MINISTRY OF HEALTH AND WELLNESS

TREATMENT OF COVID 19 INFECTION

07/10/2021

Asymptomatic patients

- Treatment for mild symptoms with paracetamol

- Use of anti-inflammatory, corticoids, including Dexamethasone
contraindicated

Symptomatic patients with mild to moderate disease. Absence of

viral pneumonia and hypoxia.

- Common symptoms: fever or chills, cough, fatigue, bodyache,

headache, new loss of taste or smell, sorethroat, runny nose, nausea
or vomiting, diarrhea

- Traitement Symptomatique : paracétamol si fièvre ou douleurs,

traitement symptomatique des diarrhées, nausées, vomissements. Les
anti-inflammatoires et l’usage des corticoïdes, y compris de la
Dexaméthasone sont contre-indiqués

Symptomatic patients with severe disease

▪ Severe illness is defined as patients with SpO2≤94% on room air and

those who require supplemental oxygen > 8 l/mn

▪ Clinical features of severe disease:

o Respiratory rate>22/min
o Altered mental state
o Systolic blood pressure<100 mmHg

▪ Examen radiologique:

o X-ray: lung infiltration, images en verre dépoli

o Scanner thoracique : si radio de poumon anormale

▪ Investigations: FBC, U&E, creatinine, LFT, RBS, ECG, CRP, D-dimer,

INR/PT, ABG, CT thorax (if available), cardiac echo si nécessaire,
 serum lactate (if not available in ABG). Procalcitonine si infection
suspectée

▪ Specific treatment for severe disease: Treatment revolves around

the supportive management of the most common complications of
severe COVID-19: pneumonia, hypoxemic respiratory failure/ARDS,
sepsis and septic shock, cardiomyopathy and arrhythmia, acute kidney
injury, and complications from prolonged hospitalization, including
secondary bacterial infections, thromboembolism, gastrointestinal
bleeding, and critical illness polyneuropathy/myopathy.

1.Use of steroids

● Dexamethasone: 6 mg per day for up to 10 days once daily or until

hospital discharge, whichever comes first, for patients who are
mechanically ventilated and in hospitalized patients who require
supplemental oxygen but who are not mechanically ventilated.

● Only if dexamethasone is not available: alternative glucocorticoids such

as prednisone, methylprednisolone, or hydrocortisone. Whether use of
other corticosteroids (e.g., prednisone, methylprednisolone,
hydrocortisone) for the treatment of COVID-19 provides the same
benefit as dexamethasone is unclear. The total daily dose
equivalencies for these drugs to dexamethasone 6 mg (oral or
intravenous [IV]) are:

▪ Prednisone 40 mg daily : 20 mg x 2 /day

▪ Méthylprednisolone 32 mg daily : 16mg x 2 /day
▪ Hydrocortisone 160 mg daily : 40mg x 4 /day

2. Use of anti-coagulants

● Elevated D-dimer levels have been strongly associated with greater risk of
death

● For all hospitalized patients thromboprophylaxis is indicated, unless

contraindicated (e.g., a patient has active hemorrhage or severe
thrombocytopenia)
 ● Lovenox : : 0,4 ml/j (4000 UI/j) en l’absence de CI, sous cutanée en 1 dose. En cas de
risque majorée de thrombose en particulier chez les obèses, il faut majorer la dose :
4000 UI/12 heures ou 6000 UI/12 heures si le poids excède 120 kg

Routine thromboprophylaxis for COVID-19 patients if on dialysis or CKD stage 4/5

Assess the risk of bleeding as soon as possible after admission and decide if the benefits of
anticoagulation outweigh the risks of bleeding.
Enoxaparin (Lovenox) 0.2ml/day for under 80kg, 0.4ml/day for above 80kg
(0.1ml = 10mg = 1000iu)
Consider stopping enoxaparin if bleeding or requiring invasive procedures
Consider increasing the enoxaparin dose by 0.2 to 0.4ml/day if evidence of
thromboembolism whilst on enoxaparin

D-dimer levels should not guide prophylactic dosing of heparin

3-Tocilizumab ( Actemra )

Pour patients adultes avec progression sévère ou critique

Indications :

- Adultes hospitalisés et enfants âgés de 2 ans et plus atteints de COVID-19

- Ayant un niveau de protéine C-réactive de >75 mg/litre (signe d'inflammation).
- Patients avec SPO2 < 94 % sous air
- Patients sous ventilation mécanique ou ECMO
- Inclus choc septique

Contre-indications  :

- Allergie connue à un des constituants

- Infection bactérienne ou virale grave ou latente (autre que COVID)
- Conditions préexistantes ou traitement concomitant entrainant une
immunosuppression
- ASAT ou ALAT > 5 fois la normale
- Plaquettes < 50 x 109 /l
- Polynucléaires neutrophiles < 0,5 x 109/l

Précautions  :

