Optimizing clinical approaches to COVID-19 patients in primary care


Authors: Bohumil Seifert 1;  Martin Balík 2;  Václava Bártů 3;  Ludmila Bezdíčková 4;  Vladimír Černý 5;  Ivana Čierná-Peterová 6;  Jozef Čupka 2;  Pavel Dlouhý 7;  David Halata 8;  Igor Karen 9;  Petr Kessler 10;  Vladimír Koblížek 11;  Norbert Král 1;  Tomáš Kvasnička 12;  Jan Kvasnička 12;  Cyril Mucha 1;  Miroslav Penka 13;  Štěpán Svačina 14;  Jana Šeblová 15;  Martin Špaček 16;  Milan Trojánek 17
Authors‘ workplace: Ústav všeobecného lékařství 1. LF UK v Praze 1;  Oddělení hematologie a transfuziologie, Nemocnice Pelhřimov 10;  Plicní klinika LF UK a FN Hradec Králové 11;  Trombotické centrum, Ústav lékařské biochemie a laboratorní, diagnostiky 1. LF UK a VFN v Praze 12;  Interní hematologická a onkologická klinika LF MU a FN Brno 13;  3. interní klinika – klinika endokrinologie a metabolismu, 1. LF UK a VFN v Praze 14;  Oddělení urgentního příjmu a LSPP dětí, FN Motol, Praha 15;  1. interní klinika – klinika hematologie 1. LF UK a VFN v Praze 16;  Klinika infekčních nemocí 2. LF UK a FN Na Bulovce, Praha 17;  Klinika anesteziologie, resuscitace a intenzivni mediciny, 1. LF UK a VFN v Praze 2;  Plicní oddělení, Medicon, a. s., Praha 3;  Praktický lékař, Praha 4;  Klinika anesteziologie, perioperační a intenzivní medicíny, UJEP a Masarykovy nemocnice v Ústí nad Labem 5;  Plicní ambulance, Brandýs nad Labem 6;  Infekční oddělení, Krajská zdravotní, a. s. – Masarykova, nemocnice v Ústí nad Labem, o. z. 7;  Praktický lékař, Hošťálková 8;  Praktický lékař, Benátky nad Jizerou 9
Published in: Čas. Lék. čes. 2021; 160: 119-125
Category: Original Articles

Overview

There is insufficient evidence from medical studies for clinical approaches to patients with COVID-19 in primary care. Patients often urge the therapeutic use and preventive administration of various medicines, often controlled by studies insufficiently or completely unverified. The aim of the project, commissioned by the Committee of the Society of General Practice of the Czech Medical Association JEP, was to compensate for this deficiency by interdisciplinary consensus and thus provide general practitioners (GPs) with a basic support in accessing patients with COVID-19. Representatives of GPs identified the most common questionable diagnostic or therapeutic approaches and formulated 17 theses, taking into account their own experience, existing Czech and foreign professional recommendations. The RAND/UCLA Appropriateness Method, modified for the needs of pandemic situation, was chosen to seek consensus. Representatives of 7 medical specialties accepted the participation in the 20-member panel. The panel evaluated in 2 rounds, with the comments and opinions of others available to all panelists before the second round. The outcome of the evaluation was agreement on 10 theses addressing the administration of vitamin D, inhaled corticosteroids in patients with COPD and bronchial asthma, acetylsalicylic acid, indications for D-dimer levels examination, preventive administration of LMWH, importance of pulse oximetry, indication for emergency services, indication for antibiotics and rules for distant contact. The panel disagreed on 6 theses recommending the administration of ivermectin, isoprinosine, colchicine and corticosteroids in patients with COVID-19 in primary care. One thesis, taking into account the use of D-dimers in primary care was evaluated as uncertain. The most discussed theses, on which there was also no agreement, were outpatient administration of corticosteroids and the importance of elevation of D-dimers levels or their dynamic increase in a symptomatic patient with COVID-19 as an indication for referral to hospital. The results of the consensus identified topics that need to be further discussed and on which it is appropriate to focus further research.

Keywords:

triage – allocation – scarce resources – ethics – law – recommendations


Sources

1. WHO. Role of primary care in the COVID-19 response. World Health Organization. Regional Office for the Western Pacific, Manila, 2021 Apr 9. Dostupné na: https://apps.who.int/iris/handle/10665/331921

2. Seifert B, Bezdíčková L, Mucha C, a kol. Pandemie infekce COVID-19 a primární péče. Doporučené diagnostické a terapeutické postupy pro všeobecné praktické lékaře. Společnost všeobecného lékařství ČLS JEP, 23. 11. 2020. Dostupné na: www.svl.cz/doporucene-postupy/doporucene-postupy- -pro-pl-zpracovane-od-2020

3. SIL. COVID-19: diagnostika a léčba mimo nemocnice. Doporučený postup. Společnost infekčního lékařství ČLS JEP, 11. 3. 2021. Dostupné na: www.infekce. cz/Covid2019/MimoNemocnice-0321.pdf

4. Kudela O, Skácel Z, Pekárek Z, a kol. Ambulantní péče o nemocné s COVID-19. Stručný poziční dokument ČPFS ČLS JEP. Česká pneumologická a ftizeologická společnost ČLS JEP, duben 2021. Dostupné na: www.pneumologie. cz/upload/1619183495.8491.doc

