Managing high clinical suspicion COVID-19 inpatients with negative RT-PCR: a pragmatic and limited role for thoracic CT

Abstract

As the COVID-19 pandemic sweeps across the UK there remain issues with reverse-transcription polymerase chain reaction (RT-PCR), the gold standard diagnostic method. Delays in obtaining results have been particularly problematic. Some patients, including those with high clinical suspicion of COVID-19, test falsely negative on initial RT-PCR test, sometimes requiring multiple subsequent tests to return an eventual positive result. Suggested possible reasons for this include: suboptimal clinical sampling techniques; variations in viral load; and manufacturer test kit sensitivity.1 With surging caseloads, managing these RT-PCR ‘negative’ patients is proving hugely challenging. An emerging bottleneck to effective care is dealing with isolation capacity. Inpatients who are truly PCR negative can be moved to a non-isolation ward, thereby freeing up isolation beds for COVID-19 positive patients and also reducing risk of nosocomial virus transmission. Patients with high index clinical suspicion of COVID-19, but who test negative on initial RT-PCR test, continue to be managed with respiratory isolation precautions, often undergoing repeat PCR testing. However, this means further delay while awaiting subsequent test results. Against this backdrop, an effective pathway to deal with negative COVID-19 RT-PCR results in the setting of high clinical probability is urgently needed. A further important concern is developing regarding deisolation on patient discharge to either home or community care: a confirmed COVID-19 diagnosis - or confirmed alternative, non-COVID-19 diagnosis - is key to imparting advice to families and carers. Imaging has been suggested as a potential solution to some of these problems. Most patients undergo chest radiograph (CXR) at presentation to hospital, with CXRs being hot-reported using a template …

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