Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics

Abstract

In December, 2019, numerous un­ explained pneumonia cases occurred in Wuhan, China. This outbreak was confirmed to be caused by severe acute respiratory syndrome corona virus 2 (SARS­CoV­2), belonging to the same family of viruses responsible for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). The SARS epi demic in 2003 was controlled through numerous measures in China. One effect ive strategy was the establishment of fever clinics for triaging patients. Based on our first­hand experience in dealing with the present outbreak in Wuhan, we have established the following clinical strategies in adult fever clinics (figure). Patients can be afebrile in the early stages of infection, with only chills and respiratory symptoms. High temperature is not a general presentation. Elevated C­reactive protein (CRP) is an important factor of 2019 novel coronavirus disease (COVID­19; formally known as 2019­nCoV) and impaired immunity, characterised by lymphopenia, is an essential characteristic. Therefore, in afebrile patients (temperature <37·3°C) without dyspnoea, we recommend measurements of complete blood count and CRP. Subsequently, if the lymphocyte concentration is ≥1100/μL, home care with self­isolation is advised. Oral azithromycin or amoxicillin can be prescribed (measure 1, figure). Chest CT is helpful (appendix) and is more sensitive than x­ray in identifying viral pneumonia. Imaging of patients with COVID­19 initially revealed characteristic patchy infil­ tration, progressing to large ground­ glass opacities that often present bilaterally. The differential diagnosis for viral pneumonia includes respir­ atory syncytial virus and influenza virus. Febrile patients (temperature ≥37·3°C) should have both chest CT and respiratory viral tests. Patients with normal chest CT scans can follow measure 1 interventions. If the consensus is bacterial community­ acquired pneumonia (CAP), then standard clinical protocols are followed. Once the patient's temperature returns to normal, they are transferred to undesignated hospitals or discharged home (measure 2, figure). Patients diagnosed with viral pneu­ monia require isolation and SARS­CoV­2 tests (measure 3). Systemic and local respiratory defense mechanisms are compromised, resulting in bacterial co­infection if early, effective antiviral treatment is not started. Empirical therapy consists of oral moxifloxacin or levofloxacin (consider tolerance) and arbidol. Arbidol is approved in China and Russia for influenza treatment. In­ vitro studies showed that arbidol had inhibitory effects on SARS. Patients testing positive for SARS­CoV­2 are transferred to designated hospitals. Lancet Respir Med 2020