Early corticosteroids are associated with lower mortality in critically ill patients with COVID-19: a cohort study

Pablo Monedero, Alfredo Gea, Pedro Castro, Angel M Candela-Toha, María L Hernández-Sanz, Egoitz Arruti, Jesús Villar, Carlos Ferrando, COVID-19 Spanish ICU Network, Pablo Monedero, Alfredo Gea, Pedro Castro, Angel M Candela-Toha, Pablo Monedero, Alfredo Gea, Pedro Castro, Angel M Candela-Toha, María L Hernández-Sanz, Egoitz Arruti, Jesús Villar, Carlos Ferrando, COVID-19 Spanish ICU Network, Pablo Monedero, Alfredo Gea, Pedro Castro, Angel M Candela-Toha

Abstract

Background: Critically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose.

Methods: This is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications.

Results: A total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n = 485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens.

Conclusion: Early use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.

Keywords: COVID-19; Cohort study; Corticosteroids; Critically ill patient; Intensive Care Unit; Mortality; Outcomes; Ventilator-free days.

Conflict of interest statement

We declare no competing interests.

Figures

Fig. 1
Fig. 1
Flow chart of study participants. ICU = Intensive Care Unit
Fig. 2
Fig. 2
Kaplan–Meier estimates of mortality according to the use of corticosteroids. Delayed = after 48 h of ICU admission. The upper graphs are crude estimates. The lower graphs are inverse probability weighted (IPW) estimates (N = 455)
Fig. 3
Fig. 3
Kaplan–Meier estimates of mortality according to corticosteroids use during total hospital stay: ever (early + delayed) or never treatment. The upper graphs are the crude estimates. The lower graphs are IP-weighted estimates (N = 392)

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