COVID-19 (Infection à SARS-CoV-2)

•   COVID-19 : PCR SARS-CoV-2 (sécretions respiratoires)
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  Examen de référence pour le diagnostic de COVID-19. Sensibilité 84-88%, spécificité 98-100% (Jarrom 2020, Mair 2021).
  Le prélèvement de référence est l'écouvillonage nasopharyngé. Alternatives, moins sensibles : écouvillonage nasal, de la gorge, ou échantillon de salive (Tsang 2021)

  Examen de choix pour le diagnostic :
  Examen de choix
•   COVID-19 : Recherche d'Antigène SARS-CoV-2 (sécretions respiratoires)
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  Moins sensible que la PCR. Sa sensibilité dépend de la quantité de virus présent : 58% chez les personnes asymptomatiques, 72% chez les symptomatiques, 94% si forte quantité de virus (Ct < 25). Spécificité très élévée : 99% (Dinnes 2021)

  Examen de choix pour le diagnostic :
  Moins sensible que la PCR, mais très spécifique
•   Scanner Thoracique
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  Chez les patients présentant une dyspnée ou une désaturation, bonne sensibilité (90%) et spécificité (84%) (Islam 2021, Mair 2021). Images typiques de plages de verre dépoli multifocales, bilatérales, plutôt périphériques, surtout dans les régions inférieures et postérieures

  Examen de choix pour le diagnostic :
  Si dyspnée ou désaturation
•   Saturation pulsée de l’hémoglobine en oxygène (SpO2) - Oxymètre de pouls
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  Pour le dépistage et suivi d'une possible insuf respiratoire secondaire à une atteinte pulmonaire

  Examen additionnel :
  Si symptômes respiratoires ou dyspnée

Autres examens, 2ème intention :

•   Echographie pulmonaire
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  Facile à faire, possible au lit du malade. Bonne sensibilité (86%) pour dépister une pneumopathie à COVID-19, mais peu spécifique (Islam 2021)

  Examen additionnel :
  Bonne sensibilité pour dépister la pneumopathie COVID-19
•   COVID-19 : Sérologie SARS-CoV-2
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  Peu utile pour le diagnostic de la maladie aigue, car prend 1 à 3 semaines pour devenir positive, sauf pour un diagnostic de rattrapage chez des patients suspects ayant une PCR initial négative et à J>7 d'évolution. Utile pour le suivi de la réponse vaccinale chez les patients immunodéprimés

  Chez certains patients :
  Diagnostic de rattrapage. Suivi de la réponse vaccinale
•   Gaz du sang artériel
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  Cas graves, évaluation de l'indication d'un support respiratoire, d'une ventilation, invasive ou non

  Chez certains patients :
  Si détresse respiratoire : besoin de ventilation assistée ?

• Aucun.e score renseigné.e pour cette maladie, pour l'instant.

• Pneumopathie aigue infectieuse

  En période d'épidémie / pandémie, une pneumopathie apparement habituel peut être une infection COVID-19
• Pneumopathie interstitielle aigue

  A différentier d'autres pneumopathies interstitielles aigues, infectieuses ou non
• Grippe

  Les symptômes peuvent être identiques, surtout au début de l'infection

• ACTIV-6 2023. Essai randomisé de grande taille : Inhaled Fluticasone Furoate for Outpatient Treatment of Covid-19. N Engl J Med

  Of the 1407 enrolled participants who underwent randomization, 715 were assigned to receive inhaled fluticasone furoate and 692 to receive placebo .. There was no evidence that the use of fluticasone furoate resulted in a shorter time to recovery than placebo (hazard ratio, 1.01 ..) .. Three participants in each group were hospitalized, and no deaths occurred. .. Treatment with inhaled fluticasone furoate for 14 days did not result in a shorter time to recovery than placebo among outpatients with Covid-19
• ACTT-4 2022. Essai randomisé de grande taille : Baricitinib versus dexamethasone for adults hospitalised with COVID-19 (ACTT-4): a randomised, double-blind, double placebo-controlled trial. Lancet Respir Med

  In hospitalised patients with COVID-19 requiring supplemental oxygen by low-flow, high-flow, or non-invasive ventilation, baricitinib plus remdesivir and dexamethasone plus remdesivir resulted in similar mechanical ventilation-free survival by day 29, but dexamethasone was associated with significantly more adverse events ...
• Arbel 2022. Cohorte rétrospective : Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge. N Engl J Med

