NIH Treatment Guidelines for COVID-19

April 22, 2020 Rima Medical Science 0

A panel of US physicians, statisticians and other experts has developed treatment guidelines for COVID-19. These guidelines intended for healthcare providers, are based on preliminary and published data and the clinical expertise of the panel. These guidelines will be updated frequently. Here is the summary of the NIH (National Institutes of Health) guidelines:

  • The COVID-19 Treatment Guidelines Panel (the Panel) does not recommend the prophylactic use of any agents against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outside of the setting of a clinical trial.
  • The Panel does not recommend the use of any agents for post-exposure prophylaxis (PEP) against SARS-CoV-2 infection outside of the setting of a clinical trial (AIII).
  • At present, no drug has been proven to be safe and effective for treating COVID-19.

Management of patients with COVID-19

Patients with COVID-19 can be grouped into the following illness categories:

Asymptomatic or Presymptomatic Infection:

  • Individuals who test positive for SARS-CoV-2 but have no symptoms. Such individuals should self-isolate. If they remain asymptomatic, they can discontinue isolation 7 days after the date of their first positive SARS-CoV-2 test.

Mild Illness:

  • Individuals who have any of various signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal imaging.
  • They can be managed at home or in ambulatory setting by through remote visits or telemedicine. However, close monitoring is required as the infection may rapidly progress.

Moderate Illness:

  • Individuals who have evidence of lower respiratory disease and a saturation of oxygen (SaO2) >93% on room air at sea level. Such patients should be admitted to a health care facility for close observation.
  • In case of bacterial pneumonia or sepsis, antibiotic treatment is recommended, and daily re-evaluation should be done. If there is no evidence of bacterial infection, stop antibiotics.
  • The number of individuals entering the room of such patients should be limited. Use of PPE (Personal Protective Equipment) and single patient dedicated medical equipment (Stethoscope, thermometer) should be followed.
  • The optimal pulmonary imaging technique for people with COVID-19 is yet to be defined. Initial evaluation may include chest x-ray, ultrasound, or if indicated, CT. Electrocardiogram (ECG) should be performed if indicated. Laboratory testing includes a complete blood count (CBC), liver and renal function tests. Measurements of inflammatory markers such as C-reactive protein (CRP), D-dimer, and ferritin may be helpful.

Severe Illness:

  • Individuals who have respiratory frequency >30 breaths per minute, SaO2 ≤93% on room air at sea level, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates >50%.
  • These patients may experience rapid clinical deterioration and should be placed in AIIRs, if available. Oxygen therapy using nasal cannula or high-flow oxygen should be administered immediately.
  • If secondary bacterial pneumonia or sepsis is suspected, antibiotics should be administered, re-evaluate daily, and if there is no evidence of bacterial infection, stop antibiotics.
  • Evaluation should include pulmonary imagining (chest x-ray, ultrasound, or if indicated, CT) and ECG, if indicated. Laboratory evaluation includes CBC with differential and metabolic profile, including liver and renal function tests. Measurements of inflammatory markers such as CRP, D-dimer, and ferritin, may have prognostic value.

Critical Illness:

  • Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
  • Most of the recommendations for the management of critically ill patients with COVID-19 are extrapolated from experience with other life-threatening infections. They should be admitted in ICU (Intensive Care Unit) and aerosol-generating procedures should be performed in a negative pressure room.
  • Healthcare workers performing aerosol-generating procedures on patients with COVID-19 in the ICU, should use fitted respirator masks (N95 respirators, FFP2, or equivalent) and proper PPE.
  • For COVID-19 patients requiring endotracheal intubation, it should be performed by the healthcare worker who is most experienced with airway management.
  • Supportive care including hemodynamic support in shock and cardiac injury, ventilatory support, fluid therapy is recommended.

Special consideration in Pregnancy and Post-delivery

  • Limited information is available regarding the effect of COVID-19 on obstetric or neonatal outcomes.
  • As with other patients, in the pregnant patient with symptoms compatible with COVID-19, the illness severity, underlying co-morbidities, and clinical status should all be assessed to determine whether in-person evaluation for potential hospitalization is needed.
  • If hospitalization is indicated, they should be kept in a facility that has the capability to conduct close maternal and fetal monitoring. The principles of management of COVID-19 in the pregnant patient may include: Fetal and uterine contraction monitoring, Individualized delivery planning and a team-based approach with multispecialty consultation.
  • Any decisions regarding the use of drugs approved for other indications or investigational agents to treat COVID-19 must be made with shared decision-making, considering the safety of the medication and the risk and seriousness of maternal disease.
  • New-born infants should be temporarily separated from mother who have COVID-19. While breastfeeding, mother should practice good hand hygiene and wear a facemask. They can also use other methods to feed breastmilk like dedicated pump. SARS-CoV-2 has not been isolated from breast milk.

Therapeutic option under investigation

  • There are no Food and Drug Administration (FDA)-approved drugs specifically to treat patients with COVID-19.
  • There are insufficient clinical data to recommend either for or against using antiviral agents like remdesivir, chloroquine or hydroxychloroquine and immune-based therapy like convalescent plasma, hyperimmune immunoglobin.

Considerations for Certain Concomitant Medications in Patients with COVID-19

  • Persons with COVID-19 who are prescribed therapies for other indications like statin therapy, ACE inhibitor or ARBs (Angiotensin Receptor Blocker), NSAIDs (Non- Steroidal Anti- Inflammatory Drugs) should continue using these medications.
  • The Panel recommends against the routine use of systemic corticosteroids for the treatment of mechanically ventilated patients with COVID-19 without acute respiratory distress syndrome (ARDS).
  • For adults with COVID-19 and refractory shock, the Panel recommends using low-dose corticosteroid therapy over no corticosteroids.
  • Oral corticosteroid therapy used prior to COVID-19 diagnosis for another underlying condition and inhaled corticosteroids used daily for patients with asthma and chronic obstructive pulmonary disease should not be discontinued in patients with COVID-19.

Note- For further information, please contact the cited source.

References

  1. https://www.esicm.org/wp-content/uploads/2020/03/SSC-COVID19-GUIDELINES.pdf
  2. https://covid19treatmentguidelines.nih.gov/