key: cord-0255223-87m4dt76 authors: Qureshi, S.; Kampani, D. D.; Al-Qutbi, T. A. H. title: COVID-19 Observations from Hospitalized Ward Patients in the Northern Emirates: A Practice Only Preached. date: 2021-10-26 journal: nan DOI: 10.1101/2021.10.20.21265254 sha: 01388ff1df376e10f7f7b344fd1d1844351f7af5 doc_id: 255223 cord_uid: 87m4dt76 The COVID-19 pandemic has established itself as the defining global health crisis of this time. The study describes the clinical profile of hospitalized, non-ICU patients with COVID-19 in the United Arab Emirates (UAE) during its second wave, through January-March 2021. It also highlights the use of antibiotic stewardship principles in patients admitted with COVID-19. d . The COVID-19 pandemic has firmly established itself as the defining global health crisis of this time and one of the greatest challenges that we continue to face as a global community. First discovered in December 2019, the world has come a long way sincefrom battling a novel, unknown virus to rolling out international vaccination programs which are working to bring down the morbidity and mortality associated with the disease. Globally, there is a sharp contrast between COVID-19 status with infection rate rising in in many countries with few of them still at the peak of their infection curve while the other countries are displaying a downward trend. (1) Infection rates have largely been disproportionate -with some populations affected worse than the others due to a host of reasons ranging from high medical comorbidity profiles to socioeconomic challenges. (2) The absence of a 'one-size fits all' strategy makes it essential to learn from the experiences of different centers around the world. Understanding which strategies worked and which strategies have the potential to work from a clinical perspective contribute to advancing global knowledge and pandemic preparedness. In the United Arab Emirates, COVID-19 infections have sharply reduced with an average of 304 new infections reported each day , at 8% of its peak (as of 29 th September 2021 Patients who are 20 years old or above and were diagnosed with COVID-19 through a confirmed positive RT-PCR test were included. Pregnant women, patients who were admitted to/transferred to/discharged from the intensive care unit (ICU), patients who were receiving antibiotics prior to admission were excluded from the study. After review by the Research Ethics Committee of University of Sharjah (REC 21-07-15-01-S) and approval from the hospital board, data was collected from the written and electronic health records of included patients within the hospital. Sample size calculation with a confidence level of 95% and margin of error of 5% for UAE's population of 9.89 million in 2020, (9) determined the minimum required sample size to be 384 participants. However, this study includes a total of 128 patients. Every For continuous variables, data has been presented as mean and standard deviation. Categorical variables have been represented using frequencies and percentages. Data was visualized using Canva Chart Designer (Canva®) to prepare the figures. remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, The copyright holder has placed this this version posted October 26, 2021. ; https://doi.org/10.1101/2021.10.20.21265254 doi: medRxiv preprint A total of 110 participants were included in the study. Out of these participants, 58.2% and 41.8% identified as males and females respectively, with a mean age of 51.2 (± 14.6, range = 20 -89) years. The majority of the patients (69.1%) had at least one comorbidity, prior to diagnosis of COVID-19. The type and percentage of patients with each comorbidity is represented in In summary, the patient's clinical and radiological assessment determined whether the patient's disease was classified as mild, moderate, and severe. Figure 2 demonstrates the distribution of patients, further highlighting that majority of the patients had severe COVID-19 disease. remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, The copyright holder has placed this this version posted October 26, 2021. ; The preliminary outcome of the study was to determine mortality on the ward during the duration of the study. 100% of the patients included in the study, who received treatment in the general ward were discharged alive. As a secondary outcome, duration of stay was assessed in the ward. The mean duration (in days) of stay from presentation to discharge was 6.2 (± 3.8 days, range = 0 -25) days, with a mode of 3 days. The COVID-19 pandemic ushered in a healthcare crisis that left behind more questions than the ones it answered. In such uncertain times, experiences from single centers like the Sheikh Khalifa General Hospital, Umm Al Quwain in UAE serve as important pieces in the large puzzle. Our study highlighted that the population admitted to the hospital in the second wave of the COVID-19 pandemic in the UAE were mostly male, older with higher prevalence of comorbidities compared to the patient profile noted in the first wave of the pandemic in the UAE. The patients admitted to the ward had failed outpatient care and were rapidly worsening; they were severely sick patients requiring oxygen. We followed guidelines for treatment as per UAE's Ministry of Health and Prevention (MOHAP) updates and treated majority of our hypoxic patients with close observation. (11) Less than 5 percent remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, The copyright holder has placed this this version posted October 26, 2021. ; https://doi.org/10.1101/2021.10.20.21265254 doi: medRxiv preprint of our patients were moved to ICU due to requirement of high flow nasal cannula (HFNC) to maintain oxygen levels >94%. Our protocol for treatment with immunomodulators and antivirals were based on MOHAP guidelines and also took into account international consensus such as Infectious Diseases Society of America (IDSA) and National Institutes of Health (NIH) protocols. 