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Abstract

All patients with symptomatic COVID-19 and risk factors for severe disease should be closely monitored. The clinical course may rapidly progress in some patients. Antibiotics are not recommended to prevent bacterial infection in mild or ordinary patients. Administer empiric antibiotics if bacterial pneumonia/sepsis strongly suspected; re-evaluate daily. In non-hospitalized patients, do not initiate therapeutic anticoagulants or anti platelet unless other indications exist.
Version 1.4 / November 2020 1
Management Protocol
in Hospitals
C VID-19
Ministry of Health and Population, Egypt
Management protocol for COVID-19
Patients
Version 1.4 / November 2020
Management Protocol for
Patients
Version 1.4 / November 2020
2
Version 1.4 / November 2020 3
Table of contents
Item Page
Number
Triage Protocol 4
Management Protocol 6
Gastrointestinal Manifestations
of COVID-19 15
Anticoagulation of COVID-19
Patients 16
High-Velocity Nasal Insuation 17
Post-acute COVID Syndrome 18
Prevention and Control of COVID-19 Inside
Health Care Facilities 20
Antibiotics in Covid-19 25
List of Editors 26
Version 1.4 / November 2020
4
1st Step: Triage
Case denition + severity assessment
Suspect Case Denition
A) Clinical AND epidemiological criteria: OR: B
Patient with severe acute
respiratory illness (SARI: acute
respiratory infection with history
of fever or measured fever ≥ 38°C
and a cough; onset within last 10
days; requires hospitalization)
-Acute onset of fever and cough OR
-≥ 3 of the followings: fever, cough, sore
throat, coryza, general weakness/fatigue,
headache, myalgia, dyspnea, anorexia/nausea/
vomiting, diarrhea, altered mental status
And 1 of the followings within 14 days of
symptom onset:
Residing or
working in an
area with high
risk of
transmission*
Working in
a healthcare
seing
Residing or
travel to an area
with community
transmission
*Closed residential seings, humanitarian seings such as camp and camp-like seings for displaced persons.
NB: Minimal role for the epidemiological criteria during the period of community spread
Probable Case
A patient who meets clinical criteria AND is a contact of a probable or conrmed case,
or epidemiologically linked to a cluster with at least one conrmed case.
OR
Suspect case with chest imaging showing ndings suggestive of COVID-19 disease*
OR
Recent onset of loss of smell or taste in the absence of any other identied cause
OR
Unexplained death in an adult with respiratory distress who was a contact of a probable
or conrmed case or epidemiologically linked to a cluster with at least 1 conrmed case
*Hazy opacities with peripheral and lower lung distribution on chest radiography; multiple bilateral ground
glass opacities with peripheral and lower lung distribution on chest CT; or thickened pleural lines, B lines, or
consolidative paerns on lung ultrasound.
Conrmed Case
A person with laboratory conrmation* of COVID-19 infection, irrespective of clinical signs
and symptoms
*Molecular testing(PCR) with deep nasal swab is the current test of choice for the diagnosis of acute COVID-19
infection
During seasonal u period, clinical dierentiation between inuenza and COVID 19 is dicult.
Swab for inuenza A &B may help in early dierentiation.
Triage Protocol
Version 1.4 / November 2020 5
OR: B
Severity assessment
Suspected case
-PCR to conrm the diagnosis *
-Assess disease severity
(clinical, lab & imaging)
-Mild symptoms
-Normal imaging
Imaging: +ve
SpO2 ≥ 92%
SpO2 < 92%, PaO2/FiO2 <
300,
respiratory rate > 30
breaths/min, or
lung inltrates > 50%
Respiratory failure,
septic shock, and/or
multiorgan
dysfunction
Admit to
Intensive care
Admit to
Intermediate Care
Hospitals admission
COVID area
Home isolation &
close follow up
If possible, < 65 years
old & no uncontrolled
comorbidity
Critical illnessSevere
Moderate
Mild Risk Factor
Yes
No
In severe and critically ill patients, if-ve 1st PCR, repeat within 48 hours, negative case is considered after 2 –ve
consecutive RT-PCR results from respiratory samples tested at least 1 day apart.
NB: Unstable patient who don’t meet the suspected criteria should receive 1st aid therapy in non-COVID area
before referral to general hospital.+ Risk factors include, old age > 60 years, uncontrolled comorbidity as hyperten-
sion, DM, ……. or Social un applicable to home isolation.
All persons with suspected, probable or conrmed COVID-19 should be immediately
isolated to contain the virus transmission.
Triage Protocol
Version 1.4 / November 2020
6
Time is an important issue Time is an important issue in management of COVID-19. Before day 12( stage of viral
load), Antiviral drug is essential. After day 12, the role of antiviral declines with
augmentation for the role of anti-inammatory, immune-modulators and Supportive drugs
(stage of hyper-immune state).
Potential antiviral drugs under evaluation for the treatment of COVID-19 include:Potential antiviral drugs under evaluation for the treatment of COVID-19 include:
- Hydroxy ChloroquineHydroxy Chloroquine 400mg/ 12 hours 1st day followed by 200 mg/12 hours for 6 days,
- IvermectinIvermectin 6 mg (36 mg on day 0 -3-6),
- FavipiravirFavipiravir 1600 twice daily rst day then 600 mg twice daily,
- RemdesivirRemdesivir 200 mg IV on day 1, followed by 100 mg IV daily for high risk population for 5
days that could be extended to 10 days if the response is unsatisfactory or
- Lopinavir/Ritonavir Lopinavir/Ritonavir 200/ 50 mg 2 tablets PO BID
- Monoclonal antibodiesMonoclonal antibodies: early testing in blocking SARS-CoV-2.
