Current best evidence for clinical care (more info)
Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.
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While it is an up to date review, I'm hoping this advice won't be needed for those in high-income countries, as long as we prevent our health systems being overwhelmed.
The article compiled a summary of diagnostic and prognostic information based on current evidence. It would certainly help raise awareness amongst hospitalists and ER practitioners for initial and follow-up workup for COVID-19 patients.
The article address a topic of relevance in low and middle income countries. Therefore, availability of the article to professionals in such countries is important for benefit of patients and professional practice.
If availability and feasibility are low for chest CT, lung ultrasound is really an alternative choice. But it is an operator skill-dependent exam and it increases the exposure time of the operator. I think its benefits should be compared with the risks for the caregiver. Since a great part of confirmed COVID-19 patients do not have pneumonia, I think it should be applied only for patients having high risk factors (senility, lymphocyte depletion, netrophil/lymphocyte > 8, high LDH, CRP, d-diner, ferritin).