Author: David Wild
Whether or not to use corticosteroids in a critically ill patient with COVID-19 is just one of the topics the Surviving Sepsis Campaign tackled in its new recommendations for managing critically ill patients with COVID-19.
This recommendation will be of particular interest to infectious disease physicians and critical care pharmacists, according to lead author Waleed Alhazzani, MD, MSc, an associate professor in the Division of Critical Care, Department of Medicine, McMaster University, in Hamilton, Ontario.
“Traditionally, there’s been an association between using systemic corticosteroids and higher risk of death in patients with viral pneumonia, but this association is based on observational studies, which may be confounded by the fact that sicker patients tend to receive corticosteroids,” Dr. Alhazzani explained. “Very limited data” from COVID-19 patients, as well as data from SARS and Middle East respiratory syndrome (MERS) also indicate treatment with systemic corticosteroids may cause harm.
“Because of the limitations of the data and because we’re not sure what the effect of systemic steroid treatment is in COVID-19 patients, we issued a weak recommendation not to use systemic corticosteroids in patients with COVID-19 pneumonia,” he said.
At the same time, there is a “decent” amount of indirect evidence from randomized controlled trials in the general critically ill population with acute respiratory distress syndrome (ARDS) that has consistently shown use of systemic corticosteroids reduces the duration of mechanical ventilation and death.
“In addition, a recent observational study from China suggested that the use of corticosteroids may reduce mortality in COVID-19 patients with ARDS, so we issued a weak recommendation that in those with moderate to severe ARDS and COVID-19, you might consider using systemic corticosteroids,” Dr. Alhazzani said.
Regarding the management of the SARS-CoV-2 pathogen itself, Dr. Alhazzani said: “There isn’t much out there, but more than 80 randomized trials are ongoing and we will update the guidelines as the evidence from these studies emerges.”
Pharmacists and physicians should note the recommendations on empiric antibiotics, fluid resuscitation, corticosteroids and antiviral agents, and they are also urged to “pay close attention to the evolving data on prophylaxis and treatment options for COVID-19,” said Sandra Kane-Gill, PharmD, MSc, a professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She was not involved in research for the guidelines.
Although COVID-19 is caused by a virus, the guidelines do recommend empiric antibiotics in mechanically ventilated patients with COVID-19 and respiratory failure. However, they should be deescalated as quickly as possible based on microbiological testing results and the patients’ clinical status. Assessment for deescalation should be done daily. The panel said there were no clinical trials evaluating the use of empiric antimicrobials for COVID-19 patients, so the recommendation was based on treatment of other viral pneumonias, such as influenza. The panel’s concern was bacterial coinfection or superinfection in patients with COVID-19. “Data on the prevalence of bacterial superinfection in patients with COVID-19 are limited, as in larger case studies clinicians were often too overwhelmed to systematically obtain high-quality samples,” the panel wrote. However, 18% of critically ill patients with MERS had a bacterial coinfection and 5% had a viral coinfection.
The panel also recommended empiric antibiotics for COVID-19 patients with hypoxic respiratory failure on mechanical ventilation because superinfection in those types of patients with other viruses is common. During pandemic influenza, this scenario increases the risk for death. Dr. Kane-Gill applauded the panel “for the speed at which they developed and released the guidelines to aid clinicians managing critically ill patients with COVID-19.”
She also said, “Although in the case of COVID-19, direct evidence is limited, the authors synthesized indirect evidence to create useful recommendations.” The Surviving Sepsis Campaign (SCC) is a joint initiative of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). The evidence-based guidelines for the management of critically ill patients with COVID-19 cover topics from infection control to laboratory diagnosis and specimens, hemodynamic and ventilator support, and therapy.
The guidelines were penned by 36 experts from disciplines as varied as critical care, emergency, infectious diseases, virology, public health, nursing and methodology—all members of a newly formed SSC COVID-19 subcommittee.
“It was a very, very tough task to get this team together and look through the literature in a short time, but everyone felt the need to help guide treatment of patients with COVID-19,” Dr. Alhazzani said. He noted the guidelines were completed in two weeks in contrast to similar guidelines that would take more than a year to create under normal circumstances.
Based on the quality and nature of the supporting data, four statements were classified as best practice recommendations, nine were considered strong, and 35 statements were classified as weak.
One best practice statement recommends that health care workers performing aerosol-generating procedures—such as intubation, bronchoscopy and open suctioning—wear N-95 or FFP2 masks or other fitted masks, as well as personal protective equipment (PPE), including gloves, gowns and eye shields. A second best practice statement recommends that these procedures be performed in a negative pressure room to minimize the spread of the pathogen between rooms.
Another best practice recommendation is that endotracheal intubations in COVID-19 patients should be performed by health care providers who have the greatest experience in airway management. Doing so should reduce the number of intubation attempts and minimize aerosolization and transmission, the experts reasoned.
The fourth best practice recommendation—that adults with COVID-19 being treated with noninvasive positive pressure ventilation or a high-flow nasal cannula should be closely monitored for worsening respiratory status and intubated early if needed—is “practical and cautious,” Dr. Alhazzani said.
He said the benefits of intubation were balanced with the risk for transmission, that “use of these devices leads to aerosolization and places everybody at risk of transmission of the disease,” and that the reality is there could be a scarcity of ventilators. “Intubating most patients is not an ideal solution, as it will likely harm some patients who could have avoided intubation and may result in a shortage of ventilators.”