- Convalescent plasmaConvalescent plasma: for impending severely ill after counseling the scientic commiee
2nd Step: Management
Home isolation and symptomatic treatment symptomatic treatment (eg, antipyretics for fever, adequate nutrition,
appropriate rehydration).
Educate the patientsEducate the patients on signs/symptoms of complications that, if developed, should prompt
pursuit of urgent care.
There are insucient data to recommend either with or against any antiviral or im-
mune-based therapy in patients with COVID-19 who have mild illness.
Mild illness
All patients with symptomatic COVID-19 and
risk factors for severe disease should be closely
monitored. The clinical course may rapidly
progress in some patients.
Antibiotics are not recommended to prevent
bacterial infection in mild patients. Administer
empiric antibiotics if bacterial
pneumonia/sepsis strongly suspected; re-evaluate
daily.
In non-hospitalized patients, do not initiate
therapeutic anticoagulants or antiplatelet
unless other indications exist.
No harmful eect for administration of vitamin
C or D or Zinc or Lactoferrin within the required
daily dose.
Check Every Patient For Risk
Factors
. Age 65 years
. SpO2 < 92%
. Heart Rate ≥110
. Respiratory Rate ≥ 25 /min.
. Neutrophil / lymphocyte ratio on
CBC ≥ 3.1
. Uncontrolled Comorbidities
. On Immunosuppressive or
chemotherapy drug
. Pregnancy
. Active Malignancy
. Obesity (BM>40)
Management Protocol
Version 1.4 / November 2020 7
All patients with symptomatic COVID-19 and risk factors for severe disease should
be closely monitored. In some patients, the clinical course may rapidly progress.
Flu or COVID-19
IS IT A FLU OR COVID-19?IS IT A FLU OR COVID-19?
SYMPTOM FLU COVID-19
FEVER
FATIGUE
COUGH
SORE THROAT
HEADACHES
RUNNY NOSE
SHORTNESS OF BREATH
BODY ACHES
DIARRHEA AND/OR
VOMITING
ONSET 1-4 days after infection About 5 days after infection but can range
from 2-14 days
LOSS OF TASTE AND/OR
SMELL
RED, SWOLLEN EYES
SKIN RASHES
Version 1.4 / November 2020
8
Mild Case
Symptomatic case
with lymphopenia or leucopenia
with no radiological signs for pneumonia
1. Age 65
2. Temperature > 38
3. SaO2 ≤ 92%
4. Heart Rate ≥ 110
5. Respiratory Rate ≥ 25 /min.
6. Neutrophil / lymphocyte ratio
on CBC ≥ 3.1
7. Uncontrolled Comorbidities
8. Immunosuppressive Drug
9. Pregnancy
10. Active Malignancy
11. On Chemotherapy
12. Obesity (BMI>40)
Check for
Any YES
All No
Age ≥ 65
OR
Age < 65
AND
• Strict Home Isolation (Symptomatic
Treatment)
• Follow and use personal protective guide
equipment
• If any deterioration occurs, back to
hospital
NB: Paracetamol is the preferred antipyretic
If more than 3
symptoms admit
Treatment
- Hydroxychloroquine (400 mg twice in
rst day then 200 mg twice for 6 days)
- Zinc 50mg daily
- Acelylcysteine 200 mg t.d.s.
- lactoferrin one sachet twice daily
- Vitamin C 1 gm daily
OR Ivermectin 6 mg (36 mg on day 0
-3-6)
OR Favipiravir 1600 TWICE daily rst
day then 600 mg twice daily
+
Version 1.4 / November 2020 9
Anti-virals
Hydroxychloroquine +
Ivermectin or
Lopinavir/Ritonavir
or
Remdesivir for high
risk population with
SaO2 < 92
Immune-modulators
Anti-inammatory Anti-coagulation
Steroids
(if patient has severe
dyspnea) RR>24 or CT
scan showing rapid
deterioration
Dexamethasone 6 mg
or its oral equivalent
Prophylactic
anticoagulation if
D-Dimer between
500 -1000
Therapeutic
anti-coagulation if
D-dimer > 1000
Patient has pneumonia manifestations on radiology associated with symptoms &/Or
leucopenia or lymphopenia.
Moderate Case
Anti-virals
anticoagulation if
D-Dimer between
500 -1000
Therapeutic
anti-coagulation if
D-dimer > 1000
Or if severe
hypoxia
Anti-inammatory Convalescent
plasma
Steroids
(Dexamethasone 6
mg or methyl
prednisolone (1 mg /
kg /24 hours)
Tocilizumab
4-8 mg/kg/day for 2
doses 12 to 24 hours
apart after failure of
steroid therapy to
improve the case for
24 hours
Before day 12
(under clinical trial)
(after scientic
commiee
approval)
RR > 30, SaO2 < 92 at room air, PaO2/FiO2 ratio < 300, Chest radiology showing more than
50% lesion or progressive lesion within 24 to 48 hrs.
Severe cases
Remdesivir
or
Lopinavir/
Ritonavir
Anti-coagulant
Prophylactic
Admit to Intermediate Care
Version 1.4 / November 2020
10
RR > 30, Sa02 < 92 at room air, PaO2/FiO2 ratio < 300, Chest radiology showing more than
50% lesion or progressive lesion within 24 to 48 hrs. Critically ill if SaO2 <92, or RR>30, or
PaO2/FiO2 ratio < 200 despite Oxygen Therapy.
