Medical treatment of 55 patients with COVID-19 from seven cities in northeast China who fully recovered

Abstract Coronavirus disease 2019 (COVID-19) is an emerging disease caused by severe acute respiratory syndrome coronavirus 2; no specific effective medication to treat the disease has been identified to date. We aimed to investigate the administered medications and intervention times for patients who completely recovered from COVID-19. This single-center, retrospective, observational study included 55 patients with COVID-19 who were transferred to Shenyang Sixth People's Hospital between January 20 and March 15, 2020. Data on demographics, symptoms, laboratory indicators, treatment processes, and clinical outcomes were collected. Administered drugs and intervention times were compared in 47 and 8 patients with mild and severe symptoms, respectively. All 55 patients recovered. Fifty-three patients (96.36%) received antiviral therapy, including 45 in the mild group (median treatment: 14 days; 17 received umifenovir) and all 8 severe-group patients (median treatment: 17.5 days; 4 received lopinavir/ritonavir). Twenty-nine patients (52.72%) were administered antibiotics, including 21 in the mild group (median treatment: 13.5 days; 15 received moxifloxacin) and all 8 in the severe group (median treatment: 9 days; 2 received linezolid). Moreover, 7 patients (12.72%) were treated with glucocorticoids and 9 (16.36%) with immunomodulators. Given the 100% recovery rate, early administration of antiviral drugs can be considered. Umifenovir may benefit patients with mild symptoms, while lopinavir/ritonavir may benefit those with severe symptoms. Prophylactic administration of common antibiotics may reduce the risk of co-infection. The use of glucocorticoids is usually not necessary. Randomized, double-blind, and controlled trials remain necessary for more accurate conclusions.


Introduction
Coronavirus disease 2019 (COVID-19) is highly contagious and spreads rapidly through human-to-human transmission. [1] The pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains unclear, and effective drugs and regimens for the treatment of COVID- 19 have not been identified. [2,3] In China, nationally recommended trial-based antiviral and other symptom-managing drugs are administered.
As such, a retrospective review of the types and doses of clinical drugs, courses of treatment, and intervention times in patients cured of COVID-19 would be highly informative for treating patients with this disease worldwide.
Data on medications that were administered to patients who ultimately recovered from COVID-19 are scarce but crucial for clinicians. To that end, we aimed to investigate the administered medications and intervention times for 55 patients confirmed to have COVID-19 who completely recovered after being transferred to Shenyang Sixth People's Hospital, a designated treatment facility in Liaoning Province.

Study design and participants
We performed a single-center, retrospective, and observational study at Shenyang Sixth People's Hospital (Shenyang, Liaoning, China), a government-designated centralized medical facility for the treatment of patients with COVID-19 in Liaoning Province. All patients were from hospitals that received patients for initial COVID-19 treatment in 7 cities in Liaoning Province, including Shenyang Chest Hospital. According to the Interim Guidelines issued by the World Health Organization (WHO) on January 12, 2020, [4] patient throat swabs and sputum samples were collected. Real-time reverse transcription polymerase chain reaction (RT-PCR) was used to detect the nucleic acid of SARS-CoV-2. We included all 55 consecutive patients with COVID-19 who were treated between January 20 and March 15, 2020; none were excluded. Patients were categorized into 2 groups: the "mild" group (with mild/moderate symptoms) and the "severe" group (those with severe/critical symptoms). These classifications were according to the criteria stated in the COVID-19 Diagnosis and Treatment Plan issued by the National Health Commission of the People's Republic of China. [3] The study was reviewed and approved by the Ethics Committee of Shenyang Chest Hospital (approval number: KYXM-2020-001-01) and was also documented by the Ethics Committee of the Shenyang Sixth People's Hospital. The requirement for written informed consent was waived owing to the rapid development of the infectious COVID-19 disease.

Data collection
We reviewed clinical manifestations as well as laboratory and radiological findings of all enrolled patients and collected data that included age, sex, epidemiological history, past history, symptoms, complications, laboratory indicators, therapeutic drugs, and intervention time.

Outcomes
The endpoint was the total patient recovery rate; individuals who met the discharge criteria were included in the "recovered" statistics. These discharge criteria were consistent with the China's COVID-19 Diagnosis and Treatment Plan [3] as follows: body temperature returned to normal and remained so for at least 3 days; respiratory symptoms were appreciably relieved; pulmonary imaging showed a significant improvement in acute exudative lesions; and nucleic acid tests of the sputum, nasopharyngeal swabs, and other respiratory specimens were negative twice consecutively following a minimum interval of 24 hours.

Statistical analysis
Given that the purpose of this study was to examine the clinical characteristics and drug administration data for patients with COVID-19, no formal hypothesis was established with which to calculate the optimal sample size. Continuous variables are expressed as means (standard deviations) or medians (interquartile ranges [IQRs]), while categorical variables are denoted as percentages.

