prognostic factors and therapies on mortality and need for mechanical ventilation. PLoS One 2021; 16:e0253465. [PMID: 34161387 PMCID: PMC8221482 DOI: 10.1371/journal.pone.0253465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/07/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION This study was aimed to identify risk factors associated with unfavorable outcomes (composite outcome variable: mortality and need for mechanical ventilation) in patients hospitalized in Galicia with COVID-19 pneumonia. METHODS Retrospective, multicenter, observational study carried out in the 8 Galician tertiary hospitals. All Patients admitted with confirmed COVID-19 pneumonia from 1st of March to April 24th, 2020 were included. A multivariable logistic regression analysis was performed in order to identify the relationship between risk factors, therapeutic interventions and the composite outcome variable. RESULTS A total of 1292 patients (56.1% male) were included. Two hundred and twenty-five (17.4%) died and 327 (25.3%) reached the main outcome variable. Age [odds ratio (OR) = 1.03 (95% confidence interval (CI): 1.01-1.04)], CRP quartiles 3 and 4 [OR = 2.24 (95% CI: 1.39-3.63)] and [OR = 3.04 (95% CI: 1.88-4.92)], respectively, Charlson index [OR = 1.16 (95%CI: 1.06-1.26)], SaO2 upon admission [OR = 0.93 (95% CI: 0.91-0.95)], hydroxychloroquine prescription [OR = 0.22 (95%CI: 0.12-0.37)], systemic corticosteroids prescription [OR = 1.99 (95%CI: 1.45-2.75)], and tocilizumab prescription [OR = 3.39 (95%CI: 2.15-5.36)], significantly impacted the outcome. Sensitivity analysis using different alternative logistic regression models identified consistently the ratio admissions/hospital beds as a predictor of the outcome [OR = 1.06 (95% CI: 1.02-1.11)]. CONCLUSION These findings may help to identify patients at hospital admission with a higher risk of death and may urge healthcare authorities to implement policies aimed at reducing deaths by increasing the availability of hospital beds.
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Affiliation(s)
- Luis Pérez-de-Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Lugo, Spain
| | - Eva María Romay-Lema
- Infectious Diseases Unit, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Lugo, Spain
| | | | | | | | - Adrián Sousa
- Internal Medicine Service, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | | | | | - Pedro J. Marcos
- Pneumology Service, Complexo Universitario de A Coruña, A Coruña, Spain
| | | | | | - Vanessa Riveiro-Blanco
- Pneumology Service, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Nuria Rodríguez-Núñez
- Pneumology Service, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - José Abal-Arca
- Pneumology Service, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - María Bustillo-Casado
- Infectious Diseases Unit, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Rafael Golpe
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Lugo, Spain
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20
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Meyerowitz EA, Sen P, Schoenfeld SR, Neilan TG, Frigault MJ, Stone JH, Kim AY, Mansour MK. Immunomodulation as Treatment for Severe Coronavirus Disease 2019: A Systematic Review of Current Modalities and Future Directions. Clin Infect Dis 2021; 72:e1130-e1143. [PMID: 33216852 PMCID: PMC7717185 DOI: 10.1093/cid/ciaa1759] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
In severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, viral load peaks early and declines quickly after symptom onset. Severe coronavirus disease 2019 (COVID-19) is marked by aberrant innate and adaptive immune responses with an abnormal cytokine profile and multiorgan system dysfunction that persists well after viral clearance. A purely antiviral treatment strategy may therefore be insufficient, and antiviral agents have not shown a benefit later in the illness course. A number of immunomodulatory strategies are being tested, including corticosteroids, cytokine and anticytokine therapies, small molecule inhibitors, and cellular therapeutics. To date, the only drug to show a mortality benefit for COVID-19 in a randomized, controlled trial is dexamethasone. However, there remains uncertainty about which patients may benefit most and about longer-term complications, including secondary infections. Here, we review the immune dysregulation of severe COVID-19 and the existing data behind various immunomodulatory strategies, and we consider future directions of study.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Pritha Sen
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
| | - Sara R Schoenfeld
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Stone
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arthur Y Kim
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
