By the University at Buffalo
The first international guidelines on treating patients severely ill with COVID-19 were published in March 2020. Now, nearly a year later, the organization that published them has issued its first update: Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU.
Authored by 43 clinicians from 14 countries, the guidelines concern patients hospitalized with severe and critical disease in intensive care units.
Manoj J. Mammen, M.D., associate professor in the department of medicine in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, section chief of UB Pulmonary at Buffalo General Medical Center and a physician with UBMD Internal Medicine, is a co-author on both the current and previous guidelines.
“The new guidelines demonstrate what we have learned about treating patients with severe COVID-19, while underscoring how much still needs to be determined,” Mammen said.
The purpose of the document is to support hospital clinicians at the bedside taking care of critically ill patients in intensive care units.
Probably the most unsurprising item in the guidelines is that no benefit to COVID-19 patients and possible harm was found to result from the use of hydroxychloroquine. Few clinicians thought it would be helpful at the time, Mammen said, but now there are data that have unequivocally confirmed this.
One of the most significant items in the guidelines is the recommendation that for critically ill patients with COVID-19, the steroid dexamethasone does result in lower mortality rates and improved outcomes.
“The guidelines report that dexamethasone is the only treatment that has been shown to reduce mortality in critically ill patients,” said Mammen, whose area of focus on the guidelines was pharmacotherapy.
While dexamethasone has not been shown to improve outcomes in outpatients or those with milder disease, he said a large clinical trial has shown that it does reduce mortality rates in patients severely ill with COVID-19.
Mammen said that, while most hospital clinicians are already aware of which treatments work and which don’t, the guidelines are important to circulate among the wider medical community. For example, he said it is important to note that steroids in patients with milder disease have not been demonstrated to result in improved outcomes.
Remdesivir is also included in the guidelines as recommended for patients with severe disease who are not on mechanical ventilation, a change from the first document that had no recommendation regarding this drug. The new guidelines also note that critically ill patients have the best chance of benefitting from remdesivir if it is administered within 72 hours of testing positive.
Despite numerous clinical trials on the use of convalescent plasma, the new guidelines do not recommend it, since outcomes from the trials have been inconclusive at best.
Vaccinations and Variants
Now that populations around the globe are beginning to get vaccinated, Mammen said the next 12 months will likely look very different from the past year.
“The questions that remain have to do with how vaccination will affect disease progression,” he said. He noted the new variants of the virus will also be an important factor. “There are probably hundreds of variants of the virus out there right now, and only a few are clinically relevant.” But how they will affect transmission and disease progression in the coming months is unknown.
“That’s why we need to continue to wear masks, continue to practice social distancing and good hand hygiene,” Mammen said. “Prevention is still the most important thing."
The guidelines were developed as part of the Surviving Sepsis campaign, an international effort launched in 2002 to develop evidence-based guidelines to drive down the numbers of deaths around the world from sepsis and septic shock. Sepsis is the body's extreme response to an infection, which, is not treated, can cause tissue damage, organ failure and death.
Mammen explained a small percentage of patients with COVID-19 experience severe sepsis; it is more likely among the elderly and those with preexisting chronic conditions.