5. ČSTH. Antitrombotická profylaxe u nemocných s COVID-19. Doporučený postup. Česká společnost pro trombózu a hemostázu ČLS JEP, 13. 11. 2020. Dostupné na: https://csth.cz/wp-content/uploads/2020/11/COVID_tromboprofylaxe_ doporučení_ČSTH_final_2020-11-13.pdf

6. Marek Š, Chrdle A, Husa P, a kol. COVID-19: diagnostika a léčba. Doporučený postup. Společnost infekčního lékařství ČLS JEP, 19. 4. 2021. Dostupné na: www.infekce.cz/Covid2019/DPcovid-19_SIL_0421.pdf

7. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User's Manual. RAND, 2001. Dostupné na: www.rand.org/pubs/ monograph_reports/MR1269.html

8. Jandhyala R. Delphi, non-RAND modified Delphi, RAND/UCLA appropriateness method and a novel group awareness and consensus methodology for consensus measurement: a systematic literature review. Curr Med Res Opin 2020; 36: 1873–1887.

9. Carson-Stevens A, Campbell S, Bell BG, et al. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Fam Pract 2019; 20: 134.

10. Basger BJ, Chen TF, Moles RJ. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method. BMJ Open 2012; 2: e001431.

11. Taylor A, Broadbent M, Gurung A, Wallis M. The development of a modified comprehensive geriatric assessment for use in the emergency department using a RAND/UCLA appropriateness method. Int Emerg Nurs 2021; 55: 100847.

12. Král N, de Waard AK, Schellevis FG, et al. What should selective cardiometabolic prevention programmes in European primary care look like? A consensus- based design by the SPIMEU group. Eur J Gen Pract 2019; 25: 101–108.

13. RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med 2021; 384: 693–704.

14. Bassetti M, Kollef MH, Timsit JF. Bacterial and fungal superinfections in critically ill patients with COVID-19. Intens Care Med 2020; 46: 2071–2074.

15. Kreitman L, Monard C, Dauwalder O, et al. Early bacterial co‑infection in ARDS related to COVID‑19. Intens Care Med 2020; 46: 1787–1789.

16. Li J, Liu Z, Wu G, et al. D-dimer as a prognostic indicator in critically ill patients hospitalized with COVID-19 in Leishenshan Hospital, Wuhan, China. Front Pharmacol 2020; 11: 600592.

17. van der Hulle T, den Exter PL, Erkens PGM, et al. Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism. J Thromb Haemost 2013; 11: 1986–1992.

18. NIH. Antithrombotic therapy in patients with COVID-19. National Institutes of Health, 2021 Feb 11. Dostupné na: www.covid19treatmentguidelines.nih.gov/ antithrombotic-therapy

19. Pořízka M, Volný L, Kopecký P, et al. Immature granulocytes as a sepsis predictor in patients undergoing cardiac surgery. Interact Cardiovasc Thorac Surg 2019; 28: 845–851.

20. Meisner M. Pathobiochemistry and clinical use of procalcitonin. Clin Chim Acta 2002; 323: 17–29.

21. Ivermectin for COVID-19. Covid Analysis. c19early.com, 2020 Nov 26. Dostupné na: https://c19ivermectin.com

22. Nauen DW, Hooper JE, Stewart CM, Solomon IH. Assessing brain capillaries in coronavirus disease 2019. JAMA Neurol 2021; 78: 760–762.

23. Lee MH. Microvascular injury in the brains of patients with Covid-19. N Engl J Med 2021; 384: 481–483.

24. Pun BT, Badenes R, Heras La Calle G, et al. Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study. Lancet Respir Med 2021; 9: 239–250.

25. Lopez-Medina E, Lopez P, Hurtado CI, et al. Effect of ivermectin on time to resolution of symptoms among adults with mild COVID-19. A randomized clinical trial. JAMA 2021; 325: 1426–1435.

26. Beran J, Šalapová E, Špajdel M; Isoprinosin study team. Inosine pranobex is safe and effective for the treatment of subjects with confirmed acute respiratory viral infections: analysis and subgroup analysis from a phase 4, randomised, placebo-controlled, double-blind study. BMC Infect Dis 2016; 16: 648.

27. Rumel AS, Newman AS, O’Daly J, et al. Inosine Acedoben Dimepranol promotes an early and sustained increase in the natural killer cell component of circulating lymphocytes: a clinical trial supporting anti-viral indications, Int. Immunopharmacology 2017; 42: 108–114.

28. Zingaropoli MA, Perri V, Pasculli P, et al. Major reduction of NK T-cells in patients with severe COVID-19 pneumonia. Clin Imunol 2021; 222: 108630

29. Diao Bo, Wang C, Tan Y, et al. Reduction and functional exhaustion of T-cells in patients with coronavirus disease 2019 (COVID-19). Front Immunol 2020; 11: 827.

30. Tardif JC, Bouabdallaoui N, L’Allier PL, et al.; COLCORONA Investigators. Colchicine for community-treated patients with COVID-19 (COLCORONA): a phase 3, randomised, double-blinded, adaptive, placebo-controlled, multicentre trial. Lancet Resp Med 2021: S2213-2600(21)00222-8.

31. RECOVERY Collaborative Group. Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet 2021; 397(10289): 2049–2059.

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