Discussion
This study represents the first case series of sequentially hospitalized
laboratory confirmed COVID-19 patients from a regional hospital in
Spain.
In comparison with other series of hospitalized patients, our study
includes and represents older patients, with a median age of 75 years
old (range 28-96) and more than a third over 80 years old. Series from
China, United States and Italy included younger patients ranging from 47
to 55 in China1,4,7 and from 61 to 64 in United States
and Italy6,12-16. In addition, the median age of a
larger retrospective study from Spanish University Hospitals (mostly
from Madrid) was 69.4 years old17.
In a similar way to these previous series, our patients had many
comorbidities (arterial hypertension, diabetes mellitus and
cardiovascular diseases were the most frequent) and a low proportion of
smokers, history of chronic respiratory diseases or HIV
infection1,4,7,12-19. The clinical and laboratory
presentation were also similar to the already described, and, unlike
other centres, we have performed few chest CT scans (in part, to avoid
transferring patients outside the isolation area) and more LUS. In our
opinion, LUS can be very useful in characterizing lung involvement of
COVID-19 even when chest radiograph is normal11.
The COVID-19 related signs and symptoms found in our study are similar
to those reported in previous studies with the exception of a low
proportion (3%) of smell and taste alterations. This is surprising when
compared to the high proportion of our healthcare workers affected by
COVID-19 who presented these symptoms (53%)8. There
is a wide range of these symptoms ranging from 7% in hospitalized
patients from Spain to 64% in mildly symptomatic outpatients from
Italy20. It is probable that less severe patients tend
to express these symptoms more often than more severely ill ones.
We found a high in-hospital mortality in our study (26%). This data is
clearly higher than those reported at the start of the pandemic in China
(1.4-11%)1,4 and the first communications from the
United States (10-21% in New York City and 15.6% in
California)13-14. This proportion is also slightly
higher than the 20% morality rate more recently reported in the
abovementioned studies from Italy and Spain16,17. The
old population and high comorbidity of our patients may explain, in
part, this high mortality rate. We believe that mortality could have
been even higher if more patients had been admitted from long-term care
facilities (17% in the present study) were mortality rates are higher
than 30%5.
Apart from age and comorbidities we have found other variables
associated with the composite outcome (death or ICU admission) including
respiratory insufficiency or radiographic abnormalities at presentation,
more prominent laboratory abnormalities, and requiring higher oxygen
concentrations. In the multivariate analysis only a high comorbidity
burden (measured with the PROFUND score) and high C-reactive protein
values, remained statistically significant risk factor. It is important
to early identify these patients and try to modify their prognosis. We
have also found that those patients treated with hydroxychloroquine and
azithromycin had a better prognosis, but this finding should be
interpreted with caution. Treatment assignation was not randomized, and
it was prescribed according to regional protocols, at treating physician
discretion and after consent of the patient.
The main strength of this study is that it is prospective (including all
consecutively hospitalized patients) and that it offers unpublished
information so far, including advanced age patients, from a
non-university regional hospital and from Spain. The main limitation of
this study is that the data only represent a single centre in a rural
region of Spain, so the findings cannot be generalized. More studies
from Spain and other European countries are necessary to verify the
clinical characteristics, in-hospital mortality rates and prognostic
factors of COVID-19.
In conclusion, case-fatality rate of patients hospitalized with COVID-19
in the early days of the Spanish epidemic was high (26%). A high
comorbidity burden and high C-reactive protein values were factors
related with increased risk of death or ICU admission.