Yaseen M Arabi1,2, Yasser Mandourah3, Fahad Al-Hameed4, Anees A Sindi5, Ghaleb A Almekhlafi3, Mohamed A Hussein6, Jesna Jose6, Ruxandra Pinto7, Awad Al-Omari8,9, Ayman Kharaba10,11, Abdullah Almotairi12, Kasim Al Khatib13, Basem Alraddadi8,14, Sarah Shalhoub15, Ahmed Abdulmomen16, Ismael Qushmaq14, Ahmed Mady17,18, Othman Solaiman19, Abdulsalam M Al-Aithan20, Rajaa Al-Raddadi21, Ahmed Ragab22, Hanan H Balkhy1,23, Abdulrahman Al Harthy17, Ahmad M Deeb24, Hanan Al Mutairi24, Abdulaziz Al-Dawood1,2, Laura Merson25, Frederick G Hayden25,26, Robert A Fowler27,28,29. 1. 1 College of Medicine. 2. 2 Intensive Care Department and. 3. 3 Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia. 4. 4 Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia. 5. 5 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. 6. 6 Department of Biostatistics and Bioinformatics, and. 7. 7 Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada. 8. 8 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. 9. 9 Department of Intensive Care, Dr. Sulaiman Al-Habib Group Hospitals, Riyadh, Saudi Arabia. 10. 10 Department of Critical Care, King Fahad Hospital, Al-Madinah Al-Monawarah, Saudi Arabia. 11. 11 Department of Critical Care, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia. 12. 12 Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia. 13. 13 Intensive Care Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia. 14. 14 Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. 15. 15 Division of Infectious Diseases, Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. 16. 16 Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia. 17. 17 Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt. 18. 18 Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia. 19. 19 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. 20. 20 Intensive Care Department, King Abdulaziz Hospital, Al Ahsa, Saudi Arabia. 21. 21 Department of Research, Ministry of Health, Jeddah, Saudi Arabia. 22. 22 Intensive Care Department, King Fahd Hospital, Jeddah, Saudi Arabia. 23. 23 Department of Infection Prevention and Control, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia. 24. 24 Research Office, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. 25. 25 International Severe Acute Respiratory and Emerging Infection Consortium, Infectious Diseases Data Observatory, Oxford University, Oxford, United Kingdom. 26. 26 Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia. 27. 27 Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and. 28. 28 Department of Critical Care Medicine and. 29. 29 Department of Medicine, Sunnybrook Hospital, Toronto, Ontario, Canada.
Abstract
RATIONALE: Corticosteroid therapy is commonly used among critically ill patients with Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients' clinical condition at the time of corticosteroid therapy initiation. OBJECTIVES: To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS. METHODS: ICU patients with MERs were included from 14 Saudi Arabian centers between September 2012 and October 2015. We performed marginal structural modeling to account for baseline and time-varying confounders. MEASUREMENTS AND MAIN RESULTS: Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (quartile 1 [Q1]-Q3, 1.0-7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141 of 151 [93.4%] vs. 121 of 158 [76.6%]; P < 0.0001) and had higher 90-day crude mortality (112 of 151 [74.2%] vs. 91 of 158 [57.6%]; P = 0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio, 0.75; 95% confidence interval, 0.52-1.07; P = 0.12) but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio, 0.35; 95% CI, 0.17-0.72; P = 0.005). CONCLUSIONS: Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.
RATIONALE: Corticosteroid therapy is commonly used among critically illpatients with Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients' clinical condition at the time of corticosteroid therapy initiation. OBJECTIVES: To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically illpatients with MERS. METHODS: ICU patients with MERs were included from 14 Saudi Arabian centers between September 2012 and October 2015. We performed marginal structural modeling to account for baseline and time-varying confounders. MEASUREMENTS AND MAIN RESULTS: Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (quartile 1 [Q1]-Q3, 1.0-7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141 of 151 [93.4%] vs. 121 of 158 [76.6%]; P < 0.0001) and had higher 90-day crude mortality (112 of 151 [74.2%] vs. 91 of 158 [57.6%]; P = 0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio, 0.75; 95% confidence interval, 0.52-1.07; P = 0.12) but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio, 0.35; 95% CI, 0.17-0.72; P = 0.005). CONCLUSIONS: Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.
Entities:
Keywords:
Saudi Arabia; coronavirus; corticosteroid; pneumonia; respiratory distress syndrome
Authors: John H Beigel; Hannah H Nam; Peter L Adams; Amy Krafft; William L Ince; Samer S El-Kamary; Amy C Sims Journal: Antiviral Res Date: 2019-04-08 Impact factor: 5.970
Authors: Zhikang Ye; Bram Rochwerg; Ying Wang; Neill K Adhikari; Srinivas Murthy; François Lamontagne; Robert A Fowler; Haibo Qiu; Li Wei; Ling Sang; Mark Loeb; Ning Shen; Minhua Huang; Zhaonan Jiang; Yaseen M Arabi; Luis Enrique Colunga-Lozano; Li Jiang; Younsuck Koh; Dong Liu; Fang Liu; Jason Phua; Aizong Shen; Tianyi Huo; Bin Du; Suodi Zhai; Gordon H Guyatt Journal: CMAJ Date: 2020-10-26 Impact factor: 8.262
Authors: Zhikang Ye; Bram Rochwerg; Ying Wang; Neill K Adhikari; Srinivas Murthy; François Lamontagne; Robert A Fowler; Haibo Qiu; Li Wei; Ling Sang; Mark Loeb; Ning Shen; Minhua Huang; Zhaonan Jiang; Yaseen M Arabi; Luis Enrique Colunga-Lozano; Li Jiang; Younsuck Koh; Dong Liu; Fang Liu; Jason Phua; Aizong Shen; Tianyi Huo; Bin Du; Suodi Zhai; Gordon H Guyatt Journal: CMAJ Date: 2020-04-29 Impact factor: 8.262