Sex Differences in Clinical Course and Intensive Care Unit Admission in a National Cohort of Hospitalized Patients with COVID-19

Abstract

Males have a higher risk for an adverse outcome of COVID-19. The aim of the study was to analyze sex differences in the clinical course with focus on patients who received intensive care. Research was conducted as an observational retrospective cohort study. A group of 23,235 patients from 83 hospitals with PCR-confirmed infection with SARS-CoV-2 between 4 February 2020 and 22 March 2021 were included. Data on symptoms were retrieved from a separate registry, which served as a routine infection control system. Males accounted for 51.4% of all included patients. Males received more intensive care (ratio OR = 1.61, 95% CI = 1.51–1.71) and mechanical ventilation (invasive or noninvasive, OR = 1.87, 95% CI = 1.73–2.01). A model for the prediction of mortality showed that until the age 60 y, mortality increased with age with no substantial difference between sexes. After 60 y, the risk of death increased more in males than in females. At 90 y, females had a predicted mortality risk of 31%, corresponding to males of 84 y. In the intensive care unit (ICU) cohort, females of 90 y had a mortality risk of 46%, equivalent to males of 72 y. Seventy-five percent of males over 90 died, but only 46% of females of the same age. In conclusion, the sex gap was most evident among the oldest in the ICU. Understanding sex-determined differences in COVID-19 can be useful to facilitate individualized treatments.

Response to Rossato et al.

“…However, previous studies show that male participants are more frequently hospitalized than female participants. 7,8 Similarly, in our study, 41 women (1.9% of COVID-19-positive women) and 54 men (4.8% of COVID-19-positive men) were hospitalized due to COVID-19 (w 2 = 22.0; Df = 1; p < 0.001). The mean age of hospitalized women was 55.8 (standard deviation [SD] = 12.0) years, compared with 59.0 (SD = 10.7) years in men.…”

“…Women's innate and humoral immune responses, as well as their ability to balance inflammation and tissue damage, appear to be stronger than men's. 7,9 These immunological sex differences may result in more effective clearing of infection in women and a potentially accelerated recovery after infection. 10 In addition, higher age-adjusted rates of pre-existing somatic comorbidities are reported in male COVID-19 patients, including cardiovascular disease, which associate with a poor COVID-19 prognosis.…”

Angiographic and clinical outcome of SARS-CoV-2 positive patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: A collaborative, individual patient data meta-analysis of six registry-based studies

“…In fact, postprocedural TIMI flow but not gender, in agreement with previous reports in STEMI patients [28], emerged as an independent predictor of mortality among SARS-CoV-2 positive patients. This unreported result probably reflects the larger population and the greater statistical power of this meta-analysis compared with previous studies, and suggests a gender difference in both pathophysiology and outcome for SARS-CoV-2 positive patients [29]. The interplay between sexual hormones, inflammation, and prothrombotic factors may affect the efficacy of mechanical reperfusion in males with SARS-CoV-2 infection.…”

Sex Differences in Clinical Characteristics and Outcomes of Patients with SARS-CoV-2-Infection Admitted to Intensive Care Units in Austria

“…Interestingly, obesity, diabetes and hypertension were more prevalent in women and diabetes, CKD, and an increased neutrophile-to-lymphocyte ratio and ferritin levels independently predicted death in women only. Interesting results could also be observed in an observational retrospective cohort study conducted in Germany (n = 23,235 patients) where it has been shown that once ventilated, the advantage of females in survival seems to disappear [13]. However, there are some important differences: in the German ICU cohort, 65% of the males but only 35% of the females needed ventilation therapy.…”