Published March 2, 2021
Manoj J. Mammen, MD, has co-authored an update of the first international guidelines on treating patients severely ill with COVID-19.
The guidelines were originally published in March 2020. Now, nearly a year later, the organization that published them has issued an update: Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update.
The purpose of the document is to support hospital clinicians at the bedside. Authored by 43 clinicians from 14 countries, the guidelines concern patients hospitalized with severe and critical disease in intensive care units.
“The new guidelines demonstrate what we have learned about treating patients with severe COVID-19 while underscoring how much still needs to be determined,” says Mammen, associate professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine.
Probably the most unsurprising item in the guidelines is that no benefit to COVID-19 patients and possible harm was found to result from the use of hydroxychloroquine. Few clinicians thought it would be helpful at the time, Mammen says, but now there are data that have unequivocally confirmed this.
One of the most significant items in the guidelines is the recommendation that for critically ill patients with COVID-19, the steroid dexamethasone does result in lower mortality rates and improved outcomes.
“The guidelines report that dexamethasone is the only treatment that has been shown to reduce mortality in critically ill patients,” says Mammen, whose area of focus on the guidelines was pharmacotherapy.
While dexamethasone has not been shown to improve outcomes in outpatients or those with milder disease, he says a large clinical trial has shown that it does reduce mortality rates in patients severely ill with COVID-19.
Mammen says that while most hospital clinicians are already aware of which treatments work and which don’t, the guidelines are important to circulate among the wider medical community. For example, he says it is important to note that use of steroids in patients with milder disease has not been demonstrated to result in improved outcomes.
Remdesivir is also included in the guidelines as recommended for patients with severe disease who are not on mechanical ventilation, a change from the first document that had no recommendation regarding this drug.
The new guidelines also note that severely ill patients have the best chance of benefiting from remdesivir if it is administered within 72 hours of testing positive.
Despite numerous clinical trials on the use of convalescent plasma, the new guidelines do not recommend it, since outcomes from the trials have been inconclusive at best.
Now that populations around the globe are beginning to get vaccinated, Mammen says the next 12 months will likely look very different from the past year.
“The questions that remain have to do with how vaccination will affect disease transmission,” he says.
He notes that the new variants of the virus will also be an important factor. “There are probably hundreds of variants of the virus out there right now, and only a few are clinically relevant.”
But how they will affect transmission and disease progression in the coming months is unknown.
“That’s why we need to continue to wear masks, continue to practice social distancing and good hand hygiene,” says Mammen, who is a physician with UBMD Internal Medicine. “Prevention is still the most important thing.”
The guidelines were developed as part of the Surviving Sepsis Campaign, an international effort launched in 2002 to develop evidence-based guidelines to drive down the numbers of deaths around the world from sepsis and septic shock.
Sepsis is the body’s extreme response to an infection, which, if not treated, can cause tissue damage, organ failure and death.
Mammen explains that a small percentage of patients with COVID-19 experience sepsis; it is more likely among the elderly and those with pre-existing chronic conditions.