- Femme enceinte ou qui allaite

- Infection latente (possibilité de réactivation) •
- Antécédents de diverticulite ou d’ulcération du tractus gastro-intestinal (risque de
perforation gastro-intestinale)
- Maladie hépatique évolutive ou insuffisance hépatique
- Plaquettes < 100 x 109 /L
- Neutrophiles < 2 x 109 /L
Examens biologique à effectuer avant traitement  :
- CRP
- Procalcitonine
- Bilan hépatique
- Numération formule sanguine + plaquettes
Posologie recommandée :
- Dose unique de 8 mg/kg en perfusion intraveineuse (ampoule de 200 mg), la dose
totale ne devant pas dépasser 800 mg (Dilution dans 100 ml de NaCl 0,9%. Durée : 60
minutes)
- En l’absence d’ampoules intraveineuses, utiliser les ampoules sous cutanées pré-
remplies de 162 mg. Mettre 4 seringues dans 100 ml de sérum salé à 0,9%, et faire
passer la perfusion sur une heure

4- Remdesivir

La prescription de Remdésivir dépendra de l’évolution des connaissances sur ce

médicament et de la situation clinique du patient. Le groupe clinico-biologique
multidisciplinaire qui se réunit quotidiennement pour passer en revue les dossiers,
aidera au choix de la prescription ou non de ce traitement pour chaque patient

- Indicated
For adults and pediatric patients aged ≥12 years who weigh ≥40 kg for treatment of
COVID-19 ayant besoin d’O2.

- Bilan biologique pré-traitement :

eGFR
Hepatic laboratory testing
Prothrombin time

- Posologie

Day 1 loading dose: 200 mg IV infused over 30-120 min, Then

Day 2 and thereafter: 100 mg IV qDay

Insuffisance rénale :
 Pharmacokinetics have not been evaluated in patients with renal impairment
 eGFR ≥30 mL/min: No dose adjustment
 eGFR <30 mL/min: Not recommended; sulfobutylether-beta-cyclodextrin
sodium salt (SBECD) excipient in the concentrated solution is renally cleared
and accumulates in patients with decreased renal function
 - Durée de traitement  :

 Not requiring invasive mechanical ventilation and/or extracorporeal membrane

oxygenation (ECMO): 5 days; if clinical improvement not demonstrated,
treatment may be extended up to 10 days total

 Requires invasive mechanical ventilation and/or ECMO: 10 days

5) Antibiotiques and anti-fungal agents:

(General treatment protocol: the use of antibiotics and anti-fungal agents in a

confirmed COVID-19 patient)

Basic principles :

1. If bacterial pneumonia or sepsis is strongly suspected, administer empiric

antibiotic treatment, re-evaluate the patient daily, and de-escalate or stop
antibiotics if there is no evidence of bacterial infection (NIH, 2020).
2. Continuation or initiation of antibiotic therapy solely due to confirmation of
COVID-19 pneumonia is not indicated. In most cases of mild or moderate
COVID-19, antibiotics are not warranted (WHO, 2020).
3. Local guidelines for the treatment of bacterial pneumonia continue to apply.
Use clinical judgement when starting antibiotics.
4. Patients may be infected with a bacterial pathogen if at least two of the
following criteria are met: CRP > 100 mg/dL, procalcitonin > 0.5 ng/mL,
lymphopenia (≤ 0.7 x 109 cells/L), neutrophilia (> 7.5 x 10 9 cells/L), unilateral
infiltrates on chest imaging, underlying lung abnormalities (e.g. COPD or
bronchiectasis), in septic shock, confused, in acute kidney injury or with
worsening hypoxia.
5. Prefer medications that can be administered once a day, so as to minimize
contact with patients.

Protocol

1. A septic screen should be performed prior to starting antibiotics i.e. 2 blood

cultures, a urine culture (if indicated) and a sputum culture (if the patient can
provide one) should be sent. Urine samples may be ordered for Legionella sp.
and Streptococcus pneumoniae antigens if symptoms are severe.
2. For community-acquired pneumonia: start a 3rd generation cephalosporin
(e.g. ceftriaxone 2g IV Q24h). In case of allergy use fluoroquinolone (e.g.
moxifloxacin 400mg IV Q24h).
 3. For hospital-acquired or ventilator-associated pneumonia: start Meropenem 1g
IV Q8h.
4. Stop treatment if there is no evidence of bacterial infections.
5. Consider adding an anti-fungal (e.g. Voriconazole: dose de charge J1 400 mg
x 2 IV, puis 200mg x 2 IV (ou 4 mg/kg) , 6 à 12 semaines si aspergilloses.

Adjustment of antibioticdosage in patient with kidney disease

ADJUSTMENT OF ANTIBIOTIC DOSAGE IN PATIENT WITH KIDNEY DISEASE

Nephrology Unit MOHW September 2021

This list is not exhaustive. For further advice, contact the Nephrology Unit.

