Investigation and treatment protocol for COVID 19

Version 40 (updated 10th May 2021)

 

Suspect COVID when:
-Fever >38 C, coryza, sore throat, cough, dyspnea
-Muscle pain, chills, repeated shaking with chills, conjunctivitis, loss of taste or smell, headache, nausea, diarrhea, hepatitis, acute abdominal pain, new skin signs around toes, rash with or without enanthem, myocarditis, STEMI, ischemic/hemorrhagic stroke, encephalitis, altered mental status/delirium in elderly -Sick contacts, residence in high prevalence area, immune disorders (MIS-C, MIS-A, ITP, ADEM)
-Any febrile illness >72 h without clinically overt localization

     

SpO2>/= 94% RA, stable vital signs, reliable follow up

-If on RA, RR >24 or SpO2 90-93%
-If on O2, requiring <5 Lt/min (~ 40% FiO2) to maintain SpO2> 90%

Moderate (Category B)

Admit to COVID-19 ward

Tests for A+

– FBG, LFT, RFT, CRP, ferritin, d-dimer, trop T, ECG, RDW7, PCT, PT/PTT, HbA1c

-Start dexamethasone10

-Start prophylactic anticoagulation6

-Consider remdesivir if <10 days from symptom onset8

– If on RA, SpO2< 90%

– If on O2, requiring>5L/min or any respiratory support (HFNC/ NIV/ Ventilation)

-BP<90/60, ARDS, end organ damage, severe MAS

Severe/critical (Category C)

Admit to COVID-19 ICU

Tests for B+

-NT-proBNP -echocardiogram

-Start dexamethasone10

-Start prophylactic anticoagulation6

–Start tocilizumab11

-Consider baricitinib for non-ventilated patients14

-Consider antibiotics9

   

Age<60 with no underlying medical conditions1

Mild (Category A)

Tests

-Consider CBC2 and CXR

Symptomatic outpatient management5

Age >=60 or at increased risk due to underlying medical conditions1

Mild

(Category A with risk factors)

Tests for A +

-NP swab for SARS CoV-2 RT-PCR3 -Consider CT chest4

Either outpatient or inpatient management5

                                

-Consider 6 minute walk test: if desaturation, treat as Cat B -Advice home pulse oximetry monitoring every 4h

-Start inhaled budesonide12 -Consider colchicine13
-Consider monoclonal antibodies15

Admit if clinical course worsening or fever persists >7 days

 

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Version 40 (updated 10th May 2021)

1Medical conditions that increase risk: chronic kidney disease, COPD, solid organ transplant, obesity (BMI>30, risk increased further if BMI>40), congestive heart failure, coronary artery disease, cardiomyopathies, sickle cell disease, type 2 diabetes mellitus, pregnancy, children who are medically complex or have neurologic/ genetic/ metabolic/ congenital heart disease, smoking, leukemia/hematological malignancy especially with recent chemotherapy,

(BMI 25-30)
Possibly increased risk with: hypertension, immunocompromised state from blood or bone marrow transplant/immune deficiencies/use of corticosteroids/use of other immunosuppressants, overweight pulmonary fibrosis, thalassemia, solid organ malignancy, obstructive sleep apnea, psychiatric disease

2Lymphocytopenia (lymphocyte count under 1.0 x 109 /L) is a risk factor for progression to severe disease. Neutrophil lymphocyte ratio >3.13 is an independent risk factor for severe disease.

3A negative test for SARS CoV-2 PCR (especially from an upper respiratory sample) or a positive test for another respiratory pathogen does not exclude SARS-CoV-2 infection: need to repeat testing if index of clinical suspicion is high, preferably from a lower respiratory tract specimen. Rapid antigen test has a specificity of 100% and sensitivity of 50-84%; if negative, PCR is needed to rule out infection. Serology for SARS CoV-2 may be considered for PCR negative individuals with late presentations 2 weeks after onset of symptoms, MIS-C/MIS-A or COVID related auto-immune syndromes. Govt rules need to be followed in decisions on testing.

4CT chest (without contrast) is more sensitive than RT-PCR for the diagnosis of febrile patients with COVID-19 and is indicated as a diagnostic aid in patients at high risk for clinical progression if RT-PCR testing is negative/not available/report is delayed. Ultrasonogram of chest (where expertise available) can be used if CT not possible. CTPA is the test of choice for suspected PE.

5Patients treated on outpatient basis should be advised regarding home isolation, warning signs and need for close follow up. The duration of isolation in home/hospital is 10 days from symptom onset (provided fever has resolved) for mild-moderate cases, and 20 days for severe/immune- compromised patients. Govt should be notified for all positive cases and advice followed regarding site of care and isolation.

6Start prophylactic anticoagulation with LMWH (eg enoxaparin or equivalent) for all admitted patients. Dose of enoxaparin is 40 mg for Cat B and 1mg/kg for Cat C given sc q24h. Contra- indications: active bleeding or a platelet count of <25×109/L. A rising d-dimer >1mcg/ml, especially >6 times normal, suggests DVT/PE. Start therapeutic anticoagulation for proven or strongly suspected DVT or PE till excluded on venous doppler/CTPA. Prolonged aPTT is not a contra-indication to anticoagulation. Repeat PT, platelet count and d-dimer every 2-3 days in patients who do not show improvement. At discharge, consider starting patients at high risk (modified IMPROVE-VTE score>4 or score>2 with d-dimer >2 times upper limit, age>75, underlying malignancy) on DVT prophylaxis (eg. rivaroxaban 10 mg od or equivalent for 4 weeks).

