Factors Affecting Prognosis and Mortality in Severe COVID-19 Pneumonia Patients

Abstract

Fatality rate in coronavirus disease 2019 (COVID-19) cases has been reported to be
3.4% worldwide. The aim of this study was to evaluate the factors that determine prognosis and mortality
in severe COVID-19 pneumonia patients. Eighty adult patients with severe COVID-19 pneumonia
hospitalized and monitored at Izzet Baysal State Hospital (Bolu, Turkey) between August and November
2020 were included in this retrospective single-center study. Demographic and laboratory data,
severity of radiological involvement, comorbidities, agents used in treatment, and clinical results were
recorded, and data were grouped as survivors and non-survivors. The mean patient age was 67.8±12.6
years. There were 59 (73.8%) male patients. Comorbid diseases were present in 53 (66.3%) patients.
There was no significant relationship between patient age, gender, smoking status or presence of comorbidity
and mortality (p>0.05). The variables such as pulmonary involvement above 50%, intubation, or
ferritin (>434.8 μg/L), troponin I (>14.05 ng/L) and procalcitonin (>0.125 ng/mL) as the sole variables
of laboratory data were found to have significant relationship with increased mortality (p

Full text

Acta Clin Croat, Vol. 62, No. 1, 2023106
Acta Clin Croat 2023; 62:106-114
doi: 10.20471/acc.2023.62.01.13
Original Scientic Paper
FACTORS AFFECTING PROGNOSIS AND MORTALITY IN
SEVERE COVID-19 PNEUMONIA PATIENTS
Emine Afşin1 and Muhammed Emin Demirkol2
1Abant Izzet Baysal University Hospital, Department of Chest Diseases, Bolu, Turkey;
2Abant Izzet Baysal University Hospital, Department of İnternal Medicine, Bolu, Turkey
Introduction
e 2019 novel coronavirus (SARS-CoV-2) was
rst detected in Wuhan Province of China and has in-
fected millions of people around the world so far, and
the pandemic still continues. It has a wide spectrum
from asymptomatic patients to respiratory failure. Fa-
tality rate in coronavirus disease 2019 (COVID-19)
cases has been reported to be 3.4% worldwide1.
After initially infecting cells lining the nose, it
progresses to the respiratory tract and alveoli con-
taining surfactant-producing type II cells rich in an-
giotensin-converting enzyme (ACE) 2 receptors,
leading to cytokine storm with excessive release of
proinammatory cytokines in some patients2. Inam-
mation is prominent in other conditions3, as well as
in COVID-19 infection. e SARS-Cov-2 infection
may present with u-like symptoms, nevertheless,
nearly half or 3 of 4 subjects with positive polymerase
chain reaction (PCR) results remain asymptomatic4.
Having a frequency of 5% in COVID-19 pneumonia,
increased inammation or cytokine storm determines
mortality. e aim of this study was to determine the
Correspondence to: Assoc. Prof. Emine Afşin, MD, Abant Izzet
Baysal University Hospital, Department of Chest Diseases,
Golkoy, 14200, Bolu, Turkey
E-mail: emineafsin@yahoo.com
Received April 6, 2021, accepted July 12, 2021
SUMMARY – Fatality rate in coronavirus disease 2019 (COVID-19) cases has been reported to be
3.4% worldwide. e aim of this study was to evaluate the factors that determine prognosis and mortality
in severe COVID-19 pneumonia patients. Eighty adult patients with severe COVID-19 pneumonia
hospitalized and monitored at Izzet Baysal State Hospital (Bolu, Turkey) between August and No-
vember 2020 were included in this retrospective single-center study. Demographic and laboratory data,
severity of radiological involvement, comorbidities, agents used in treatment, and clinical results were
recorded, and data were grouped as survivors and non-survivors. e mean patient age was 67.8±12.6
years. ere were 59 (73.8%) male patients. Comorbid diseases were present in 53 (66.3%) patients.
