Covid-19 Prophylaxis & Treatment

Severity Category

• Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 by virologic testing using a molecular diagnostic (RT-PCR) or antigen test, but have no symptoms.
• Mild: Individuals who have any of the various signs and symptoms of COVID 19 (e.g. fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.
• Moderate: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SpO2 ≥94%
• Severe: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94%, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%
• Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction

UP Govt Guidelines (6th Aug 2020)

• Prophylaxis in contacts: Ivermectin 200 μg / Kg BW on Day 1 and Day 7, 2 hours after dinner
• For Prophylaxis in health care workers: Ivermectin 200 μg / Kg BW on Day 1, 7 & 30, followed by once in a month
• For treatment of Asymptomatic or mild symptomatic covid Positive:
  • Ivermectin 200 μg / Kg BW (max=12 gm) for 3days.
  • Azithromycin 1o mg/kg BW (adult 500 mg) for 3 days.
  • Cap Doxycyclin 100 mg twice daily from 4th day to 10th day.
  • Vitamin C 500 mg thrice daily for 10 days
  • Zinc 50 mg twice daily for 10 days
  • Vitamin-D 60K once a week.
• Ivermectin: Not for pregnant, lactating mothers and children below 2 yrs of age
• Doxycyclin: Not for pregnant, lactating mothers and children below 12 yrs of age

Treatment of mild Covid

Only symptom of fever & URTI. Rx as advised above.

Treatment of moderate Covid

Pneumonia, RR 24+, sPO2 less than 94, but no signs of Severe disease.

• Favipiravir, under the brand name FabiFlu (for mild to moderate). 200 mg tablet, recommended dose being 1,800 mg twice daily on day one, followed by 800 mg twice daily up to day 14. (MRP) of Rs 3,500 for a strip of 34 tablets.
• O2 by non-rebreathing mask, or nasal canula with N95 mask over canula.
• Awake proning.

Treatment of severe Covid

• Inj. Solumedrol 40-60 mg IV b.d. x 5-7 days
• Inj. Enoxaparin 40 mg sc b.d. or heparin prophylaxis. Dalteparin 5000 units bd.
• HFNC (high flow nasal canula)
• Antibiotics: Ceftriaxone, Doxycycline
• Awake proning
• Ventilator: ARDSnet protocol (LTV, proning, etc)
• Remdesivir. Covifor 200mg inj, COVIFOR 100 mg vial (Hetero). 200 mg 1st day. Then 100mg od. 5day course.
• Inj. Tocilizumab 8mg/kg IV infusion single dose.
• Convalescent plasma.
• NOAC therapy at discharge.

Defining ARDS

Onset: new or worsening respiratory symptoms within one week of known clinical insult.
Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.
Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.

Oxygenation (adults):

• Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cm H2O, or nonventilated)
• When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

Oxygenation (children, note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)

• Bilevel NIV or CPAP ≥5 cm H2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
• Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Septic shock

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level < 2 mmol/L
Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; bradycardia or tachycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

Points to remember

• Corona is not a lung disease
• It is a hyper inflammation Vasculitis
• Treatment is Anti coagulants and immune suprresants
• Anti Virals even Remdesiver has not shown to reduce mortality. They only shorten hospital stay
• Starting treatment early even with Ivermectin and Doxycycline, followed by LMWH and dexamethasone at right time can reduce need of Remdesiver and Tocilizumab

More & more info coming..

• There are papers that Sirolimus with dexamethasone given early day 5 or6 can prevent many complications as Cytokine Strom Syndrome.
• Anticoagulants may need to be given for 3weeks or more.
• People are developing Myocardial infarctions, Stroke , etc few weeks after Corona infection. Usually it is because of Thromboembolic phenomenon