Chemoprophylaxis, diagnosis, treatments, and discharge management of COVID-19: An evidence-based clinical practice guideline (updated version)

Abstract

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, coronavirus disease 2019 (COVID-19), affecting more than seventeen million people around the world. Diagnosis and treatment guidelines for clinicians caring for patients are needed. In the early stage, we have issued "A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)"; now there are many direct evidences emerged and may change some of previous recommendations and it is ripe for develop an evidence-based guideline. We formed a working group of clinical experts and methodologists. The steering group members proposed 29 questions that are relevant to the management of COVID-19 covering the following areas: chemoprophylaxis, diagnosis, treatments, and discharge management. We searched the literature for direct evidence on the management of COVID-19, and assessed its certainty generated recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Recommendations were either strong or weak, or in the form of ungraded consensus-based statement. Finally, we issued 34 statements. Among them, 6 were strong recommendations for, 14 were weak recommendations for, 3 were weak recommendations against and 11 were ungraded consensus-based statement. They covered topics of chemoprophylaxis (including agents and Traditional Chinese Medicine (TCM) agents), diagnosis (including clinical manifestations, reverse transcription-polymerase chain reaction (RT-PCR), respiratory tract specimens, IgM and IgG antibody tests, chest computed tomography, chest x-ray, and CT features of asymptomatic infections), treatments (including lopinavir-ritonavir, umifenovir, favipiravir, interferon, remdesivir, combination of antiviral drugs, hydroxychloroquine/chloroquine, interleukin-6 inhibitors, interleukin-1 inhibitors, glucocorticoid, qingfei paidu decoction, lianhua qingwen granules/capsules, convalescent plasma, lung transplantation, invasive or noninvasive ventilation, and extracorporeal membrane oxygenation (ECMO)), and discharge management (including discharge criteria and management plan in patients whose RT-PCR retesting shows SARS-CoV-2 positive after discharge). We also created two figures of these recommendations for the implementation purpose. We hope these recommendations can help support healthcare workers caring for COVID-19 patients.

Keywords: COVID-19; Chemoprophylaxis; Diagnosis; Discharge management; Recommendation; SARS-CoV-2; Traditional Chinese medicine; guideline; Treatment.

Fig. 1

Chest CT of mild patient. A 27-year-old male patient was positive for SARS-CoV-2 after contact with COVID-19 and occasionally had a dry cough. A few old fibroses was seen in the middle lobe of the right lung, and there were no obvious changes in CT images on admission (a) and discharge (b). R: right

Fig. 2

Chest CT of moderate patient. A 48-year-old male patient coughed for 1 week. Patchy ground-glass opacities were seen in the upper lobes of both lungs and the middle lobe of the right lung. Coronal (a) and axial (b) sections in lung window. R: right

Fig. 3

Chest CT of severe patient. A 53-year-old male patient with cough and fever for 6 days. Patchy ground-glass opacities were seen in both lungs, the central density increased, and the lesions were mainly distributed under the pleura. Axial (a) and coronal (b) sections in lung window. R: right

Fig. 4

Chest CT of critical patient. A 58-year-old female patient with intermittent fever, cough and sputum for more than 1 week. Multiple patchy ground-glass opacities were seen in both lungs, and air bronchogram in the left upper lobe. Axial (a) and coronal (b) sections in lung windows. R: right

Fig. 5

Chest CT of asymptomatic patient. A 27-year-old female with no clinical symptoms who had been in contact with COVID-19 patients was found to be positive for SARS-CoV-2 during screening. Patchy ground-glass opacities were seen in the lateral segment of the right middle lobe. Coronal (a), sagittal (b), and axial (c) sections in lung window. A: anterior; R: right

Fig. 6

Chest CT of SARS-CoV-2 reactivation patient. A 30-year-old male patient was negative for PCR at 2 weeks’ follow-up but reverted to positive for RT-PCR at 4 weeks. The range of ground-glass opacities in the left upper lobe narrowed and the density increased slightly, while the density of ground-glass opacities in the lower right lobe decreased. R: right

Fig. 7

Implementation tool for diagnosis section and discharge management section

Fig. 8

Implementation tool for chemoprophylaxis and treatments section