Critically ill patients
Admit to Intensive care
Anti-virals
Remdesivir
or
Lopinavir/
Ritonavir
Anti-coagulant Anti-inammatory
Therapeutic
anti-coagulation
Steroids
(Methyl prednisolone 2mg /kg or its
equivalent)
Tocilizumab
4-8 mg/kg/day for 2 doses 12 to 24 hours
apart after failure of steroid therapy to
improve the case for 24 hours
Tocilizumab
4-8mg/kg/dose
2 doses
Early Block
the storm
if steroids
failed
Antiviral
Drugs As is In
Severe case
Steroids
Methylpred-
nisolone
1-2 mg/kg/d
Anti-
Coagulation
Enoxaparine
1 mg/kg BID
Prone
Awake or
ventilated
Avoid
Hypoxia
O2/ NIV/
HFNC/IMV
Add
Antibiotics
As per
protocol
1 mg for non
ventilated
and 2 mg for
ventilated
Consider
D-dimer level
as a guide
Improves
V/Q matching
and survival
Don’t wait
too much for
any type of
support Keep
plateau<30
High ow nasal oxygen is an important modality in the early management of critically ill patients.
Version 1.4 / November 2020 11
(HFNC):
Conscious patients with minimal secretions.
Hypoxia SpO2 < 90% on oxygen. Or PaCO2 >40 mmHg provided pH 7.3 and above.
NIV trial shall be short with ABG 30 minutes apart.
Any deterioration in blood gases from baseline or oxygen saturation or consciousness
level shift to IMV.
CPAP gradually increased from 5-10 cmH2O.
Pressure support from 10-15 cm H2O.
HFNC can be alternative to NIV.
Use PPE specially goggles during intubation and avoid bagging.
Indications:
Failed NIV or not available or not practical.
PaO2 < 60 mmhg despite oxygen supplementation.
Progressive Hypercapnia.
Respiratory acidosis (PH < 7.30).
Progressive or refractory septic shock.
Disturbed consciousness level (GCS ≤ 8) or deterioration in consciousness level from
baseline
Non Invasive Ventilation or High Flow Nasal Cannula
Invasive Mechanical Ventilation:
Version 1.4 / November 2020
12
COVID-19 PNEUMONIA (type L & type H)
Type LType H
Type L
Low elastance
Low VA/Q mismatch
Low lung weight
Low recruitability High elastance
High RL shunt
High lung weight
High recruitability
Type H
Non invasive
support Early intubation Late intubation
HFNC
CPAP
NIV
PEEP (5-10 cmH2O)
Sedation
NMBA
Higher PEEP(10-15
cmH2O)
Prone
(ECMO)
STOP STOP STOP
Lung Damage Progression
(Virus + P-SILI)
Inspiratory eort - edema
Type L and Type H patients are best identied by CT scan and are aected by dierent
Pathophysiological mechanisms. If CT not available, denition could be used as surrogates:
Respiratory system elastance and recruitability.
Understanding the correct pathophysiology is crucial to establishing the basis for appropriate
treatment.
Version 1.4 / November 2020 13
Plateau
P<30 cmH2O
Incremental
PEEP
Shift to ARDSNet protocol if needed
Step 2:
- ARDSNet protocol:
LOW TV
6-4 ml/kg Driving
P<15 cmH2O
Initiation of Invasive Mechanical Ventilation
Step 1:
VCV
TV 8 ml/kg
PEEP 5 cmH2O
Plateau
Pressure
Less than 30
cmH2O
Sat >93
Keep and Watch
Less than 30
Sat<93
Increase PEEP
to 10
More than 30
ARDSnet
protocol
Inspiratory Pause for 1 second
IF PLATEAU ABOVE 30 CMH2O
Version 1.4 / November 2020
14
Assessment of respiratory support outcome
Step 3:
Improved
Weaning of
respiratory
support
Assess
ABGs, Clinical
Radiological
Stationary
Continue
respiratory
support as
needed
*Criteria for VV ECMO: Age below 55, mechanical ventilation duration
less than 7 days, no comorbidities, preserved conscious level,
PaO2/FiO2 <100 despite prone RESPscore >0.
Expert opinion is needed and depends on availability.
Deteriorating
Criteria for
ECMO*
Start with tidal volume of 6 ml/Kg to keep plateau pressure on volume controlled
ventilation (VCV) below 30 cmH2O, decrease to 4 ml/kg if the plateau remain higher
than 30 allow permissive hypercapnia so long the pH is above 7.3
compensate by increasing respiratory rate up to 30 breath/ minute. Consider heavy
sedation and paralysis. If pressures are high or any evidence of barotrauma shift to
pressure controlled ventilation and be cautious about low tidal volume alarms for
fear of unnoticed endotracheal tube obstruction. Consider ECMO
early if eligible. Increase PEEP gradually if the patient remains hypoxic
according to FIO2 level to keep driving pressure < 15cmH2O. NEVER FORGET
PRONE POSITION.
Version 1.4 / November 2020 15
- Gastrointestinal (GI) symptoms are seen in patients with COVID-19. The preva-
lence could be as high as 50%, but most studies show ranges from 16% to 33%
- Some patients with COVID-19 have presented with isolated GI symptoms that may
precede the development of respiratory symptoms
- It is important to note that medications used for COVID-19 may be associated with
GI symptoms as well.
