CURSO NACIONAL DE ACTUALIZACIÓN EN PREVENCIÓN Y CONTROL DEL NUEVO CORONAVIRUS

(COVID-19)

Manejo terapéutico del adulto

Dr. C. Daniel González Rubio

 Sumario
• Consideraciones generales.
• Pilares del tratamiento.
• Posible tratamiento antiviral.
• Otras alternativas terapéuticas.
 El manejo terapéutico debe
tener un accionar simultáneo a
las medidas de bioseguridad
 Consideraciones generales
 El cumplimiento estricto de las medidas de bioseguridad resulta de
extrema importancia.
 Pueden presentarse uno o varios casos al mismo tiempo.
 Las manifestaciones clínicas más frecuentes son fiebre, tos y disnea.
 Las principales complicaciones son la insuficiencia respiratoria, las
arritmias cardiacas, la sobreinfección bacteriana y el choque séptico.
Las complicaciones respiratorias se presentan habitualmente a partir
del 7mo día de inicio de los síntomas.
 Hasta el momento no está identificada una droga antiviral totalmente
eficaz, ni una vacuna. El tratamiento fundamental es sintomático y de
soporte, con vigilancia y manejo de las complicaciones.
 La letalidad calculada es de aproximadamente 2 a 4 %, aunque esta
cifra puede variar.
 Pilares del manejo clínico
I. Adecuado triaje (reconocer y aislar).
II. Tratamiento sintomático.
III. Toma de muestra para estudios virológicos.
IV. Otros estudios complementarios.
V. Evaluar comorbilidades y su estado de compensación.
VI. Medicamentos antivirales, antibióticos y otras alternativas
terapéuticas.
VII. Identificación temprana y manejo de la insuficiencia respiratoria
aguda.
VIII. Reconocimiento y manejo de otras complicaciones.
I. Adecuado triaje (reconocer y aislar).
Conocimiento de las definiciones de casos
Sala de aislamiento
 La sala de aislamiento debe cumplir con los requisitos mínimos exigidos para
este tipo de unidad. La sala operará bajo régimen de cuarentena, no
permitiéndose visitas ni acompañantes a los pacientes.
 Se definirá el personal que trabajará en la sala, y se les instruirá sobre las
medidas de protección individual y el manejo de los materiales y utensilios
contaminados.
 Debe disponer de los medios individuales para la protección sanitaria de
contención de la contaminación (nasobucos, batas, guantes, protección facial)
y soluciones para descontaminación.
 Implementación de inmediato de las medidas de control de infección
estándares establecidas y precauciones basadas en la transmisión.
II. Tratamiento sintomático.
III. Toma de muestra para estudios virológicos.
IV. Otros estudios complementarios.

Complementarios generales indispensables donde se incluyen

(hemograma con diferencial, glicemia, creatinina, ionograma, gasometría
y Rx de tórax). Reforzar las medidas de protección necesarias para el
traslado y procesamiento de las muestras.

Hemograma
Rx Tórax
V. Evaluar comorbilidades y su estado de compensación.

• 72 314 casos

- Enfermedades cardiovasculares 10,5 %.

• Mortalidad - Diabetes 7,3 %.
- Enfermedades respiratorias crónicas 6,3 %.
- HTA 6.0 %.
- Cáncer 5,6 %.

JAMA feb/24/2020
VI. Medicamentos antivirales, antibióticos y otras alternativas
terapéuticas.
2020 Mar;83(3):217-220. doi: 10.1097/JCMA.0000000000000270.

The outbreak of COVID-19: An overview.

Wu YC1, Chen CS1, Chan YJ1,2,3.

Abstract
In late December 2019, a previous unidentified coronavirus, currently named as the 2019 novel
coronavirus#, emerged from Wuhan, China, and resulted in a formidable outbreak in many cities in China
and expanded globally, including Thailand, Republic of Korea, Japan, United States, Philippines, Viet Nam,
and our country (as of 2/6/2020 at least 25 countries). The disease is officially named as Coronavirus
Disease-2019 (COVID-19, by WHO on February 11, 2020). It is also named as Severe Pneumonia with
Novel Pathogens on January 15, 2019 by the Taiwan CDC, the Ministry of Health and is a notifiable
communicable disease of the fifth category. COVID-19 is a potential zoonotic disease with low to
moderate (estimated 2%-5%) mortality rate. Person-to-person transmission may occur through droplet or
contact transmission and if there is a lack of stringent infection control or if no proper personal protective
equipment available, it may jeopardize the first-line healthcare workers. Currently, there
Currently, there isisno
no
definite treatment
definite treatmentfor
forCOVID-19
COVID-19although
althoughsomesomedrugs
drugsare
areunder
underinvestigation.
investigation. To promptly identify
patients and prevent further spreading, physicians should be aware of the travel or contact history of the
patient with compatible symptoms.
 Dificultades para desarrollar una droga antiviral

Enfermedad emergente, aún muy joven.

Desconocimiento de muchos aspectos de la biología del virus.
No definición exacta de la especie animal que generó el brote inicial.

• Cuba (casos confirmados).

