Management of COVID-19 patients outside ICU: SITA and SIP guideline
Italy: An expert panel has developed evidence-based guidelines for the clinical management of adult patients with coronavirus disease 2019 (COVID-19) outside intensive care units. The guideline is published in the journal Infectious Diseases and Therapy.
The expert panel was constituted by the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP).
For developing the guideline, the panel performed ten systematic literature searches to answer ten different key questions. The retrieved evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation methodology (GRADE).
The literature searches mostly assessed the available evidence on the management of COVID-19 patients in terms of antiviral, anti-inflammatory, immunomodulatory, and continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) treatment.
Key recommendations include:
- Hospitalization should be considered in patients with at least one of the following: low oxygen saturation on room air ≤ 92% at rest or partial pressure of oxygen < 60 mmHg at arterial blood gas analysis*; respiratory rate > 30 breaths /min; new onset of dyspnea at rest or during speaking; reduction of oxygen saturation on room air below 90% during the walking test; a high value of prognostic scores; the presence of anuria, confusion, hypotension, cyanosis, and/or other medical conditions requiring hospitalization per se—best practice recommendation.
- Based on available results from RCTs, the authors do not recommend the administration of hydroxychloroquine in outpatients with COVID-19.
- The authors do not recommend the use of corticosteroids in outpatients with COVID-19, unless needed for other medical reasons.
- In the absence of proven bacterial infections, the administration of antibiotics in outpatients with COVID-19 should be considered only as empirical treatment of highly suspected bacterial co-infection or superinfections.
- At the present time, antivirals should not be administered in outpatients with COVID-19 outside RCTs.
- The use of neutralizing monoclonal antibodies may be considered in outpatients with COVID-19 with mild/moderate diseases at risk of progression and within at most 10 days after symptoms onset.
- Unless contraindicated, the authors recommend prophylactic anticoagulation in hospitalized patients with COVID-19.
- Hospitalized patients with COVID-19 who the authorsre already under chronic anticoagulant therapy for the authorsll-defined indications, unless contraindicated, should continue anticoagulant treatment.
- Therapeutic anticoagulation may be considered in patients possibly at higher risk of thrombotic events.
- Unless contraindicated, the authors recommend the use of dexamethasone at the dosage of 6 mg/day for 10 days in inpatients with COVID-19 requiring oxygen supplementation.
- Methylprednisolone at the dosage of 0.5 mg/kg twice daily for at least 5 days could be considered in inpatients with COVID-19 requiring oxygen supplementation and aged 60 years or older.
- Lopinavir/ritonavir should not be administered to hospitalized patients with COVID-19.
- Pending further results from large RCTs, administration of a 5-day course of remdesivir should be considered in hospitalized patients with COVID-19 pneumonia requiring oxygen supplementation.
- Hydroxychloroquine should not be administered to hospitalized patients with COVID-19.
- Other antiviral agents should not be administered for treating COVID-19 in hospitalized patients, unless they are administered within RCTs.
- The authors recommend against the routine use of antibiotics in hospitalized patients with COVID-19 without proven bacterial infection.
- The authors recommend collection of respiratory specimens for culture or molecular detection of respiratory pathogens, blood cultures, and urinary antigens for Streptococcus pneumoniae and Legionella spp. in hospitalized patients with COVID-19 and suspected bacterial pneumonia.
- Empirical antibiotic treatment of suspected bacterial pneumonia alongside proper diagnostic procedures, should be considered in patients with COVID-19 with evidence of consolidative radiological lesions.
- The authors recommend considering tocilizumab administration in hospitalized patients with COVID-19 not responding to steroid treatment, with oxygen saturation < 92% on room air.
- Pending further results from RCTs, currently the authors do not support the administration of convalescent plasma in hospitalized patients with COVID-19 outside RCTs.
- Unless contraindicated, non-invasive ventilatory support by means of NIV or CPAP is feasible and safe in patients with acute respiratory failure secondary to COVID-19, and should be considered for patients in whom standard oxygen supplementation is not or no longer sufficient and who do not require immediate intubation.
- CPAP delivery systems allowing for PEEP titration should be preferred, and PEEP should not exceed 10 cmH2O.
- Clinically stable patients with COVID-19 who no longer require isolation (or who can be isolated outside the hospital) should be discharged from acute care hospitals when oxygen supplementation is no longer required or with a maximum requirement of low-flow oxygen at 2 L/min through nasal cannula (with the exception of patients already under oxygen supplementation at home at baseline or patients requiring initiation of long-term oxygen therapy after discharge), in line with common practice with other types of the non-contagious lower respiratory tract infections, and provided there are no complications or other reasons that require continuation of hospitalization.
- For patients with COVID-19 still requiring isolation but who could be discharged from a clinical standpoint, isolation outside the hospital (at home, in community facilities, or in long-term facilities, according to the specific need for non-acute care of any given patient) should be supported and made feasible for as many patients as possible.
"The presence of many best practice recommendations testified to the need for further investigations by means of randomized controlled trials, whenever possible, with some possible future research directions stemming from the results of the ten systematic reviews," concluded the authors.
"Clinical Management of Adult Patients with COVID-19 Outside Intensive Care Units: Guidelines from the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP)," is published in the journal Infectious Diseases and Therapy.