COVID-19 TREATMENT GUIDELINEIN TANZANIA, MARCH 2021
Posted by ULY CLINIC
24 Machi 2021 14:49:23
The guidance is based on proper case management aspects intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen frontline clinical management and the public health response.
NOTE. THIS GUIDELINE IS THE POPERTY OF MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN
4. MANAGEMENT BASED ON DISEASE SEVERITY
It should be noted that there is no cure or “Magic-bullet” for the treatment of COVID-19 and no single drug will be effective in treating this complex disease, multiple drugs with different mechanisms of action should be used in specific disease category to achieve a good outcome.
Management Protocol based on the clinical severity
• Mild covid-19 disease (home care)
• Moderate covid-19 disease (pneumonia)
• Severe covid-19 disease (severe pneumonia)
• Critical disease
a. Mild covid-19 disease (home care)
TREATMENT
Counsel the patient on danger signs (including difficulty in breathing, chest tightness, high grade fever, altered mentation) and discharge with instructions to perform self-isolation
Consider to provide supplemental support
• Tabs. Vitamin C 500 mg OD for 2/52.
• Tabs Zinc Sulphate 40mg (Ped zinc 40mg) OD for 2/52.
• Tabs. Vitamin D3 1000-5000 IU OD for 2/52.
• Antipyretics (if indicated)
• Encourage warm hydration, balanced diet and physical exercise.
• Advise to return back to hospital in case of worsening conditions or in case of any Danger sign
• If bacterial pneumonia is suspected, give antibiotics as per STG
• If you suspect upper respiratory infection give antihistamine and cough syrup.
• If MRDT positive, give antimalarial as per regime.
If you suspect any other infection, treat as per STG Advise to return in case of worsening conditions.
REMARKS
No antibiotic combination needed in this group unless bacterial infection is suspected.
• Community awareness is key for disease prevention
• Supplements should be initiated earlier on
• Vitamin C- regulate post immune response to viruses, Selenium – Deficiency linked to increase of viral replication and increased oxidative stress and higher and higher COVID-19 mortality.
• Zinc – low serum levels of zinc is a risk factor for infection.
b. Moderate covid-19 disease (pneumonia)
Counsel the patient on danger signs (difficulty in breathing, chest tightness, high grade fever, altered mentation) and discharge with instructions to perform self-isolation at home.
Consider supplemental support, antibiotic and steroid as suggested below;
Tabs. Vitamin C 500mg OD for 2/52.
Tabs. Zinc Sulphate 40mg OD for 2/52.
Tabs. Vitamin D3 1000-5000IU OD for 2/52
Antipyretics (if indicated)
Tabs. Dexamethasone 6mg PO OD for 5/7 OR Tabs. Prednisolone 20mg PO OD for 5/7
Tabs. Azithromycin 500mg OD for 5/7 PLUS Tabs. Amoxicillin & clavulanic acid 625mg BD7/7
OR
Tabs. Azithromycin 500mg OD for 5/7 od PLUS Caps. Amoxicillin 500mg TDS for 7/7
OR
Tabs Azithromycin 500mg OD for 5/7 PLUS ceftriaxone 1gm OD for 5/7 (if there is evidence of bacterial super-infection).
Encourage warm hydration, balanced diet and physical exercise.
Advise to return in case of worsening conditions.
c. Severe covid-19 disease (severe pneumonia)
Admit to a designated room with oxygen delivery capacity.
Oxygenation
• Oxygen therapy via Nasal cannula 1-5L/min OR simple facemask 6-10L/min OR non-rebreather facemask 10- 15L/min.
• NIPPV-CPAP for patients who can’t tolerate high flow oxygen etc.
• Encourage the patient to lie on their front (prone position) if they are comfortable.
