Guidelines for Management of COVID-19 and Mucormycosis/Black Fungus Patients

Amid COVID-19 cases soaring in India, the Union health ministry’s Directorate General of Health Services (DGHS) has come up with new guidelines and advisory regarding the management of COVID-19 patients.

DGHS issued new guidelines for the management of patients with asymptomatic, mild, moderate or severe COVID-19 infection, and management of Mucormycosis/Black Fungus. As per the new guidelines, no medicines, except for fever and cold, are to be given for asymptomatic and mild COVID-19 cases.

Managing COVID-19 Cases

Managing Asymptomatic COVID-19

An asymptomatic patient does not show any COVID-19 symptoms. If you are living in a house with COVID-19 positive patients, you may be a suspected case . You may also be incidentally showing up as positive in contact testing .

While usually no investigations are required for asymptomatic COVID-19 patients (whether RTPCR or RAT negative or positive), a 6-minute walk test is recommended to unmask hypoxia (low oxygen in your tissues) and asses cardio-pulmonary exercise tolerance.

Must-Dos for Asymptomatic COVID-19 Patients:

1. No medication required except for cold and fever
2. Stay isolated in a well-ventilated room allowing fresh air in the room
3. COVID-19 appropriate behaviour
4. Maintain physical distance
5. Strict Hand Hygiene
6. Use triple layer medical mask indoor (discard mask after 8 hours of use)
7. Have a healthy balanced diet with proper hydration
8. Stay connected with family and friends and engage in positive talks through phone, video-calls, etc.
9. Stay in contact virtually with a treating doctor

Managing Mild COVID-19

Mild COVID-19 infection is identified as having upper respiratory tract symptoms, mild fever with or without loss of smell and/or taste, cough, throat irritation/sore throat, without shortness of breath (SpO2 : ≥ 94% on room air) or hypoxia and Respiratory rate less than 24 per minute . Patients with these symptoms are advised to be isolated at home.

Must-Dos for Mild COVID-19 Patients:

1. Stay isolated in a well-ventilated room allowing fresh air in the room
2. A 6-minute walk test is recommended to unmask hypoxia and asses cardio-pulmonary exercise tolerance
3. COVID-19 appropriate behaviour
4. Maintain physical distance
5. Strict Hand Hygiene
6. Use triple layer medical mask indoor (discard mask after 8 hours of use)
7. Have a healthy balanced diet with proper hydration
8. Stay connected with family and friends and engage in positive talks through phone, video-calls, etc
9. Monitor body temperature and oxygen saturation (SpO2), look out for breathlessness, or worsening of any symptoms
10. Symptomatic management/relief- hydration, fever medicines, cold medicines, multi-vitamins
11. Inhalational Budesonide (administered via metered dose inhaler with space device) at a dose of 800 mcg BD for 5 days) for cough
12. No other COVID-19 specific medication needed.
13. Stay in contact virtually with a treating doctor

Seek medical attention if there is:

• Difficulty in breathing
• High-grade fever or severe cough, mainly lasting over five days

Careful monitoring is needed for people with high-risk features such as:

• Obesity
• Aged above 60 years
• Hypertension, cardiovascular disease and CAD (Coronary Artery Disease)
• Diabetes and other immunocompromised states
• Chronic kidney, lung or liver disease
• Cerebrovascular disease

Managing Moderate COVID-19

Moderate COVID-19 infection is identified by symptoms like fever, cough, throat irritation/sore throat, loss of smell and/or taste, body ache/head ache, shortness of breath (SpO2: 90-93% on room air), difficulty in breathing (respiratory rate more than 24 but less than 30). Patients with these symptoms are advised to get admitted to COVID Hospital.  

