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Vol. 6. Núm. 3.
(Julio - Septiembre 2023)
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Vol. 6. Núm. 3.
(Julio - Septiembre 2023)
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Comparison of three prognostic and predictive scores in 10 patients with COVID-19 pneumonia caused by nosocomial infection
Comparación de tres puntuaciones pronósticas y predictivas en 10 pacientes con neumonía COVID-19 causada por infección nosocomial
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Yu Kijimaa,b,c,
Autor para correspondencia
meyu10033@gmail.com

Corresponding author.
, Tomokazu Shimizub,c, Hiroshi Tomab,c, Shoichi Iidab,c, Masashi Inuia, Toshio Takagic
a Department of Urology, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
b Department of Urology and Transplant Surgery, Toda Chuo General Hospital, Saitama, Japan
c Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
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Tablas (2)
Table 1. Patient characteristics.
Table 2. Determination of the COVID-GRAM score, International Severe Acute Respiratory and Emerging Infections Consortium’s (ISARIC) World Health Organization (WHO) 4C Mortality Score, and COVID-19 Registry Japan (COVIREGI-JP).
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Abstract
Introduction

A nosocomial outbreak of coronavirus disease (COVID-19) occurred in the Toda Chuo General Hospital in Toda City, Saitama Prefecture, Japan in December 2020. The purpose of this study was to compare the accuracy of three prognostic indices for predicting the outcome of COVID-19 in patents with COVID-19 pneumonia.

Patients and methods

Patients in the Department of Urology and Transplant Surgery at Toda Chuo General Hospital with nosocomially acquired COVID-19 confirmed by a positive polymerase chain reaction test were included in the study. We used the COVID-GRAM, International Severe Acute Respiratory and Emerging Infections Consortium’s World Health Organization 4C Mortality Score, and COVID-19 Registry Japan to independently predict the prognoses of 10 patients and identify common prognostic factors. All three indices include age, dyspnea, and comorbidities as prognostic factors.

Results

Ten patients were included in the study, of which two patients died. According to the COVID-GRAM both patients were “high risk,” whereas the 4C Mortality Score predicted “high risk” and “very high risk.”

Conclusion

The prognostic scores of all three indices were useful for predicting illness severity.

Keywords:
Comorbidity
COVID-19
Dyspnea
Mortality
Prognosis
Resumen
Objetivos

En diciembre de 2020 se produjo un brote nosocomial de enfermedad por coronavirus (COVID-19) en el Hospital General Toda Chuo de la ciudad de Toda, prefectura de Saitama, Japón. El propósito de este estudio fue comparar la exactitud de tres índices pronósticos para predecir el resultado de COVID-19 en pacientes con neumonía por COVID-19.

Métodos

Se incluyeron en el estudio pacientes del Departamento de Urología y Cirugía de Trasplantes del Hospital General Toda Chuo con COVID-19 adquirida por vía nosocomial confirmada por una prueba de reacción en cadena de la polimerasa positiva. Se utilizaron los índices COVID-GRAM, International Severe Acute Respiratory and Emerging Infections Consortium's World Health Organization 4C Mortality Score y COVID-19 Registry Japan para predecir de forma independiente el pronóstico de 10 pacientes e identificar factores pronósticos comunes. Los tres índices incluyen la edad, la disnea y las comorbilidades como factores pronósticos.

Resultados

Se incluyeron en el estudio 10 pacientes. Dos pacientes fallecieron. Según el COVID-GRAM ambos pacientes eran de "alto riesgo", mientras que el 4C Mortality Score predijo "alto riesgo" y "muy alto riesgo".

Conclusión

Las puntuaciones pronósticas de los tres índices fueron útiles para predecir la gravedad de la enfermedad.

Palabras clave:
Comorbilidad
COVID-19
Disnea
Mortalidad
Pronóstico
Texto completo
Introduction

Toda Chuo General Hospital is a 517-bed acute care general hospital in Toda City, Saitama Prefecture, with a dedicated ward for patients with coronavirus disease 2019 (COVID-19). On December 19, 2020, an infection was confirmed in one staff member, and simultaneously, six staff members and five patients were also confirmed to be infected. A cluster was consequently confirmed in the hospital, resulting in infections in 150 patients and 174 staff members, among which 45 deaths occurred. The outbreak occurred during the first wave of COVID-19 when no treatment was available. Ten cases of COVID-19 occurred in patients in our department during the outbreak. The purpose of this study was to compare the accuracies of three prognostic indices for predicting the outcome of COVID-19 in patents with COVID-19 pneumonia.

