Patient care and clinical outcomes for patients with COVID-19 infection admitted to African high-care or intensive care units (ACCCOS): a multicentre, prospective, observational cohort study



African COVID-19 Critical Care Outcomes Study (ACCCOS) Investigators.


Lancet. 2021 May 22;397(10288):1885-1894. doi: 10.1016/S0140-6736(21)00441-4.


BACKGROUND: There have been insufficient data for African patients with COVID-19 who
are critically ill. The African COVID-19 Critical Care Outcomes Study (ACCCOS) aimed
to determine which resources, comorbidities, and critical care interventions are
associated with mortality in this patient population. METHODS: The ACCCOS study was
a multicentre, prospective, observational cohort study in adults (aged 18 years or
older) with suspected or confirmed COVID-19 infection who were referred to intensive
care or high-care units in 64 hospitals in ten African countries (ie, Egypt,
Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria, and South
Africa). The primary outcome was in-hospital mortality censored at 30 days. We
studied the factors (ie, human and facility resources, patient comorbidities, and
critical care interventions) that were associated with mortality in these adult
patients. This study is registered on, NCT04367207. FINDINGS:
From May to December, 2020, 6779 patients were referred to critical care. Of these,
3752 (55·3%) patients were admitted and 3140 (83·7%) patients from 64 hospitals in
ten countries participated (mean age 55·6 years; 1890 [60·6%] of 3118 participants
were male). The hospitals had a median of two intensivists (IQR 1-4) and pulse
oximetry was available to all patients in 49 (86%) of 57 sites. In-hospital
mortality within 30 days of admission was 48·2% (95% CI 46·4-50·0; 1483 of 3077
patients). Factors that were independently associated with mortality were increasing
age per year (odds ratio 1·03; 1·02-1·04); HIV/AIDS (1·91; 1·31-2·79); diabetes
(1·25; 1·01-1·56); chronic liver disease (3·48; 1·48-8·18); chronic kidney disease
(1·89; 1·28-2·78); delay in admission due to a shortage of resources (2·14;
1·42-3·22); quick sequential organ failure assessment score at admission (for one
factor [1·44; 1·01-2·04], for two factors [2·0; 1·33-2·99], and for three factors
[3·66, 2·12-6·33]); respiratory support (high flow oxygenation [2·72; 1·46-5·08];
continuous positive airway pressure [3·93; 2·13-7·26]; invasive mechanical
ventilation [15·27; 8·51-27·37]); cardiorespiratory arrest within 24 h of admission
(4·43; 2·25-8·73); and vasopressor requirements (3·67; 2·77-4·86). Steroid therapy
was associated with survival (0·55; 0·37-0·81). There was no difference in outcome
associated with female sex (0·86; 0·69-1·06). INTERPRETATION: Mortality in
critically ill patients with COVID-19 is higher in African countries than reported
from studies done in Asia, Europe, North America, and South America. Increased
mortality was associated with insufficient critical care resources, as well as the
comorbidities of HIV/AIDS, diabetes, chronic liver disease, and kidney disease, and
severity of organ dysfunction at admission. FUNDING: The ACCCOS was partially
supported by a grant from the Critical Care Society of Southern Africa.

Keywords: .

Link/DOI: 10.1016/S0140-6736(21)00441-4