Clinical and epidemiological characteristics of patients admitted to the COVID-19 intensive care unit at the Moulay Ismail Military Hospital in Meknes, Morocco

¹Resuscitation Department, Moulay Ismail Military Hospital, Hassan II University Hospital in Fez, Meknes, Morocco

^&Corresponding author
Ayoub Maaroufi, Resuscitation Department, Moulay Ismail Military Hospital, Hassan II University Hospital in Fez, Meknes, Morocco

Introduction    

The coronavirus pneumonia epidemic is a Public Health Emergency of International Concern (PHEIC) [1]. According to the latest update of May 17, 2022, COVID-19 is responsible for 6,268,281 confirmed deaths. A huge and alarming figure that has created an unprecedented state of alert in the world [2]. Our study describes the demographic and clinical characteristics of patients with severe forms of COVID-19 admitted to the intensive care unit of the Moulay Ismail Military Hospital (HIMM) in Meknes-Morocco, during four and a half months (Delta wave period), a relatively short period but during which 419,494 cases were infected in Morocco, of which 4.3% were of severe Covidosis and a total number of deaths of 5430 patients [3]. The objective of this study is to study the sociodemographic, and clinical characteristics and the impact of the vaccine in severe COVID-19 patients.

Methods     

Study design and population: this is a retrospective descriptive and analytical study of 97 cases of infection by SARS-CoV-2, hospitalized in the resuscitation department of the Moulay Ismail Military Hospital (MIMH) in Meknes, during the second wave (DELTA wave) of the epidemic in Morocco, schematically between 21/06/2021 and 01/11/ 2021 and which lasted 133 days (19 weeks).

Inclusion criteria: included in our study were adult patients over 18 years of age, COVID-19 positive (diagnosis confirmed using real-time reverse transcription polymerase chain reaction (rt-PCR) on a nasopharyngeal swab) and admitted to the intensive care unit at the MIMH, who present signs of acute respiratory distress, a pulse saturation of less than 90% in room air, with the presence of CT lesions compatible with a COVID-19 infection. These patients were transferred to the intensive care unit of the MIMH by the emergency department or by the hospitalization department, COVID-19 of the same hospital.

Exclusion criteria: all patients with incomplete records (clinical, biological, imaging) and those whose stay in the intensive care unit was less than 48 hours; pregnant women and young subjects under 18 years of age.

Data collection: the data was collected from medical records using a data sheet. Data extraction was performed by two reviewers. Entries that were illegible to both reviewers were excluded. The information included: epidemiological data: (age, sex, vaccination profile, CHARLSON score, duration of symptoms before diagnosis, admission method, length of stay in intensive care unit); clinical data: type of symptomatology (particularly respiratory symptoms), pulsed SpO₂ saturation (initial SpO₂ determined at rest in room air and under 15 L of oxygen (with oxygen goggles or oxygen mask), blood pressure BP, Glasgow Coma Scale (GCS); biological data: blood count (WBC/lymphocytes /PQ), blood ionogram (natremia, Kalemia and fasting blood sugar), liver transaminases (GOT/GPT), renal function (urea, creatinine), biomarkers of inflammation (C-reactive protein, ferritin and procalcitonin) and coagulation (D-dimer); radiological data: a chest CT scan, without contrast, was performed. An evocative image of COVID-19 [4] was found in all the patients. The extension of the radiological lesions was evaluated as a percentage.

Data analysis: study populations were analyzed using simple descriptive statistics; continuous data are summarized by median and interquartile range or median sum (min; max) and categorical data are n (%). Comparisons were made using the student´s t-test for quantitative variables, and the chi-square test for qualitative variables. The date of death and ICU discharge were recorded on day 7 and on day 14 as well. Our study population was divided into 2 populations according to a selection criterion which is the survival at day 7 and day 14, and then the different clinical, biological and radiological parameters of both populations were compared. The statistical analysis was performed using IBM SPSS STATISTICS VERSION (version 25.0). The analysis consisted of two steps: univariate and multivariate analysis, using binary logistic regression, with the use of the Chi-square test and Fisher's exact test for comparison of frequencies within subgroups. The significance level was set at 5% (p<0.05).

Ethical considerations: data collection was carried out for the anonymity of the patients and the confidentiality of their information. Ethics approval was not required due to the registry-based design.

