Sir,
Wang and colleagues recently reported in this journal the characteristics and prognostic
factors of novel coronavirus 2019 (COVID-19) disease in 339 patients over 60 years
of age presenting to Renmin Hospital of Wuhan University in Wuhan, China.
1
This highlighted the higher case fatality rate in this patient group with 19.2% dying
within 30 days and frequent comorbidities including hypertension, diabetes and cardiovascular
disease. Numerous other case series of hospitalised patients in China have provided
valuable insight into the clinical features of disease, risk factors for severity
and case fatality rate. These have informed diagnostic criteria, treatment strategies
and public health policy worldwide. In the largest of these, patients over 65 years
of age represented 27% of patients with severe disease and 49.2% of patients admitted
to the intensive care unit.
2
To date there has been limited clinical data published outside of China and none from
the epidemic in the UK which is estimated to be now nearing its peak (14th April,
2020). It is anticipated that age and the frequency of co-existing comorbidities in
the UK population are likely to be strong drivers of outcome of and mortality in patients
hospitalised with COVID-19 disease.
Here, we describe a retrospective single-centre study of all patients hospitalised
with SARS-COV-2 infection from March 10th to March 30th within North Bristol NHS Trust,
a large, regional teaching hospital in the UK. During this period, 95 cases were admitted
to the trust and by the final day of follow up on April 6th, 21 patients (21%) had
died, 44 patients (43%) had been discharged, and 30 (29%) were still inpatients. Of
the 21 patients that died, 20 died within 14 days suggesting that most mortality occurs
within two weeks. 7 patients were admitted to the intensive care unit, of whom 4 had
died by the 6th of April, and 3 remained in intensive care. Length of stay for patients
who were discharged from hospital was a median of 4 days (IQR 1-16), for those that
died 8 days (IQR 6-9) and for those that remained inpatients 9 days (IQR 3-23). Longer
length of stay was influenced by the timing of a positive test, which for 23 patients
(24%) was more than 7 days after admission. Fifteen patients (16%) had a negative
test preceding the positive result indicating some delay in diagnosis due to false
negative results.
The demographics, symptoms, radiology, laboratory findings and comorbidities of our
patient group are presented in Tables 1
and 2
. The median age of patients was similar in both patients alive at 14 days and those
that had died, at 74 and 77 respectively. No differences by gender were observed,
but there were more men in the study overall (63%). Cardiovascular and cerebrovascular
disease was significantly more common in those that had died by 14 days (90% vs 48%) and
of these; congestive cardiac failure was the most notably associated with non-survival
(35% vs 11%). Diabetes was also significantly more common in those that had died at
14 days (65% vs 32%) whilst respiratory disease was equally distributed between the
two groups (30% vs 33%).The most common symptoms were fever (72%) cough (74%) and
shortness of breath (43%), followed by confusion (20%). Two patients presented with
anosmia. This has recently been recognised as an early clinical feature in European
patients
4
and may be underrepresented in our cohort due to the frequency of advanced disease
and confusion. Shortness of breath was the only symptom that was significantly more
common in patients that died within 14 days (p= 0.013).
Table 1
Patient demographics, comorbidities and symptoms.
