Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries

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  • 1 Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand;
  • 2 Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;
  • 3 Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;
  • 4 Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom;
  • 5 Department of Internal Medicine, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia;
  • 6 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Toronto, Canada;
  • 7 Operational Research Unit, Doctors with Africa – CUAMM, Padova, Italy;
  • 8 Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy;
  • 9 Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand;
  • 10 Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina

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.

Author Notes

Address correspondence to Marcus J. Schultz, Department of Intensive Care Amsterdam University Medical Centers, Location ‘AMC’, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands. E-mail: marcus.j.schultz@gmail.com

Group members of the “COVID–LMIC Task Force”

(Heads) Alfred Papali (Atrium Health, Charlotte, NC, USA) and Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC”, Amsterdam, The Netherlands).

(Advisors) Neill K. J. Adhikari (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada); Emilie J. Calvello Hynes (University of Colorado School of Medicine, Department of Emergency Medicine, Denver, USA); Martin Dünser (Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria) and Mervyn Mer (University of the Witwatersrand, Johannesburg, South Africa).

(Subgroup members, in alphabetic order) Andrew Achilleos (Sunnybrook Health Sciences Centre, Toronto, Canada); Hanan Y. Ahmed (Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia); Kevan M. Akrami (Universidade Federal da Bahia, Faculdade de Medicina, Salvador, Brazil and Division of Infectious Disease, Department of Medicine, University of California San Diego, San Diego, USA); Lia M. Barros (University of Washington, Seattle, USA); B. Jason Brotherton (AIC Kijabe Hospital, Kijabe, Kenya); Sopheakmoniroth Chea (CalmetteHospital, Phnom Penh, Cambodia); William Checkley (The Johns Hopkins University School of Medicine and The Johns Hopkins University Center for Global Health, Baltimore, USA); Elif A. Cizmeci (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Natalie Cobb (University of Washington, Seattle, USA); Finot Debebe (Department of Emergency Medicine and Critical Care, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia); Juliana Ferreira (University of São Paulo, São Paulo, Brasil); Gabriela Galli (University of Pittsburgh School of Medicine, Pittsburgh, USA); Tewodros Haile (Department of Internal Medicine, College of Health Sciences, Addis Ababa University); Bhakti Hansoti (Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA); Madiha Hashmi (Ziauddin University, Karachi, Pakistan); Rebecca Inglis (Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao People's Democratic Republic and Department of Intensive Care, Oxford University Hospital Trust, Oxford, United Kingdom); Burton W. Lee (Critical Care Department, NIH, Bethesda, USA; Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, USA); Faith Lelei (AIC Kijabe Hospital, Kijabe, Kenya); Ganbold Lundeg (Mongolian National University of Medical Sciences, Ulan Bator, Mongolia); David Misango (The Aga Khan University, Nairobi, Kenya); Ary Serpa Neto (Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia; Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', University of Amsterdam, Amsterdam, The Netherlands); Alfred Papali (Atrium Health, Charlotte, NC, USA); Casey Park (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Rajyabardhan Pattnaik (Ispat General Hospital, Rourkela, India); Jennifer L. Pigoga (Division of Emergency Medicine, University of South Africa, Cape Town, South Africa); Luigi Pisani (Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Doctors withAfrica – CUAMM, Padova, Italy; Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand); Elisabeth D. Riviello (Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA); Kristina E. Rudd (University of Pittsburgh School of Medicine, Pittsburgh, USA); Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC”, Amsterdam, The Netherlands); Varun U. Shetty (University of Pittsburgh Medical Center, Pittsburgh, USA); Gentle S. Shrestha (Tribhuvan University Teaching Hospital, Kathmandu, Nepal); Chaisith Sivakorn (Mahidol University, Salaya, Thailand); Shaurya Taran (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada); T. Eoin West (University of Washington, Seattle, USA).

Group members of the subgroup ‘diagnostic testing and prognostic modeling’

Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, UK; Amsterdam University Medical Centers, location “AMC”, Amsterdam, The Netherlands); Tewodros Gebremariam (Department of Internal Medicine, College of Health Sciences, Addis Ababa University), Casey Park (Interdepartmental Division of Critical Care Medicine, Toronto, Canada), Luigi Pisani (Mahidol–Oxford Tropical Medicine Research Unit’ (MORU), Bangkok, Thailand), Chaisith Sivakorn (Department of Clinical Tropical Medicine, Bangkok, Thailand), Shaurya Taran (Interdepartmental Division of Critical Care Medicine, Toronto, Canada), and Alfred Papali (Atrium Health, Charlotte, NC, USA).

Authors’ addresses: Marcus J. Schultz, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, and Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom, E-mail: marcus.j.schultz@gmail.com. Tewodros H. Gebremariam, Department of Internal Medicine, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia, E-mail: drtewodroshaile@gmail.com. Casey Park and Shaurya Taran, Interdepartmental Division of Critical Care Medicine, Department of Medicine, Toronto, Canada, E-mails: casey.park@medportal.ca and shaurya.taran@mail.utoronto.ca. Luigi Pisani, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand, Operational Research Unit, Doctors with Africa – CUAMM, Padova, Italy, and Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy, E-mail: luigipisani@gmail.com. Chaisith Sivakorn, Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand, E-mail: chaisith.siv@mahidol.edu. Alfred Papali, Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, NC, E-mail: alfred.papali@atriumhealth.org.

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