ere was no signicant relationship between patient age, gender, smoking status or presence of comor-
bidity and mortality (p>0.05). e variables such as pulmonary involvement above 50%, intubation, or
ferritin (>434.8 µg/L), troponin I (>14.05 ng/L) and procalcitonin (>0.125 ng/mL) as the sole variables
of laboratory data were found to have signicant relationship with increased mortality (p<0.05). Mortal-
ity was signicantly higher in patients using steroid pulse therapy + tocilizumab, steroid pulse therapy +
hydroxychloroquine, or solely steroid pulse therapy, while it was signicantly lower in patients receiving
azithromycin therapy and those in the plasma + steroid pulse therapy group. e severity of pulmonary
involvement, intubation, and increase in inammation markers such as ferritin, troponin and procal-
citonin were found to be signicantly associated with mortality (p<0.05). Treatment approaches with
azithromycin and plasma + steroid pulse therapy were found to reduce mortality.
Key words: COVID-19; Pneumonia; Prognosis; Mortality

Acta Clin Croat, Vol. 62, No. 1, 2023 107
E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
factors predicting the prognosis in COVID-19 pneu-
monia, to follow the individuals at risk more closely,
to determine the role of medication treatments in re-
ducing mortality, and to contribute to the choice of
appropriate treatment.
Materials and Methods
Patient selection
is retrospective and single-center study was
carried out in patients hospitalized and monitored
at Department of Chest Diseases, İzzet Baysal State
Hospital. Eighty Rt-PCR (+) COVID-19 patients
with severe pneumonia in line with WHO Interim
Guidance5 were included in this study. Ethical approv-
al was obtained from the local Ethics Committee (no.
2020/319 as of January 19, 2021).
Patients under 18 years of age, pregnant and post-
partum women were not included in the study. Patient
disease history, demographic and laboratory data, se-
verity of radiological involvement and medication
treatments were recorded retrospectively. Favipiravir
(1600 mg BID on day loading, 600 mg/day mainte-
nance) and methylprednisolone 0.5-1 mg/kg/day were
administered to all patients routinely. Besides ocial
approval by the Hospital Ethics Committee, informed
consent was obtained from all patients involved in the
study.
Data collection
Patient comorbidities (grouped as cardiovascular
disease, chronic lung disease, diabetes mellitus, cancer),
laboratory data (complete blood count, biochemical
parameters, coagulation parameters, procalcitonin),
severity of radiological computer tomography (CT)
involvement (above and below 50%), medication treat-
ments (hydroxychloroquine, corticosteroid, convective
plasma, tocilizumab, antibiotics) and presence of intu-
bation were recorded.
Statistical analysis
e data obtained in this study were analyzed by
use of SPSS 20. Descriptive statistics were expressed as
frequency, mean, standard deviation, median, and min-
imum-maximum. In addition to Kolmogorov-Smirn-
ov test, normal distribution was tested based on the
coecients of skewness and kurtosis as ±2. Paramet-
ric data were expressed as mean ± standard deviation
and compared with the independent sample t test. On
the other hand, nonparametric data were expressed as
median (minimum-maximum) and compared with
Mann-Whitney U test. e relationship between cat-
egorical variables was tested using the χ2-test. e ef-
fect size was tested with Cohen d, and Cohen d: 0.10
showed small eect; d: 0.25 showed medium eect; d:
0.40 showed large eect (Cohen, 1988). e cut-o
value was determined by the receiver operative char-
acteristics (ROC) analysis for data used in mortality
prediction. e level of statistical signicance was set
at p<0.05.
Results
e mean patient age was 67.8±12.6 years. ere
were 59 (73.8%) male patients. Comorbid diseases
were present in 53 (66.3%) patients. Of the 80 pa-
tients, mortality was witnessed in 46.3% (37 patients),
while the mortality rate was 96.9% in intubated pa-
tients (p<0.05). ere was no signicant relationship
of age (65.34±13.94 in survivors and 70.70±10.41 in
non-survivors) and non-smoking status (52.1% in
survivors and 29.7% in non-survivors) with mortality
(p>0.05). ere were no smokers among study patients.
Gender and presence of comorbidity were not statisti-
cally signicant factors in mortality either (p>0.05). In
the order of frequency, cardiovascular diseases (47%),
coexistence of diabetes mellitus and cardiovascular
diseases (24.5%), chronic pulmonary disease (9.4%),
malignancy (7.5%), and coexistence of cardiovascular
and chronic pulmonary diseases (3.8%) were identi-
ed as comorbidities in the patients reported to have
comorbidities. On chest CT, 50% pulmonary involve-
ment was detected in 44.1% of survivors and 55.9% of
non-survivors (p<0.05) (Table 1).