Must-Do to Treat Moderate COVID-19 Patients:

1. Oxygen support to be titrated to maintain SpO2 between 92 percent – 95 percent in patients without Chronic obstructive pulmonary disease (COPD). Initial equipment for oxygen administration (nasal prongs, simple face mask or NRB mask) depends upon work of breathing or severity of hypoxia.
2. In case of COPD, oxygen therapy may not be needed as target SpO2 is between 88 percent – 92 percent which by definition of moderate cases is already present
3. Monitoring and controlling co-morbid conditions, mainly diabetes.
4. Steroids to be given if SpO2 is below 92 percent (Check Guidelines for Using Steroids given below)
5. Proning helps in better oxygenation of lungs
6. Obtain baseline investigations like CBC, Blood Glucose, urine routine, LFT, KFT, CRP, S. Ferritin, D-DIMER, LDH and CPK. Baseline investigations can be repeated as follows
   1. CRP and D-DIMER 48 – 72 hourly
   1. CBC, KFT, LFT 24 – 48 hourly
   1. IL-6 levels to be done if deteriorating (subject to availability), may have to be repeated more frequently in ICU settings
   1. Serial CXR at least 48 hours apart
   1. HRCT chest to be done ONLY if there is worsening of symptoms
7. Further treatment by steroids, anti-coagulants and/or of immunemodulators shall be guided by the outcomes of the baseline and repeat investigations.
8. Prophylactic doses of anti-coagulants like LMWH or unfractionated heparin.

Managing Severe COVID-19

Severe COVID-19 infection is identified by symptoms like high fever, severe cough, throat irritation/sore throat, loss of smell and/or taste, body ache/head ache, shortness of breath (SpO2: less than 90 on room air, except in COPD), difficulty in breathing (respiratory rate more than 30/minute). Patients with these symptoms may be admitted in ICU of COVID Hospital.

Must-Do to Treat Severe COVID-19 Patients:

1. Immediate oxygen therapy. To be initiated at 5 L/Minute and titration to reach a target of SpO2 ≥ 90% in non-pregnant adults and 92-96% in pregnant patients

2. Consider use of NIV or non-invasive  (helmet or face mask interface depending on availability) in patients with increasing oxygen need

3. Consider use of HFNC if patient does not improve

4. Consider intubation and mechanical ventilation if patient still does not improve or work of breathing

is very high.

5. Start steroid therapy

6. Obtain baseline investigations like CBC, Blood Glucose, urine routine, LFT, KFT, CRP, S. Ferritin, D-DIMER, LDH and CPK. Baseline investigations can be repeated as follows:

• CRP and D-DIMER 48 – 72 hourly
• CBC, KFT, LFT 24 – 48 hourly
• IL-6 levels to be done if deteriorating (subject to availability), may have to be repeated more frequently in ICU settings
• Serial CXR at least 48 hours apart
• HRCT chest to be done ONLY if there is worsening of symptoms

7. Further treatment by steroids, anticoagulants and/or of immune-modulators shall be guided by

the outcomes of the baseline and repeat investigations. (Check Guidelines for Use of Drugs for details)

8. Prophylactic doses of anticoagulants like LMWH or UFH, example 40 mg enoxaparin S/C daily

9. Antcoagulants may also be given based on clinical judgement (Check Guidelines for Use of Anti-coagulants given below)

Managing Mucormycosis/Black Fungus Cases

As per the new guidelines from DGHS, the treatment of Mucormycosis also known as black fungus involves mix of surgical debridement and anti-fungal therapy.

The treatment of choice include administering Liposomal Amphotericin B in initial dose of 5-mg per kg body weight (10-mg per kg body weight in case of CNS involvement). The same should be diluted in 5 percent dextrose as it is incompatible with normal saline/Ringer Lactate. Liposomal Amphotericin B should be given over 2-3 hours and should be started with full dose from day 1.

Monitoring for kidney function tests and serum elecrolytes is recommended. The drug has to be continued till a favourable response is achieved and the disease is stabilized which can take 3-6 weeks. Following this, it has to be stepped down to oral Isavuconazole (200-mg 1 tablet 3 times every day for 2 days followed by 200 mg daily) or Posaconazole (300-mg delayed release tablets twice a day for 1 day followed by 300-mg every day) shall have to be given for prolonged period as per advice of the doctor.

The therapy should be continued until clinical resolution of signs and symptoms of infection, and resolution of radiological signs of active disease and elimination of pre-disposing risk factors like immunosuppression, hyperglycemia, etc. As per the guidelines, the therapy may have to be continued for quite long periods of time.

Conventional Amphotericin B (deoxy cholate) in the dose 1 to 1.5mg per kg body weight may be used if liposomal form is unavailable.

Kidney functions should be monitored throughout the entire management period.