CASE CLASSIFICATION

CATEGORY Symptom Fever Pneumonia Oxygen- Critically ill with MANAGEMENT

(Cough/SOB) dependent Shock/MOF/ARDS
1 Observation
2A + PO Hydroxychloroquine1 400mg BD x1/7 and 200mg BD for 4/7 OR
2B + + PO Chloroquine3 500mg BD x5/7
3A** + + PO Hydroxychloroquine1 400mg BD x1/7 and 200mg BD for 4/7 ONLY
3B** + + + *If risk of clinical progression to Stage 4 is present, add in:
PO Lopinavir/Ritonavir (Kaletra)2 11/11 BD x 2/52
4A** + + + PO Hydroxychloroquine1 400mg BD x1/7 and 200mg BD for 4/7
4B** + + + + + PO Lopinavir/Ritonavir (Kaletra)2 11/11 BD x 2/52
5 + + + + + PO Hydroxychloroquine1 400mg BD x1/7 & 200mg BD for 4/7 OR Chloroquine3 500mg BD x5/7
+ PO Lopinavir/Ritonavir (Kaletra)2 11/11 BD x 2/52
+ PO Ribavirin 2.4g stat & 1.2g BD OR S/C Interferon Beta-1b5 (250mcg/8MIU) EOD 7 doses
4

+/- Immunomodulators (eg. Steroids/IVIG/Tocilizumab)

*Risk of clinical progression from 3 to 4: Increasing fever, increasing SOB (especially exertional dyspnoea), tachycardia, ↓ absolute lymphocyte count (ALC), ↑ CRP trend
**Calculate Modified Early Warning Score (MEWS), increase in score will suggest clinical deterioration. Use MDCalc or table below.
Score +3 +2 +1 0 +1 +2 +3
SBP (mmHg) ≤70 71-80 81-100 101-199 ≥200
HR (bpm) <40 41-50 51-100 101-110 111-129 ≥130
RR (/min) <9 9-14 15-20 21-29 ≥30
Temp (‘C) <35 35-38.4 ≥38.5
Conscious level Alert Voice Pain Unresponsive
If MEWS >4 or SPO2 <90% with oxygen therapy or if concern on patient’s condition, inform consultant immediately and alert GICU.
Colour-Code MEWS Score Follow-up/Next measurements
Blue 0 24 hours
Yellow 1 8-12 hours
Orange 2 4-8 hours
Red 3–4 1-4 hours
>4 Inform consultant and alert ICU team

MIMS Malaysia Drug Guide:

- Hydroxychloroquine1 : Baseline ECG, LFT, RP. S/E: ↑QTc (cardiomyopathy), marrow suppression (agranulocytosis, haemolytic anaemia, leukopenia, thrombocytopenia),
proximal myopathy, GI (diarrhoea, vomiting, abdominal pain), neurological (headache, dizziness, emotional disturbance), hypoglycaemia
- Lopinavir/Ritonavir (Kaletra)2 : Baseline ECG, LFT. S/E: ↑QTc, heart block, ↑AST/ALT, GI (diarrhoea, vomiting, abdominal pain), headache, skin rash, pancreatitis (in ↑TG).
- Chloroquine3 : S/E: myocarditis, hypersensitivity, retinopathy, alopecia, tinnitus, myopathy, psychosis, seizure etc.
- Ribavirin4 : Contraindicated in eGFR<50, liver impairment, haemoglobinopathies, history of unstable/severe IHD
- Interferon Beta-1b5 : S/E: leukopenia, headache, hypertonia, myasthenia, transaminitis, pancreatitis, hypersensitivity, nephrotic syndrome, depression or suicidal
ideation, flu-like symptoms, thrombotic microangiopathy etc. Use in caution in those with history of seizure disorder
© Infectious Diseases Unit, Penang General Hospital (Last revised on 23/03/2020)