Key clinical pearls in the medical management of hospitalized patients with coronavirus (Covid-19) infection

First, a shout-out to dedicated healthcare workers everywhere who have selflessly given of themselves to care for the sick during this pandemic. Thank you! Together, I know we will get through it!

Although our understanding of Covid-19 infection is far from complete, in the spirit of clarity and brevity of my posts on Pearls4Peers, here are some key points I have gleaned from review of existing literature and the CDC that may be useful as we care for our hospitalized patients with suspected or confirmed Covid-19 infection.

  • Isolation precautions.1 Per CDC, follow a combination of airborne (particularly when aerosol generating procedures is anticipated, including nebulizer treatment) and contact precaution protocols. Routinely use masks or respirators, such as N-95s (subject to local availability and policy) and eye protection. Don gowns (subject to local availability and policy) and gloves and adhere to strict hand hygiene practices.

 

  • Diagnostic tests1-9
    • Laboratory tests. Routine admission labs include CBC, electrolytes, coagulation panels and liver and renal tests. Other frequently reported labs include LDH, C-reactive protein (CRP) and procalcitonin. Testing for high sensitivity troponin I has also been performed in some patients, presumably due to concern over ischemic cardiac injury or myocarditis.2 Check other labs as clinically indicated.
    • Chest radiograph/CT chest. One or both have been obtained in virtually all reported cases with CT having higher sensitivity for detection of lung abnormalities.
    • EKG. Frequency of checking EKGs not reported in many published reports thought 1 study reported “acute cardiac injury” in some patients, based in part on EKG findings.4 Suspect we will be checking EKGs in many patients, particularly those who are older or are at risk of heart disease.
    • Point-of-care ultrasound (POCUS). This relatively new technology appears promising in Covid-19 infections, including in rapid assessment of the severity of pneumonia or ARDS at presentation and tracking the evolution of the disease. 9 Don’t forget to disinfect the probe between uses!

 

  • Treatment 1-8
    • Specific therapies are not currently available for treatment of Covid-19 infections, but studies are underway.
    • Supportive care includes IV fluids, 02 supplementation and nutrition, as needed. Plenty of emotional support for patients and their families will likely be needed during these times.
    • Antibiotics have been used in the majority of reported cases, either on admission or during hospitalization when superimposed bacterial pneumonia or sepsis could not be excluded.
      • Prescribe antibiotics against common community-acquired pneumonia (CAP) pathogens, including those associated with post-viral/influenza pneumonia such as Streptococcus pneumoniae (eg, ceftriaxone), and Staphylococcus aureus (eg, vancomycin or linezolid if MRSA is suspected) when concurrent CAP is suspected.
      • Prescribe antibiotics against common hospital-acquired pneumonia (HAP) (eg, vancomycin plus cefepime) when HAP is suspected.
    • Corticosteroids should be avoided because of the potential for prolonging viral replication, unless indicated for other reasons such as COPD exacerbation or septic shock. 1
    • Monitor for deterioration in clinical status even when your hospitalized patient has relatively minor symptoms. This is because progression to lower respiratory tract disease due to Covid-19 often develops during the 2nd week of illness (average 9 days).
    • ICU transfer may be necessary in up to 30% of hospitalized patients due to complications such as ARDS, secondary infections, and multi-organ failure.

 

Again, thank you for caring for the sick and be safe! Feel free to leave comments or questions.

 

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References

  1. CDC. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
  2. Ruan Q, Yang K, Wang W, Jiang L, et al. Clinical predictors of mortality due to COVID-19 based on analysis of data of 150 patients with Wuhan, China. Intensive Care Med 2020. https://link.springer.com/article/10.1007/s00134-020-05991-x
  3. Holshue ML, BeBohlt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36. https://www.nejm.org/doi/full/10.1056/NEJMoa2001191
  4. Huang C, Wang Y, Li Xingwang, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30183-5.pdf
  5. Young BE, Ong SWX, Kalimuddin S, et al. Epideomiologic features and clinical course of patients infected with SARS-CoV-2 Singapore. JAMA, March 3, 2020. Doi.10.1001/jama.2020.3204 https://www.ncbi.nlm.nih.gov/pubmed/32125362
  6. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical chacteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-13. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext
  7. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl Med 2020, Feb 28, 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032
  8. Zhang J, Zhou L, Yang Y, et al. Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics. Lancet 2020;8: e11-e12. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30071-0/fulltext 9.
  9. Peng QY, Wang XT, Zhang LN, et al. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med 2020. https://doi.org/10.1007/s00134-020-05996-
Key clinical pearls in the medical management of hospitalized patients with coronavirus (Covid-19) infection

