Impact of early corticosteroids on 60-day mortality in critically ill patients with COVID-19: A multicenter cohort study of the OUTCOMEREA network

Abstract

Objectives In severe COVID-19 pneumonia, the appropriate timing and dosing of corticosteroids (CS) is not known. Patient subgroups for which CS could be more beneficial also need appraisal. The aim of this study was to assess the effect of early CS in COVID-19 pneumonia patients admitted to the ICU on the occurrence of 60-day mortality, ICU-acquired-bloodstream infections(ICU-BSI), and hospital-acquired pneumonia and ventilator-associated pneumonia(HAP-VAP). Methods We included patients with COVID-19 pneumonia admitted to 11 ICUs belonging to the French OutcomeReaTM network from January to May 2020. We used survival models with ponderation with inverse probability of treatment weighting (IPTW). Results The study population comprised 303 patients having a median age of 61.6 (53–70) years of whom 78.8% were male and 58.6% had at least one comorbidity. The median SAPS II was 33 (25–44). Invasive mechanical ventilation was required in 34.8% of the patients. Sixty-six (21.8%) patients were in the Early-C subgroup. Overall, 60-day mortality was 29.4%. The risks of 60-day mortality (IPTWHR = 0.86;95% CI 0.54 to 1.35, p = 0.51), ICU-BSI and HAP-VAP were similar in the two groups. Importantly, early CS treatment was associated with a lower mortality rate in patients aged 60 years or more (IPTWHR, 0.53;95% CI, 0.3–0.93; p = 0.03). In contrast, CS was associated with an increased risk of death in patients younger than 60 years without inflammation on admission (IPTWHR = 5.01;95% CI, 1.05, 23.88; p = 0.04). Conclusion For patients with COVID-19 pneumonia, early CS treatment was not associated with patient survival. Interestingly, inflammation and age can significantly influence the effect of CS.

Impact of Early Corticosteroids on Preventing Clinical Deterioration in Non-critically Ill Patients Hospitalized with COVID-19: A Multi-hospital Cohort Study

“…Hence, we wanted to focus specifically on hospitalized COVID-19 patients requiring supplemental oxygen therapy to assess whether early use of steroids would be beneficial, and to identify the threshold of illness at which steroids would be helpful. Our study results are consistent with other observational studies that showed no difference in risk of intubation or mortality between non-critically ill hospitalized patients who received versus those that did not receive corticosteroids [ 11 , 15 , 25 , 26 ].…”

Early Corticosteroid Therapy May Increase Ventilator-Associated Lower Respiratory Tract Infection in Critically Ill Patients with COVID-19: A Multicenter Retrospective Cohort Study

“…This selection bias towards the sickest patients could possibly explain the difference in the corticosteroid impact on outcomes compared to recent prospective trials. Of note, corticosteroids have recently been shown to exert less beneficial effects in certain patient subgroups, including elderly patients [ 27 ] and those with a hypo-inflammatory phenotype [ 28 , 29 ]. As expressed by De Backer et al, the beneficial effects on the Day-28 mortality endpoint, relatively short in duration, may not necessarily translate into longer-term benefits [ 30 ].…”

How common is ventilator-associated pneumonia after coronavirus disease 2019?

“…Still, COVID-19-associated and steroid-induced immunomodulation also implies superinfection because of other opportunistic pathogens. Patients treated with dexamethasone had reduced ICU length of stay, more ventilator-free days but similar mortality regardless of the timing of administration [ 48 ]. A true concern also exists about fungal superinfections that could be associated with lung abscesses.…”