COVID-19 Case Management

Author(s): Ruot Garjiek Teny (1), Charles O. C. Langoya (2), Ader Macar Aciek (3)

1.     Department of Cardiology, The Karen Hospital, Nairobi, Kenya

2.     Department of Infectious Diseases and Medical Microbiology, Royal Infirmary of Edinburgh, UK

3.     Department of Internal Medicine, University of Juba, South Sudan 

Correspondence: Ruot Garjiek Teny [email protected]

Citation: Teny et al, COVID-19 Case Management. South Sudan Medical Journal 2020; 13(2):37-39  © 2020 The Author (s)  License: This is an open access article under CC BY-NC-ND

Submitted:  April 2020  Accepted: April 2020 Published: May 2020

Background

Coronavirus disease (COVID-19) was first reported to the World Health Organization (WHO) on 31 December 2019 from Wuhan province of China as a cluster of pneumonia cases. The WHO on 11 March 2020 declared this as a global pandemic.  COVID-19 is caused by SARS-CoV-2 virus which is a member of coronaviruses.

South Sudan has 35 confirmed cases by 30 April 2020 with the first case announced on 4 April, 2020 while the last case (of the 35) declared on 29 April 2020.

WHO case definition - suspected COVID-19 case

  • Any person with acute respiratory illness (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath),

AND

  • With no other aetiology that fully explains the clinical presentation

AND

  • A history of travel to/or residence in a country / area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset.[1] 

Clinical presentation

The majority of persons with COVID-19 exhibit no symptoms, however around 20% of patients will have fever, dry cough, fatigue, anorexia, shortness of breath, anosmia, productive cough and myalgia.[2] While gastroenterological and neurological symptoms were reported in less than 10% in certain studies.[3]

Also, it is worth mentioning that a patient might present with either a combination of the above symptoms or any single one of them.

Assessments and initial investigations in COVID-19 suspects

Clinical assessment

A COVID-19 patient should follow the same assessment as that of any respiratory case, ensuring that Personal Protective Equipment (PPE) is worn. That is to say,  the ABCDE approach is followed, addressing each abnormality as it is found.

Suspected and positive COVID-19 cases should be isolated in designated areas which must be different from those areas where non COVID-19 patients are managed. Those patients deemed to be severely ill should be managed in a high dependency or intensive care unit. If a suspected case turns out to be negative, then consider an alternative diagnosis and manage accordingly.  False negatives exist in COVID-19 cases probably due to errors of sampling when specimens are collected by nasopharyngeal swabbing. 

Haematology and biochemistry

Complete Blood Count usually shows a significantly low lymphocytes count with neutrophil to lymphocyte ratio of >1.3. This ratio is found to be useful as an independent mortality risk factor.[4] Leukocytosis and neutrophilia are predictors of superimposed bacterial infection. However, this should be correlated with clinical judgment to ensure antimicrobial stewardship is observed. 

Elevated C-reactive protein (CRP), D-dimers and normal pro-calcitonin are common features of COVID-19 though not always.[5]

Baseline Urea and Electrolytes and Liver Function Tests (LFTs). There is no known trend relating COVID-19 and abnormalities for these indices. However, it is important to know the baseline on admission. 

Microbiology

The diagnosis of COVID-19 is confirmed by isolating the SARS-CoV-2 virus from a nasopharyngeal or oropharyngeal swab by a RT-PCR. Deeper respiratory samples such as those obtained during bronchoalveolar lavage can equally be used for isolating SARS-CoV-2.

 Viral throat swab to exclude other respiratory viruses could be important once SARS-CoV-2 is ruled out. 

Check sputum for microscopy, culture and sensitivity for Acid and Alcohol Fast Bacilli (AAFB). 

Blood culture (not available in government hospitals in South Sudan at the moment) is quite important due to the fact that, COVID-19 victims may present with fever and cough but, bacterial septic patients could present in the same way. Therefore, ruling out a bacterial infection is of paramount importance. Clinical judgment becomes crucial in a setting with no blood culture facilities.

Radiology

Chest X-ray looking for bilateral lower lobes infiltrates and CT scan of the chest (if available) looking for bilateral ground glass changes. Note that no government hospital in South Sudan currently has a CT scan machine. 