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21
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Sahilu T, Sheleme T, Melaku T. Severity and Mortality Associated with Steroid Use among Patients with COVID-19: A Systematic Review and Meta-Analysis. Interdiscip Perspect Infect Dis 2021; 2021:6650469. [PMID: 34035806 PMCID: PMC8101483 DOI: 10.1155/2021/6650469] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/25/2021] [Accepted: 04/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There are controversial suggestions about steroid use to treat patients infected with COVID-19. Conclusive evidence regarding the use of steroids to treat COVID-19 is still lacking. This meta-analysis aimed to determine the mortality and severity associated with corticosteroid therapy compared to noncorticosteroid treatment in patients with COVID-19. METHODS The information was collected from electronic databases: PubMed, CINAHL, the Cochrane Library, clinicaltrials.gov, and Google scholar through January 30, 2021. Risk ratios (RRs) with 95% confidence intervals (CIs) were performed using random effect models. Endnote citation manager software version X9 for Windows was utilized to collect and organize search outcomes (into relevant and irrelevant studies) and to remove duplicate articles. RESULTS Thirty-two studies were included in the meta-analysis, including 14,659 COVID-19 patients. No significant differences in mortality between the steroid and nonsteroid treatment groups (RR = 0.95; 95% CI: 0.80-1.13; p = 0.57). There was no significant reduction in mortality in critically ill COVID-19 patients treated with corticosteroid (RR = 0.89; 95% CI: 0.62-1.27; p = 0.52). Significant differences were observed in severe disease conditions between the steroid and nonsteroid treatment groups (RR = 1.10; 95% CI, 1.03-1.19, p = 0.007). CONCLUSION There was no significant difference in all-cause mortality between the steroid and nonsteroid treatment users' of COVID-19 patients. There was no significant reduction of all-cause mortality in critically ill COVID-19 patients treated with corticosteroids.
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Affiliation(s)
- Tamiru Sahilu
- Department of Pharmacy, College of Health Science, Assosa University, Assosa, Ethiopia
| | - Tadesse Sheleme
- Department of Pharmacy, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Tsegaye Melaku
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
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22
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Gopalaswamy R, Subbian S. Corticosteroids for COVID-19 Therapy: Potential Implications on Tuberculosis. Int J Mol Sci 2021; 22:ijms22073773. [PMID: 33917321 PMCID: PMC8038708 DOI: 10.3390/ijms22073773] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022] Open
Abstract
On 11 March 2020, the World Health Organization announced the Corona Virus Disease-2019 (COVID-19) as a global pandemic, which originated in China. At the host level, COVID-19, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), affects the respiratory system, with the clinical symptoms ranging from mild to severe or critical illness that often requires hospitalization and oxygen support. There is no specific therapy for COVID-19, as is the case for any common viral disease except drugs to reduce the viral load and alleviate the inflammatory symptoms. Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis (Mtb), also primarily affects the lungs and has clinical signs similar to pulmonary SARS-CoV-2 infection. Active TB is a leading killer among infectious diseases and adds to the burden of the COVID-19 pandemic worldwide. In immunocompetent individuals, primary Mtb infection can also lead to a non-progressive, asymptomatic latency. However, latent Mtb infection (LTBI) can reactivate symptomatic TB disease upon host immune-suppressing conditions. Importantly, the diagnosis and treatment of TB are hampered and admixed with COVID-19 control measures. The US-Center for Disease Control (US-CDC) recommends using antiviral drugs, Remdesivir or corticosteroid (CST), such as dexamethasone either alone or in-combination with specific recommendations for COVID-19 patients requiring hospitalization or oxygen support. However, CSTs can cause immunosuppression, besides their anti-inflammatory properties. The altered host immunity during COVID-19, combined with CST therapy, poses a significant risk for new secondary infections and/or reactivation of existing quiescent infections, such as LTBI. This review highlights CST therapy recommendations for COVID-19, various types and mechanisms of action of CSTs, the deadly combination of two respiratory infectious diseases COVID-19 and TB. It also discusses the importance of screening for LTBI to prevent TB reactivation during corticosteroid therapy for COVID-19.