- Approximately 50% of patients with coronavirus disease 2019 (COVID-19) have
detectable viral RNA in the stool
- Loss of appetite or anorexia is the most commonly reported symptom.
- Diarrhea was the second most common symptom.
- Other digestive manifestations include nausea or vomiting and abdominal pain.
- Dysgeusia has also been reported, often in conjunction with anosmia.
- Currently, management of GI symptoms in patients with COVID-19 is mainly sup-
portive.
- Treatment should be individualized according to the patient’s symptoms, underly-
ing comorbidities and COVID-19–associated complications.
- Oral or intravenous hydration
- The antidiarrheal agent loperamide can be used in an initial dose of 4 mg and with
a maximum daily dose of 16 mg in patients without fever, bloody stools, or risk fac-
tors for C. dicile infection
- Antiemetic drugs can often help relieve symptoms.
Gastrointestinal Manifestations of COVID-19
Gastrointestinal Manifestations
of COVID-19
Version 1.4 / November 2020
16
Yes No
Anticoagulation in COVID-19 Patients
the patient clinically indicated
for hospitalization
Is he/she critically ill
No Yes
Prophylactic dose
Higher than standard
dose
0.5 mg/kg/m
Therapeutic dose
Consider also therapeutic
anticoagulation for
patients with high
clinical susceptibility
of VTE and those with
Severe hypoxia not
explained by the chest CT
ndings
The preferred agents
are LMWH and
Fondaparinux unless
contraindicated
In renal patients, heparin
is the preferred agent.
If the dose of LMWH
exceeds 150 twice daily
use heparin instead.
Anticoagulation in COVID-19
Patients
Version 1.4 / November 2020 17
High Velocity Nasal Insuation
(Hi-VNI)
Hi-VNI is a rst-line therapy for COVID-19 patients who are struggling to
breathe.
Hi-VNI Technology and WOB reduction: The fact that small-bore
cannulas reduce the time required to fully purge the upper airway dead space3 is
signicant because as the respiratory rate of a patient in respiratory distress
increases, the time between breaths decreases. By quickly clearing the upper
airway dead space of end-expiratory gas rich in CO2, Hi-VNI Technology helps
patients breathe directly from a fresh gas reservoir and thereby reduces their
WOB.
0
70
60
50
40
30
20
10
10 20 30 40 50 60
HVNI
HFNC
Volumetric Flow (L.min-1)
Velocity (m.sec-1)
High-Velocity Nasal Insuation
Version 1.4 / November 2020
18
Post- acute COVID syndrome
(long COVID)
Denition & incidence:
In the absence of agreed denition, it may be dened as “patients not
recovering for several weeks or months following the start of symptoms that
were suggestive of COVID, whether patients were tested or not.” It may
extend beyond 3 weeks from the onset of rst symptoms up to 3 months,
sometimes occurring after a relatively mild acute illness. If symptoms are
extending beyond 3 months, it is termed Chronic COVID.
In short, “Despite their illness being ‘over,’ they are having a lot of
trouble returning to normal life.” It occurs in around 10% of patients.
Patients can be divided into those who may have serious sequelae (such as
thromboembolic complications) and those with a non-specic clinical pic-
ture, often dominated by fatigue and breathlessness. One last group of
covid-19 patients whose acute illness required intensive care management.
Management:
Specialist referral may be indicated based on clinical nding, for example:
Respiratory: if suspected pulmonary embolism, severe pneumonia.
Cardiology: if suspected myocardi-
al infarction, pericarditis, myocarditis or new heart failure.
Neurology: if suspected neurovascular or acute neurological event.
Pulmonary rehabilitation may be indicated if patient has persistent
breathlessness.
Post-acute COVID syndrome
Version 1.4 / November 2020 19
Medical management:
Symptomatic: treating fever by paracetamol & NSAIDs
Management of co-morbidities including diabetes, hypertension, kidney
diseases & ischemic heart diseases
Listening and empathy
Consider antibiotics for secondary infection
Treat specic complication as indicated
Self-management:
Daily pulse oximetry.
Aention to general health like:
Good diet
Good sleep hygiene
Quiing smoking
Limiting alcohol
limiting caeine
Rest and relaxation.
Self-pacing and gradual increase exercise.
Set achievable targets.
Post-acute COVID syndrome
Version 1.4 / November 2020
20
Prevention and Control of Transmission
of COVID-19 inside
Health Care Facilities
Version 1.4 / November 2020 21
General Recommendations for
Prevention and Control of Transmission of COVID-19
inside Health Care Facilities
1-Daily screening of health care workers and patients before entering the
health care facility (HCF) based on clinical signs (fever, respiratory symp-
toms…….).
2- Any health care worker appears/reports to be diseased should be segregated
until proper examination/management.
3- All health care workers are required to wear surgical masks during work
hours (during existence in HCFs).
4- Minimal number of health care workers should be present at the same time
in patient’s units to keep social distancing
5- Restrict unneeded movements between departments.
6- Suspected or conrmed cases should take a separate route from other pa-
tients beginning from the facility entrance (Triage area), and all facility sec-
tions should follow the same separation.
7- Suspected or conrmed cases should be isolated in a well- ventilated isola-
tion room.
8- Standard precaution should be applied :
• Hand hygiene
• Cough etiquee.
