the lebanese society of infectious diseases and clinical ......microbiology (lsidcm) guidelines for...

TheLebaneseSocietyofInfectiousDiseasesandClinicalMicrobiology(LSIDCM)GuidelinesfortheManagement

ofCOVID19

TheseinvestigationandmanagementpathwaysandalgorithmswerepreparedbytheCOVID-19TaskForceof

LSIDCM:

RimaMoghnieh,MD,FRCP;JacquesMokhbat,MD,ABIM(ID),FACP,FIDSA;AbdulRahmanBizri,MD,MSc;MadonnaMatar,MD,MPH;

NadineYared,MD,MPH;MonaJradeh,MD;PierreAbiHanna,MD,MPH;ZahiHelou,MD,

GhenwaDakdouki,MD

• Theserecommendationsarereleasedon23/03/2020andarebasedontheavailableliteratureuntil23/03/2020.

• Theserecommendationsaresubjecttochangeandamendmentsaccordingtoemergingscientificdataandaccordingtotheepidemiologicsituationinthecountry.

• Theyincludepathwaysandalgorithmsforthefollowing:1. ApproachtoinvestigatingCOVID-19inpatientspresentingtoEmergencyRoomDepartment

2. ApproachtoPlacementandSiteofCareofCaseswithPositiveCoVPCRTesting

3. ApproachtoManagingCloseContactsofCOVID-19ConfirmedCases

4. ApproachtoManagingHealthcareWorkerExposuretoCOVID-19

5. PharmacotherapyofConfirmedCOVID-19

Algorithms for COVID-19 investigation in patients presenting

to ER Department

• ThesealgorithmsarerelatedtoCOVID-19investigationinpatientspresentingtoERdepartments.

• Theymostlydealwithhospitaladmission,self-isolationandtestingofsuspectcaseswithCOVID-19.

• Theywereputinviewoftheglobalshortageofdiagnostictechniquesandthelocalshortageofhospitalbeds.

AlgorithmsforpatientscomingtoERforCOVID-19investigationDefinitions

1. SuspectCase:a. Apatientwhosatisfiesepidemiologicalandclinicalcriterialisted

below:i. Epidemiologicalcriteria

1. Internationaltravelinthe14daysbeforetheonsetofillness.or

2. Closecontactinthe14daysbeforeillnessonsetwithaconfirmedcaseofCOVID-19.

ii. Clinicalcriteria1. Fever

or2. Acuterespiratoryinfection(e.g.shortnessofbreath,

coughorsorethroat)withorwithoutfever.or

3. Acuteunexplainedchangeingeneralconditionofelderlypatients≥75yearsofage.

ORb. Apatientwhohasbilateralseverecommunity-acquired

pneumonia(criticallyill)andnoothercauseisidentified,withorwithoutrecentinternationaltravel,requiringcareinICU,withrespiratoryormulti-organfailure.ClinicaljudgmentshouldbeexercisedconsideringthelikelihoodofCOVID-19.OR

c. Anyhealthcareworkerwithdirectpatientcontacthasafever(≥37.5degreesCelsius)ANDanacuterespiratoryinfection(e.g.shortnessofbreath,cough,sorethroat).

Release Date: 23/03/2020

Definitions(continued)

1. Clinicallystablepatient:AnypatientwithnocomorbiditiesAND,a. Age<50yearsAND,b. Clinicallyappearingwell,c. Withfever,mildcough,nodyspnea(oxygensaturation>94%on

roomair),d. Normalchestexaminationand/ornormalchestradiography

2. Mildtomoderatelyillpatient:a. PatientwithmildsymptomslikeaboveANDcomorbidities

i. Symptoms:Fever,mildcough,nodyspnea,oxygensaturation>94%onroomair,clinicallyappearingwell,

ii. Normalchestexaminationand/ornormalchestradiography

iii. Comorbidities:cardiovascular,pulmonary,diabetes,renalinsufficiency,malignancywithimmunosuppressivemedication,HCTS/Ptransplant,rheumaticdiseasewithimmunosuppressivemedication.

b. NocomorbiditiesWITHi. Moderatetoseverecough,ii. Fever,iii. ORCURB>2iv. ANDNormalchestexaminationand/ornormalchest

radiography3. Moderatetoseverelyillpatient

a. Chestexaminationorchestradiographysuggestiveofpneumonia,b. Oxygensaturation>94%onroomair,c. Norespiratorydistressorhypotension.