Antibiotic GFR ml/min or Dosing

kidney replacement modality
Colistin >50 3mu every 8h
30-50 3 to 4 mu every 12h
10-30 2 to 2.5 mu every 12h
< 10 1.5mu every 12h
Haemodialysis 1mu every 12h non HD days
1.5mu every 12h HD days
CVVHD* 3mu every 8h
Gentamicin >70 5-7 mg/kg once daily
30-70 3-5 mg/kg once daily
Drug level** before subsequent 10-30 2-3 mg/kg once daily
dosing is strongly advised. < 10 1.5 mg/kg once daily
Readminister only when level Haemodialysis 1.5 mg/kg after each HD
<1mg/l. CVVHD* 3-5 mg/kg once daily
Meropenem >50 1g every 8h
20-50 1g every 12h
10-20 500mg every 8h
< 10 500mg bd
Haemodialysis 500mg bd
CVVHD* 1g every 12h
Vancomycin >50 1g every 12h
20-50 1g every 24h
Consider increasing the dose by 10-20 0.5g every 24h
up to 50% in bigger and younger < 10 0.5g every 2 days
patients. Haemodialysis 0.5g after every HD
Drug level** before subsequent CVVHD* 1g every 24h
dosing is strongly advised.
Readminister only when level
<10mg/l.
* assuming CVVHD runs for a full 24h a day ** liaise with Special Assay Central Labs (VH) ext
3455

The kidney function measure used here is GFR and may not equal to eGRF (which gives the
GFR for someone with an average 1.73m2 body surface area BSA). To make use of the above
table, calculate the GFR as follows:

GFR in ml/min= eGFR (CKD-EPI) in ml/min/1.73m2 x BSA in m2

1.73

Get the patient’s GFR (CKD-EPI) from

https://www.kidney.org/professionals/kdoqi/gfr_calculator
Get the patient’s BSA from http://www.medcalc.com/body.html

Please note the following cautions about eGFR (and GFR)

• it is not accurate in obesity or in people with abnormal amounts of muscle, GFR will
be underestimated in those with increased muscle mass and over-estimated in those
with reduced muscle mass such as amputees and malnourished people
• it is not validated in pregnant women or in children
• Creatinine levels/renal function should be relatively stable and not rapidly changing (as in
developing AKI and AKI recovery) for the reported eGFR to be valid

CRITICALLY ILL PATIENTS WITH COVID – 19 AT ENT

1. Protocol for Admission in ICU

 Patient requiring 6 – 8 L of O2/min to reach a peripheral oxygen

saturation ≥ 90 – 92 %
 Patient requiring BPAP
 GCS < 8/15
 SBP < 100 monthly

 SPO2 < 92% on 10 LO2

 RR ≥ 25/min
 Lung infiltrates > 50%
 Respiratory failure
 Shock
 Acute oxygen dysfunction
 Patients at high risk for clinical determinations

2. Patient at risk for ARDS

 Age > 65 years
 Temp. > 390c
 Neutrophilia
 Lymphocytopenia
 Increased AST, Alt, urea and creatinine
 Increased markers of inflammation: Highly-sensitivity creatine protein,
Procalcitonin,Serum ferritin
 Increased Prothrombin, Fibrinogen and D-Dimer

3. Initial Approach
 Adequate use of individual protection equipment
 SPO2 < 94%, initiate supplemented oxygen
 SPO2 goal no higher than 96%
 Persistent hypoxemia, start HNFC or BPAP
 Objective: SPO2 92 - 96%,
 Possible ARDS: SPO2/FIO2 ratio < 315
 If there is clinical worsening or refractory hypoxemia orotracheal intubation

4. Intubation/resuscitation of patients

 Minimize number of personnel (high aerosol generation risk) with full PPB
protection / FFP2 mask

 Rapid sequence induction

 Video laryngoscope to be used by trained personnel

 Intubation to be done by the senior anesthetist

 Why intubation is called or considered

Cardiopulmonary arrest Hypoxemia Lost airway or Respiratory distress

jeopardized airway

5. Indications for Intubation

Prompt tracheal intubation should be performed on the presence of one of the following
conditions:

 Accute and rapid alteration of consciousness

 Risk of airway inhalation

 Severe decompensated acidosis (pH<7.2-7.25)

 Severe hypoxemia :PaO2<50 mmHg or SaO2<90% despite maximal non-

invasive support

 Signs or symptoms of significant respiratory distress or tissue hypoxia

(e.g. respiratory rate above 25-30 per minute, use of accessory respiratory muscles,
sweating, dyspnoea, tachycardia, increased blood lactate levels

6-Treatment

▪ Symptomatic patients: moderate: Sp02 on room air < 94% on room air

• O2: Venturi, face mask with reservoir bag, High Flow Nasal
Canhula,
• Non Invasive Ventilation in a negative pressure chamber

• In all cases PRONE positioning

• Medical treatment
 • Arterial line for ABG monitoring

▪ Severe needing INTUBATION, PF ratio < 300 and lung infiltmtes > 50%

Rapid Sequence Induction

• Use of Videolaryngoscopy

• Physiotherapy

• Nasogastric tube Insertion, Central Venous Catheter,

arterial catheter, CBD

7- Ventilation Strategy:

a. Invasive Mechanical Ventilation

- Low VT ventilation 4 – 8 ml/kg of PBW
- Target PPlat < 30 cmH2O
- Target driving pressure < 15 cmH2O
- SPO2 goal no higher than 96%
- Conservative fluid strategy
- Prone position
- Nitric oxide rescue therapy
- V-V or V-A ECMO (in refractory hypoxemia)

b. Additional Care
1. Cardiac Output Monitors, Echocardiography, markers of tissue oxygenation
2. Oximetry, gas analysis, lung ultrasound respiratory mechanic, electrical impedemic
topography
3. Analgesia, sedation and neuromuscular blocking
4. Early external nutrition and glycaemic control
5. Thromboprophylaxis
6. Renal supportive therapy, consider CVVH
7. Rational use of antibiotics
8. Rehabilitation