• Personal protective equipment.
• Clean and disinfected Environmental surfaces.
• Sterile instrument and devices
• Sharp safety.
• Isolation transmied precaution.
• Safe injection practices.
General Recommendations
Version 1.4 / November 2020
22
Recommendations
According To The Type Of Procedure
1) Non Aerosol Generating Procedures (AGPs)
• Standard precautions.
• Isolation precautions taken to prevent the spread of infection by spray and
contact.
• The need to adhere to washing hands before donning personal protective
equipment and immediately upon dong.
• The necessity to adhere to donning personal protective equipment as
follows:
1- Surgical mask.
2- Protect your eyes by wearing goggles or face shield.
3- Long-sleeve medical gowns (gown) clean, non-sterile or sterile, according to
type of technique.
4- Clean or sterile gloves depending on type of technique.
5- Health care worker are not required to wear protective boots and protective
suits during routine care of cases.
6- Extended use of surgical masks, gowns, eye protectors, and face shields can
be applied while caring for COVID-19 patients in the event of a shortage of
personal 2 protective equipment for the length of the work shift (preferably
not more than six hours).
7- Always remember not to touch the eyes, mouth or nose with contaminated
hands or used gloves (wash your hands or rub using alcohol when touch any
environmental surface).
8- Always clean and disinfect surfaces .
Medical Recommendations
Version 1.4 / November 2020 23
2) Procedures that include (AGPs):
• Tracheal intubation .
• Non-invasive ventilation e.g. BiPAP, CPAP.
• Tracheotomy.
• Cardiopulmonary resuscitation.
• Manual ventilation before intubation or bronchoscopy.
• Sputum induction by using nebulizer hypertonic saline.
The health care workers must adhere to the following:
• Standard precautions.
• Perform procedures inside a well-ventilated room.
• Follow the isolation precautions taken to prevent the spread of infection
through air and contact.
• The need to adhere to washing hands before donning personal protective
equipment and immediately upon dong them.
Medical Recommendations
Version 1.4 / November 2020
24
Donning personal protective equipment as follows:
- A high-performance respiratory masks such as N95 or FFP2 or equivalent,
with the need to conduct a tightness test to ensure that there is no leakage.
- Protect your eyes by wearing goggles or face shield.
- Long-sleeve medical gowns (gown) clean, non-sterile or sterile according to
the procedure.
- Clean or sterile gloves depending on type of technique.
- The extended use of a mask, medical gown, eye goggles, or face shield
(Extended use) can be applied while caring for patients with COVID-19 in the
event of a lack of personal protective equipment and for the length of the work
shift (preferably no more than six hours).
- Care must be taken not to touch the eyes, mouth or nose with contaminated
bare hands or using gloves (wash your hands or rub using alcohol when touch
any environmental surface).
- Always clean and disinfect surfaces regularly.
Personal Recommendations
Version 1.4 / November 2020 25
Indications:
- Rapid development of consolidation paern.
- Development of lobar consolidation.
- Leukocytosis with absolute neutrophilia.
- Reappearance of fever after afebrile days.
- Increased CRP with improved other markers as ferritin.
- Procalcitonin is highly specic.
ANTIBIOTICS IN COVID-19
Low-risk inpatients:
- Combination therapy:
β-lactam (eg, ceftriaxone, or cefotaxime) plus either a macrolide
(eg, azithromycin or clarithromycin) or doxycycline.
- Monotherapy:
Respiratory uoroquinolone (eg, levooxacin or moxioxacin)
High-risk inpatients:
- β-lactam plus a macrolide or uoroquinolone is recommended.
ANTIBIOTICS IN COVID-19
Version 1.4 / November 2020
26
Treatment Protocol
Revised By:
NAME AFFILIATION
Hossam Hosny Masoud
Professor of Chest Diseases. Head of
Pulmonary Hypertension Unit, Faculty of
Medicine, Cairo University
Gehan Elassal Professor of Chest Diseases, faculty of
Medicine , Ain Shams University
Dr. Mohamed Hassany
Fellow of Infectious Diseases and Endemic
Hepatogastroentrology , National Hepatology
and Tropical Medicine Research Institute
Dr. Ahmed Shawky Professor of Chest Diseases, faculty of
Medicine , Tanta University
Dr. Mohamed Abdel Hakim Professor of Chest Diseases, faculty of
Medicine , Cairo University
Dr. Samy Zaky
Professor of Hepatogastroentrology and
Infectious Diseases, faculty of Medicine ,
Al Azhar University
Dr. Amin Abdel Baki
Consultant and Head of Hepatology ,
Gastroentrology and Infectious Diseases
Department. National Hepatology and Tropical
Medicine Research Institute
Dr. Akram Abdelbary
Professor of Critical care Medicine , Cairo
University
Chairman elect of ELSO SWAAC chapter
Dr. Ahmed Said Lecturer of Critical care Medicine , faculty of
Medicine, Cairo University
Dr. Khaled Taema Assistant Professor of Critical care Medicine ,
faculty of Medicine, Cairo University
Dr. Noha Asem
Minister”s Counselor for Research and Health
Development
Chairman of Research Ethics Commiee
MOHP, Lecturer of Public Health , Cairo
University
Version 1.4 / November 2020 27
NAME AFFILIATION
Dr. Ehab Kamal
Minister of Health Assistant for Continuous
Medical Education
General Director of Fever hospitals Directorate
Dr. Wagdy Amin Director General for Chest Diseases , MOHP
Dr. Ehab Aia General Director of IPC Department , MOHP
Dr. Hamdy Ibrahim
Infectious Diseases Consultant , National
Hepatology and Tropical Medicine Research
Institute
Dr. Alaa Eid Head of Preventive Medical Sector MOHP
Treatment Protocol
Revised By:
Version 1.4 / November 2020
28
Ministry of Health and Population
Egypt / November 2020
... This result in agree with study of (fancello et al., 2021), their study including 20 patients; about 25% of patients had isolated hearing loss. 10 In our study, the mean pure tone average for air conduction threshold at frequencies 0. 25 The mean PTA average in both sides were higher than normal PTA threshold defined by ANSI ana ASHA indicating great association between COVID-19 infection and hearing loss. There is no statistically significant difference between both sides as regard PTA average. ...
