IDSA updates treatment guidelines, while studies identify symptoms in specific age groups

The Infectious Diseases Society of America (IDSA) recently updated its guidelines on treatment and management of COVID-19, making several changes to the original guidance, which was released on April 11 and summarized in the April 14 ACP Internist Weekly.

In a June 25 update, the IDSA suggested glucocorticoids for hospitalized patients with severe COVID-19, defined as oxygen saturation of 94% or less on room air or a need for supplemental oxygen, mechanical ventilation, or extracorporeal mechanical oxygenation (ECMO). Specifically, the guideline mentioned oral or IV dexamethasone, 6 mg, for 10 days (or until discharge if earlier) or, if unavailable, an equivalent glucocorticoid dose (methylprednisolone, 32 mg, or prednisone, 40 mg). Previously, the IDSA recommended steroids in the context of a clinical trial for patients with acute respiratory distress syndrome due to COVID-19. The group still suggested against glucocorticoids for patients without hypoxemia requiring supplemental oxygen.

IDSA added new recommendations on remdesivir to the guidelines on June 22. It now suggests remdesivir for hospitalized patients with severe COVID-19. For those who are on supplemental oxygen but not mechanical ventilation or ECMO, the IDSA panel suggested treatment with five days of remdesivir rather than 10 days. In patients on mechanical ventilation or ECMO, the duration of treatment is 10 days. If supply of the drug is limited, clinicians should consider that the most benefit has been demonstrated in patients on supplemental oxygen rather than mechanical ventilation or ECMO, the panel noted.

IDSA also updated recommendations on several other potential therapies. The group now recommends hydroxychloroquine or chloroquine only in the context of a clinical trial and suggested against hydroxychloroquine or chloroquine plus azithromycin outside of trials. The guideline on COVID-19 convalescent plasma also changed; this experimental therapy is recommended for inpatients only in the context of a clinical trial. The IDSA also added a recommendation to address the use of famotidine, suggesting against using it for the sole purpose of treating COVID-19 outside the context of a clinical trial.

In other COVID-19 news, the results of a national French survey, published by Clinical Infectious Diseases on June 18, described symptoms in patients ages 70 years and older. More than half of patients exhibited three or fewer symptoms in the first 72 hours of illness, with the most common being thermal dysregulation (83.6%), cough (58.9%), asthenia (52.7%), polypnea (39.9%), and gastrointestinal signs (24.4%). A comparison of those younger and older than age 80 years found that falls and sudden deterioration of general condition were more common in the oldest patients, whereas fever was less common. “These findings should be integrated into the clinical reasoning in geriatric medicine, and encourage the systematization of diagnostic tests for SARS-Cov-2 infection in older adults,” the authors said.

Another study, published by The Lancet Psychiatry on June 25, used a British database to analyze neurological complications. Of 125 neurological presentations of COVID-19 reported by clinicians in the U.K., 62% were a cerebrovascular event (74% of which were ischemic stroke). Thirty-one percent of the reported cases presented with altered mental status (23% with unspecified encephalopathy, 18% with encephalitis, and 59% with psychiatric diagnoses). About half of the patients with altered mental status were younger than age 60 years, whereas only 18% of those with cerebrovascular events were.