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Affiliation(s)
- Radha Gopalaswamy
- Department of Bacteriology, ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India;
| | - Selvakumar Subbian
- Public Health Research Institute at New Jersey Medical School, Rutgers University, 225 Warren Street, Newark, NJ 08854, USA
- Correspondence:
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23
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Kim SB, Ryoo S, Huh K, Joo EJ, Kim YJ, Choi WS, Kim YJ, Yoon YK, Heo JY, Seo YB, Jeong SJ, Park DA, Yu SY, Lee HJ, Kim J, Jin Y, Park J, Peck KR, Choi M, Yeom JS. Revised Korean Society of Infectious Diseases/National Evidence-based Healthcarea Collaborating Agency Guidelines on the Treatment of Patients with COVID-19. Infect Chemother 2021; 53:166-219. [PMID: 34409790 PMCID: PMC8032920 DOI: 10.3947/ic.2021.0303] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Indexed: 02/06/2023] Open
Abstract
Despite the global effort to mitigate the spread, coronavirus disease 2019 (COVID-19) has become a pandemic that took more than 2 million lives. There are numerous ongoing clinical studies aiming to find treatment options and many are being published daily. Some effective treatment options, albeit of variable efficacy, have been discovered. Therefore, it is necessary to develop an evidence-based methodology, to continuously check for new evidence, and to update recommendations accordingly. Here we provide guidelines on pharmaceutical treatment for COVID-19 based on the latest evidence.
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Affiliation(s)
- Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seungeun Ryoo
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Jeong Joo
- Division of Infectious Diseases, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung hospital, Seoul, Korea
| | - Youn Jeong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yae Jean Kim
- Division of Infectious Diseases and Immunodeficiency. Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University school of Medicine, Suwon, Korea
| | - Yu Bin Seo
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Su Yeon Yu
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Hyeon Jeong Lee
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jimin Kim
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Yan Jin
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jungeun Park
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Miyoung Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.
| | - Joon Sup Yeom
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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24
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van Paassen J, Vos JS, Hoekstra EM, Neumann KMI, Boot PC, Arbous SM. Corticosteroid use in COVID-19 patients: a systematic review and meta-analysis on clinical outcomes. Crit Care 2020; 24:696. [PMID: 33317589 PMCID: PMC7735177 DOI: 10.1186/s13054-020-03400-9] [Citation(s) in RCA: 224] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the current SARS-CoV-2 pandemic, there has been worldwide debate on the use of corticosteroids in COVID-19. In the recent RECOVERY trial, evaluating the effect of dexamethasone, a reduced 28-day mortality in patients requiring oxygen therapy or mechanical ventilation was shown. Their results have led to considering amendments in guidelines or actually already recommending corticosteroids in COVID-19. However, the effectiveness and safety of corticosteroids still remain uncertain, and reliable data to further shed light on the benefit and harm are needed. OBJECTIVES The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of corticosteroids in COVID-19. METHODS A systematic literature search of RCTS and observational studies on adult patients was performed across Medline/PubMed, Embase and Web of Science from December 1, 2019, until October 1, 2020, according to the PRISMA guidelines. Primary outcomes were short-term mortality and viral clearance (based on RT-PCR in respiratory specimens). Secondary outcomes were: need for mechanical ventilation, need for other oxygen therapy, length of hospital stay and secondary infections. RESULTS Forty-four studies were included, covering 20.197 patients. In twenty-two studies, the effect of corticosteroid use on mortality was quantified. The overall pooled estimate (observational studies and RCTs) showed a significant reduced mortality in the corticosteroid group (OR 0.72 (95%CI 0.57-0.87). Furthermore, viral clearance time ranged from 10 to 29 days in the corticosteroid group and from 8 to 24 days in the standard of care group. Fourteen studies reported a positive effect of corticosteroids on need for and duration of mechanical ventilation. A trend toward more infections and antibiotic use was present. CONCLUSIONS Our findings from both observational studies and RCTs confirm a beneficial effect of corticosteroids on short-term mortality and a reduction in need for mechanical ventilation. And although data in the studies were too sparse to draw any firm conclusions, there might be a signal of delayed viral clearance and an increase in secondary infections.