Among laboratory data, only increased ferritin
(Cohen large eect), troponin (Cohen medium eect)
and procalcitonin (Cohen large eect) were signi-
cantly associated with mortality (p<0.05) (Table 2).
e cut-o value for ferritin was identied as 434.8
µg/L (normal: 23.9-366.2 µg/L) while it was 14.05
ng/L (normal: 12.6-20.7 ng/L) for troponin and 0.125
ng/mL for procalcitonin (p<0.05) (Table 3). e re-
sults of ROC analysis showed that while the cut-o
values for ferritin and procalcitonin were signicantly
related to mortality, the relationship between troponin
and mortality was identied as p>0.05 (Fig. 1).
e major antibiotics used in the order of their
frequency were azithromycin (58.8%), moxioxacin
(36.3%) and ceftriaxone (32.5%). A consideration of
treatments showed that while mortality was signi-
cantly higher in patients administered steroid pulse
therapy + tocilizumab, steroid pulse therapy + hydroxy-

Acta Clin Croat, Vol. 62, No. 1, 2023108
E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
Table 1. Demographics and baseline characteristics of patients with severe COVID-19 pneumonia
nSurvivors
(n=43) Non-survivors
(n=37) χ² value p-value
Gender:
Female
Male 21
59 12 (27.9%)
31 (72.1%) 9 (24.3%)
28 (75.7%) 0.13 0.8
Smoking status:
Non-smoker
Ex-smoker 33
47 22 (51.2%)
21 (48.8%) 11 (29.7%)
26 (70.3%) 3.77 0.07
Comorbidity:
Present
Not present 53
27 31 (72.1%)
12 (27.9%) 22 (59.5%)
15 (40.5%) 1.42 0.25
CT involvement:
CT below 50%
CT above 50% 21
59 17 (39.5%)
26 (60.5%) 4 (10.8%)
33 (89.2%) 8.48 <0.001*
Intubation:
Yes
No 32
48 1 (2.3%)
42 (97.7%) 31 (83.8%)
6 (16.2%) 54.9 <0.001*
*p<0.05 statistically signicant; CT = computed tomography
Table 2. Comparison of laboratory parameters according to mortality
Survivors (n=43) Non-survivors (n=37) p-value Cohen
X±ss**
CRP (mg/L) 96.02±39.78 101.42±39.34 0.54 -
Ferritin (µg/L) 453.41±410.69 668.75±431.74 0.025* 0.51
Lymphocytes (K/uL) 0.86±0.47 0.75±0.41 0.26 -
Platelets (K/µL) 205.49±85.33 207.43±90.79 0.92 -
Median (min-max)***
D-dimer (mg/L) 0.33 (0.14-12.10) 0.51 (0.08-7.70) 0.24 -
Troponin (ng/L) 8.80 (1.70-687.50) 17.40 (2.20-2327.00) 0.005* 0.27
Lymphocytes % (K/
µL) 11.30 (3.40-33.6) 9.90 (1.00-30.90) 0.15 -
LDH (U/L) 420 (183-1884) 440. (237-1375) 0.71 -
Procalcitonin
(ng/mL) 0.08 (0.02-4.34) 0.23 (0.02-35.60) 0.008* 0.44
Prothrombin time (s) 14.80 (12.30-193.00) 15.80 (12.60-54.90) 0.15 -
*p<0.05 statistically signicant; **independent sample t test; ***Mann-Whitney U test; CRP = C-reactive protein; LDH = lactate dehy-
drogenase

E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
Acta Clin Croat, Vol. 62, No. 1, 2023 109
Table 3. Receiver operating characteristic (ROC) analysis of laboratory parameters
AUC (95% CI) Cut-o p-value Sensitivity (%) Specicity (%)
CRP (mg/L) 0.536 (0.407-
0.664) -0.59 --
Ferritin (µg/L) 0.659 (0.534-
0.785) 434.8 0.014* 70.3 69.8
D-Dimer (mg/L) 0.577 (0.448-
0.705) -0.24 --
Troponin (ng/L) 0.681 (0.564-
0.799) 14.05 0.005* 64.9 65.1