 Oseltamivir (incluso casos sospechosos) 75mgs mgs cada 12 horas por 10
días.
 Kaletra (200 Lopinavir -50 Ritonavir) 2 cápsulas cada 12 horas por 10 días.
 Antibióticos: Azitromicina 500 mgs diario por 5 días.
 2020 Feb 5;43(0):E002. doi: 10.3760/cma.j.issn.1001-0939.2020.0002. [Epub ahead of print]

[Potential antiviral therapeutics for 2019 Novel

Coronavirus].
[Article in Chinese; Abstract available in Chinese from the publisher]
Li H1, Wang YM1, Xu JY2, Cao B1.

Abstract
The recent outbreak of respiratory illness in Wuhan, China is caused by a novel coronavirus, named 2019-
nCoV, which is genetically close to a bat-derived coronavirus. 2019-nCoV is categorized as beta genus
coronavirus, same as the two other strains - severe acute respiratory syndrome coronavirus (SARS-CoV) and
Middle East respiratory syndrome coronavirus (MERS-CoV). Antiviral
Antiviral drugs commonly
drugs commonly used in used in
clinical
clinical practice,
practice, includingincluding neuraminidase
neuraminidase inhibitorsinhibitors (oseltamivir,
(oseltamivir, paramivir,paramivir,
zanamivir,zanamivir, etc.), ganciclovir,
etc.), ganciclovir, acyclovir
acyclovir
and and are
ribavirin, ribavirin,
invalidare
for invalid for 2019-nCoV
2019-nCoV and not recommended.
and not recommended.
Drugs are possibly effective for 2019-nCoV include: remdesivir, lopinavir / ritonavir, lopinavir / ritonavir
combined with interferon-β, convalescent plasma, and monoclonal antibodies. But the efficacy and safety
of these drugs for 2019-nCoV pneumonia patients need to be assessed by further clinical trials.
Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel
Coronavirus–Infected Pneumonia in Wuhan, China
Dawei Wang, MD; Bo Hu, MD; Chang Hu, MD; Fangfang Zhu, MD; Xing Liu, MD; Jing Zhang, MD; Binbin Wang, MD; Hui Xiang, MD;
Zhenshun Cheng, MD; Yong Xiong, MD; Yan Zhao, MD; Yirong Li, MD; Xinghuan Wang, MD; Zhiyong Peng, MD

RESULTS
Of 138 hospitalized patients with NCIP, the median age was 56 years (interquartile range, 42-68; range, 22-92
years) and 75 (54.3%) were men. Hospital-associated transmission was suspected as the presumed mechanism
of infection for affected health professionals (40 [29%]) and hospitalized patients (17 [12.3%]). Common symptoms
included fever (136 [98.6%]), fatigue (96 [69.6%]), and dry cough (82 [59.4%]). Lymphopenia (lymphocyte count,
0.8 × 109 /L [interquartile range {IQR}, 0.6-1.1]) occurred in 97 patients (70.3%), prolonged prothrombin time (13.0
seconds [IQR, 12.3-13.7]) in 80 patients (58%), and elevated lactate dehydrogenase (261 U/L [IQR, 182-403]) in
55 patients (39.9%). Chest computed tomographic scans showed bilateral patchy shadows or ground glass
Most patients received antiviral therapy (oseltamivir, 124 [89.9%]),
opacity in the lungs of all patients. and many
received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]) and
glucocorticoid therapy (62 [44.9%]). Thirty-six patients (26.1%) were transferred to the intensive care unit (ICU)
because of complications, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]),
and shock (11 [30.6%]). The median time from first symptom to dyspnea was 5.0 days, to hospital admission was
7.0 days, and to ARDS was 8.0 days. Patients treated in the ICU (n = 36), compared with patients not treated in
the ICU (n = 102), were older (median age, 66 years vs 51 years), were more likely to have underlying
comorbidities (26 [72.2%] vs 38 [37.3%]), and were more likely to have dyspnea (23 [63.9%] vs 20 [19.6%]), and
anorexia (24 [66.7%] vs 31 [30.4%]). Of the 36 cases in the ICU, 4 (11.1%) received high-flow oxygen therapy,
15 (41.7%)
received noninvasive ventilation, and 17 (47.2%) received invasive ventilation (4 were switched to extracorporeal
membrane oxygenation). As of February 3, 47 patients (34.1%) were discharged and 6 died (overall mortality,
4.3%), but the remaining patients are still hospitalized. Among those discharged alive (n = 47), the median hospital
stay was 10 days (IQR, 7.0-14.0).

JAMA. doi:10.1001/jama.2020.1585
Published online February 7, 2020.
 OSELTAMIVIR

 MEDICAMENTO CON SEGURIDAD PROBADA PARA EL USO EN

HUMANOS.

 POSIBLE PRODUCCIÓN NACIONAL (ACCESIBLE).

 EFECTIVO CONTRA LA INFLUENZA, QUE CONSTITUYE UN IMPORTANTE

DIAGNÓSTICO DIFERENCIAL DE COVID-19.

 TODAVÍA NO SE HA DESTAPADO UN ENSAYO QUE DEMUESTRE SU

INEFICACIA PARA COVID-19.
 2020 Feb 17;35(6):e79. doi: 10.3346/jkms.2020.35.e79.