  A total of 109,254 patients met the eligibility criteria, of whom 3902 (4%) received nirmatrelvir during the study period. .. Among patients 65 years of age or older, the rate of hospitalization due to Covid-19 was 14.7 cases per 100,000 person-days among treated patients as compared with 58.9 cases per 100,000 person-days among untreated patients (adjusted hazard ratio, 0.27). .. The adjusted hazard ratio for death due to Covid-19 was 0.21 .. No evidence of benefit was found in younger adults
• COV-BARRIER 2021. Essai randomisé de grande taille : Efficacy and safety of baricitinib for the treatment of hospitalised adults with COVID-19 (COV-BARRIER): a randomised, double-blind, parallel-group, placebo-controlled phase 3 trial. Lancet Respir Med

  Between June 11, 2020, and Jan 15, 2021, 1525 participants were randomly assigned to the baricitinib group (n=764) or the placebo group (n=761). ... The 60-day all-cause mortality was 10% (n=79) for baricitinib and 15% (n=116) for placebo (HR 0·62). ... Interpretation: Although there was no significant reduction in the frequency of disease progression overall, treatment with baricitinib in addition to standard of care (including dexamethasone) ... was associated with reduced mortality in hospitalised adults
• Dinnes 2021. Révision systématique Cochrane : Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection. Cochrane Database of Systematic Reviews

  Antigen tests vary in sensitivity. In people with signs and symptoms of COVID-19, sensitivities are highest (72.0%, 95% CI 63.7% to 79.0%) in the first week of illness when viral loads are higher
• EPIC-HR 2022. Essai randomisé de grande taille : Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. N Engl J Med

  A total of 2246 ... symptomatic, unvaccinated, nonhospitalized adults at high risk for progression to severe Covid-19 were assigned in a 1:1 ratio to receive either 300 mg of nirmatrelvir plus 100 mg of ritonavir ... or placebo. ...The incidence of Covid-19-related hospitalization or death by day 28 was lower in the nirmatrelvir group [0.77%] than in the placebo group [7.01%] ... All 13 deaths occurred in the placebo group. ... [There was no] evident safety concerns
• Giossi 2021. Révision systématique : A Systematic Review and a Meta-Analysis Comparing Prophylactic and Therapeutic Low Molecular Weight Heparins for Mortality Reduction in 32,688 COVID-19 Patients. Frontiers Pharmacology

  Heparin at both full and prophylactic dose is effective in reducing mortality in hospitalized COVID-19 patients, compared to no treatment (pooled Hazard Ratio [HR] 0.63, 95% confidence interval [CI] 0.57-0.69). However, full dose was associated with an increased risk of bleeding.
• Gottlieb 2021. Essai randomisé : Effect of Bamlanivimab as Monotherapy or in Combination With Etesevimab on Viral Load in Patients With Mild to Moderate COVID-19: A Randomized Clinical Trial

  Chez des patients avec formes légères / modérées de COVID-19, non hospitalisés. Le traitement combiné réduit la charge virale mieux que le placebo et pourrait réduire le nombre d'hospitalisations
• Hammond 2024. Essai randomisé de grande taille : Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. N Engl J Med

  Among the 1296 participants who underwent randomization and were included ... The median time to sustained alleviation of all targeted signs and symptoms of Covid-19 was 12 days in the nirmatrelvir-ritonavir group and 13 days in the placebo group (P = 0.60) ... The time to sustained alleviation of all signs and symptoms of Covid-19 did not differ significantly between participants who received nirmatrelvir-ritonavir and those who received placebo
• Hansen 2021. Cohorte de population : Assessment of protection against reinfection with SARS-CoV-2 among 4 million PCR-tested individuals in Denmark in 2020: a population-level observational study. Lancet.