Steroids administration
• IV Methylprednisolone 80mg stat then 40mg BD for 1/52 OR IV Hydrocortisone 200 mg BD for 1/52 OR IV Dexamethasone 8mg TDS for 1/52
Anticoagulation
• Anticoagulation with enoxaparin (LMWH) 1mg/kg SC BD
• If low-molecular weight (LMWH) or high molecular weight heparin is not available, consider using other anticoagulants such as;
• Tab. Rivaroxaban 10mg OD (if available) and if not available at all consider using;
• Tabs. Junior Aspirin 75mg PO OD for 2/52
OR
• Tabs. Clopidogrel 75mg PO OD for 2/52
Antibiotic administration
• Tabs. Azithromycin 500mg BD 5/7 OR Tab. Clarithromycin 500mg BD 5/7 (for patient with cardiac conditions)
PLUS
• IV Piperacillin & tazobactam 4.5gm QID x7/7
OR
• IV Ceftriaxone & Sulbactam 1.5mg BD 7/7
NB: Antibiotic should be changed according to Culture Result (whenever available).
Hydration
• Maintain hydration through cautious IVF administration.
PPI administration
• IV / PO. Pantoprazole 40mg BD
OR
• IV/PO. Rabeprazole 20mg BD
OR
• PO Esomeprazole 40mg BD
OR
• PO Omeprazole 20mg BD
Other supportive treatment
• Ivermectin (400mcg/kg) 6- 12mg PO OD for 5/7
• Tabs. Vitamin C 500mg OD for 2/52.
• Tabs. Zinc Sulphate 40mg OD for 2/52.
• Tabs. Vitamin D3 1000-5000IU OD for 2/52
• Antipyretics (if indicated)
• Magnesium 2g stat IV (serum magnesium-2.0- 2.4mmol) Then Magnesium 400mg or 300Mg OD for 5/7
• Ensure patient receive appropriate and adequate nutrition (see section 10 for details on nutrition).
• Provide chest physiotherapy on daily basis (see section 8 for details on physiotherapy).
• Provide psychosocial support to patient and close relatives.
REMARKS
• The mainstay of treatment in severe disease is to treat hypoxia and support the vital organ functions.
• There is good evidence for corticosteroids in this group, and for prevention of thromboses using low molecular weight heparin.
• Ivermectin – Inhibits the replication of SARS COV-2, but there is little evidence of efficacy and it is not recommended in WHO or other clinical guidelines.
• Judicious fluid management in patients with Covid-19 is needed- Aggressive fluid resuscitation may worsen oxygenation. This may cause problem in settings where there is limited availability of mechanical ventilation, and in patients with established ARDS.
• If low-molecular weight heparin is not available, consider using another anti- coagulant such as rivaroxaban
• Prevent hypomagnesemia, which increases the cytokine storm and prolongs QTc.
d. Critical disease
Admit to a designated room with oxygen or with mechanical ventilation capacity.
Airway: Maintain open airway: If patient cannot protect the airway, intubate or transfer to facility with capacity to intubate.
Oxygenation
• Oxygen therapy via Nasal cannula 1-5L/min OR simple facemask 6-10L/min OR non-rebreather facemask 10- 15L/min.
• NIPPV-CPAP for patients who can’t tolerate high flow oxygen etc.
• If required, endotracheal intubation and mechanical ventilation to manage ARDS with target SpO2 > 90%, Tidal volumes of 4-8Ml/kg, inspiratory pressures < 30 cmH20.
• Encourage the patient to lie on their front (prone position) if they are comfortable.
Steroids administration
• IV Methylprednisolone 80mg stat then 40mg BD for 1/52 OR IV Hydrocortisone 200 mg BD for 1/52
OR
• IV Dexamethasone 8mg TDS for 1/52
Anticoagulation
• Anticoagulation with enoxaparin (LMWH) 1mg/kg SC BD
• If low-molecular weight (LMWH) or high molecular weight heparin is not available, consider using other anticoagulants such as;
• Tab. Rivaroxaban 10mg OD (if available) and if not available at all consider using;
REMARKS
• Tabs. Junior Aspirin 75mg PO OD for 2/52
OR
• Tabs. Clopidogrel 75mg PO OD for 2/52
Antibiotic administration
• Tabs. Azithromycin 500mg BD 5/7 OR Tab. Clarithromycin 500mg BD 5/7 (for patient with cardiac conditions)
PLUS
• IV Piperacillin & tazobactam 4.5gm QID x7/7
OR
• IV Ceftriaxone & Sulbactam 1.5mg BD 7/7
NB: Antibiotic should be changed according to Culture Result (whenever available).
