Infectious Diseases & Clinical Care

infectious-diseases-clinical-care, science-brief

| September 30, 2021

Evidence-Based Recommendations on the Use of Casirivimab + Imdevimab, and Sotrovimab for Adults in Ontario

Critically and Moderately Ill Patients In clinically unstable patients with no history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 8000 mg IV is recommended if patients are within 9 days of onset of any COVID-19 symptom AND have demonstrated rapid clinical deterioration. Antibody testing is not required in this case. In clinically stable patients with or without a history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 8000 mg IV may be considered if patients are within 9 days of onset of any COVID-19 symptom AND are not at risk of acute decompensation AND if COVID-19 anti-spike antibody testing demonstrates that they are seronegative. Casirivimab + imdevimab is not recommended for moderately/critically ill patients who are beyond 9 days of onset of any COVID-19 symptom, whether or not they are presumed to have immunity to SARS-CoV-2. Mildly Ill Patients Antibody testing is not required in mildly ill patients. In patients with no history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 1200 mg intravenous (IV) or subcutaneous (SC) is recommended if patients have confirmed, symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom AND have at least one of the following risk factors: age > 50, obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease, chronic liver disease, immunosuppression, or receipt of immunosuppressants. In patients with a history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 1200 mg IV or SC may be considered if patients have confirmed symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom. In patients with a history of COVID-19 infection or full vaccination with risk factors other than immunocompromise or immunosuppression, SARS-CoV-2 neutralizing antibodies are not recommended as these patients have presumed immunity. In patients with no risk factors, SARS-CoV-2 neutralizing antibodies are not recommended as these patients are at low risk of adverse outcomes. At this time, for mildly ill patients, casirivimab + imdevimab 1200mg IV or SC is preferred over sotrovimab 500mg IV due to practical considerations (i.e. it can also be administered subcutaneously). Ontario’s supply of SARS-CoV-2 neutralizing antibodies is limited, and demand by eligible patients may exceed supply in the near future. Understanding the impact of these agents on patient and system important outcomes will ensure that they are used to greatest benefit. There are clear barriers to allocating SARS-CoV-2 neutralizing antibodies ethically and equitably. A number of strategies are suggested to address these barriers, including optimization of distribution, supply, administration, and allocation, dashboarding, and application of an evidence-informed risk framework for patient selection.

infectious-diseases-clinical-care, science-brief

| September 30, 2021

Clinical Practice Guideline Summary: Recommended Drugs and Biologics in Adult Patients with COVID-19

infectious-diseases-clinical-care, science-brief

| September 14, 2021

Understanding the Post COVID-19 Condition (Long COVID) and the Expected Burden for Ontario

The “post COVID-19 condition” (or long COVID) describes a range of symptoms which can persist for months after severe, mildly symptomatic or asymptomatic SARS-CoV-2 infection. The most common of more than 200 reported symptoms include fatigue, shortness of breath, pain, sleep disturbances, anxiety, and depression. Many people with the post COVID-19 condition have difficulty returning to baseline levels of function and have high rates of health care utilization. A conservative estimate suggests that 57,000 to 78,000 Ontarians have or are currently experiencing the post COVID-19 condition, although prevalence estimates can vary widely depending on the case-definition applied. Vaccination is likely protective against development of the post COVID-19 condition. More research is required to develop a consensus definition of the post COVID-19 condition, understand risk factors including the role of viral variants, quantify the impact on specific populations such as children, and develop strategies for prevention and treatment.

infectious-diseases-clinical-care, science-brief

| September 13, 2021

The Incidence, Severity, and Management of COVID-19 in Critically Ill Pregnant Individuals

The rate of SARS-CoV-2 infection in pregnancy does not appear to be higher than in the general population; however, compared to their non-pregnant counterparts, pregnant individuals have higher morbidity and mortality, with a higher risk of intensive care unit (ICU) admission, mechanical ventilation, and need for extracorporeal membrane oxygenation (ECMO). They also have a higher frequency of pre-eclampsia, Cesarean delivery, and a higher rate of preterm birth. Care of the critically ill pregnant patient with COVID-19 requires a multidisciplinary team that includes obstetrics, neonatology, anesthesia, infectious diseases, medicine, and critical care. Potentially life-saving evidence-based therapies such as corticosteroids and tocilizumab should not be withheld from pregnant individuals with severe COVID-19. Vaccines against SARS-CoV-2 are safe to use among pregnant individuals and vaccination is highly recommended in this population.