Materials and methodsStudy cohort

Ten patients in the Department of Urology and Transplant Surgery at Toda Chuo General Hospital with a positive polymerase chain reaction test and a confirmed diagnosis of COVID-19 were included in the study. They were infected at the Toda Chuo General Hospital between December 19, 2020 and January 5, 2021.

Prognostic scoring

The COVID-GRAM, International Severe Acute Respiratory and Emerging Infections Consortium’s (ISARIC) World Health Organization (WHO) 4C Mortality Score, and COVID-19 Registry Japan (COVIREGI-JP) were used as the prognostic scoring tools.

Ethics approval

This study was approved by the committee of Toda Chuo General Hospital Institutional Review Board (0542).

Statistical analysis

A simple descriptive analysis was conducted. In view of the small sample size, no inferential statistics or hypothesis testing were employed.

Results

The backgrounds of the 10 patients are shown in Table 1. Of the 10 patients, the COVID-GRAM score showed intermediate risk in four patients and high risk in six patients. The ISARIC WHO 4C Mortality Score showed intermediate risk in three patients, high risk in six patients, and very high risk in one patient. Nine patients in the COVIREGI-JP group were at a risk of requiring oxygen therapy (Table 2).

Table 1.

Patient characteristics.

【Case】  10 
Age  57  66  73  73  74  85  87  87  87  88 
Sex  Man  Man  Woman  Man  Man  Man  Man  Woman  Man  Woman 
Primary disease  Metastatic renal cell carcinoma  Pelvic tumor Multiple bone metastases of unknown primary cancer  After living donor kidney transplantation  Localized prostate cancer  Muscle-invasive bladder cancer  Non-muscle-invasive bladder cancer  Benign prostatic hyperplasia  Emphysematous pyelonephritis  Benign prostatic hyperplasia  Metastatic bladder tumor 
Stage  cT1bN0M1  cT1cN0M0  cT1N0M0  cTaN0M0  cT4aN0M1b 
Result  Mild  Dead  Severe  Mild  Severe  Moderate II  Mild  Moderate I  Mild  Dead 
Table 2.

Determination of the COVID-GRAM score, International Severe Acute Respiratory and Emerging Infections Consortium’s (ISARIC) World Health Organization (WHO) 4C Mortality Score, and COVID-19 Registry Japan (COVIREGI-JP).

Patient:  10 
Age  57  66  73  73  74  85  87  87  87  88 
Number of comorbidities 
Cancer history  Yes  Yes  No  Yes  Yes  Yes  Yes  Yes  No  Yes 
Radiographic abnormality  No  Yes  Yes  No  Yes  No  Yes  Yes  No  Yes 
Dyspnea  No  No  No  No  No  No  No  No  No  No 
Hemoptysis  No  No  No  No  No  No  No  No  No  No 
Unconsciousness  No  No  No  No  No  No  No  No  No  Yes 
NLR  14  15  14  32 
LDH  574  321  210  175  206  151  257  186  149  378 
Total bilirubin  0.3  1.2  0.1  0.1  0.1  0.3  0.1  0.1  0.1  0.1 
COVID-GRAM Score  High  High  Intermediate  Intermediate  High  Intermediate  High  High  Intermediate  High 
                     
Age 
Sex  1 (M)  1 (M)  0 (F)  1 (M)  1 (M)  1 (M)  1 (M)  0 (F)  1 (M)  0 (F) 
Number of comorbidities 
Respiratory rate, breaths/min 
Peripheral oxygen saturation on room air 
GCS 
BUN 
CRP 
WHO 4C Mortality Score  4/Intermediate  11/High  11/High  8/Intermediate  9/High  10/High  12/High  10/High  8/Intermediate  18/Very high 
                     
Age  57/+1  66  73  73  74  85/+2  87/+2  87/+2  87/+2  88/+2 
Sex  Man/+1  ×  ×  ×  ×  ×  ×  ×  ×  × 
BMI  15.44  31.85/+2  17.04  23.08  19.63  22.32  ··  19.65  21.97  15.8 
CHF  × 
Cerebrovascular disease  × 
DM  × 
Hypertension  × 
Malignancy  ×  ×  ×  ×  ×  ×  ×  ×  × 
Fever 
Cough 
SOB 
Wheezing  ×  ×  ×  ×  ×  ×  ×  ×  × 
Fatigue  ×  ×  ×  ×  ×  ×  ×  ×  × 
COVIREGI-JP Score  13  11 
Result  Mild  Dead  Severe  Mild  Severe  Moderate II  Mild  Moderate I  Mild  Dead 

