key: cord-0788259-xklk8ga5
authors: Sekhavati, Ehsan; Jafari, Fatemeh; SeyedAlinaghi, SeyedAhmad; Siahkali, Saeidreza Jamali Moghadam; Sadr, Sara; Tabarestani, Mohammad; Pirhayati, Mohammad; Zendehdel, Abolfazl; Manafi, Navid; Hajiabdolbaghi, Mahboubeh; Ahmadinejad, Zahra; Kouchak, Hamid Emadi; Jafari, Sirous; Khalili, Hosein; Salehi, Mohamadreza; Seifi, Arash; Golestan, Fereshteh Shahmari; Ghiasvand, Fereshteh
title: NSafety and Effectiveness of Azithromycin in Patients with COVID-19: an open-label randomized trial
date: 2020-08-25
journal: Int J Antimicrob Agents
DOI: 10.1016/j.ijantimicag.2020.106143
sha: d923fe3e77a5c19b8543779d3e10ab10fa51e882
doc_id: 788259
cord_uid: xklk8ga5

BACKGROUND: As no specific pharmacologic treatment has been validated for use in COVID-19, we aimed to assess the effectiveness of azithromycin in these patients at a referral center in Iran. METHODS: An open-label, randomized, and controlled trial was conducted on patients with laboratory confirmed COVID-19. The 55 patients of the control group receiving hydroxychloroquine and lopinavir / ritonavir were compared with the 56 patients of the case group who in addition to the same regimen were also receiving azithromycin. Patients with prior cardiac disease were excluded from the study. Furthermore, patients from the case group were assessed for cardiac arrythmia risk based on the American college of cardiology (ACC) risk assessment for use of azithromycin and hydroxychloroquine. The main outcome measures were vital signs, SpO2 levels, duration of hospitalization, need for and length of intensive care unit (ICU) admission, mortality rates, and results of 30-day follow-up after discharge. RESULTS: Initially, there was no significant difference between the general conditions and vital signs of the two groups. The SpO2 levels at discharge were significantly higher, the respiratory rate was lower, and the duration of admission was shorter in the case group. There was no significant difference in the mortality rate between the two groups. CONCLUSION: Patients who received azithromycin in addition to the hydroxychloroquine and Kaletra regimen had a better general condition. he hydroxychloroquine-azithromycin combination may be beneficial for individuals who are known to have a very low underlying risk for cardiac arrhythmias based on the ACC criteria.

In late December 2019, an outbreak of an emerging disease with a remarkably high virulence in Wuhan, China, soon became a global concern. Disease symptoms resemble a viral pneumonia and genetic analysis of lower respiratory tract samples of early infected patients showed an infection caused by a novel coronavirus subsequently named COVID-19, also known as 2019-nCoV. The disease rapidly spread throughout China and infected multiple other countries [1, 2] . On March 12 th , the world health organization (WHO) declared the epidemic of COVID-19 as a global pandemic. In addition to the primary respiratory involvements, reports show other organ systems including gastrointestinal, neurological, and hematopoetic systems can also be considerably affected by this virus [3, 4] . Coronavirus infection in humans are mostly mild, and a meta-analysis of the epidemiologic studies conducted in China showed 12.6 to 23.5% of patients experience a severe form of the disease with an overall mortality rate of 2.0-4.4% [5] . There are no specific pharmacological treatments for the novel coronavirus yet [6] . Repositioning well known medications as antiviral treatment is preferred in circumstances where there is little time for standard randomized control trial (RCT) studies and preliminary laboratory investigations into a new medication. Complete knowledge of the possible side effects and safety profiles of old medications lays the groundwork for better monitoring the treatment effect and outcome [7] .