Table 1
Characteristic
N = 951
Alive N = 751
Dead N = 201
p-value2
Age
75 (59, 82)
74 (56, 82)
77 (72, 85)
0.062
Gender
>0.9
F
35 (37%)
27 (36%)
8 (40%)
M
60 (63%)
48 (64%)
12 (60%)
Comorbidities
All Cardiovascular disease
54 (57%)
36 (48%)
18 (90%)
0.002
Hypertension
35 (37%)
24 (32%)
11 (55%)
0.10
Ischaemic heart disease
21 (22%)
14 (19%)
7 (35%)
0.14
Cardiac failure
15 (16%)
8 (11%)
7 (35%)
0.014
Arrhythmia
13 (14%)
10 (13%)
3 (15%)
>0.9
Valve disease
6 (6.3%)
6 (8.0%)
0 (0%)
0.3
Cerebrovascular
8 (8.4%)
6 (8.0%)
2 (10%)
0.7
All Respiratory disease
31 (33%)
25 (33%)
6 (30%)
>0.9
Asthma
21 (22%)
17 (23%)
4 (20%)
>0.9
COPD
10 (11%)
6 (8.0%)
4 (20%)
0.2
Bronchiectasis
1 (1.1%)
1 (1.3%)
0 (0%)
>0.9
Obstructive Sleep Apnoea
8 (8.4%)
6 (8.0%)
2 (10%)
0.7
Gastrointestinal disease
11 (12%)
8 (11%)
3 (15%)
0.7
Endocrine disease
6 (6.3%)
4 (5.3%)
2 (10%)
0.6
Diabetes
37 (39%)
24 (32%)
13 (65%)
0.015
Malignancy
20 (21%)
17 (23%)
3 (15%)
0.6
Neurological disease
14 (15%)
11 (15%)
3 (15%)
>0.9
Renal disease
22 (23%)
16 (21%)
6 (30%)
0.6
Immunocompromised
1 (1.1%)
1 (1.3%)
0 (0%)
>0.9
Symptoms
Fever
68 (72%)
56 (75%)
12 (60%)
0.3
Cough
70 (74%)
56 (75%)
14 (70%)
0.9
Shortness of breath
41 (43%)
27 (36%)
14 (70%)
0.013
Myalgia
13 (14%)
12 (16%)
1 (5.0%)
0.3
Confusion
20 (21%)
16 (21%)
4 (20%)
>0.9
Seizure
1 (1.1%)
1 (1.3%)
0 (0%)
>0.9
Headache
9 (9.5%)
9 (12%)
0 (0%)
0.2
Sore throat
6 (6.3%)
6 (8.0%)
0 (0%)
0.3
Chest pain
7 (7.4%)
6 (8.0%)
1 (5.0%)
>0.9
Diarrhoea
11 (12%)
7 (9.3%)
4 (20%)
0.2
Nausea and vomiting
13 (14%)
9 (12%)
4 (20%)
0.5
Abdominal pain
5 (5.3%)
4 (5.3%)
1 (5.0%)
>0.9
Constipation
4 (4.2%)
4 (5.3%)
0 (0%)
0.6
Anosmia
3 (3.2%)
3 (4.0%)
0 (0%)
>0.9
1
Statistics presented: median (IQR); n (%)
2
Statistical tests performed: Wilcoxon rank-sum test; chi-square test of independence;
Fisher's exact test
Table 2
Patient laboratory, imaging findings and respiratory support.
Table 2
Characteristic
Normal Range
N = 951
Alive N = 751
Dead N = 201
p-value2
C-reactive protein (mg/L)
<6
42 (18, 86)
36 (14, 67)
77 (53, 124)
0.001
Not measured
3
3
0
Lymphocytes (x109/L)
1-4
0.79 (0.54, 1.23)
0.81 (0.52, 1.22)
0.73 (0.55, 1.26)
0.9
Not measured
3
3
0
Neutrophil:Lymphocyte Ratio
6 (3, 11)
6 (3, 11)
7 (4, 11)
0.6
Not measured
3
3
0
Ferritin (ug/L)
33-490
557 (235, 974)
493 (184, 948)
816 (592, 1706)
0.4
Not measured
68
54
14
Alanine aminotransferase (U/L)
10-60
26 (19, 37)
26 (19, 38)
28 (17, 37)
0.7
Not measured
17
17
0
Albumin (g/L)
35-50
31 (26, 34)
32 (27, 36)
30 (24, 32)
0.024
Not measured
16
16
0
Troponin T (ng/L)
<14
25 (15, 65)
23 (15, 61)
31 (19, 66)
0.5
Not measured
60
50
10
Creatinine (umol/L)
45-84
98 (69, 138)
87 (66, 120)
117 (102, 151)
0.014
Not measured
3
3
0
Chest-X Ray Findings
0.008
Bilateral Consolidation
24 (27%)
14 (20%)
10 (50%)
Unilateral Consolidation
25 (28%)
18 (26%)
7 (35%)
No Consolidation
31 (34%)
28 (40%)
3 (15%)
Not Performed
10 (11%)
10 (14%)
0 (0%)
CURB65+ Score
0.001
0
11 (14%)
11 (18%)
0 (0%)
1
16 (21%)
16 (27%)
0 (0%)
2
29 (38%)
22 (37%)
7 (41%)
3
15 (19%)
7 (12%)
8 (47%)
4
5 (6.5%)
3 (5.0%)
2 (12%)
5
1 (1.3%)
1 (1.7%)
0 (0%)
Not calculable
18
15
3
Respiratory support:
<0.001
Non-invasive ventilation
10 (10.5%)
4 (5.5%)
6 (30%)
Invasive ventilation
6 (6.3%)
3 (4.1%)
3 (15%)
Oxygen
38 (40%)
27 (37%)
11 (55%)
None
39 (41%)
39 (53%)
