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Communique

Communique # 42

22 April, 2021

Message from the Chair and Executive Director

Dear Colleagues

We’ve just passed 12-months since the first publication of the Australian clinical guidelines for the care of people with COVID-19.

It feels difficult to celebrate milestones while the pandemic still casts such a shadow on our lives here and globally. However, it is important to acknowledge the commitment of our Taskforce members, partner organisations and volunteer experts to ensuring Australian clinicians have access to up-to-date and trustworthy guidelines and can deliver evidence-based treatment which saves and improves the lives of patients with COVID-19.

The success of the Taskforce is the result of the wholehearted investment from our 32-member organisations and their unwavering support of the multi-disciplinary 100% consensus approval model for all Taskforce recommendations.

We recognise the generosity of over 250 expert clinicians and the members of the Consumer Panel in volunteering their time and expertise each week to review the evidence and develop more than 135 living recommendations. It’s a staggering 18,000 volunteer hours from leading experts who already have extensive commitments within their peak health bodies and beyond.

It has been humbling to witness this extraordinary sense of service and goodwill and it is evident that Australian clinicians have valued your guidance as highlighted in the feedback from our impact survey:

‘We find them really useful because it’s a one-stop shop for the latest evidence of where we’re up to.’

‘I just think that it’s a source of truth that you can refer to in times where you might not know the answer and feel confident that it’s been reviewed and trustworthy.’

‘When the living guidelines came on board, it was just fantastic to have someone distilling all the evidence that was coming in and writing some high-level national guidelines that we could use as our source of truth, because there was just so much disparate information. It was really lovely to have them, assimilated and presented as this is the best practice currently with what we know.’

We also gratefully acknowledge the support of our funders, the Commonwealth Department of Health, Victorian Government Department of Health, Ian Potter Foundation, Walter Cottman Endowment Fund and the Lord Mayor’s Charitable Fund.

Australian clinicians and consumers can be reassured that the Taskforce will continue its daily global evidence surveillance and update the living recommendations as new and reliable evidence emerges. We believe that this dynamic approach to clinical guideline development represents a paradigm shift and can accelerate the translation of research to practice which will benefit the health and wellbeing of Australians.

We look forward to continuing this journey and to building a strong, sustainable evidence capability in Australia which will ensure our future preparedness.

Sharon McGowan (Chair, Steering Committee) and Julian Elliott (Executive Director)

 

 

WEEK IN REVIEW

UPDATES TO THE LIVING GUIDELINE

New recommendation for timing of surgery following COVID-19 infection
The Hospital and Acute Care Panel has reviewed the evidence from a large multi-centre study of patients undergoing elective or emergency surgery (COVIDSurg Collaborative March 9) and determined that evidence indicates that there may be an increase in mortality and morbidity in patients who have elective surgery within seven weeks of a diagnosis of SARS-CoV-2 infection.

As a result, the Taskforce has made the following conditional recommendation:

Do not routinely perform elective surgery within eight weeks of recovery from acute illness, following a diagnosis of SARS-CoV-2 infection, unless outweighed by the risk of deferring surgery, such as disease progression or clinical priority.

Informed consent and, where deemed necessary, shared decision-making with a valid substitute decision-maker, should include discussion about the potential increased risk of surgery following a diagnosis of COVID-19 and in the presence of post-acute COVID-19 symptoms.

This is in line with the Royal Australasian College of Surgeons recommendation that surgery should not be conducted within 8 weeks of confirmed SARS-CoV-2 infection.

New recommendation against therapeutic anticoagulant dosing in adults with severe or critical COVID-19
The Hospital and Acute Care Panel has incorporated the March 12 pre-print results from the REMAP-CAP, ACTIV-4A, ATTACC multi-platform trial into the body of evidence underpinning the VTE prophylaxis recommendations.

Evidence now comes from three randomised trials in patients with severe or critical COVID-19. The Taskforce has determined that increased dosage of anticoagulants probably has little or no difference, when compared with standard dose anticoagulants, on critical outcomes in patients with severe or critical COVID-19 and so makes a conditional recommendation against its therapeutic use:

Do not routinely offer therapeutic anticoagulant dosing in adults with severe or critical COVID-19. There is no additional indication for therapeutic dosing for anticoagulants in adults with severe or critical COVID-19 beyond current standard best practice.

The Taskforce has also updated the consensus recommendation supporting the use of prophylactic anticoagulants to include adults with severe and critical COVID-19.

Other new recommendations

  • Interferon β-1a plus lopinavir-ritonavir added to ‘do not use’
  • Tocilizumab for pregnant and breastfeeding women 
  • Budesonide added to ‘only in clinical trials’
  • CT-P59 monoclonal antibody added to ‘only in clinical trials’

Updated recommendations

  • VTE prophylaxis for adults
  • Azithromycin
  • Tocilizumab
  • Corticosteroids

Further details about these recommendations and additional updates are below.

Consumer Panel reviews preferences and values through lived experience lens
Last month, the Taskforce announced a reconstituted panel that includes consumers and carers with lived experience of COVID-19. This week they provided invaluable insights while reviewing the existing preferences and values for the corticosteroids, remdesivir and tocilizumab for adults recommendations. The Panel provided overall endorsement of the recommendations with some minor changes to the wording of the preferences and values statements for the corticosteroids and tocilizumab recommendations.