4. ClinicallyUnstablepatient:Anypatientwithoxygensaturation<94%onroomairORwithevidenceofseverepneumoniaORwithANYofthebelow:

a. Confusion,b. Lowbloodpressure,c. Decreasedurineoutput,d. Anyevidenceofend-organdamage,e. Severedyspneawithrespiratorydistress.


1

AlgorithmA Pt.comingtotheER

Pt.givenamaskanddirectedtoTriageroom

InTriage,vitalsignstakenbynursewithfullPPE,ERphysicianwithfullPPEinterviewsthePt.andfollows

theCOVID-19checklist*

Pt.issuspecttohaveCOVID-19 Pt.isNOTsuspecttohaveCOVID-19

ManagementasaregularERPt.Mild Severe

AlgorithmB

Moderatetosevere

Mildtomoderate

AlgorithmC

*Checklistisbasedonthedefinitionofsuspectcase


AlgorithmB

Mild/MildtoModerateSymptoms

Self-isolation/BrochureMonitorsymptomprogressionDailytelecommunication

OnDay7

Asymptomatic

DiscontinueIsolationafter14days

Symptomatic

Mild

Keepisolatedtillday14

Fromday14andthereafter,releasefrom

isolationonlyifasymptomaticfor>72h

Severe

FollowalgorithmC

Pt.withconfirmedsymptomsasevaluatedbyERphysicianinTriageroom


AlgorithmC

Pt.withconfirmedsymptomsasevaluatedbyERphysicianinTriageroom

AdmitPt.totheHospital

Moderatetosevere/Severesymptoms

CoVtest–ve

DoCoVtest;preferablydoLRTsamplingifpt.hasrespiratorysymptoms

CoVtest+ve

ConsiderotheretiologiesRepeatCoVtesting

ConsiderLRTsampletesting

-Manage-Pt.canbedischargedtoself-isolationtocomplete

14daysif>72hcompletelyasymptomatic

CoVPCRonday14

CoVtest+ve CoVtest–ve

Repeatafter24hManageasasymptomatic+vePCRcase

If+ve,keepPt.isolated

CoVtest–ve,preferablydoLRTsampletesting

CoVtest+ve

ManageassevereConsiderotheretiologies&Manageasseverecase

If–ve,releasefromisolation

Fordischargefromisolation:after14days,2–vePCRand

>72hbeingasymptomatic

Fordischargefromisolation:after14

daysand>72hbeingasymptomaticRelease Date:

23/03/2020

Algorithms for patients with nCoV-19 positive PCR site of care

and further follow-up• Thesealgorithmsarerelatedtositeofcareandfollow-uponpatientswithpositivenCoV-19PCR.

• Theymostlydealwithhospitaladmission,outpatientself-isolationandtesting.


Patients with positive PCR Placement and Testing

• SOME of the patients with positive PCR can be sent to “Outpatient Isolation”, which is defined as isolating the patient in his own home or in a non-acute care facility like a designated hotel or an officially-assigned facility for non-acute care.

• Below are the suggested conditions where patients with positive PCR can be referred to Outpatient Isolation, in order to spare the hospital beds to those who are in need.

• In order to be able to realize this plan, a telecommunication/help center should be installed with physicians providing advice and daily checks when needed by telecommunication.

Release Date:

23/03/2020

Patientswith+vePCR

Age<60yearsANDwithoutcomorbiditiesAge≥60yearsORwithcomorbidities

Asymptomatic MILDsymptomsandNOsuspicionofpneumoniaonCXRorPE

Pt.looksillorhasasuspectedpneumonia

onCXRorPE

OutpatientIsolation

Ifsymptomsstart,callhotline.

Manageaccordingtosymptom

severity(MildorSevere)

OutpatientIsolationDailytelecommunicationforahealthcheckbyachecklistAccesstoahotlineforanyemergingsymptoms

HospitaladmissionWhencompletely

asymptomaticfor72h,Pt.dischargedto

outpatientisolationtocomplete14days

Dailytelecommunicationfora

healthcheckbyachecklist

AccesstoahotlineforanyremergingsymptomPt.advisedtogotohospitalifsymptoms

recur.

Releasefromisolation:Pt.remains

asymptomaticafter14dayswith-vePCRon2occasions24h

apart.

Releasefromisolation:Pt.completely

asymptomaticfor>72hafter14dayswith-vePCRon2

occasions24hapart.Releasefromisolation:

Pt.completelyasymptomaticfor>72hafter14dayswith-vePCRon2occasions24hapart.