Lymphocytes (K/µL) 0436 (0.309-
0.563) -0.33 --
Lymphocytes % (K/µL) 0.407 (0.282-
0.533) -0.15 --
LDH (U/L) 0.524 (0.395-
0.653) -0.71 --
Procalcitonin (ng/mL) 0.673 (0.555-
0.792) 0.125 0.008* 64.9 64.3
Platelets (K/uL) 0.497 (0.367-
0.627) -0.96 --
Prothrombin time (s) 0.594 (0.467-
0.720) -0.15 --
Survivors
(n=43) Non-survivors
(n=37) χ² value p-value
Ferritin (µg/L) 0-434.80 30 (73.2%) 11 (26.8%) 12.76 <0.001*
≤434.81 13 (33.3%) 26 (66.7%)
Troponin (ng/L) 0-14.05
≤14.06 21 (56.8%)
16 (64.0%) 16 (43.2%)
9 (36.0%) 0.32 0.61
Procalcitonin (ng/mL) 0-0.125
≤0.126 27 (67.5%)
15 (38.5%) 13 (32.5%)
24 (61.5%) 6.69 0.01*
AUC = area under the ROC curve; 95% CI = 95% condence interval; CRP = C-reactive protein; LDH = lactate dehydrogenase
Fig. 1. ROC curve of the parameters
signicant in predicting mortality.

chloroquine, or only steroid pulse therapy, it was signi-
cantly lower in patients administered azithromycin or
convalescent plasma + steroid pulse therapy (Table 4).
Discussion
Fatality rate in COVID-19 cases has been reported
to be 3.4% worldwide1. Xie et al. showed that dyspnea
at admission and hypoxia despite oxygen support were
strong independent predictors of mortality. While
99% of the patients with an oxygen saturation level of
90% and above survived with oxygen support adminis-
tered during hospitalization, 69% of those with oxygen
saturation of 90% or less died despite oxygen support6.
In the present study, mortality rate was 46.3% (37 pa-
tients) in 80 patients with severe pneumonia, and this
rate was 96.9% in intubated patients (p<0.05).
e Centers for Disease Control categorize ad-
vanced age, cancer, chronic obstructive pulmonary dis-
ease, chronic kidney disease, immune system suppres-
sion due to solid organ transplantation, obesity, severe
heart disease, sickle-cell anemia and type 2 diabetes as
the risk factors for severe disease and complications7.
In this study, 53 (66.3%) patients had comorbid dis-
eases. In the order of their frequency, cardiovascular
diseases (47%), coexistence of diabetes mellitus and
cardiovascular diseases (24.5%), chronic pulmonary
disease (9.4%), malignancy (7.5%), and coexistence of
cardiovascular and chronic pulmonary diseases (3.8%)
were identied as the diseases in the patients reported
to have comorbidities. However, the level of signi-
cance of the relationship between the presence of co-
morbidity and mortality was p>0.05.
To date, in 10624 patients requiring critical care
in the UK, their median age was 60 (interquartile
range (IQR), 51-68) and 70.2% of them were males8.
In the present study, the mean age of patients was
67.83±12.64, and 73.8% of them were males, which is
comparable to the study mentioned above. e mean
age was 65.34±13.94 in survivors and 70.70±10.41
in non-survivors, yielding no statistical signicance
(p>0.05). Gender and mortality were not signicantly
related (p>0.05). However, Xie et al. report on a signif-
icant relationship between age, gender or comorbidity
and mortality6.
