Short-term outcomes in individuals aged 75 or older with severe coronavirus disease (COVID-19): First observations from an infectious diseases unit in Southern Italy
Authors: Giuseppe Bruno, Serena Perelli, Claudia Fabrizio, Giovanni Battista Buccoliero
Journal: Journal of Infection (2020)

We read with great interest the article by Zhaohai Zheng et al., recently published in The Journal of Infection.1Zheng Z. Peng F. Xu B. Zhao J. Liu H. Peng J. et al.Risk factors of critical & mortal COVID-19 cases: a systematic literature review and meta-analysis.J Infect. 2020 Apr 23; (pii: S0163-4453(20)30234-6[Epub ahead of print] Review)https://doi.org/10.1016/j.jinf.2020.04.021Abstract Full Text Full Text PDF Scopus (1506) Google Scholar In this systematic review and meta-analysis male gender, age over 65 years, current smoking habit and the presence of underlying diseases were associated with severe coronavirus disease (COVID-19) and poor outcomes. As of May 03, 2020, there were 210,717 confirmed cases of COVID-19 in Italy and 28,884 deaths, mostly aged 70 or more, thus severely testing the national healthcare system.2Ministero della Salute. Novel Coronavirus in Italy. 2020. Available at:https://www.salute.gov.itGoogle Scholar To date, published studies describing short-term outcomes in elderly with severe COVID-19 disease admitted in the Italian Infectious Diseases units, are still limited.3Colaneri M. Sacchi P. Zuccaro V. Biscarini S. Sachs M. Roda S. et al.Clinical characteristics of coronavirus disease (COVID-19) early findings from a teaching hospital in Pavia, North Italy, 21 to 28 February 2020.Euro Surveill. Apr 2020; 25https://doi.org/10.2807/1560-7917.ES.2020.25.16.2000460Crossref PubMed Scopus (89) Google Scholar Therefore, we would like to describe short-term outcomes in all consecutive patients, aged 65 or more, with severe COVID-19 infection, hospitalized in our Infectious Diseases Unit. To our knowledge, this is the first report regarding elderly with COVID-19 from Southern Italy. Our inpatient unit is composed of 37 beds served continuously by eleven infectious diseases specialists, and is designed by the regional COVID-19 pandemic plan as one of the reference institutions for the hospital care of COVID-19 in Apulia region. Among the 67 patients with confirmed COVID-19 hospitalized from February 25, 2020, to April 29, 2020, 31 (46.2%), aged ≥ 65 years, were evaluated. Clinical, laboratory and radiological findings of these patients at baseline are illustrated in Table 1 and compared by age (group A: 65–74 years, group B: >75 years). Median age was 74 years and 19 (61.3%) were males. Baseline clinical and laboratory features of the two groups were similar. The most frequent comorbidities were hypertension (87.1%), cardiovascular disease (16.1%) and neurological disease (19.6%).Table 1Clinical characteristics of the patients at baseline, radiological findings and therapy.ABTotal(65–74)≥75p-valueN171431Median age72 (67.5–73.5)81 (77.5–85.5)74 (71–81)0.01Male12 (70.5)7 (50)19 (61.3)0.28BMI ≥ 308 (47.1)3 (21.4)11 (35.4)0.25Smoking or smoking history7 (41.1)1 (7.1)8 (25.8)0.04Chronic ComorbiditiesHypertension16 (94.1)11 (78.5)27 (87.1)0.3Cardiovascular disease2 (11.7)3 (21.4)5 (16.1)0.63Chronic kidney disease1 (5.8)2 (14.2)3 (9.6)0.57All