National Institute for the Infectious Diseases “L. Spallanzani”, IRCCS. Recommendations for COVID-19 clinical management

Nicastri, Emanuele; Petrosillo, Nicola; Bartoli, Tommaso Ascoli; Lepore, Luciana; Mondi, Annalisa; Palmieri, Fabrizio; D’Offizi, Gianpiero; Marchioni, Luisa; Murachelli, Silvia; Ippolito, Giuseppe; Antinori, Andrea

vere respiratory conditions related to SARS-CoV-2 infection and/or to its complications. Adjunctive goals of clinical management at this stage are: 1) Strict monitoring, especially between 5 th and 7 th day since symptoms onset, in order to ensure an immediate life support and an increase of the level of care, whenever required 2) Maintenance of an adequate peripheral oxygenation, through O2 administration 3) Use of potentially efficacious antiviral experimental drugs, aimed at rapidly reducing viral replication 4) Empirical or targeted treatment of possible bacterial co-infections; 5) Prompt assessment of the need of drugs aimed at modulating the immune and inflammatory response, in order to counteract the evolution to ARDS Characteristics: -Clinical and/or laboratoristic evidence of worsening of gas exchange (mild-tomoderate dyspnoea, high respiratory rate, shortness of breath, low peripheral SpO2 or altered arterial blood gases while breathing room air), without any critical or warning signs (severe respiratory failure, respiratory distress, consciousness disorders, hypotension, shock) Additional microbiologic diagnostics: -Influenza virus detection and/or respiratory agents multiplex PCR on single rhinopharyngeal swab sample -SARS-CoV-2 serology if available -Urinary L. pneumophila and S. pneumoniae antigen detection -In case of availability of sample representative of lower respiratory tract (e.g. sputum), perform gram stain and culture; avoid aerosol-generating procedures to induce sputum, because of the higher infectious risk for healthcare workers -In case of fever (>38˚C), perform at least 2 blood cultures, possibly before starting new antimicrobial therapies -Other eventual diagnostics based on the specific clinical picture (e.g. HIV test, P. jirovecii detection on respiratory fluids, MRSA on nasal swab, etc…) Clinical monitoring: -Strict clinical re-evaluation -Strict periodic vital signs recording (blood pressure, heart rate, respiratory rate, SpO2, GCS, body temperature), in order to early identify a possible rapid worsening of respiratory functions, requiring an increase of the level of care -Arterial blood gas analysis monitoring (mainly between 5 th and 7 th day), to be evaluated together with the intensive care specialist in charge -Consultation with an intensive care specialist Virologic, immunologic and biochemical monitoring: -SARS-CoV-2 RT-PCR performed on rhinopharyngeal swab every 48-72 hours until persistently negative -IL-6 plasma levels -D-dimer, ferritin, fibrinogen, C-reactive protein, tryglicerides, lactate dehydrogenase (LDH) Imaging diagnostics: -Chest X-ray: useful as a first-line radiological examination, for the follow-up and for a rapid assessment of certain pulmonary/thoracic emergencies. Quick and easy to perform; in case of necessity, it can be performed using portable systems -Chest computed tomography, without contrast: high sensitivity in identifying and quantifying lung parenchymal involvement. To be performed in every patient affected by lung involvement causing respiratory failure. Use of contrast only in case of specific clinical questions (e.g. pulmonary embolism). Chest CT report should be evaluated together with the intensive care specialist in charge -Ecocardiography: indicated in case of suspected hearth failure as a contributing factor to lung involvement/respiratory failure