... Some studies support that; CHL as same as mixed hearing loss may occurring in COVID-19 patient due to middle ear effusion or acute otitis media [24]. This discrepancy could be explained by that; the proven Egyptian protocol to control COVID-19 infection including mucolytics, antibiotics and corticosteroids, so a large number of subjects in our study may had OME and cured during treatment journey [25]. As regard, from our results, there is mild SNHL for the whole complaining group and AC. ...
... The study included adult patients with type 2 diabetes aged 18 and above who tested positive for COVID-19 through real-time reverse transcriptase polymerase chain reaction (RT-PCR) testing. 15 Diabetes diagnosis was confirmed based on HbA1c levels ≥ 6.5% and RBS levels ≥ 200 mg/dl, in accordance with the American Diabetes Association guidelines. 16 We precluded pregnant diabetic COVID-19 patients due to the likely decrease in erythrocyte lifespan during pregnancy, leading to an increase in young erythrocytes that can lower HbA1c levels. ...
... Egyptian patients proved to be COVID-19 positive were classified according to Ministry of health and Population COVID-19 Protocol (MOHP), EGYPT [11]. ...
Article
Background: The viruses' direct damage plays a part in the disease's beginning, the cytokine storm brought on by COVID-19 is crucial to the emergence of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). This study aimed to investigate the correlation between IL-6 and its IL- 6 gene (174G/C) single nucleotide polymorphism with the pathogenesis of COVID-19 severity in Egyptian patients. Materials & Methods: Egyptian patients proved to be COVID-19 positive were classified into three groups; Group 1 (mild cases), Group 2 (moderate cases) and Group 3 (severe and critical cases). Complete blood count, liver function tests, renal function tests, CRP, and coagulation profile, serum ferritin, D-dimer, procalcitonin, lactate dehydrogenase and detection of serum interleukin 6 levels, and IL-6 gene polymorphism were investigated for all enrolled 135 patients. Results: There was a significant decrease of platelets count of group II & III as compared to group I. There was a significant increase of total leucocytic count, CRP, ferritin, D – dimer, procalcitonin, blood urea and IL6 of group III as compared to group I & II. There was significant decrease of relative lymphocyte counts % of group III as compared to group I & II. There was significant increase of LDH of group II & III as compared to group I. There were no statistically significant differences were found as regards hemoglobin, SGPT, SGOT, serum creatinine and I.N.R & interleukin-6 174G/C distribution of the different studied groups. There were positive correlations between serum interleukin 6 levels and CORAD scores, ferritin count, LDH, and D- dimer, and blood urea, and only a negative correlation with relative lymphocyte count %. Conclusion: interleukin-6 plays an important role in the pathogenesis of COVID-19. In addition, it reveals that serum IL6 can be used as a predictor of disease severity in COVID-19 patients, but interleukin-6 174G/C genotype distribution cannot be used as a predictor of disease severity in COVID-19 Egyptian patients.
... All participating patients were subjected to thorough clinical examination. Laboratory and radiological imaging were performed according to the Egyptian Ministry of Health COVID-19 guidelines and according to their clinical conditions [21]. Mild cases were either asymptomatic or symptomatic (upper respiratory tract illness with or without one of the following symptoms: fever <38, cough, gastrointestinal symptoms, myalgia, or arthralgia) with leucopenia or lymphopenia with no radiological evidence of pneumonia [22]. ...
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Objectives Patients with COVID-19 infection appear to develop virus-induced hypercoagulability resulting in numerous thrombotic events. The aim of the present study was to determine the relationship between the thrombophilia genes mutations (prothrombin G20210A, factor V Leiden, and methyltetrahydrofolate reductase (MTHFR)) and the severity of COVID-19 patients. Design Prospective cross-sectional study. Method One hundred and forty patients (80 adults and 60 children) were included in the current study. They were divided into the severe COVID-19 group and the mild COVID-19 group, with each group comprising 40 adults and 30 children. The patients were assessed for FV R506Q, FV R2H1299R, MTHFR A1298C, MTHFR C677T, and prothrombin gene G20210A polymorphisms. CBC, D-dimer, renal and liver function tests, hs-CRP, ferritin, and LDH were also assessed. Thrombotic events were clinically and radiologically documented. Results Severe COVID-19 cases were significantly more frequent to have a heterozygous mutation for all the studied genes compared to mild COVID-19 cases (p<0.05 for all). Being mutant to gene FV R506Q carried the highest risk of developing a severe disease course (p<0.0001). Patients with abnormally high D-dimer levels were significantly more frequent to be heterozygous for FV R506Q, FV R2H1299R, and prothrombin gene G20210A (p = 0.006, 0.007, and 0.02, respectively). Conclusion We concluded that there is an evident relationship between severe COVID-19 and inherited thrombophilia. In the current study, FV R506Q gene mutation carried the highest risk of developing a severe COVID-19 disease course.