Muscle Relaxation Recommended

Recruitment Recommended
manetÑers

Weaning For patients who are ready for

Spontaneous Recommended weaning
breathing trial

Weaning protocol Recommended For patients who can tolerate

weaning

Prevention of complications

Antici pated outcome Interventions

Reduce days of Use weaning Protocols that include daily
ínvasive ventilation assessment for readiness to breath
spontaneously Window Period reduce sedatives
Reduce incidence of Oral intubation
VAP Patient semi recumbent position (Head of Bed 30 —
45 degrees)
Close suctioning System
New ventilator circuit for each patients
Charr e each moisture exchan er eve 5 days
Reduce incidence of Pharmacological prophylaxis — if contraiñdication
— use intermittent neurnatic com ression devices
Reduce incidence of Daily catheter check — remove if not required
Catheter related blood
stream infection
Reduce incidence of Turn patient 2 hourly
pressure ulcers
Reduce stress ulcer Early enteral feediñg within 24
hrs. ppr
Reduce ICE reJated Earl Active mobilization of patients
weakness
 I) MANAGEMENT OF COVID-19 ASSOCIATED ACUTE KIDNEY
INJURY

This guideline should be read in conjunction with the 2020 MOHW AKI and Hyperkalaemia
Guidelines and the National COVID-19 Guidelines and the advice of a nephrologist should
be sought sooner rather than later.

A. Pathophysiology of AKI in COVID-19

Most causes of COVID-19 AKI are the same as in non-COVID19 critically ill patients: mostly
acute tubular injury (with rhabdomyolysis not uncommon). However, causes of AKI particular
to COVID-19 include thrombotic microangiopathy and complement and/or immune
dysfunction leading to vasculitis or glomerulonephritis.

B. KDIGO Classification of AKI

KDIGO AKI Staging

Stage Serum creatinine Urine Output

1.5 to 1.9 x baseline OR increase by ≥ 26 μmol/L within <0.5 mL/kg/hr for > 6
1
48hrs consecutive hrs

2 2 to 2.9 x baseline <0.5 mL/kg/ hr for > 12 hrs

≥3 X baseline OR increase to ≥ 354 μmol/L <0.3 mL/kg/ hr for > 24 hrs

3
OR initiation on renal replacement therapy OR anuria for 12 hrs

C. Identification patients with Covid-19 at risk of AKI

Demographic: Age, DM, HBP, obesity, CKD, heart disease, immunosuppression, smoker
COVID-19 related: respiratory status, inflammatory markers, haematological abnormalities
Drugs and nephrotoxins: ACEI, ARB, NSAID, contrast, statins, inotropes
Exposure: hypovolaemia/dehydration, sepsis, fluid overload, high PEEP ventilation

D. Early detection of AKI in at risk patients

Monitor daily for (1) fluid status and balance (2) urine output (3) U+E and creatinine
Consider checking urine dipstick and urine ACR for new haematuria and/or albuminuria

E. Investigation of AKI in Covid-19 patients

Urine: dipstick, ACR, microscopy, culture and sensitivity
Blood: U+Es, creatinine, LFTs, calcium PO4, uric acid, Fbc with differential, blood film,
clotting screen with D-dimers, CK, ABGs
Imaging: USS of kidneys and urinary tract
Further investigations may be required and the advice of a nephrologist should be sought. It
is very unlikely that a native renal biopsy will alter management in COVID-19 AKI.

F. Management of AKI in COVID-19 patients

Measurement of Monitor at a minimum serum creatinine and urine output with careful
kidney function consideration of the limitations of both.
Haemodynamic We recommend individualized fluid and vasopressor based on dynamic
optimization assessment of cardiovascular status
Use balanced crystalloids (Ringer’s lactate) as initial management for volume
expansion unless an indication for other fluids exists. Fluid losses can be
Fluid
important in high fever and diarrhoea but fluid overload will compromise
management
patients with ARDS. The volume of fluids should be individualised according to
the clinical context with achieving euvolaemia as target.
Check for palpable bladder. Urethral catheterisation NOT mandatory. Only
Exclude urinary
indicated if patient immobile, obstructed, uncooperative or critically ill. Urgent
obstruction
USS abdomen.
Sepsis Early recognition and treatment of secondary and opportunistic infections.
Both hyperglycaemia due to insulin resitance and hypercatabolism and
Glucose
hypoglycaemia due to severe sepsis and multi-organ failure can occur. Close
management
monitoring of blood glucose is required.
Nephrotoxin Limit nephrotoxic drug (including NSAIDS and aminoglycosides) exposure
management where possible. Careful monitoring needed.
Medicine Dosage and timing of drugs to take into account the reduced renal clearance.
management Stop nephrotoxins.
Optimization of intravascular volume status is the only specific intervention to
Use of contrast
prevent contrast nephropathy. Sodium bicarbonate or N-acetyl-cysteine not
media
useful. Do not withhold contrast if no other diagnostic options available.
RAAS inhibitors should only be stopped if there is hyperkalaemia or
RAAS inhibitors
hypotension. Restarted as soon as clinically possible.
Excessive PEEP might result in high systemic venous pressure and a
Lung-protective
reduction in kidney perfusion and glomerular filtration. Therefore,
mechanical
individualization of PEEP with consideration of its risks and benefits is
ventilation
recommended.
Risk of Increase protein intake to.3g/kg/d in AKI not on RRT and if on intermittent HD
malnutrition vs and up to 1.7 g/kg/d if on CVVHD. Early enteral feeding (prone position not a
impaired renal contraindication) is preferred over parenteral nutrition. Limitation of sodium,
clearance phosphate, potassium or fluid intake may be required in individual patients.
Patients with AKI at at risk of upper Gi bleed and a PPI should be prescribed
PPI
prophylactically.
Anticoagulation Please refer to the main National COVID-19 Guidelines
G. Timing of the initiation of RRT (renal replacement
therapy/dialysis)
Do not start RRT uniquely on the basis of urea and creatinine levels but also on the following:

 The clinical state of the patient

 Prolonged oligo-anuria
 The presence of life-threatening complications that cannot be treated medically
- hyperkalaemia - metabolic acidosis - fluid overload
- uraemic pericarditis - uraemic symptoms

Recent clinical trials show no advantage in pre-emptive start of RRT for AKI in critically ill
patients. RRT initiation may be delayed by a judicious and safe use of diuretics in fluid
overload has long as the patient is diuretic responsive, of enteral or IV sodium bicarbonate
for worsening metabolic acidosis and of calcium resonium for hyperkalaemia.

H. RRT use in patients with COVID-19 AKI

The advice of a nephrologist should be sought well before considering the initiation of RRT.

Indications Consider acute RRT when metabolic and fluid demands exceed total
kidney capacity. Consider the broader clinical context and conditions that
can be modified by RRT rather than urea or creatinine alone.
Modality CVVHD should be considered for haemodynamically unstable patients,
those with marked fluid overload, or in whom shifts in fluid balance are
poorly tolerated. Intermittent HD should be used in more stable patients.
Dose CVVHD: 12 to 24d/day- prescribed effluent dose of 25–30 ml/kg/h
Intermittent HD: First session should be limited to 2 hours at 150-
200ml/min pump speed to avoid disequilibration reaction and can be
repeated the next day. Once established, minimum three times per week
(alternate days) for 3 to 4 hours 200 to 300ml/min pump speed.
Vascular access Right IJ is the preferred site. Prone position, obesity and
hypercoagulability may affect vascular access performance
Antocoagulation The decision to use anticoagulation to maintain circuit patency should be
based on the individual potential risks and benefits.

II) ASSESSMENT AND TREATMENT OF ELDERLY PATIENT

In addition to the normal process of assessment and treatment conducted for

patients of any age with COVID-19, in a patient 70 years or older these following
potential issues should be assessed and treated.
Note that a collateral history taken from family in person or by phone is sometimes
essential in obtaining the relevant information.
 Alertness level, dementia and delirium:

o Score the GCS and in particular whether the patient is well-orientated

o Observe and note any agitation
o Is there a known background of dementia?
o Has there been the onset of delirium (fluctuating alertness, confusion,
hyperactivity or hypoactivity of behaviour in relation to the patient’s
normal behavior)?
o Check and record the blood glucose level
o Consider Psychiatry referral, especially if the patient is agitated or
severely distressed (e.g. with hallucinations)
o Avoid mechanically restraining the patient as far as possible, unless
there is an immediate health risk to the patient or to others that cannot
be otherwise dealt with (if so, record in notes)
 Mechanical restraints besides possibly causing emotional trauma
may increase risk of injury to the patient, further increase
agitation through pain or frustration due to restriction of freedom
of movement and positioning, and impair feeding, urination and
defaecation.

 Falling tendency:
o Did the patient usually have a falling tendency even before contracting
COVID-19?
o If so, the falling tendency is likely to be exacerbated with the illness,
increasing the risk of fracture, other injury, and functional incontinence
due to loss of mobility or loss of confidence in mobility to the toilet.
o Reducing number and dosage of prescribed medications, especially in
the case of anti-hypertensive and medications acting on the central
nervous system (e.g. benzodiazepines, anti-depressants, anti-
psychotics) has been shown to significantly decrease falls risk in the
elderly.

 Incontinence of urine and/or faeces:

o Is there urinary and/or faecal incontinence?
o Urinary catheterization is generally a poor solution for urinary
incontinence as it increases the risk of infections, haematuria, falls and
delirium
o Incontinence pads will generally be used

 Urinary retention:
 o If urinary catheterization is used, the necessity of keeping the catheter
in must be re-assessed on a daily basis, as it otherwise increases the
risk of complications as above
o Irrespective of the cause of urinary retention, assessment must occur
about whether the patient is also constipated, as constipation
commonly increases the risk of developing urinary retention in the
elderly

 Pressure sores:
o Assess for pressure sores (especially sacral) and note size, depth,
discharge, smell and appearance of sores
o Primary and secondary prevention are essential, as these can develop
very quickly in the elderly
o Avoid or remove any unnecessary lines and catheters, as these restrict
freedom of movement
o Ensure through communication with nursing staff that incontinence
pads are checked and changed as fast as possible after urination or
defaecation
o Recommend regular re-positioning of the patient (at least every 2
hours) paying particular attention to avoiding pressure on the sacrum,
heels, elbows, greater trochanters and neck
o Recommend a Ripple mattress if available
o Check the albumin level and recommend/prescribe protein
supplementation if no contraindications
o Refer early to Orthopaedics team