infectious-diseases-clinical-care, science-brief

| September 8, 2021

The Impact of the COVID-19 Pandemic on Opioid-Related Harm in Ontario

Rates of opioid-related harms, particularly fatal overdose, have increased significantly in Ontario during the COVID-19 pandemic and have disproportionately impacted marginalized and racialized populations. Strategies to address this crisis include ensuring uninterrupted and equitable access to addiction, mental health, and harm reduction services; incorporating these services into high-risk settings such as shelters, hotels, and encampments; adapting harm reduction services to meet current needs; and promoting access to alternative service delivery methods such as telemedicine programs when in-person services are not available. Leveraging Ontario’s capacity to monitor rates of opioid-related harms can help optimize public health strategies. Data gaps on disparities for those disproportionately impacted by the opioid overdose crisis need to be addressed to improve our understanding of the effectiveness of interventions and guide implementation in high-risk populations.

infectious-diseases-clinical-care, science-brief

| September 3, 2021

Heparin Anticoagulation for Hospitalized Patients with COVID-19

Critically Ill Patients Prophylactic dose low molecular weight or unfractionated heparin are recommended in critically ill patients hospitalized with COVID-19. These patients should not receive therapeutic dose anticoagulation unless they have a separate indication for this treatment. Therapeutic dose anticoagulation in this patient population does not reduce the need for organ support and may increase bleeding events as compared to prophylactic dose anticoagulation. Moderately Ill Patients Therapeutic dose low molecular weight or unfractionated heparin may be considered over prophylactic dose anticoagulation in moderately ill patients who are felt to be at low risk of bleeding. All other patients should receive prophylactic dose anticoagulation, unless they have a separate indication for therapeutic dose anticoagulation. Therapeutic dose anticoagulation may reduce the need for organ support (including the need for high-flow nasal oxygen) and appears to decrease thrombotic events in moderately ill patients compared to lower intensity anticoagulation. Its benefits on survival are unclear, and it may increase major bleeding events. Given the small absolute risk reduction for patient-important outcomes and the known harms, a strong recommendation for therapeutic dose anticoagulation in moderately ill patients cannot be made. Mildly Ill Patients There is insufficient evidence to make a recommendation around anticoagulation for mildly ill patients.

infectious-diseases-clinical-care, science-brief

| August 24, 2021

Clinical Practice Guideline Summary: Recommended Drugs and Biologics in Adult Patients with COVID-19

infectious-diseases-clinical-care, science-brief

| June 17, 2021

Drugs and COVID-19: Information for Patients and Healthcare Professionals

infectious-diseases-clinical-care, science-brief

| June 16, 2021

Clinical Practice Guidelines Webinar: Tocilizumab

Webinar hosted by the Ontario COVID-19 Drugs & Biologics Clinical Practice Guidelines Working Group Presenters: Laveena Munshi MD MSc, Stephanie Carlin PharmD, Beth Leung PharmD MsCI Moderator: Brad Langford PharmD Date: Monday, April 26, from 12:00-1:00 p.m. EST Audience: Clinicians in all hospital settings (acute teaching, large community, small community) Objectives: • Summarize the data on the use of tocilizumab in patients with COVID-19 • Describe the recommended populations to receive tocilizumab • Provide advice and considerations regarding secondary infections • Discuss access and use of tocilizumab in the context of a shortage situation

infectious-diseases-clinical-care, science-brief

| June 16, 2021

Clinical Practice Guidelines Webinar: Medications for Outpatients with COVID-19

Webinar hosted by the Ontario COVID-19 Science Advisory Table's Drugs & Biologics Clinical Practice Guidelines Working Group on June 15, 2021. Presenters: Kate Miller, MD, CCFP, FCFP, Ullanda Niel, MD, CCFP, FCFP, and Sumit Raybardhan BScPhm, ACPR, MPH, BCIDP Moderator: Brad Langford, PharmD Objectives: Provide evidence-based recommendations on the use of medications for managing COVID-19 in the outpatient setting. Address patient questions about the appropriate use of medications for acutely managing COVID-19. Describe tools and resources that can be used to help support prescribing for outpatients with COVID-19.

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