Arnold, Forest W

Bordon, Jose

Cavallazzi, Rodrigo

Furmanek, Stephen P

Huang, Jiapeng

Ramirez, Julio A

Wiemken, Timothy L

English

University of Louisville

University of Louisville Journal of Respiratory InfectionsOPINION PIECEDefining Early and Late Clinical Outcomes in Patients withSARS-CoV-2 PneumoniaJulio Ramirez1; Jose Bordon2; Rodrigo Cavallazzi1; Stephen Furmanek1; Jiapeng Huang1; Timothy Wiemken3; Forest Arnold11Center of Excellence for Research in Infectious Diseases, Division of Infectious Diseases, University of Louisville, Louisville, KY, USA; 2Washington Health Institute,Washington, D.C., USA; 3Department of Health and Clinical Outcomes Research, St. Louis University, St. Louis, MO, USARecommended Citation: Ramirez JA, Bordon J, Cavallazzi R, et al. Defining early and late clinical outcomes in patients with SARS-CoV-2 pneumonia. UnivLouisville J Respir Infect 2021; 5(Iss 1): Article 5.Opinion PieceSARS-CoV-2 is now added to the list of respiratoryviruses able to cause community-acquired pneumo-nia (CAP).[1] The clinical outcomes of hospitalized pa-tients with non-SARS-CoV-2 CAP have been character-ized as early outcomes—or outcomes occurring duringthe acute infection, and late outcomes—or outcomesoccurring after the episode of acute pneumonia has re-solved.[2]The early clinical outcomes of hospitalized patientswith SARS-CoV-2 CAP can be characterized as illus-trated in Figure 1. Some patients develop SARS-CoV-2infection from an exposure in the community, requir-ing subsequent hospitalization due to development ofpneumonia. The initial severity of disease can be char-acterized in levels as depicted in Figure 2. These lev-els are suggested by the National Institutes of Healthtreatment guidelines for COVID-19.[3] During hospi-tal follow-up, if the severity of the patient’s illness de-creases by two or more levels, they can be consideredto be clinically improving. Conversely, if the severityof the patient’s illness increases by two or more levels,they can be considered to be clinically deteriorating. Inour prior studies of clinical outcomes in patients withnon-SARS-CoV-2 CAP, we proposed 3 days as the cut-off for early and late outcomes, since the majority of pa-tients with non-SARS-CoV-2 CAP have a hospitaliza-tion of 3–7 days.[4] In the case SARS-CoV-2 CAP, ourdata indicate that the hospitalization of these patientsextends to 7–14 days.[5] Therefore, we have decided todefine the cutoff between early and late outcomes at 7days. After 14 days, if the patient remains without dete-rioration or improvement, their case will be considerednon-resolving SARS-CoV-2 CAP. At 30-day follow-up,the final early outcomes will be categorized as 1) dis-charged home fully recovered (optimal outcome), 2)discharged home partially recovered, 3) discharged to arehabilitation facility, 4) discharged to a long-term carefacility, 5) continued hospital care if the patient remainshospitalized at 30 days, 6) discharged to hospice, and 7)death. Discharge to hospice and death are consideredthe worst outcomes.The late (post-discharge) outcomes of hospitalized pa-tients with SARS-CoV-2 CAP can be characterized asdescribed in Figure 3. If the patient is discharged homefully recovered (optimal outcome), and the patient re-mains asymptomatic during the 1-year follow-up, thiswill constitute the optimal outcome at 1 year. Duringthis year, some patients will develop symptoms andmay be re-hospitalized according to the severity of thesymptoms. At intervals during the follow-up, patientswill need to be evaluated in a post-COVID-19 clinic todetermine whether any organ system has been affectedby the acute illness. Since any organ system can be af-fected, the follow-up of these patients should occur ina multi-disciplinary clinic. At 1 year, outcomes will bedetermined according to the same levels as at the 30-day follow-up.These classifications of the clinical course and post-acute sequelae of SARS-CoV-2 CAP fit nicely into thetheoretical framework of multi-state modeling. Thisstatistical methodology may enable researchers to pre-dict what class and level of outcome a patient may ex-perience over the year following diagnosis of SARS-CoV-2 pneumonia.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/5 1ULJRI Defining Early and Late Clinical Outcomes in Patients with SARS-CoV-2 PneumoniaFigure 1. Early clinical outcomes for hospitalized patients with SARS-CoV-2 CAP.Figure 2. Levels of severity for hospitalized patients with SARS-CoV-2 CAP.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/5 2ULJRI Defining Early and Late Clinical Outcomes in Patients with SARS-CoV-2 PneumoniaFigure 3. Long term outcomes for patients with SARS-CoV-2 CAP.Received: March 19, 2021Accepted: March 19, 2021Published: March 19, 2021Copyright: © 2021 The author(s). This original article isbrought to you for free and open access by ThinkIR: The Uni-versity of Louisville’s Institutional Repository. For more infor-mation, please contact thinkir@louisville.edu. This article isdistributed under the terms of the Creative Commons Attribu-tion 4.0 International License (CC BY 4.0), which permits un-restricted use, distribution, and reproduction in any medium,provided the original author and source are credited.Funding Source: The author(s) received no specific fundingfor this study.Conflict of Interest: All authors declared no conflict of inter-est in relation to the main objective of this work.References1. Ramirez JA. Overview of community-acquired pneu-monia in adults. 2020. Available at: https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults?search=overview%20of%20community%20acquired%20pneumonia%20in%20adults&source=search result&selectedTitle=1∼150&usage type=default&display rank=1 Accessed 19 March 2021.2. Peyrani P, Arnold FW, Bordon J, et al. Incidence and Mor-tality of Adults Hospitalized With Community-Acquired Pneu-monia According to Clinical Course. Chest 2020; 157:34–41.3. Clinical Spectrum of SARS-CoV-2 Infection. 2021.Available at: https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/. Accessed 17 March 2021.4. Aliberti S, Zanaboni AM, Wiemken T, et al. Criteria for clin-ical stability in hospitalised patients with community-acquiredpneumonia. Eur Respir J 2013; 42:742–749.5. Ramirez JA, Bordon J, Cavallazzi R, et al. Characteris-tics and Outcomes of Adults Hospitalized with SARS-CoV-2 Community-Acquired Pneumonia in Louisville, Kentucky.Univ Louisville J Respir Infect 2020; 4:Article 72.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/5 3

Defining Early and Late Clinical Outcomes in Patients with SARS-CoV-2 Pneumonia

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Defining Early and Late Clinical Outcomes in Patients with SARS-CoV-2 Pneumonia

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