 Anorexia and poor feeding:

o Assess state of hydration and nutrition (e.g. is the patient

cachectic?), presence of dentures
o Chronic conditions such as dementia may cause poor feeding, as may
acute conditions

o Temporary NGT insertion for feeding may or may not be appropriate

after discussion with the family
 This options may cause distress to the patient, especially in the
case of confused patients with delirium or dementia
 The patient may pull on the tube, especially at night, therefore
dislodging the tube and/or causing harm to self
 Discussion of the pros and cons with family is therefore often
needed in order to prevent recurrent attempts at tube insertion
that may in some cases distress the elderly confused patient
unnecessarily, especially if the medical prognosis is estimated to
be poor
 Comorbidities:
o The elderly may of course suffer from the range of pathologies possibly
present in younger adults
o E.g. a myocardial infarction, fracture or schizoaffective disorder if
suspected should be appropriately assessed and treated

 Polypharmacy and drug dosing:

o In particular, before prescribing a drug in the elderly, consider:

 Polypharmacy.
 Polypharmacy means being on too many prescription
drugs, and is an independent risk factor for falls, and for a
broad range of other adverse reactions causing
complications requiring prolonged hospitalization.
 Do not “reflex-prescribe” in the elderly. Limit the number
of drugs and reduce their doses and duration wherever
other options are available. For example, some types of
pain may respond to using a heat pack together with low
doses of paracetamol.
 The weight of the patient.
 Many elderly patients have lost weight compared to when
they were younger, and this will affect doses for many
drugs, such as enoxaparin, phenytoin, etc.
 Renal impairment.
 Many elderly patients have renal impairment and this will
affect doses for a broad range of drugs.

 Hepatic impairment.
 Many elderly patients have liver dysfunction and this will
affect doses for a broad range of drugs.
 In particular, for paracetamol do not exceed the dose of 1
g three times a day.
 Congestive cardiac failure.
 Several drugs can worsen congestive cardiac failure, e.g.
NSAIDs.
 Electrolyte disturbance.
 Several drugs can cause hyponatraemia or disturbances
in potassium and magnesium levels in the elderly, for
example proton-pump inhibitors.
  Prescribe the minimum effective dose and stop the drug
when no longer needed.
 Falls risk.
 Medications treating high blood pressure, and
medications acting on the central nervous system,
increase falls risk in the elderly.
 Osteoporosis.
 Steroids such as prednisolone, and proton pump
inhibitors, are among a range of drugs associated with
osteoporosis.
 Prescribe the minimum effective dose and stop the drug
when no longer needed.
 Antibiotic resistance.
 Avoid unnecessary prescription of antibiotics, for example
for asymptomatic urinary tract infections in elderly
females, for which evidence for the prescription of
antibiotics is poor.
 Comorbidities.

 The elderly often have a number of diseases affecting

them concurrently. Safe prescription must take into
account comorbidities, e.g. a history of gastric ulcers
before prescribing dual anti-platelet therapy or prescribing
NSAIDs.
 Drug interactions.

 The elderly often take several drugs every day. It is

important to consider potential drug interactions before
adding a drug, especially with warfarin, lithium and other
drugs where the “therapeutic window” is important to
preserve.

III) MANAGEMENT PROTOCOL OF IMMUNOSUPPRESSED

PATIENTS

1. People who are considered to be immunosuppressed:

Patients with neutropenia, HIV / AIDS patients with CD4 count < 200 cells / mm 3,
patients with primary immunodeficiency
Patients on immunosupressive therapy (transplant patients, cancer patients on
chemotherapy in the last 4 weeks, patients treated for auto-immune disease with
immunosuppressants (e.g.methotrexate, azathioprine, mycophenolate mofetil,
cyclosporine, tacrolimus, cyclophosphamide, rituximab etc). The immunosuppressive
effect of these drugs may persist a few months after the last dose and possibly
beyond 6 months for rituximab and ATG.

2. Immunosuppressed patients without COVID-19 infection

Infection prevention
Practice social distancing, wear mask when outside, avoid crowded places, restrict
visitors and remain up-to-date on vaccines e.g. influenza.

Management
 Continue the same dose of immunosuppressant.
 Prioritize outpatient therapy over in-patient treatment
 Poursuite d’un traitement substitutif ou d’une antibiothérapie préventive pour
les DIP

3. Immunosuppressed patients infected by SARS-CoV -2

a. Clinical presentation

 Many patients will present in a similar manner to any other COVID-19 patients
who are not immunosuppressed.
 Consider atypical presentations of COVID-19 (eg no fever, loin pain in patients
with lower lobe infection) and have a low threshold for considering COVID-19.