0 (0%)
1
Statistics presented: median (IQR); n (%)
2
Statistical tests performed: Wilcoxon rank-sum test; Fisher's exact test
We found significantly higher CRP and creatinine in those that died in keeping with
progressive inflammation and end organ damage. Median lymphocyte count was low in
both groups, ALT was raised in 5 patients and Ferritin was > 2000 in 6 patients but
was performed infrequently and showed no significant difference between survivors
and non-survivors. We found little evidence of viral or bacterial co-infection with
rhinovirus and human metapneumovirus in 2 of the 88 patients tested and one significant
respiratory isolate (K. oxytoca). However, sputum culture and testing for Legionella
and Pneumococcal antigens was performed infrequently. There were 3 positive blood
cultures (D. hominis, S. aureus and E. faecium) none of which were felt to be respiratory
in origin. 55 patients received antibiotic therapy, including 20 of the 21 patients
that died and 2 patients received antivirals (Aciclovir for suspected meningoencephalitis).
Consistent with evidence supporting the use of CURB65 as a predictor of mortality
secondary to community acquired pneumonia
5
we found a significantly higher median score in non-survivors versus survivors (2.5
versus 1 respectively). Patients who did not survive were more likely to have chest
X-ray findings, and in particular, were more likely to have bilateral consolidation
than unilateral. 40% of survivors did not have any radiological evidence of consolidation.
Only 6 patients had a CT chest performed which may be useful in detecting early disease
in patients that test negative by rtRT-PCR.
6
To our knowledge, this is the first description of a UK cohort of patients with SARS-COV-2
infection and the largest descriptive study of the infection outside of China. We
found a much higher median age and case fatality rate than that reported by other
studies of all hospitalised patients with COVID-19. All the patients that died were
over the age of 60 and only 4 were admitted to intensive care. Given the current availability
of beds and ventilatory equipment in the hospital during this study this does not
represent deficiencies of medical care. Rather it suggests that there was an anticipated
deterioration in these patients in the context of poor premorbid state, and planned
decision making around intensive care unit admission. NICE guidance published during
this period endorsed the use of a Clinical Frailty Scale (CFS) Score in the assessment
for critical care admission which has been shown to perform better than evaluation
of cognitive function or comorbidity in estimating risk of death and has been validated
in intensive care outcomes.
7
,8 Further assessment of its application to the COVID-19 pandemic is required and
may be instrumental in guiding further public health policy, particularly in areas
with a low prevalence where the suspension of health care services such as cancer
services may be detrimental to other preventable health outcomes. In summary, despite
limited stress on our health care service, around 20% of our hospitalised population
died, with the majority dying outside intensive care with significant comorbidities.
Further work is needed to characterise other UK cohorts.
Uncited References:
[3]