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Affiliation(s)
- Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jeroen S Vos
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Eva M Hoekstra
- Faculty of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Katinka M I Neumann
- Faculty of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Pauline C Boot
- Faculty of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Sesmu M Arbous
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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25
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Lammers AJJ, Brohet RM, Theunissen REP, Koster C, Rood R, Verhagen DWM, Brinkman K, Hassing RJ, Dofferhoff A, El Moussaoui R, Hermanides G, Ellerbroek J, Bokhizzou N, Visser H, van den Berge M, Bax H, Postma DF, Groeneveld PHP. Early hydroxychloroquine but not chloroquine use reduces ICU admission in COVID-19 patients. Int J Infect Dis 2020; 101:283-289. [PMID: 33007454 PMCID: PMC7524430 DOI: 10.1016/j.ijid.2020.09.1460] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The global push for the use of hydroxychloroquine (HCQ) and chloroquine (CQ) against COVID-19 has resulted in an ongoing discussion about the effectivity and toxicity of these drugs. Recent studies report no effect of (H)CQ on 28-day mortality. We investigated the effect of HCQ and CQ in hospitalized patients on the non-ICU COVID-ward. METHODS A nationwide, observational cohort study was performed in The Netherlands. Hospitals were given the opportunity to decide independently on the use of three different COVID-19 treatment strategies: HCQ, CQ, or no treatment. We compared the outcomes between these groups. The primary outcomes were 1) death on the COVID-19 ward, and 2) transfer to the intensive care unit (ICU). RESULTS The analysis included 1064 patients from 14 hospitals: 566 patients received treatment with either HCQ (n = 189) or CQ (n = 377), and 498 patients received no treatment. In a multivariate propensity-matched weighted competing regression analysis, there was no significant effect of (H)CQ on mortality on the COVID ward. However, HCQ was associated with a significantly decreased risk of transfer to the ICU (hazard ratio (HR) = 0.47, 95% CI = 0.27-0.82, p = 0.008) when compared with controls. This effect was not found in the CQ group (HR = 0.80, 95% CI = 0.55-1.15, p = 0.207), and remained significant after competing risk analysis. CONCLUSION The results of this observational study demonstrate a lack of effect of (H)CQ on non-ICU mortality. However, we show that the use of HCQ - but not CQ - is associated with a 53% reduction in risk of transfer of COVID-19 patients from the regular ward to the ICU. Recent prospective studies have reported on 28-day, all-cause mortality only; therefore, additional prospective data on the early effects of HCQ in preventing transfer to the ICU are still needed.
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Affiliation(s)
| | - R M Brohet
- Department of Epidemiology and Statistics, Isala Academy, Zwolle, The Netherlands
| | | | | | - R Rood
- Diakonessen Hospital, Utrecht, The Netherlands
| | - D W M Verhagen
- Medisch Centrum Jan van Goyen, Amsterdam, The Netherlands
| | | | | | - A Dofferhoff
- Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | | | - J Ellerbroek
- Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - N Bokhizzou
- BovenIJ Hospital, Amsterdam, The Netherlands
| | - H Visser
- Beatrix Hospital Gorinchem, The Netherlands
| | | | - H Bax
- Erasmus MC Rotterdam, The Netherlands
| | - D F Postma
- University Medical Center Groningen, Groningen, The Netherlands
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26
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Tlayjeh H, Mhish OH, Enani MA, Alruwaili A, Tleyjeh R, Thalib L, Hassett L, Arabi YM, Kashour T, Tleyjeh IM. Association of corticosteroids use and outcomes in COVID-19 patients: A systematic review and meta-analysis. J Infect Public Health 2020; 13:1652-1663. [PMID: 33008778 PMCID: PMC7522674 DOI: 10.1016/j.jiph.2020.09.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To systematically review the literature about the association between systemic corticosteroid therapy (CST) and outcomes of COVID-19 patients. METHODS We searched Medline, Embase, EBM Reviews, Scopus, Web of Science, and preprints up to July 20, 2020. We included observational studies and randomized controlled trials (RCT) that assessed COVID-19 patients treated with CST. We pooled adjusted effect estimates of mortality and other outcomes using a random effect model, among studies at low or moderate risk for bias. We assessed the certainty of evidence for each outcome using the GRADE approach. RESULTS Out of 1067 citations screened for eligibility, one RCT and 19 cohort studies were included (16,977 hospitalized patients). Ten studies (1 RCT and 9 cohorts) with 10,278 patients examined the effect of CST on short term mortality. The pooled adjusted RR was 0.92 (95% CI 0.69-1.22, I2 = 81.94%). This effect was observed across all stages of disease severity. Four cohort studies examined the effect of CST on composite outcome of death, ICU admission and mechanical ventilation need. The pooled adjusted RR was 0.41(0.23-0.73, I2 = 78.69%). Six cohort studies examined the effect of CST on delayed viral clearance. The pooled adjusted RR was 1.47(95% CI 1.11-1.93, I2 = 43.38%). CONCLUSION In this systematic review, as of July 2020, heterogeneous and low certainty cumulative evidence based on observational studies and one RCT suggests that CST was not associated with reduction in short-term mortality but possibly with a delay in viral clearance in patients hospitalized with COVID-19 of different severities. However, the discordant results between the single RCT and observational studies as well as the heterogeneity observed across observational studies, call for caution in using observational data and suggests the need for more RCTs to identify the clinical and biochemical characteristics of patients' population that could benefit from CST.
