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Effect of Early Administration of Systemic Corticosteroids on Outcomes in Patients with Severe COVID-19 Pneumonia
Early Steroids Cut Need for Ventilation, Shorten ICU Stay, With COVID
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IDWeek 2020, October 22-25, 2020
Mark Mascolini
Earlier corticosteroids for inpatients with COVID-19 independently cut the need for mechanical ventilation and shortened intensive care unit (ICU) stays in a 469-person analysis at Stony Brook University Hospital near New York City [1]. The analysis also linked early steroids to a longer hospital stay.
Hospital clinicians have long used systemic corticosteroids empirically to manage acute respiratory distress syndrome, now often a feature of advanced COVID-19. A UK trial that randomized 6425 COVID-19 inpatients to oral or intravenous dexamethasone or to usual care found that dexamethasone independently lowered death risk in people receiving invasive mechanical ventilation or oxygen without invasive ventilation, but not in those getting no respiratory support [2]. Stony Brook researchers who conducted the new study suggested that early steroid use for inpatients with COVID-19 could help resolve symptoms and shorten ICU stays.
This record review started with 498 adults admitted to the hospital in March and April, 2020, with COVID-19 requiring high-flow oxygen. Researchers excluded people who started mechanical ventilation or died within 24 hours of admission. Follow-up continued until death or hospital discharge. The study aimed to compare outcomes in people who got early steroids (before mechanical ventilation) and those who did not. Adjusted Cox models compared these groups for progression to a composite endpoint of death or need for mechanical ventilation.
Of the 469 study participants, 175 (37%) got early steroids and 294 did not. The early and not-early groups were similar in age (median 62 and 61 years) and proportions of women (33% and 37%), whites (54% and 53%), blacks (5% and 8%), Asians (6% and 6%), and Hispanics (32% and 35%). Body mass index was similar in the early-steroid group and in controls (median 29.7 and 29.1 kg/m2). The early-steroid group had significantly higher (worse) NT-proBNP, which is used to rule out heart failure (266 vs 161 pg/mL, P = 0.043). O2 saturation was slightly but significantly lower in the early-steroid group (90% vs 91%, P = 0.002), and duration of COVID-19 symptoms was slightly but significantly longer in the early group (median 7 vs 6.5 days, P = 0.020).
By day 7, Kaplan-Meier analysis charted a lower risk of reaching the composite endpoint of death or intubation in people with early steroids than in the control group (32.5% vs 44.8%, P = 0.008). A Cox model adjusted for race, age, sex, comorbidities, baseline O2 saturation, and procalcitonin (which boosts risk of systemic bacterial infection) figured a 44% lower risk of death or intubation with early corticosteroids (adjusted hazard ratio [aHR] 0.56, 95% confidence interval [CI] 0.42 to 0.76, P < 0.001). That effect proved time-dependent, starting at a 66% lower risk of the composite endpoint with early steroids (aHR 0.34, 95% CI 0.21 to 0.56, P < 0.001), with a 10.2% drop in that rate every day (95% CI 1.7% to 19.4%, P = 0.017). Notably, mortality alone did not differ significantly between the early-steroid group and the control group at day 7 or day 14 (8.1% vs 8.3%, and 19.1% vs 21.0%, P = 0.75).
People who got corticosteroids before mechanical ventilation had a significantly shorter ICU stay (median 10 vs 12 days, P = 0.021) but a significantly longer hospital stay (median 14 vs 12 days, P = 0.030). Need for mechanical ventilation proved significantly lower in the early-steroid group (18.4% vs 30.8%, P = 0.018).
The Stony Brook team concluded that early corticosteroid use "reduced primarily the need for mechanical ventilation"-and not necessarily mortality-in their group with high-risk COVID-19.
References
1. Papamanoli A, Kalogeropoulos A, Fung J, et al. Effect of early administration of systemic corticosteroids on outcomes in patients with COVID-19 pneumonia. IDWeek 2020, October 22-25, 2020. Abstract 76.
2. The RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19--preliminary report. N Engl J Med. July 17, 2020. DOI: 10.1056/NEJMoa2021436. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436
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