On February 25, 2020, the first case of covid-19 was identified in Catalonia, just two weeks after the Mobile World Congress in Barcelona was canceled. It was about a 36-year-old Italian woman who had recently arrived from Milan and Bergamo. That was the first patient that doctor Álex Soriano, head of the infectious disease service At the Hospital Clínic de la Ciudad Condal, a reference center in Catalonia for this type of pathology, he faced the disease that has paralyzed Spain and the world for more than a year.
“Despite the news, he caught us on the wrong foot, first because we thought it would not arrive “Despite the fact that he had been in China for weeks or even months, and when the first case arrived and we saw there was a lot of ignorance,” the infectologist acknowledges in an interview with El Confidencial.
Pablo G. Sacristán Antonio Villarreal
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That morning, the Catalan Health Minister, Alba Vergés, had said that the Catalan health system was prepared to treat a possible case of coronavirus, but none had yet been detected. Also before the confirmation, Carmen Calvo offered the press conference after the Council of Ministers, which since the previous month began to be held on Tuesdays: “We have a great health system, our country has faced similar crises and we have resolved them” . Back then, the confirmation of positives like that was carried out at the National Epidemiology Center.
“I remember that the first patients we saw, although more than 85% had a very mild infection, we admitted them and we followed everyone with great concern,” says Soriano. “The ignorance led us to be more cautious even of what was finally necessary. ”
At that time, the Clinic’s doctors were beginning to design protocols: who, how and when to wear PPE, where to enter or leave with covid patients. At that time, it was still seen as a disease contracted abroad and that only seriously affected older people or people with previous pathologies. On March 6 he passed away in the Germans Trias i Pujol Hospital from Badalona the first Catalan victim by covid-19. She was an 89-year-old woman with comorbidities, but with her there were two other serious cases, one 50 years old and the other 29. None of the three had traveled to risk areas.
There it was like the doctors their faces began to change.
Blind treatments
“At first, we had some patients who were fine, but we kept them admitted to monitor them, little by little we began to see that we could send them home,” explains Soriano, “until we reached the second week of March and everything exploded: the spread of the virus in the street was so high that 15% of seriously ill patients was already a very important volume, and these they began to arrive en masse at the hospital“.
On March 14, Catalonia was the second community with the most cases of covid-19, behind Madrid. The Clinic and other hospitals suspended non-urgent consultations and operations. This meant that the doctors had to adapt the entire hospital to forced marches to attend to a single pathology, very specific and “that always consumed the same resources, and therefore those resources were exhausted,” recalls Soriano. “The situation was adaptation to a demand that was not 100% covered“.
“We were sending patients home, but in the second week of March everything exploded.”
In hospital pharmacies, some products such as the sedative propofol, essential for intubations, they began to be scarce. In the Terrassa hospital, the reserves that until then had lasted six months disappeared in two weeks.
Due to the experience that was already beginning to accumulate in China, Italy and other countries, names of potential drugs that appeared to have an activity against the virus. “Among them, the most characteristic was an AIDS drug that we knew well, Kaletra, lopinavir / ritonavir,” recalls Soriano. “We were also very familiar with hydroxychloroquine or a common antibiotic, azithromycin, because we had kicked them in.” Due to the safety profile of these drugs, they soon began to be used at will for the next two months. With the de-escalation and the arrival of summer, the evidence against all these drugs began to accumulate. “It is not that they did not have any, but in general their effectiveness was not what we would have liked,” says the infectologist.
And with seriously ill patients?
The June 16, 2020, they were finally published in the ‘BMJ’ the results of use of dexamethasone in critically ill patients with covid-19. There it was confirmed that it was able to reduce deaths from the disease by a third, ultimately caused by the inflammatory response that corticosteroids were precisely able to reduce. But until then, both in the Clinic and in the rest of the hospitals, the intensivists had to speculate.
“We began to use them without evidence and then little by little these were added,” says Soriano. “But when the dexamethasone data came out, if I look at our patients who until then received dexamethasone or some other corticosteroid, it was a very high percentage. And we were not very prone to corticosteroids either.”
“In fact, to this day, it is not clear at what time and under what conditions it must be given,” he continues. “We knew that in infections with a virus a corticosteroid was not a good thing, and with this virus it is probably not very good either, but it depends on when you administer it, which is what the Recovery study supports: critical patients with an infection advanced, not in those with a very early infection. ”
Although fortunately already with a vaccine, a year later there are still some unresolved gaps in the treatment of covid-19. “It is clear that antivirals in general such as remdesivir, the only one approved so far, as well as monoclonal antibodies or plasma from patients, are effective if administered early,” explains the head of infectious diseases at the Barcelona hospital. “The problem is that this blockade should be administered on days when the patient is not very seriously ill, and, therefore, is on the street and does not go to the hospital. That window of opportunity today is not a reality, because you cannot put a catheter in the vein of someone who is on the street: to put a parallel, we need for the coronavirus what the seltavir is for the flu: a product that can be administered orally or nasally, such as an inhaler. That would be a major change“.
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