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Affiliation(s)
- Haytham Tlayjeh
- Department of Intensive Care, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Olaa H Mhish
- College of Medicine, Al Faisal University, Riyadh, Saudi Arabia
| | - Mushira A Enani
- Infectious Diseases Section, Department of Medical Specialties, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Alya Alruwaili
- Clinical Pharmacy Department, Pharmacy Services Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Rana Tleyjeh
- College of Medicine, Al Faisal University, Riyadh, Saudi Arabia
| | - Lukman Thalib
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | | | - Yaseen M Arabi
- Department of Intensive Care, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Imad M Tleyjeh
- College of Medicine, Al Faisal University, Riyadh, Saudi Arabia; Infectious Diseases Section, Department of Medical Specialties, King Fahad Medical City, Riyadh, Saudi Arabia; Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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Jin YH, Zhan QY, Peng ZY, Ren XQ, Yin XT, Cai L, Yuan YF, Yue JR, Zhang XC, Yang QW, Ji J, Xia J, Li YR, Zhou FX, Gao YD, Yu Z, Xu F, Tu ML, Tan LM, Yang M, Chen F, Zhang XJ, Zeng M, Zhu Y, Liu XC, Yang J, Zhao DC, Ding YF, Hou N, Wang FB, Chen H, Zhang YG, Li W, Chen W, Shi YX, Yang XZ, Wang XJ, Zhong YJ, Zhao MJ, Li BH, Ma LL, Zi H, Wang N, Wang YY, Yu SF, Li LY, Huang Q, Weng H, Ren XY, Luo LS, Fan MR, Huang D, Xue HY, Yu LX, Gao JP, Deng T, Zeng XT, Li HJ, Cheng ZS, Yao X, Wang XH. Chemoprophylaxis, diagnosis, treatments, and discharge management of COVID-19: An evidence-based clinical practice guideline (updated version). Mil Med Res 2020; 7:41. [PMID: 32887670 PMCID: PMC7472403 DOI: 10.1186/s40779-020-00270-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 02/08/2023] Open
Abstract
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, coronavirus disease 2019 (COVID-19), affecting more than seventeen million people around the world. Diagnosis and treatment guidelines for clinicians caring for patients are needed. In the early stage, we have issued "A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)"; now there are many direct evidences emerged and may change some of previous recommendations and it is ripe for develop an evidence-based guideline. We formed a working group of clinical experts and methodologists. The steering group members proposed 29 questions that are relevant to the management of COVID-19 covering the following areas: chemoprophylaxis, diagnosis, treatments, and discharge management. We searched the literature for direct evidence on the management of COVID-19, and assessed its certainty generated recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Recommendations were either strong or weak, or in the form of ungraded consensus-based statement. Finally, we issued 34 statements. Among them, 6 were strong recommendations for, 14 were weak recommendations for, 3 were weak recommendations against and 11 were ungraded consensus-based statement. They covered topics of chemoprophylaxis (including agents and Traditional Chinese Medicine (TCM) agents), diagnosis (including clinical manifestations, reverse transcription-polymerase chain reaction (RT-PCR), respiratory tract specimens, IgM and IgG antibody tests, chest computed tomography, chest x-ray, and CT features of asymptomatic infections), treatments (including lopinavir-ritonavir, umifenovir, favipiravir, interferon, remdesivir, combination of antiviral drugs, hydroxychloroquine/chloroquine, interleukin-6 inhibitors, interleukin-1 inhibitors, glucocorticoid, qingfei paidu decoction, lianhua qingwen granules/capsules, convalescent plasma, lung transplantation, invasive or noninvasive ventilation, and extracorporeal membrane oxygenation (ECMO)), and discharge management (including discharge criteria and management plan in patients whose RT-PCR retesting shows SARS-CoV-2 positive after discharge). We also created two figures of these recommendations for the implementation purpose. We hope these recommendations can help support healthcare workers caring for COVID-19 patients.