While the rate of non-smokers was higher in the
survivor group (52.1%) than in the non-survivor group
(29.7%), there was no signicant dierence between
the two groups in terms of non-smoking status. It is
E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
Acta Clin Croat, Vol. 62, No. 1, 2023110
Table 4. Comparison of result parameters according to medication status (survivors/non-survivors)
All patients Survivors
(n=43) Non-survivors
(n=37) χ² value p-value
HCQ user 36 21 (58.3%) 15 (41.7%) 0.55 0.50
HCQ non-user 44 22 (50.0%) 22 (50.0%)
Pulse steroid user
Pulse steroid non-user 28
52 7 (25.0%)
36 (69.2%) 21 (75.0%)
16 (30.8%) 14.32 <0.001*
Pulse + plasma
Pulse + plasma
Pulse non-user
11
17
52
1 (2.3%)
6 (14.0%)
36 (83.7%)
10 (27.0%)
11 (29.7%)
16 (43.2%) 16.17 <0.001*
Pulse + tocilizumab-
Pulse + Tocilizumab +
Pulse non-user
15
13
52
4 (26.7%)
3 (23.1%)
36 (69.2%)
11 (73.3%)
10 (76.9%)
16(30.8%)
14.36 <0.001*
HCQ + pulse-
HCQ + pulse +
HCQ non-user
23
13
44
17 (78.3%)
4 (30.8%)
22 (50.0%)
6 (21.7%)
9 (69.2%)
22 (50.0%) 6.78 0.03*
Azithromycin user
Azithromycin non-
user
47
33
30 (63.8%)
13 (39.4%)
17 (36.2%)
20 (60.6%) 4.66 0.04*
*p<0.05 statistically signicant; HCQ = hydroxychloroquine; Pulse = steroid pulse therapy

E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
strange to note that there were no smokers among
patients in this study. Lippi and Henry revealed that
there was no relationship between active smoking and
the severity of COVID-199. e most frequently ob-
served laboratory anomalies were increase in troponin
and C-reactive protein (CRP) (>60%) and lactate de-
hydrogenase (LDH) (~50%-60%) with lymphopenia
(83%); increased D-dimer level (43%-60%), increase in
aspartate aminotransferase (AST) (~33%) and serum
alanine aminotransferase (ALT) (~25%); prolonged
prothrombin time (>5%) and moderate thrombocyto-
penia (~30%)10,11. Serum procalcitonin level was found
to be normal in most of the patients12. e mean values
of inammation parameters obtained in our study are
shown in Table 5. Among laboratory data, only the in-
crease in ferritin (Cohen large eect), troponin (Cohen
medium eect) and procalcitonin (Cohen large eect)
was associated with mortality (p<0.05). e cut-o
value was determined as 434.8 for ferritin, 14.05 for
troponin, and 0.125 for procalcitonin (p<0.05). As a
result of ROC analysis, cut-o values of ferritin and
procalcitonin were signicantly related to mortality
while the cut-o value of troponin was found to be
p>0.05 in relation to mortality. In a study conducted
on 140 patients with COVID-19 pneumonia in Wu-
han, leukopenia, increased CRP and D-dimer were
associated with mortality6. In the study conducted by
Guo et al., troponin increase was detected in 27.3% of
hospitalized patients with a diagnosis of COVID-19.
In these patients, increased in-hospital mortality was
found compared to those with normal troponin values
(59.6% and 8.9%, p<0,001)13.
Favipiravir (1600 mg/day loading, 600 mg/day
maintenance) and methylprednisolone 0.5-1 mg/kg/
day were administered routinely to all patients. Favi-
piravir is a nucleotide analog and RNA polymerase
inhibitor. While favipiravir is an antiviral agent devel-
oped against inuenza14, it is also expected to be eec-
tive against COVID-1915. is agent is included in the
standard treatment in the COVID-19 Guide of the
Ministry of Health in our country.
COVID-19 causes diuse lung injury with dysreg-
ulation and excessive inammation. Glucocorticoids
also reduce the progression of lung damage to respira-
tory failure and death by modulating inammation. In
the study conducted by the RECOVERY Collabora-
tive Group, it was found that the use of dexamethasone
decreased 28-day mortality in the group of COVID-19
patients receiving mechanical ventilation or oxygen
support16. Gao et al. showed that chloroquine reduced
the severity of pneumonia, improved lung damage, and
shortened recovery time17. In our study, there was no
signicant relationship between hydroxychloroquine
use and mortality (the rate of mortality among those
using hydroxychloroquine was 41.7%, while that rate
was 50% among those not using hydroxychloroquine,
p>0.05) (Table 4).