Results     

Of the 150 patients admitted to the intensive care unit, a total of 97 patients were included in the study and 53 patients were excluded, either for lack of data or a stay of less than 48 hours in the unit. A total of 61 (62.9%) of the patients were male, i.e. a sex ratio of 1.69, the mean age was 66 years (range, 26-94 years). Regarding pathological history, 36 patients (37%) were hypertensive (complicated or not), 31 (32%) had diabetes, 8 (8%) had cancer in their history, 6 (6%) had chronic renal failure, one patient had HELP syndrome and one was followed for sclerosing cholangitis. Concerning vaccination, 46 (47.4%) of the patients received a complete vaccination schedule. Sixty-two (64%) of the patients had fever as the initial symptom, 59 (60%) had dyspnea, while 44 (45%) and 31 (32%) had asthenia and cough respectively.

The mean saturation on admission was 69% ± 11 and 84% ± 5 on room air and 15 l/min respectively. Lung involvement on chest CT was 63% ± 16. The patients in our series had a biological check-up (CBC, blood Ionogram, CRP, ferritinemia, D-dimer, procalcitonin) and a thoracic CT scan as soon as they were admitted, then a daily check-up was carried out according to the evolution of each patient. All patients received a standardized treatment in the department based on the national protocol for the management of COVID-19; also, each patient received a treatment according to the clinical evolution and the results of the biological assessment. In our study, 21 patients (21.6%) had a good outcome with a decision to transfer to a medical ward, yet we recorded 76 (78.33%) deaths. The average length of stay in the ICU of our patients was 8 ± 5 days (min 3 days and max 25 days).

Discussion     

Our study focused on the second wave of the SARS-CoV-2 (DELTA wave) epidemic in Morocco, which lasted for four and a half months [3]. A period during which the management of patients suffering from COVID-19 was codified [5]. Most patients were male (62.9%) which is consistent with data found in other studies [6-9] in favour of male gender being a risk factor for developing severe forms of COVID. The mean age of our patients was 66 years, which is close to previous studies (66 years) [10], (65 years) [11]. Advanced age was identified as a predictive factor of mortality in our series of patients (P=0.024).

The most frequent comorbidities in our series were hypertension and diabetes (37% and 32% respectively) confirming the results published in previous studies [9,12,13]. Although no statistically significant results were obtained, these two comorbidities were found to be associated with an increased susceptibility to develop severe forms of COVID-19 infection with a generally poor prognosis [14,15]. Also, chronic renal failure and cancer were significantly related to excess mortality in our study. This is consistent with the majority of studies in this setting [8,9]. The most frequent reason for admission to the hospital in our series, before being transferred to the intensive care unit, was fever and cough (64% and 60% respectively), which is in line with what is already described in the literature [2,10,16]. The average length of stay in intensive care was 8 days, close to that reported in several studies, 7.83 [11,17]. Vaccination in our study was statistically significantly associated with a reduction in mortality (p=0.003). This confirms the role of vaccination as a protective factor against both death and severe forms of the disease [18-20], which was reflected in our context by the decrease in the number of admissions to the COVID intensive care unit during the Delta wave compared to the first wave during which the bed capacity was saturated even though the service had been extended.

In the multivariate logistic regression model, with in-hospital death as the dependent variable, only vaccination was established in this multivariate analysis as a statistically significant protective factor against mortality (p=0.01). In an analysis specific to vaccination, no difference in length of hospital stay between vaccinated and unvaccinated subjects was retained (p=0.779) This study has several limitations. First, the small size of the study population. Second, although several confounding factors were controlled for, unmeasured confounding in this retrospective observational study could have occurred. Third, we did not include all the clinical, biological, and radiological parameters on admission (morbidity and mortality factors). Fourth, this analysis included only hospitalized patients and cannot inform whether vaccination attenuates COVID-19 severity among outpatients. The data found in our study confirm those in ICU settings worldwide, and they give an idea about the Moroccan population for further analysis. However, a study with a larger sample will confirm these data and find other associations.

Conclusion     

Severe forms of COVID-19 admitted to the intensive care unit of the HMMI of Meknes-Morocco had the following major risk factors for severe forms: age, male sex, diabetes, and high blood pressure, whereas vaccination was shown to be a protective factor. These results are consistent with those of other international studies, but a more extensive national study with a larger population is needed to confirm these findings.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Ayoub Maaroufi and El m'rabet Ilias: conceptualisation, methodology writing the original draft. Omari Mohammed and Abdellatif Diai:logiciel, formal analysis and interpretation. Nouredine Jebbar: reviewing and editing. Hicham Kechna and Jaouad Laoutid: supervision. All the authors have read and agreed to the final manuscript.

References