OutpatientIsolationPt.remainsasymptomatic

Ifsymptomsdisappear

-Pt.advisedtogotohospitalifsymptomsaggravate

-Manageasapatientwith

severesymptoms

Seepage3


Patientswith+vePCR

Age<60yearsANDwithoutcomorbidities Age≥60yearsORwithcomorbidities

Asymptomatic ANYsymptoms

OutpatientIsolationDailytelecommunicationforahealthcheckbya

checklistAccesstoahotlineforanyemergingsymptoms

Pt.counselingaboutthesymptoms

HospitaladmissionWhencompletely

asymptomaticfor72h,Pt.dischargedto

outpatientisolationtocomplete14days

Dailytelecommunicationfora

healthcheckbyachecklist

AccesstoahotlineforanyremergingsymptomPt.advisedtogotohospitalifsymptoms

recur.Releasefromisolation:Pt.remains

asymptomaticfor>72hafter14dayswith-vePCRon2occasions24h

apart. Releasefromisolation:Pt.completelyasymptomaticfor>72hafter14dayswith-vePCRon2occasions24h

apart.

Seepage2

Pt.shouldbeadmittedif

symptomsstartandmanageaccordingly

Ifpt.remainsasymptomatic


Algorithms for COVID-19 investigation in close contacts of an

already confirmed case

• ThesealgorithmsarerelatedtoCOVID-19investigationinclosecontactsofanalreadyconfirmedcase.

• Theymostlydealwithhospitaladmission,self-isolationandtesting.


Closecontactofaconfirmedcasealgorithm(page1/2)

Closecontactofaconfirmedcase

Asymptomatic/MildSymptoms

MildtoModerate/ModeratetoSevere/SevereSymptoms

-Self-isolationfor14days-Self-isolationbrochure

-Counselingaboutseverityofsymptoms

-Dailyfollow-upandtelecommunicationwithhotline

Becomessymptomaticor

symptomsaggravate

Remainsasymptomatic

-Discontinueisolationonday14OR

-DoCoVPCRonday7andifnegative,discontinue

isolation

Followalgorithmonpage2

Seepage2


Closecontactofaconfirmedcasealgorithm(page2/2)

Closecontactofaconfirmedcase

Asymptomatic/MildSymptoms MildtoModerate/ModeratetoSevere/SevereSymptoms

Seepage1 MildtoModerateSymptoms ModeratetoSevere/SevereSymptoms

Self-isolationorAdmitandDoCoVPCRat36hafteronsetofsymptoms/Manageaccordingtoseverityofsymptoms

AdmitandDoCoVPCRuponpresentation

+vePCR -vePCR

Dischargeafter14daysofself-isolation,being>72h

asymptomatic,with2-vePCRtests

Managebasedontheseverityofsymptoms RepeatPCR,withLRTsamplingandconsiderotheretiologies

+vePCR-vePCR

Managebasedonsymptomseverity&considerotheretiologies Manageasseverecase

Dischargeafter14daysofself-isolation,being>72hasymptomatic,with2-vePCRtestsRelease Date: 23/03/2020

Algorithms for investigation and management of Healthcare

Workers exposed to COVID-19 confirmed cases• ThesealgorithmsarerelatedtoCOVID-19investigationandmanagementofhealthcareworkerswhowereexposedtoaconfirmedcase.

• Theymostlydealwithhospitaladmission,self-isolationandtesting.


ManagementofHCWwhowereexposedtopatientwithconfirmedCOVID-19(Page1/3)DefinitionofRiskyExposure:

• HCWwhoperformedorwerepresentintheroomforproceduresthatgenerateaerosolsorduringwhichrespiratorysecretionsarelikelytobepoorlycontrolled(e.g.,cardiopulmonaryresuscitation,intubation,NIV,extubation,bronchoscopy,nebulizertherapy,sputuminduction)onpatientswithCOVID-19

• Whenthehealthcareproviders’eyes,nose,ormouthwerenotprotected.• HCWwhohadprolongedclosecontactwithpatientswithCOVID-19• WhereHCWmucousmembranesorhandswereexposedtopotentially

infectiousmaterialsforCOVID-19


Management of HCW Exposed To Covid-19 Confirmed Case: Risky Exposure (Page 2/3)

Remains asymptomatic Develops symptoms

-Off work -Consider other etiologies

-Manage based on the severity of symptoms *If mild/moderate to moderate, then self-isolate + management

*If moderate to severe/severe, admit to the hospital + management

Exposed HCW on Day 1

Full PPE Breach in PPE/No PPE

Allow to work and counseling about symptoms

-ve PCR +ve PCR

Repeat after 24 h If this 2nd PCR is –ve and HCW

is asymptomatic > 72 h, then allow to work

Managed to come back to work after 14 days of self-isolation,

being > 72 h asymptomatic, with 2 -ve PCR tests.

