Coronavirus Disease 2019 (COVID-19) Waves, Treatment Enclaves and Changes in Management

Abstract

Background: The coronavirus disease (COVID-19) global pandemic commenced at the end of 2019 and continues into 2022. Throughout the world, countries have seen spikes of an increased number of cases followed by a period of decrease, a phenomenon now referred to as “waves.” Recommendations for management of this infection have changed, guided by new experiences, an ever-increasing plethora of medical publications, and rapid developments in vaccines and therapeutics. Some treatments are recommended only in the outpatient setting, while others are indicated for patients admitted to the hospital, creating mutually exclusive “enclaves” for patients to receive recommended therapies. The purpose of this study was to compare and contrast medication use, as well as outcomes between the first two waves of COVID-19 infection. Methods: This is a retrospective cohort study of patients with COVID-19 infection at a community hospital in Massachusetts, USA. Consecutive adult patients admitted to the hospital with consultation by the authors were included. The first wave extended from March 2020 to June 2020, the second wave was from October 2020 to January 2021. Patient demographics, medications used, and outcomes were abstracted from the electronic medical records. Results: Of the 238 patients evaluated, 109 (45.7%) were admitted in the first wave and 129 (54.2%) were admitted in the second wave. A large number of patients received hydroxychloroquine (50%), azithromycin (17%) and tocilizumab (22%) in the first wave, but none of these medications were used during the second wave. Remdesivir was used in 15% patients in the first wave. No patient in the first wave received corticosteroid therapy. In contrast, the majority of patients in the second wave received corticosteroids (70%) and remdesivir (63%). There were marked differences in overall mortality (25% v/s 6%), admission to intensive care unit (48% v/s 8%), and use of mechanical ventilation (31% v/s 5%) between the first and second waves respectively. Monoclonal antibody therapy was not available for use in hospitalized patients. Conclusions: There were remarkable differences in medications used, need for intensive care admission and need for mechanical ventilation for patients with COVID-19 infection between the first two waves of this pandemic. There was an improvement in outcomes in terms of overall mortality, need of intensive care unit admission, and need for mechanical ventilation during the second wave compared to the first. Further research is needed to determine whether the improved outcomes are a reflection exclusively of better therapeutics or a combination of therapeutics and other early interventions and the role of the COVID-19 variant (beta) in second wave compared to the original wild-type virus in both waves.