Having a frequency of 5% in COVID-19 pneu-
monia, cytokine storm (symptoms such as persistent
fever despite treatment, persistently high or increas-
ing CRP and ferritin levels, high D-dimer levels,
cytopenia in the form of lymphopenia and throm-
bocytopenia, deterioration in liver function tests,
hypobrinogenemia or increased triglyceride values)
determines mortality.
High dose corticosteroid, i.v. immunoglobulin,
anakinra (IL-1 receptor antagonist) or tocilizum-
ab (IL-6 receptor antagonist) are the agents used in
cytokine storm18. In our study, tocilizumab was ad-
ministered to patients with increased oxygen need or
acute phase reactants manifested within 24 hours de-
spite methylprednisolone 0.5-1 mg/kg/day treatment.
However, if clinical deterioration persisted, pulse ste-
roid (1 g/day methylprednisolone for 3 days, followed
by 0.5-1 mg/day maintenance) was administered. It
was stated in the November 7 guide19 that anti-cyto-
kine treatment should be considered in patients not
responding to high-dose steroid therapy used for at
least 3 days, therefore a group of patients were admin-
istered pulse steroid rst. ere were 10 patients who
were administered tocilizumab but did not use pulse
steroids, and because of their small number, no statis-
tically signicant results were obtained. In this study, it
was found that pulse steroid alone and in combination
with tocilizumab and hydroxychloroquine increased
mortality. Monreal et al. also report that high-dose ste-
roids were associated with higher mortality, increased
need for mechanical ventilation and death as compared
to low-dose steroids. e risk of developing severe
acute respiratory distress syndrome (ARDS) in these
two steroid groups was found to be similar. Interaction
analysis showed that high dose steroid increased mor-
tality only in elderly patients. It is recommended that
1-1.5 mg/kg day corticosteroids should not be exceed-
ed in severe COVID-19 cases with ARDS, especially
in elderly people. is approach supports the need to
modulate rather than suppress immune responses in
patients20. In a study with pulse steroids (3 days, 1000
Acta Clin Croat, Vol. 62, No. 1, 2023 111

mg methylprednisolone, followed by 8 mg dexameth-
asone for 3-5 days), decreased dyspnea, improved ox-
ygen saturation and decreased CRP were observed;
however, there was an increase in D-dimer21. In anoth-
er retrospective study, no dierence was observed in
survival of two groups of patients, one group receiving
pulse steroid and the other group receiving steroid at a
dose of 1 mg/kg day22.
Tocilizumab is a recombinant humanized mono-
clonal antibody targeting the IL-6 receptor and was
found to reduce the risk of invasive mechanical venti-
lation and death in a multicenter retrospective study23.
In another meta-analysis, tocilizumab was not found
to have an additional benet in treatment24. Tocilizum-
ab reduced the use of invasive mechanical ventilation
when used early in the presence of bilateral lung in-
ltration and hypoxemia during cytokine storm25. No
statistically signicant dierence was found between
a single dose of tocilizumab (8 mg/kg, maximum 800
mg, intravenous infusion) and placebo with regards to
intubation or pre-intubation mortality26. Adding cor-
ticosteroids to tocilizumab treatment was demonstrat-
ed to have a benecial eect on reducing mortality27.
In our study, there was no patient taking only tocili-
zumab, and an increase in mortality was found in those
who received pulse steroid in combination with tocili-
zumab (p<0.05).
In the study comparing early (before intubation or
within one day after intubation) and late administra-
tion (one day after intubation) of tocilizumab in treat-
ment, a signicantly lower mortality was found in the
patients given tocilizumab early (13.5% and 68.2%,
p<0.05)28. However, the exact timing of the rst dose
of tocilizumab is controversial.
Convalescence plasma can be administered as an
addition to supportive treatments, along with the use
of antiviral agents in patients with COVID-1929. Con-
valescence plasma is passive immunotherapy through
which the antibodies obtained from healed people are
administered.
