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. 2023 Apr 11;17(1):7.
doi: 10.1186/s13037-023-00358-9.

Investigational medications in 9,638 hospitalized patients with severe COVID-19: lessons from the "fail-and-learn" strategy during the first two waves of the pandemic in 2020

Adam C Delgado  1 , Brendon Cornett  2 , Ye Ji Choi  2 , Christina Colosimo  1 , Vincent P Stahel  3 , Oliwier Dziadkowiec  2 , Philip F Stahel  4   5   6
Affiliations

Investigational medications in 9,638 hospitalized patients with severe COVID-19: lessons from the "fail-and-learn" strategy during the first two waves of the pandemic in 2020

Adam C Delgado et al. Patient Saf Surg. .

Abstract

Background: The early surge of the novel coronavirus disease 2019 (COVID-19) pandemic introduced a significant clinical challenge due to the high case-fatality rate in absence of evidence-based recommendations. The empirical treatment modalities were relegated to historical expertise from the traditional management of acute respiratory distress syndrome (ARDS) in conjunction with off-label pharmaceutical agents endorsed under the "emergency use authorization" (EUA) paradigm by regulatory agencies. This study was designed to evaluate the insights from the "fail-and-learn" strategy in 2020 before the availability of COVID-19 vaccines and access to reliable insights from high-quality randomized controlled trials.

Methods: A retrospective, multicenter, propensity-matched, case-control study was performed on a data registry comprising 186 hospitals from a national health care system in the United States, designed to investigate the efficacy of empirical treatment modalities during the early surge of the COVID-19 pandemic in 2020. Reflective of the time-windows of the initial two surges of the pandemic in 2020, patients were stratified into "Early 2020" (March 1-June 30) versus "Late 2020" (July 1-December 31) study cohorts. Logistic regression was applied to determine the efficacy of prevalent medications (remdesivir, azithromycin, hydroxychloroquine, corticosteroids, tocilizumab) and supplemental oxygen delivery modalities (invasive vs. non-invasive ventilation) on patient outcomes. The primary outcome measure was in-hospital mortality. Group comparisons were adjusted for covariates related to age, gender, ethnicity, body weight, comorbidities, and treatment modalities pertinent to organ failure replacement.

Results: From a total of 87,788 patients in the multicenter data registry screened in this study, 9,638 patients were included who received 19,763 COVID-19 medications during the first two waves of the 2020 pandemic. The results showed a minimal, yet statistically significant, association with hydroxychloroquine in "Early 2020" and remdesivir in "Late 2020" with reduced odds of mortality (odds ratios 0.72 and 0.76, respectively; P = 0.01). Azithromycin was the only medication associated with decreased odds of mortality during both study time-windows (odds ratios 0.79 and 0.68, respectively; P < 0.01). In contrast, the necessity for oxygen supply showed significantly increased odds of mortality beyond the effect of all investigated medications. Of all the covariates associated with increased mortality, invasive mechanical ventilation had the highest odds ratios of 8.34 in the first surge and 9.46 in in the second surge of the pandemic (P < 0.01).

Conclusion: This retrospective multicenter observational cohort study on 9,638 hospitalized patients with severe COVID-19 during revealed that the necessity for invasive ventilation had the highest odds of mortality, beyond the variable effects observed by administration of the prevalent EUA-approved investigational drugs during the first two surges of the early 2020 pandemic in the United States.

Keywords: Azithromycin; COVID-19; Corticosteroids; Hydroxychloroquine; Mechanical ventilation; Mortality.; Remdesivir; Tocilizumab.

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Conflict of interest statement

The senior author (PFS) is employed by HCA Healthcare. The views expressed in this editorial exclusively represent the authors’ personal perspective and do not necessarily represent official views of HCA Healthcare or any of its affiliated entities. PFS is the Editor-in-Chief of the journal (www.pssjournal.com) and attests that he was not involved in the peer-review process or editorial management and decision-making related to this submission. The authors declare no other conflicts of interest related to this study.

Figures

Fig. 1
Fig. 1
Patient selection flowchart Legend: *Exclusion criteria listed in the methods section Abbreviations: COVID, novel coronavirus disease; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; PCR, polymerase chain reaction
Fig. 2
Fig. 2
Forrest Plot of mortality odds ratios in the “Early 2020” cohort, stratified by medication and supplemental oxygen delivery modality Odds ratios below 1 indicate decreased odds of mortality Odds ratios above 1 indicated increased odds of mortality
Fig. 3
Fig. 3
Forrest Plot of mortality odds ratios in the “Late 2020” cohort, stratified by medication and supplemental oxygen delivery modality Odds ratios below 1 indicate decreased odds of mortality Odds ratios above 1 indicated increased odds of mortality
See this image and copyright information in PMC

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