Translated material
Military secret
Military doctors proposed new algorithms for the treatment of patients with COVID-19
Covid-19 treatment protocols change right before our eyes. In severe cases, the prescription of anticoagulants comes to the fore to prevent microtrombosis and anti -inflammatory drugs, allowing not to bring the patient to the use of Ivl. On May 22, 2020, the long-awaited results of multinational research of the use of a hydroxikhlorokhin who had recently submitted so many hopes of hydroxychlorokhin-in 96,032 patients who received treatment from Covid-19 from December 20, 2019 to April 14, 2020 appeared. The conclusions of the authors are disappointing: “We could not confirm the positive impact of the use of hydroxychlorokhin or chlorochine in combination with or without macrolide on the hospitals of the Covid-19 treatment. Each of these drugs is associated with a decrease in patient survival. ”
The chief pulmonologist of the Ministry of Defense of the Russian Federation, the president of the Interregional Association of Respiratory Medicine Specialists, Andrei Zaitsev , addressed colleagues-doctors with an open letter, sharing with them those conclusions that his practical experience led to: military doctors help civilian doctors fight the Covid-19. Alla Astakhova decided to ask Andrei Zaitseva more about this.
- Andrei Alekseevich, did military doctors take part in the treatment of Covid with the civilian population?
- Yes, sure. The Department of Health of Moscow once turned to the Ministry of Defense for help. The brigades of military doctors, including from the Main Military Clinical Hospital named after N. N. Burdenko and other institutions, were sent to work in civilian hospitals. Now the hospitals of the Ministry of Defense, built as soon as possible. As far as I know, it is planned to assist the civilian population there.
-In your letter you wrote about the unjustified prescription of antibiotics in the treatment of Covid-19. Why do you think they are prescribed? The disease is viral.
- This problem has existed for a long time - it arose long before the pandemic of coronavirus. With a conventional cold caused by respiratory viruses, or, for example, acute bronchitis - diseases of the primary viral etiology - antibiotics are prescribed very often. According to foreign data, in 30-60% of cases in acute bronchitis. This is a real problem that exists, existed and, unfortunately, will exist. Treatment of coronavirus infection is from the ordinary example in this context.
- What is the motive of doctors? Afraid of missing a bacterial complication?
- Often - in approximately 20% of cases - the disease proceeds with damage to the lower parts of the respiratory tract. We understand that this is a life -grooming process. Doctors in this situation in the absence of adequate viral treatment tend to prescribe antibiotics. It may also be triggered that the diagnosis sounds like this: “a new coronavirus infection. Navalic pneumonia. " If there is a diagnosis of “pneumonia”, then it is necessary to prescribe antibacterial treatment.
- What is the danger of the general purpose of antibiotics in coronavirus?
- The danger is well known - this is an increase in the number of antibiotic -resistant strains of microorganisms. If a patient with coronavirus receiving antibiotics will develop bacterial complications, then they will be associated with resistant strains. In this case, it will be much more difficult to cope with a bacterial infection.
- You suggested another diagnosis: not pneumonia, in pneumonitis. What is the difference?
- Pneumonia - in most cases a bacterial process. Pneumonitis is a term indicating the non -bacterial and not non -infectious nature of inflammation. Certificates are currently appearing that with coronavirus disease the walls of blood vessels are affected, microtrombosis in the vascular bed occur. That is, the nature of the lung damage here is completely different than with pneumonia. By the way, the term "pneumonite" in relation to the Covid-19 is also not entirely correct. I like the term “interstitiopathy” more, which was first voiced by Italian doctors as part of the leaders with a coronavirus infection. That is, a process manifested by inflammation and violation of the structure of alveolar walls, the endothelium of the pulmonary capillaries. But this term has not yet taken root in our country. Why do we insist on the diagnosis of “pneumonitis”, “interstitiopathy”? This wording will force the doctor not to resort to unjustified prescription of antibiotics, but to think about using other means of therapy, primarily anti -inflammatory drugs.
- As anti -inflammatory drugs, you suggested, in addition to monoclonal antibodies, use glucocorticosteroids ...
- As for glucocorticosteroids, this is so far our point of view. They are used in therapy modes in a number of countries - separate messages from Italy, the USA and China, including in our country (national recommendations), but small doses of these drugs are recommended there. Our proposal to use higher doses of glucocorticosteroids is based on a sufficient number of clinical observations. This point of view is supported by a number of colleagues. We noticed that if you start using these drugs on time and according to indications, this allows you to stop the inflammatory process at an acceptable level of oxygenation for the patient.
- Is there a chance not to transfer the patient to Ivl with her risks?
- In fact, this is the most important task is to keep the patient at an acceptable level of oxygenation. Anti -inflammatory drugs do not treat coronavirus infection, but give a chance to stop the process and give the patient the time to recover, being on minimal respiratory support - on oxygen inhalations, on high -flow oxygenation. This is a viable strategy.
- In the world, the opinion on the use of corticosteroids in coronavirus is ambiguous.
-So far, in the recommendations of many countries to corticosteroids, a wary attitude due to the lack of adequate clinical studies (on May 14, 2020, the use of corticosteroids was included in the Covid-19 treatment protocol in East Virginia.- A. A. ). In our national recommendations they are. We were one of the first to notice the effect of the early (according to indications) of the use of corticosteroids and, of course, we are only talking about patients with moderate course of the disease who receive treatment in the hospital. We believe that this fact must be voiced. Now we have already received statistical material that proves this point of view. We hope that in the near future we will publish our results.
- In your letter there is another important point. When conducting patients with coronavirus infection, you propose monitoring the level of two biomarkers of inflammation-C-reactive protein and proskalcitonin.
-Usually, C-reactive protein is a very good marker of distinguishing between viral and bacterial infection. This is reflected in a number of world recommendations for the management of patients with pneumonia.
-Why, in the case of Covid-19, this test cannot be used to determine the onset of bacterial complications?
-We all saw that with coronavirus damage to the lungs, the level of C-reactive protein is almost always increased. In this case, it is not an indicator of the connection of the bacterial flora. But, since it indicates the activity of a process that correlates with high fever, it can and should be used to determine the need to attract anti -inflammatory drugs. To determine the onset of bacterial superinfection, another test is used - the determination of the level of the precursor of the hormone of the Prokalcitonin. In patients with lung lesions against the background of Covid-19, it remains within the limits of reference values. But when the bacterial infection is joined, the level of this marker rises. A patient with an increased level of prosagalcitonin needs antibiotics. This indicator works well for patients in a hospital, but it can also be used in those who are treated on an outpatient basis. When maintaining the patient, both of these markers, and C-reactive protein, and prosagalcitonin need to be used. This will help determine what drugs are needed and when.
- In order not to give medicine just just in case?
- It seems to me that this is a very important point. We tried to spread our experience, convince our colleagues that this should be done.
- More and more data that the new coronavirus affects the walls of blood vessels ...
- In our opinion, any change on computed tomography, indicating the lesion of the lung tissue as part of a coronavirus infection, is a reason for the appointment of anticoagulants. Preventively, they are given to all patients with severe lung lesions - this is reflected in national recommendations. In outpatient practice, according to indications, oral anticoagulants are possible. This is the main therapy that should be prescribed to the overwhelming number of patients with coronaviral lung damage.
Andrey Zaitsev
Distant Alla Astakhova