New ACP living practice points, mortality data on COVID-19

Practice points from ACP and recent studies offered new information on COVID-19.

The latest set of rapid, living practice points from ACP, published by Annals of Internal Medicine on Nov. 29, offered guidance on outpatient treatment of COVID-19 patients. The practice points recommended that clinicians consider using molnupiravir, nirmatrelvir-ritonavir, or remdesivir within five to seven, five, and seven days, respectively, of onset of mild to moderate COVID-19 in high-risk patients. ACP recommended against the use of certain monoclonal antibodies, including casirivimab-imdevimab, regdanvimab, and sotrovimab, unless they are considered effective against a variant or subvariant in local circulation. ACP also recommended against azithromycin, chloroquine or hydroxychloroquine, convalescent plasma, ciclesonide, fluvoxamine, ivermectin, nitazoxanide, and lopinavir-ritonavir. An accompanying editorial discussed the challenges of gathering new data on effective treatment of COVID-19 now.

Multiple recent studies looked at mortality trends in COVID-19. An observational analysis, published by Annals of Internal Medicine on Nov. 29, compared treatments and outcomes among sequential cohorts of inpatients treated in four stages of the Adaptive COVID-19 Treatment Trial (ACTT). It found that between ACTT-1 and ACTT-2, hydroxychloroquine use decreased dramatically while empirical antibiotic use decreased gradually; intubation was lower in ACTT-2 than ACTT-1, but 28-day recovery and mortality did not change. Recovery and mortality did improve from ACTT-2 to ACTT-3, and the most likely explanation was increased use of dexamethasone. No improvements were seen between ACTT-3 and ACTT-4. The results show the importance of using concurrent instead of historical patients as controls in research, the study authors said.

Another analysis, published by JAMA on Nov. 18, compared COVID-19 deaths around the world during 2021 and 2022. It found that during the delta and omicron waves, COVID-19 deaths per capita in the U.S., even in the 10 states with the highest vaccination uptake (73% coverage), exceeded those in 20 peer countries. Excess mortality overall was also higher in the U.S., but in the most vaccinated states, it was similar to that in some peer countries. The results “highlight that the US continued to lag peer countries in COVID-19 and excess all-cause mortality,” the authors said.

A third study, published by Annals of Internal Medicine on Nov. 29, found that patients who died of COVID-19 in 2021 were younger than those who died in 2020. In total, 350,702 Americans died of COVID-19 in March to December 2020 versus 277,739 in the same period of 2021. “Despite this, 7.4% more years of life were lost in the second pandemic year during that interval due to a 35.7% increase in [years of life lost] per COVID-19 death,” the authors said.

Finally, an international study, also published by Annals of Internal Medicine on Nov. 29, compared COVID-19 infections in health care workers caring for patients with suspected or confirmed COVID-19 in EDs, medical units, and long-term care facilities in Canada, Israel, Pakistan, and Egypt by whether the clinicians were wearing medical masks or fit-tested N95 respirators. In the intention-to-treat analysis, COVID-19 infection occurred in 52 of 497 (10.46%) participants in the medical mask group versus 47 of 507 (9.27%) in the N95 group (hazard ratio [HR], 1.14). “The observed results are consistent with a range of protection, from a 23% reduction in the HR with medical masks to a 69% risk increase,” said the study authors, who noted that the results varied by country, which might relate to differences in circulating strains. “Decisions about mask types in health care workers should be informed by the uncertainty around the estimates and continue to account for health care worker preferences about potential tradeoffs, N95 respirator availability, and resource constraints,” said an accompanying editorial.