Bibliographic information
Guideline—
Year of Publication—
Issuing Institution—
Recommendation
New
WHO recommends that for patients with suspected or confirmed filovirus disease, systematic laboratory monitoring be performed based on clinical assessment, rather than on routine testing.
Recommended in favor
Strong
Certainty of evidence
Low
Notes and Remarks
- This recommendation applies to all children and adults, including pregnant women.
- Laboratory monitoring should be linked to actionable clinical interventions intended to improve patient outcomes. The laboratory result turnaround time should be appropriate to inform clinical decision-making.
- The scope and frequency of laboratory testing should be tailored to the needs of the patient, with selection to use resources wisely and minimize venous punctures.
- The minimal set of available tests should include: point-of-care malaria rapid diagnostic tests, glucose, haemoglobin/haematocrit, complete blood count, pregnancy test, urinary dipstick, tests required for blood transfusion, electrolytes and biochemistry. Additional tests may be required based on level of care.
- Biosafety must be implemented during all phases, including sample collection, transport, laboratory manipulation and sample disposal. Organization
- Laboratory facilities should be as close as possible to patient care areas. This is preferentially delivered using point-of-care devices where they are cheap and available.
- Organize laboratory availability as core laboratories then add on based on level of care.
- Put in place standard operating procedures for use, for training, and for staffing of the laboratory facilities. This will depend on the configuration and choices of assays and analysis platforms.
- Anticipate the needs in terms of disposables (such as cartridges), reagents and quality assurance. Frequency of analysis
- Limit sampling to avoid bleeding risk from venepuncture sites.
- Avoid overtesting or “routine monitoring” without consideration of the resource use – this may decrease equity due to unnecessary costs and risk stock-outs which will mean essential care delivery to the highest risk patients is compromised. Measurement of individual analytes
- Measure and record serum biochemistry and haematology on admission and daily during the resuscitation phase (typically the first 4 days of illness, or longer depending on the clinical condition of the patient) and as clinically indicated.
- This includes sodium, potassium, bicarbonate, urea/blood urea nitrogen, creatinine, liver transaminases, magnesium, glucose, complete blood count including haemoglobin, white blood cells and platelets, prothromin time/international normalized ratio (INR), creatine kinase, chloride, calcium, albumin and lactate.
- Glucose should be monitored daily as part of the biochemistry panel and at every shift when vital signs are performed as point-of-care testing, during the early phase of the disease.
- In patients with symptomatic or severe hypoglycaemia (< 3 mmol/dL = 54 mg/dL), patients should be treated immediately and glucose measured every 1–2 hours until stable (i.e. no evidence of hypoglycaemia confirmed by four checks over 4–8 hours, and no increase in glucose administration). • In children, measure glucose on admission and, at a minimum, every 8 hours. Measure glucose more frequently in patients with symptomatic hypoglycaemia and in neonates.
- Point-of-care testing for glucose (glucometer), pregnancy and malaria rapid diagnostic testing should be available. Polymerase chain reaction (PCR) diagnostics This section is not focused on PCR diagnostics for filovirus disease, which are considered separately. However, it is noted that:
- WHO has strong recommendations for mba114 and REGN-EB3 for EBOV (Zaire). These are time critical therapeutics, with time delays in therapeutic administration leading to increased mortality. Therefore, for EBOV, where Xpert platform testing is available, the time from admission of suspected case to receipt of PCR result should be within 6 hours.
- Immediate 24-hour access to diagnostic filovirus PCR and CT values are a critical component to drive clinical management including early initiation of antiviral therapies and patient prognostication.
- For confirmed admitted patients with filovirus disease, repeat PCR testing should be offered (for example on day 3) so that CT values can guide prognostication.