In a cohort study of COVID-19 patients, a de-
crease in symptoms and mortality besides a decrease
in CRP and viral load, an increase in lymphocyte per-
centage, and radiological improvement were found in
severely and critically ill patients receiving convales-
cence plasma30. In a randomized controlled study on
patients with COVID-19 pneumonia, no signicant
dierence was found between the convalescent plasma
group and placebo receiving group in terms of clinical
improvement, mortality, and side eects31. According
to the guideline published in April 2020 in our coun-
try, it is recommended that patients with a diagnosis
of COVID-19 be administered convalescence plasma
preferably at 7-14 days after the onset of symptoms,
and the patients in this study were administered con-
valescence plasma in this way32. In our study, the mor-
tality rate was reduced through a combination of con-
valescence plasma and pulse steroid (p<0.05).
e single-center and retrospective design were
limitations of the present study. Another limitation
could be a relatively small study cohort. However, the
results of our study are important for providing useful
data on COVID-19 infection.
In conclusion, having a frequency of 5% in
COVID-19 pneumonia, cytokine storm determines
mortality. In this study, it was determined that the in-
crease in ferritin, troponin and procalcitonin, which
are among the poor prognostic factors in COVID-19
pneumonia, was associated with mortality. Further-
more, the present study showed that among treatment
strategies, the use of pulse steroid + tocilizumab, pulse
steroid + hydroxychloroquine and pulse steroid alone
increased mortality, whereas azithromycin treatment
and combined use of plasma + pulse steroid reduced
mortality. However, studies involving larger numbers
of cases and control groups are needed. e factors
predicting the prognosis in COVID-19 pneumo-
nia should be determined and the individuals at risk
should be followed more closely, and more eective
treatments should be preferred in order to reduce mor-
tality.
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Sažetak
ČIMBENICI KOJI UTJEČU NA PROGNOZU I SMRTNOST BOLESNIKA S TEŠKOM PNEUMONIJOM
UZROKOVANOM INFEKCIJOM COVID-19
E. Afşin i M. E. Demirkol
Stopa smrtnosti bolesnika s bolešću koronavirus 2019. (COVID-19) iznosi 3,4% širom svijeta. Cilj ovoga istraživanja
bio je procijeniti čimbenike koji određuju prognozu i smrtnost bolesnika s teškom pneumonijom uzrokovanom infekcijom
COVID-19. U ovu retrospektivnu studiju provedenu u jednom centru bilo je uključeno 80 bolesnika s teškom COVID-19
pneumonijom koji su hospitalizirani i praćeni u Izzet Baysal State Hospital, Bolu, Turska, od kolovoza do studenoga 2020.
godine. Bilježili smo demografske i laboratorijske podatke, težinu radiološke zahvaćenosti, supostojeće bolesti, lijekove prim-
ijenjene u liječenju i kliničke rezultate, a podaci su grupirani kao preživjeli i ne-preživjeli. Srednja dob bolesnika bila je
67,8±12,6 godina, bilo je 59 (73,8%) muških bolesnika, a subolesti su bile prisutne u 53 (66,3%) bolesnika. Utvrđen je znača-
jan odnos bolesnikove dobi, spola, pušenja ili prisutnosti subolesti i smrtnosti (p>0,05). Značajan odnos s povećanom smrt-
nošću (p<0,05) utvrđen je za varijable kao što su zahvaćenost pluća iznad 50%, intubacija ili feritin (iznad 434,8 µg/L), tropo-
nin I (iznad 14,05 ng/L) i prokalcitonin (iznad 0,125 ng/mL) kao pojedinačne varijable iz laboratorijskih nalaza. Smrtnost
je bila značajno viša među bolesnicima koji su uzimali pulsnu terapiju steroidom + tocilizumab, pulsnu terapiju steroidom +
hidroksiklorokin ili samo pulsnu terapiju steroidom, dok je bila značajno niža među bolesnicima koji su primali azitromicin
te u bolesnika iz skupine koja je primala plazmu + pulsnu terapiju steroidom. Težina zahvaćenosti pluća, intubacija i porast
upalnih biljega poput feritina, troponina i prokalcitonina bila je značajno udružena sa smrtnošću (p<0,05). Utvrđeno je da
pristup liječenju azitromicinom i plazmom + pulsnom terapijom steroidom snižavaju smrtnost.
Ključne riječi: COVID-19; Pneumonija; Prognoza; Smrtnost
E. Afşin i M. E. Demirkol Factors aecting prognosis and mortality in severe COVID-19 pneumonia patients
Acta Clin Croat, Vol. 62, No. 1, 2023114