BUN, blood urea nitrogen; BMI, body mass index; CHF, congestive heart failure; CRP, C-reactive protein; DM, diabetes mellitus; GCS, Glasgow Coma Scale; LDH, lactate dehydrogenase; NLR, neutrophil-lymphocyte ratio SOB, shortness of breath

Of the ten study patients, two (Patients 2 and 10) died, and two (Patients 3 and 5) experienced severe outcomes. The COVID-GRAM predicted Patient 3 to have intermediate risk, whereas the ISARIC WHO 4C Mortality Score predicted a high risk. Patient 5 was scored as high risk using both these prognostic tools. Patient 2 was also scored as high risk by both these tools, whereas Patient 10 was scored as high risk using the COVID-GRAM and very high risk using the ISARIC WHO 4C Mortality Score. Furthermore, six of the nine patients in the COVIREGI-JP group required supplemental oxygen.

Discussion

There are several prognostic factors for COVID-19. Currently, vaccination and new oral medications can prevent severe disease; however, at the time of this study, neither vaccination not oral medications were available. We compared the predictive accuracies of three prognostic factor indices, i.e., the COVID-GRAM, the ISARIC WHO 4C Mortality Score, and COVIREGI-JP.1–3 Prognostic factors shared by all three indices included age, dyspnea, and comorbidities. Level of consciousness was common to the COVID-GRAM and the ISARIC WHO 4C Mortality Score, whereas sex was common to the ISARIC WHO 4C Mortality Score and COVIREGI-JP.

SARS-CoV-2 infection following kidney transplantation has been reported to be associated with a higher mortality rate (28%) than that in the general population or in patients older than 70 years.4 Within our patients, Patient 3 had undergone a kidney transplantation and had a severe outcome. In the COVID-GRAM scale, high risk was more common due to the presence of malignancy. Within the 4C mortality scores, the proportion of high risk was high due to the high score due to age. The 4C Mortality Score was more accurate in predicting outcomes than the COVID-GRAM scale.

Patients with perioperative COVID-19 infections have a significantly higher risk of postoperative complications, especially in men older than 70 years.5,6 Postoperative pulmonary complications occurred in half of the patients with COVID-19 infections diagnosed from within seven days pre-operation to 30 days post-operation and were associated with a high mortality rate.5 Patient 5, a man aged over 70 years, experienced severe complications on the eighth postoperative day.

Patients 2 and 10 died. Patient 2 had a pelvic tumor of unknown origin with bone metastasis, and Patient 10 had a metastatic bladder tumor with uterine invasion and lung metastasis. Metastases may contribute to severe disease and death. Old age is the most important risk factor for severe disease, and in an analysis using COVIREGI-JP, the fatality rate was 3.9% in patients aged 60 years or older with no underlying disease and 12.8% in patients aged 60 years or older with underlying disease.3,7 Although the number of cases in this study was small, the patients with underlying conditions, such as metastatic cancer and an immunosuppressed status, tended to develop more severe COVID-19 pneumonia. In addition, several meta-analyses have shown that men are at a higher risk of severe illness and death than women.8 With the development of vaccination and treatment methods, new prognostic factors should be evaluated in the future.

In conclusion, all three prognostic scoring systems were useful for predicting illness severity.

Funding source

This research received no external funding.

Approval by institutional review board

This study was approved by the committee of Toda Chuo General Hospital Institutional Review Board (0542).

Informed consent

Written informed consent was obtained from the patient for publication of this report.

Author contributions

Y.K. and T.S.: writing – original draft preparation; H.T., S.I., M.I and T.T.: writing – review and editing.

Acknowledgments

The authors would like to thank Editage (www.editage.jp) for English language editing.

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Risk stratification of patients admitted to hospital with COVID-19 using the ISARIC WHO clinical characterisation protocol: development and validation of the 4C mortality score [published correction appears in].
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Risk factors for severity on admission and the disease progression during hospitalisation in a large cohort of patients with COVID-19 in Japan.
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Male sex identified by global COVID-19 meta-analysis as a risk factor for death and ITU admission.
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