I typically appreciate guidelines. They do a pretty reasonable job to help us take care of our patients and standardize how we do things. Here, I break down the IDSA guidelines on COVID. With all due respect to the Infectious Disease Society of America (IDSA) , I do not like these guidelines. I’d rather they didn’t say anything at all. In fact, they do not give any recommendations as to what to do. Seems like they’re saying “don’t do anything in the absence of a clinical trial”. Sorry guys, the RCT days are at a halt. People are dying faster than we can wait for results for clinical trials. We can’t just sit back and do nothing while these people get sicker on us. This is all my opinion and download the source material. Do not trust me. 

Here we go with the recs and my interpretation:

Recommendation 1 from the IDSA guidelines on COVID

Hydroxychloroquine (hospitalized patients): give in the context of a clinical trial. What about all the other hospitals who are not in a clinical trial? We are learning that it is not so good in severe/ICU cases with better data but there is still a void and a large absence of adverse effects in this population when patients are carefully monitored (daily EKGs, telemetry).

Recommendation 2

HCQ/Azithro combo: give in a clinical trial. I’m cool with this. Two QTc prolonging agents is a time bomb. 

Recommendation 3

Lopinavir/Ritonavir: give only in a clinical trial. We have learned via an NEJM article I posted that this doesn’t work in severe patients but what about the mild/moderate camp? Remdesivir is hard to get a hold of these days. 

Recommendation 4

Steroids in patients without ARDS: recommendation against. I tend to agree with this.

Recommendation 5

Steroids in patients with ARDS: give in the context of a clinical trial. Yeah, sure. And what am I supposed to do for the cytokine storm if I’m not in a center that enrolls patients in a clinical trial? Can the IDSA then, since they’re not helping, facilitate the PI contact info for these clinical trials?

Recommendation 6

Tocilizumab: only in the context of a clinical trial. Should I sit on my hands as I watch the inflammatory markers skyrocket? Sigh.

Recommendation 7

Convalescent plasma: in the context of a clinical trial. Well at least this is something you can ONLY get in a clinical trial so there’s that.

I’d like to invite these fine folks to step out of the Ivory tower, and into the front lines with us in non-academic centers/community hospitals to practice some real world medicine. I trained in an Ivory tower institution myself. The vast majority of us are not in the Cleveland Clinic, Bringham and Women’s, Vanderbilt, Mass Gen, Northwestern, Mayo Clinic, and Johns Hopkins. 

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