Multiple medications have been used in clinical trial studies against COVID-19. Chloroquine, an immunomodulant drug, is widely used as an antimalarial agent and it was discovered to have broad spectrum antiviral effects in 2006 [8] . Hydroxychloroquine (an analogue of chloroquine) has a better clinical safety profile, and allows for a higher daily dose compared to chloroquine [9, 10] . Lopinavir/ritonavir combination has been approved, and used in human immunodeficiency virus (HIV) infection across the world, both substances are protease inhibitors but ritonavir also enhances the pharmacokinetic and pharmacodynamics properties of lopinavir [11] ; and these antiviral agents have been used in the treatment of middle east respiratory syndrome (MERS) [12] . Lopinavir has also been proven to have in vitro activity against SARS-CoV infection (SARS) in humans [13] [14] [15] . Azithromycin, a macrolide antibiotic, has shown efficacy in preventing severe respiratory infections in patients suffering from viral pneumonia [16] and in vitro studies have demonstrated that it is active against Zika and Ebola viruses [17] and has a high affinity for the binding interaction site of the SARS-CoV-2 spike and angiotensin converting enzyme II (ACE II) [18] ; which is the critical human cell receptor of the COVID-19 and, it is believed that blocking this interaction can potentially cure the infection [19] .

The hydroxychloroquine and azithromycin combination has been very well received among physicians and according to an online international survey of 5,500 physicians, fielded over April 13 th -15 th , these medications are the most commonly used medication in treatment of COVID-19 [20] ; but there is a considerable cardiac risks associated with the concomitant use of azithromycin and hydroxychloroquine and cardiac arrhythmias caused by QT interval prolongation can potentially increase the mortality rate in patients who are treated with this combination [21, 22] .

In this clinical trial we used the scoring system proposed by the American College of Cardiology (ACC) [23] to exclude patients with a moderate to high risk of cardiac arrhythmias from the study and evaluate the potential treatment benefits of this combination in patients with low risk for QT prolongation and arrhythmia.

Between April 24 th and May 8 th , 202 patients with compelling clinical symptoms for a diagnosis of COVID-19 were admitted to Ziaeian Hospital, Tehran, Iran. All patients underwent reverse-transcriptase-polymerase-chain-reaction (RT-PCR) testing, and a lung CT-Scan. The inclusion criteria were a positive RT-PCR test and significant findings compatible with radiographic imaging of a COVID-19 pulmonary involvement. The exclusion criteria were age less than 18 years old, pregnancy or nursing during the time of admission, past history or concurrent cardiac disease, recent history of antiviral therapy, and contraindications for use of hydroxychloroquine, azithromycin, or lopinavir/ritonavir (kaletra, AbbVie Inc. North Chicago, IL 60064), such as retinopathy or G6PD deficiency, or a history of allergic reactions to these medicines.

Patients were randomly divided into two treatment groups of 56 and 55 patients. On the first day of admission, laboratory studies including complete blood count (CBC), and erythrocyte sedimentation rate (ESR) were performed. The first (case) group received daily oral azithromycin 500 mg, twice-daily oral lopinavir/ritonavir 400/100 mg, and daily 400 mg of oral hydroxychloroquine. The second (control) treatment group received twice-daily oral lopinavir/ritonavir 400/100 mg, and oral daily 400 mg of hydroxychloroquine; for both treatment groups, all medications were administered for five days.

On the first day of admission, for the patients assigned to the first treatment group, the risk for ventricular arrhythmia in concurrent treatment with hydroxychloroquine and azithromycin was calculated based on the proposed guideline by the ACC [23] , and patients with a score of seven or higher, were excluded from the study.

Patients were assessed by daily measurements of core body temperature, respiratory rate (RR), heart rate (HR), and peripheral capillary oxygen saturations (SpO2). Daily electrocardiogram (ECG) studies were also conducted to monitor possible evolution of QTc (corrected QT) interval prolongation; in which case, treatment with azithromycin and hydroxychloroquine would have been stopped. For correction of QT interval, Bazett formula (QT C = QT / √ RR) was used [24] . In case of deterioration in general and/or pulmonary conditions, methyl-prednisolone was prescribed [25] . Patients were discharged when they achieved a stable SpO2 > 92%, had no respiratory distress, and were afebrile for three consecutive days. The primary end points in this trial were decrease in mortality, duration of hospitalization, and need for ICU admission. The secondary endpoints were determined as the improvements in SpO2 and vital signs, and also the general well-being of the patients.