90% of our patients also received anticoagulants as recommended by American Society of Hematology (ASH) and International Society on Thrombosis and Hemostasis (ISTH). We based our use of antibiotics on our initial and daily assessments. superinfection. (14) . A regional COVID-19 study also showed similar infection rate data. (15) Prior to the COVID-19 pandemic, higher c-reactive protein levels have traditionally been considered to be associated with a bacterial infection source. Monocytes and neutrophils may be recruited to the site of infection and clear the exudate containing virus particles and infected cells, in turn leading to uncontrolled inflammatory response. During this process, adaptive immunity is difficult to start effectively due to the significant decrease of lymphocyte number and T-cell mediated immune dysfunction. Therefore, a deep understanding of the clinical significance of CRP in the diagnosis, treatment, and prognosis of sepsis in SARS-CoV-2 infection is helpful to the early rationale in using antibiotics (20) . The limitation of this study lies in its relatively small sample size. Combined with its design as a single-center study, there is limited generalizability of the results. Lack of information on post-discharge health status of these patients could be a potential limitation addressed by future studies to expand knowledge on management of this illness. remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, The copyright holder has placed this this version posted October 26, 2021. ; https://doi.org/10.1101/2021. 10.20.21265254 doi: medRxiv preprint There is growing concern for a potential rise in antimicrobial resistance due to increased antibiotic prescription for COVID-19 patients around the world. The potential of bold strategies as adopted in our study, pave the way forward to cement existing antimicrobial stewardship programs. A recent study conducted in the UAE identified that 63.4% medical professionals follow national health authorities as their primary source of COVID-19 information. (21) Thus, a national framework would serve as a context-specific reference covering education about antimicrobial resistance, tracking local patterns, development of clinical guidelines and antibiotic control. The second wave of the COVID-19 pandemic ushered in a difficult time with challenging patients for the United Arab Emirates. Our study is the first formal publication to describe the clinical profile of hospitalized non-ICU patients during the country's second wave -they were male, older and had more comorbidities. Given the limited knowledge of the new disease, we took bold but calculated clinical measures to maintain antibiotic stewardship practice and brought antibiotic prescribing to an extraordinarily low level previously not seen during the COVID-19 pandemic. We hope to share our experience with the world and create an impactful discussion. The latest global coronavirus statistics, charts and maps: reuters.com Health equity and COVID-19: global perspectives United Arab Emirates: the latest coronavirus counts, charts and maps: reuters.com Coronavirus Pandemic (COVID-19). OurWorldInData.org Clinical and Laboratory Profile of Hospitalized Symptomatic COVID-19 Patients: Case Series Study From the First COVID-19 Center in the UAE Updated rules: Dubai ramps up coronavirus restrictions amid rising cases in UAE Seven field hospitals to combat COVID-19 in the UAE United Arab Population Statistics (2021): Global Media Insight Web Design and Development Clinical Spectrum of SARS-CoV-2 Infection. National Institutes of Health; 2021. 11. Cases NcfMoC-. National Guidelines for Clinical Management and Treatment of COVID-19 Antibiotics in treatment of COVID-19 complications: a review of frequency, indications, and efficacy Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study Coinfections in Patients Hospitalized with COVID-19: A Descriptive Study from the United Arab Emirates Cytokine storm and leukocyte changes in mild versus severe SARS-CoV-2 infection: Review of 3939 COVID-19 patients in China and emerging pathogenesis and therapy concepts Elevated level of C-reactive protein may be an early marker to predict risk for severity of COVID-19 ):e0251270. remix, or adapt this material for any purpose without crediting the original authors preprint (which was not certified by peer review) in the Public Domain We would like to acknowledge the REC committee of University of Sharjah as well as Quwain for their support in facilitating the study. None. None.