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Affiliation(s)
- Ying-Hui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Qing-Yuan Zhan
- National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, 100029, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 10029, China
| | - Zhi-Yong Peng
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Xue-Qun Ren
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
| | - Xun-Tao Yin
- Department of Medical Imaging, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Lin Cai
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Departments of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yu-Feng Yuan
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Department of Hepatobiliary Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Ji-Rong Yue
- National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Department of Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xiao-Chun Zhang
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Qi-Wen Yang
- Department of Clinical Laboratory, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College, Chinese Academy of Medical Sciences (CAMS), Beijing, 100730, China
| | - Jianguang Ji
- Center for Primary Health Care Research, Lund University and Region Skåne, 25002, Malmö, Sweden
| | - Jian Xia
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, 403371, China
| | - Yi-Rong Li
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Fu-Xiang Zhou
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, 43071, China
| | - Ya-Dong Gao
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, 250002, China
| | - Ming-Li Tu
- Department of Respiratory and Critical Care Medicine, Suizhou Central Hospital, Hubei University of Medicine, Suizhou, 441300, Hubei, China
| | - Li-Ming Tan
- Department of Clinic Pharmacy, Second People's Hospital of Huaihua City, Huaihua, 418000, Hunan, China
| | - Min Yang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China
| | - Fang Chen
- Department of Internal Medicine, Zhengzhou University Hospital, Zhengzhou, 450001, China
| | - Xiao-Ju Zhang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, 450003, China
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yu Zhu
- Department of Infectious Disease, West China Second Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Can Liu
- Department of Cardiology, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, 450000, China
| | - Jian Yang
- Department of Cardiology, Yichang NO.1 Hospital, Renmin Hospital of China Three Gorges University, Yichang, 443000, Hubei, China
| | - Dong-Chi Zhao
- Department of Pediatrics, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yu-Feng Ding
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ning Hou
- Department of Pharmacy, Shandong Provincial Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250021, China
| | - Fu-Bing Wang
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hao Chen
- Laboratory of Integrated Acupuncture and Drugs, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Yong-Gang Zhang
- National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Department of Periodical Press, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wei Li
- Department of Clinical Laboratory, Yantai Yuhuangding Hospital, Qingdao University, Yantai, 264000, Shandong, China
| | - Wen Chen
- Department of Radiology, Taihe Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, China
| | - Yue-Xian Shi
- School of Nursing, Peking University, Beijing, 100191, China
| | - Xiu-Zhi Yang
- Department of Respiratory and Critical Care Medicine, Kaifeng Central Hospital, Kaifeng, 475000, Henan, China
| | - Xue-Jun Wang
- Department of Emergency, Beijing Electric Power Hospital, Beijing, 100073, China
| | - Yan-Jun Zhong
- ICU Center, The Second Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ming-Juan Zhao
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Bing-Hui Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Lin-Lu Ma
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Haematology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Hao Zi
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
| | - Na Wang
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
- College of Nursing and Health, Henan Medical School, Henan University, Kaifeng, 475000, Henan, China
| | - Yun-Yun Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Shao-Fu Yu
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Clinic Pharmacy, Second People's Hospital of Huaihua City, Huaihua, 418000, Hunan, China
| | - Lu-Yao Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
| | - Qiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hong Weng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Xiang-Ying Ren
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
- College of Nursing and Health, Henan Medical School, Henan University, Kaifeng, 475000, Henan, China
| | - Li-Sha Luo
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Man-Ru Fan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Di Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hong-Yang Xue
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Lin-Xin Yu
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jin-Ping Gao
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- School of Nursing, Shanxi Medical University, Taiyuan, 030001, China
| | - Tong Deng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Institutes of Evidence-based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China.
| | - Hong-Jun Li
- Department of Diagnostic Radiology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China.
| | - Zhen-Shun Cheng
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China.
- Department of Respiratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
| | - Xiaomei Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Xing-Huan Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Leishenshan Hospital in Wuhan, Wuhan, 430200, China.
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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