Sample size calculation was performed for non-inferiority tests of difference between two group proportions. We assumed the effectiveness of 65% for the intervention group and effectiveness of 50% for the control group. We also assumed the margin of non-inferiority of at least 10% between two group. With these assumptions, sample size of 48 cases in each group was calculated. After consideration of dropout rate of 10%, the total sample size of 110 cases was calculated. The power of the study was determined as 90% (G*Power, Erdfelder, Faul, & Buchner, 1996).

In accordance to the declaration of Helsinki, written informed consent was obtained from all participants before initiation of the study. Patients were assured that declining to participate or leaving the study at any point would not affect the quality of their treatment and that they would thereafter receive standard care. The study protocol was approved by the institutional review board of Tehran University of Medical Sciences (IR.TUMS.VCR.REC.1399.165).

Distribution of age, gender, initial clinical symptoms and vital signs measured on the first day of admission were compared between the two groups. The vital signs including core body temperature, RR, HR and SpO2 were also compared on the third and last day of treatment between the two groups as an outcome measure. Difference in duration of hospitalization, number of patients whose condition deteriorated and needed ICU admission, length of ICU hospitalization, difference between mortality rates, and results of 30-day follow-up after discharge were also evaluated as outcome measures.

Analysis was performed using SPSS software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Quantitative variables were reported by mean and standard deviation (SD) and qualitative variables were reported using frequency and percentage.

Because of the normal distribution of the data, the independent t-test was used to assess the means differences. Chi-square and Fisher exact tests were used to assess the statistical relationships between categorical variables. The level of significance was set as P value < 0.05 for all analyses. Number needed to treat (NNT) with a confidence interval (CI) of 95% was reported for need for ICU admission, need for intubation, and mortality rate. We also evaluated the effect size based on Hedges' g because of the difference in the number of participants in each group.

Since a step wise plan was practiced in our study, patients with any prior cardiac disease were excluded from the study. Furthermore, the ACC criteria for risk assessment of simultaneous use of azithromycin and hydroxychloroquine were assessed for each person to make sure no patient has increased risk of ventricular arrythmia. All patients were also monitored closely for any signs of ECG rhythm abnormality or clinical features of cardiac arrhythmia.

Based on the inclusion criteria and after excluding 91 cases, 111 cases were included in the study which were randomized and allocated between two groups of case (56 patients) and control (55 patients). All evctprcet detpcpmc ptnitap -mvinpuqtnpmcnpvcdprcmqnvct r

The ventricular arrhythmia risk score was three in 12 (21.4%) patients, four in 32 (57.1%) patients, and five in 12 (21.4%) patients. The mean age and demographic factors such as gender were not significantly different between the two arms (P value = 0.70 and 0.387, respectively) ( Table 1) . Table 1 illustrates clinical features and laboratory test results of patients in both groups. Fever, dyspnea, chills, cough, production of sputum, hemoptysis, and chest pain were not significantly different between the two groups (P value > 0.05). Myalgia, headache, and vomiting were initially more reported by the control patients (P values = 0.000, 0.005, 0.031, respectively). Weakness was significantly more often found in patients of the case group (P value = 0.042) . The mean SpO 2 levels upon admission and on the third day of admission were not remarkably different between the two groups (P values = 0.920, 0.610 respectively). Laboratory test results did not show a significant difference between two groups (P value > 0.05). 4) . The calculated effect size for SpO 2 levels, RR at discharge, and duration of hospitalization were -0.461, 0.721 and, 0.618 (all medium effect sizes) respectively ( Table   2 ). Two patients in the case and seven patients in the control groups needed ICU admission which did not show statistical significance ( 3.5% vs. 12.7% respectively, P value = 0.07).

Three patients in the control group were intubated during the course of admission versus no patients in the case group; which was statistically insignificant (P value = 0.118) (Figure3).

The difference between the mean duration of ICU admission was not significant between the groups (5.00 vs 4.43 days, P value = 0.157). There was one mortality in the control group and no mortalities in the case group; this difference was insignificant (P value = 0.495). No patient in either group experienced cardiac arrhythmia or QTc prolongation.