Is there any evidence that routinely wearing gowns and gloves upon entry into the rooms of patients on contact precautions for MRSA or VRE really works?

Although routine gowning and gloving in the care of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE)—also known as contact precautions (CP)— is considered a standard of care (1), the evidence supporting its effectiveness in preventing endemic hospital-associated multidrug-resistant organism (MDROs) infections is not robust and is often conflicting. In fact, this practice is increasingly being questioned (including by some hospital epidemiologists) as means of preventing endemic transmission of MDROs in hospitals (1-7).

Critics often point out that studies supporting the use of CP in MDROs are observational, involving only outbreak situations where they were instituted as part of a bundled approach (eg, improved hand hygiene), making it difficult to determine its relative contribution to infection prevention (2,6).

In fact, recent cluster-randomized trials have largely failed to demonstrate clear benefit of CP over usual care for the prevention of acquiring MRSA or VRE in hospitalized patients (2,4). Furthermore, a meta-analysis of studies in which CP were eliminated failed to find an increase in the subsequent rates of transmission of MRSA, VRE, or other MDROs (2,7).

Based on these and other studies, some have suggested that in the presence of other infection prevention measures (eg, hand hygiene monitoring), CP be implemented only in select circumstances such as open or draining wounds, severe diarrhea or outbreak situations (3).

 

The United States Centers for Disease Control and Prevention (CDC), along with the Infectious Diseases Society of America (IDSA) and the Society of Healthcare Epidemiologists of America (SHEA), however, continue to recommend implementation of CP in the care of patients with MDROs.  

 

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References
1. Maragakis LL, Jernigan JA. Things we do for good reasons: contact precautions for multidrug-resistant organisms, including MRSA and VRE. J Hosp Med 2019;14:194-6. https://www.ncbi.nlm.nih.gov/pubmed/30811332
2. Young K, Doernberg SB, Snedcor RF, et al. Things we do for no reason:contact precautions for MRSA and VRE. J Hosp Med 2019;14:178-80. https://www.ncbi.nlm.nih.gov/pubmed/30811326
3. Bearman G, Abbas S, Masroor N, et al. Impact of discontinuing contact precautions for methicillin-resistant Staphylococcus aureus and vancomyin-resistant Enerococcus: an interrupted time series analysis. Infect Control Hosp Epidemiol 2018;39: 676-82. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/impact-of-discontinuing-contact-precautions-for-methicillinresistant-staphylococcus-aureus-and-vancomycinresistant-enterococcus-an-interrupted-time-series-analysis/869CD5E44B339770AC771BC06049B98F
4. Harris AD, Pineles L, Belton B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU. A randomized trial. JAMA 2013;310:1571-80. https://www.ncbi.nlm.nih.gov/pubmed/24097234
5. Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol 2015;36:1163-72. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/reconsidering-contact-precautions-for-endemic-methicillinresistant-staphylococcus-aureus-and-vancomycinresistant-enterococcus/CCB41BF48CEC2185CC4D69AF3730584C
6. Morgan DJ, Wenzel RP, Bearman G. Contact precautions for endemic MRSA and VRE. Time to retire legal mandates. JAMA 2017;318:329-30. https://jamanetwork.com/journals/jama/article-abstract/2635333
7. Marra AR, Edmond MB, Schweizer ML, et al. Discontinuing contact precautions for multidrug-resistant organisms: a systematic literature review and meta-analysis. Am J Infect Control 208;46:333-340. https://www.ncbi.nlm.nih.gov/pubmed/29031432

Is there any evidence that routinely wearing gowns and gloves upon entry into the rooms of patients on contact precautions for MRSA or VRE really works?