7RDW>14.5% at diagnosis or a rise in RDW during hospitalization predicts increased mortality.

8Remdesivir: dose is 200 mg iv on day 1 followed by 100 mg once daily for 4 more days. Does not reduce mortality, reduces duration of hospital stay and improves oxygenation in patients requiring oxygen, but not on high flow O2/NIV/HFNC/mechanical ventilation. Benefit greater if started <10 days from symptom onset. Avoid co-administration of HCQ (reduces efficacy). Monitor LFT.

 

diabetes, moderate-to-severe asthma, dementia and other neurologic conditions, stroke/cerebrovascular disease,

 

liver disease, overweight

, and HIV infection.

2

cystic fibrosis, type 1

Version 40 (updated 10th May 2021)

9Community acquired bacterial pneumonia complicating COVID is uncommon, unlike influenza. Elevated PCT may help decide if antibiotics indicated: use narrow spectrum antibiotics like ceftriaxone or amoxicillin-clavulanate. Blood cultures are not routinely recommended for suspected bacterial CAP. CAPA should be considered and looked for in patients on mechanical ventilation using serum AG/BDG and ET fungal stain and culture.

10Dexamethasone: dose is 8 mg once daily iv/po for 7-10 days (or till discharge if earlier). Alternatives are hydrocortisone 50 mg IV q8h or methylprednisolone 40 mg/day. In hypoxemic patients (either at rest or after 6 minute walk test) who cannot be admitted due to bed unavailability or other reasons, oral dexamethasone 8 mg od can be administered with close monitoring for side effects. Consider adding a single dose of ivermectin 12 mg to prevent Strongyloides hyper-infection. In patients continuing to remain severely hypoxemic after a 10 day course of dexamethasone, re- assess need for continued steroids after CTPA.

11Tocilizumab: administer single dose within 24 h of worsening in patients requiring FiO2>0.4, HFNC rate >30 l/mt or higher levels of respiratory support. Dose is single infusion of 400 mg iv or 8 mg/kg (not to exceed 800 mg of total dose). A second dose may be considered if there is no improvement 24h after first dose. Avoid if infection present or suspected.

12Inhaled budesonide: Start as early as possible after symptom onset. Dose is 800 micrograms via metered dose inhaler twice daily for 7-14 days.

13Colchicine: consider for high risk patients presenting early in disease within 24 h of positive test. Dose is 0.5 mg bd for 3 days, then od till clinical illness resolves.

14 Baricitinib: Indicated in non-ventilated patients who do not receive tocilizumab. Dose is

either orally or through a nasogastric tube for 14 days or until hospital discharge. Modify dose for

4 mg

 

renal function, avoid if creat cl<15.

15Monoclonal antibodies should be given as an intravenous infusion in a monitored setting as early as possible after a positive test and within 10 days of symptom onset. They are contra-indicated for

hospitalized patients or patients on oxygen:

Casirivimab plus imdevimab: single dose of 1200 mg and 1200 mg imdevimab

Bamlanivimab (700 mg) plus etesevimab (1400 mg): administered together as a single intravenous

infusion

Note:

Abbreviations

RA: room air, FBG: fasting blood glucose, ITP: idiopathic thrombocytopenic purpura, GBS: Guillain Bare syndrome, RFT: renal function test, LFT: liver function test, NP/OP: naso/oropharyngeal, CXR:

1. An informed consent is required wherever newer/unlicensed tests and therapies are used

2. This guideline is an advisory and does not replace appropriate clinical judgment. The treating clinician will need to decide on appropriate treatment for individual patients based on their unique clinical features

3

Version 40 (updated 10th May 2021)

chest X ray, PCT: procalcitonin, LMWH: low-molecular-weight heparin,

CTPA: computed tomography pulmonary angiogram, ADEM: acute disseminated encephalomyelitis, MAS: macrophage activation syndrome, CAPA: Covid associated pulmonary Aspergillosis, AG: Aspergillus galactomannan, BDG: serum 1-3 Beta d glucan,

CVA: cerebrovascular accident

Compiled by

Dr. Babu Abraham, Chennai.
Dr. Dhanya Dharmapalan, Navi Mumbai. Dr. Jayalakshmi, Navi Mumbai.
Dr. Manoj Singh, Ahmedabad.
Dr. Ram Gopalakrishnan, Chennai.
Dr. Rajesh Chawla, Delhi.
Dr. Ramakrishnan N, Chennai.
Dr. Ramasubramanian V, Chennai.
Dr. Ravi Mehta, Bangalore.
Dr. Sai P Haranath, Hyderabad.
Dr. Senthur Nambi P, Chennai.
Dr. Subba Reddy, Hyderabad.
Dr. Sudha Kansal, Delhi.
Dr. Suneetha Narreddy, Hyderabad.
Dr. Surendran R, Chennai.
Dr. Sushmita Roy Chowdhury, Kolkata. Dr. Suresh Ramasubban, Kolkata.
Dr. Yamunadevi Ramanathan V, Chennai.

inflammatory syndrome in children, MIS-A: multi-system inflammatory syndrome in adults, COPD:

4

MIS-C: multi-system

 

chronic obstructive airways disease,

Version 40 (updated 10th May 2021)

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