Research on strokes and readmissions in COVID-19, updated guidance from NIH and SSC

One study showed that strokes were rare in COVID-19 patients, while another didn't find any connection between fever or biomarkers before discharge and readmissions. The NIH and the Surviving Sepsis Campaign (SSC) updated their COVID-19 critical care recommendations.

Acute ischemic strokes were relatively rare among patients with COVID-19, according to a study published by Stroke on Feb. 4. Among 8,163 patients from 54 hospitals who were treated in the ED or admitted for COVID-19, 1.3% had an acute ischemic stroke, compared to 1.0% of 19,513 studied patients without COVID-19. Patients who had strokes had higher prevalence of hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure than other COVID-19 patients. Dying or being discharged to a destination other than home was significantly more common among patients with both COVID-19 and a stroke than those with only one of those conditions. The authors noted that COVID-19 and stroke were mostly diagnosed during the same encounter so “an acute ischemic stroke patient with suspected COVID-19 has to be evaluated under the assumption that the patient has COVID-19.”

Another recent study, published by the Journal of General Internal Medicine on Feb. 2, tried to identify markers to predict readmissions of patients with COVID-19. A chart review of 99 patients discharged from a medicine service early in the pandemic found that within 30 days, five patients were treated in an ED and another five required readmission. However, none of the studied characteristics from the patients' inpatient stays, including fever in the 24 hours before discharge, oxygen requirement, and laboratory abnormalities, predicted return to the hospital. The authors noted that many have taken a conservative approach to discharging COVID-19 patients, but that carries numerous downsides. “In hopes of foregoing these avoidable consequences, we offer this single-center experience as the first case series of its kind supporting reliance on clinical improvement rather than fixation over laboratory abnormalities, persistent oxygen requirement, or continued fever in the absence of other causes,” they wrote.

Several sources of guidance on critical care for COVID-19 were recently updated. On Feb. 2, the NIH's COVID-19 Treatment Guidelines Panel issued a statement on the use of tocilizumab and other interleukin-6 inhibitors. Overall, the panel found insufficient evidence to recommend for or against tocilizumab or sarilumab for ICU patients, but some panel members would administer a single dose of tocilizumab in addition to dexamethasone to patients who are within 24 hours of ICU admission and require mechanical ventilation or high-flow oxygen. For all other patients, the panel does not recommend the drugs.

The Surviving Sepsis Campaign (SSC) updated its COVID-19 guidelines for the first time on Jan. 29. Among the updated guidance on treating ICU patients, the SSC strongly recommends systemic corticosteroids and venous thromboprophylaxis and suggests dexamethasone over other corticosteroids. The guidelines suggest against using convalescent plasma outside of clinical trials. Remdesivir is suggested for nonventilated patients with severe COVID-19, but for patients with critical COVID-19, the panel suggested against it, except in trials.

A living systematic review of prediction models for diagnosis and prognosis of COVID-19 was also updated, in a Feb. 3 publication in The BMJ. The update found two promising prediction models: the Jehi et al diagnostic model and the prognostic 4C Mortality Score.

Finally, a study published in the CDC's Emerging Infectious Diseases on Feb. 1 described 22 cases of COVID-19 in health care workers who had just been vaccinated. These cases represented 0.54% of 4,081 workers vaccinated within a week at one hospital in Israel. Eleven of the workers who tested positive reported COVID-19 symptoms, at a median of 3.5 days after their first vaccine dose (range, 0 to 10 days). Based on the findings, the authors said that “almost every physical complaint after vaccination poses a true diagnostic dilemma as to whether an adverse reaction or a new COVID-19 infection is the cause” and suggested clinicians maintain “a high level of suspicion of reported symptoms and avoid dismissing complaints as vaccine-related until true infection is ruled out and vaccinees are tested.”