Hydration
• Give IV fluids for shock until SBP>90mmHg or MAP >65mmHg
PPI administration
• IV / PO. Pantoprazole 40mg BD
OR
• IV/PO. Rabeprazole 20mg BD
OR
• PO Esomeprazole 40mg BD
OR
• PO Omeprazole 20mg BD
Other supportive treatment
• Ivermectin (400mcg/kg) 6- 12mg PO OD for 5/7
• Tabs. Vitamin C 500mg OD for 2/52.
• Tabs. Zinc Sulphate 40mg OD for 2/52.
• Tabs. Vitamin D3 1000-5000IU OD for 2/52
• Antipyretics (if indicated)
• Magnesium 2g stat IV (serum magnesium-2.0- 2.4mmol) then Magnesium 400mg or 300Mg OD for 5/7
• Ensure patient receive appropriate and adequate nutrition (see section 10 for details on nutrition).
• Provide chest physiotherapy on daily basis (see section 8 for details on physiotherapy).
• Provide psychosocial support to patient and close relatives.
REMARKS
• The mainstay of treatment in severe disease is to treat hypoxia and support the vital organ functions.
• There is good evidence for corticosteroids in this group, and for prevention of thromboses using low molecular weight heparin.
• Ivermectin – Inhibits the replication of SARS COV-2, but there is little evidence of efficacy and it is not recommended in WHO or other clinical guidelines.
• Judicious fluid management in patients with Covid-19 is needed- Aggressive fluid resuscitation may worsen oxygenation. This may cause problem in settings where there is limited availability of mechanical ventilation, and in patients with established ARDS.
• If low-molecular weight heparin is not available, consider using another anti- coagulant such as rivaroxaban
• Prevent hypomagnesemia, which increases the cytokine storm and prolongs QTc.
NOTE
In other countries, Remdesivir, Tocilizumab and Colchicine have been used with reported benefits, though they are at different phases of randomized clinical trials.
Updated,
25 Machi 2021 07:20:15
References
1. THE UNITED REPUBLIC OF TANZANIA. MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDRENCORONAVIRUS DISEASE 2019 (COVID-19) TREATMENT GUIDELINES. MARCH 2021
2. Del Rio, C. and P.N. Malani, (2020). 2019 Novel Coronavirus—Important Information for Clinicians. JAMA, 2020. 323(11): p. 1039-1040.
3. World Health Organization, (2020). Coronavirus disease 2019 (COVID-19) Situation Report 46, 2020.
4. World Confederation of Physical Therapists (WCPT) (2020). Physiotherapy management for COVID 19 version 1.0 23 March 2020
5. Sohrabi, C., Z. Alsafi, N. O'Neill, M. Khan, A. Kerwan, A. Al-Jabir, C. Iosifidis, and R. Agha, (2020). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg, 2020. 76: p. 71-76.
6. Guan, W.-j., … Ye, C.-j. Zhu, S.-y. and Zhong N.-s., (2020). Clinical Characteristics of Coronavirus Disease 2019 in China. NewEngland Journal of Medicine, 2020.
7. van Doremalen, N., … Lloyd-Smith, J.O., de Wit, E., and Munster, V.J., (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine, 2020.
8. Yoon, S.H., K.H. Lee, J.Y. Kim, Y.K. Lee, H. Ko, K.H. Kim, C.M. Park, and Y.H. Kim, Chest Radiographic and CT Findings of the 2019 Novel Coronavirus Disease (COVID-19): Analysis of Nine Patients Treated in Korea. Korean J Radiol, 2020. 21(4): p. 494-500.
9. Zhao, D., F. Yao, L. Wang, L. Zheng, Y. Gao, J. Ye, F. Guo, H. Zhao, and R. Gao, A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clin Infect Dis, 2020.
10. Peng, Q.Y., X.T. Wang, L.N. Zhang, and G. Chinese Critical Care Ultrasound Study, Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med, 2020.