 Exclude other causes for symptoms (eg CMV, pneumocystis, community or

hospital acquired pneumonia, influenza, urinary sepsis, lymphoma and fluid
overload among other diagnoses).
 A negative swab result requires repeat if clinical suspicion is high.
 Patients may have prolonged periods of SARS-CoV-2 PCR positivity although
not necessarily infectious.
 Proven or suspected cases must to be reported to the treating specialist

b. Management

 In general, treatment recommendations do not differ from those of non-

immunocompromised patients.
  Immunosuppressed patients are at higher risk of secondary and opportunistic
infections. Consider adjunctive antimicrobials if superadded bacterial infection
is suspected
 Deterioration to requirement for ventilation may occur precipitously and early
transfer to ENT Hospital is advised.
 Reduce the dose of prednisolone to < 20mg per day if possible.
 Hydroxychloroquine, chloroquine and sulfasalazine can be continued in
patients with active COVID-19.
 For most infected patients, withhold immunomodulators and biologics for at
least 2 weeks while monitoring the patient.
 Interrupting anti-cancer treatment in patients with active COVID-19 should be
based on the risk of interrupting treatment versus the “poorly defined risk of
adverse COVID-19 outcomes in patients receiving active cancer treatment.”
(to contact treating oncologist).
 Ensure drug-drug interactions are minimized

4. Cas particuliers:

a. HIV / AIDS patients infected by SARS-CoV-2

 Recommendations for the triage and management of COVID-19 in people with

HIV are the same as those for the general population.
 The treatment of COVID-19 in patients with HIV is the same as that for
patients without HIV.
 When starting treatment for COVID-19 in patients with HIV, clinicians should
pay careful attention to potential drug-drug interactions.
 Dexamethasone is an inducer of hepatic enzymes and could potentially lower
levels of certain co-administered anti-retroviral drugs. However, this interaction
is not expected to be clinically significant based on the short duration of
dexamethasone therapy (up to 10 days) in the RECOVERY trial. Although
some anti-retroviral drugs are being studied for the prevention and treatment
of COVID-19, no agents have been shown to be effective.
 For more details on management of HIV patients, contact the AIDS physician

b. Immunosuppressed kidney patients infected by SARS-CoV-2

 Patients with kidney transplants, lupus nephritis, renal vasculitis, nephrotic
syndrome and various glomerular diseases may be on significant
immunosuppression.
 These patients are at risk of acute kidney injury (AKI). Fluid administration to
maintain circulating volume but avoid significant overload. Please refer to
“Management of COVID-19 associated Acute Kidney Injury” guidelines.

Immunosuppression
strategy in kidney Asymptomatic/ mild Needing oxygen Critically ill
patients
Steroids Continue maintenance Start dexamethasone Start dexamethasone
dose steroids. 6mg daily for 10 days. in patients with severe
High or increased dose If not indicated, COVID pneumonia. If
 steroid is NOT continue or moderately not indicated, continue
recommended at this increase maintenance or moderately increase
stage steroids. maintenance steroids.
Antiproliferative
agents STOP
(MMF/Azathioprine)
Cytotoxic drugs
(cyclophosphamide)
Antimetabolite drugs
STOP
(methotrexate)
Calcineurin Inhibitors Review overall burden Consider reducing or Dramatically reduce or
CNI (cyclosporin/ of immunosuppression. stopping CNI pre- stop CNI pre-
tacrolimus) If high, reduce emptively. emptively.
accordingly
If AKI, CNI levels must be requested urgently.

 Recommencement of immunosuppression is best done by the (treating)

nephrologist. Regular monitoring of renal function is essential. It is essential to
organize a clear follow-up with the nephrology team.
 If asymptomatic or mild disease: Consider restarting immunosuppression 14
days after onset of symptoms if symptom free in absence of antipyretics for
minimum of 3 days.
 If moderate or severe disease: There may be a rather prolonged period
(during which immunosuppression should be kept low) before full recovery of
the immune system leads to acute rejection or kidney disease relapse
depending on the individual patient.
 For more details on management of kidney patients, contact the nephrologist

VI) PREGNANCY AND NEWBORN BABIES

1. COVID-19 infection in pregnancy will be managed regional wise in the five

regional hospitals.
2. Isolation rooms should be set up for safe labor and delivery and neonatal
care. Since maternity and newborn care units vary in physical configuration in
the 5 regional hospitals, each facility should consider their appropriate space
and staffing needs to prevent transmission of the virus that causes COVID-19.
3. The following setup facilities should be ensured:
a. An isolation ward for ante/postpartum patients
b. A separate room for delivery
c. OT facilities to perform CS
d. ICU facilities if ever the need arises
4. All medical staff involved in management of infected women should do PPE
(personal protective equipment) as required.
5. All staff engaged in obstetrics should receive training for COVID-19
infection control.
6. For transfer of confirmed cases, the attending medical team should do PPE
and keep themselves and their patient a minimum distance of 1–2 meters
from any individuals without PPE.
7. Pregnant healthcare professionals should follow risk-assessment and infection
control guidelines following exposure to patients with suspected, probable or
confirmed COVID-19.
8. Chest imaging, especially CT scan, should be included in the work-up of
pregnant women with suspected, probable or confirmed COVID-19 infection.
9. Following an ultrasound scan of a suspected, probable or confirmed COVID-
19-infected pregnant patient, surfaces of transducers should be cleaned and
disinfected.
10. Maintain oxygen saturation level to minimize maternal hypoxia and hence fetal
distress.
11. Treatment with hydroxychloroquine as per protocol of Ministry of Health &
Wellness