... Patients' medications and length of hospital stay were also recorded. The management of COVID-19 patients and sepsis was carried out in accordance with local and international guidelines and protocols [14,15]. Methylprednisolone was the steroid used following our protocol, at a dosage of 1-2 mg/kg/day; 1 mg/kg/day for non-ventilated patients and 2 mg/kg/day for ventilated patients. ...
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Background Critically ill COVID-19 patients are highly susceptible to opportunistic fungal infection due to many factors, including virus-induced immune dysregulation, host-related comorbidities, overuse and misuse of antibiotics or corticosteroids, immune modulator drugs, and the emergencies caused by the pandemic. This study aimed to assess the incidence, identify the potential risk factors, and examine the impact of fungal coinfection on the outcomes of COVID-19 patients admitted to the intensive care unit (ICU). Methods A prospective cohort study including 253 critically ill COVID-19 patients aged 18 years or older admitted to the isolation ICU of Zagazig University Hospitals over a 4-month period from May 2021 to August 2021 was conducted. The detection of a fungal infection was carried out. Results Eighty-three (83) patients (32.8%) were diagnosed with a fungal coinfection. Candida was the most frequently isolated fungus in 61 (24.1%) of 253 critically ill COVID-19 patients, followed by molds, which included Aspergillus 11 (4.3%) and mucormycosis in five patients (1.97%), and six patients (2.4%) diagnosed with other rare fungi. Poor diabetic control, prolonged or high-dose steroids, and multiple comorbidities were all possible risk factors for fungal coinfection [OR (95% CI) = 10.21 (3.43–30.39), 14.1 (5.67–35.10), 14.57 (5.83–33.78), and 4.57 (1.83–14.88), respectively]. Conclusion Fungal coinfection is a common complication of critically ill COVID-19 patients admitted to the ICU. Candidiasis, aspergillosis, and mucormycosis are the most common COVID-19-associated fungal infections and have a great impact on mortality rates.
... All enrolled patients followed the case definition for confirmed cases of Egyptian national protocol for COVID-19 issued by MOHP. Severe COVID-19 is diagnosed as dyspnea, respiratory rate more than or equal to 30/min, SaO 2 less than or equal to 93%, PaO 2 /FiO 2 ratio less than 300, and/or lung infiltrates in more than 50% of the lung field within 24-48 h, and critical COVID-19 is diagnosed as respiratory failure requiring mechanical ventilation, shock, or other organ failure that requires intensive care [6]. ...
Article
Background Inflammatory markers like interleukin-6 (IL-6) are linked to the worse outcome in coronavirus disease 2019 (COVID-19) cases. Other markers such as C-reactive protein are not as reliable as IL-6 in predicting respiratory failure. Aim To assess the function of IL-6 as a predictor of COVID-19 severity. Patients and methods A total of 50 severe and critical patients with PCR-confirmed COVID-19 were included. All enrolled patients followed the case definition for confirmed cases of Egyptian national protocol for COVID-19 issued by MOHP. Clinical assessment, imaging, and laboratory data were recorded at admission. Pulmonary function was evaluated by SpO 2 /FiO 2 ratio. Outcomes included hospital stay, prognosis of the disease, complications, death rate, and discharge, which were recorded during the follow-up. Results The elevated IL-6 group showed a significantly higher critical rate (87.1%) than the normal IL-6 group (26.3%) ( P <0.0001), and the improvement rate was higher in the normal IL-6 group (73.7%). Moreover, the death rate was significantly greater in the elevated IL-6 group (38.7%) than the normal IL-6 group (10.5%) ( P =0.033). The cutoff value of IL-6 levels in prediction of severity and mortality of COVID-19 was assessed. Our receiver operating characteristic results revealed that IL-6 cutoff value is higher than 50.27 for severity and the cutoff value is greater than 120.83 for mortality. The sensitivity values of IL-6 for severity and mortality were 93.3 and 90.5%, respectively, and the specificity values were 90.0 and 86.7%, respectively. Conclusion Elevated levels of serum IL-6 in COVID-19-infected patients were related with a variety of adverse outcomes, including severe illness, mechanical ventilation, and acute respiratory distress syndrome. When it came to accurately predicting the severity and mortality of COVID-19, the optimum IL-6 cutoff levels were 50.27 and 120.83 pg/ml, respectively.
... if the patient had di culty in reporting the medical treatment they received, we contacted their treating physicians. According to our national ministry of health COVID-19 treatment protocol, the recommendation was to give corticosteroid as an anti-in ammatory if the patient has moderate (pneumonia without hypoxia and could be treated at home) or severe (pneumonia with hypoxia responding to oxygen therapy, but should be admitted to intermediate care) respiratory symptoms, in the form of Dexamethasone 6 mg or methylprednisolone 1 mg/kg/24 hours [13]. ...