Case of the Index Patient Who Caused Tertiary Transmission of COVID-19 Infection in Korea: the
Application of Lopinavir/Ritonavir for the Treatment of COVID-19 Infected Pneumonia Monitored
by Quantitative RT-PCR.
Lim J1, Jeon S2, Shin HY3, Kim MJ1, Seong YM4, Lee WJ5, Choe KW6, Kang YM6, Lee B7, Park SJ8.

Abstract
Since mid-December of 2019, coronavirus disease 2019 (COVID-19) infection has
been spreading from Wuhan, China. The confirmed COVID-19 patients in South Korea are
those who came from or visited China. As secondary transmissions have occurred and the
speed of transmission is accelerating, there are rising concerns about community
infections. The 54-year old male is the third patient diagnosed with COVID-19 infection in
Korea. He is a worker for a clothing business and had mild respiratory symptoms and
intermittent fever in the beginning of hospitalization, and pneumonia symptoms on chest
computerized tomography scan on day 6 of admission. This patient caused one case of
secondary transmission and three cases of tertiary transmission. Hereby, we report the
clinical findings of the index patient who was the first to cause tertiary transmission
outside China. Interestingly, after lopinavir/ritonavir (Kaletra, AbbVie) was administered,
β-coronavirus viral loads significantly decreased and no or little coronavirus titers were
observed.
 2020 Mar 3. doi: 10.1001/jama.2020.3204. [Epub ahead of print]

Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2

in Singapore.

Young BE1,2,3, ET AL.

Descriptive case series of the first 18 patients diagnosed with polymerase chain reaction (PCR)-
confirmed SARS-CoV-2 infection at 4 hospitals in Singapore from January 23 to February 3, 2020;
final follow-up date was February 25, 2020.
Exposures: Confirmed SARS-CoV-2 infection.
Main Outcomes and Measures: Clinical, laboratory, and radiologic data were collected, including
PCR cycle threshold values from nasopharyngeal swabs and viral shedding in blood, urine, and
stool. Clinical course was summarized, including requirement for supplemental oxygen and
intensive care and use of empirical treatment with lopinavir-ritonavir.
Results: Among the 18 hospitalized patients with PCR-confirmed SARS-CoV-2 infection (median
age, 47 years; 9 [50%] women), clinical presentation was an upper respiratory tract infection in 12
(67%), and viral shedding from the nasopharynx was prolonged for 7 days or longer among 15
(83%). Six individuals (33%) required supplemental oxygen; of these, 2 required intensive care.
There were no deaths. Virus was detectable in the stool (4/8 [50%]) and blood (1/12 [8%]) by PCR
but not in urine. Five individuals requiring supplemental oxygen were treated with lopinavir-
ritonavir. For 3 of the 5 patients, fever resolved and supplemental oxygen requirement was reduced
within 3 days, whereas 2 deteriorated with progressive respiratory failure. Four of the 5 patients
treated with lopinavir-ritonavir developed nausea, vomiting, and/or diarrhea, and 3 developed
 La terapéutica general y la antiviral
son susceptibles de
modificaciones en dependencia de las
recomendaciones internacionales.
 Otros antivirales utilizados o en fase de investigación
Un paciente en EUA proveniente de Wuhan con COVID -19, y neumonía
del lóbulo inferior del pulmón derecho. Evolucionó a una neumonía grave.
Recibió tratamiento con Remdesivir con mejoría posterior.
The New England Journal of Medicine
El remdesivir fue desarrollado por Gilead Sciences, como una respuesta al
virus del Ébola que surgió al Oeste de África en 2014 , esencialmente
interfiere en la síntesis de ARN necesarios para la replicación del genoma
del virus.

Favipiravir (T -705): actúa inhibiendo la acción de la enzima RNA

polimerasa , esencial para la replicación del virus. Se ha empleado
experimentalmente para tratar la infección por el virus Ébola en humanos,
tras mostrarse eficaz en un estudio con ratones de laboratorio.
 Cloroquina
Inhibe la replicación de distintos tipos de virus incluidos el VIH
y los coronavirus. En los primeros quince ensayos clínicos
realizados en China en pacientes hospitalizados por Covid-19,
ha demostrado que previene complicaciones graves de la
neumonía y que acorta la duración de la enfermedad, según
resultados presentados el 19 de febrero en BioScience Trends .

Ante estos resultados, los autores de los ensayos clínicos han

recomendado que la Comisión Nacional de Salud de China
incluya la cloroquina en el protocolo de tratamiento del Covid-
19.
Alternativas con productos cubanos.
Posibles ensayos clínicos

¿Dosis y vía?: 5 millones inhalatorio 2v/dia

INF α 2B Aplicar en etapas temprana de la infección.

Surfacen Para pacientes críticos con ventilación invasiva.

Recomendaciones para esta fecha

Oseltamivir
Kaletra
Azitromicina

TENER EN CUENTA LA CLOROQUINA

CANDIDATOS PARA ENSAYOS CLÍNICOS:
INF α 2B y Surfacen
Bibliografía