During the rapid global pandemic of COVID-19, it is important to have an effective and safe treatment plan. There are several reports on the effectiveness of various medications, but none of them have been proven to be significantly effective yet. Recently, a combination therapy of hydroxychloroquine and azithromycin has become one of the most favored treatment regimens among medical professionals [26] [27] [28] . studies have shown the combination of hydroxychloroquine and azithromycin can reinforce the efficacy of hydroxychloroquine [28, 29] . Gautret In our study there was one mortality in the control group and no mortalities in the case group;

this difference was insignificant (P value = 0.495); but, Arshad et al, in their multi-center retrospective observational study in hospitalized patients positive for COVID-19 reported that treatment with azithromycin alone significantly decreased the mortality hazard ratio by 66% and combination therapy with hydroxychloroquine decrease the mortality hazard ratio by 71%. They also performed a multivariate COX regression model and found that combination therapy had no significant effect on mortality rate [37] . Rosenberg et al., reported the probability of death for patients who were under treatment by hydroxychlorquine and azithromycin was 25.7% (CI 95%:22.3%-28.9%). They compared patients who were treated with hydroxychloroquine, azithromycin, and both with patients who received no treatment and reported there was no significant association between treatment with these medicationsalone or in combination-and the in-hospital mortality rate [36] . However, the observational design of their study may limit definite interpretations of their findings. Despite the results of other studies which report an effective virucidal potency for the combination of hydroxychloroquine and azithromycin [34, 36, 38] , Molina et al., reported that they didn't find any evidence to support the efficacy of this combination in viral clearance or improvement of clinical status of their patients [33] .

Our study also showed that patients in the experimental treatment group who were treated with azithromycin in addition to the main treatment regimen, had significantly higher SpO 2 levels (P value = 0.030) and a lower respiratory rate at the time of discharge (P value = 0.010). The effect sizes showed the differences between two groups in these variables were considerable (Hedges' g = -0.461, Hedges' g = 0.721, respectively). Calvalcanti et al reported that patients receiving hydroxychloroquine and azithromycin compared to patients who received azithromycin alone had a non-significant lower rate of need for oxygenation with high flow nasal cannula or non-invasive ventilation during the treatment (9.3% vs 10.7%, Odds ratio: 0.92, 95% CI: 0.5-1.7) [35] .

Possible side effects of a treatment are determining factors in evaluating the suitability of a medication regimen. Chloroquine or hydroxychloroquine as a monotherapy has some common adverse effects such as pruritus, nausea, headache and some uncommon but serious adverse effects such as arrhythmias due to QT interval prolongation, hypoglycemia, idiosyncratic hypersensitivity reactions and neuropsychiatric effects [39] . Prolongation of the QTc interval and torsade de pointes (TdP) are the most important side effects of separate, and specially concomitant treatments with HCQ and macrolides such as azithromycin that can negatively affect the survival rate [35, 37] . Lane et al evaluated the safety of HCQ alone, and in combination with azithromycin. They studied 323,122 patients who were treated with this combination, and concluded that a short term treatment with HCQ is safe but, a long-term treatment or addition of azithromycin to the treatment-even in short-term-may increase the risk of heart failure or cardiovascular mortality rate which can be caused by their synergetic effects on the QTc interval, leading to a lethal arrhythmia [40] . Considering the possible side effects of this combination therapy, clinicians should consider having a baseline corrected QT interval and monitoring of QTc intervals, heart-rate and serum electrolytes during administration of these drugs [38] . A scoring system to predict the risk of QT interval prolongation in hospitalized patients has been designed ( Table 1) ; Score of less than 7, 7 to 10, and greater than 11 respectively correlate with a low, medium and high risk of QT interval prolongation in hospitalized patients [23] . In our study, all patients had a risk score of less than 6, all patients were monitored during treatment and none of them experienced QTc interval prolongation, which would have warranted a halt in treatment with hydroxychloroquine and azithromycin.

A small sample size and an open label design are the limitations of our study. Because of the shortage in our resources, we could not test the viral loads of the patients in daily intervals.

The patients in the group receiving the experimental treatment regimen which included azithromycin, had a significantly shorter hospital stay and significantly higher SpO 2 and lower respiratory rates at discharge. However, risk scoring system should be utilized before initiating treatment to prevent QTc prolongation, especially for high risk patients. 

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