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

Abstract

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.

An Early Warning Mobile Health Screening and Risk Scoring App for Preventing In-Hospital Transmission of COVID-19 by Health Care Workers: Development and Feasibility Study

“…Similarly, regular routine DNA-PCR testing is globally recognized as unfeasible, especially in low- and middle-income countries; therefore, in-hospital transmission of COVID-19 remains a substantial challenge [ 17 , 18 ].…”

Continuous positive airway pressure for moderate to severe COVID-19 acute respiratory distress syndrome in a resource-limited setting

“…Patients were admitted in Covid19 unit at BCH based on Respiratory failure (SpO2 < 90% or Respiratory Rate > 30), in the presence of a clinical history and examination suggestive of Covid19 pneumonia with appropriate radiological and laboratory findings (14). SARS-CoV-2 PCR was performed on affording patients but limited due to cost and availability (6). However, all patients tested had positive results, and Covid 19 antigen testing was implemented from August.…”

Continuous Positive Airway Pressure (CPAP) for Moderate to Severe Covid19 Acute Respiratory Distress Syndrome (CARDS) in a Resource limited setting

“…Patients were admitted in Covid19 unit based on Respiratory failure (SpO2 < 90% or Respiratory Rate > 30), in the presence of a clinical history and examination suggestive of Covid19 pneumonia (Acute onset fever, cough, dyspnea, crepitations on lung auscultation) with appropriate radiological and laboratory findings (Infiltrates on CXR +/- lymphopenia on CBC)(14). SARS-CoV-2 PCR was performed on affording patients but limited due to cost and availability(20). However, all patients tested had positive results.…”