Results
The mean age of the 55 patients in our study was 46.8 years. Among them, 30 (54.55%) were male, 28 (50.91%) had been in Wuhan/Hubei, and 19 (34.55%) were complicated with other chronic diseases. Lung computed tomography scans showed local or diffuse infiltration shadows in 54 patients (98.18%), whereas the remaining patients (1.82%) had no inflammatory changes. There were 47 patients (85.45%) in the mild group and 8 (14.55%) in the severe group ( Table 1). The most common symptoms of COVID-19 were fever (32 patients, 58.18%) and cough (27 patients, 49.09%). Seventeen patients (30.91%) were complicated with liver function impairment, 15 (27.27%) with hypoxemia, and 2 (3.64%) with acute respiratory distress syndrome (ARDS) ( Table 2). The white blood cell counts, lymphocyte counts, and percentage of lymphocyte counts of patients in the mild group were in the normal range, although C-reactive protein levels (15.73 mg/ L) were elevated. In the severe group, however, lymphocyte counts (0.78 Â 10 9 /L) and the percentage of lymphocytes (12.30%) were suppressed, while C-reactive protein levels (47.21 mg/L) were elevated ( Table 2). In the mild and severe groups, the median durations for the lymphocyte counts to return to normal were 11 and 9 days, respectively; for those with lung shadows, marked improvements took on average 4 and 6 days, respectively. The time it took to achieve a negative COVID-19 RNA conversion was 12 and 19 days, respectively ( Fig. 1).