Do CoV PCR 36-48 h after symptom resolution

Check page 3

Continue to work as usual


Management of HCW Exposed To Covid-19 Confirmed Case: Risky Exposure (Page 3/3)

Remains asymptomatic Develops symptoms

Continue isolation Do CoV PCR on day 14 if still asymptomatic

Exposed HCW on Day 1

Full PPE Breach in PPE/No PPE

-ve PCR +ve PCR

Self-isolation at home Check page 2

-Manage as a +ve PCR case based on the severity of

symptoms -Return to work after 14 days of self-isolation, being > 72 h still asymptomatic, with 2 -ve

PCR tests

Release from isolation after 2 -ve PCR tests, go back to

work

Moderate to Severe/Severe

CoV PCR immediately

Mild/ Mild to Moderate

CoV PCR 36-48 h after onset of symptoms

Manage

+ve PCR -ve PCR

Manage as moderate contact

-ve PCR +ve PCR

Repeat PCR in 24 h

Return to work after 14 days of self-isolation, being > 72 h asymptomatic, with 2 -ve

PCR tests

Manage clinically

Repeat PCR Do preferably LRT sampling

Return to work after 14 days of self-isolation,

being > 72 h asymptomatic, with 2 -ve

PCR tests

Manage as severe contact


TreatmentofCOVID-19patientsconfirmedbyPCRtesting

Scope:

• ThisprotocolisusedtoguidethepharmacotherapyforCOVID-19infectedsymptomaticpatients.• Theserecommendationsarebasedontheavailableliteratureuntil23/03/2020.• Allprotocolsincludingantiviralsandothersareexperimentalandareunderinvestigation.• SomeantiviralsarenotavailableinLebanonatthemoment.

Clinicalstagingofpresentingillness:

1. MildDisease:a. Mildupperrespiratorysymptomsb. Age<70yearsc. NOcomorbiditiessuchas:lungdisease,cardiovasculardisease,DM,CKD,cancer,

immunosuppression,hematologicdisease,etc.2. Mildtomoderatedisease:

a. Mildupperrespiratorytractsymptomswithi. Age>70yearsOR

ii. Anycomorbidity3. ModeratetoSevereinfection:

a. Evidenceforpneumoniawithi. RR<24/minii. ANDoxygensaturation>93%onroomair.

4. SeverepneumoniarequiringICUadmissionasper:FeverORSARIwithatleastonefrombelow:a. RR≥30/minb. PaO2/FiO2≤250mmHgc. Rapidprogressionofdiseaseonchestradiographyd. Leukopeniae. Hypothermiaf. Platelet<100000g. Hypotensionrequiringfluidresuscitationh. Non-invasivepositivepressureventilation

5. ARDS/CytokineReleaseSyndrome:PatientwithrapidlyprogressingpneumonialeadingtoARDSGeneralSupportiveTreatment:

• Acetaminophen(paracetamol)1gIVevery6-8hoursforpain/fever(Maxdoseof4g/day)• AvoidNSAIDs• Avoidsystemiccorticosteroidunlessnewstudiesrecommendtheiruse.• Bronchospasm:Avoidnebulizertherapy-usemetereddoseinhalerbronchodilators• Putintubatedpatientsinpronepositionwheneverpossible.• Chloroquine/Hydroxychloroquine+Azithromycinneedsclosecardiacmonitoringfor

arrhythmiasofQTprolongation,andwhentheriskofcardiaccomplicationsisverylow.

• Antibiotictherapyandotherantiviraltherapy(i.eoseltamivir)forpneumonialeftatthediscretionoftheinfectiousdiseasesphysician.

