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MARCH 13, 2020 -- Clinicians are working out how to manage patients with or suspected of having COVID-19. Here's what several physicians have told Medscape Medical News about how they're treating COVID-19 cases now.
"Over the past couple of weeks, we've been preparing for the oncoming onslaught of patients," said Lillian Wu, MD, of the HealthPoint network in the Seattle area of greater King County and president elect of the Washington Academy of Family Physicians.
Step One: Triage
The first step, Wu says, is careful triage.
When patients call one of the 17 clinics in the HealthPoint system, nurses gauge how sick they are. High fever? Shortness of breath? Do they have a chronic illness, such as diabetes, cardiovascular disease, or a lung condition, that increases risk for infection and complications?
"If a patient has mild symptoms, we ask them to stay home or to check back in 24 hours, or we'll reach out to them. For moderate symptoms, we ask them to come in, and [we] clearly mark on the schedule that it is a respiratory patient, who will be sent to a separate area. If the patient is severe, we don't even see them and send them directly to the hospital to the ER," Wu told Medscape Medical News.
These categories parallel the World Health Organization's designations of uncomplicated illness, mild pneumonia, severe pneumonia, acute respiratory distress syndrome, sepsis, and septic shock. The Centers for Disease Control and Prevention (CDC) advises case by case regarding decisions as to outpatient or inpatient assignment.
"Patients who pass the initial phone triage are given masks, separated, and sent to different parts of the clinic or are required to wait in their cars until it's time to be seen," Wu said.
Step 2: Hospital Arrival
Once at the hospital, the CDC's interim guidance kicks in.
"Any patient with fever, cough, and shortness of breath presenting with a history of travel to countries with high ongoing transmission or a credible history of exposure should be promptly evaluated for COVID-19," said Raghavendra Tirupathi, MD, medical director, Keystone Infectious Diseases/HIV; chair in infection prevention, Summit Health; and clinical assistant professor of medicine, Penn State School of Medicine, Hershey, Pennsylvania.
"We recommend obtaining baseline CBC with differential, basic metabolic panel, liver function tests, and procalcitonin. Clues for COVID-19 include leukopenia, seen in 30% to 45% of patients, and lymphocytopenia, seen in 85% of the patients in the case series from China," Tirupathi said. He uses a respiratory virus polymerase chain reaction panel to rule out other pathogens.
Wu concurs. "This is the one time we are grateful when someone tests positive for the flu! If flu is negative and other common respiratory infections are negative, then we do a COVID-19 test," she said.
But test results may be delayed. "At the University of Washington, it takes 8 hours, but commercial labs take up to 4 days," Wu said. All patients with respiratory symptoms are treated as persons under investigation, for whom isolation precautions are required. In addition, for these patients, use of personal protective equipment by caregivers is required.
For suspected pneumonia, the American College of Radiography recommends chest CT to identify peripheral basal ground-glass opacities characteristic of COVID-19.
However, diagnosis should be based on detection of SARS-CoV-2, because chest images for COVID-19 are nonspecific ― associated signs can also be seen in H1N1 influenza, SARS, and MERS.
Step 3: Supportive Care
Once a patient is admitted, supportive care entails "maintaining fluid status and nutrition and supporting physiological functions until we heal. It's treating complications and organ support, whether that means providing supplementary oxygen all the way to ventilator support, and just waiting it out. If a patient progresses to acute respiratory distress syndrome, it becomes tougher," said David Liebers, MD, chief medical officer and an infectious disease specialist at Ellis Medicine in Schenectady, New York.
Efforts are ramping up to develop therapeutics. Remdesivir, an investigational antiviral drug developed to treat Ebola and Marburg hemorrhagic fevers, shows activity against SARS-CoV-2 in vitro.
Remdesivir has been used in a few patients on a compassionate-use basis outside of a clinical trial setting. "It's a nucleotide analogue, and like other drugs of that class, it disrupts nucleic acid production. Some data suggest that it might have some efficacy," Liebers said.
Antibiotics are reserved for patients suspected of having concomitant bacterial or fungal infections. Liebers said clinicians should be alerted to "the big three" signs of secondary infection ― fever, elevated white blood cell count, and lactic acidosis. Immunosuppressed patients are at elevated risk for secondary infection.
Step 4: Managing Complications
Patients do die of COVID-19, mostly through an inability to ventilate, even when supported with oxygen, Liebers told Medscape Medical News. (According to Tirupathi, "The studies from China indicate that from 6% to 10% of patients needed ventilators.")
Liebers continued, "Others may develop sepsis or a syndrome of multisystem organ failure with renal and endothelial collapse, making it difficult to maintain blood pressure. Like with so many pathologies, it is a vicious circle in which everything gets overworked. Off-and-on treatments can sometimes break the cycle: supplementary oxygen, giving red blood cells, dialysis. We support those functions while waiting for healing to occur."
A facility's airborne-infection isolation rooms may become filled to capacity, but that isn't critical, Liebers said. "Airborne precautions are standard to contain measles, tuberculosis, chickenpox, and herpes zoster, in which very small particles spread in the air," he said.
Consensus is growing that SARS-CoV-2 spreads in large droplets, he added. Private rooms and closed doors may suffice.
Step 5: Discharge
Liebers said that as of now, the million-dollar question regards criteria for discharge.
Patients who clinically improve are sent home with instructions to remain in isolation. They may be tested again for virus before or after discharge.
Liebers and Wu pointed to the experience at EvergreenHealth Medical Center, in Kirkland, Washington, as guidance from the trenches. "They're the ones who are learning firsthand and passing the experience along to everyone else," Wu said.
"The situation is unprecedented," said Liebers, who, like many others, has barely slept these past weeks. "We're swimming in murky water right now."
The epidemic in the United States is still months from peaking, Wu emphasized. "There is no vaccine, and many cases are subclinical. COVID-19 has to spread through the country before it infects a critical mass of people who will develop immunity. It's too late to contain."
Added Liebers, "It's a constantly changing situation, and we are still being surprised ― not that this wasn't predicted."