respiratory disease2 (11.7)3 (21.4)5 (16.1)0.63Neurological Disease2 (11.7)4 (28.5)6 (19.3)0.36Diabetes2 (11.7)2 (14.2)4 (12.9)1Endocrine disease1 (5.8)01 (3.2)1Malignancy02 (14.2)2 (6.4)0.19Clinical symptomsFever14 (82.3)11 (78.5)25 (80.6)1Dry cough or sputum16 (94.1)9 (64.2)25 (80.6)0.06Fatigue3 (17.6)3 (21.4)6 (19.3)1Shortness of breath or dyspnea7 (41.1)8 (57.1)15 (48.3)0.48Gastrointestinal disorders1 (5.8)01 (3.2)1Laboratory indicators at admissionWhite blood cell, cells/μL6530 (4925–8322)6190 (3330–9630)6430 (4677–8885)0.4Lymphocyte, cells/μL870 (620–1172)760 (490–1647)825 (607.5–1197.5)0.66Hemoglobin, mg/dL13.3 (12.1–15.4)11.9 (10.9–13.2)12.5 (11.7–14.2)0.09Platelet (count, x 109/L)188 (143–327)196 (147–255)193 (143–293)0.82C-reactive protein, mg/L68.7 (37–148)79.2 (24.5–130)79.2 (34.7–133.5)0.96Procalcitonin, ng/mL0.11 (0.02 - 0.18)0.13 (0.08–0.18)0.12 (0.07–0.18)0.25Lactate dehydrogenase, UI/L305.5 (251–344)214 (197–289)268 (213.5–335)0.78Serum Creatinine, mg/dL0.93 (0.88–1.22)1.01 (0.7–1.33)1.01 (0.76–1.23)0.53Blood urea nitrogen, mg/dL45 (37.5–70.5)53.5 (37.5–76.2)49.5 (37.5–73.2)0.23SpO2 (%)91 (88–93.5)92.5 (91–94.5)92 (91–94)0.13qSOFA score ≥ 22 (11.7)3 (21.4)5 (16.1)0.63SOFA score ≥ 28 (47.1)9 (64.2)17 (54.8)0.47Radiological evidence of Pneumonia17 (100)13 (92.8)30 (96.7)0.45Radiological findings at admissionUnilateral Consolidation01 (7.1)1 (3.2)0.45Bilateral Consolidation6 (35.3)3 (21.4)9 (29)0.45Multiple mottling/ground-glass bilateral11 (64.7)9 (64.2)20 (64.5)1TreatmentHydroxychloroquine14 (82.3)10 (71.4)24 (77.4)0.6Lopinavir/ritonavir12 (70.5)7 (50)19 (61.2)0.28Heparine12 (70.5)11 (78.5)23 (74.1)0.69Azitromycin1 (5.8)1 (7.1)2 (6.4)1Antibiotic therapy11 (64.7)10 (71.4)21 (67.7)0.72Glucocorticoids9 (52.9)8 (57.1)17 (54.8)1Tocilizumab4 (23.5)04 (12.9)0.1Oxygen supplement15 (88.2)13 (92.8)28 (90.3)1Abbreviations: BMI, body mass index; qSOFA, quick Sepsis related organ failure assessment. Results are presented as frequencies (%) for qualitative values and median (interquartile range) for quantitative values. Open table in a new tab Abbreviations: BMI, body mass index; qSOFA, quick Sepsis related organ failure assessment. Results are presented as frequencies (%) for qualitative values and median (interquartile range) for quantitative values. Short-term outcomes were classified as follows: discharged, not discharged and death. Clinical findings according to the short-term outcomes are reported in Table 2. Pneumonia was radiologically confirmed in 30 individuals (96.7%), 27 of whom were defined severe according to the American Thoracic Society guidelines for community-acquired pneumonia.4Metlay J.P. Waterer G.W. Long A.C. Anzueto A. Brozek J. Crothers K. et al.Diagnosis and treatment of adults with community-acquired pneumonia. an official clinical practice guideline of the American thoracic society and infectious diseases society of America.Am J Respir Crit Care Med. 2019 Oct 1; 200: e45-e67https://doi.org/10.1164/rccm.201908-1581STCrossref PubMed Scopus (1784) Google ScholarTable 2Clinical findings according to the short-term outcomes.DischargedNot dischargedDiedTotalN718631Male5 (71.4)10 (55.5)4 (66.7)19 (61.3)Median age71 (68–72)81 (77.7–85.5)77.5 (72–91)74 (71–81)65–702 (28.5)3 (16.6)1 (16.6)6 (19.3)71–744 (57.1)5 (27.7)2 (33.3)11 (35.4)75–801 (14.2)4 (22.2)05 (16.1)81–8905 (27.7)1 (16.6)6 (19.3)≥ 9001 (5.5)2 (33.3)3 (9.6)≥ Two comorbidities6 (85.7)13 (72.2)5 (83.3)24 (77.4)Severe Pneumonia6 (85.7)15 (83.3)6 (100)27 (87)Patients requiring Oxygen supplement6 (85.7)16 (88.8)6 (100)28 (90.3)Low flow (nasal cannula/simple mask)3 (42.8)7 (38.8)010 (32.2)High flow (Venturi or reservoir masks)2 (28.5)6 (33.3)2 (33.3)10 (32.2)Non invasive-ventilation0000Invasive Ventilation1 (14.2)3 (16.6)4 (66.7)8 (25.8)Transferred to the ICU1* (14.2)3 (16.6)4 (66.7)8 (25.8)baseline qSOFA score ≥ 203 (16.6)2 (33.3)5 (16.1)baseline SOFA score ≥ 24 (57.1)8 (44.4)5 (83.3)17 (54.3)Severe clinical events771428ARDS2 (28.5)3 (16.6)6 (100)11 (35.4)Septic shock003 (50)3 (9.6)Secondary infections3 (42.8)4 (22.2)2 (33.3)9 (29.1)Acute hearth injury001 (16.6)1 (3.2)Multiple organ failure002 (33.3)2 (6.4)Pancreatitis2 (28.5)002 (6.4)Duration of hospital stay23 (21–33)27.5 (20.5–32)12 (5.7–17)23 (16–30)Abbreviations: ARDS, acute respiratory distress disease. Open table in a new tab Abbreviations: ARDS, acute respiratory distress disease. Oxygen supplement was administered in 28 cases (90.3%) including 8 patients (25.8%) who required invasive ventilation and were transferred to the intensive care unit. No patient underwent non-invasive ventilator support. A total of 28 severe clinical events were observed in 16 patients (51.6%), six of whom showed at least two severe events. Six deaths occurred due to acute respiratory distress syndrome, complicated by septic shock in three cases and acute hearth injury in one patient. Overall, median length of hospitalization was 23 days including 18 patients who are still hospitalized thus suggesting that prolonged hospital stay might have been depended on several factors, including onset of complications, frailty, slower healing, social and behavioural issues.5Armitage R. Nellums L.B. COVID-19 and the consequences of isolating the elderly.Lancet Public Health. 2020 Mar 19; (pii: S2468-2667(20)30061-X[Epub ahead of print] No abstract available)https://doi.org/10.1016/S2468-2667(20)30061-XAbstract Full Text Full Text PDF Scopus (920) Google Scholar Our results are in agreement with other studies reporting higher rates of severe outcomes in patients with COVID-19 aged 65 or more.6Grasselli G. Zangrillo A. Zanella A. Antonelli M. Cabrini L. Castelli A. et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the lombardy region, Italy.JAMA. 2020 Apr 6; https://doi.org/10.1001/jama.2020.5394Crossref Scopus (3792) Google Scholar,7Wang D. Yin Y. Hu C. Liu X. Zhang X. Zhou S. et al.Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-CoV-2, discharged from two hospitals in Wuhan, China.Crit Care. 2020 Apr 30; 24: 188https://doi.org/10.1186/s13054-020-02895-6Crossref PubMed Scopus (242) Google Scholar Moreover, the remarkable burden of comorbidities of this peculiar population probably plays a role in increasing the rate of severe outcomes, prolonging the duration of hospital stay and, consequently, raising healthcare costs. Altogether, these considerations call for further studies aiming to improve clinical management of serious disease complications in the elderly with COVID-19. None. We all contributed to editing the tables, and writing and editing the manuscript.