Antepartum care

a. During the COVID-19 epidemic period, a detailed history regarding

recent travel, occupation, significant contact and cluster (TOCC) and
clinical manifestations should be acquired routinely from all pregnant
women attending for routine care.
b. Obstetrical patients with respiratory symptoms should be asked to wear
a surgical mask immediately upon presentation to the health care facility.
c. Women suspected of having or having been exposed to COVID-19
should be triaged quickly, given a mask to wear, and transferred to the
isolation ward as quickly as possible and referred to the medical unit.
d. Threshold for testing in pregnant women should be low.
e. Discuss with the physician before initiation of antepartum corticosteroids
for fetal maturation. WHO guidance and some clinical evidence does not
recommend the use of corticosteroids for COVID-1
f. For those with confirmed infection who are asymptomatic or
recovering from mild illness, should be monitored with 2–4weekly
 ultrasound assessment of fetal growth and amniotic fluid volume, with
umbilical artery Dopplerif necessary.

Intrapartum care

g. All stages of labour should be carried out in a dedicated isolated room.

h. Patients will be given a mask to wear.
i. Only essential staff should enter the room and should be kept to a
minimum.
j. Droplet/contact precautions should be used, including wearing a
surgical mask with eye protection, a gown, and gloves.
k. Given that intubation is considered an aerosol-generating procedure, the
surgical team should wear N95 respirators for cesarean delivery in case
there is a need to convert from neuraxial to general anesthesia.
l. Elective cesarean delivery should be delayed, if possible, until a woman
is no longer considered infectious.
m. Appropriate patient transfer planning should be made so as to minimize
exposure of other patients in the hospital.
n. Miscarried embryos/fetuses and placentae of COVID-19-infected
pregnant women should be treated as infectious tissues and disposed of
appropriately; if possible, testing of these tissues for COVID-19 by
quantitative reverse transcription polymerase chain reaction (qRTPCR)
should be undertaken.

Postpartum and Newborn care

a. Regardless of the gestational age at which a pregnant woman was

infected COVID-19, the newborn infant should be tested for COVID-
19 at birth (i.e., nasopharyngeal swab and umbilical swab for COVID-
19 polymerase chain reaction)

b. Universal isolation of the infant from either confirmed or not

If suspected infection in the mother is not recommended.
However, depending on a family’s values and availability
of resources they may choose to separate infant from
mother until isolation precautions for the mother can be
formally discontinued.

If the patient is asymptomatic or mildly affected, breastfeeding

and co-location (also called rooming-in) can be considered
by the mother in coordination with healthcare providers,
or may be necessary if facility limitations prevent
mother-baby separation.
 • Women should practice good handwashing before and use of
a mask while engaging in infant care.

• There is currently no evidence to suggest that the virus can be

transmitted through breast milk. Women who choose to breastfeed
should be allowed to do so after appropriate handwashing and while
wearing a mask. It is possible that the mother can transmit antibodies
to the infant through breastmilk; however, there is limited evidence of
this transmission and the potential benefits are unclear.

Management of babies born to COVID-19 positive mothers

 Precautions for birth attendants:

Staff attending a birth when the mother has COVID19 should use
gown and gloves, with either an N95 respiratory mask and eye
protection goggles or with an air purifying respirator that provides eye
protection. The protection is needed due to the likelihood of maternal
virus aerosols and the potential need to perform newborn resuscitation
that can generate aerosols.

 Rooming-in for mothers and well newborns:

While difficult, temporary separation minimizes the risk of postnatal infant infection
from maternal respiratory secretions. If possible, admit the infant to an area
separate from unaffected infants, and wear gowns, gloves, eye protection goggles
and standard procedural masks for newborn care.

If the center cannot place the infant in a separate area - or the mother chooses
rooming-in despite recommendations - ensure the infant is at least 6 feet from the
mother. An isolette (closed incubator) can help facilitate separation.

 Breastfeeding:

Because studies to date have not detected the virus in breast

milk, mothers may express breast milk after appropriate breast
and hand hygiene. Caregivers who are not infected may feed
the breast milk to
the infant. Mothers who request direct breastfeeding should
comply with strict preventive precautions that include use of a
mask and meticulous breast and hand hygiene.

 Intensive care :
L’ICU néonatal national pour les enfants de moins de 40 jours et infectés par le
SARS-CoV2, est situé à l’hôpital Jeetoo.

 Conduite à tenir devant une suspission d’infection à COVID chez les

nouveaux nés et les enfants

Bathe newborn after birth to remove virus potentially present on skin surfaces (as
is being done for HIV exposed babies).

o Test first at around 2 hours of age

• Use one swab to sample first the throat and then the
nasopharynx. Place single swab in one viral transport
media tube and send it to the lab for molecular testing.

• For infants who are positive on their initial testing, follow

up testing of combined throat/nasopharynx specimens
should be done at day 5 and then tous les 3 jours

o Positive test results:

If an infant tests positive for COVID-19 but does not display

symptoms, plan for frequent inpatient followup through 10 days

o Negative test results:

Discharge the infant, ideally, to the care of a designated

healthy caregiver. The mother should maintain a 6-foot
distance when possible and use a
mask and hand hygiene when directly caring for the infant until
either she has negative results from a COVID19 test from at least
two consecutive specimens collected 24 or more hours apart.