Moscow Healthcare Department Moscow clinical hospital 52 management

ДЕПАРТАМЕНТ ЗДРАВООХРАНЕНИЯ ГОРОДА МОСКВЫ Moscow Healthcare Department Moscow clinical hospital № 52: management of patient with community-acquired pneumonia (CAP) suspected COVID and COVID +

Community-acquired pneumonia (CAP) suspected COVID and COVID + 1 Assessment of patient severity at admission - NEWS (National Early Warning Score) 2 Collection of patient symptom’s information at admission (filled by patient ) 3 Initial diagnosis of the patient 4 Confirmation of CAP diagnosis 5 Produce infiltration of lung tissue on CT o COVID-19 virus testing (nasal/throat swab) o influenza testing (nasal swab) o Sputum culture (if available) or bronchoalveolar lavage for other etiological agents of pneumonia analysis 6 Assessment of pneumonia severity based on CT data and risk factors (LABs, Comorbidities, Vital Signs ) 7 Prescription of pathogenic therapy 8 Therapy assessment according to criteria of efficiency 9 Patient's condition monitoring 1

Assessment of pneumonia severity based on CT data Signs ∙ ∙ No more than 3 seal foci of ground glass type <3 cm in maximum diameter ∙ ∙ More than 3 seal foci of ground glass type <5 cm in maximum diameter ∙ Seal foci of ground glass type combined with foci of consolidation ∙ Diffuse compaction of lung tissue of ground glass type and consolidation combined with reticular modification Severity Typical picture Mild (CT-1) Moderate (CT-2) Moderate-severe (СT-3) Severe (CT-4) 2

Assessment Risk Factors for COVID-19 Disease Progression Epidemiological – Category 1 Vital Signs – Category 2 Labs – Category 3 Age > 65 Respiratory rate > 28 breaths/min D-dimer > 1000 ng/m. L Chronic pulmonary disease Heart rate > 125 beats/min CRP > 50 Chronic kidney disease Sp. O 2 ≤ 94% on ambient air Elevated troponin Diabetes Fever more than 38º Ferritin > 300 mcg / l History of transplantation or other immunosuppression Admission absolute lymphocyte count < 1000 Cardiovascular disease LDH > 245 U/L Obesity II, III 3

CT-1 without risk factors STAGE 1 STAGE 2 Pathogenic treatment Disintoxication therapy + Antipyretics (paracetamol 500 mg orally, no more than 2. 0 g per 24 hours) СT-1 + risk factors СT-2 without risk factors hydroxychloroquine 400 mg PO BID x 2 followed by 400 mg daily while hospitalized, up to 7 days +azithromycin 500 mg daily within 7 days if therapy is ineffective (CT-2, 3, 4) hydroxychloroquine 400 mg PO BID x 2 followed by 400 mg daily while hospitalized, up to 7 days + azithromycin 500 mg daily within 7 days concilium for decision of prescribing OR STAGE 3 СТ-2 + risk factors СT-3, 4 hydroxychloroquine 400 mg PO BID x 2 followed by 400 mg daily while hospitalized, up to 10 days + darunavir 600 mg x 2 daily + ritonavir 100 mg x 2 within 14 days tocilizumab (Actemra) or sarilumab (Kevlar) or ? OR kaletra (200 mg/50 mg) x 2 within 5 -7 days C-RP > 30 mg/l Levofloxacin 500 mg x 2 within 7 -10 days OR* Moxifloxacin 400 mg once a day within 7 -10 days OR Amoxicillin/clavulanate 1000 mg x 2 within 7 -10 days OR Amoxicillin 1000 mg x 3 within 7 -10 days 4

Patients on Tocilizumab N=77 Sp. O 2= 90. 28 ± 4. 89 Mean age (sd)= 54. 06± 13. 9 H_CRB_L_Lymph = 45/77 (58. 4%) 21/77 56/77 15 - lung ventilation support 15(21) CT initial CRB Day of disease 12 8 4 CT initial no GW ICU 5

CLINICAL CASE 1 Gender: male, Age: 69 Co-morbidities: none Therapy: Disease days: 7 -th on admission Temperature: 38. 7 C Tocilizumab 27. 03. 20 (4 d day/10 th disease day) Sat. O 2: 92% Antibiotic therapy 4 -14 days Initial CT: 3 Control CT: 3+ Hydroxychloroquine + Lopinavir + Ritonavir LYM, (10^6/l)= 1100 CRP, mg/l= 73, 52 IL-6, pg / ml= 36, 1 Hospitalization date: 25. 03. 20 4 LYM, (10^6/l)= 900 9 LYM, (10^6/l)= 1300 CRP, mg/l= 43, 4 10 13 LYM, (10^6/l)= 1400 CRP, mg/l= 35, 9 CRP, mg/l= 89, 36 28. 03. 20 06. 04. 20 Patient’s discharge date: 07. 04. 20 6

CLINICAL CASE 2 Gender: male, Age: 71 Co-morbidities: hypertonic disease, obesity I, arrhythmia Disease days: 6 -th on admission Temperature: 38. 1 C Therapy: Sat. O 2: 82% Initial CT: 4 Control CT: 4 Tocilizumab: 27. 03. 20 (1 st day/7 th disease day) 1 LYM, (10^6/l)= 800 CRP, mg/l= 301 IL-6, pg / ml>1000 Hospitalization date: 27. 03. 20 2 LYM, (10^6/l)= 1300 CRP, mg/l= 429 IL-6, pg / ml=472 Antibiotic therapy (1 -4 days) 3 LYM, (10^6/l)= 1300 CRP, mg/l= 407 4 LYM, (10^6/l)= 1400 CRP, mg/l= 321 Death date: 30. 03. 20 7

CLINICAL CASE 3 Gender: male, Age: 61 Co-morbidities: hypertension disease Disease days: 8 -th day on admission Therapy: Initial CT: 3 Control CT: 3+ Temperature: 38, 5 C Tocilizumab - 31. 03. 20 (5 th day/13 th disease day) Sat. O 2: 90% Antibiotic therapy (1 -12 days) 1 Hydroxychloroquine 1 -12 days + Lopinavir + Ritonavir 3 -12 days 5 6 LYM, (10^6/l)= 1000 CRP, mg/l= 91 LYM, (10^6/l)= 900 CRP, mg/l= 206^31 LYM, (10^6/l)= 1420 CRP, mg/l= 46, 6 IL-6, pg / ml=101 Hospitalization date: 27. 03. 20 31. 03. 20 04. 20 Patient’s discharge date: 07. 04. 20 8

Thank you for your attention ! 9