Criteria for hospital admission

The main reason for admission of COVID-19 patients is respiratory compromise. Therefore, the WHO recommends the admission of the following groups of patients presenting with:

  • Shortness of breath
  • Low/reduced oxygen saturation for age and co-morbidity
  • Fever
  • Respiratory failure of any type

Medical management of a COVID-19 suspect/patient

For positive cases, determine severity and admission criteria as mentioned above. Review observations which are oxygen saturation, respiratory rate, blood pressure, pulse rate and temperature. Each abnormality identified in the observations should be addressed.

Therefore, aim for SpO2 of 90-96% for majority of patients and adjust oxygen provision accordingly. Please note that the maximum quantity of oxygen that should be delivered via nasal cannulae is 4L/minute. Anything more than this via nasal cannulae is considered aerosol generating and therefore will require different types of PPEs.

Lying in the prone position has been proven to improve oxygenation significantly and therefore should be tried on patients who can tolerate it.

Paracetamol and analgesia for fevers and myalgias

Intravenous fluid therapy should be given with caution. Over-hydration is associated with increased risk of intubation being required in COVID-19 patients. 

Consider antimicrobials for super-added community acquired pneumonia (usually a penicillin +/- macrolide) if clinically, biochemically and radiologically indicated. Use the CURB65 severity score to assess severity of illness, C=confusion, U=Blood urea nitrogen >7mmol/litre, R-respiratory rate ≥30/minute, B=systolic blood pressure <90mmHg, or diastolic blood pressure ≤60mmHg, 65=Age and above 65. Each positive   of the CURB65 scores one (1) point. The severity of the condition is assessed on the following scale: 1 is low risk, 2 is short inpatient stay or manage as an outpatient, 3 manage as an inpatient and consider intensive care Unit admission, 4 or 5 Intensive management with high probability of Intensive Care Unit treatment. 

BOX 1. CURB65 score for mortality risk assessment in hospital a

CURB65 score is calculated by giving 1 point for each of the following prognostic features:

  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)b
  • raised blood urea nitrogen (over 7 mmol/litre)
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.

Patients are stratified for risk of death as follows:

  • 0 or 1: low risk (less than 3% mortality risk)
  • 2: intermediate risk (3‑15% mortality risk)
  • 3 to 5: high risk (more than 15% mortality risk).

 Reference

a.      Lim WS, van der Eerden MM, Laing R et al. Defining community‑acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58: 377–82.

b.     For guidance on delirium, see the NICE guideline on delirium.

 

Consider enrolling patients on any COVID-19 trials whenever feasible.

Ensure that venous thromboembolism (VTE) prophylaxis is prescribed to all admitted COVID-19 patients unless contraindicated.

Observe patients with COVID-19 for signs of clinical deterioration, such as progressive respiratory failure by monitoring the respiratory rate and arterial blood gases and sepsis by measuring the lactate dehydrogenase levels (LDH > 49-90 units per litre) and respond promptly with appropriate intervention. 

Patients who failed to respond to standard oxygen therapy, should be provided with high oxygen flow and assessed for mechanical ventilator support. Their management should be escalated early to an intensive care unit (ICU). ICU management is outside the scope of this paper.

Discharge criteria

1.     Symptoms resolution

2.     Viral clearance as documented by two negative viral PCR in two nasopharangeal samples collected 24 hours apart. A repeat swab should be done at least seven days from the start of symptoms and 48 hours of being fever free (though some guidelines say fever free without the use of an antipyrexic drugs).[6] 

However, note that point 2 above might not be practical especially when capacity is limited as in South Sudan. In such a case, patients can be discharged home even with positive results when they feel well. This will require close remote follow up by telephone. These patients should be advised to self-isolate for 14 days from symptom onset. It is worth mentioning that all the preventive measures should be explained to/and maintained by both swab positive and negative individuals.

References

  1. World Health Organization. Coronavirus disease. Situation reports
  2. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. The New England Journal of Medicine 2020; 382 (18):1708-20
  3. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet, 2020; 395(10223):507-513.
  4. Yuwei Liu et al. Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19. Journal of Infection (in press)
  5. Lippi G, Plebani. Laboratory abnormalities in patients with COVID-2019 infection. Clinical Chemistry and Laboratory Medicine, Received for publication February 24, 2020
  6. European Centre for Disease Prevention and Control. Technical Report Novel coronavirus (SARS-CoV-2) Discharge criteria for confirmed COVID-19 cases
  7. NICE Pneumonia in adults