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Review
. 2020 Dec 29;104(3_Suppl):48-59.
doi: 10.4269/ajtmh.20-1106.

Pragmatic Recommendations for Therapeutics of Hospitalized COVID-19 Patients in Low- and Middle-Income Countries

Varun U Shetty  1 , Brian Jason Brotherton  1   2 , Andrew Achilleos  3 , Kevan M Akrami  4   5   6 , Lia M Barros  7 , William Checkley  8   9 , Natalie Cobb  10 , Stephanie Maximous  11 , David Misango  12 , Casey Park  13 , Shaurya Taran  13 , Burton W Lee  11   14 ; COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
Affiliations
Review

Pragmatic Recommendations for Therapeutics of Hospitalized COVID-19 Patients in Low- and Middle-Income Countries

Varun U Shetty et al. Am J Trop Med Hyg. .

Abstract

The therapeutic options for COVID-19 patients are currently limited, but numerous randomized controlled trials are being completed, and many are on the way. For COVID-19 patients in low- and middle-income countries (LMICs), we recommend against using remdesivir outside of a clinical trial. We recommend against using hydroxychloroquine ± azithromycin or lopinavir-ritonavir. We suggest empiric antimicrobial treatment for likely coinfecting pathogens if an alternative infectious cause is likely. We suggest close monitoring without additional empiric antimicrobials if there are no clinical or laboratory signs of other infections. We recommend using oral or intravenous low-dose dexamethasone in adults with COVID-19 disease who require oxygen or mechanical ventilation. We recommend against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen. We recommend using alternate equivalent doses of steroids in the event that dexamethasone is unavailable. We also recommend using low-dose corticosteroids in patients with refractory shock requiring vasopressor support. We recommend against the use of convalescent plasma and interleukin-6 inhibitors, such as tocilizumab, for the treatment of COVID-19 in LMICs outside of clinical trials.

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Conflict of interest statement

GROUP MEMBERS OF THE “COVID-LMIC TASK FORCE”

Heads: Alfred Papali (Atrium Health, Charlotte, NC) and Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC”, Amsterdam, The Netherlands).

Advisors: Neill K. J. Adhikari (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada); Emilie J. Calvello Hynes (University of Colorado School of Medicine, Department of Emergency Medicine, Denver, CO); Martin Dünser (Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria) and Mervyn Mer (University of the Witwatersrand, Johannesburg, South Africa).

Subgroup members, in alphabetical order: Andrew Achilleos (Sunnybrook Health Sciences Centre, Toronto, Canada); Hanan Y. Ahmed (Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia); Kevan M. Akrami (Universidade Federal da Bahia, Salvador, BA, Brazil and University of California San Diego, San Diego, CA); Lia M. Barros (University of Washington, Seattle, WA); B. Jason Brotherton (Kijabe Medical Center, Kijabe, Kenya); Sopheakmoniroth Chea (Calmette Hospital, Phnom Penh, Cambodia); William Checkley (Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD); Elif Cizmeci (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Natalie Cobb (University of Washington, Seattle, WA); Finot Debebe (Department of Emergency Medicine and Critical Care, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia); Juliana C. Ferreira (University of São Paulo, São Paulo, Brasil); Gabriela Galli (University of Pittsburgh School of Medicine, Pittsburgh, PA); Tewodros Haile (Department of Internal Medicine, College of Health Sciences, Addis Ababa University); Bhakti Hansoti (Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD); Madiha Hashmi (Ziauddin University, Karachi, Pakistan); Rebecca Inglis (Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit [LOMWRU], Mahosot Hospital, Vientiane, Lao People’s Democratic Republic and Department of Intensive Care, Oxford University Hospital Trust, Oxford, United Kingdom); Burton W. Lee (University of Pittsburgh, Pittsburgh, PA; NIH, Bethesda, MD.); Faith Lelei (AIC Kijabe Hospital, Kijabe, Kenya); Ganbold Lundeg (Mongolian National University of Medical Sciences, Ulan Bator, Mongolia); David Misango (The Aga Khan University, Nairobi, Kenya); Ary Serpa Neto (Department of Critical Care Medicine and Institute of Education and Research, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Intensive Care, Amsterdam University Medical Centers, location “AMC,” University of Amsterdam, Amsterdam, The Netherlands); Jennifer L. Pigoga (Division of Emergency Medicine, University of South Africa, Cape Town, South Africa); Alfred Papali (Atrium Health, Charlotte, NC); Casey Park (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Rajyabardhan Pattnaik (Ispat General Hospital, Rourkela, India); Luigi Pisani (Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Doctors with Africa–CUAMM, Padova, Italy; Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand); Elisabeth D. Riviello (Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA); Kristina E. Rudd (University of Pittsburgh School of Medicine, Pittsburgh, PA); Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC”, Amsterdam, The Netherlands); Varun U. Shetty (University of Pittsburgh Medical Center, Pittsburgh, PA); Gentle S. Shrestha (Tribhuvan University Teaching Hospital, Kathmandu, Nepal); Chaisith Sivakorn (Mahidol University, Salaya, Thailand); Shaurya Taran (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); T. Eoin West (University of Washington, Seattle, WA).

Group members of the subgroup “Therapeutics”: Varun U. Shetty (University of Pittsburgh Medical Center, Pittsburgh, PA); B. Jason Brotherton (Kijabe Medical Center, Kijabe, Kenya and University of Pittsburgh, Pittsburgh, PA); Andrew Achilleos (University of Toronto, Toronto, Ontario, Canada); Kevan M. Akrami (Universidade Federal da Bahia, Salvador, BA, Brazil and University of California San Diego, San Diego, CA); Lia Barros (University of Washington, Seattle, WA); William Checkley (Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD); Natalie Cobb (University of Washington, Seattle, WA); Stephanie Maximous (University of Pittsburgh, Pittsburgh, PA); David Misango (Aga Khan University, Nairobi, Kenya); Casey Park (University of Toronto, Toronto, Ontario, Canada); Shaurya Taran (University of Toronto, Toronto, Ontario, Canada); and Burton W. Lee (University of Pittsburgh, Pittsburgh, PA and NIH, Bethesda, MD).

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