11. Chen, N., M. Zhou, X. Dong, J. Qu, F. Gong, Y. Han, Y. Qiu, J. Wang, Y. Liu, Y. Wei, J. Xia,
T. Yu, X. Zhang, and L. Zhang, Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet, 2020. 395(10223): p. 507-51s3.
12. Zhou, F., T. Yu, R. Du, G. Fan, Y. Liu, Z. Liu, J. Xiang, Y. Wang, B. Song, X. Gu, L. Guan, Y. Wei, H. Li, X. Wu, J. Xu, S. Tu, Y. Zhang, H. Chen, and B. Cao, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 2020.
13. Xie, J., Z. Tong, X. Guan, B. Du, H. Qiu, and A.S. Slutsky, Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Medicine, 2020.
14. Australian and New Zealand Intensive Care Society, ANZICS COVID-19 Guidelines, 202, ANZICS: Melbourne.
15. Kress, J.P. and J.B. Hall, (2014). ICU-acquired weakness and recovery from critical illness.
N Engl J Med, 2014. 370(17): p. 1626-35.
16. Herridge, M.S., C.M. Tansey, A. Matte, G. Tomlinson, N. Diaz-Granados, A. Cooper, C.B. Guest, C.D. Mazer, S. Mehta, T.E. Stewart, P. Kudlow, D. Cook, A.S. Slutsky, and A.M. Cheung, (2011). Functional disability 5 years after acute respiratory distress syndrome. N Engl JMed, 2011. 364(14): p. 1293-304.
17. Brouwers, M.C., M.E. Kho, G.P. Browman, J.S. Burgers, F. Cluzeau, G. Feder, B. Fervers,
I.D. Graham, S.E. Hanna, and J. Makarski, (2010). Development of the AGREE II, part 1: performance, usefulness and areas for improvement. Cmaj, 2010. 182(10): p. 1045-52.
18. Schunemann, H.J., …Cuello, R. Waziry,and Akl, E.A., (2017). GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol, 81: p. 101-110.
19. Moberg, J., A.D., …Morelli, G. Rada, and P. Alonso-Coello, (2018). The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst, 16(1): p. 45.
20. Clinical Skills Development Service, Q.H. Physiotherapy and Critical Care Management eLearning Course. Accessed 21/3/20]; Available at https://central.csds.qld.edu.au/central/courses/108].
21. World Health Organisation, (2020). Infection prevention and control during health care when COVID-19 is suspected: Interim Guidance, M. 2020, Editor 2020.
22. Queensland Health,(2020). Clinical Excellence Division COVID-19 Action Plan: Statewide General Medicine Clinical Network,
23. The Faculty of Intensive Care Medicine. (2019). Guidelines for the provision of the intensive care services.; Available from: https://www.ficm.ac.uk/news-eventseducation/ news/guidelines-provision-intensive-care-services-gpics-%E2%80%93-secondedition.
24. Alhazzani, W., … Hayden, F., Evans, L., and Rhodes, A., (2019). Surviving sepsis campaign: Guidelines of the Management of Critically Ill Adults with Coronavirus Disease (COVID- 19). Critical Care Medicine, 2020. EPub Ahead of Print.
25. World Health Organization, (2020). Clinical Management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected Interim Guidance, 2020. p. WHO Reference number WHO/2019-nCoV/clinical/4.
26. Metro North, (2020). Interim infection prevention and control guidelines for the management of COVID-19 in healthcare settings,: https://www.health.qld.gov.au/ data/assets/pdf_file/0038/939656/qh-covid-19- Infectioncontrol- guidelines.pdf.
27. Stiller, K., (2013). Physiotherapy in intensive care: an updated systematic review. Chest,
144(3): p. 825-847.
28. Green, M., V. Marzano, I.A. Leditschke, I. Mitchell, and B. Bissett, (2016). Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscipline Health, 9: p. 247-56.
29. Hodgson, C.L. Zanni, L. Denehy, and S.A. (2014). Webb, Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 2014. 18(6): p. 658.
30. Australian and New Zealand Intensive Care seeliery, ANCS COVID 19 Guidelines 202 ANZICS Melhsore.
31. Zanni, M.J., denehy,L.(2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical care. 18 (6): p 658.