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

Cases not presenting any clinical feature suggesting a complicated course of the infection. Individuals presenting COVID-19 clinical symptoms or signs. Considering the burden of clinical symptoms and the higher risk for complications, the goals of clinical management are, in addition to the ones stated for the asymptomatic patients: 1) Closer monitoring of clinical conditions and analytical data 2) Strategy aimed at accelerating viral clearance, through use of potentially efficacious experimental antiviral drugs Characteristics: -Prostration, severe asthenia, high fever (>38ËšC) and/or persistent cough, clinical or radiological signs of lung involvement -No clinical or laboratoristic parameters of clinical severity and/or respiratory impairment 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 samples 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 (> 38ËšC), perform at least 2 blood cultures, possibly before starting new antimicrobial therapies Clinical monitoring: -Periodic clinical re-evaluation (once/work shift; thrice/day) -Periodic vital signs recording (blood pressure, heart rate, respiratory rate, SpO2, GCS, body temperature) (once/work shift, thrice/day), 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 or if clinical worsening), to be evaluated together with the intensive care specialist in charge Virologic monitoring: -SARS-CoV-2 RT-PCR performed on rhinopharyngeal swab every 48-72 hours until persistently negative 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. No absolute indication at this stage of the disease, but highly valuable, together with blood gas analysis, to predict clinical worsening. Chest CT report should be evaluated together with the intensive care specialist in charge Antiviral therapy: -Lopinavir/ritonavir* 200/50 mg tablets, 2 tablets q12h, during 14 days and Hydroxychloroquine phosphate** 400 mg tablets, 1 tablet q12 as loading dose, followed by 200 mg tablets, 1 tablet q12, during 10 days, or Chloroquine phosphate** 250 mg tablets, 2 tablet q12, during 10 days * Alternatively to Lopinavir/ritonavir, Darunavir 600 mg tablets, 1 tablet q12 plus Ritonavir 100 mg tablets, 1 tablet q12, during 14 days. ** Before chloroquine and hydrossichloroquine administration, G6PD deficiency test should be performed. Supportive therapy: -Symptomatic -Oral rehydration -Consider antimicrobial therapy (broad spectrum-empiric or based on microbiological results) -Prompt availability of O 2, in case of necessity Patient affected by respiratory symptoms, clinically unstable, not in critical conditions (e.g.: MEWS clinical deterioration score 3-4) Patients presenting se