Discussion
Patients with COVID-19 in the present study achieved a 100% recovery rate. Thus far, effective antiviral drugs to treat COVID-19 have not been identified, and opinions on whether antiviral drugs should even be used to treat COVID-19 differ. [2] The National Health Commission of the People's Republic of China has repeatedly issued and revised the COVID-19 Diagnosis and Treatment Plan, which recommends antiviral drugs such as lopinavir/ritonavir, ribavirin, umifenovir, and alpha-interferon. [3] In the present study, 53 patients (96.36%) received antiviral therapy early in the course of their disease for a median time of 14 days (IQR 12-18 days). In the mild group, 17 (37.78%) of the patients were treated with umifenovir (0.2 g orally once every 8 hours) and another 17 (37.78%) received a combination of umifenovir (0.2 g orally once every 8 hours) + lopinavir/ritonavir (400 mg/100 mg orally once every 12 hours) for a median time of 14 days (IQR 12-17 days). Liu et al [5] described the effectiveness of umifenovir in the treatment of emerging respiratory infectious     diseases such as influenza A (H1N1). Ji et al [6] also confirmed the efficacy of umifenovir for the treatment of coronavirus infections in an in vitro study. Our present findings indicated that umifenovir might benefit patients with mild symptoms. In the severe group, 8 patients (100%) were administered antiviral drugs for a median time of 17.50 days (IQR 11-19.25 days); 4 (50%) were treated with lopinavir/ritonavir and 3 (37.50%) received a combination of lopinavir/ritonavir regimen. Lopinavir alone has poor bioavailability. Ritonavir can increase the plasma concentration of lopinavir by inhibiting CYP3A-mediated degradation of lopinavir in the liver. [7] Nukoolkarn et al [8] observed through molecular dynamics simulation studies that lopinavir/ritonavir can combine with the main protease 3CLpro of the severe acute respiratory syndrome (SARS) virus to achieve anti-coronavirus effects, but their affinity is not obvious. Chu et al [9] found that lopinavir/ ritonavir could inhibit coronavirus replication to some extent, thereby reducing the risk of ARDS or death in patients with SARS. Chan et al [10] confirmed the efficacy of the combination of lopinavir/ritonavir and interferon-b for the treatment of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in animal models. In the present study, the use of lopinavir/ ritonavir in the severe group was apparently effective in mitigating fever symptoms, promoting lung shadow absorption, and rapidly restoring the number of lymphocytes. The efficacy and safety of lopinavir/ritonavir are expected to be verified in future clinical randomized controlled trials. Ribavirin and interferon are also mentioned in the COVID-19 Diagnosis and Treatment Plan [3] ; in the present study, 4 patients in the mild group (7.27%) were administered ribavirin combined with antiviral therapy. Nucleoside analogs theoretically ought to possess anti-coronavirus activity to a certain extent [11] ; however, ribavirin was found to have a minimal antiviral effect against coronavirus in vitro. [12] In the present study, 20 patients received aerosol inhalation of alphainterferon soon after diagnosis (50 mg, twice per day). A retrospective study of patients with Middle East Respiratory Syndrome (MERS) in 2019 showed that interferon did not accelerate virus clearance, [13] while a study of patients with SARS showed that alpha-interferon did not improve the patients' prognosis. [14] In the present study, a small number of patients were treated with ribavirin, and alpha-interferon was simply used to assist aerosol inhalation. Therefore, the usefulness of these 2 drugs for patients with COVID-19 is difficult to evaluate. In terms of antimicrobial use, the WHO recommends empirical antimicrobial therapy based on the clinical diagnosis. [4] China's COVID-19 Diagnosis and Treatment Plan [3] also emphasizes the avoidance of blind or inappropriate use of antibiotics. Kim et al [15] found that 38% of their patients with H1N1 infection developed secondary bacterial pneumonia 48 hours after admission to the intensive care unit, and that early empirical treatment helped improve their prognosis. Experience with SARS [16] and MERS [17] also suggests that prophylactic antibiotics may be appropriate after assessing the risk of co-infection in patients with severe symptoms.
Bacterial infection rates after SARS-CoV-2 infection remain unclear. In the present study, among 21 patients received antibiotics in the mild group, 12 (57.14%) patients were administered prophylactic drugs and 9 (42.86%) underwent empirical treatment (mainly with single-antibiotic moxifloxacin 400 mg ivgtt, qd); the possibility of atypical pathogenic bacteria (such as Mycoplasma pneumoniae) related infections was also considered. Epidemiological survey results in China show that M pneumoniae and Streptococcus pneumoniae are the main pathogens of adult community-acquired pneumonia in China. Because of their high resistance to macrolides, our guidelines recommend respiratory quinolone antibiotics usage. [18] In the severe group, 8 patients received antibiotics, 5 (62.50%) patients were administered prophylactic medication, and 3 (37.50%) received empirical treatment. Prophylactic medication was administered to comorbid patients with diabetes, chronic lung diseases, and ARDS who were at the early stage of receiving glucocorticoids. In the severe group, patients with a relatively high risk of infection by drug-resistant bacteria (1 case each of prehospital antibacterial treatment ineffectiveness with ARDS, ventilator-associated pneumonia, and chronic structural lung www.md-journal.com disease with ARDS) were treated with broad-spectrum antibiotics. In consideration of influenza virus infection, Staphylococcus aureus and S pneumoniae are the main infections. [19,20] The treatment plan is based on linezolid combined with cefoperazone and sulbactam or imipenem and cilastatin. One patient with ventilator-associated pneumonia had multi-drugresistant Klebsiella pneumoniae in sputum culture and was administered meropenem. Gradually treatment was downgraded after symptoms improved. No evidence of secondary bacterial infection was observed in patients who received prophylactic medication. The present study suggested that early and prudent use of prophylactic antibiotics in patients with COVID-19 may help reduce the risk of co-bacterial infections. Empirical antiinfective treatment for severely ill patients under the pressure of high risk of drug resistance may benefit the prognosis of the disease.
The WHO does not recommend the systematic use of glucocorticoids for viral pneumonia or concurrent ARDS. [4] China's COVID-19 Diagnosis and Treatment Plan recommends hormones as adjuvant therapy. [3] In the present study, 48 (87.28%) patients did not receive glucocorticoids, while 7 patients (12.72%) received such agents during the rapid progression of their disease (i.e., respiratory failure and large area exudation in both lungs). Glucocorticoids were administered to inhibit inflammation and improve oxygenation at a dose of Methylprednisolone 1 to 2 mg/kg/day. Treatment was gradually reduced over 5 to 7 days until discontinuation; and they showed no adverse reactions. As such, glucocorticoids appear to be unnecessary for patients with mild manifestations of COVID-19, while their use in treating patients with severe disease is controversial.
Thymosin a1 is a thymosin hormone responsible for restoring the homeostasis of the immune system. It plays a key role in the development of thymocytes, as well as increases the resistance of thymocytes to glucocorticoid-induced death. There is evidence that thymosin a1 is used as an immune enhancer for SARS patients and can effectively control the spread of infection. According to the COVID19 treatment guidelines of the National Health Commission of China, the use of thymosin a1 may be an alternative treatment option for COVID-19 patients with low lymphocyte count or immunodeficiency. [21] There are currently research reports that Thymosin a1 (Ta1) can restore reduced lymphocytes and improve the function of failed T cells, thereby reducing the mortality of severe COVID-19, [22] In the present study, 9 (16.36%) patients were administered thymalfasin. Thymus Faxin is a chemically synthesized drug, similar to the human body's natural thymosin a1 in chemical structure and spatial structure with potential clinical application. This notion requires further clinical observation and study. While high-flow oxygen therapy, invasive mechanical ventilation, and extracorporeal membrane oxygenation were provided to patients in the present study, their use was not investigated.
Our findings suggest that, while specific antiviral drugs are yet to be developed, currently available antiviral agents should be considered when treating patients with COVID-19. The prophylactic administration of single antiviral drugs to patients with severe symptoms, as well as to a proportion of those with mild manifestations, may help reduce the risk of co-infection. However, the use of glucocorticoids and immunomodulators needs further study.
Our study had some limitations given its single-center, retrospective, and observational nature. Owing to its small sample size, only descriptive data were available, and no statistical analyses were performed. Hence, randomized, double-blind, and controlled trials remain necessary for more accurate conclusions. Nevertheless, our data ought to provide helpful preliminary information at this stage of the COVID-19 pandemic.