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Background: COVID-19 is relatively a new condition, the long-term effects of which have not been thoroughly studied yet. Musculoskeletal complications following COVID-19 infection or because of its medications used had been reported in the literature. Here, we report on seven hips in four patients who presented with osteonecrosis of the femoral head (ONFH) after having COVID-19 infection and their treatment regimen included glucocorticoid. Cases presentation: Four patients presented to us complaining of hip pain (bilateral in three patients and unilateral in one), all reported being diagnosed as having COVID-19 infection, and their line of management included corticosteroids intake for various durations. The diagnosis was confirmed by plain hip radiographs and magnetic resonance imaging. The disease was in the early stages in all patients without femoral head collapse. Thus, all hips were treated by core decompression. Conclusion: ONFH is a real concern in patients who had COVID-19 infection, especially when corticosteroids were administered as part of their management. A follow-up and screening strategy should be established for patients who had COVID-19 infection to detect early development of hip osteonecrosis.
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A green and simple UPLC method was developed and optimized, adopting a factorial design for simultaneous determination of oseltamivir phosphate and remdesivir with dexamethasone as a co-administered drug in human plasma and using daclatasvir dihydrochloride as an internal standard within 5 min. The separation was established on UPLC column BEH C18 1.7 μm (2.1 ××\times 100.0 mm) connected to UPLC pre-column BEH 1.7 μm (2.1 ××\times 5.0 mm) at 50 °C with an injection volume of 10 μL. The photodiode array detector (PDA) was set at three wavelengths of 220, 315, and 245 nm for oseltamivir phosphate, the internal standard, and both dexamethasone and remdesivir, respectively. The mobile phase consisted of methanol and ammonium acetate solution (40 mM) adjusted to pH 4 in a ratio of 61.5:38.5 (v/v) with a flow rate of 0.25 mL min⁻¹. The calibration curves were linear over 500.0–5000.0 ng mL⁻¹ for oseltamivir phosphate, over 10.0–500.0 ng mL⁻¹ and 500.0–5000.0 ng mL⁻¹ for dexamethasone, and over 20.0–500 ng mL⁻¹ and 500.0–5000.0 ng mL⁻¹ for remdesivir. The Gibbs free energy and Van't Hoff plots were used to investigate the effect of column oven temperatures on retention times. Fluoride-EDTA anticoagulant showed inhibition activity on the esterase enzyme in plasma. The proposed method was validated according to the M10 ICH, FDA, and EMA’s bioanalytical guidelines. According to Eco-score, GAPI, and AGREE criteria, the proposed method was considered acceptable green.
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Background: The world has been suffering from the Coronavirus Disease-2019 (COVID-19) pandemic since the end of 2019. The COVID-19-infected patients differ in the severity of the infection and the treatment response. Several studies have been conducted to explore the factors that affect the severity of COVID-19 infection. One of these factors is the polymorphism of the angiotensin converting enzyme 2 (ACE-2) and the type 2 transmembrane serine protease (TMPRSS2) genes since these two proteins have a role in the entry of the virus into the cell. Also, the ACE-1 regulates the ACE-2 expression, so it is speculated to influence the COVID-19 severity. Objective: This study investigates the relationship between the ACE-1, ACE-2, and TMPRSS2 genes single nucleotide polymorphism (SNPs) and the COVID-19 disease severity, treatment response, need for hospitalization, and ICU admission in Egyptian patients. Patients and Methods: The current study is an observational prospective, cohort study, in which 109 total COVID-19 patients and 20 healthy volunteers were enrolled. Of those 109 patients, 51 patients were infected with the non-severe disease and were treated in an outpatient setting, and 58 suffered from severe disease and required hospitalization and were admitted to the ICU. All 109 COVID-19 patients received the treatment according to the Egyptian treatment protocol. Results: Genotypes and allele frequencies among severe and non-severe patients were determined for ACE-1 rs4343, TMPRSS2 rs12329760, and ACE-2 rs908004. The GG genotype and the wild allele of the ACE-2 rs908004 and the mutant allele of the ACE-1 rs4343 were significantly more predominant in severe patients. In contrast, no significant association existed between the TMPRSS2 rs12329760 genotypes or alleles and the disease severity. Conclusion: The results of this study show that the ACE-1 and ACE-2 SNPs can be used as severity predictors for COVID-19 infection since also they have an effect on length of hospitalization.
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Introduction: Non cystic fibrosis bronchiectasis is an uncommon respiratory disease and was described as a rare imaging feature of COVID-19 infection, but no published studies are reporting the clinical course and outcome of coexisting COVID-19 and confirmed cases of bronchiectasis during acute stage. The aim of this study was to assess the course and outcome of COVID-19 infection in bronchiectasis patient. Patients and methods: A cross-sectional study including 411 COVID-19 confirmed cases that were examined by high resolution computed tomography of the chest during acute phase (4 weeks) of the infection. They were divided into Group A: COVID-19 patients without bronchiectasis (n=400) and Group B included COVID-19 patients with preexisting clinical and radiologic evidence of bronchiectasis (n=11). Results: Patients with preexisting chronic bronchiectasis (Grup B) had significantly higher cough score, frequency of colored sputum and mMRC score, respiratory distress (p< 0.001) and respiratory failure (p= 0.02) than those without bronchiectasis. They also had the higher frequency of ICU’s admission (p< 0.001), need to non-invasive (p= 0.01), and invasive mechanical ventilation (p= <0.001), duration of mechanical ventilation, ICU’s stay and overall hospital stay (p<0.001). Death rate was also statistically significantly higher in Group B compared to Group A (p= 0.04). Conclusion: Concomitant bronchiectasis increases disease burden in COVID-19 patients. It increased the severity of presenting symptoms and was associated with worse clinical outcome (ICU admission, need for ventilator support) and mortality.
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