1Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
2Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.
Am J Trop Med Hyg. 2021 Jan 22;104(3_Suppl):34-47. doi: 10.4269/ajtmh.20-0730.
Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.
严重或危急 COVID-19 患者的管理主要是仿照其他病因导致的严重肺炎或急性呼吸窘迫综合征患者的治疗方法。这些模型基于主要源自高收入国家调查的证据，但将这些建议应用于资源有限的低收入和中等收入国家（LMICs）可能不切实际。我们报告了一套针对微生物学和实验室检测、影像学以及在 LMICs 中严重 COVID-19 患者中使用诊断和预后模型的实用建议。对于可进行且负担得起的逆转录聚合酶链反应（RT-PCR）检测，我们建议使用上呼吸道或下呼吸道标本进行 RT-PCR，并建议对疑似 COVID-19 但上呼吸道标本 RT-PCR 结果为阴性的患者使用下呼吸道标本。我们建议任何解剖来源的阳性 RT-PCR 都可被视为 SARS-CoV-2 感染的确诊依据，但由于可能出现假阴性检测，建议如果患者高度怀疑 COVID-19，阴性 RT-PCR 并不能明确排除活动性感染。我们建议在有更好证据证明其有用性之前，不要使用血清学检测来检测活动性或过去的 SARS-CoV-2 感染。在有条件的情况下，我们建议仅在严格保证质量控制措施的情况下，将基于床旁抗原检测的快速诊断检测用于 SARS-CoV-2 感染的替代 RT-PCR。对于实验室检测，我们建议进行白细胞分类计数、血小板计数、血红蛋白、肌酐和肝功能检测，并且建议在有条件的情况下进行 C 反应蛋白、乳酸脱氢酶、肌钙蛋白、凝血酶原时间（或其他凝血检测）和 D-二聚体检测。对于影像学，如果标准胸部影像学的可用性有限，我们建议使用肺部超声来识别可能患有 COVID-19 的患者，但建议不要使用肺部超声来排除 COVID-19。我们建议使用肺部超声与临床参数结合，以监测 COVID-19 患者的疾病进展和对治疗的反应。我们目前建议不要使用诊断和预后模型，因为这些模型需要广泛的实验室检测和影像学检查，而这些检查在 LMICs 中通常受到限制。
