Category of paper: Original Article
Title: Predictors of severity and mortality of COVID-19 at a tertiary
care center in a Lower-middle income country
Abstract
Objective
COVID-19 mortality and outcomes differ significantly across the globe.
Limited data exists from low-middle income countries (LMICs) on
risk-factors for COVID-19 severity and mortality. We describe the
clinical spectrum and predictors of mortality and severity of illness in
COVID-19 from a single center in Karachi, Pakistan.
Methods
Retrospective cohort study of adults admitted with COVID-19 between
February-June 2020 were reviewed and logistic regression applied on
admission related risk-factors for severity and mortality.
Results
A total of 445 patients [66.97% males, mean age 51.6 (18-91) years]
were admitted with PCR confirmed COVID-19 during the study period.
Asymptomatic and severe/critical disease occurred in 55 (12.36%) and
137 (30.79%) patients, respectively. The proportion of severe disease
increased with time and most (268, 60.22%) had ≥ 1 co-morbid. Disease
severity was associated with age ≥ 60 (OR:1.92), shortness of breath
(OR:4.43) , CRP ≥150mg/L (OR:1.77), LDH ≥ 500 I.U/L (OR:1.98),
Neutrophil to Lymphocyte ratio (NLR) ≥5 (OR:2.80) and unit increase in
serum creatinine (OR:1.32). All-cause mortality was 13%. Mortality was
associated with septic shock (AOR= 13.2), age ≥ 60 (AOR: 3.25), Ferritin
≥ 1500ng/ml (AOR: 3.78) and NLR ≥ 5 (AOR: 4.04).
Conclusion
We describe the experience with COVID-19 from a tertiary-care hospital
in a LMIC. Our study found a comparatively low inpatient mortality, high
proportion of diabetics, and neutrophil to lymphocyte ratio of greater
than 5 as a predictor of both severity of illness and as poor prognostic
marker in COVID-19.
Keywords:
COVID-19; Mortality; Pakistan;
What is known about this topic?
1. COVID-19 mortality and outcomes differ significantly across the
globe.
2. Pakistan’s COVID-19 fatality rate of 2.13% is significantly lower
than that reported from developing countries.
3. Factors predictive of severity of illness and mortality have varied
and there is limited data from low and middle income countries although
these countries differ in disease burden as well as in prevalence of
co-morbids such as Diabetes and have poor infrastructure to deal with
this pandemic.
What does this article add?
1. There is under-representation of data on outcomes of COVID-19 from
these LMICs in international literature despite substantial disease
burden in these countries.
2. This is the first retrospective cohort study from this country which
was conducted to determine predictors of severity of illness and poor
prognostic markers in COVID-19 on 445 patients.
3. Outcome assessment for mortality as well as other complications
including development of Acute Respiratory Distress Syndrome, Nosocomial
infections and acute kidney injury was performed and poor prognostic
markers were determined.
4. We found a comparatively lower mortality despite greater prevalence
of diabetes in our cohort and we found that a neutrophil to lymphocyte
ratio of greater than 5 at presentation can be used as a marker to
predict greater severity of illness and mortality
Introduction
The World Health Organization (WHO) declared a Coronavirus Disease 2019
(COVID-19) a global pandemic on March 11, 2020, and since then it has
affected 213 countries and territories worldwide. Pakistan currently
ranks at number 16 with greater than 250,000 reported cases and 6000
mortalities (1). COVID-19 displays a spectrum of presentations ranging
from asymptomatic to fatal. While the causative organism, Severe Acute
Respiratory Syndrome Coronavirus-2, has a tropism for multiple organ
systems (2), pulmonary manifestations predominate. Cough, fever,
shortness of breath, myalgia, and headaches are some of the most
commonly reported symptoms (3). For management and research, the World
Health Organization categorizes disease severity into mild (symptomatic
without evidence of pneumonia or hypoxia), moderate (with clinical signs
of pneumonia and oxygen saturation >= 90% on room air),
severe (signs of pneumonia with respiratory rate > 30
breaths/min or severe respiratory distress or SpO2 < 90% on
room air) and critical (development of Acute Respiratory Distress
Syndrome or sepsis) (4)
COVID-19 mortality and outcomes differ significantly across the globe.
Six months into its COVID-19 outbreak, Pakistan, a low middle-income
country, has crossed the peak of its epidemic. Pakistan’s COVID-19
fatality rate of 2.13%(5) is significantly lower than that reported in
America and Europe, and lower than that of its neighbors Iran,
Afghanistan, and China, but comparable to that of India (6). Sindh was
the first Pakistani province to report a case of COVID-19. Since then it
has had the highest number of cases (43%) in the country (5), most from
its largest city- the metropolitan Karachi. We report data on
comorbidities, and clinical, biochemical, and radiological features and
outcomes of COVID-19 in a larger cohort of 445 patients from our
center-an academic, private, tertiary care hospital in Karachi with a
dedicated facility for COVID-19.
Methods