Release Date:23/03/2020

1

PharmacotherapyforCOVID-19Infection

1closefollow-upofcardiacsideeffectswithmonitoringforarrhythmiasofQTprolongationisrecommended.2Ifhydroxychloroquineisnotavailableusechloroquine.3G6PDscreeningisrecommendedbutthedrugcanbeadministeredbeforetheresultsareback.4Lopinavir/Ritonavirhastobestartedearlyinthecourseofthedisease.Monitorbloodglucose(especiallyindiabeticpatients)andelectrolyteswhileonLopinavir/Ritonavir5NotavailableinLebanonatthemoment.6Tocilizumabisnotforpatientswithactivepulmonarytuberculosisandwithdefinitebacterialorfungalinfections.

Mild MildtoModerate ModeratetoSevere SeverepneumoniarequiringICU

ARDS/cytokinereleasesyndrome

Supportivecare+/-Acetaminophen

(Hydroxychloroquine+/-Azithromycin)1,2,3**)

Treatmentaspertheclinicalstagingofillness

(Hydroxychloroquine+Azithromycin)1,2,3

ORHydroxychloroquine+(Lopinavir/Ritonavir)4

-(Hydroxychloroquine+Azithromycin)1,2,3

OR-Compassionateuse

ofRemdesivir5

OR-Favipiravir5

Tocilizumab6+availablelistedantivirals(exceptLopinavir/Ritonavir)


2

**Inmildtomoderatecases,thecombinationistobeusedonlyifcardiacmonitoringispossibleandwhentheriskofcardiaccomplicationsislow.Dosingconsiderations:

1. Azithromycin:500mgPOx1onday1then250mgPOdailyfor4days2. Chloroquine:100mg5tablets(500mg)POwithmeals/PNGBIDfor10days3. Favipiravir:1.6gPOBIDonday1then0.6gBIDondays2to54. Hydroxychloroquine:Loadingdose400mgPOBIDonday1,then200mg1tabletPOwithmeals/PNGTIDfor10days5. Lopinavir-Ritonavir:400mg/100mgPOBID(durationbasedonclinicalresponse)6. Remdesivir:200mgIVthen100mgIVdailyfor5-10days7. Tocilizumab:Initialdose8mg/kgMax800mg/dose.Seetablebelowfordosing.Oneextraadministrationatthesamedosecan

begivenafter12hoursifneededDilutedoseto100mLNSandinfuseover1hour

Weight 8mg/kgdoserange SuggestedDose Vialsizeandnumber

40-43kg 320-344mg 320mg 4x80mgvials44-54kg 352-432mg 400mg 1x400mgvial55-62kg 440-496mg 480mg 1x400mgvialand1x80mgvial63-75kg 504-600mg 560mg 1x400mgvialand2x80mgvial76-87kg 608-696mg 640mg 1x400mgvialand3x80mgvial88-92kg 704-736mg 720mg 1x400mgvialand4x80mgvial93-100kg 744-800mg 800mg 2x400mgvial


3

References:- CaoB,WangY,WenD,LiuW,WangJ,FanG,RuanL,SongB,CaiY,WeiM,LiX.Atrialoflopinavir–ritonavirinadultshospitalized

withsevereCovid-19.NewEnglandJournalofMedicine.2020Mar18.- GaoJ,TianZ,YangX.Breakthrough:ChloroquinephosphatehasshownapparentefficacyintreatmentofCOVID-19associated

pneumoniainclinicalstudies.Biosciencetrends.2020.- Gautretetal.(2020)HydroxychloroquineandazithromycinasatreatmentofCOVID-19:resultsofanopen-labelnon-randomized

clinicaltrial.InternationalJournalofAntimicrobialAgents–InPress17March2020.- InformationforCliniciansonTherapeuticOptionsforCOVID-19Patients.http://www.cdc.gov/coronavirus/2019-

ncov/hcp/therapeutic-options.html.Accessed22March2020.- MassachusettsGeneralHospitalCOVID-19TreatmentGuidance.Version1.03/17/20204:00PM- NIHclinicaltrialofremdesivirtotreatCOVID-19begins.NationalInstitutesofHealth,February2020.- Wang,M.,Cao,R.,Zhang,L.etal.Remdesivirandchloroquineeffectivelyinhibittherecentlyemergednovelcoronavirus(2019-

covid-19)invitro.CellRes30,269–271(2020).https://doi.org/10.1038/s41422-020-0282-0- WorldHealthOrganization.ClinicalManagementofSevereAcuteRespiratoryInfectionwhenNovelCoronavirus(2019-covid-19)

InfectionisSuspected.Interimguidance.13March2020.- XuX,HanM.,LiT.,andcolleagues.EffectiveTreatmentofSevereCOVID-19PatientswithTocilizumab.


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