The Consumer Panel is co-convened with the Consumers Health Forum of Australia (CHF)

 

QUICK STATISTICS

COVID-19 research pipeline

  • 52,228 studies published or registered in Cochrane COVID-19 Study Register, 1,755 added this week
  • 2,846 randomised controlled trials registered (data from Covid-nma site), 28 added this week
  • 3,836 systematic reviews registered in PROSPERO, 73 added this week
  • 254 randomised controlled trials published (data from Covid-nma site), 5 added this week

 

LIVING GUIDELINES

Australian guidelines for the clinical care of people with COVID-19: Version 38.0

NEW RECOMMENDATIONS

  • Timing of surgery following COVID-19 infection
  • Conditional recommendation against

Do not routinely perform elective surgery within eight weeks of recovery from acute illness, following a diagnosis of SARS-CoV-2 infection, unless outweighed by the risk of deferring surgery, such as disease progression or clinical priority.

Informed consent and, where deemed necessary, shared decision-making with a valid substitute decision-maker, should include discussion about the potential increased risk of surgery following a diagnosis of COVID-19 and in the presence of post-acute COVID-19 symptoms.

  • Conditional recommendation

For people undergoing elective surgery following a diagnosis of SARS-CoV-2 infection, consider carrying out multisystem preoperative assessment in consultation with a unit familiar with the assessment of people recovering from COVID-19.

  • Tocilizumab for pregnant and breastfeeding women

Consider using tocilizumab for the treatment of COVID-19 for pregnant or breastfeeding women who require supplemental oxygen, particularly where there is evidence of systemic inflammation.

  • Interferon β-1a plus lopinavir-ritonavir

Do not use for the treatment of COVID-19.

  • Budesonide, CT-P59 monoclonal antibody

Do not use for the treatment of COVID-19 outside of randomised trials with appropriate ethical approval.

  • VTE prophylaxis for adults 

Do not routinely offer therapeutic anticoagulant dosing in adults with severe or critical COVID-19. There is no additional indication for therapeutic dosing for anticoagulants in adults with severe or critical COVID-19 beyond current standard best practice.* Note updated recommendation for prophylactic anticoagulants below.

UPDATED RECOMMENDATIONS

  • VTE prophylaxis for adults

The ‘consensus recommendation’ supporting the use of prophylactic anticoagulants in adults with moderate COVID-19 has been updated to include adults with severe and critical COVID-19:

Use prophylactic doses of anticoagulants, preferably low molecular weight heparin (LMWH) (e.g. enoxaparin 40 mg once daily or dalteparin 5000 IU once daily) in adults with moderate, severe or critical COVID-19 or other indications, unless there is a contraindication, such as risk for major bleeding. Where the estimated glomerular filtration rate (eGFR) (see below) is less than 30 mL/min/1.73m2, unfractionated heparin or clearance-adjusted doses of LMWH may be used (e.g. enoxaparin 20 mg once daily or dalteparin 2500 IU once daily).

  • Azithromycin

Updated evidence base with no change to the strength or direction of the recommendation.

  • Tocilizumab

A statement has been added to the ‘Preferences and Values’ following review by the Consumer Panel.

  • Corticosteroids

‘Preferences and Values’ for the corticosteroids ‘conditional against’ recommendation has been updated following review by the Consumer Panel.

The Taskforce is continually monitoring research to update recommendations as new evidence emerges.

 

CLINICAL FLOWCHARTS

11 clinical flowcharts have been developed by the Taskforce to cover:

  • Assessment for suspected COVID-19
  • Management of adults with mild COVID-19 UPDATED
  • Management of adults with moderate to severe COVID-19 UPDATED
  • Management of adults with severe to critical COVID-19 UPDATED
  • Respiratory support for adults with severe to critical COVID-19
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment
  • Management of people with COVID-19 who are receiving palliative care
  • Care of people who experience symptoms post acute COVID-19
  • Preparedness for CPR during the COVID-19 pandemic
  • CPR for adults with COVID-19 in healthcare settings
  • Basic life support for adults in the community during the pandemic

Changes to flowcharts this week include:

  • Addition of budesonide and
  • Interferon β-1a plus lopinavir-ritonavir added to ‘do not use’

 

EVIDENCE UNDER REVIEW

We are currently reviewing evidence to develop recommendations and flowcharts to guide practice in areas including:

  •  P2/N95 respirators and surgical masks
  •  Eye protection
  •  Levels of ventilation
  •  Portable air cleaning devices
  •  Reduction in patient occupancy
  •  Bromhexine hydrochloride
  •  Corticosteroids
  •  Ivermectin
  •  Proxalutimide
  •  Post-exposure hydroxychloroquine prophylaxis
  •  Immunoglobulin plus methylprednisolone
  •  Care of people with post acute COVID-19

 

NEWS & EVENTS

Cochrane
As part of their Coronavirus resources, Cochrane has recently updated the following rapid reviews:

New Cochrane Clinical Answers related to COVID have also been published:

View the full list of Cochrane Reviews relating to the pandemic here.

Infection Control Matters Podcast
Taskforce Executive Director A/Prof Julian Elliott and Taskforce Director of Evidence and Methods Dr Tari Turner joined the Infection Control Matters podcast to discuss the role of the Taskforce, the new infection prevention and control panel, topics currently under investigation and developing infection control recommendations.

Consumers Health Forum of Australia

 

NEW TOPICS AND QUESTIONS

It is a core mission of the Taskforce to engage with frontline clinicians to rapidly identify and address priority clinical questions.

Each week we collect suggestions for new clinical questions or topics for consideration by the Taskforce. A document that lists all of the suggested questions, topics and new patient groups that we have received to date is available here.

Please encourage your clinical colleagues to provide their insights via the website.

Topics