  0,65% des patients COVID+ de la 1ère vague eurent une nouvelle infection COVID, confirmée par PCR, des mois après. Protection de 80% face à une nouvelle exposition après une 1ère infection, persistante > 7 mois
• Hu 2020. Révision narrative : Characteristics of SARS-CoV-2 and COVID-19. Nature reviews: Microbiology

  Bonne révision des aspects virologiques, épidémiologiques et cliniques du SARS-CoV-2
• Islam 2021. Révision systématique Cochrane : Thoracic imaging tests for the diagnosis of COVID-19. Cochrane Database of Systematic Reviews

  Chest CT is sensitive (88%) and moderately specific (80%) for the diagnosis of COVID-19. Chest X-ray is moderately sensitive (81%) and moderately specific (72%) for the diagnosis of COVID-19. Ultrasound is sensitive (86%) but not specific (55%) for the diagnosis of COVID-19.
• Jarrom 2020. Révision systématique : Effectiveness of tests to detect the presence of SARS-CoV-2 virus, and antibodies to SARS-CoV-2, to inform COVID-19 diagnosis: a rapid systematic review. BMJ Evid Based Med

  For an initial PCR test, pooled analysis of 16 studies (3818 patients) estimated a sensitivity of 88% (95% CI 81% to 92%). For antibody tests, sensitivity ranged in 10 studies from 18% to 96% and specificity 89% to 100%
• Living Recos WHO 2023. Recommandations de pratique clinique : Therapeutics and COVID-19: living guideline. World Health Organization (WHO)

  This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for COVID-19 therapeutics... Recommended for patients with severe or critical COVID-19:
  - a strong recommendation for systemic corticosteroids;
  - a strong recommendation for interleukin-6 (IL-6) receptor blockers (tocilizumab or sarilumab);
  - a strong recommendation for the Janus kinase (JAK) inhibitor baricitinib;
  - .. IL-6 receptor blockers (tocilizumab or sarilumab),
• Mair 2021. Révision systématique, méta-analyse : A systematic review and meta-analysis comparing the diagnostic accuracy of initial RT-PCR and CT scan in suspected COVID-19 patients. Br J Radiol

  11 studies including 1834 patients. Pooled estimates of sensitivity for CT scan and PCR were 0.91 [95% CI (0.84-0.97)] and 0.84 [95% CI (0.71-0.94)], respectively
• REACT 2021. Revue systématique : Association Between Administration of IL-6 Antagonists and Mortality Among Patients Hospitalized for COVID-19. A Meta-analysis. JAMA

  This prospective meta-analysis of 27 randomized trials included 10 930 patients, of whom 2565 died by 28 days. The 28-day all-cause mortality was lower among patients who received IL-6 antagonists compared with those who received usual care or placebo (summary odds ratio, 0.86). The summary odds ratios for the association of IL-6 antagonist treatment with 28-day all-cause mortality were 0.78 with concomitant administration of corticosteroids vs 1.09 without administration of corticosteroids.
• RECOVERY 2021. Essai randomisé : Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med

  La dexaméthasone réduit la mortalité à 28 jours chez les patients hospitalisés ayant besoin d'oxygène ou de ventilation
• REMAP-CAP 2021. Essai randomisé : Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19. N Engl J Med

  In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival
• Rosas 2021. Essai randomisé : Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia. N Engl J Med

  The use of tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days
• Salama 2021. Essai randomisé : Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia. N Engl J Med

  Le tocilizumab a diminué dans cet étude le nombre de patients nécessitant une ventilation mécanique, mais pas la mortalité à 28 jours (10% tociliz VS 9% placebo)
• STOIC 2021. Essai randomisé : Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial. Lancet Respir Med

  Early administration of inhaled budesonide reduced the likelihood of needing urgent medical care and reduced time to recovery after early COVID-19
• Tsang 2021. Révision systématique et méta-analyse : Diagnostic performance of different sampling approaches for SARS-CoV-2 RT-PCR testing: a systematic review and meta-analysis. Lancet Infect Dis

  Using nasopharyngeal swabs as the gold standard, pooled nasal and throat swabs gave the highest sensitivity of 97% (95% CI 93-100), whereas lower sensitivities were achieved by saliva (85%, 75-93) and nasal swabs (86%, 77-93) and a much lower sensitivity by throat swabs (68%, 35-94)
• Weinreich 2021. Essai randomisé : REGN-COV2, a Neutralizing Antibody Cocktail, in Outpatients with Covid-19. N Engl J Med

  Chez des patients avec formes légères / modérées de COVID-19, non hospitalisés. Ce cocktail d'anticorps réduit la charge virale mieux que le placebo et pourrait réduire le nombre de consultations médicales
• Wiersinga 2021. Révision narrative : Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. JAMA

  Excellente révision général, très exhaustive et complète, des connaissances actuelles sur l'infection à SARS-CoV-2 (en anglais)